When Upton Sinclair wrote The Jungle in 1906 about the meat-packing industry, the book changed the way food gets to our table and marked the start of a social movement. Sinclair was part of a group of reporters and writers called “muckrakers” who changed American life.

This year's EMS Today conference in Philadelphia offered a chance to listen to modern-day muckraker Bob Davis, the principle author of the USA Today article “Six Minutes to Live or Die.” The article was the conclusion of 18 months of research on the nation's EMS delivery. Davis very candidly stated, “There is no doubt the fire service, in my opinion, is who should provide ALS; however, they do not have the leadership, knowledge or culture to do it right.” [Ed.: Davis will present “Six Minutes to Live or Die” Aug. 13 at Fire-Rescue International in Denver.]

You can imagine the emotions that stirred among attendees, but without statistics and facts, they could not argue logically with Davis. The reaction triggered a passionate conversation and provoked serious thought about what, when and how Advanced Life Support services get to the public.

If you have used an HMO recently, you realize that health care is being rationed simply because it has become too expensive. It's only logical that this rationing of health care will trickle down to EMS. Someone will ask the question, why does this patient need ALS? Government providers may find it hard to justify sending expensive ALS resources to the 70- to 80% of the calls that require only BLS skills. This is already reflected in Medicare rates for ALS 1 and 2; Medicare reimburses for the procedures performed and not just the presence of an ALS provider.

The irrefutable point the USA Today article makes is that we don't know if EMS and paramedic-level care really makes a difference in a significant percentage of our major metropolitan areas. Fire and EMS chiefs simply don't know their statistics or at what level of efficiency their EMS systems operate.

As government budgets continue to dwindle and federal and state money gets siphoned off, expect EMS to be scrutinized. This will become a battle waged entirely on the statistics, and the fire service isn't prepared. Most EMS systems that received poor ratings did so because they didn't know their statistics. The real cost of delivering EMS is now being studied by the Government Accountability Office, which has been asked to cost out the delivery of EMS by provider type. The results undoubtedly will be skewed toward the private-ambulance industry, putting pressure on the fire service to show that we do make a difference.

A significant portion of EMS cost is generated by labor. The IAFF has argued for paramedic-level staffing and front-loading ALS, citing the need to respond to a cardiac arrest in six minutes or less and drawing parallels to the need to arrive in six minutes or less to contain a flash-over as an example of an economy of scale that makes fire-based EMS benefit both scenarios. The front-loading of EMS with ALS services has been on the increase in the last 10 years.

After years of investing in ALS resources, some of the science is starting to question whether that intervention is what really makes a difference. Current research from Canada indicates that saving a patient in cardiac arrest is really about defibrillation, an EMT skill. The greater than 60% neurologically intact cardiac-arrest rate from the Las Vegas Strip has shown that rapid defibrillation can make a tremendous difference. USA Today found that the highest cardiac-arrest survival rates were in areas with 0.2 paramedics per 1,000 populations. For every extra paramedic in the system over that ratio, the cardiac-arrest save rate declined by 0.8%.

Some argue the focus on cardiac arrest, which is often about 1% of the call volume, doesn't tell the whole story. Many point to the need for ALS to facilitate intubation of respiratory patients, yet a recent study on the San Diego system indicated poor outcomes for patients intubated in the field versus those handled by BLS methods.

Other issues with front-loaded ALS or ALS engine companies are being discussed. One system is looking at the difference in trauma scene times when front-loaded ALS is first on scene verses a BLS engine company. Another system is looking at costs related to medications and medical supplies that expire due to lack of use. Some say that more paramedics mean fewer recruits crave the care-giving and opt in more for the financial incentives, resulting in numerous but weaker paramedics. Debate is developing over rotations and call volume required for proficiency. A 20-year-old anecdote suggested that a paramedic must run 700 calls annually to maintain proficiency. That benchmark was removed from the IAFF EMS implementation guide when the source was found not to be a valid scientific study. No one really knows just how many calls it takes to maintain proficiency.

