Is EMS A Failed Experiment?

I got the word last night.

Another nail has been driven into the coffin carrying the remains of what were once some of the best EMS systems in the country.

Emerson Hospital will discard its non-transporting ALS service next month, ending over three decades of service to its 14-town region spread along Route 2 and centered on the town of Concord.

A private ambulance company will buy the service from Emerson and has pledged to keep things the way they are, right down to the uniforms and offering employment to the service’s current paramedics. Though it will no longer run the service, Emerson Hospital will still provide the district’s medical oversight.

Of course, such employment will come at a significant pay cut for Emerson’s soon-to-be-former paramedic staff, especially considering this private has a lousy pay scale for the area ($16 per hour base, with 25 cents per year of experience) and doesn’t appear to offer differentials for working nights and weekends.

I also think the pledges to maintain the status quo were a means to placate nervous customers (ie, the towns once served by Emerson, the hospital itself) and won’t last.

And so another hospital-based paramedic service bites the dust, this time the oldest in Massachusetts.

Where once there were over a dozen in the late-1990s, there now stand just three – Lawrence General Hospital in Lawrence, Saints Memorial Medical Center in Lowell, and UMassMemorial in Worcester.

Three hospitals in the entire state committed to caring for the people in their catchment areas but outside the walls of the building. Before I say anything else, I think I need to laud in the highest way possible these three hospitals for keeping faith with the idea that prehospital medicine is important, and has a rightful place at the table of the medical professions. There is going to be some criticism in these paragraphs of hospital commitment to prehospital medicine. Saints, Lawrence and UMass have proven themselves the stalwart exceptions, and I wish them all decades of continued success and service.

Some of the hospital-based services that shut down previously have since re-started as transfer-only services, but these bear little resemblance to the non-transporting regional 911 paramedic units they replaced.

Throughout the years the argument has raged over whether EMS should fall under public health or public safety.

Those supporting EMS under the umbrella of the fire service champion it as another facet of the “all-hazards” approach to public safety, where the local fire brigade does everything from putting out the fire in your kitchen to inspecting your new boiler to treating your chest pain.

Advocates of the public health model say that the “M” in EMS stands for “Medical,” and that the proper delivery method for EMS should rightly fall under the auspices of the medical experts.

Which sounds good in theory, but in practice most public health entities from whom paramedics have sought employment – ie, the hospitals – have ultimately decided the cost far outweighed the benefit of providing Emergency Medical Services via a single-role, medically-oriented delivery model.

In other words, hospitals have proven they only have an appetite for running paramedic services if someone else pays for dessert.

Critics point out, correctly in a lot of cases, I believe, that fire departments often only want EMS as a way to bolster their numbers, a backdoor means to securing employment for the most firefighters possible and reinforcing personnel rosters in an era of declining fires, an imploding world economy and an exponentially increasing utilization of EMS.

Deep Throat told Woodward and Bernstein to “follow the money,” and I think anyone who follows the money in public safety realizes that EMS, unlike Police or Fire services, generates revenue.

Whether it generates revenue in excess of expenses is another conversation altogether and depends mainly on your customer base. Decaying former mill cities will have fewer customers with high-end private insurance or HMO coverage than the ‘burbs, plain and simple. It might be math, but it ain’t rocket science.

But these critics unjustly let hospitals off the hook.

Some in EMS pillory as morally bankrupt fire departments who want EMS as a way to keep their people gainfully employed, and yet don’t bat an eyelash at hospitals who unceremoniously drop their ALS programs as a way to slash the payroll and balance the budget by breaking the backs of some of their lowest paid employees, employees who, it needs to be said, also bear patient-care responsibilities that much higher-paid health workers, like nurses, could only dream of in their worst nightmares.

In the end the closures of the hospital-based paramedic programs at Emerson, Milford, Holyoke hospitals and MetroWest Medical Center in Natick, as but a few examples, served no higher purpose than the saving of a few bucks.

Even UMassMemorial in Worcester, which is to be commended for its commitment to providing 911 to Worcester and Shrewsbury, had its limits. Earlier this decade UMass shut down its non-transporting ALS unit out of Marlboro Hospital for cost concerns.

The claim, often touted in these hospital-based service closings, that a declining call volume due to fire department upgrade to the ALS level is responsible for hospitals shutting down their paramedic units has clearly proven over time to be a red herring, meant to distract us from the fact that hospitals in Massachusetts do not believe in EMS as a core public health mission vital enough to be supported in the one way support is registered in 21st century America – money.

Were it otherwise my MAHOPS patch (a wonderfully and pitiably anachronistic acronym for the Massachusetts Association of Hospital Operated Paramedic Services – it is worn on the right shoulder of my soon-to-be defunct Emerson Hospital Paramedics uniform and was designed by a former longtime Emerson medic who had to quit and become a municipal bus driver in order to get the same benefits and retirement plan as local police, fire and DPW workers) would not be adorned with the names of a half-dozen hospital-based paramedic services shut down over the last decade even while recording robust call volumes.

