Selects: How Paramedics Work
The origins and evolution of emergency medical services across the United States are explored in this episode summary. It traces the history of mobile ambulances and pre-hospital care from the Crusades to the groundbreaking 1973 Emergency Medical Services Act, which established national guidelines for a coordinated EMS system.
The summary outlines the roles and training of EMTs and paramedics, as well as challenges such as funding gaps, fragmentation of services, and misaligned incentives between ambulance providers and efficient patient care. The complexities surrounding coordinated emergency medical response are examined through this overview of the system's development and current state.
This is a preview of the Shortform summary of the Oct 12, 2024 episode of the Stuff You Should Know
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1-Page Summary
Historical Origins of Emergency Medical Services
The origins of emergency medical services can be traced to the Knights Hospitaller from the Crusades, who created the stretcher for transporting injured soldiers on the battlefield. In 15th-century Spain, "ambulancias" or field hospitals emerged to meet medical needs. According to the summary, the modern concept of mobile ambulances equipped for en-route care was developed by Napoleon's forces in the 19th century.
Establishing a National EMS System in the US
Prior to the 1970s, the US lacked a standardized emergency medical system, leading to preventable deaths. A National Academy of Sciences study in the 1960s highlighted the need for nationwide EMS reform. Dr. J. Frank Pantridge introduced the idea of ambulances staffed with medical personnel in 1967.
The pivotal Emergency Medical Services Act of 1973 established federal guidelines for a coordinated EMS system across the US, with trained personnel providing pre-hospital care. This act was instrumental in advancing today's systematic emergency medical response.
EMT vs. Paramedic Training and Roles
As outlined in the 1977 national curriculum, EMTs receive around 120-150 hours of training for basic life-saving procedures like CPR, while paramedics undergo 1,200-1,800 hours for advanced care like IVs and defibrillation. Paramedics often face demanding schedules and low pay relative to their high-stakes responsibilities.
Funding and Logistics Challenges
Since federal EMS funding ended in 1981, the system fragmented into state/local programs with disparities in service quality. Competition among private ambulance providers aimed to improve services, but has complicated matters in some areas.
The reliance on Medicaid/Medicare reimbursements, which only cover transports to hospitals, has created problematic financial incentives. EMS providers may unnecessarily transport patients just to get paid, contributing to ER overcrowding. The summary highlights the need to align incentives with efficient, quality patient care.
1-Page Summary
Additional Materials
Counterarguments
- The Knights Hospitaller were indeed involved in early medical care during the Crusades, but the concept of transporting the injured dates back even further, with examples found in ancient civilizations.
- While "ambulancias" in 15th-century Spain were significant, the development of field hospitals and medical transport systems occurred concurrently in various parts of the world, influenced by different military and civilian needs.
- Napoleon's contribution to the development of mobile ambulances was notable, but it was part of a broader evolution of military medicine that included innovations by other armies and nations.
- The lack of a standardized emergency medical system in the US before the 1970s was a complex issue, and while preventable deaths did occur, there were also many local and regional systems that functioned effectively.
- The National Academy of Sciences study was influential in EMS reform, but it was one of several factors that prompted change, including grassroots efforts and advances in medical technology.
- Dr. J. Frank Pantridge's introduction of ambulances staffed with medical personnel was a key development, but similar concepts were being explored and implemented in other countries as well.
- The Emergency Medical Services Act of 1973 was a significant legislative milestone, but the implementation and evolution of EMS systems have been influenced by ongoing state and local legislation, as well as changes in healthcare policy and practice.
- The training hours for EMTs and paramedics are averages and minimums; actual training can vary significantly by region, provider, and over time as standards evolve.
- Paramedics may face demanding schedules and low pay, but this is not universal, and there are regions and employers where paramedics are compensated in line with their training and responsibilities.
- The fragmentation of EMS systems post-1981 federal funding cuts is a concern, but some argue that local control allows for more tailored and responsive EMS systems that better meet the needs of diverse communities.
- While competition among private ambulance providers has presented challenges, it has also led to innovations and improvements in efficiency and patient care in some markets.
- The reliance on Medicaid/Medicare reimbursements does create financial incentives that can be problematic, but it also ensures that a baseline level of service is available to underinsured or uninsured populations.
- The issue of EMS providers transporting patients to receive payment is complex, and there are protocols and oversight in place to mitigate unnecessary transports, though these systems are not always perfect.
- Aligning incentives with efficient, quality patient care is a widely supported goal, but there are differing opinions on the best ways to achieve this, with some advocating for more market-driven solutions and others for increased regulation and public funding.
