Protecting highly populated city districts with block EMS rationalizes urban EMS and delivers a much higher standard of life safety
An ambulance paramedic’s prime purpose is early intervention in medical crises. Call volume, thick traffic, address confusion, security – they all take their toll, and because of this, vehicular EMS (fire, ambulance) cannot reliably deliver its most valuable service.
If that response time can be 3-5 minutes, when conventional ambulance or fire ordinarily takes 13+ minutes, then definitive treatments will be enabled. High rise buildings have an endemic risk for that reason – no easy rescues here – unless we respond within this short time frame. So let’s try this again, except onsite and on foot.
Block EMS means there is a trusted onsite community health worker responding, seven days a week.
These paramedics are at your call for medical emergencies only, but they have lots to do each shift – including registering every person on the block that is working or living there, and configuring their cellphones to call them with one icon press, if needed.
That alert can be in the form of an MMS text, and display any confidential information you offered, to assist the EMR or the 911 dispatcher during a life emergency.
Then, if your chest tightens up someday, you need not become one of the 85% of sudden cardiac arrests, e.g. who are not “witnessed” – and among the few that are cleanly resuscitated.
In quantum mechanics an electron can appear at a remote location without having to travel there, and in block EMS a paramedic appears instead. When the 911 dispatchers get the call, they note that a block paramedic is monitoring it and is entering the building’s access control room to get a key and attend within 3-5 minutes.
In truth this deployment is decided upon when two models are compared – conventional station vs block paramedics, i.e. sending two responders in an ambulance vs sending one (the driver) and having the second one already onsite, in high population areas.
When you consider that California e.g. has almost 100,000 paramedics, moving some out into the field seems to make sense. Community paramedicine (CP) and clinics are expanding, and localized EMS can economically form their backbone.
Costs and Benefits
Upfront Costs If it sounds expensive to have a dedicated block medical worker – what is the estimated cost? Let’s look at having one EMR always on duty protecting 1000+ people.
- Monthly salaries for a team of 3 EMRs, delivering 7am-Midnight, 7 day coverage, might be $12-13,000 in the US and Canada at living union wages.
- Overhead of $3000/month for a small apartment onsite to use as the paramedics’ (and possibly the drivers’ base) with supplies, utilities and insurance.
- An estimated total is $15,000 or $15 per person per month in this block unit.
Benefits of block EMS deployment
So what will be the value to society – and the impact on jurisdictional health care budgets We need to consider two cost layers:
1. EMS cost savings – for running the ED, dispatch, ambulance and fire vehicles and crews.
Block EMS™ creates an endpoint in the ambulance hub-and-spoke system, utilizing onsite paramedics to access patients within five minutes. Note that the hub infrastructure for supporting station or block paramedics remains the same, so pilot projects should begin by looking at the net cost differences related to paramedic staffing and redeployment.
Having boots on the ground allows the 911 dispatcher to readily distinguish acute emergencies from less urgent calls, that can then be scheduled safely and efficiently. This in turn allows a higher level of service from the same crews and vehicle fleet for acute calls.
Costs escalate when fire fighting crews and vehicles are dispatched – one estimate for the Vancouver area is $3500 more per incident and a local medical study questions the wisdom or efficacy of utilizing firefighters as first responders.
Professional rivalries aside, it is clear that as urban cores migrate toward community health models, that paramedics will progressively displace legacy firefighters in areas of high population density. And as the trend toward digital telemedicine continues, having health professionals who can conference with emergency physicians and involve community workers will increasingly be required. Future paramedic curricula will include these modernizations, and any retraining issues will then be moot.
So the $15K cited above for a paramedic in the field is going to largely offset the need for firefighter attendance in a conventional public safety scheme – a major economy. If the net staffing cost difference for a contiguous city core is found to be as small as expected, then block EMS becomes widely affordable – especially where municipalities fund the fire calls.
2. Aftercare costs – ED and hospital, rehabilitation, disability or death for EMS patients.
Medical crises are like fires – they can become irretrievable in seconds, and the damage they leave behind is often overwhelming. Block paramedics, like fire extinguishers are there to prevent a treatable incident from becoming a tragedy – whether it be premature death from cardiac arrest, a traumatic brain injury, or paralysis that results in a lifetime of disability.
These human or health ‘costs’ are not to be viewed as inevitable, taken for granted, or assigned to some other balance sheet – society must shoulder them financially and emotionally. The mandated and mature approach is prevention, using early intervention to optimize patient safety. Conventional EMS alone is not reliable, and increasingly a sunset solution when high population grants us additional options for communal cost-sharing.
Health authorities have a challenge: to upgrade EMS from century-old vehicular responses toward tight integration with community health, and to put the waiting toolbox of our cellular revolution to work. The intangible savings in lives not lost, in bodies and families not broken, will always be incalculable.
Diversifying Onsite Services
Multimedia Messaging Service (MMS) video from the paramedic’s phone enables interactive conferencing with emergency physicians, during diagnosis, decisions and treatments, and may extend their ways of working together, within telemedicine. Some definitive treatments like defibrillation, naloxone (overdose) and new stroke therapies demand early intervention – and dictate ensuing life, death or injury outcomes.
