EMS: An Alarming Situation in the Healthcare Landscape

Dave Edgar, Assistant Chief Emergency Medical Services,City of West Des Moines

Dave Edgar, Assistant Chief Emergency Medical Services,City of West Des Moines

The pandemic has been stressful on all areas of society and has especially exposed the issues within the healthcare system. There were many leaks in all that encompass the healthcare bucket before the pandemic, but now those leaks have turned into constant flows. The concern is that the bucket may not be able to stay together much longer. Conditions such as employee pay, employee retention, insurance reimbursement, working conditions, mental health and new expectations by employees have all contributed to this perfect storm.

One area of the healthcare system that is getting more attention with the pandemic is Emergency Medical Services (EMS). I recently watched a news report from a rural area where the issue was being discussed with politicians and their response was something similar to....yes, we know staffing is a problem in all healthcare. When I heard this, my thought was yes, there is no doubt staffing issues in most areas of business and healthcare shortages get more attention because the consequences of not being available. But, while I am sure there are arguments for multiple areas of healthcare to be a priority, the reality of today’s ambulance transportation system is that our failure will cause widespread impacts on all areas of healthcare.

I could write an entire article on the makeup of EMS systems and why they are taken for granted, but I will focus on the staffing issue for this article. Emergency Medical Service (EMS) gives somewhat of a false message of the work we perform as only a small portion of calls are actual emergencies. The use of ambulances falls under two main areas of service.

The first is the response to medical assistance requested through the 911 system. In larger metropolitan areas, this is set up for rapid response, usually with certain time targets for arrival at a scene. The basis of those time targets is related to time sensitive medical emergencies such as strokes, heart attacks and severe trauma. The vast majority of 911 type calls still require an immediate response but are not necessarily time sensitive. Examples of these types of cases are falls, weakness, mental health, and minor traumatic injuries.

The second type of response is related to movement of patients within the healthcare system. This encompasses most of all ambulance transports. Over the years, many services completed within a hospital are now done at clinics, outpatient surgery centers, skilled nursing, rehab facilities and other outpatient testing centers. In rural areas, certain services are no longer offered at smaller hospitals, requiring transfers to tertiary care centers some distance from the hospital. I do not want to portray that this is necessarily a bad thing, however, these changes in healthcare have caused a continued increase and need for medical treatment and transport from facility to facility by ambulance.

“Ambulance transportation has become the spokes in the wheel of healthcare or the “bucket” that allows the system to be decentralized and keep the throughput of patients ongoing.The bucket with many leaks is starting to come apart.”

If you want to offend someone in EMS, call them an “Ambulance Driver”!When is the last time you have heard of a “police car driver” or a “firetruck driver”? The provision of medical care and monitoring of patients during transport is a complex and expensive process, yet not understood by many.Paramedics have 1 to 2 years of training depending on their training institution. This is after they have completed training at the EMT level. When ambulance transportation is just looked at as a “ride” it demeans the profession and doesn’t reflect the complexity that needs to be in place for all types of patients. This all brings me to the point where we are today and the crisis of the failing EMS System and the lack of understanding of the role of ambulance transportation in the healthcare system. In short, the impact is not understood, overlooked, and taken for granted.

Ambulance transportation has become the spokes in the wheel of healthcare or the “bucket” that allows the system to be decentralized and keep the throughput of patients ongoing.The bucket with many leaks is starting to come apart. The first place we are seeing this is in the rural areas. Volunteer ambulances can no longer get volunteers, Paramedic and EMT pay in most areas equates to the pay of entry level jobs that require no education or training. The hours, stress, and mental strain of working through the pandemic are causing providers to go into other areas of healthcare or getting out of healthcare all together. Hospitals, clinics, and other non-ambulance locations are starting to employ EMTs and Paramedics because they have a needed skill set and are cheaper to employ. These are all contributing to the lack of EMTs and Paramedics working on ambulances.

A failure of the non-emergent ambulance system is already having an impact on the 911 ambulance system. In many areas the provider does both types of responses.The following is an example of how this happens.

A rural county with a 15,000-person population has one hospital for their entire county. The hospital provides a paramedic ambulance 24 hours per day for transfers from the local hospital to larger facilities. This ambulance also provides 911 response for the community it is located in. In addition, this ambulance meets with volunteer ambulance services throughout the county who have EMTs but no Paramedics when Paramedic care is required. The volunteer services have no one to volunteer, no income to support the service and eventually they stop providing ambulance service. The primary ambulance now must come from that hospital for all calls, which then takes the ambulance out of its primary response and makes them less available. Now the local hospital needs to transfer a patient to a cardiac catheterization lab at a tertiary care center that is having a heart attack. They request an ambulance come from that larger hospital 2 hours away to transfer the patient. The heart attack patient has a poor outcome because their time-sensitive condition was not treated rapidly. The hospital ambulance sent from the tertiary care center to pick up the rural patient now is not available for the transport of the patient in the intensive care unit (ICU) that was scheduled to go to a skilled nursing center. That bed was going to be used for another patient needing ICU care that is being held in the emergency department....and the domino effect just keeps going.

EMS systems are starting to fail throughout the US. We in EMS are sounding the alarm as no one wants to see patients suffer from delayed care. We are having the same issues as other areas of healthcare, but if the ambulance system fails, the entire system starts to fail. I wish there was a simple solution, but there is not. It will most certainly take money to solve the problem.... yet money alone is not the solution. We have many organizations at the local, state, and national level working on solutions, but that will take time, out of the box thinking and resources to accomplish.