What can be done about it? Where do we begin to prepare for the defense of fire-based EMS? First the fire chief needs to ask the EMS chief what the agency's cardiac-arrest survival rate is; if you don't get an answer, make it a priority for the organization to capture that information. It most often will be the first question posed by someone evaluating your system.

Implement the Utstein criteria into your quality-improvement project to ensure that you can defend your cardiac-arrest standards against what is considered the gold standard by the medical community. The cardiac arrest survival rate is not the complete measure of efficiency, but it is something the press, the public and the politicians can relate to. Also, federal agencies and insurance actuaries have established the value of a single human life based on several demographics. The Centers for Disease Control and Prevention now tracks the “years of life lost” related to certain diseases and has been able to attach a dollar figure to intervention strategies to prioritize their money.

Second, collaborate with the local union on implementing the performance indicators from IAFF headquarters. Despite the best efforts of the IAFF to market and implement strong data collection to back up the science, only a fraction of the fire service is on board with the program. These key performance indicators have been researched and established through a consensus-building process to represent best evidence medicine. The performance indicators have been put through the beta-testing process and build on the National Highway Transportation Safety Administration's minimum data set.

Fire departments must standardize their data collection to form a united front against attacks on the public service model of EMS delivery. Some may remember in the early 1980s the statistical debate on how to measure workload. The private ambulance companies used unit hours and the fire service used in-service ratio. Both told the same story of workload but measured in two different ways, confusing the politicians and those who oversee performance contracts.

Third, start looking for EMS-based research that justifies your staffing levels. For example, according to pre-hospital trauma life support standards, the correct movement of a patient out of a vehicle using rapid extrication is a four-person evolution. The solution to ensure a well-performed intubation may be a four-person team conducting an intubation as a team, again justifying the need for adequate staffing.

Challenge your medics and your medical director to conduct research on your patient outcomes. Most existing research has reported negative findings. As an industry we need to look for and document procedures and skills that truly make a difference and reduce health care cost. Outcome data on what paramedics do that affects the morbidity and mortality of patients must be analyzed and shared with the greater fire service.

Last, consider adding to your department's organization structure a division or position responsible for conducting analysis on your EMS statistics. Recruit or train a person qualified in research methodologies and statistics to report on a routine basis your operational effectiveness. Ensure your department can establish links with other relative databases to get the complete picture of your efforts and outcomes. For example, your fire department should be able to link with the local trauma center to establish outcomes for critical traumas transported by your system. With pen-based computers, data collection in the cardiac monitors and dispatch software, it's possible to get a longitudinal look at patients as they pass through the EMS system.

The debate about ALS will continue and can be expected to remain in the mainstream media. As city and county managers become educated on the issues, it will be hard to defend services that do not get results or generate a positive outcome. With a national shortage of health care workers, expect government to deploy resources to make the best use of limited funds. Will budget restraints slow the constant search to fill paramedic positions as we re-evaluate the science and ask the question: Do we have too many paramedics? Those who study the medicine will continue to evaluate number and effectiveness of Advanced Life Support personnel. As it is with all medicine, remember that it is the dose that makes the poison.

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Bruce Evans is the fire science program coordinator at the Community College of Southern Nevada as well as an adjunct faculty member for the National Fire Academy's EMS and injury prevention courses. A captain at the Henderson (Nev.) Fire Department, he has an associate's degree in fire management and a master's degree in public administration.

Online Tools

www.usatoday.com/news/nation/ems-main.htm
Written by Bob Davis, this USA Today article raises the question of too many paramedics and the effectiveness of EMS in several major cities.

www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12634522&dopt=Abstract
This San Diego airway study indicates a poor outcome for patients intubated in the field by paramedics.

www.chsrf.ca/final_research/ogc/stiell_e.php
This OPALS study questions the effectiveness of Advanced Life Support services. This is an ongoing research project, and the site frequently updates the content related to pre-hospital research.