Last week I was passing through an airport with a two hour layover. Shortly after landing, I was strolling up and down the concourse looking for food when I suddenly noticed a crowd beginning to gather surrounding a man seizing on the floor. I made my way quickly into the group and heard advice being shouted out to “hold him down” and “put something in his mouth” as well as “someone go grab the AED.” I knew this victim needed help, not only from any potential self-inflicted injury, but also any detrimental effect from the good intentions of the Samaritan crowd. While there is a whole story I could go into regarding the need for public education on epilepsy, or first-aid in general, what struck me most was the comments I began to hear about 20 minutes later. ”Where are the paramedics?” “So much for an 8 minute response.” “They’re never in any hurry.” While another airport recently had a deadly responder delay involving security, I do not believe these responders had any unusual circumstances. Still, I felt the desire to explain and justify my colleagues’ response, but it also made me pause and reflect on just how the public views EMS response time during a personal crisis.
I don’t know what would have happened to the man if I hadn’t been there to fend off the well-intentioned. Regardless of the severity that a call is triaged into, this was an excellent visualization of the practical chance of further injury that a patient may sustain at the hands of bystanders before medics arrive. In a very real sense, a fast response may reduce the likelihood of further injury to many patients. Were respiration or circulation to have stopped, as could have happened due to choking in this case, the patient outcome would have been considerably worse with any minutes lost. Add to that a genuine threat of an external MOI were the convulsing patient to be forcibly restrained or shocked, we have just cause for an timely response. Then from a community politics perspective, response time is also important. The 20 minute response I experienced in this case was much better than the 30 minutes a City Councilwoman in NY waited for an ambulance after her 18-year old intern collapsed. This lag gave the council member plenty of time to make calls to police and fire officials. And to this black eye, add the specter of public anxiety as there is a growing concern by many citizens that they may have to assist in a medical emergency at some public location before EMS arrives.
There are two objections I expect you are thinking about. The first is the so-called “fact” that response time doesn’t really matter as the “8-minute” response standard has no scientific foundation. But whenever I hear a medic say that response doesn’t actually matter, it reminds me of someone trying to convince himself that he doesn’t need to pee even though he knows he really does. No amount of wishful thinking can significantly alter the underlying physical condition. At some point, you must yield to nature’s call. However, to be fair, I admit that the statement also makes me think of those all too common “routine” calls where additional minutes, or even hours in some cases, would actually have very little impact on the patient outcome. Still, we must be careful not to allow the “norm” to become an “absolute” in our minds. Just because a majority of calls can wait, doesn’t mean they should wait or that every other call we will take would be similar. Each call is unique and has several participants, not just the patient. And while they may not be accurate judges of time, the situation affects them all. And while I agree that 8 minutes cannot be justified, a 4-minute response can be – particularly when it comes to cardiac, stroke, or respiratory failure events. As this goal seems impossible, it is easier (and plain careless) just to say “it doesn’t matter” since we simply assume it is not practical.
The other common objection is safety – both of the responders and the general public. Undue haste in responding to a call puts not only the medics in danger if the vehicle exceeds safe operating conditions, but others around that vehicle as well. However, whether we like it or not part of the performance we are judged on is speed of response. In fact the mere consideration that the parent company of a private service would issue an IPO was enough to cause concern regarding potential future response times. Unfortunately, the way we react to performance measures depends on who we represent. Most medics I know will put the patient first and foremost. Their decisions are based exclusively on the expected outcomes of treatments not the economics. Union representatives are tasked with preserving jobs and will cite facts to support the means to protect jobs of union members. An example is the EMS workers union charging that an FDNY change in the calculation of response time statistics misrepresents the efficiency of that agency. Administrators will take positions that ensure legal compliance with contractual agreements to ensure the preservation of the service. In each case, response time plays a role.
It is common for services to be measured on performance standards including the time between dispatch and arrival. While it is fair to question an arbitrary 8-minute standard when it comes to measuring improved patient outcome, it is a valid criteria if it was agreed to by contract and failure can mean a negative employment outcome. But is the assumption of fast response time mutually exclusive with safe operation? We train to perform and perform as we train. If an efficient response measure were to be removed, we will then perform to the remaining measures.
In my mind there are at least two ways to improve a response while still maintaining a safe environment. The first way is to implement EMD protocols for dispatchers in the PSAP who could then provide immediate first responder assistance at the time that the call is taken. When this works correctly, the effective response time is zero. The other method is to pre-position ambulances closer to the call before it is made. When this is done correctly, the ambulance does not need to operate hastily in order to arrive within the response compliant time. While this idea sounds a little like the movie “Minority Report”, it does not require “precogs” but only existing proven System Status Management (SSM) optimization tools.
Sedgwick County EMS has used components of the MARVLIS system in their operation. Their experience with posting ambulances has meant that response time compliance has been regularly achieved to the point that it has become a measure they look back at for the previous month instead of pushing in the moment. Dynamic deployment of resources allows them to achieve better responses by better utilizing the current level of resources in the system at any given moment. This efficiency has allowed them to focus on improving patient care instead of monitoring response time. Come to think of it, perhaps they have proven that response time is not an operational management objective after all, but that safe and effective care are the measures to be used in a high performing EMS service.