One variation of block EMS might be to upgrade existing first aid attendants at large complexes to become field paramedics, and perform the same function – delivering critical intervention before vehicular EMS arrives. This can map in larger outlying facilities and incorporate them like city blocks.
Remote Patient Monitoring – Before the Call
Meanwhile, making rounds up on the 22nd floor, the EMR might get a call from 911: “Mrs Jones in 2515…can’t turn on her dialysis.” The EMR looks in, and shows her where the new switch was installed.
Next is an appointment with Mr. Smith, who tends to call 911 as a ‘familiar face’ owing to a chronic addiction – best handled by his doctor or counsellor, he’s been told. The EMR looks for other community support resources with Mr. Smith, and points out the day clinic in the next block, as a better option over 911 services – please.
These community health contacts enable monitored discharges from hospitals, fewer re-admits, and can generate ‘reimbursables‘ i.e. revenues for remote services – financial entries over there on the plus side of the ledger.
As insurance payers migrate toward P4P (Pay for Performance) and ACO ‘outcomes’ results, EMS will be a baseline partner, as first care and early intervention are the gold standard anywhere – and it makes sense to share revenue with the front line practitioners. Block EMS and community health can flower in tandem, within free enterprise models, given adaptive medical direction.
These possible revenue sources will lower net EMR costs, and provide incentives for paramedics to augment their base salaries with telehealth services, share in medical surveillance IT, mentor EMS and inspire youth. Improved property and lease values will enable municipalities to formalize and modestly underwrite paramedicine, by balancing assessments with implementation incentives – all stakeholders will benefit and contribute, as they do now with other city services.
Health Equity In keeping with the deep value of a trained human attendant, a program providing early intervention to everyone, with health equity is truly priceless. To legally support this, legacy EMS policies that muster fire crews every time, or mandate obligatory transport to a hospital must be updated, once this more comprehensive model is introduced, if the benefits are to flow.
Block EMS might (someday) be structured as a frontline practicum taught by working veterans, creating an independent business paradigm as a late career option for these life savers, if the stairs and sirens become too trying. Their experienced, direct and diversified care of this city demographic will resolve issues locally, within optimal time and cost limits, and robustly protect their communities to a bright new standard.
Contiguous Block EMS
Interweaving city blocks that are not as densely populated into one fabric should be practical and studied for best practices, as it promises to extend contiguous protection across less peopled districts.
If a paramedic’s home block has only 500 occupants, but is adjacent to a block with 300 people on one side and 250 on the other side, this sequence of three less populated blocks can be assigned to one team in the center block. If required, the end blocks can be appended as well, for a total of 5 blocks, to make up sufficient occupants for economic scale. The adjacent blocks all remain within a 4-5 minute total response time from the center. (See the end-to-end protocol.)
Ambulances can be rolled if there is uncertainty about some calls, but dispatchers will be able to assess the situation confidently, knowing that a block paramedic has accepted the alert, is conversing with video, and will reliably be alongside within 5 minutes. In this way the health authority can economically protect a city core, including some less densely populated districts.
With a mix of pilot programs in varying urban contexts and municipalities, we can learn to map in city paramedicine and migrate block units and districts away from our singular dependence on this 911-ambulance-hospital axis, toward distributed and diversified treatment, with communications supporting improved outcomes at less cost.
Barriers to Implementation
The human logistics of stepping down the use of firefighters as first responders, while moving a big fraction of ambulance crews out into the field are relatively straightforward – just add courage. However, fire culture runs deep, paramedics are the junior profession and the pushback may be almost categorical.
The prime limitations are expected to be presented as:
- Legislative, whereby some jurisdictions are legally required to transport ambulance patients, e.g. – and the answer to those snares is simple EMS regulatory reform.
- Scope of practice, whereby EMT’s will be portrayed as being under-trained, when they begin to undertake general medical duties within community health.
Distinguishing Paramedics from Medical Aides
Expanding paramedics’ role, not scope of practice, and taking care to clarify and formalize it, provides the required boundary with community paramedicine. Equating paramedics with paramedicine is confusing and may be needlessly concerning to other health care professionals.
Whether within conventional or block EMS, paramedics are emergency personnel responsible for early intervention, injury control, and communications. Community paramedicine anticipates paramedics working in non-emergency settings.
Block EMS does not stand down from the obligation to respond immediately, for which everyone is already certified. They continue as EMS personnel, and may participate in telehealth, but do not become medical aides – a more suitable description might be medical services officers, since it is unlikely that community paramedicine will be renamed.
Block EMS is an interface between hospital care and community paramedicine, a forward deployment of ambulance services, it does not become immersed in generalized patient care or overlap with primary care or nursing practitioners.
EMTs will need more education about telehealth, and becoming liaisons to neighboring health and social resources, but understanding cellular communications and local care options or programs is not medical training, not regulated, and must not be used as a omnibus excuse to delay or sidetrack change. If EMTs continue as emergency medical technicians, with ongoing uptake of referral opportunities, their communications duties will likely constitute their main task.
Authorities are within their mandate to require this level of care, that a full range of community paramedicine and localized EMS support be provided in cities. The public will embrace the interactive and very human landscape that block EMS offers, and welcome its introduction into their living and work spaces with pride and appreciation.