EMS In The 21st Century


EMS has changed a lot in 17 years. Some of that change has been good, some of it has been, well, not so good.

Here is my take on the good and bad of EMS in the 21st Century.

The good.

Power stretchers. These probably made their debut in the late 20th century, but no one really thought that they would catch on. “No one” includes me, but I was wrong. They certainly seem like back (and career) savers. The only downside is that they add some complexity and more than a little weight to the stretcher. Oddly, I still see instances where people carry the whole damned thing up a flight of stairs.  I’m not 100% sold on those track systems that lift the stretcher into the ambulance, but if I’m wrong about that, at least I’ll be consistent.

Which brings me to another good thing. Stair chairs with tracks. Or rollers or whatever you want to call them. The devices seem to have been inspired by devices used to move refrigerators up and down stairs. Which considering how many more ginormously obese patients EMS seems to see, is somewhat apt.

EMS education. Overall, EMS education is better. Or at the least opportunities for good EMS education are more available. That’s both on line formal education and EMS blogs.

Vehicles. Ambulances are better designed, and better built now than they were at the end of the 20th Century. They are also safer, but the major factor in EMS safety is still good driving practices. There finally seem to be suspension systems available that make the ride far less truck like.

CPAP. It took a while to get there, but pre hospital CPAP is a great tool and a life saver. It also reduced the number of intubations in the field, although there is some downside to that because some paramedics hardly ever get to intubate these days.

ETCO2 is another great EMS tool. It’s not used as much in the field as it should be, but ironically it seems to be used in the field far more than in Emergency Departments. Funny that.

The bad.

ePCR systems. This is not nearly as much about the technology as the way it is applied. It can be a great tool for documentation, but because all of the states and the federal government have decided that collecting data is more important than writing a clinically accurate report, we have a nationwide situation of “GIGO”. That is, Garbage In, Garbage Out”. I’ve seen many EMS reports where the author filled in every mandatory field, yet there is not one bit of clinically useful information in the entire report. Just as some EMS educational programs “teach to the test”, lots of EMS providers seem to “Enter data until the buttons turn green.”, even if there is no really useful data there. If I were the King of EMS, I’d ban both NEMSIS, and the various state versions. Those strike me as being sort of like a dog chasing a car. Once they catch it, they don’t know what to do other than pee on the hubcaps.

Paramedics. Many areas have too many of them. Because of that, there is a lot of unnecessary ALS being performed. Or maybe committed is a better term. Not every patient needs an IV, but some systems operate that way. Not every patient needs their blood glucose checked, but again and again, I see that done no matter what the complaint (if any). Not every patient needs a 12 lead EKG, but it seems that younger paramedics can’t differentiate between a rhythm strip and a 12 lead EKG. Or at least the different circumstances under which they are indicated. I also see a curious lack of, well, curiosity. A patient in Atrial Fibrillation, yet there is no notation whether this is new, long standing, or a change in pattern. Which could change the course of treatment for a patient. A long list of medications, but the Past Medical History says “Patient Denies PMH”. Really? The patient takes twenty different prescribed medications, but has no PMH? That would be a good opportunity to use your smart phone for something other than selfies or updating your Facebook status. Look up those medications and see what they are for. Then ask the patient about that. Some won’t know, but most will.

National Scope of Practice. Especially one developed by any federal agency. While anatomy and physiology don’t differ by region of the country, EMS systems do. There are hundreds of variables that effect EMS system design and operations. Location (urban, suburban, rural, middle of no where), hospital proximity, system configuration, transport times, are just a few. If you work in an urban system with several Level 1 trauma centers and teaching hospitals within 10 minutes of your location, you operate one way. If you are in a rural area of a county with a hospital that has 15 beds over an hour away, you’re going to have to take a different approach.

Pay, benefits, recognition. It’s funny how little that has changed in most area.  I saw a Facebook post the other day where it was pointed out that a local fast food chain was paying the same hourly rate as BLS providers in the area make to start. That’s pretty sad, but part of that is because in a lot of areas there is staunch resistance to increasing educational requirements for EMTs. If you can churn out 1,000 new EMTs in your area every three months, the market is going to be glutted and salaries are going to be depressed. Some systems consider their personnel to be as disposable as a 4×3. That is a bit less so for ALS providers, but it’s still a factor.

Which is why I find the calls for paramedics to have to have a college degree a joke. The logic, which is flawed, is that like nurses once we have paramedics with college degrees wages will have to rise. The problem is that in most areas nurses are one thing that EMS providers are not. Organized. For whatever reason, the vast majority of EMS providers think that belonging to a union or association is a bad thing and “undermines the profession.” Of course EMS is not a profession. It’s not even a trade. It’s a skill set in most areas. In the areas where that skill set is  part of another profession, such as fire fighting, wages, benefits, working conditions, are much better in most areas where it’s not. There are a few exceptions, but those generally also municipal or county based operations.

There is little sense in spending a couple or more years and several thousand dollars to get a degree when you are still going to make $30,000.00 a year.

Expectations.  It seems like EMS is everyone’s service of last resort. Cops call when they don’t want to deal with a person for whatever reason. Annoying homeless person? Call EMS for an “evaluation.” Prisoner is being a pain in the ass? Call EMS for a “psych evaluation.” Homeless shelters call when they don’t want to deal with a “client.” Nursing homes call when they don’t want to deal with a patient or the patient’s doctor won’t make a decision. Schools call when one of their “youts” is misbehaving. HOSPITALS call when anyone gets sick in a non clinical area, instead of having in hospital response times. No matter what the problem is, if you don’t want to deal with is, call EMS. They’ll come and remove your problem.

It’s our own fault, of course. Since the 1980s, EMS as an entity has been telling people “If you’re in doubt, call us, we’ll decide if it’s an emergency.” We succeeded all to well, because like that girl that was a “Good Sport” back in high school, we just can’t say no.

There’s my take on EMS in the 21st Century. What’s yours?