Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Corner Posting – Better, Faster, and Cheaper than Stations – Prove It

A recent article in JEMS has reignited discussion about street-side posting.

Why?

One reason is that it is seen as cheap and some employers become tumescent at the thought of cheap.

The debate to define “acceptable” response times is finally coming to a head, with evidence-based research and customer satisfaction and expectations driving this definition;[1]

Evidence-based research?

Would that be something like clock-based time?

We do not have any evidence (that I know of) that response time is important – except for cardiac arrest.

Cardiac arrest is generally estimated to be about 1% of our calls. Whatever the percentage, it is tiny. Should we respond to every call as if it is a cardiac arrest?

If any of you think we should, please explain why.

If any of you know of any evidence that supports 7:59 response times, or 8:59 response times (on 70%, or 80%, or 90% of calls), please provide that, as well.

customer satisfaction and expectations driving this definition;

That is a part of the problem, we have a system that is poorly understood – even by the people who work in it (the medical directors, employers, and the people in the ambulances), but we let the least informed people tell us how to run things. There will always be some need for public accountability, but they probably do not want to be making decisions based on ignorance.

The people I have talked to are surprised, when I tell them how the system really works. Some don’t want to know. Some want to know more. If they have any expectation of needing an ambulance, they want to know that it is going to be available and competently staffed. They think that response times are very important, but we still have a lot of people in EMS who think that response times are very important. And nothing good seems to happen quickly when we’re having an emergency.

R Adams Cowley did some good, but he also dragged us deep into the superstition of The Golden Hour.[2] Many of us refuse to escape from that golden cocoon of ignorance. It isn’t gold, it’s urine, but as long as we are warm and wet, we are happy.

EMS is not just package delivery. Even if it were, the outcome for the package is more than just the pick-up time. Should out motto be What can Blue do for you? If you think so, UPS has a position that may interest you, although their slogan doesn’t rhyme. 😉

Prehospital medicine across the U.S. is, for the most part, standardized,[1]

No. EMS care can vary dramatically by travelling across a city line, or a county line, or a state line.

If this is supposed to be justification for ignoring that nasty medical stuff, then Mr. Washko has this backwards. The patients who really need EMS, need the medical care, not a savings of two minutes, or four minutes, or six minutes, just to be bundled into an ambulance for a carefree version of Mr. Toad’s Wild Ride to the closest ED (Emergency Department).

We can initiate care on scene and continue care on the way to the most appropriate ED.

Some services are even providing Community Paramedics, who don’t need to transport patients to the ED. That is a concept that might blow Mr. Washko’s mind – in a grow three sizes kind of way.

Grinch:
How could it be so?
It came without sirens! It came without lights!
It came without yelps, wails, or frights!
Narrator:
And he puzzled and puzzed, till his puzzler was sore.
Then the Grinch thought of something he hadn’t before!
“Maybe EMS,” he thought, “isn’t being first to the door.
Maybe EMS… perhaps… means a little bit more.”
[3]

Some have attempted to correlate survival rates with the number of active paramedics used in the system, but I find this absurd. (I know the e-mail inbox will be filled after this one with those who disagree with this statement.)[1]

Not absurd.

More medics = worse outcomes.

Skills are important. Diluting those skills among a bloated paramedic population that is three, four, or five times larger than it needs to be dilutes skills.

If we dilute skills, and assessment is the most important skill, then maybe we do need to drive fast.

We do not need to dilute skills. We need to educate the public, and those who drink the more medics = better medic Kool-Aid.

Sitting in the front of an ambulance and being placed on a street corner is not as comfortable as responding from a warm bed in a station’s bunk room, but it gets the medicine into a critically ill patient’s veins a lot quicker.[1]

Sleep is important for shift workers. Police, fire, EMS, and emergency medicine. We need to be incorporating naps into our schedules. Lack of sleep may result in the wrong medication going into the patient’s veins.

The results revealed that taking a single 20-min nap during the first night shift significantly improved speed of response on a vigilance task measured at the end of the shift compared with the control condition.[4]

There is a lot to criticize in Mr. Washko’s article.
 

Go read what Bob Sullivan wrote about the rest of the article.[5]
 

Bob also provides links to evidence that more medics means more skill dilution, but there is a lot of evidence, so I will be writing more about that.

And will anyone want us sitting in trucks, with out engines running, with increasing awareness of the connection between diesel exhaust and cancer?[6] Because we often hear people yelling –

Please, put the carcinogens in my backyard!

Footnotes:

[1] EMS Moves Toward New Care Delivery Methods
JEMS.com
Jonathan D. Washko, BS-EMSA, NREMT-P, AEMD
From the July 2012 Issue
Tuesday, July 3, 2012
Article

[2] The golden hour: scientific fact or medical “urban legend”?
Lerner EB, Moscati RM.
Acad Emerg Med. 2001 Jul;8(7):758-60. Review.
PMID: 11435197 [PubMed – indexed for MEDLINE]

Link to Free Full Text Download in PDF format from Acad Emerg Med

[3] How the Grinch Stole Christmas! (TV special)
Wikiquote
The original lyrics.

