Updated February 2015
Bob Bass almost skipped a career in EMS and medicine, opting for law enforcement instead. As an undergraduate in the late ’60s, he took a break from his studies to work as a Chapel Hill, N.C., police officer and volunteer EMT for a local rescue squad. After finishing up his degree, he thought about going to medical school but wasn’t sure. “WD Blake was my very wise police chief at the time,” he notes. “I said, ‘I really like law enforcement. I’m going to miss it.’ He said, ‘Are you nuts? Go to medical school.’”
Bass studied medicine at the University of North Carolina Chapel Hill, where he continued to run EMS calls. “My partner and I would sit in the back of the lecture hall,” he says. “If we got a call on our pager, we’d go out the back door, down the stairs and had the ambulance parked on the loading dock.” After graduating in 1975, Bass went into the Navy. He did a family medicine residency at the Naval Regional Medical Center in Portsmouth, Va., and served as assistant medical director, and later medical director, for Charleston County EMS in South Carolina.
After leaving the Navy in 1982, Bass became board-certified in emergency medicine and was appointed director of the emergency department and trauma center at the Medical University of South Carolina. He went on to serve as director of the emergency department for Beaufort Memorial Hospital and medical director for Beaufort County EMS in Beaufort, S.C.; associate medical director for the Houston Fire Department; operational EMS medical director for the Nansemond-Suffolk Rescue Squad and City of Norfolk Fire Department in Norfolk, Va.; and director of the Emergency Medical Services Bureau for the Washington, D.C., Fire and EMS Department. He’s also a past president of the National Association of State EMS Officials and the National Association of EMS Physicians.
In 1994, Bass became executive director of the Maryland Institute for Emergency Medical Services Systems (MIEMSS), which oversees the state EMS and trauma system. After 20 years leading the organization, he announced he would retire at the end of the year. “I’m turning 66 in January and it’s time,” he says, adding that he’s going to continue to teach, write and serve on the Institute of Medicine’s Personal Protective Equipment Committee. “I’m looking forward to spending more time with my family, two grandkids and friends.”
Bass spoke with Best Practices about the continuing evolution of EMS and his quest to improve helicopter EMS safety.
Healthcare is undergoing a shift away from pay for service to pay for performance. How will this impact EMS?
At some point, EMS is going to get brought into the whole notion of value-based care. Government is interested for the first time in how EMS can play a role in healthcare for something other than transportation. A lot of people say they know where this is going to end for EMS, but I don’t think we do. It’s all still evolving.
It’s very interesting to watch what’s happening with community paramedicine and now mobile integrated healthcare, although we’re changing what we call these new EMS specialties even before we’ve defined them. Community paramedicine means different things to different people in different places; it’s akin to the early EMS systems of the late ’60s and ’70s. You do what’s expedient to address your community’s particular health needs.
I do worry that we will overlook the role that EMS plays in emergency care. Particularly for stroke, STEMI and trauma, we need to make sure that patients with time-critical conditions get the right response in the right amount of time to get to the right place. While I think it’s exciting to get engaged in broader issues of healthcare such as community paramedicine, mobile integrated healthcare or preventive care, we have to balance that with our role as emergency responders and our role in systems of care. People with time-critical conditions depend on us. As we move forward, we can’t lose sight of why we are here in the first place. We can’t forget that paramedics are playing a critical role day to day in the transport of patients who are very sick or injured.
In particular for field providers who have been on the street for 20 or 30 years, community paramedicine or mobile integrated healthcare is a great opportunity to transition into a role that is less stressful on the back and less stressful on the psyche. But we’re jumping ahead with community paramedicine and mobile integrated healthcare and doing it in a very fragmented way. We do it differently in Fort Worth than in Maine or Minnesota. In the United States, we don’t have national consensus on the training, the role or the curriculum. How do you teach? What do you teach?
There was a great article in Prehospital Emergency Care this summer about community paramedicine. It basically said that we really haven’t defined the role or the educational requirements well, and we haven’t collected much evidence in the way of safety, value or effectiveness. And candidly, community paramedicine is emerging differently from place to place. They have much more experience with it in the United Kingdom, Canada and Australia than we do in the U.S.
