Recently, a story broke out of Charlotte, North Carolina, about an emerging protocol that would allow Charlotte firefighters to leave the scene of a medical call if the patient is safe and a Mecklenburg EMS Agency (MEDIC) ambulance is on the way.
This story ignited a fiery response on every EMS-related social media platform with comments ranging from concerns about patient abandonment, to the sentiment of, if patients are OK to be left alone, they are OK to take a taxi!
The details in the news coverage were not crystal clear, so in order to understand exactly what is being proposed, I spoke to the Deputy Director of MEDIC, Jon Studnek, who has been working with MEDIC’s Medical Director, Doug Swanson, MD, on this protocol change proposal. Studnek, a former EMS research fellow with NREMT and later, director of prehospital research at Carolinas Medical Center, is eminently qualified to both comment and conduct the proposed project.
Studnek related, “we think about the fact that an ALS ambulance is a scarce resource and what is the best way to utilize their response, and in a system like ours where we have first responder, non-transport BLS response with ALS coming next, are all aspects of that system being as efficient with their time as they could be?”
MEDIC’s plan is to conduct an approved, controlled trial where the responding fire crew can identify after a BLS assessment if a patient is of a low-acuity level where they can be left to wait for an ALS crew to arrive, conduct further assessment and determine if transport is necessary.
This enables the fire crew to stand down and prepare for the next response, while also ensuring that responding ambulance crews aren’t racing across town under emergency conditions unnecessarily – a serious issue affecting the safety of our crews, other road users and pedestrians alike.
MEDIC responded to 155,081 calls for service in FY2019 and conducted 117,321 transports. Studnek estimates that only 16% of MEDIC’s responses are life threatening/potentially life threatening. Fire first response is not tasked to lower acuity calls as determined by MPDS but for those calls that begin with a higher priority, that are subsequently downgradable through on scene BLS assessment, the crew can return to duty.
A classic example of this is the “third-party caller,” where the call taker cannot speak to the patient directly as the call is routed through another agency, such as a police department. Those dealing with medical dispatch will know that a third party is assumed to be life-threatening until proven otherwise. These types of call could include anything from a welfare check to a fight in progress, and while the patient condition may not be critical, the lights, sirens and number of assets responding is. Once an on-scene assessment has occurred, crews can stand the responding ambulance down and take a patient refusal or leave the patient in place, return to duty and allow the ambulance to arrive under normal driving conditions.
The project, as described, is only at the proposal stage. It has been vetted by the North Carolina Office of EMS and the State Medical Director to ensure that no regulatory problems could occur. The project hypothesis has also been discussed at the Charlotte quarterly Medical Control Board (MCB) meeting. The MCB consists of eight voting clinicians from the local Novant Health and Atrium Health systems. The clinicians have wide-ranging areas of clinical expertise and are the ultimate approver of any clinical changes to medical protocols proposed by Dr. Swanson.
The MEDIC team is now at the data gathering and clinical pilot-writing stage and will present again on February 18, 2020, to MCB to gain approval to proceed with the control trial. It is their intention to produce outline results in time for the May 19, 2020, MCB meeting. I for one, will be watching with great interest.
Peer-reviewed research in the ET3 era
It is no secret that our current EMS system is unable to keep up with growing call volumes. Creating a safe and well-managed protocol to address low-acuity patient calls is essential. The proposed MEDIC protocol takes an academic approach with the MCB acting in the capacity of an Institutional Review Board (IRB), providing governance, safeguarding and direction.
We are all proponents of conducting small tests of change by planning, doing, studying and acting to achieve positive outcomes, and this process and this program will be an excellent example of this. The resulting proposal, test and, ultimately, results will be interesting to read and provide material for much needed EMS peer-reviewed research. As we enter the ET3 era on the road to 2050, this cohort of low-acuity patients could also be an easy referral for treatment in place or transport to an alternative destination.
In this case, the news got ahead of the actual study, and, thanks to the power of the internet, spread quickly without the benefit of the proposal back story. So rather than dismissing this a risky ploy that will endanger patients, we must pay close attention to the eventual results and outcomes – we may all learn something.