The International Association of Fire Fighters and the Ontario Association of Fire Chiefs continue to lobby for fire-based EMS, and rumor has it that Macleans magazine is working on an article for an upcoming edition in which the Canadian Division of the IAFF will argue the benefit of that service model. The debate for and against fire-based EMS has escalated over the past decade and is all too often fraught with emotion. The arguments tend to be clouded by partial truths so it's little wonder our policy and decision makers are reluctant to take a stand one way or the other. At the risk of being accused of adding to those half truths, let me suggest what I think decision makers should focus on in this debate.
Cardiac arrests tend to be used most often as the benchmark when arguing an appropriate EMS response time, yet less than 1% of our calls are cardiac arrest calls. To design an entire EMS system around this subset of calls seems questionable, especially when evidence based options are available. Studies have shown that early recognition and early CPR with minimal interruption to chest compressions has tripled the survival rate in witnessed cardiac arrests. The Heart and Stroke Foundation of Canada Public Access Defibrillation (PAD) trial demonstrated a doubling of survival rates when AEDs were utilized by lay responders in facilities with a high likelihood of cardiac arrest. Promoting and enabling public education that emphasizes good CPR, early notification of EMS and strategic placement of public access AEDs is of great importance when weighing the arguments of cardiac arrest in EMS system design.
Another measure used to argue certain system benefits is the time taken to "stop the clock". When it comes to capturing response times, it's important to remember this is nothing more than a measure of how quickly someone arrives on scene. This initial response time is certainly a statistic worth capturing, but the clock really doesn't stop until the system delivers a level of care able to definitively treat that patient. In the case of a cardiac arrest (less than 1% of EMS calls) it might be argued that the clock stops when a trained responder with a defibrillator is at the patient's side. But the clock really has not stopped when the patient needs advanced respiratory care, pain management or IV medication to treat a variety of medical conditions or cardiac arrythmias. For the most part, "stop the clock" arguments are fairly misleading, especially in the public arena. Getting medical assistance to the patient's side as quickly as possible needs to be given appropriate consideration, but the clock doesn't stop unless that paramedic is able to provide definitive treatment. Policy makers need to ensure their EMS system gets the right care to the right patient at the right time.
Paramedicine has joined the ranks of health care...paramedics are health care providers with growing education and skill set requirements. As with any health profession, it is critical that paramedics are committed to maintaining competence in their practice, stay abreast of best practices and familiarize themselves with new technologies. While call volumes are on the rise, so too is the need for EMS to deliver health care in the community setting. Continuing competence and professional development must be given serious consideration by both paramedics and our policy makers when considering service delivery models.
In life-threatening emergencies, patient outcomes are dependent not only on the speed with which medical care is provided, but more-so by ensuring patients receive the most appropriate medical care.
