Author: Jerry Overton
Published in Spring 2019 Edition of Ambulance Today Magazine
In this column, Jerry Overton- who is viewed by many world EMS and healthcare leaders as one of the best when it comes to improving ambulance systems globally- gives his opinion on the allocation of funding in theEMS system. He identifies some of the issues within EMS systems globally and, whether it’s saving ambulance hours or reallocating funds, you can trust Jerry to have a pretty good idea on how to improve on the system.
Oh, a storm is threat’ning
My very life today
If I don’t get some shelter
Oh yeah, I’m gonna fade away
Yes, it is a storm that is constantly threatening, and it threatens us all. Cardiac events know no shelter; they do not “fade away”. How sadly ironic it is that the emphasis on this issue of Ambulance Today is the recent London Cardiac Arrest Symposium last December, an event that Dec, lover of the Rolling Stones, had planned to cover. This all still just does not make any sense.
As always, the symposium was excellent, and I am sure the specifics will be comprehensively reported elsewhere. From this perspective, the welcome change was less on research and more on resources; human resources. The first, “Community CPR”, and second, “Kids Saving Lives”, really hit the mark.
This does not mean that cardiac research is not important, because itis. But, at the end of the day, whenone considers the amount of money committed to research compared to the amount of money needed to increaseour resources, one wonders if it is not time to discuss priorities.
Back in the day (okay, my day), the initial intervention for an out of hospital cardiac arrest was the precordial thump and if that did not work, there was always intracardiac epinephrine and sodium bicarb. Other meds came and went, depending on the latest research, and sometimes even who did the research. The contents of the drug box varied from system to system and the decisions of the local medical director. Sadly, ROSC rates failed to show any real improvement, whether in the United States, the United Kingdom, or Asia.
Today, every responder knows that two interventions make a difference, timely CPR and timely defibrillation, stressing the word “timely”. The question now, though, is what constitutes “timely”. It sure is not an eight-minute requirement. As has long been stressed by any paramedic, there will be little difference in outcome if the response time is 9 minutes 1 second rather than 8 minutes 59 seconds.
Response times are outputs, and what is needed are outcomes. And to achieve outcomes, we need resources. That, clearly, requires our most important resource, which is our people. If we really do have money for new programs, it is time to invest in the “research” necessary to seriously examine howwe can better recruit and retain those that can change patient outcomes. And if we do not have any “new”, perhaps reallocation of funds is in order.
There can be no debate that shaving seconds in telephone CPR instruction is important, but if there are insufficient dispatchers to answer the increasing number of calls, those seconds will make little difference. It is an under appreciated, almost invisible position, that drives the first link of the Chain of Survival.
The shortage of paramedics is even more acute. In the U.K., a 2017 report by the Comptroller and Auditor General of NHS England, reported 10 percent vacancy rate, with Trusts “struggling to recruit the staff they need and then retain them.” The U.S. is facing a similar problem. A recent broadcast from CNBC news reported that in the next six years, a 15 percent increase of paramedics would be required at a time “when unemployment continues to hover near historic lows”.
Of course, it is not just the out of hospital care world that is facing a crisis, other sectors of health care are also, and it directly impacts our ability to respond. That same 2017 report by the Comptroller and Auditor General found that in “2015-16, approximately 500,000 ambulance hours were lostdue to turnaround at accident and emergency departments taking more than 30 minutes, which equates to 41,000 12-hour ambulance shifts.”That is an almost unbelievable (but it is) staggering waste of both human AND financial resources.
Longer hours, more responsibility, higher utilization, fatigue, inequitable pay, and, of course, working conditions when considered together would make any sane person wonder why another sane person would ever consider makingthe commitment to a dispatcher or paramedic. The answer is, obviously, EMS personnel give a damn.
All too often, that is forgotten. It was just under three years ago that the first European congress dedicated to EMS was held in Copenhagen, EMS2016. The theme of that congress, and the subsequent congresses, was “It takesa system to save a life,” and indeed,it does. But the foundation for that system, or any system, is its people. In other words, without you, it is nothing.
That is my point. If we are ever to increase cardiac arrest outcomes,it will be done by human resources that have the education, experience, and motivation to make a difference. Telephone CPR does little good if a call goes unanswered. A medication has little impact if there is no paramedic to administer it.
Just like human resources, economic resources are limited. And it is a basic tenet of EMS that “nothing in life is free”. That includes community and kids’ CPR. Wisely using the financial resources that we do have is key, and if that means reallocating research grant funds away from the latest in drone delivery systems that could potentially increase survival one-half of one-half percent (yes, that is sarcasm), it needs to happen if those same funds can help us better find the keys to retain the human resources that WILL make a difference (No, I am not naive, higher wages is definitely a major key!!!).
And just when you think that all of us have at least a basic understanding for the need for a resource, any resource, that can respond and make a difference, comes this from the western section of the United States. It seems that officials in a Pacific Northwestern state have decided that call taking in dispatch centers has become so structured, and telephone CPR so protocol driven that they are proposing a rule change that would permit local agencies to no longer require its dispatchers to be certified in CPR. Yes, you read that correctly, public safety responders will not need to know CPR.
It is not like a fellow dispatcher has not arrested in a control center, because it has happened. It is notlike a fellow public safety officer has not arrested at headquarters, becauseit has happened. And it is not likea dispatcher has never witnessed a cardiac arrest as a layperson, because it has happened. Whether the proposal passes will be decided in early spring. And, interestingly, most local public safety agencies are AGAINST it. Perhaps those state officials need to take a step back and consider this from the Rolling Stones. It certainly fits.
You can’t always get what you want
You can’t always get what you want
You can’t always get what you want
But if you try sometimes well you just might find
You get what you need
“You Can’t Always Get What You Want”