Hypocritically Speaking – My opinions about EMS models and philosophies

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.

Your thoughts?

  • The short version of my thoughts: it’s about triage.
    There are times when it’s most important to begin ALS treatment on scene, times when it’s most important to transport, and times when it’s important to do both- and provide ALS treatment while rapidly transporting.
    I don’t think you’re being hypocritical.
    Besides being about triage, it’s about training, and it’s about tools.
    I’m out in the middle of nowhere, where it seems that in some ways time stands still. A lot of the older people out here believe the ambulance is just a taxi with flashing lights, and will insist they “don’t need it.” Aunt Mabel will drive them just fine. I’ve explained to more than one person that the ambulance is like bringing the emergency room to them, that the medics can start treatment right now, rather than waiting until they drive to the hospital and wait there for what could end up being a long time before seeing a doctor.
    The other big difference is that with our small hospital, sometimes, the care provided in the back of an ambulance is better than the hospital. I’m not knocking the hospital, it’s not a bad place, but they don’t get a lot of true emergencies. It’s not a trauma center.
    I think the best thing that could happen to EMS is to look at the entire system and make it fit together better. Play to the strengths of each part.
    Or, as the song says, you’ve got to know when to hold ’em, know when to fold ’em, know when to walk away and know when to run.

  • Steve Rowland

    I think you’re right about different systems and I don’t think you are being hypocritical about picking the best parts of different systems and seeing them incorporated into one successful system.
    The problem is the “us against them” attitude, or rather “ours against theirs”. EMS and the medical community need to realize that we (EMS) can make a positive impact on the number of people being seen at the local ER and the wait times MAY be decreased if we work together.
    It may take a system where MD’s either show up at scenes and dispense medications, arrange for visits from other medical practioners, or have the patient moved to an urgent care centre or their own doctor’s office for an appropriate follow-up. Could EMS do this without the MD’s? Probably. But it will take a  lot of public education as well the cooperation of the other health disciplines to make it work. Should we try it?
    Why not. The system is broken as it stands and EMS make be one way to improve it.
    That’s my 2 cents worth.

  • Bmac161

    I know how you feel.  I support tiered ALS/BLS systems for several reasons, not the least of which are ALS skills maintenance vs over-saturation in all-ALS systems, and that some of the best cardiac arrest survival rates come from such systems.

    But I also think that most BLS providers, given the amount of training they receive vs what is left out of their education, have no business decided what is and what is not an ALS patient- a key necessity for tiered systems.  I’ve had a rash of patients over the last year, including 2 STEMIs, that I think I would have under-triaged as a BLS provider, and that only with my ALS training and experience was I able to appreciate their true condition and treat them appropriately.

    Hence, I feel like a hypocrite every time I advocate for BLS/ALS systems. 

  • Paulemorris Cma Rma

    Could someone please find this Medical Assistant-EDTech of Twenty Seven plus Years / EMT / EMS Evaluator a Paramedic School that does NOT require 1500 documented EMT calls/ patient contacts to get in? I have everything else already done. I am prepping to sit for the NREMT written. Also have previously been AHA ACLS / PALS certified. The Chuch I belong to wants to sponsor me financially.

    Any help out there?

  • Greg

    I am currently on the dividing line between the EMS and physician communities (active EMT for 7 years and finishing up my 3rd year of medical school). Interestingly, this past year has made me question the way I approached a number of patients over the past 7 years while working on the ambulance. Did the young athletic patient who had a syncopal event that I didn’t advise against refusing really have a deadly cardiomyopathy? Did the patient with chest pain who had a normal EKG who we told was not having a heart attack really have unstable angina or an NSTEMI and end up in the ICU? I bring these scenarios up because of the advocation of treat and release by paramedics in this article. Although not the main concept, I felt that in the end this is possibly what the author was advocating. Paramedics receive approximately 1 year of training but yet have a scope of practice rivaled by few in the medcal arena. The safety mechanism which I believe allows this is that most patients will end up under hospital care in a short period of time and that paramedics must follow rigid protocols. Diagnosis and determination of whether someone is acutely ill is not something that can be done without a thorough understanding of the pathophysiology of all diseases within the differential diagnosis. Even with this understanding many times a determination cannot but made without the use of advanced testing available only in the hospital setting. Am I saying that the concept of a primary care paramedic is completely flawed? No I don’t believe so. However I feel there role should more closely mirror that of nurse care managers in PCP offices who focus on prevention and follow up rather than on triage of emergencies.

    • Too Old To Work

       Well said, Greg. The few studies done have pretty much all shown that paramedics are poor at deciding who needs to go to the hospital and who doesn’t. One of my former medical directors never worried much about an ALS crew sending a patient in via BLS because the patient was still going to end up in the hospital. He was far more worried about residents sending patients home where there was no medical care to be had.

