Another Case of Let's Fire the Paramedics

A recent editorial opinion piece in The Denver Post caught my eye. It was written by State Senator John Morse, a former paramedic who worked for Denver General (now called Denver Health). Senator Morse writes in response to the recent criticism centering on the response times of ambulances in the Denver EMS system.

The Denver Health Paramedic Division (Denver Paramedics) is a division of Denver Health and Hospital Authority and provides all 911 services in the City and County of Denver. According to its website, Denver Paramedics operates 14 advanced life support (ALS) ambulances and six basic life support (BLS) ambulances at peak times for some 80,000 calls a year. You can easily call it a busy system where the medics run back-to-back calls with little rest.

Denver Paramedics came to the attention of media recently when Denver Auditor Dennis Gallagher sent out an alert that ambulances were not in compliance with the response-time standards of National Fire Protection Association (NFPA) 1710, which the city adopted in its building and fire code. Apparently, one way of measuring response times was to start the clock when an ambulance was given an assignment, not when a call came in. And, apparently, it was sometimes necessary to hold calls because no ambulances were available. In the Post article, paramedics reported statistics for one month showing they failed to meet response-time standards in nearly 25% of calls involving cardiac arrest or severe trauma.

Senator Morse, in his opinion piece, reminisces about his days as a paramedic and his response to a call involving a gentleman in a woodworking business who became caught in the thigh by an errant piece of wood that lacerated his femoral vein. He wrote his family a final goodbye in his own blood because he felt he was going to die.

Morse and a partner arrived in 17 minutes and spent four minutes on the scene. The medics cut off the victim's pants, put pressure on the wound and started a pair of large-bore IVs. The man's blood pressure was less than 60 systolic. As they raced to the hospital, two more IVs were started into both sides of the man's neck and they prepared to do CPR while a firefighter continued to hold pressure on the wound to keep it from bleeding. Four IVs were now pouring fluid into the patient. The ambulance arrived at the emergency room in 19 minutes. The man was given blood and his laceration was repaired. He left the hospital a few days later.

Morse's opinion piece makes the case that when your circulatory system is collapsing, you need a paramedic who has started lots of IVs. He argues that if you add more ambulances to decrease response time, you decrease quality. Skill levels deteriorate when paramedics do not run enough calls, he contends; if they do not run enough calls, they are not starting enough IVs, not intubating enough and not reading enough EKGs to stay proficient, he writes. Bottom line - fewer paramedics and ambulances are a good thing, he says.

If this is true, then we should start downsizing the U.S. military and just have a small effective fighting force. Too big of an army and we lose quality. After all, with too many soldiers, the U.S. would not have an efficient fighting force.

Of course, this is ludicrous. If EMS response times do not matter, then why are there successes with getting STEMI (ST segment elevation myocardial infarction) patients into a catheterization lab in less than 90 minutes from the onset of symptoms? Door-to-balloon time is a significant determinant in whether heart damage occurs. New areas of helping stroke victims are now also becoming more known, if we can get them the proper treatment within the onset of symptoms.

Putting that aside, there is the whole issue of customer service. Forget anything else regarding the science of the effectiveness of response times. When citizens call 911, they expect someone to show up at the door in a reasonably short period.

Response times are important. But having enough firefighters, paramedics and EMTs to provide good response times is also important. Having "too many" firefighters, paramedics and EMTs does not dilute their proficiency or quality of care.

Let's look again at my military analogy. The armed forces continually train for when war is needed. The same applies to the members of an emergency medical service. What is required is a first-class quality-improvement program that identifies those paramedics who are not starting enough IVs, not intubating enough and not reading enough EKGs. Second, we need good training programs to keep them proficient.

When enough firefighters, paramedics and EMTs are available in the system, and there is a good quality-improvement program with training, what is achievable is excellent response times and outstanding quality care. When all of these components are in place, the patient is the ultimate winner.

GARY LUDWIG, MS, EMT-P, a Firehouse® contributing editor, is a deputy fire chief with the Memphis, TN, Fire Department. He has 30 years of fire-rescue service experience. Ludwig is chairman of the EMS Section for the International Association of Fire Chiefs (IAFC), has a master's degree in business and management, and is a licensed paramedic. He is a frequent speaker at EMS and fire conferences nationally and internationally, and can be reached through his website at www.garyludwig.com.