The New EMS
Much has changed in the world of fire-based EMS in the last 50 years. When the National Academy of Sciences published the whitepaper “Accidental Death and Disability: The Neglected Disease of Modern Society” in 1966, their recommendations to increase survival from medical emergencies included several EMS system enhancements that made great sense for the fire service to adopt. Specifically, the call for communities to “adopt ways and means of providing EMS by local levels of government that are applicable to the conditions of the locality” naturally led to leveraging the existing infrastructure of the fire service to meet the mission of EMS service delivery. Firefighters were already equipped and trained to respond to a variety of emergencies from stations that were typically dispersed throughout a community. Enhancing the medical training of firefighters for the purpose of quickly and efficiently responding to life threatening emergencies made sense for many communities. When funding became available in the early 1970’s through federal EMS Systems act grants, the fire-based EMS service delivery model was already being implemented in several cities to varying degrees across the country. For many communities, using fire department resources for EMS responses was an opportunity to leverage existing capabilities for an expanded mission.
In the case of EMS service delivery, community commitment to ensuring that highly trained EMS providers were immediately available at all times and for any emergency has had some unintended consequences over the years. First and foremost, the definition of “emergency” and the interpretation of what constitutes and emergency by the public has changed dramatically. In the 1960’s and 1970’s deficiencies in EMS systems were being addressed because people were dying unnecessarily due to the lack of adequate EMS services. Our success in creating high performing systems has led to more and more people taking advantage of the EMS services that are available to them. With increased trust in EMS came a decreased threshold for accessing EMS services. Today, EMS is used in much the same way walk-in clinics are. Any medical concern is emergency enough to summon an ambulance and go to an emergency department. While we still provide lifesaving care for many, EMS has become a convenient point of access to healthcare rather than a service to be used in true emergencies for a large percentage of patients in many communities.
The system put in place to ensure a first responder is delivered to the side of a patient experiencing a life-threatening emergency in minutes is still needed for life-threatening emergencies. In many communities – especially in urban areas – true emergencies are now a small fraction of the EMS workload. Most requests for EMS do not require a quick response by highly trained EMS providers today. In my community, approximately half of all EMS incidents do not require a paramedic and I estimate that at least half of these incidents could be appropriately managed without being transported to an emergency department.
We are at a crossroads in EMS. This particular crossroads presents some unique challenges and opportunities for fire-based EMS systems. Today, healthcare delivery is changing in almost every care environment. Funding drives care in many cases. Without getting deep in the weeds here, the need for cost savings without negatively impacting patient outcomes has forced healthcare systems to be more proactive in addressing the patient experience as well as the appropriateness of how patients are cared for. This same model is slowly making its way into EMS in the form of Mobile Integrated healthcare. In short, our work as emergency service providers is still important but is no longer the majority of our workload. Most of our EMS patients need access to appropriate healthcare, which may not necessarily be a trip to the local emergency department.
As EMS transitions in to an allied health team member instead of a dedicated emergency service, the fire service needs to re-evaluate how it fits in to this model. For the majority of EMS calls today, the need for manpower and a short response time no longer exists. For some emergencies, like cardiac arrest and severe trauma for examples, time will remain a key metric and highly skilled first responders deployed quickly from the nearest fire station will be the difference between life and death. For most medical emergencies, however, an ambulance with two EMS providers that can arrive in 10 – 20 minutes is more than sufficient. It is no longer efficient to send fire trucks to every request for medical assistance. Aside from wear and tear on the vehicles, many fire departments struggle to keep up with much needed training and valuable public relations and community safety initiatives because they are overwhelmed with medical calls. Similarly, EMTs and Paramedics serving as dual role firefighters also struggle to keeping up with EMS training and education requirements because they are serving two masters that often have conflicting priorities.
I recommend that fire-based EMS systems that want to remain relevant begin planning for a very different EMS landscape in the near future. As leaders we need to be thinking differently about service delivery. Now is the time to take a 10,000 foot look at how we provide service and adjust for what our communities need instead of settling for what we think we should be providing. To begin with, every community should have a system for appropriately triaging calls for service to the right resource. This is a pivotal function of any EMS system. If we can’t differentiate life-and-death from low acuity than we’re stuck over resourcing requests. Next, we need to ensure that we’re making the best use of the resources that we have. We need to look at how we are deploying EMS providers and what impact that has on the delivery of other public safety services such as fire suppression and rescue work. Next is healthcare system integration. A key element of this is building partnerships between EMS and the greater healthcare systems that we integrate with. Community Care Teams are a great example of healthcare system resource integration that can result in a better patient experience. Mobile Integrated Healthcare programs are successfully addressing challenges such as high frequency EMS system utilizers and hospital readmission avoidance in several areas of the country. In addition to positively impacting the healthcare system, MIH programs support patients in the community by connecting patients with services and navigating patients to the most appropriate care and support for their situation.
While the needs of each community are different, I believe that fire-based EMS systems can play a valuable role in tying together the community with the healthcare system. This is the direction EMS is heading. We are no longer just emergency service providers. As the demands of us by the public change, so must our approach to them.