From Ambulance Attendant to EMS Telemedicine Practitioner
Paramedics were once simply “ambulance drivers” with a duty to “scoop and scoot” to the nearest hospital, which was understandable because they were often undertakers driving a hearse, and since embalming has never been shown to improve survival, the patients were willing to waive any “stay and play” or enroute treatments.
However, once it was pointed out that soldiers wounded in battle had a better chance of surviving than traffic accident victims did, the army medic model was appropriated and vehicles designed as miniature hospitals became the modern ambulance. As in war, they were then connected by radio to their headquarters and, in concert with the 911 phone system, this universal infrastructure became established. Many more patients survived long enough to face their medical bills.
Seeing the success of paramedics, beleagured health authorities are embracing “paramedicine” and, under the baleful watch of the medical profession, are suggesting paramedics might be employed outside their emergency setting, to reach underserved or rural sectors of the population. Increasingly, paramedicine is being viewed as applicable in the general community, to stem the rising tide of demand on healthcare systems and to supplement the declining percentage of doctors available to deliver primary care.
Defining the Paramedic’s Role
Just as registered nurses (RN’s) do not wish to be confused with LPN‘s (licensed practical nurses) – nursing itself is not a direction for onsite paramedics. A common complaint among firefighter EMT’s, when presented with a particularly messy patient is “This is not what I signed up for.” And they have every right to do say that.
Here is a rather graphic description of what LPN or Licensed Vocational Nurses’ duties very often entail:
“In California, licensed vocational nurses (LVNs) empty bedpans, commodes and clean and change incontinent adults. Licensed vocational nurses read vital signs such as pulse, temperature, blood pressure and respiration. They administer injections and enemas, monitor catheters and give massages or alcohol rubs. They may apply dressings, hot water bottles and ice packs. They help patients bathe and dress, treat bedsores and change soiled bed sheets. LVNs feed patients and record their food consumption, while monitoring the fluids they take in and excrete.”
Is this something a fireman or police officer might do? – of course not. So it becomes important at this juncture to further clarify what duties paramedics will have or acquire.
A large California pilot project to study community paramedicine (CP) begins in June 2015 and it’s clear that a) paramedics are going to be in the spotlight and b) the project is pre-designed to flounder due to admitted legal obstacles and supposed retraining requirements.
Why take EMTs, who are trained to work in emergency settings, and retrain them for other protocols in non-emergency venues? Others ask “Why not just train more practical nurses?” As Oscar Wilde insisted on his deathbed “Either me or this wallpaper has to go.” – it is that kind of choice.
It may be time to again call paramedics just medics and leave the para- designation to others; the army got it right the first time. It is also conceivable that onsite responders may be paramedic or medical school students, nurses, dentists etc. because EMRs (medical responders) are regulated healthcare professionals in their own right. So it may be best to call paramedics with a communications ticket telemedics to identify them as telemedicine practitioners, so that all stakeholders understand their expanded role.
In a block EMS deployment, the veteran paramedic would cover business hours, and 2 EMR FTEs assume the afternoon and weekend shifts (7 day, 7am-midnight coverage). For skills dissemination, employment fairness and staffing flexibility it makes sense to not limit the EMR recruits just to paramedic students. Its operation will constitute a de facto healthcare grad school, perhaps someday a teaching Society, so credentialing the students who are “earning and learning” within it should be straightforward, and under local EMS medical direction.
An authoritative Framework Paper on Paramedics stresses “That an information campaign to promote awareness and understanding of paramedic practice and community paramedic programs be developed, targeting both the public and health care professions in general.” The public largely understands what a practical nurse does, but what can or should a telemedic do? – that is the next question.
The Special Attributes of a Field Telemedic
1) The key attribute is that they continue to work in an emergency setting, as first responders dedicated to very early intervention (VEI, <5 min) and first care in medical crises. To remove them from emergency calls and to retrain them as community health aides – no matter how attractive 4000 BC paramedics or 60,000 California firefighter EMTs might appear as an underused medical labour pool – it’s not an option, and most would quit beforehand. In Canada they would not be affordable.
