Improving EMS part 3 Regulation

ImageThis next portion of how to improve EMS may be controversial. Depending on your political leanings this could be anathema.

I will be very blunt to hopefully diminish any misunderstandings. I also want to start by saying this may be very restricted to what happens in the USA and maybe even just what is needed in my home state of Texas. This is after all where I work and see most of the first hand things that happen in the EMS systems around me.

We need more regulation in our industry and more power given to those tasked with regulating it. Currently if a semi-truck driver is working and he is pulled over by the state troopers that truck driver is responsible for everything going on with his vehicle. Broken lights, missing license plate, too many hours on the road without taking mandatory breaks for sleep and he can get cited and even stopped completely until he complies. A paramedic can work 48 hours or more and no one even thinks to question if he is still safe to operate an ambulance.


 We can talk about how much this would cost, or who would implement it, or even if it would initially be more of a burden followed by the benefits it would bring across the field. What is plain to see is that it would help normalize what is expected from ems in the long run. Imagine if a police officer working for one city went and worked another full time job somewhere else. Adding up both full time jobs would only equal 80 hours. There are some medics that can work 96 hours per week and no one examines it, no one even is tasked with trying to look into it. Some companies are policing themselves, but even then it is sparse and hard to do if other companies are hurting for medics. We can talk about why it shouldn’t be necessary for a person to work so much to provide for their family and the role of increasing pay for medics across all levels would help cut this down, but no one wants to begin the conversation of setting concrete limits on amount of hours worked in one shift, let alone in one week or some sort of network to monitor if they are moonlighting somewhere else.

Some will come right out and say the agencies are already in place for dealing with these types of incidents and much more. The state regulating agencies and so forth. So let me tell you a story of an ambulance service in a nearby area. In the past few years this company has been investigated and fined for animal cruelty, lacking necessary medical equipment such as oxygen, dextrose sticks for their glucometers, functioning lights both in the patient compartment and emergency light bars. There were cases against that ambulance service for hiring a registered sex offender and then mandating he work on an ambulance that went out and made contact with children. There were cases of missing equipment on an ambulance that responded to a cardiac arrest, the missing equipment? A cardiac monitor.

With all this going on with the service, surely the powers that be, who sided against the ambulance service, must have taken some pretty drastic steps to prevent it from happening again. So what was the result of all of these incidents? A fine. The service was never even threatened with closure or suspension of their license. Accidents involving serious injury to medics, even deaths, have happened with this company. Two of them, at least, were a direct result of a medic being on duty for too long and lack of equipment. (One case involved a paramedic who was on duty for 36 hours with the last 9 or so hours spent driving, the other case involved a unit deficient in needed emergency supplies that made them transport a normally code one transport code 3 that resulted in a massive collision with a death and six other people transported to the hospital.) This has to be an isolated case? A fluke in the system. Unfortunately that is not what I have seen. Sure we occasionally hear about a suspension, a closure of an EMS service, usually these are due to extreme financial problems within a company and not a direct result of deficiencies or a state agency taking action. Suspensions of medics are usually drawn out affairs and I have heard of many more cases involving very bad care go unpunished, not because there was a lack of evidence or a clear lack of explanation by the medic, but because the agency tasked with investigating was overburdened. Can you imagine how fast companies would rush to comply with each and every rule if one day, just for one day even, they started shutting down ambulances on the spot if major deficiencies were found?

I did an informal survey in my area, two things came into shocking focus. One: most EMS personnel do not even know where to look for the rules and regulations that can cause the state agency to suspend, fine or decertify them. Two: most EMS personnel were more afraid of getting sued than being punished by a state agency. Even though no one they personally knew had ever been successfully sued. (This survey is still in progress and if anyone wants to participate just let me know, it is only a few questions and will be used in a future post.)

I’m going to take this argument one step further. Critical Care ambulance services. Currently there is a local hospital that requires critical care ambulance transports for cases they cannot handle internally. There are 4 services that rotate throughout the month. Each service takes a full week of transfers. Each of the ambulance services that provide the care say they are critical care certified and have the capabilities to do these transports. The differences between the services is staggering. One service carries LTV ventilators as well as Carevents on each and every critical care ambulance as back up, along with the usual assortment of BVM’s, ET tubes, LMAs, Cric kits, EZIO’s, Lucas devices, IV pumps, refrigerators for medications and hypothermia treatment equipment. Training on ventilators is done by respiratory therapists and an unusual amount of training, at least for this area, is provided yearly. AMLS, NRP, PHTLS, ATLS, ACLS, PALS, and more that I’m not thinking of right now. Each of the critical care trucks must be manned by at least one flight certified medic.

Now that is one service out of 4. The other services, even though they are called critical care by the hospital, do not do any of this. Let me repeat, they do not do any single thing that I mentioned as far as training. All training is done in-house and such gems as these have been heard:

  1. I was told we didn’t need to know what PEEP was, just plug in what the RT tells you.
  2. I didn’t know we could turn on the waveform of the CO2 on our monitors, I thought we could only see the numbers.
  3. We went through that class too, well we got the cards, we didn’t really take a test or anything.

Now let me be extremely clear here, I am not saying the other three services are bad, but shouldn’t there be clear cut policy for who can and can’t be classified as critical care? Shouldn’t an agency be able to monitor who is taking these extreme patient cases out of ICU’s and transporting patients with extremely sensitive medications? In just my current area there have been at least two cases of a ventilator failing and a patient dying. I was not at those scenes and I know that some of these patients are very sick and can be troublesome, but it also nags at me thinking about some of the comments I’ve heard from even the people that provide training in our areas on critical care.

Can there be problems with more regulation and more power given to those that are entrusted with policing it? Yes, of course, but the problems we are facing right now in many areas are too dangerous to just be let up to the capitalist survival of the fittest. A coworker I talked to about this told me why I worry so much about this if our immediate area and service is not a problem and would pass any regulatory visit. I answered because I have family in other areas that may one day need an ambulance and may have to be treated by a service that has not been compliant with state regulations in a long time. It is because there should be very clear cut minimums when it comes to anyone providing ambulance transport. It is because a service that is cutting every possible corner and hurting people ends up hurting our reputation as a whole.

Any questions or comments are always welcome.


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