Changes

 People are always asking me what changes I have seen over the years.  Here are four changes I have been thinking about lately.

More paramedics.  When I started we had anywhere from two to six paramedics on to cover the entire city of Hartford and backup the other three large towns we covered.  On many days I was the only medic for the northern half of the city.  I never did transfers unless they were ALS, I was rarely deliberately dispatched to drunks or psychs, and I intercepted constantly with BLS cars.  Today, we have anywhere from five to twelve medics on, and I believe if we could do it, we would put a medic in every car.  How do I feel about this?  I miss the old days, but if I was a patient and I was sick, I would want a paramedic taking care of me.  Going along with this, I think today it is much easier to be a paramedic.  Today’s medics have capnography, CPAP, combitubes and other backup airways, EZ-IOs, and much wider array of drugs that no longer require an IV.  Intranasal Fentanyl, oral Zofran, IM Versed area examples.  Gone are the days when you had a cardiac arrest that you couldn’t get an airway and IV access on.  Someone having a horrible time breathing and you don’t know why?  Slap the CPAP on.  I don’t mean this as a criticism, I think this is great for all medics and patients.

More calls at Dr.s offices and walk-in clinics.  We have always done these calls, but the numbers have increased to the point that a shift rarely goes by that I don’t do at least one call and often more at these offices.  For years, the complaint had been people were using emergency rooms as their primary care.  Now with the proliferation of these walk in clinics and more people covered by insurance now having doctors, they go there first.  Blood pressure high?  Short of breath?  Or an odd looking ECG?   911 is called.  Some are true emergencies, others not.

Safer equipment for moving patients.  Power stretchers and stair chairs with treads.  The days of the two person dead-lift and the back-breaking carry downs are largely gone thanks to these wonderful improvements.

More Fire-based EMS.  At least around here, we rarely saw fire departments on our calls.  In Hartford, the PD was the first responder -- their 02 tanks were empty, and they did not like touching patients.  Now, the Fire Department goes to all priority one calls.  And since we have fewer cars in the city than we used to, they are almost always there before us.  It is a big help -- everything from seeing the big red truck to help us pinpoint the location of the call to all the help they give us on scene, particularly with carrying.  In one town we respond in -- West Hartford -- we have seen the Fire Department go from only going to car crashes needing extrication, to going to priority ones, to going to all calls, to starting in January, actually providing paramedic care as the first responders in town.

What do these four changes all have in common?  Money.  The ambulance services make more money through the added paramedic assessment charges.  Walk-in clinics are much more profitable to health care organizations than EDs.  Safer equipment means reduced worker’s comp costs and less employee turnover.  The only outlier here is the fire involvement, which could be argued costs more, but when properly spun, comes out as getting more bang out of the fire personnel for the buck than when they were just firefighters.

I am not criticizing this.  Money has always driven change.  It is the way of the world, and not necessarily a bad thing.

The next big change coming down the pike driven by dollars. --  Mobile Integrated Health Care, aka, paramedic community medicine.  For years, nurses have used their political power (nursing organizations, power of the vote, donations, numbers), as all groups do, to keep paramedics off their turf in hospitals and home care settings, but in today’s world, the dollars to be saved by using medics to fill gaps in the health care system, are too great.  Many states have already gone to this new model of care.  Here in Connecticut, a law was passed to study the issue and consider regulatory change to make it happen.

Here’s how it might happen.  After a medic has completed the additional education, he comes to work and is given a list of appointments.  He takes the ambulance or a fly car and visits people recently released from the hospital for say CHF.  He takes vitals signs, does an ECG, weighs the patient, makes certain they have been taking their medicine, and calls the patient’s doctor with his report, and may either give the patient Lasix and make a followup appointment with him or, if necessary, call for an ambulance to transport.  If all goes well, the patient doesn’t have to use the ED, doesn’t need a costly readmission to the hospital, is healthier for the interventions, and saves the system a ton of money.  A win for everyone.

A patient calls 911 because they took two of their beta blockers by mistake.  Under community paramedicine (which if done properly will pay EMS not to transport), the paramedic calls the patient’s MD and is able to tell him to skip his next dose.  An elderly patient is short of breath because she ran out of her combivent.  The community paramedic will give her a breathing treatment, and then go to the pharmacy to get her refills.  Another patient is a little short of breath and due for dialysis in a hour.  The medics calls the MD, and gets permission to transport the patient right to dialysis, instead of the ED, and the ambulance service now gets paid for this transport.  

Now I did not get into EMS just to do home care, but I also didn’t get into EMS to take people to the hospital who didn’t need to go.   Times change, and thanks to better equipment, my back has made it this far.  Maybe community paramedicine, and all it promises, can keep my paycheck coming long after I would have otherwise retired.  When money and what’s best for the patient and the provider can go hand and hand, it’s all good.