There are other aspects of EMS that are evolving that we also need to be paying attention to, including the role of BLS providers and the growth of paramedic specialties.
What’s happening with regard to paramedic specialties and how does that relate to community paramedicine?
Community paramedic is one type of paramedic specialty. The bigger one, at least for now, is actually the critical care paramedic. They do specialty care transports and we have observed a proliferation of these transport services since the 2002 Medicare national ambulance fee schedule was enacted. Specialty care transports receive a higher level of reimbursement from Medicare than do ALS or BLS transports. The increased regionalization of care has also fueled growth of specialty care transport.
We’ve gone from the old paradigm of every hospital attempting to do everything, to the development of trauma centers in the ’80s and ’90s and, more recently, STEMI and stroke centers. Increasingly you have patients arriving at one hospital who need to be transported to another hospital at a higher level of care than can be provided by traditional BLS and ALS providers. The most common model for specialty transport is a nurse and a paramedic with critical care training. In a number of places, transports are being done with two specialty-trained paramedics. At this time, there are numerous curricula for critical care paramedics, and the scope of practice and licensure varies from state to state.
Is that of concern?
Maybe. There really isn’t enough evidence yet to say one way or another. But the major evolution in EMS that we’re seeing right now at the paramedic level is the development of these specialty care roles for paramedics. At the present time, the National EMS Education Standards do not address advanced practice paramedics and the National Registry doesn’t test or certify them.
My point is we shouldn’t get too distracted focusing only on community paramedicine or mobile integrated healthcare when we have these other paramedic specialties to look at as well. Critical care paramedics, tactical paramedics and others are emerging as we speak and states are having to deal with all of this with very little in the way of national consensus.
Earlier you mentioned an evolving role for BLS providers. What’s occurring?
We went through an era where the BLS role to a certain extent was diminished a bit. If it was a really bad call, you needed the paramedics to save them. It created an impression that BLS care didn’t matter as much.
We all struggled historically with abysmal outcomes for sudden cardiac arrest. With the advent of advanced cardiac life support, we got sidetracked into thinking improving rates depended on this higher level of care, which included manual defibrillation—something only paramedics could do—and the use of meds and endotracheal intubation. We didn’t have AEDs until the late ’80s and early ’90s. I can remember interrupting CPR to intubate patients because we thought it was the right thing to do.
But now, with resuscitation medicine, the important role of the BLS provider is getting renewed focus. We’re now finally starting to figure out that it’s more about the basics: early defibrillation not necessarily by the paramedic but by anybody who can get a defibrillator there, high-quality uninterrupted CPR and bystander CPR, driven by the dispatcher if necessary.
So while I was talking all about the evolution of paramedics into specialty care, we are also seeing a return to the basics, but in a much more sophisticated way. That has huge potential in terms of improving outcomes for sudden cardiac arrest. We shouldn’t get carried away by the glamorous stuff happening in community paramedicine. There is also huge, huge exciting stuff happening at the BLS level.
At the recent NASEMSO conference, you hosted a “hot topics” session that included helicopter EMS. Why is it particularly relevant now?
The rapid growth of helicopter EMS has really posed challenges for states. There were two phases of growth. There was the early phase, which started in about 1980 and went until 2002, when there was modest growth. Helicopter programs were mostly not-for-profit, hospital-based, well integrated with EMS systems and by and large had a collegial relationship with state EMS regulators.
Some states regulated HEMS, others didn’t, because they didn’t feel a need to regulate them because there weren’t any significant issues identified. What fueled the growth during that period was need. There was greater understanding of the golden hour for trauma and helicopters were part of the early phase of the regionalization of trauma care. Though helicopters are expensive to operate, hospitals did it in part because it brought patients to them.
Then, with the new ambulance fee schedule in 2002, reimbursement markedly improved. During that same era, we were also expanding the regionalization of stroke care, STEMI care and cardiac arrest care. HEMS growth became much steeper. During this more recent phase, we’ve seen HEMS programs that are not affiliated with hospitals. They are independent services, not well integrated with the local EMS system. States started seeing helicopters placed in the same places where there already were helicopters, while in others there weren’t any helicopters. Increasingly, states became concerned about the issue.
