EMS has an identity problem. We don’t know whether we are public safety, health care or public health. Heck, we don’t even know if we make a difference. The Ontario Prehospital Advanced Life Support Studies (OPALS) and other studies have demonstrated that standard practices and procedures that we thought made a difference in outcomes actually do not. They also demonstrated that there were some things that did make a difference; but have we as a profession reacted to these studies and changed our practices? Not that I can tell.
There is an interesting article in the September 2008 issue of Emergency Physicians Monthly by Greg Henry, MD. Dr. Henry is a past-president of the American College of Emergency Physicians and a thought leader in emergency medicine. In his article, “Get Serious about Health Care Spending,” he details problems with emergency medicine as he sees it and the nine areas that need change. The first area he lists regards EMS. He writes:
#1 The EMS Mess As a so-called necessary health care expenditure, I think EMS is the largest hoax ever foisted on the American People. There is no data, not one study, which shows that anything beyond the intermediate level — basic EMT with defibrillator capabilities — does anything in the long run to change the health care of the United States. The problem is this: it is a hidden cost. Do you realize what it costs for a fire department to simply keep everyone current with their ACLS cards? This is what Casey Stengel would call a long run for a short slide. This has become a local government power base and the numbers are not even figured in to the overall health care costs in the United States. |
This is quite a strong statement. Dr. Henry is both right and wrong. There are several areas where ALS has limited benefit — principally trauma and cardiac arrest. But, there are areas where it does make a difference: early aspirin administration, administration of nebulized bronchodilators, CPAP, nitroglycerin administration, and pain relief, among others. Stated another way, the less glamorous things we do are often the most helpful.
So is it our egos or our ignorance that keeps us from changing to meet the science? It is probably a little of both. It is glamorous to work a cardiac arrest and flip the tops off the pre-filled syringes like Johnny Gage did on Emergency! in the 1970s. It is glamorous to “do procedures” on trauma patients. Yet, we continue this despite overwhelming evidence to the contrary. The only thing in cardiac arrest that really makes a difference is defibrillation and CPR (and induced hypothermia). Drugs do not seem to make a difference. Even the mainstay of cardiac arrest — epinephrine — probably does more harm than good.
The same holds true for trauma. IV fluids do not make much difference in the prehospital setting; yet, we have an assortment of items (e.g., IO needles, large volume catheters) that we try to use. The literature is showing that prehospital intubation — especially in patients with moderate to severe head injuries, worsens outcomes — but, we keep intubating trauma patients.
 EMS, as we know it, is at a crossroads. Funding, whether it is governmental subsidy or user fees, is inadequate to support the system we are operating.  | ||
| — Bryan Bledsoe | ||
There is also no evidence that such things as chest decompression, MAST, mannitol, central lines, helicopters and other prehospital trauma care procedures make a difference. Yet, we continue to do them and many of these are expensive. It is hard to accept the concept that the most important thing for the severely-injured trauma patient is transport. It goes against our need to “do something.”
The lack of scientific evidence behind standard protocols will eventually come back to haunt us. Insurance companies and the Centers for Medicare and Medicaid Services (the federal agency that oversees government healthcare expenditures) will simply quit paying or pay only the rates that are justified by the evidence. This will ultimately be the death knell for the out-of-control air medical industry. As for ground providers, decreased reimbursement means low salaries. Low salaries result in an itinerate workforce. An itinerate workforce better describes a trade rather than a profession.
EMS, as we know it, is at a crossroads. Funding, whether it is governmental subsidy or user fees, is inadequate to support the system we are operating. Thus, salaries remain low. With low salaries there is a constant turnover of personnel and we never really achieve excellence as a result. Any service business (and EMS is a service business) that relies upon an itinerate workforce never achieves greatness. Think about the fast food industry. They have a constant turnover of personnel. When you go into a McDonalds or Wendy’s you generally don’t expect good service nor do you receive it. EMS, at present, is not all that much different.
Change is painful. We have to let go of some of the emotion and practice based upon the evidence. Anecdotal evidence (e.g., “I have seen it work” or “our system is different”) does not trump quality EMS research. Sir Winston Churchill once said, “There is nothing wrong with change, if it is in the right direction.” It is time to change for the good of the profession. When those who follow us in EMS look back on our decisions, let’s hope they see that we changed for the better. If not, they might well accuse us of “weapons-grade” stupidity. For me, I prefer the former.
