Quality Corner--Part 5: Patient Care Standards--A Quality Comparison

Modern EMS began with a sense of sudden and belated urgency. The stage was set by the release of the National Academy of Sciences' 1966 report Accidental Death and Disability: The Neglected Disease of Modern Society, which claimed a soldier wounded in combat in Vietnam had a better chance of survival than a victim of a car crash on an American highway. A few visionaries in Los Angeles, Seattle, Pittsburgh and Columbus started the early prehospital advanced life support programs. Then in 1972 the television show Emergency! opened the floodgates, and people all over the country started asking, "Why shouldn't we have the benefit of prehospital ALS?"

At that time, no doctor or nurse in their right mind wanted to leave the familiar and secure environment of the hospital to crawl into overturned cars or administer care to victims of shootings and stabbings at uncontrolled (and many times still dangerous) scenes. Enter the firefighter and ambulance attendant, who were familiar and in many cases nutty enough to thrive on such intense challenges. And unlike doctors and nurses, they were "little fish"--i.e., not worth suing.

Forty years have since passed. Today physicians in many systems, many of whom started their careers as EMTs and paramedics, are more willing to actively participate in prehospital medicine. EMS has evolved and matured in other ways as well. But in the quality of patient care standards, the gap between many EMS systems and the rest of medicine remains cavernous.

It's an illogical disconnect. For all intents and purposes, paramedics practice physician-level medicine, albeit more limited and focused in scope. This is despite the fact that the typical paramedic, even as of this late date, receives between 9 and 24 months of training, compared to a physician's 8 years.

After medical school, physicians typically serve four years of internship and residency. This is where they practice what they learned under the watchful eye of senior physicians to ensure their practical application of medicine meets accepted standards. Most paramedics, by comparison, serve a preceptorship of between 3 and 6 months where they are mentored by a senior medic, after which they are turned loose on society. Back in the 1980s, I finished my nine months of medic school, completed a three-month preceptorship and then spent the next 20 years repetitiously doing what little I was trained to do.

In my first 20 years, I received exactly five letters of inquiry from my service's quality assurance committee. Twenty years, thousands of patients, and just five questions ever asked. I'd like to think I was that good. But, in retrospect, knowing what I know today, I am much more humble.

Given the meager amount of medical training I received, it's hard to imagine I didn't miss all kinds of things and make all kinds of mistakes along the way. But if no one ever catches your mistakes and points them out to you, how would you ever know? This is how many EMS systems throughout the country have operated for 40 years--and, in many systems, continue to operate today.

Short of manning all ambulances with doctors, it is not practical to expect the same care standards for medics as we do for physicians. But since the pathology, risks and stakes are the same for patients regardless of whether they're initially seen by a doc in the ER or a medic in the field, common sense dictates that quality review and improvement are critical to trying to close the gap as much as possible. It also makes sense that in EMS, index of suspicion and caution should be increased, not decreased from hospital standards.

EMS vs. Hospital Standards

A few years back, I arrived on the scene of a chest pain call. The patient was a 45-year-old male who presented conscious, oriented and in no apparent distress. His vital signs were unremarkable. His only past medical history was esophageal reflux. He described his discomfort as a burning sensation in his chest. He had just finished a spicy dish at a Mexican restaurant a couple of hours before, and there were no other associated complaints or symptoms, so I quickly determined it was a likely exacerbation of his GERD. I climbed up front and drove to the hospital and let my EMT ride with the patient. Who in EMS hasn't made such a clear-cut field diagnosis?

When we arrived at the hospital, I gave my report to an ER doc who graciously accepted the patient without questioning my working diagnosis. He then turned to the nurse and ordered an IV, blood draw and 12-lead EKG--all the things I could have done 20 minutes sooner, but felt were unnecessary.

I pointed out to the doctor that I was pretty sure the patient's chest discomfort was just a flare-up of his GERD. He agreed it probably was, but told me that a long time ago, the department head had told him, "We don't really care what you think it is, doctor. You'll do a full cardiac workup on every patient who comes in with chest pain or any other symptom that even remotely resembles cardiac ischemia, and definitely rule it out before you make your diagnosis." At that moment I realized what a huge difference there was between hospital and EMS standards of care.

Job #1 in Emergency Medicine

Defensive medicine is the somewhat negative term applied to the use of more rigorous protocols in other areas of medical practice. There's a good reason for it. Somewhere along the way, patients whose diagnoses seemed obvious proved those who diagnosed them wrong--sometimes dead wrong. Where is it written that a person with GERD cannot also have a heart attack? Many patients, including more than one physician, have complained of seemingly benign symptoms such as indigestion that ultimately ended up signaling MIs. Critical illness may not always be easily identifiable. Much more important than making a rapid and likely diagnosis or guessing right is the most important job in emergency medicine: early identification of all critical and potentially critical patients. A little humility and a lot of caution can go a long way to avoiding disaster for them.

In addition to failing the patient medically, there's also legal reality to consider. We're living in the age of the lawsuit. Billions of dollars in lost cases have made hospitals risk-averse. This has, it must be acknowledged, significantly reduced morbidity and mortality, but also added significantly to the cost of medical care.

Defensive medicine is a concept whose time has come for EMS. We have been living on borrowed time for too long. We've faced some lawsuits, but nowhere near as many as hospitals, doctors and the rest of medicine. One possible reason is that in many areas of the country, EMS is volunteer and EMS personnel are still perceived as "ambulance drivers." But the first well-publicized high-priced case followed by the realization that most EMS agencies now carry million-dollar malpractice insurance will open the dam.

It also doesn't take a prophet to realize that much higher standards for the quality of patient care will eventually be required for EMS. We've already seen the beginning of quality targets being mandated by Medicare, whereby reimbursements to hospitals are based on their achieving certain treatment standards. For instance, if a hospital's door-to-balloon time for STEMI is greater than 90 minutes, Medicare will reimburse it at a lower rate.

For all the complaints about insurance companies, it will ultimately be they and the pressure they bring to bear with financial incentives that will dramatically improve the quality of healthcare. It will likely take several additional years, but at some point this same market pressure will trickle down to EMS. The only question is whether your agency will get ahead of the curve now or play catch-up later.

Joe Hayes, NREMT-P, is deputy chief of the Bucks County Rescue Squad in Bristol, PA, and a staff medic at Central Bucks Ambulance in Doylestown. He is the quality improvement coordinator for both of these midsize third-service EMS agencies in northeastern Pennsylvania. He has 30 years' experience in EMS. Contact Joe at jhayes763@yahoo.com.