Actionables
- You can learn basic life-saving skills like CPR to be prepared for emergencies and reduce the reliance on EMS for non-critical situations. By taking a certified CPR course through your local community center or health organization, you'll be equipped to provide immediate assistance in case of a medical emergency, potentially saving lives and alleviating some pressure on emergency services.
- Advocate for policy changes that incentivize quality care over quantity by writing to your local representatives. Explain the importance of aligning financial incentives with patient outcomes in the EMS system, which could lead to reforms that prioritize efficient and effective care rather than the number of transports.
- Educate yourself on when to call an ambulance versus when to seek alternative transportation to the hospital. This knowledge can help reduce unnecessary EMS calls and ER overcrowding. For instance, if someone has a non-life-threatening condition that doesn't require immediate medical intervention, consider using a ride-sharing service or driving them to the hospital yourself.
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Historical development of emergency medical care and ambulances
The modern emergency medical services that we rely on today have their origins in wartime efforts to transport and care for the injured. These services have evolved significantly over the centuries, from the Crusades to 15th-century Spain, and were later refined during the Napoleonic wars.
The origins of emergency medical services can be traced back to wartime efforts to transport and treat injured soldiers on the battlefield.
During the Crusades, the Knights Hospitaller of the Order of St. John of Jerusalem were the first to practice emergency medicine on the battlefield. This organization invented what we now recognize as the stretcher, historically referred to as a "litter," which was significant in the evacuation and care of wounded soldiers.
In 15th century Spain, amidst the period of the Inquisition, there emerged a great need for medical services. This need led to the establishment of field hospitals, known as "ambulancias." These facilities provided critical medical assistance and can be seen as the precursors to the mobile emergency care units we are familiar with today.
The modern concept of a mobile ambulance unit emerged in the 19th centu ...
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Clarifications
- The Crusades were a series of religious wars fought between the 11th and 13th centuries. They were sanctioned by the Latin Church in the medieval period, with the goal of recapturing Jerusalem and other holy sites from Muslim rule. The Knights Hospitaller, also known as the Order of St. John, were a prominent military order during the Crusades, providing medical care to wounded soldiers on the battlefield. The stretcher, or "litter," was a significant invention by the Knights Hospitaller for evacuating and treating injured individuals during these conflicts.
- The Knights Hospitaller of the Order of St. John of Jerusalem were a medieval Catholic military order dedicated to providing care for the sick and injured. They played a crucial role in developing early emergency medical practices, including the invention of the stretcher for battlefield evacuation and care. Their contributions laid the foundation for modern emergency medical services.
- The use of stretchers, historically known as litters, in emergency medicine dates back to the Crusades, where the Knights Hospitaller of the Order of St. John of Jerusalem first utilized them for transporting wounded soldiers. These stretchers played a crucial role in the evacuation and care of injured individuals on the battlefield. They were early innovations that helped establish the foundation for modern emergency me ...
Counterarguments
- The assertion that the Knights Hospitaller were the first to practice emergency medicine on the battlefield may be too narrow, as various forms of battlefield medicine were likely practiced in different cultures and by different groups throughout history.
- The concept of a "stretcher" or "litter" may have been used in various forms before the Crusades, as transporting the injured has always been a logistical challenge in warfare.
- The term "ambulancia" in 15th-century Spain may not directly correlate with the modern concept of ambulances as mobile emergency care units, and the connection might be more etymological than practical.
- The development of emergency medical services and ambulances was not linear and involved many different innovations from different cultures and time periods, not just those mentioned in the text.
- The innovations attributed to Napoleon's forces might have been influenced by or based on earlier practices from other armies, which the ...
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Emergence and evolution of the modern EMS system in the US
The modern Emergency Medical Service (EMS) system in the United States has gone through a significant evolution from the 1960s to the establishment of federal guidelines for a standardized system. This transformation was primarily in response to a pressing need for improved outcomes in medical emergencies.
The need for standardized emergency medical services in the US
Prior to the 1970s, the United States did not have a standardized emergency medical system, which often resulted in preventable deaths from accidents and injuries. In the late 1960s, medical emergencies were frequently managed with house calls by doctors. However, in urgent cases, emergencies were handled by local morticians or police who would perform "scoop and run" operations to transport injured individuals to hospitals with no trained medical professionals in attendance.
It was recognized that outcomes for medical emergencies could be significantly improved if ambulances were staffed with trained medical personnel who could begin treatment immediately. Before the mid-1970s, even hospital treatment for emergencies was not specialized as emergency rooms were yet to be developed.
