What ‘Level Zero’ Really Means in EMS

Rampart, Medic 13 with an incoming patient report.”

Go ahead, 13.”

I have a patient with a pulse of 120. ETA less than 10 minutes. Over.”

Well, this sort of report certainly leaves something to be desired. What is the age of the patient? For an infant, this may be a normal rate, but in a geriatric person it could be a bigger concern. Has the patient been involved in any physical activity? If the subject just completed a marathon it may not be a concern, but if the patient had been sitting on the couch watching TV and the pulse suddenly spiked, it could be a legitimate emergency. In any of these cases, we still need more information. The patient’s blood pressure would be another good measure along with age. Some OPQRST or SAMPLE would be enlightening too. A treatment, let alone a diagnosis, cannot be advised from this single piece of data.

In a very similar vein to our pulse example, there have been several articles written lately bemoaning the dangers of any particular EMS system having hit a ‘Level Zero’ situation some number of times in the last however many months. For instance, there is an article where San Bernardino firefighters attack AMR. Don’t misunderstand my point, not having any ambulances available can definitely be a serious situation, but how long does the situation last in each occurence? In any significant service area, its bound to happen at some point even with proper planning and normally adequate staff. My concern is the media attention over this single measure of an emergency health system. It may be that reporters finally got the message that response time was not a good defining metric by itself. But just like our bodies, an EMS organization is a complex system of interoperating systems. Performance is not defined by any single measure. Although individual metrics, however, can cause us to want to look deeper to understand the likelihood of potential serious problems.

A case in point is a story last year on Paramedics Plus in Sioux Falls, that revolved around two specific cases where an ambulance was not available for patients in distress. While this is not ever a desirable position, the compliance of the ambulance provider in question was 95% and even the investigative news reporter found that EMS arrived before the fire department’s own “first responders” in 25% of cases. Perfection is simply not easy to maintain. While not making light of any potentially serious situation, my intention is to place this measure within some context, just as a sole pulse reading is only a singular measure of performance and one that is not meant to be interpreted by itself.

The MARVLIS application, in use by almost every member of the AIMHI (Academy of International Mobile Healthcare Integration) organization (formerly known as the Coalition of Advanced Emergency Medical Services or CAEMS) is often viewed as a tool for improving response times. While it has proven to be beneficial in achieving that goal, that is not the only reason these “high value” systems use it. Improving individual response times also improves compliance. Consistently short response compliance can also have clinical value if the times are low enough in the right situations. Jersey City has correlated a response time near 4 minutes to improved ROSC. But other benefits are improved value in post moves. Not moving ambulances for the sake of changing posts, but in positioning units closer to their next call with fewer moves. This also means fewer miles driven with lights and sirens to improve crew safety. Mobile Medical Response (MMR) credits MARVLIS in their annual report with reducing their costs associated with unloaded miles driven. As a collection, these improvements mean more than any single measure.

The reality is that our profession is fundamentally changing. We are coming from an EMS world where measurements of specific vital performance are evolving into a diagnosis of value. Just as good vitals indicate good health, positive measures of performance will be interpreted as higher value. In the same way that a general impression should guide a clinician in measuring vital statistics, the evaluation of an EMS should also be guided by a broader vision of value rather than a microscope trained only on specific measures.


  • Oh, and as a reader pointed out to me, “Level Zero” doesn’t mean that there are no medical responders available, just no transport vehicles at the moment.

  • Justin Schorr says:

    Indeed Level Zero is a single indicator of system performance and can not be evaluated in a bubble. Logistics, crew turn around and especially hospital wall time can impact ambulance availability, but so can treat and release and alternate destinations.

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