2) Men are welcome in health care, and onsite telemedics within block EMS must work alone, have patient lifting challenges, have to deal with aggressive clients and are de facto security guards, intended or not. All of these abilities add to their value – and men have an interest in cellular gadgetry and networks. It’s a solid calling for them – and like nursing is equally open to everyone.
3) An onsite telemedic brings exclusive benefits to his community:
- Very early intervention of 3-5 minutes instead of 13+ minutes, and he does that far more reliably than remote vehicles can manage.
- Connection to a medical network that includes overseeing emergency physicians, and to dispatchers who can call him.
- Telemedicine as multipoint video conferencing within the EMS medical networks or with collaborating practitioners and agencies in his neighbourhood.
- Access to next generation cloud repositories, EHRs, diagnostics and supercomputer analytics
- Informing residents of their local medical options, for care by clinics and other healthcare professionals – and for triaging 911 callers in the field, not the ED.
- A lifeline for victims to rescue themselves in life crises, after registration online, by summoning the paramedic directly as their own option – true, equitable healthcare ownership.
Radio and Cellular Enablers and Technicians
Telemedics will have to master two communications networks:
- The dispatching wide-area radio network, for communications with Dispatch and other emergency agencies such as police, fire, disaster response etc.
- The public cellular network used by patients for summoning them, and for routine communications with Dispatch, residents, other health professionals and social agencies.
As the registrar for the occupants of his block(s) onto websites noting volunteered medical conditions, each paramedic will contribute to a unique medical database documenting early emergency treatments and outcomes.
A combination of these communications networks and registries may be required for telemedicine, although it is likely to be routinely delivered on the client end via a secure cellular platform such as Blackberry’s BES/EMM, which has an established infrastructure that supports the required privacy and security standards.
The skills around assessment and collaboration for clinical decision making, in conference with physicians can be expected to evolve and take center stage as the telemedic’s key responsibilities, enabling the frontline triage of medical crises, for their best treatment and disposition, with clearer insight into the urgency or destination for ambulance transportation.
Physicians Can Support EMS Telemedicine
Telehealth and especially its DTC (Direct To Consumer) variants constitute a legitimate threat to the western medical tradition. From Web self-diagnosis on the Internet, or Skype sessions with offshore “physicians” the intrusion is unprecedented; both for the medical profession and for its inherent risk to patients. Yet the existing hegemony and level of care can be preserved with a single legal provision: that telemedicine be conducted over an EMS network anchored by monitoring physicians.
When a field telemedic connects to the EMS medical network, with access to emergency physicians in real time, and then conducts a telemedicine session, he is enabling enhanced clinical decision making within the shortest possible time, without needlessly transporting the patient. All these are nextgen features and hopefully will be implemented by regulated professionals imminently.
Physicians have an opportunity to recognize this field extension of EMS, and to wholeheartedly and pre-emptively support the field telemedic as their standard bearer.
In addition, telemedics will function as communications technicians for the field station they work from. This mobile infrastructure and the patient registries and databases they populate will enable other healthcare workers in the community to work alongside them as a lean, congenial team, without role duplication or competing interests.
Mapping a City with Field Stations
A Field Station need not be more than a studio apartment within a telemedic’s center block, which he securely shares with other practitioners. These are not drop-in medical clinics offering primary or after care – the telemedic offers only first care medically, and communications and monitoring services otherwise – there is no competition with other caregivers.
Depending on the population density, his territory may be just one block or as many as a 3×3 group of nine blocks, sufficient to cover at minimum 1000 residents, on foot, within 3-5 minutes of a call – all of which will originate within one block’s distance. Census data can be utilized to lay out a lattice of these stations across the city, for uniform coverage on a per-capita basis.