Pioneering changes in emergency medical care
The need for improvement in emergency medical care was further highlighted by a study conducted by the National Academy of Sciences in the 1960s. The study underscored the urgency for a nationwide emergency medical services system. Following this notion, Dr. J. Frank Pantridge of Belfast introduced a groundbreaking concept in 1967. He posited that the success rate of saving lives increased when a physician or nurse was included in mobile units, such as ambulances, allowing immediate, on-the-scene medical care to patients during the transport to a hospital.
The establishment of the Emergency Medical Se ...
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Emergence and evolution of the modern EMS system in the US
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Clarifications
- Before the 1970s, the lack of a standardized EMS system in the US was mainly due to the historical approach to medical emergencies, which often involved ad hoc responses by local entities like police or funeral homes. The absence of trained medical personnel in ambulances and the limited focus on pre-hospital care contributed to the need for a more organized and efficient system. The fragmented nature of emergency response services and the absence of federal regulations further hindered the establishment of a uniform EMS system nationwide. The recognition of these deficiencies eventually led to the development of federal guidelines and the Emergency Medical Services Act of 1973 to address these shortcomings and improve emergency medical care.
- "Scoop and run" operations were emergency response practices where non-medical personnel, like police or morticians, would quickly transport injured individuals to hospitals without providing medical care on-site. This approach prioritized rapid transportation over on-scene medical intervention, aiming to get patients to hospitals as fast as possible for treatment. However, this method often led to suboptimal outcomes as patients missed out on crucial immediate medical attention that could have improved their chances of survival. The term "scoop and run" reflects the swift and basic nature of these operations, lacking the comprehensive medical care now standard in modern EMS practices.
- Before the mid-1970s, hospital emergency rooms were not specialized in the way we recognize them today. They were often not equipped to handle urgent medical cases with the level of expertise and resources available in modern emergency departments. The concept of specialized emergency room ...
Counterarguments
- The evolution of the EMS system, while significant, may not have been uniform across all regions, with rural areas potentially lagging behind urban centers in implementing standardized practices.
- The characterization of pre-1970s emergency responses as uniformly inadequate may overlook existing pockets of effective emergency care and innovative practices in certain localities.
- The role of house calls by doctors in managing medical emergencies could be seen as a form of personalized care that has benefits, which are lost in the modern EMS system.
- The impact of the National Academy of Sciences study might be overstated if other concurrent studies or societal pressures also played a significant role in the establishment of a nationwide EMS system.
- The idea that emergency rooms were not specialized before the mid-1970s might be too broad a generalization, as some hospitals may have had specialized trauma care even before this period.
- Dr. J. Frank Pantridge's concept, while innovative, may not have been the sole or initial catalyst for change in the EMS system, as other individuals and countries were also exploring similar improvements.
- The Emergency Medical Services Act of 1973, while a major legislat ...
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Roles, training, and challenges of EMTs and paramedics
Josh Clark and Chuck Bryant delve into the essential yet taxing world of emergency medical services, discussing the differences in roles, training, and challenges faced by EMTs and paramedics.
Emergency Medical Technicians (EMTs) undergo shorter, more basic training compared to the more advanced Paramedic certification
The first national standard curriculum for EMTs and paramedics was established in 1977, setting the stage for the systems in place today. EMTs have between about 120 and 150 hours of coursework. They’re trained to handle life-saving procedures such as CPR, oxygen administration, and severe allergic reactions. However, EMTs are not cleared to perform invasive treatments like administering injections, which leaves them limited in their medical capabilities compared to paramedics.
Paramedics, on the other hand, face about 10 times the coursework of EMTs, with 1,200 to 1,800 hours depending on jurisdiction, which includes the ability to provide advanced emergency care. Some of their responsibilities include giving IVs, dealing with heart attacks, and operating defibrillators. The cost of paramedic training can be steep, approximately $10,000 just for tuition, not including additional expenses for books, equipment, and uniforms.
Paramedics often face grueling work schedules and relatively low pay despite the high-stress, high-stakes nature of their jobs
Employment for these professionals is in demand, but the job doesn't always pay well. The mean annual wage for EMTs and paramedics was about $31,000 a few years ago, whereas the top earners made around $54,000, and in certain areas like Washington state, the income can reach up to $71,000. Clark and Bryant suggest that paramedics, much like school teachers, are driven more by passion for their work than the fina ...
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Roles, training, and challenges of EMTs and paramedics
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Counterarguments
- EMTs, while not trained in invasive procedures, are critical for providing immediate care and can be essential in stabilizing patients for transport.
- The distinction between EMTs and paramedics in terms of scope of practice is not always clear-cut, as some regions may have intermediate levels of certification that allow for some invasive procedures.
- The cost of paramedic training, while high, can be offset by scholarships, grants, and in some cases, employer sponsorship, which is not mentioned in the text.
