Editor’s note: Skip Kirkwood takes the reins as our guest columnist for this issue.
The importance of words, and their precise definitions, was drummed into me throughout my legal education. And as the debates about EMS, particularly about the development of a national EMS policy, swirl around us, it appears to me that we lack agreement on what we are trying to convey when we use those three letters.
A paradigm is something that serves as a pattern or model, a set of assumptions, concepts, values and practices that constitutes a way of viewing reality for the community that shares them. Until we agree on a shared paradigm for EMS, our discussions continue to wrap around themselves without useful outcome.
The classic debate involves the question, “What is EMS?” Is it public safety, health care, public health or community service? My answer is: Yes. It is some of each of these related disciplines. So what? Where does that discussion take us?
A lesson to be learned
The U.S. Marine Corps has a long and storied history of being America’s “force in readiness.” In other countries, their versions of our Marines are called “naval infantry.” Naval infantry? What the heck? Infantry are ground troops, and the Navy is maritime. Yet the Marine Corps doesn’t lose a lot of sleep, become divided against itself and become paralyzed by this debate. There is rarely discussion about whether its federal home should be in the Department of the Navy or the Department of the Army. They are the Marine Corps: They fight our country’s battles and do whatever is asked of them.
EMS in the U.S. could stand to take a lesson from the Marine Corps: Focus on what needs to be done, not the organizational chart or the semantics or philosophy. The Marines are shipboard infantry; EMS is mobile health care. We go where health care is needed, and we do (or should do) what is needed to deliver that care.
It is clear that what we do today is medical care. We respond to requests for medical or health care-related services, we assess and treat patients, and we transport patients to additional sources of care. And at the edge of our core activities, we make some efforts to prevent or limit illness and injury, and we explore ways to apply more appropriate, more efficient, more effective resolutions to our community’s needs beyond “transport to the hospital.” That is health care—that is what we do. We may be moving from purely “emergency medicine” to a blend of emergency medicine, community health and public health, but it is still health care.
It’s time to cut the chatter
In some quarters, the discussion is about funding sources. “Public safety” is shorthand for “funded by local tax dollars.” “Health care” means fee for service. So where is it graven in stone that one can only be funded by a single source? In truth, many municipal and county government EMS systems have combined health care fee-for-service dollars (sometimes known as “reimbursement”) with local tax dollars (sometimes called “subsidy”), resulting in an unfortunate negative connotation. Yet there are people who are invested in being purely funded by one model, eschewing the other as somehow being evil.
Guess what? Neither is evil. Public funding is how responsible organizations pay for the cost of preparedness, and the costs of caring for those who aren’t insured and can’t pay, after they make a diligent effort to collect the bill from whatever appropriate source. Evil? No, it’s highly appropriate. We should collect available health care dollars through rates set reasonably (no ridiculous cost shifting), and our communities should fund the level of availability and response performance that they desire, along with care of indigents, community events, and whatever level of prevention and paramedicine programs the policy-makers believe the community requires.
In other quarters, it’s about compensation, pension and favored status. The 19th century civil service systems in some communities, and collective bargaining in others, created a favored class that enjoyed better job protection, early retirement systems and a defined-benefit pension system. All of that is up in the air now, and the once-important distinctions between “sworn” and “unsworn” positions never were written in stone, anyway. They can, and should, be changed.
It is, for example, not reasonable to expect that a career paramedic should work until age 671/2 (which is when I am eligible to retire). The physical demands of lifting and moving simply wear the knees, shoulders and back out in less than 40 years, and a retirement scheme should recognize that—just like it does for police officers and firefighters. (Note to all of us: You can only make changes like that if you work together and forget the artificial divisions.)
The services we deliver are health care in nature—and we should be defined by the services we deliver. That we sometimes look like public safety, and that we deploy to achieve timely response and equitable coverage cannot, and should not, distract from the fact that we deliver primary and emergent health care. It is what we do, and we should do it well. We should not expend one more calorie or spend one more minute being divided by distinctions that distract and don’t matter. We are the mobile field force of health care, and though we are few, we should be proud.