      Primary care paramedic bumps right up against the scope of practice of visiting nurses. If there is a need for that type of service, it more appropriately belongs to NP and PAs, not paramedics.

  • Layne Bradford

    My first thought is that hypocracy is less an issue than understanding the various methods of service. Ambulance service providers still need to transport in order to receive funding. The question of funding should come along side the level of service desired. There are parts of America where an advanced first aid card and a drivers license are all that a volunteer service can afford.

  • I think we’re splitting hairs here. If you look at what paramedics in the US were allowed to do 30 years ago it was rather limited, especially if you took away base contact. In some areas of the country a paramedics scope now far outclasses what RN’s can do. We’ve come a long ways. I think that we will continue to advance in our scope of practice as evidence based medicine keeps proving that we’re doing good and it fulfills a need. Let’s look at “their” system and take what works well and improve ours.

    I’d be curious to see some hard statistics on our system vs theirs. You know, survival rates for STEMI’s, strokes, full arrests, trauma’s etc. I think that would be a great place to start the comparison. Once a difference is noted, figure out why. Who knows, the EMS differences may have nothing to do with any possible change in outcomes. There’s a lot of variables.

  • Tpoole1

    I agree in the fact the cost and over treatment of a physician in a field would be a huge detriment. As you said, the physician would be apt to over treat in the field instead of transporting to definitive care as would a paramedic.  To many times doctors have the god syndrome, “I am a doctor I will save you.”  Paramedic who have had more 3 years experience typically do not have the mentality.  I say you are not a hypocrite, you just have a bias opinion based on experience and all available input.  

  • Dslashdranchservice

    I believe triage is very important. Probably as important is the availability of training and support for a higher level of care in areas that could really benefit from a higher level of care. In an area of Idaho that I regularly work in there is one hospital that serves 2 1/2 counties and receives ground transports from up to 60 miles away in one direction. This hospital would double in size and staffing by moving into the neighboring veterinarians 10 stall horse barn. These counties total approximately 6000 total human population between them. These areas are serviced by 3 ambulances operated by 3 different volunteer fire departments. These departments require a first responder (primarily to drive) a basic and an intermediate to respond to calls. These departments provide free training to first responders and EMT basics and depending on weather and training schedule can take up to a year to complete each. Intermediates pay for their own training at one of the colleges up to 100 miles away. Their training depends on the availability of internship hours and contacts and can take 2 years to complete. In a rural ranching community it’s difficult for a person to justify that kind of expense in time and money. Upgrading to paramedic service would be an even bigger burden considering the average wage in the area is $8.00 an hour. Keep in mind also most paramedics are seen only in the big city fire departments and air ambulances. Also keep in mind that average initial response times can be up to an hour depending on if the required personnel are working in an area that their pagers will actually work. One example was when I severely cut my hand with a skill saw on a job site 4 miles out of town. 45 minute wait for the ambulance, 40 minute ride to the hospital, 20 minute wait for the on call doc to come from home. I was really glad I wore a belt that day and that EMT training kicked in before shock did and that there was good flying weather from the local hospital to the big hospital 90 miles away.

  • Two14gwo

     First off, great article. I found it honest and refreshing. I could go on blowing sunshine, but that’s not what you asked for. So I will get on with the constructive criticism I think you’re after. The fear of being a hypocrite or confused in our opinions of EMS, is something we share my friend. The subject is so unique from system to system, I just think blanket statements fall short as far as relevance, from system to system. So when you talk to Mr rural emt dude, he may be totally on board with the pearls of wisdom you lay on him. Try sharing with medic big city and he falls out of his chair laughing. This isn’t the case all the time, some blanket statements like “EMTs shouldn’t hurt patients.” vary well be universally excepted by your audience. If not someone should be urinating in a cup. So should medics be the standard of care in a system? Maybe. Should 911 triage be run by a DR? Perhaps. Are you picking up what I’m laying down? It depends on the system. I started ems in a very conservative medic based system. ALS was the standard and everyone was a medic it seamed. It wasn’t long until I asked why. When you are on scene and you flip a coin or play rock paper scissors to decide which er to drop your bls patient off at, it may be time to reevaluate the necessity of making every ambulance and fire engine in your city als. There were times I would go a whole shift running nothing but bls jobs. Without driving more than ten minutes to the er of my choice. It was so severe, I started getting sick of patients if I had to be with them for more than 15 minutes! Fast forward a few years, and I found myself on the other side of the country in a bls based system in an even bigger city. For every 5 ambulances, 1 was als. Als units ran life threats, chest pains, alt loc, backed up bls units. In a year I could count the times I ran with fire on one hand, half of those times were fires. Bls units ran jobs like; gsw, ped struck, mild med aids, oh and all als jobs als was unavailable for. At first I was terrified to be on a bls unit, “what if we get a sick patient?” then I realized if we did we took em to the er around the corner. Problem solved. I know I’m over simplifying things and anyone can “what if” my stories to death, and that’s ok. Life is full of what ifs, and the best ems system will never be able to account for all of them. I guess we do our best for the most. That’s all we can do. Oh I humbly feel the word hypocrite is over and miss used way to much these days. In general I think people use it to label people they disagree with. So next time someone calls you one, ask em to use it in a sentence.

