Wednesday, December 29, 2004

Don't let the perfect become the enemy of the good

Rural Emergency Crews Fear Proposed Federal Rules

The link above is to an AP story on discussing proposed new national training standards for emergency medical technicians (EMTs). This is a subject dear to my heart since I served for over two years as an ambulance driver in what was then an all-volunteer basic EMS service in a rural and small town area of northern Berks County, Pennsylvania. At that time, most of the EMS services in the county were volunteers, and even some of the paramedics (EMT-P).

Before anyone reflexively says, oh yes, I want the most highly trained responders, consider what you are really saying. Do you think EMS ought to roll up on the scene of your emergency with an orthopedic surgeon, a cardiologist, an anesthesiologist and nurses in truck fitted out with a mobile operating room? That would be a high standard of care, but how much of it could we afford? On the other extreme you would prefer not to see the coroner's van pull up on scene. Somewhere in between we have to balance capabilities with availability.

In some locales, all EMS runs might be made by paid paramedics. This is a high level of care, but it can only be justified where there are high utilization rates and and a need for paramedic skills on a high proportion of calls, or where the taxpayers are relatively wealthy. In most places, what you get is EMTs on scene for all calls and paramedics sent only to the more serious trauma and respiratory or cardiac cases. The proposed new DOT (the origin of federal involvement was highway safety, not public health, so the standards fall under the Department of Transportation and not the Department of Health and Human Services) rules are designed to extend the skill set of basic EMTs. That is a desirable goal in general, but it will increase costs.

Some of the pressure for higher standards is motivated by concern for patients, but some is also motivated by the desire of those in paid services for higher wages to reflect their greater responsibilities. Also, every addition to the skill set adds skills that are less often used than most of those in the existing skill set. Skills you don't use often require more training time to maintain proficiency. Increased training commitments will also drive up costs for the many fire and some police services that require cross-training of some or all their personnel as basic EMTs. Expanded skills will likely also result in higher insurance premiums for EMS providers.

For volunteer services which are vital in vast rural reaches of the country, the higher initial training and the increased need for refresher training will put a serious crimp in the ability to recruit and train personnel. Not only that, but to the extent that we shift to paid services, we usually end up with fewer stations and that can increase response times significantly. There is a reason we put lights and sirens on those buses, it is because minutes count. In most cases, a basic EMT on the spot quickly is of more use to the patient than a paramedic by-and-by.

There is another reason to prefer volunteer to paid services which was not mentioned in the AP story. A community with 30 volunteers instead of a half dozen paid EMTs is one in which your chances of getting help quickly are actually enhanced. In my experience, most volunteers carried their own crash bags in their personal vehicles and might, while off duty, happen upon an accident before it was reported, or they might monitor the radio dispatch and respond directly when they were closer to the scene than the responding squad. I did both on several occasions. I also recall a mass casualty incident - a bus wreck on the Interstate - where many off-duty volunteers arrived long before the second, third, and fourth due squads could get to the scene. You can't get that kind of surge capacity out of an all paid service structure and you end up calling in back up from even farther away. And when you have a more general crisis like a blizzard or recovery from ice or wind storms, all your back-up services are likely in the same boat and have no extra capacity to offer to you. In blizzards in our area, I have seen volunteers responding to calls using their personal snowmobiles where no other vehicles could travel.

This is a prime example of how "one size fits all" federal regulation ends up serving many people very poorly indeed. There is an old saying that is very appropriate to keep in mind in any public policy debate, and it fits this case very well - Don't let the perfect become the enemy of the good. It means not letting pursuit of the very best standard which is actually unobtainable get in the way of a good standard which can be acheived.

Many communities rely on volunteers, not only in EMS, but in the fire service, auxiliary police, hazmat teams, emergency management and other essential roles. We ought to make it easier for people to volunteer, not harder.


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