USA Today Series Mostly Misses the Mark
Judging by the number of e-mails I received after the series was published, it is obvious that there are more opinions on this subject than there are candidates in the California governor’s race.
The senders of many of the e-mails asked me what I thought of the series. Here is what I think.
I certainly think the authors did extensive research into different EMS systems and how they work. Some points within the articles were correct, but others were stretched or misrepresented to an audience of readers who for the most part have no EMS background. The articles relied mainly on data provided or in some cases not tracked by EMS systems.
The authors missed the mark in many ways, in my opinion. The United States has the finest emergency medical service and trauma system in the world. Thousands of professional EMTs, paramedics, firefighters, first responders and flight nurses put their lives on the line every day. But if you are not in the profession, after reading the articles, you would walk away thinking the system is broken and in urgent need of repair.
The series focused on only one type of call, sudden cardiac arrest, and did not focus on the hundreds of thousands of other calls that through quick intervention, advanced technology, and sophisticated EMT and paramedic training prevent people from getting to the point of suffering a cardiac arrest.
I believe a snapshot of 50 most populous cities is not a true reflection of how EMS works in this country. Most of the EMS systems in this country are communities with less than 50,000 population and transporting fewer than 5,000 patients a year. Essentially, what USA Today would have you believe is only a small slice of the pie.
Over the past 30 years, most cities were still contending with the fire problem. In these same cities, EMS – which also really only came about over the last 30 years – had to grow, develop and compete with suppression issues because of the fire problems that most cities were still experiencing. At the same time, many older cities saw the middle class move out to suburbs, leaving less tax money for fire departments to deal not only with the fire problem, but to develop emergency medical systems.
In contrast, as suburban communities grew, so did their fire departments. And as their fire departments grew, so did EMS, since it was also a growing profession and a service to the community. Many of these growing fire departments in suburbia did not have a true fire problem as did their counterparts in the older cities because of the newer construction and tougher building codes. Essentially, as suburban fire departments grew, so did their EMS systems – EMS was most of their focus since they did not have a fire problem.
The articles also compared one city against another with their ability to save a cardiac arrest victim. One city claimed a 40% cardiac arrest save rate! Forgive me for being skeptical, but small communities with less than two square miles that also have an advanced life support (ALS) engine company and an ALS ambulance with less than a three-minute response time do not have even have a 40% save rate. To me, a save from cardiac arrest is a person who walks out of the hospital, neurologically intact after suffering a cardiac arrest.
What this points out is merely that EMS in the United States has not created a standardized definition of what is a save on a cardiac arrest and further what is a response time.
EMS systems measure their response times in different fashions. Some EMS systems measure response times from when the engine or ambulance starts rolling until they stop at the curb. Other systems measure response times from when the telephone in the 911 center starts ringing until the first apparatus pulls up next to the curb. Other EMS systems take it a step further and measure the response time from the curb to the patient’s side. This type of response time measurement would be useful in cities like New York and Chicago where anywhere from five to 10 minutes can be added to a response time because of the vertical response in a high-rise structure.
Even if all systems measure response times with the same definition, there are different ways of defining response times. Some look at each individual response time, while others average the median response time and still others use fractals for measurement.
When you look at cardiac arrest save rates, EMS systems measure them in different ways. Some systems say a cardiac arrest is a save if they get any type of perfusing rhythm on the patient. Other systems call a cardiac arrest a save if the patient is resuscitated and admitted to a hospital. Finally, other EMS systems classify a cardiac arrest a save if the patient walks out of the hospital neurologically intact.
Unless EMS systems can agree on a response time definition, how it should be measured and how to define a save from a cardiac arrest, we will never have a clear understanding of how effective our EMS systems are.
Where the authors of the USA Today articles really missed the mark is the delivery of emergency medical service as a local issue. What might work in one city in Florida might not necessarily work in a city in California. One city may choose to run its EMS system totally under the fire department while another city may choose to run an EMS system by having a fire department do first response and a third-service model do transport.
Ironically, the USA Today articles criticized some of the most populous EMS systems for poor cardiac arrest save rates at a time when most are struggling with budget reductions. How are you supposed to deliver better response times and care when your budget is getting cut?
Delivering proper and efficient emergency medical service care in a cardiac arrest is not only coming up with standard definitions for response times, measurements and defining what a cardiac arrest save is, It also means creating public-access defibrillation programs and providing well-trained personnel and timely first responder and transport vehicles.
Gary Ludwig, MS, EMT-P, a Firehouse® contributing editor, is the chief of Special Operations for Jefferson County, MO. He retired in 2001 as the chief paramedic for the St. Louis Fire Department after serving the City of St. Louis for 25 years. He is also vice chairman of the EMS Section of the International Association of Fire Chiefs (IAFC). He is a frequent speaker at EMS and fire conferences nationally and internationally, and is on the faculty of three colleges. Ludwig has a master's degree in management and business and a bachelor's degree in business administration, and is a licensed paramedic. He also operates The Ludwig Group, a professional consulting firm. He can be reached at 636 789-5660 or via www.garyludwig.com.