  • Tj

    #preventionparamedic !

  • Chris, 

  • Pingback: Reply to the Kaiser | Rescue Monkey()

  • Too Old To Work

    A couple of thoughts about French EMS.

    First what is the liability situation for physician triage over there? Over here, you are rarely going to get a doctor to tell you NOT to come in for a look see. There is really only so much that can be done on the phone.

    Second, for those who think it’s a great idea to have doctors on the ambulances, I’d suggest you ask the Princess of Wales how that worked out for her. Oh, you can’t because a physician on an ambulance farted around long enough for her to bleed out from a survivable injury. If she had been transported to something like a Level 1 trauma center, she likely would have survived. 

  • Ex_navy_nuke

    I wonder if in France they have as much nonsense calls for service given differences in healthcare and culture.  I have noticed cultural differences in using ‘911’ within different area in which I work.  Some use it every time they get emotional or have a stubbed toe, others use it as a last resort.

    In the end, a lot of it comes down to cost – benefit analysis.  What is the best use of resources?  Is putting doctors on the street to respond to BLS/ALS calls worthwhile given the cost and shortage of doctors?  What can they do in the field that well trained medics cannot do?  I think the system needs some improvements, but I don’t think doctors on the street is necessarily appropriate in most parts of the U.S.

  • MSG

    I would like to give my two cents, although I am not a paramedic and not American. I am Brazilian, and I am a physician. However, I am very interested in the development of the EMS models and how they could be applied to my own country. I currently live in the US, so I think I have witnessed a little of the American model in order to be able to evaluate it. I would like to give an outsider’s opinion on the matter.

    I think that the American model is very good and cost-effective. In bringing a middle-level healthcare provider to the scene is one of the most effective inventions in EMS care ever made. However, I think the concept of “bringing the care to the patient” is a little bit far-fetched. By using an EMS crew you can bring a little bit of the ER to the scene, but not the whole thing. You cannot bring the whole care to the scene without bringing all the equipment, labs and, of course, doctors. If you really believe that EMS is about bringing care to the patient, then you need to send doctors, as the French do. If you want to send paramedics, then you should assume that you are bringing a little care, just enough to make it possible for the patient to arrive alive at the ER.

    In my opinion, all “treat-or-discharge” decisions should be made by doctors. Nobody should evaluate a patient on the scene and “discharge” him/her, I think this is potentially dangerous. So, in my view, you may have two different systems:

    1. Physicians ride the ambulance and treat/discharge their patients on the scene. It is more expensive to have a physician riding, but you save costs by not bringing everybody to the hospital.

    2. Paramedics ride the ambulance and everybody is brought to the hospital, no matter what. Paramedics provide initial treatment, but do not have the power to discharge anybody. Once called and there, the patient goes to the hospital. This system saves money by not needing a physician on the scene, but on the other hand costs more by bringing everybody to the hospital.

    This is what makes sense for me, at least. I hope this helps!

  • nick

    Here are my 2 cents. I see why you advocate a Primary Care Paramedic program.. to remedy ER overcrowding among other things. I think that it would be costly to administer something like this. Lets be honest, there are alot of paramedics out there that shouldn’t be allowed to do half the stuff theyre allowed to do now. It would take LoTS of money to properly train a medic to do this. It would also take immense coordination and money to institute an EMR system for this as well. You think drug seekers are bad in the ER, just wait till you are allowed to deliver the drugs to them. Then they call another competing service out for the same thing and hkw would they know you just left there a few hours ago after “treating” them. As for triage, being an 8yr dispatcher, I would say (selfishly) that Docs belong in a clinical setting, not a 911 center. I think if we train all dispatchers as EMD’s and when I say that, I dont mean a 3 day class… I mean come up with an EMT like program taylored to provide first responder services via phone, we would be fine. I personally have had a couple of code saves via phone among many other things. I am also a huge supporter of a tiered response system using system status management and response protocols with a mix of bls/als/semv’s to get the job done efficently while being more cost effective. Thats just me though…