Stop Dissing Response Times and Start Dissecting the Argument

It is not hard to find an article that bashes the industry’s insistence on measuring response time as a performance goal. The latest one I saw was published just today in “Don’t let response times overshadow the role of EMS” by the respected author Arthur Hsieh. The flow of his article follows the traditional pattern of claiming that measuring time is an outdated historical artifact of EMS without any basis in science, followed by the inevitable near-contradiction confessing that time is critical is only a limited number of cases before finishing by imploring future leaders to take a courageous stand against the uneducated politicians who simply fail to understand our modern evolving business. Hsieh is certainly not alone in making this well-worn, if not self-serving and short-sighted, argument.

Assuming my readers are familiar with the clinical EMS process of assessment, let me present a reasonable differential in terms we can hopefully appreciate. First, what bothers me in the common debate is the assumption that what we see is the totality of the problem. The ingrained reflex of our ABC mnemonic is only for the initial impression, not the final diagnosis. We must resist the urge to simply treat the surface presenting problem and investigate even deeper for an underlying pathophysiology. Our assessment should probe whether the response time concept itself is really the source of the disease, or is it possibly the uncomfortable idea of a formulaic approach to system “compliance” underlying the measure that makes us protest so loudly? Are we taking our frustrations of prescribed protocols out on one single measure when it is actually any measure that attempts to pit arithmetic against our artistic judgement and the free expression of our healing knowledge? Another idea of an underlying cause may be that we equate good response times with unsafe speeds or the very real growing risk of ambulance-involved collisions from excessive speeds and increasingly inattentive drivers. Or could it be a frustration, often expressed as “running hot to a stubbed toe,” that suggests we are simply expending extraordinary efforts on the wrong cases altogether because current EMD processes are not adequately refined in order to triage our limited response options to the unworthy types of calls we are seeing lately?

Without exception, everyone that brings this topic up recognizes at some point that there are clearly instances where time is actually critical. STEMI, stroke, and anaphylaxis are usually among the list of obligatory concessions. Still, we seem way too willing to just “throw the baby out with the bathwater.” In the fire service, there is a well-known motto that says, “train like you fight, fight like you train.” To me, that translates to always practicing the things that are important even if it doesn’t make a difference every single time. There are often instances when (whatever “it” is) genuinely saves a life (whether your own or that of a patient). Sometimes, the “it” is time. There may not be any magic in “10 minutes” (or whatever your standard may be) or even the “golden hour” itself, but there is inevitably an “expiration” on our efforts. There is a time limit when the value of all our interventions diminish to the point that they can no longer buy back the life of our patient. A short response time gives us more time to consider options. It is no longer a question of “stay and play” versus “load and go”, but always to “think and act.” The anxiety of our patients and their family or friends at the scene are measurably lowered by our professional presence. If that is not your experience, then you may actually be correct in believing that your response time truly does not matter.

Just as we do our assessments, we can’t stop at the first symptom of a problem and treat it in isolation. We must often dig deeper to understand an underlying cause that needs to be treated more importantly than just the first observed sign of it. Hsieh is correct in saying that “It’s really time to move on and get with the times,” but  not by neglecting the value of our response, rather in addressing the underlying objection to having it measured. Politicians are never likely to admit to understanding our disagreement to measuring response times because they do not account themselves to us, but to the public that demands our prompt service that keeps them in office. If we insist on expending energy to attempt change, direct that energy in the most productive way it can be used. This begins by recognizing the root problem and the limitations of our interventions to affect change in it.

5 Comments

  • Dave Shrader says:

    I had meetings recently with a client in an underserved County. They have multiple tax supported volunteer organizations, and a City FD as EMS providers. The system is totally Balkanized with each agency doing it’s own thing. One agency failed to even respond to 66% of its calls last year. So, 66% of the time, their RT was infinite. Does that matter?

    Well, yesterday I had lunch with a guy who thinks so. 3 years ago, he called 911 because his father was hemorrhaging. He couldn’t stop the bleeding and called more than three times over the hour that it took to get an ambulance on scene. He lived a couple miles from the volunteer station and a few hundred yards from a fire station.

    Then, the crew couldn’t lift his father and wanted to call for a second unit. Fire was dispatched but got there after he did most of the work of loading his dad in the ambulance. The trip to the hospital was only 20 minutes, but his dad had exsanguinated by the time they got there.

    In conversations recently about the use of ALS and about RT’s I have often used two analogies.

    While talking to a Fire Captain who said that in his second capacity in a Volunteer EMS organization, they didn’t really need paramedics unless they called for an intercept. I asked him how often that the $2Million platform truck at his paid job had been used at a real fire. His reply was once in 7 years, but it was really important then. I told him that ALS RT’s are critical in 5% of patients, so they are more relevant than the platform truck that they need “for the big one.”