Another major advantage of this distribution is its value after something like a serious earthquake or flood, for disaster recovery. Having hundreds of paramedics already distributed widely, each of them reporting in to HQ using common carrier cellphones, introduces a level of disaster preparedness that is unheard of, and is a prime pointer toward the field deployment model – Pacific Rim cities nota bene.
Patient engagement is cited as a goal of coming healthcare, and having a field medic drop in to discuss your safety and health status, to confess your sins and habits with before any medical incidents have occurred – is a deeply civilized approach that will be appreciated. This is premium healthcare with complete health equity. The data gathered into your own, accessible EHR is what many initiatives have been seeking for patient involvement for decades, and assembling it might some day save your life.
As an example, with sudden cardiac arrest more than half will be “unwitnessed“. However, if your medic provides you with a cellphone app/icon that you can press with your last seconds of consciousness – he can reliably come through your door in 3-5 minutes and resuscitate you. Conventional EMS relies largely on bystanders who can rarely locate an AED in time – which is 3-8 minutes from onset. That magic lamp that has always been cloistered is now nearby, comes alive for you in your moment of greatest peril, and restores your life.
Ownership Block EMS is up close and personal, qualitatively different from vehicular EMS, and early intervention will be a difference maker. Diverse medical technologies can bloom as one, with a trained human partner decisioning with experienced ER doctors.
Funding and Justifying Field Operations
Critics of block EMS may cite outsized costs as a barrier, but quite the opposite prospect is true. Field paramedics transfer internally as ambulance personnel who have been assigned a territory – and it is a promotion – as their communications skill sets and responsibilities will set them apart at once – they then become “officers” in every sense of the word. They were already being paid to be in ambulances, which now have only the driver aboard because there is always another paramedic at the destination.
Becoming a mentoring field medic is a late career option that veterans of the sirens, streets and stairways might relish. What they have learned should be passed along within practicums, for the patient contacts needed as young medical trainees qualify for their own careers.
In British Columbia the per capita healthcare expenditure by all authorities is just over $6000/year, and the wage cost for coverage by an onsite medic adds less than $180 annually. From that small increment we can deduct the wages they won’t accrue in ambulances, and those paid by the City for fire crew sorties, because with full city distribution, fire services no longer have to respond to medical calls – the field medic is already there. A reposting of fire EMTs to Medical Services can be expected – this is human engineering and HR management – and it will be welcomed by healthcare professionals.
Some rationalization of EMS is overdue and promises to offset any transitional cost – this is a pilot project that could be rolled out tomorrow, and former fire service EMT’s, with their practical skills and system knowledge, like other medical professionals would invigorate the integrated ranks with diverse experience. The field stations and telemedicine’s introduction enable a vibrant new business environment for practitioners such as care aides, physiotherapists, RT’s etc. who will benefit from the presence of local EMS, with its secure medical network and physician oversight, as one connected quilt – the long sought template for variegated, distributed community health.
The value for the 911 Dispatch system, to suddenly have eyes, ears and boots on the ground to investigate calls before ambulance allocation is game-changing, of course, and goes far beyond dollar efficiencies. It resolves the rivalry with fire services for responder status, and introduces crucial benefits like very early intervention (VEI) medically, which will bring the admiration of EMS services (and the press) everywhere. Associated staff and the patients they elevate to this new standard will take pride in the new environment, and the legacy “ambulance” designation will give way to the wider array of medical services that can now be offered.
Pressure taken off hospitals and ED’s with Remote Patient Monitoring enables patients to continue to live and be treated at home, and promises welcome relief to all parties. The simple act of “looking-in” on a frail or struggling resident is the human secret to safe, widespread home care.
With socialized medicine – essentially a single-payer system – the savings when citizens are spared needless damage or disability, through timely intervention followed by home care, will be incalculable but very evident to all stakeholders.
Field services binding together with strong physician participation shall enfranchise the many ad hoc players today delivering healthcare, and the era of the “ambulance” as its legacy figurehead will cede precedence to the EMS medical network. As the central nervous system of healthcare, its end points will be these invaluable telemedics.