Sunday, February 15

Rural EMS, Response Time and Standard of Care

How much time should elapse from when you call 911 with a medical emergency and when help is on its way? To see where I am headed you need to know a little about how volunteer systems work where I live (if you are a volunteer EMS or Fire worker you may want to page down a several paragraphs to skip the background and get to the main point of this vent).

Most emergency medical services around my area are run by volunteers. Down at the station house is a “board” where people sign up for shifts. If you are “on the board”, you are expected to respond to every call that happens on your shift. You do not have to be at the station, you just have to make it down within a fixed amount of time from when a call comes in.

When there is a call the flow of information goes something like this:

Person with or witnessing an emergency calls 911.

911 dispatcher determines nature of call (police, fire, medical or some combination).

If the emergency is medical or fire the dispatcher obtains basic information and then makes a preliminary warning announcement over a radio frequency monitored by the volunteers. The volunteers have “pagers” that can be set to constantly “monitor” (play out loud) this radio frequency (in which case they would hear the following) or set to only alert the user if their particular squad is needed (in which case the would not hear the following). The initial announcement sounds something like: “Blank ambulance monitors, you have a call for a 70 year old male with chest pains at 5555 Main Street, the Jones residence”.

The dispatcher then plays a series of “tones” (a unique combination for each corps). Every volunteer ambulance and fire group has pagers that “listen” for their particular tones. When the pager detects the tone combination it is programmed for it beeps and, if it was set for alert only, becomes active (starts to play subsequent announcements). The dispatcher then re-announces the call, usually with more information: “Blank ambulance monitors, you have a call for a 70 year old male with chest pains at 5555 Main Street, the Jones residence. Bystanders report patient is unresponsive and not breathing”.

Right before the call, spread all over town, the people on the board were working, eating, playing with their kids, in the bathroom, sleeping, etc. Between the onset of the initial announcement and the end of the official call coming after the tones, these individuals will be in their personal vehicles trying to safely but quickly make it to the station. Many of us have flashing lights (in my state green for EMS and blue for fire) that are supposed to make this trip easier and safer for everyone. The fact of the matter is that the lights are “warning” lights only and (again, in my state) the public has no legal obligation to yield to a volunteer responding to a call, and the volunteer has the legal obligation to obey all traffic laws (we are not supposed to speed, run stop signs, etc).

One of the first people to arrive at the station, even if he or she is not a driver, will open the garage bay, start the ambulance, pull it out, and close the door. This person will also check the board to see if there is a full crew listed (there are “gaps” in the board – demand outstrips supply). Unlike most professional EMS systems, we have people who are pure drivers as this lets people who do not want to be directly involved with patient care (for whatever reason) contribute and allows the medical personnel we have to be spread across more shifts. When the ambulance is outside and running with the garage door closed, the person can respond (acknowledge the call) to the dispatcher. Without this response the dispatcher will keep sending out alerts until an acknowledgement is made or the decision is reached to send another ambulance (“mutual aid”). The timing of this is very important. If the call is acknowledged before a full crew is on its way to the station, someone who missed the first call (because the radio didn’t pick it up, or a lawnmower muffled the noise, etc.) may have no way of knowing they are needed and people are waiting on them. On the other hand, people besides those who are on the board monitor the radio and listen attentively for the acknowledgement. This is because we all understand that the board may not have had a full crew, and additionally things can and do happen that make it impossible for someone to respond. If enough time goes by, people who were not on the board try to get down to the station so the call can be served. Thus if you acknowledge too soon you risk not having a full crew and if you acknowledge too late you risk having 15 people stop what they were doing and drive quickly to the station thinking things are desperate. Since we have two ambulances and only one crew on call, any call requiring two rigs, or a second call while the first is being served, means people who were not on call have to show up. Combined, the above results in lots of ears on monitors, even those who are not officially on call.

When the full crew is there, 911 control is told the rig (ambulance) is “out of service” meaning they are on their way to the scene.

Thanks to the help of the college students, our corps almost always can get two rigs out when needed. We are lucky in this regard and every summer or break (when the students are gone) reminds us how much we depend upon student support. Other local corps are not so lucky and do miss calls or take too long to get out.

So, how long is too long? One night my wife was monitoring the scanner (I was out) and heard a call from outside our district that took too long by anyone’s measure. The alert came for a 20 year-old with a suspected overdose and depressed breathing. The call was acknowledged within a few minutes. Then nothing. For many, many minutes, nothing. Since the call was acknowledged the dispatcher, who has a lot of things to do, is on to other business. More minutes pass without the crew calling “out of service”. Someone from the crew in question then radios control and asks them to re-page for a driver. This is not good. Hard to know if there was no driver on the board and the crew did not notice this at first or if the driver on the board did not show. More time. Crew in question radios control and asks them to send another corps out on “mutual aid” as it is clear they are not getting out.

My wife guessed the above took 15 minutes. Note that the other ambulance needed to be toned out in the same fashion, starting the whole process over again. In addition, since the call is now being handled by someone from outside the district the transit time would be longer.

The above is not good and is rare around these parts, but it happens. Is this acceptable? What is the alternative?

The EMT text we are using in my class has a spiel about “equal access” to EMS for the entire U.S. The argument is that all U.S. citizens should have emergency medical service and that where you live or how much money you have shouldn’t influence your care. Of course states implement their EMS and EMS costs money. When considering response time and standard of care we are a long way from equality. Rural EMS is not going to be the same as suburban EMS. In the ideal world your driver, or soon-to-be (I hope!) EMT, would not be a volunteer 38 year-old college professor working 45 to 65 hours a week at his day job with a wife, kids and other distractions. There is no way I’ll EVER be as good a driver or EMT as the pros, if not for any other reason than call volume. My agency handles, at most, 500 calls a year. Many people take “just” one 6 hour shift a week. While this is 6 more hours of community service than many members of society put in each week, it clearly won’t give you a lot of experience driving or providing patient care (on average you’ll get about one call every three weeks if you take one shift a week).

Volunteer systems provide EMS and fire coverage where people will not or cannot pay for it. The alternatives, as far as I can tell, involve trying to make the current system the best it can be, paying higher taxes or having even higher health care costs. The family of that overdose may well wish they had paid a little extra in their taxes or health care premiums over the last 20 years so that they could have had an ALS ambulance at their door in a reasonable amount of time. Their daughter’s life was likely worth it to them. It clearly isn’t worth it to most of us or I would be looking for another way to try and give something back to my community.

As a society we make tradeoffs between costs and benefits. Obviously it would be a mistake for each of us to have our own trauma doc following us around “just in case” (besides, this would result in some sort of infinite recursive function where each doc needs a doc following them around, etc.). Standard of care issues are real tradeoffs with costs and benefits I am not used to thinking about. I do not know the answer. I do know it is like a reverse lottery. You decide NOT to pay and you run the chance of “winning” a delayed BLS response instead of a timely ALS response. Every once in a while the outcome will be radically different in the two systems and those of us in the know will realize these types of outcomes are the result of decisions made based on money. That is a cost society is willing to pay but it has to be hard to swallow if the currency is your child.