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Re-inventing EMS with a BLS intercept

EMS doesn’t have an actual paramedic shortage; instead, EMS has a shortage of paramedics willing to work for low wages in terrible working conditions


The entire profession of EMS has a skewed concept of resource allocation.


My first EMS job was at a little mom and pop ambulance service with barely the finances to buy the next box of 4x4 gauze, much less make payroll.

The owner of the service was a great boss, but a terrible businessman. As our finances improved, so did things like making payroll, but the increased revenue rarely translated to better working conditions or equipment.

My boss was enamored of expensive computer dispatch and billing programs, and thought nothing of spending $25,000 on software to dispatch a system that ran 1,500 transports a year, but would shop eBay auctions for used cardiac monitors and equipment.

We had great computers and software, but he would balk at paying over $1,000 for a cardiac monitor. I know this, because I spent a year working with one that was one step above an Etch-A-Sketch that he picked up for $500 from a neighboring service that was planning to throw it away. Mine once caught fire while I was trying to defibrillate a patient.

He paid substantially more to an unscrupulous mechanic every year to keep our vehicles on the road than he would have paid to finance an entirely new fleet, with factory warranties. He once paid $20,000 to an “efficiency expert” whose report could basically be summed up as, “Turn over your checkbook to someone more responsible, clean off your desk and stop wasting good money on things like efficiency experts.”

He was the epitome of the proverb, “Penny-wise and pound-foolish.”

We have too much EMS

Over the years, I’ve come to realize he wasn’t unusual at all. The entire profession of EMS has a skewed concept of resource allocation. We fall prey to the conceit that new technology trumps better education, and like much of the health care consumers in our country, believe that more equals better.

ALS must be better than BLS.

If one paramedic is good, two is better.

If two paramedics is good, critical care paramedics would be even better.

Let’s not stop at critical care interfacility transports, let’s do community paramedicine!

I’m one of the contrarians in EMS who believes that there is no paramedic shortage in the United States. What we have instead is simply a shortage of paramedics willing to work for chump change and terrible working conditions.

And if anything, we don’t have too little of EMS in this country, we have too much.

EMS in the United States reminds me of the hype about Saddam Hussein’s million-man army and the vaunted Republican Guard in the prelude to Desert Storm. When it finally came to battle against coalition forces — who were significantly outnumbered but vastly better equipped and trained — Iraq’s army folded like a cheap suit. To quote the diminutive, but bad-assed warrior Yoda, “Size matters not.”

We can do EMS much better

That’s us right now; bloated, poorly educated and equipped, with no clearly defined mission, and inadequate leadership. We could do EMS so much leaner in this country, with fewer expenditure of resources.

Case in point: the concept of the ALS intercept.

A rural, typically volunteer, system is staffed with EMTs and when they have a really bad patient (defined as “anything the crew is uncomfortable with”), they load the patient and boogie toward a distant hospital in the big city, and request a paramedic ambulance or fly car to meet them on the route.

That’s totally backwards.

Why is it that major urban EMS systems, with highly capable hospitals a stone’s throw away in any direction, are overwhelmingly staffed with paramedics, while rural and underserved communities, where distance to definitive care presumably makes ALS care more necessary, are staffed almost entirely with EMTs?

I’ve worked both rural and urban EMS. And while I see far greater run volume in urban systems, the reality is that the most lifesaving fluid on my ambulance in the urban setting is diesel fuel. There is precious little that I must do for the patient, that cannot be deferred for five minutes until someone with more education and resources can do it in a more controlled environment.

On the other hand, I may spend a 24-hour shift at a rural station without rolling a wheel, but when I do get a patient, generally they really need a paramedic. I never wade so deep into a treatment protocol or algorithm as when I am in rural EMS. I’ve emptied many a drug kit, rendered the last interventions in my protocol, and then checked my watch and thought, “Only 30 more minutes to the hospital. Let’s hope he makes it.”

We need to flip resource allocation

So what would I do differently? Well, when my legion of flying monkeys completes my quest for world domination, here’s how I’d set it up:

I’d have tiered response EMS systems in the large urban centers. They’d be staffed with a bunch of dual-EMT trucks, with a small cadre of dual-medic ALS ambulances available. They’d all be dispatched via a validated triage protocol, one that bases response resources on evidence-based medicine, not perceived liability.

The BLS trucks in this system would handle the vast majority of calls. If an ALS unit transports, it’s only because the patient needed an intervention only a paramedic could provide.

Within this urban EMS system, there would be a robust community paramedicine program. Those community paramedics would do their typical jobs in the city, making sure that super-users of system resources are not calling 911 or visiting the emergency department unnecessarily. They’d be monitoring health and medication compliance, making specialist referrals, all the things community paramedics do.

And they’d also be staffing a rural health clinic in those outlying communities typically served by a volunteer BLS ambulance squad. They’d be doing public health outreach on behalf of the large hospitals that support their program and doing education and mentoring of the BLS squads in their area.

When an ambulance call comes in, they’d hop in their fly car or ambulance and sprint to the call and render care right along with the BLS squad. And if there was no BLS squad in that area, they’d transport into the city if the patient needed ALS care.

But if he was like the vast majority of our patients, and not in need of ALS care, they’d call for a BLS intercept unit from the city, or hand them off to the BLS volunteer squad for transport and head back to the clinic.

It would be a cushy job, one that the city medics could rotate into on a regular basis; work a few weeks in the city, then spend a week at the vacation station.

And just like that, we’d cut down on skill dilution and rust-out in our ALS crews. We’d have better seed corn for future paramedics in the BLS crews, by virtue of them handling more patient care and the rural vollie squads would get regular education and mentoring.

And we could probably make it revenue-neutral, if not cheaper than the current model.

We could make this work

Don’t think it could work? I’m open to suggestions and critiques, but before you say “That’ll never work,” keep in mind that staying wed to the current paradigm isn’t doing us much good, either. I’d imagine Da Vinci’s design for the helicopter garnered a few odd looks from his contemporaries, too, but look at how Da Vinci is regarded today.

If you think it could work, welcome to the legion of flying monkeys. Tell your friends to join us, we have cookies! columnist Kelly Grayson, is a paramedic ER tech in Louisiana. He has spent the past 14 years as a field paramedic, critical care transport paramedic, field supervisor and educator. Kelly is the author of the book Life, Death and Everything In Between, and the popular blog A Day in the Life of An Ambulance Driver.