I hate when this happens.
I recently had two separate conversations with people that made me think some of my opinions may be in conflict with each other. In fact, the outcome of these conversations made me realize that I may be a tad bit of a hypocrite when it comes to some of my long held beliefs. I hate when that happens. While I freely admit I will happily change any of my opinions in response to new and/or better information, I can’t seem to change my opinion on either one of these beliefs and it’s making me feel… well… like a hypocrite.
Let’s see if you can help me out.
Opinion #1: Modern EMS exists to bring care to the patient.
That’s an important sentence up there if you didn’t realize, because it represents two monumentally different schools of thought. I believe that the primary purpose of modern EMS is to bring care to the patient, not the other way around. That statement may not sound like much, but it is hugely important for the development of our profession. In the very beginning of what evolved to be EMS, back even before the Cadillac ambulances and hearses, EMS existed to bring the patient to care. Everything was based upon that fact. From the “Flying Ambulances” invented by Napoleon’s surgeons to bring injured soldiers to the surgeons away from the battlefield to the ambulances used in the US in the 60s and 70s, most everything that existed before the advent of paramedics and EMTs existed for the purpose of bringing the patient to the care that could only be provided for them in a hospital. That’s why the Cadillac ambulances had those big engines that could drive so fast and the qualifications for being an “Ambulance Attendant” involved mostly being able to burn exceptional amounts of rubber without killing the majority of the motoring public.
The conversation that brought this up was one I had recently with a Wisconsin EMT-IV Tech (think: NREMT-I 85 level) about a community of 15,000 people nearby that I think should upgrade their EMS to the paramedic level. Their ambulance service is operated by their local fire department and runs an excess 1000 calls for service per year. They have a fairly large state college in their jurisdiction that pumps up their population during the school year and increases the diversity of their response area. I believe that they should upgrade to provide their citizens better care. She believes differently. Her thoughts were that even though there is no hospital in the town, they have three within the area that they transport to. The closest is 10 miles away from their city limits in another town and the other two are both +/- 20miles away. She believes that they don’t need to offer their citizens paramedic service because they’re so close to the hospital. (This is Wisconsin, 20 miles is a run to the corner store ‘round these parts)
I trotted out my old standby, the one I wrote about above that says that EMS is about bringing care to the patient. I explained the two schools of thought and stated that they would be saving more lives and caring for their patients better by offering paramedic care immediately at the patient’s side, rather than withholding advanced care until they had driven a minimum of ten miles. While they provide good service at their current level, I believe that paramedic ambulances in our area bring with them the majority of the care a patient would receive in an emergency room for the first hour or so of their care sans most of the lab work and x-rays. Why wait to stabilize any patient’s condition? Why let someone deteriorate when there are tools out there that can help them?
She seemed to agree with me after I explained it using the “Bring to care Vs. Care brought out” analogy and I, for lack of a better term thought that I had “won” the conversation. (I like winning things) The next week, however, I had a conversation that completely challenged my original argument and made me resort to saying “Because I like it that way” when being asked my opinion about something somewhat similar.
Opinion #2: The US model of EMS is better than the French model.
There are a few competing models of EMS in the world, but two of the starkest contrasts are the French Model of EMS and the US model. In a nutshell, the US model employs paramedics and EMTs who provide limited stabilizing care on site and remove the patient to an emergency room to be attended to by a physician for definitive treatment. The French model relies on physician triage of emergency calls and then sends either a physician to the scene or an “ambulance” with the basic capabilities of a taxi. It’s more complicated than that, and you can read more on the French system on this well-written Wikipedia entry: Emergency Medical Services in France
My thoughts are that the French Model provides too in-depth of care on scene of an incident for severe complaints. For example, while most US paramedics can diagnose and begin treatment on most STEMIs (severe heart attacks) immediately and have the patient undergoing a cardiac cath by a cardiologist in under 30-40 minutes, I challenge the French system to do similarly. I believe that putting physicians on the ambulance limits the availability of EMS care and causes rationing due to the immense costs of having a physician attend to the patient. I also think that the economy lies in having a physician present in the ER where they have the best availability of their necessary tools and the ability to treat many patients at once. However in truth, most my belief comes from little personal experience and more from media reports of incidents like the death of Princess Diana where the doctors sat on scene for two hours trying to treat her injuries rather than bringing her to a hospital with full capabilities.
The conversation I had that made me question this is one I had about a local helicopter ambulance service that provides either a physician/nurse or physician/physician flight crew. I remarked that I didn’t know how an on-scene interface with a physician would be and that I would be worried that they would over-treat a patient that needed to be swiftly removed to a trauma center instead. Of course, I’ve never seen nor heard of an experience like that with this service, I just was airing my biases. That fact was swiftly, and correctly, pointed out to me and I resorted to the shallow argument that I simply thought that EMS was “Our place” and that other professions needed to butt out…
And I was wrong, and admitted that I was. Then we all laughed heartily.
My potential hypocrisy lies in the fact that I want to support the neighboring community to pursue the paramedic level for their service but cannot seem to extend the same argument to support physician/physician crews on the helicopter. Isn’t it the same argument?
In addition… why don’t I support the French model of providing EMS over the US model for the exact same reason? Aren’t I the guy who thinks it’s time for Primary Care Paramedics in the US?
I’d like you to poke holes in all my arguments and call me out in the comments section, but before you do that, in my pre-defense I like parts of the French system and want to adopt them here. I like that they provide physician-level triage for 911 (or 112) calls and send out appropriate resources, provide instructions for self-care, and/or direct people to primary care by alternate transport. I like that they can treat-and-release on scene for appropriate complaints. I think that they have a lot aspects of their service I like, the same things I like about the British EMS model that are provided by paramedics. I also think that Paramedics are the experts in field care. We exist for the purposes of being the masters of the acute, the experts in the expedient, and the… somethings of the… people who need immediate stabilizing care. (Hey, you try thinking up a third thing). I like the US model because I think that it provides appropriately advanced care and proper specialized focus of training while allowing for cost-effective deployment, availability, and access across the broad spectrum.
But nobody’s perfect.