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EMS Highs and Lows of 2009

By Kelly Grayson

Well, here we are, another year in EMS drawing to a close, and a new year, bright with promise and uncertainty, set to begin. As I look back on my years in EMS, I marvel at the advances in medical theory and technological innovations that few could have foreseen 15 years ago, and I wonder what new things we'll see in the coming 15 years.

After all, it wasn't so long ago that 12-lead EKGs were considered beyond the grasp of most paramedics, that rotating tourniquets were the standard of care for CHF, and ALS in cardiac arrest was the thing that mattered most. It's been only a few years since we were saying things like, "It's not a dead body until it's a warm dead body," and now, we're infusing many of those bodies with chilled saline as soon as we get a return of pulses.

No doubt, when we look back on 2009 in years hence, we'll have a better idea as to which developments in EMS were positive, and which set our profession back. But first, we'll have to at least examine what some of those notable events were. Will they prove to be watershed events, or merely historical footnotes? Only time will tell.

National EMS Educational Standards
2009 saw the release of the National EMS Educational Standards, a major step forward in the way we approach provider education. The National EMS Educational Standards are the third phase in implementing the EMS Education Agenda for the Future, and hopefully represent a sea of change in our approach to EMS education. The old DOT curricula, static and heavily scripted, struggled to keep pace with the rapid advances in medical care, often keeping us mired in outdated theory and obsolete technology. The new standards, based upon core competencies from the National EMS Scope of Practice Model, should prove to be more fluid and adaptive to advances in medical theory and standards of care. Coupled with the National Registry of EMTs' requirement that all paramedic educational programs be nationally accredited by 2013, the next few years may mark the turning point where EMS becomes a profession in more than name.

The Pigocalpyse
2009 also saw "Hinny" become a part of the medical lexicon, and not just as the street name for the chosen beverage for many of our intoxicated patients. The H1N1 variant of the influenza virus, commonly referred to as swine flu, has caused far more hysteria, panic and misinformation in the past year than it has deaths. The Flu Pandemic of 1918, which killed an estimated 50-100 million people worldwide, was thought to be H1N1, a factor which probably contributed significantly to the current hysteria.

The current iteration of H1N1 has been shown to be more contagious than seasonal influenza, but far less virulent (roughly 10,000 deaths versus 36,000 for seasonal flu). Usually, H1N1 only causes mild illness in healthy adults. More worrisome, however, is its higher mortality rate in younger patients. H1N1 deaths seem to be predominately children, thought to be because many of them lack naturally acquired immunity, since the last major outbreak of H1N1 was back in the 1950s.

With our current understanding of how to limit the spread of the disease and how to treat its complications, it is doubtful that the 1918 death toll will ever again be approached. Indeed, the CDC reports that cases of H1N1 seem to be on the decline, and school closures from H1N1 have dropped to zero.

Still, that hasn't stopped people from wearing surgical masks around Wal-Mart, or calling EMS at the first sniffle, dead certain that they've "got that pig flu that’s been killin' people."

Helicopter EMS Safety Standards
Over the past few years, the only objects that have dropped out of the sky with more frequency than EMS helicopters are the yearly Perseid meteor showers. Over the past 10 years, increases in Medicare reimbursement have spurred rapid proliferation of EMS helicopter services, and a corresponding spike in the number of crashes. Currently, medical helicopters are allowed to operate without even the most basic safety features the FAA requires of commercial flights.

Industry critics have complained that helicopter EMS providers have done little voluntarily to address the problem, and that the FAA has been slow to respond with tighter safety standards. In response to the distressingly high number of EMS helicopter crashes — a number that propelled EMS helicopter flight crews to mortality rates rivaled only by Alaska crab fishermen — in September, the National Transportation Safety Board released new safety recommendations for EMS helicopters.

The recommendations — autopilot systems, flight data recorders, night vision systems, and terrain-following radar — are non-binding, but the NTSB took the additional step of recommending that Medicare reimbursements be tied to implementation of the new standards. The FAA is expected to release new regulations for EMS helicopters in early 2010. No one knows how many, if any, of the NTSB recommendations the FAA will adopt, but hopefully those regulations will substantially improve the safety of our EMS helicopter flight crews.

Whether they curb the abuse and overuse of helicopter EMS prevalent in much of the United States, remains to be seen.

Health Care Finance Reform
No discussion about the events of 2009 would be complete without addressing the elephant in the room. Health care reform has been a core element of President Obama's agenda, and the Senate Democratic leadership just garnered the 60 votes necessary to prevent a Republican filibuster of the bill. Presumably, the bill will pass the Senate by Christmas, and then the work begins of reconciling the House and Senate versions of the bill.

So it looks as if we'll have some version of health care reform enacted by early 2010. As it stands now, we can expect to see the ability of private insurers to deny coverage based upon pre-existing conditions severely curtailed, and we'll see a massive expansion of the Medicaid program. Whether you favor or oppose either of those things depends upon your political persuasion, I suppose, but there seems to be enough in the legislation for everyone to hate. The liberal Democrats decry the removal of the public option from the bill, while the Republican leadership opposes what they say will be massively increased cost and the tax hikes necessary to pay for it.

What doesn't seem to be mentioned much, if at all, in the legislation, is reimbursement for EMS. Whatever effects our profession may feel, good or bad, are likely to be indirect ones.

What does seem patently obvious, Congressional Budget Office predictions to the contrary, is that health care will become more expensive. Whether out of pocket or by increased taxes, we’re going to be paying more for it. You cannot expand coverage of a taxpayer-funded program to many millions of additional subscribers, and have it become cheaper.

Whether or not that bodes well for EMS, I suppose we'll just have to wait and see.

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