- While paramedics do face grueling work schedules, there are variations in shift patterns, and some services may offer more sustainable work hours.
- The statement about paramedics waiting for calls at street corners may not reflect the diversity of EMS systems, where some have well-established stations and dynamic deployment systems.
- The comparison of rural paramedics to traditional country doctors may oversimplify the range of services and the complexity of care that paramedics provide.
- The assertion that paramedics are driven more by passion than financial rewards could be seen as a generalization; motivations can be multifaceted and include a combination of passion, financial necessity, and other personal factors.
- The reliance on Medicaid and Medicare reimbursements is a compl ...
Actionables
- You can show appreciation for EMTs and paramedics by writing thank-you notes or providing care packages to your local station. This small gesture acknowledges their hard work and dedication, despite the challenges and low pay they face. For example, you could include items like energy bars, hydration packets, and hand warmers that they might find useful during their long shifts.
- Consider enrolling in a basic CPR and first aid course to better understand the initial level of training EMTs receive. This not only gives you a practical skill that could be life-saving but also provides a deeper appreciation for the medical professionals who undergo extensive training to serve the community.
- Advocate for better funding and support f ...
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Systemic issues with the funding and logistics of the EMS industry
The EMS industry is facing systemic issues related to funding and logistics, challenging the current emergency medical services delivery model since federal funding was pulled in the 1980s.
The shift away from federal funding for emergency services
Since the omnibus budget of 1981 removed federal funding for emergency services, the EMS system developed up to that point fragmented into a mixture of state, local, and county programs. This decentralized and underfunded system has led to disparities, with some regions having multiple competing private ambulance providers, while others contend with long response times and limited access to advanced care.
Decentralized system: Competition and disparities
It's mentioned that there can be ambulance competition among local EMS services, and sometimes multiple ambulances may arrive at a scene, causing complications. The idea that competition would improve services led to the privatization of EMS, but this has not consistently resulted in better outcomes. New York is one place that’s scaling back on the privatization of ambulance services due to these issues, and Las Vegas has resisted total privatization after finding private companies often had less efficient response times than the fire department or local EMS.
The reliance on Medicaid/Medicare reimbursements and its issues
The reliance on Medicaid and Medicare reimbursements has created financial incentives that may not always align with patient needs or the efficacy of the system.
Problematic financial incentives for patient transport
Josh Clark points out that Medicaid and Medicare only reimburse for transports to the hospital, which can influence EMS providers to perform unnecessary hospital transports to ensure they get paid. This reimbursement policy pressures paramedics to transport all patients, including performing continued chest compressions on an individual who is patently deceased, just to enable billing for tra ...
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Systemic issues with the funding and logistics of the EMS industry
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Counterarguments
- Decentralization can foster innovation and tailored solutions to meet local needs, which a one-size-fits-all federal approach may not provide.
- Privatization can lead to increased efficiency and cost-effectiveness in some cases, as private companies may have more flexibility to innovate and respond to market demands.
- Competition among EMS providers could potentially improve service quality and response times as companies strive to outperform each other.
- Medicaid and Medicare reimbursements for transport to hospitals are designed to ensure that patients receive necessary emergency care, which is a priority for these programs.
- Transporting all patients, including those who appear to be deceased, ensures a standard of care that accounts for rare cases of misdiagnosed death and potential legal liabilities.
- Overcrowding in emergency rooms is a complex issue that involves many factors beyond EMS practices, including healthcare system inefficiencies and a lack of alternative care settings.
- Ambulance diversions, while not ideal, are a mechanism to manage resources and can be a necessary response to ensure patient care when ER capacities are exceeded.
- Fiscal sustainability challenges in the EMS i ...
Actionables
- You can educate yourself on the EMS system to make informed decisions during emergencies by researching alternative care options in your area, such as urgent care clinics or telemedicine, which could be more appropriate for non-life-threatening situations and help reduce unnecessary hospital transports.
- Understanding the local EMS structure and the types of services available can empower you to choose the most suitable care in an emergency, potentially alleviating the strain on ambulance services and emergency rooms. For example, if you have a minor injury, consider whether an urgent care clinic could provide the necessary treatment instead of calling for an ambulance.
- You can advocate for EMS system improvements by writing to local representatives to express concerns about the current state of emergency services and suggest the need for reforms that prioritize patient care over financial incentives.
- By voicing your concerns to policymakers, you contribute to the dialogue on EMS reform and highlight the importance of aligning financial incentives with patient needs. For instance, propose ideas like reimbursing EMS for on-site treatment when transport isn't necessary, which could help reduce unnec ...
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