[4] The impact of a nap opportunity during the night shift on the performance and alertness of 12-h shift workers.
Purnell MT, Feyer AM, Herbison GP.
J Sleep Res. 2002 Sep;11(3):219-27.
PMID: 12220318 [PubMed – indexed for MEDLINE]

Free Full Text from J Sleep Res.

[5] Corner Posting: Better, Faster, & Cheaper than Stations? Prove It.
EMS Patient Perspective
July 7, 2012
Bob Sullivan
Article

[6] Diesel exhaust
American Cancer Society
Information page

.

Comments

  1. Frankly I’m disapointed that the spewing of one person’s opinions, without any references, not even bad ones, made it through the JEMS editorial review process. . What’s worse is that those opinions are presented as facts in a cover story.

    On the cover of June’s issue, there was a picture of a stroke patient on a NRB. The AHA has said this is bad for at least 10 years now. Lots of people take for granted that information in the trade magazines is accurate. Articles and pictures like this just lead to more confusion.

  2. Why do all system managers push this notion of a time critical response? Unless they can staff enough ambulances to get a crew on scene within 4 minutes of cardiac arrest, the arbitrary time requirements will continue to cripple advancement of EMS.

    Kudos, Rouge, you are right on track. Now how do we get the rest of the nation to understand?

  3. SSM is a fraud. 90% of our calls are not time sensitive, and posting/relocating/etc is as much smoke and mirrors as a NRB.

  4. Please! We still have people following the cookbook method of EMS that was drilled into them by instructors who had it drilled into them (not to mention they don’t know the difference between they’re/there/their, two/too, it’s/its. How many times have we seen the school of “Just in case”, “why not”, “it won’t hurt, “CYA” and my personal favorite “It’s protocol” drive the way EMS providers treat patients? Keeping this in mind, does it surprise you that we’re flying like a bat out of hell to get to a “leg pain for 5 hours” call? Does it surprise you that we are boarding/collaring a patient with back pain from spinal stenosis (for 4 years) and the driving like mad hitting every bump on the way? No.

    The average EMS provider was force fed stuff in school that gets them to pass a test. They then refused to learn what’s really going on out there and keep on keepin’on! The fact that some of them even so much as read JEMS shocks me, if it’s not the latest BestBuy flyer most don’t read anything (maybe the comics).

    Oh and heavens forbid you try and change things in your service because you’ll get a whole lot of “well, everyone I’ve talked to says you have to do _____.” Luckily shoving a bunch of peer reviewed publications in their direction usually shuts them up.

    Now I have heartburn. Hope you’re happy…I’m off to call 911. Just in case.

  5. Very disappointing article in JEMS. It’s really disappointing when a JEMS cover article spreads more of the “Earn Money Sleeping” insults.

    As EMS providers, we see these system designs as the means to earn money sleeping, but these designs are often ineffective clinical delivery models because of poor response-time reliability.

    It’s not like a station has to be a fully-equipped “man-cave” with HDTV, lounge chairs, and plush carpeting. Just someplace to sit down and eat, read, and nap when possible. Maybe Mr. Washko used all his station time to sleep; but many of us make productive use of the “down-time”.

  6. If I had my way, you, sir, would have a stage and a bullhorn to preach this message. Well done.

    • Here is my soapbox. I feel that there are many reasons why posting on a street corner and remaining in your rig does not provide a positive or safe work environment.
      1: For the most part our calls are not time sensitive and the 3-5 minute increase will not in any way result in a poor outcome for the patient. In addition if the area has appropriate resources (EMS first response) then the few calls that time may make a difference may be mitigated by good EMS.
      2: For the most part the young providers will not be effected by sitting in a rig for multiple hours or so in a less than adequate rig seat, However, As I advance in my career and age I have found that my back is probably suffering from many long shifts and my Chiropractor is benefiting from this.
      3. You will not stop people from getting a nap on duty so I would rather have the person responsible for getting me to the scene safely has that minute or so of standing up, walking and clearing the cobwebs before stepping on the gas pedal and responding. I have seen my share of partners (myself included) driving impaired by just waking up.
      4. We know that all of our vehicles are safe and sound with no hazardous exhaust fumes in the front compartment, (enough said). Any studies out there on the effects of long term exposure to low levels of diesel exhaust.
      5. When the companies expectation is that you do QA and CE while on duty, the front of a rig with a laptop in your lap looking down at a screen is not a productive work or learning environment, And again is probably not good for those of us with older backs. I have found that I am able to spend much more productive time doing QA and Continuing Ed while at a desk with a more comfortable seat and environment.

  7. I am disgusted that Paramedics are made to “post” on a street corner or at some gas station for hours and hours on end without adequate rest facilities … it is a crime against humanity!

  8. So, why is it only me, you and Dr. Bledsoe that see this and rail against it rather than just saying yeah it doesn’t work but that it’s the only “standard” we have and so we have to use it? I’m looking at you Mr. Washko.

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