They tried to limit the number of helicopters in an area, saying you need a certificate of need, something that hospitals need. States tried to apply that to helicopters and passed rules to require integration with EMS and affiliation with trauma centers. Except this time they frequently got resistance and push-back from the HEMS services on grounds of the Airline Deregulation Act [of 1978], which preempts states from regulating air transport services and anything that has to do with rates, routes or services. States that required certificates of need went to court, which ruled repeatedly against the states. For instance, the state of Hawaii wanted to require air ambulances to operate 24/7, like they require of ground, but the U.S. Department of Transportation said you can’t do that due to the Airline Deregulation Act.
So there are things we can’t regulate, such as operating 24/7, requiring a certificate of need, or telling them where they can or can’t base. What states can and must regulate is the medical aspects of what they do, such as requiring that their providers meet certain licensing requirements, setting standards for equipment, maintaining a reasonable temperature range in the aircraft, sanitary requirements, configuring the aircraft so that providers have access to the patient and, more recently, requiring that trauma patients go to a trauma hospital.
Let the federal government regulate the air safety side. Our responsibility is to protect patients. They are vulnerable. It’s very important the state makes sure the medical safety issues are addressed—that they have appropriate medical staff, medical equipment and protocols, are integrated with the EMS system and that they take patients to the right hospital.
What has brought the issue of HEMS regulation to the forefront?
Exponential growth and crashes. What came up at the 2009 National Transportation Safety Board air medical transport hearings is that HEMS has an unacceptable crash rate and is possibly over-utilized. Helicopters can be a good way to get people with time-sensitive issues to the hospital. The problem is, we don’t always know with certainty if patients have a time-critical issue or not. With trauma, there are national field triage guidelines, but a lot of over-triage is built into those algorithms to prevent the potentially deadly under-triage of injured patients to non-trauma centers.
Another issue that raised concerns was helicopter shopping, in which an EMS provider in the field calls a helicopter and is told they can’t fly because the weather is bad. So EMS calls another helicopter service and doesn’t tell the helicopter service they were already turned down because of bad weather. Then that helicopter tries to respond and crashes. What the FAA has asked the states to do is work with EMS providers to stop that process—EMS needs to tell the second company they’ve been turned down due to bad weather.
What is one of your greatest accomplishments during your career?
When I was a medical director in Charleston, we didn’t have a national organization of medical directors. We called a meeting in Hilton Head and 130 people involved in the medical direction of EMS systems came. That included Paul Pepe, Ron Stewart and others who were in the vanguard of providing medical direction for EMS. We were so stimulated by the experience that we founded the National Association of EMS Physicians. In 1986, we held the first national meeting in San Antonio. Today, NAEMSP is one of the leading voices for medical direction for EMS in the country.
How about as state EMS director?
My greatest accomplishment was being able to come into a system that was in turmoil. They had lost their leader, Dr. R Adams Cowley, a very visionary surgeon who set up the state EMS system. [Cowley also founded the nation’s first trauma center at the University of Maryland in 1958.] After he died, there was a vacuum in leadership and the system was in turmoil. We had a series of crises. What I’m most proud of is that I was able to come in and stabilize it, and then through consensus, cooperation and coordination build on his tremendous legacy.
We have formalized the standards and designation process for trauma center and perinatal centers, stroke, STEMI and burn centers. We now have statewide protocols for all EMS providers, a statewide quality assurance program, statewide medical oversight and a statewide medical communications system, which is now converted from analog to digital. We recently put in a NEMSIS-compliant statewide EPCR system provided at no charge to local jurisdictions. We really have evolved over the past 20 years, and there’s a sense in the system that we’re all in this together to take care of patients. United we stand, and we know that.
After many years of public service, how do you plan to spend your retirement?
I don’t know right now, but I’m not going to stay home. I will hopefully continue to teach. I’d like to be able to help other states and other countries develop their EMS systems.
What are you going to miss most?
All of it. I love coming to work. I will miss the opportunity to build out regionalized systems of care. We regionalized trauma, stroke, STEMI and perinatal care and know that we are collectively providing the best level of care that we can. I’ve also loved working with the doctors, nurses and EMS providers. It’s been a blast. They are wonderful people—special people who want to help other people.
