Migrating from Vehicular to Onsite EMS in Cities
A century ago cities began to use motorized fire trucks and ambulances to respond to medical emergencies, as they were called in by the new telephones. Vehicles were clustered by firehalls, usually, and then dispatched to the individual properties.
This strategy remains valid today, for single family dwellings, but when the address is a modern high rise in an area with hundreds of them, at some point the population becomes so dense that vehicular EMS gets progressively delayed and degraded, by any number of factors, most obviously city traffic and call volume. A fresh approach must be sought for high rises, preferably one that does away with the need to send emergency vehicles as a first option.
When faced with a highly populated demographic to protect, EMS can take advantage of the larger people base to affordably place paramedics onsite beforehand, eliminating the need for ambulance or fire vehicles as first responders.
At first look this may seem expensive, but if each is protecting at least 1000 residents or workers, with redeployed ambulance personnel, enabling definitive treatments that remote vehicles cannot reliably deliver, the operational costs reach an inflection point where they begin to decline in relation to the number of patients served. And when the value of the treatments and the resultant patient safety that true early intervention enables, it becomes clear that an onsite model shared with other community health workers will be far superior.
A possible medical mega-pilot would be to introduce onsite EMS into a dense urban population that is surrounded by conventional single family houses, and compare the legacy and onsite results after two years – a project that will be presented for BC health authorities to consider shortly.
Let’s take a look at how Vancouver would provide the ideal venue for a major trial of onsite or “block EMS”.
Estimates of Coverage of Downtown Vancouver As One Project
First we’ll open a zoning map of Vancouver (Click to see larger version).
This is the entire city (without suburbs) and the grey areas denote single-family dwellings – these districts are largely individual houses and businesses and will continue to be served by conventional EMS. We are interested only in the more populated zones, as block EMS becomes economical and practical when given sufficient scale and is applied selectively to take advantage of high density, which otherwise can present obstacles.
So the high population areas will include:
- The multi-family areas in yellow, which are typically 3-5 storey apartment and condo buildings. One paramedic on duty can protect 1 to 5 of these low-rise blocks if adjacent as a block ‘unit’, to have a minimum of 1000 people in their care.
- The purple and dark blue areas above the yellow band contain many of the largest towers and high rises in Vancouver (see the photo).
We’ll assign one paramedic team (3 FTE’s) to each block – as all residents and workers must be reachable on foot by them, within 5 minutes from onset of a medical crisis.
Let’s look a little closer at the downtown core then, as a possible large pilot project, with this map detail showing the buildings’ footprints:
Here we can see how the city blocks will divide up, one block per team of 3 paramedics to protect 1000 or more citizens, and we can count them – an estimate in this view is about 200 blocks in this image, so 200 paramedics on duty for 7×17=119 hours/week from 7am-midnight, with conventional EMS thereafter until 7am.
From a budgetary viewpoint, we can subtract the number of firefighter crewmen no longer dispatched as first responders for medical calls to this area, and allow for the number of staff paramedics who internally move from ambulances to onsite block duty. (In block EMS the ambulances have one, not two paramedics.)
There are ~4000 paramedics in British Columbia, and ~500 ambulances in 184 stations – this pilot would also create 200 shared community health field stations – these are studio apartments that can be used for secure telemedicine.
Given the number of major tower buildings downtown, the population covered may be as high as 300,000, from a city population of 603,000 in 2014.
A refined analysis is required, but in rough figures this city core of 200 field stations will each cost $15,000/mo or $36 Million total per year, before the large funding offsets mentioned are subtracted. These modest studios also provide the EMS backup, secure medical network and video infrastructure to support community health aides and telemedicine delivery, so they are not all costed to the account of EMS.
Block EMS appears to be distinctly affordable given optimal demographics – and it has notably small capital requirements.
Staging Block EMS
The project can begin by establishing service from 9am-6pm weekdays, with the 200 supervising paramedics setting up the field stations and registering the block occupants with their volunteered texts onto the cloud website. During these hours, he can lend support to other health professionals for telemedicine, and deal with the local clinics, social agencies and businesses during everyone’s working hours.
Once that infrastructure is in place and dispatchers are familiar with it, then the afternoon and weekend shifts can be appended utilizing student paramedics as EMRs. This gives the fire department time to reallocate their resources, and for ambulance crews to understand the single driver staffing and all these new mini-stations in the downtown area.
This city core has the largest concentration of people in western Canada, and reassigning 200 ambulance staff within a prosperous city hub harbouring ‘Greenest City’ ambitions is a relatively modest budgetary adjustment. Yet it completely alters the healthcare landscape with unprecedented new features – no more will defibrillation be left to bystanders, or overdoses to their unfortunate conclusions – this is nextgen emergency medicine settling deep into the community, with new responsibilities and opportunities for all parties.
Cities will have the option of limiting block EMS to business hours, or adding the remaining shifts – these are the questions pilot projects are meant to examine – where is the sweet spot?
The net cost may be zero when all aspects are considered, especially the intangible and lasting benefits of early intervention for preventing premature death and serious patient injury. At some point other health authorities such as the Ministry of Health should assume all or part of the cost of these forward “communications officers” who have come out of the ambulance fleet, granted – but now deliver broad functions to a wider constituency.
As a new generation of ‘mobile integrated healthcare’ begins and paramedics explore this late career option, to pass on the experience that EMS people uniquely have – they will anchor EMS’ direction away from ambulance dispatch, toward comprehensive field operations as a template for community health.