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EMS From a Distance: Upgrading EMS

Changing a fragmented industry from the bottom up

“EMS 3.0 Summit.” That headline from the NAEMT about a seminar promising “strategies to navigate healthcare change” reminded me how out of touch I am with the latest proposed upgrade to our industry. I can’t even recall what happened to EMS 2.0. Am I the only one who thinks we’re still stuck somewhere around EMS 1.1?

I am in awe of people who champion change in EMS. Forward thinkers like Nick Nudell, Kelly Grayson, Matt Zavadsky, Mike Taigman and Bryan Bledsoe put their reputations on the line each time they suggest new ways for us to think about our jobs. Their critics, scattered across rural, urban and suburban outposts, seem unified only by distrust of ambitious plans.

Even dedicated innovators are no match for a workforce as fragmented and skeptical as ours. That’s one reason I believe broad initiatives should first be tested on a small scale – or, to put that in terms of the EMS 3.0 software vibe, debugged by a few motivated users. I learned that lesson long before I joined EMS. All I needed was a box of red stickers and a conveyor belt.


How not to make changes

In 1974, I was working at a cosmetics plant as a production supervisor – my first job after graduating engineering school. I’d been hired to help modernize largely manual manufacturing systems.

Most days, I was responsible for 12 assembly lines manned by about 120 workers who’d fill, cap, label and box beauty products. The goal was to yield no less than the budgeted quantity of finished goods per hour.

I thought I could help meet quotas by pasting bright red circles as targets on conveyor belts, at intervals that would ensure above-average productivity as long as assemblers kept up with the bottles or jars on each marker. I was so confident employees would appreciate my ingenuity that I neglected to tell anyone about the change until I’d applied all those stickers one morning before the shift began. What followed was a master class in human nature, with me as the only student.

After I got the whole group together to describe the new procedures and give a little speech about the merits of efficiency, I found an anonymous note on my desk with this sarcastic query:

“How efficient is your brain?”

Then random stickers started disappearing from conveyer belts, which caused productivity to sag below what it would have been without any “improvements.” I tried to find out who was sabotaging my brilliant plan, but I was no match for factory-floor omertà. I never did make those stickers work.

Employees were accustomed to management promoting bold schemes with lots of fanfare and little follow through – not unlike what sometimes happens in EMS – but the fault was mostly mine. I should have experimented on a smaller scale: a single assembly line staffed by employee-partners whose constructive opinions and enthusiasm could have helped shape a favorable outcome.

EMS success from the bottom up

I’d like to see EMS evolve in a similar fashion. Instead of overreaching for universal acceptance of new ideas, start small – with one agency that’s busy enough to generate lots of reps for all the proposed changes, or with one idea embraced by a few agencies. Either way, the likelihood of actionable suggestions goes way up when a manageable group of participants are engaged as allies.

My first EMS supervisor subscribed to that philosophy. He asked me to evaluate an early form of electronic documentation before introducing it to everyone. It wasn’t a random request; my boss knew I’d been a software developer before becoming a paramedic. He treated me as a valuable resource even though I was a virtual nobody, and paid close attention to my detailed feedback about the first version of what would eventually become a functional system. By starting with one user, it was easier to fix problems and then build support among other employees.

EMS innovations that thrive when N=1 are better positioned for progressive rollouts – from agency to county to state, for example. Succeed at the state level and you’ll face no more than 49 opposing points of view, but probably fewer, as some states just go with what works. Eventually, there’s a critical mass of success that is a surer route to nationwide acceptance.

So what upgrade of EMS are we at? Most of what we do – treating and transporting sub-critical patients; and how we do it – mostly with oxygen, heart monitors, IV meds and diesel, isn’t all that different from the first version of EMS I encountered 26 years ago. Yes, we have cell phones, 12-lead EKGs, capnography, powered stretchers and some new drugs, but EMS 3.0 implies much bigger changes industry-wide. I think major initiatives like community paramedicine and strategic information management would have to be more mainstream before we deserve even an EMS 2.0 designation. I don’t see that happening without methodical, progressive piloting.

Meanwhile, I can live with EMS 1.1.

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