    When someone asserts that RT’s don’t matter, I invite them to hold their breath for 10 full minutes and tell me that again!

    I also, when talking with elected officials often ask why, if 90% of cops will never draw their weapons in a 20 year career, do we have them all carry guns and qualify regularly. Such a waste and possibly dangerous! Let’s just give a gun to the sergeants and let the cops call for an intercept by the sergeant when someone starts shooting at them.

    It is true that 90+% of calls are not really clinically time critical. It is true that studies (e.g.: Blackwell) have shown that RT’s do not statistically improve “all-cause mortality” unless we can get to them in less than 5 minutes (and BTW, some have done this with 90% reliability). But it is also true that for at least 5% of patients and the 1% that are cardiac arrests, the RT’s are crucial matters of morbidity and mortality. We prepare for the low frequency, high acuity events because they matter.

    There is also the matter of public expectations. When people call for help they a expect prompt, competent, and caring response. Anything less will eventually result in public demands for “better” service. One high profile event is often the trigger for a complete system change.

  • Jeffrey Hammerstein says:

    I think that the position someone takes on this issue depends entirely on the circumstances of the particular EMS system they have in mind when they consider the question. If we’re comparing a 7 minute response time to a 70 minute response time (or infinite as mentioned above), then of course it matters. That’s a no brainer. Save yourself the energy and astonishment that there are professionals out there saying that it doesn’t. That’s not exactly what they’re talking about when they make their point.

    I would expect that most argue for a broader look at patient outcome as the better measure of system performance as opposed to the simplest, easiest to score metric that, in the vast majority of situations, does not affect patient outcome. If you’re using patient outcome as the primary system performance measurement you will come across situations in which it most certainly did matter how quickly the patient got help. So in that sense response time is “covered” anyway.

    Having said that, there are 2 obvious extremes in which response times truly affect outcome. The first is the time-critical, immediately life threatening situation where the speed of intervention is the primary indicator of outcome (e. g. cardiac arrest, choking, severe anaphylaxis, severe hemorrhage, name your favorite, etc.). But it’s worthwhile to distinguish that in those cases, it’s not about ambulance response time as much as it’s about arrival of the first trained responder. A paramedic ambulance arriving on a cardiac arrest at 7 minutes vs. 15 minutes probably doesn’t have a measurable sway on outcome if there are effective 1st responders doing good CPR with an AED in tow. Add in the epi pen, narcan, nebulizer and CAT tourniquet to the other time critical responses here.

    This is an example of my point that the type of EMS system you’re thinking of is likely the main thing that influences your view of the question in the first place. Are you thinking of a system that sends only a single ambulance to a crashing respiratory distress with no other resources for miles around? Then you are understandably pounding your fist on the table yelling out that they’re crazy for even thinking response time doesn’t matter.

    The opposite extreme of the issue at hand is the ridiculously long response time. Obviously taking 70 minutes has a whole host of potentially bad outcomes. Included is the fact that a greatly extended times begin to collide with public expectation of emergency services. A complete failure to respond deserves no further mention, and I doubt you would find a single argument on any of that.

    I suspect when people argue that response time doesn’t matter, the system they have in mind is one that is reasonably healthy in the first place. They may have some good 1st responders in place, or the system they’re thinking of is arguing about a 9 minute response time vs. 16 minute response time. They’re saying, “Hey, I’ve got a way to show you how well our patients actually do” instead of non-experts making uninformed judgments on the quality of our service based exclusively on an entirely arbitrary measure of minutes. It’s as simple an argument as data vs. “I reckon.”

    The opening line of the original post says people are bashing the goal of measuring response time as a performance goal. I don’t think they are, and I think that’s where the misunderstanding begins. What they’re bashing is the idea that anyone accepts response time as THE measure of EMS performance. You need look no further than the title of the article rebutted: “Don’t let response times overshadow the role of EMS.”

    Don’t let them overshadow. To me, that couldn’t be better advice.

  • John Riggs says:

    Times are measured because:
    (1) its easy to measure time (and by extension, not easy to measure “good patient care”) and
    (2) the faster (ie: less time) you take on patient A the more patients (B-ZZZ) you can see.

    Time is therefore an extension of money. EMS has become more and more about this and it is reflected more and more in our public image and our own self image as well. And this is what is killing the profession.

  • Joseph Zillmer says:

    Response times are of course important. Hindsight on same is easy. If we don’t strive for excellence why are we here? Excuses on delays, does not change the fact that it is our first priority (assuming we have trained personnel that are adequately trained). The question is rhetorical.

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