Will the Average Play in Peoria?

At first glance, the title of this may not make much sense, but bear with me. This is a compilation of three separate articles that I have had in mind but combined due to intersecting messages; not coincidentally, it is also less work to write one as opposed to three.

I recently completed a rewrite and update of emergency medical guidelines for one of the larger cities in my area. While there were additions and changes, my greater effort was directed toward translating them into street medic language. There are many more physicians than ever who are highly involved in EMS. Excellent laboratory research has produced much potential for advancement of prehospital care, although some of the pig studies in the lab do not seem to be very kosher. The results, however, must be plainly presented for consumption.

Many developments also arise out of well-intentioned studies that would ideally be randomized, double-blinded and prospective in nature, but are often retrospective and based on limited data. At times they offer the potential for better outcomes based on a bundle, or combination of multiple changes. This can lead to a conclusion and change of guidelines based on the aggregated results; the whole is often greater than the sum of its parts. This should lead some to wonder whether the manipulation of one variable at a time from the bundle might lead to even better outcomes.

There are two major themes that I keep in mind, whether teaching or constructing guidelines. The first is whether the average medic in the field will understand the reason for following the written guidance. I have found that providers are more likely to perform as expected if they understand why they should. Of equal importance is that the document is written in plain and concise language that is clearly understandable. In simple but older terms, will it play in Peoria?

Several EMS-based studies in recent years are based either on data predominantly provided by one vendor representing a portion of the services who utilize their services, or a summary of all the data that is provided to the national system. It is often said that if you have seen one EMS system, you have seen one EMS system. An average of either all systems or the users of one particular vendor does not necessarily represent the results of your system. To rephrase, is it the average in Peoria?

There is a fairly recent initiative to reduce the use of lights and sirens for both initial response and patient transport. These are likely to be overused in many regions, but the underlying premise often is based on statements that equate light and sirens use to speed and increased fatalities. Much of the data is based on averages from disparate systems. 

Having responded to calls in urban, suburban and rural areas, it is apparent that average responses are different from the individual components. Combining them will give a somewhat inaccurate representation for each area.

The majority of patient transport should be handled under routine driving conditions. The obvious exceptions include alert patients for trauma, stroke and STEMI. 
The erroneous impression that speed is a component of lights and sirens responses or transports needs to be corrected. Many years ago, it was explained to me that the main purpose of warning devices is to enable you to maintain a consistent speed as opposed to the frequently seen rush to stop at the next red light. Traffic pre-emption has been available for decades yet is still not available in most areas. These are systems that truly enable that constant speed in a reasonably safe manner. A normal response in my city with frequent traffic congestion may be extended by over four minutes solely as a result of waiting for two traffic signals. The greater purpose of emergency response is to reduce that waiting time to brief periods that help ensure safe passage through negative intersections.

With regard to response, it would be ideal if telephone screening accurately identified those with genuine emergencies. I am very familiar with “average” data that shows the minority of calls that benefit from earlier intervention. One local jurisdiction in my area has a disproportionate share of overdoses and shootings, which are both often time-sensitive conditions. Lumping them together may produce an average that does not accurately represent either one. It is not uncommon to have an inaccurate perception of the situation until at least one unit has arrived and determined severity.

Standardized caller screening is also prone to distortion of both under- and over-estimation due to either calltaker underestimation of a situation based on key words or caller overestimation as they perceive certain answers to produce a more urgent response. I have been told that this amounts to a small percentage of calls. It would seem apparent that the small percentage might be significant if the loss of brain, heart or life affects close to home.

One area that can be applied universally to every system, regardless of circumstances, is better selection and training. Perhaps it is long past time that we hand the keys to the newest EMT in our agency and hope for the best. Emergency driving is a potentially deadly serious process that requires training, judgment and restrained execution. I have responded with both very experienced and inexperienced drivers who performed with little patience but ample disregard for the potential actions of those around them on the road.

There is much knowledge to be gained by learning from the increasing number of studies that are performed on our operations. While proceeding to assimilate data and conclusions into your system, it is highly worthwhile to evaluate their relevance to local circumstances, even if you are not in Peoria.  

Lew Steinberg, MPA, NRP, became an EMT in 1971, remains certified as a firefighter, paramedic and instructor of many disciplines, and still teaches for several fire rescue agencies. He is a former fire chief and, besides the prehospital environment, has worked in both the emergency department and outpatient surgery in-hospital settings. He may be contacted at ffpmlew@bellsouth.net