Split Second

This week touched on something I'm quite involved in, namely, EMS medicine. Paramedicine is a fascinating world unto itself, featuring challenges and clinical care issues that aren't even approached in contemporary in-hospital medicine. Mark has been offered the job of EMS director by, presumably, the Chicago Fire Department. All EMS (emergency medical services) agencies need a directing physician, whose primary role is establishing and ensuring standards of care -- training and actual practice are, of course, major components of that job.

A number of current issues in EMS were discussed in this episode -- foremost in my mind is the placement of automated external defibrillators on first responder vehicles. The first responders in a community will vary, but generally, we're talking about (rarely) the police or (more commonly) the fire department. (Don't confuse the fire department with the EMS agency -- it may be one and the same, but we're talking about vehicles here -- engine companies versus ambulances.) One of the most important things you can do for a person who has arrested is to defibrillate them quickly, and because the fire department usually beats the ambulance to the scene, it makes sense to equip them with a device that'll allow them to rapidly defibrillate these patients. The jury's still out on the introduction of automatic external defibrillators on first responder vehicles, mostly because there isn't enough data to draw any conclusions yet. (AEDs have really only come into their own in the past few years, thanks to the introduction and successful trials of cheap, easy-to-use units by several manufacturers, notable among them Laerdal, PhysioControl, Zoll, and Heartstream. I'm a big PhysioControl person, myself..) In the end, I think what we'll see is a general upward trend in survival from sudden cardiac arrest, if the whole emergency medical system works the way it's supposed to. Time will, however, be the final arbiter of this discussion.

While he was sewing up Doris' battle wounds, he heard the story about heading into an uncontrolled scene and getting smacked around by the patient. We had a discussion about this sort of thing on alt.tv.er over the summer, and I stand by what I said then: at an uncontrolled scene, especially one involving a violent crime, you stay put until the police have the area secured. There's an EMS aphorism that says "if anyone dies at the scene due to hazards, it should be the patient, not you," and it's very, very true. Walking into an uncontrolled scene, no matter how important it may seem at the time, is a good way to end up permanently retired. Doris, as a paramedic for several years in Chicago, should know better.

Mark and Doris also talked about the need for more paramedic units. This is a chronic problem that plagues every EMS agency in the world -- I don't know of any that are staffed properly to meet patient demand levels. It is not uncommon, in large cities, to have multiple emergency calls holding because there are no clear units available to respond. The reasons for this are varied, but they usually involve the turn-around time at the hospital. First responders can clear a call and be back in service quickly (which is part of the reason they usually beat the ambulance crews to the call) mostly because they don't transport patients to the hospital. If there are three hour backups at an emergency department, there are going to be ambulance crews sitting around doing nothing while calls are going un-answered. I don't have a solution for this, at least not one that's financially acceptable. Doris laments this, but it's an unfortunate reality that there is not an infinite supply of money, and no agency can be fully funded and properly staffed. The fact that her complaint overlooks a fiscal reality doesn't make it less true or less valid, though.