So the question I find myself asking, in light of the fact that the medical profession here in Massachusetts has by and large turned its back on prehospital medicine, is this:

Is EMS a failed experiment?

What does it mean if the only people who truly want you do so mainly because it helps them fight fires, and that the medical professionals who should want you don’t think you’re worth the money?

If so few doctors, the high priests of medicine themselves, have railed against the closing of the hospital-based paramedic services (although it should be noted that the doctors who have tried to stop the madness have fought with great passion and conviction – and to them I would say that we know who you are, and we are proud to have worked for you), what does that say about our place in the medical cosmos?

Not much, I’m afraid.

Part of that, of course, might have something to do with the relative age of our profession. The first cops were probably the biggest guys in the prehistoric post-Ice Age caves, who tens of thousands of years ago used clubs to keep order. The first recorded firefighters were loosely organized under Emperor Trajan during the Roman Empire. I, however, am 40-years-old, yet still older than my profession.

We’re new to everyone.

But are some people in the medical profession beginning to have doubts about EMS, or even the necessity of paramedics?

I think so. It doesn’t take a Burmese scout to track the scent.

Numerous studies have appeared in journals in recent years documenting paramedic shortcomings in everything from intubation to STEMI recognition to the overall morbidity and mortality of every living human over the last 30 years. There are too many of us, the studies say, we’re not particularly good at what we do, and the evidence doesn’t seem to suggest we make much of a difference.

Adding insult to injury, the powers-that-be in Massachusetts want to give EMT-Basics the ability to place invasive, advanced airways in patients despite the fact that the curriculum for EMT certification is so watered down that we can’t get them to bring Stair Chairs or do blood pressures on calls on their own initiative.

Such suggestions smack of the low regard paramedics have garnered in some corners of the medical establishment, that someone with 110 hours of training is pretty much interchangeable with someone who’s had 2,000.

It reminds me of the stand taken by the Massachusetts Board of Registration in Nursing several years ago in a white paper that said, in its view, paramedics were no more capable than a certified nurse’s aide and had no place working in hospitals at all.

Of course, those of us who actually do this job for a living and are not sitting in a university office somewhere with a graphing program and an Excel spreadsheet, know that these conclusions are ludicrous, because our eyes and ears tell us so every day in the real world, with actual patients who have more substance than mere data points on some PhD's graph.

There are people walking this Earth who would be dead had my various partners and I not arrived in our ambulance and done a few things correctly, things that took experienced paramedics working in concert with the committed physicians who trained and watched over us. There aren’t as many of these former patients as I’d like, but they’re out there, and I know their loved ones would have an opinion or two about whether paramedics make a difference, and what price competent ALS is worth to the general public.

The truth is that many of these studies (and, perhaps predictably, most often the most damning examples), though given the veneer of hard science, are really just sociological ruminations, promulgated under the guise of science, made at the behest of certain “investigators” who simply want the imprimatur of publication in a scientific journal to advance their own agendas, even when those agendas are often in direct contradiction to the reality on the streets.

I find it laughable to read these serious-minded “studies” that come to such broad conclusions based on a heterogeneous mess of self-reported data and guesswork, assigning cause-and-effect via intuitive leaps in reasoning so confounded by flaws in logic that they would never pass muster in a laboratory, where real science using objective data to come to repeatable conclusions is performed.

But the state of "scientific" research in EMS leads me to the conclusion that EMS itself, at least here, where I live and ply my trade, is verging on a failed experiment:

Hospitals don’t want to pay for us. Most doctors don’t want to work with us. Most nurses don’t respect us.

But I have hope, and it’s that word “most” that gives me hope.

I know there are physicians out there who have given immense chunks of their professional and personal lives trying to advance prehospital medicine, often working even harder than my paramedic colleagues and probably to the detriment of their own careers. I often wonder how much different this field would be if some of my paramedic friends gave as much of themselves to advance our profession as some of the physicians we’re privileged enough to work with and for?

And I know plenty of nurses who give paramedics their due, who realize we’re an important part of that chain of care that begins by the bedside and continues in the hospital. And to be fair, paramedics don’t always do themselves any favors by the way we interact with nurses. Some of my best mentors have been, and continue to be, nurses. But we’re not going to get any where with the nursing profession as a whole until we hold ourselves to their standards, which is why I think the minimum entry to being a paramedic should be at least a two-year Associate’s Degree program. Again, a conversation for another time.

So for the time being I personally don’t think EMS is a failed experiment, but we’re in trouble.
I think the model is changing, and I think we need to embrace the change. That’s the only way we’ll have a voice in whatever’s coming down the pike to replace what’s already been done.

For EMS, we’re at the end of the beginning. The question is, now what?

Hospitals don’t want us. Fire departments, private ambulance companies and third-services do. I think we need to find a way to keep the “M” in EMS, even if the medical establishment couldn’t care less, and practice the best MEDICINE possible, no matter what the patch on our shoulder says.