Establishment of a national office representing city, state, and federal EMS (Emergency Medical Services) departments and agencies is a proposal that has been discussed for years. Last month, George Washington University’s Homeland Security Policy Institute gave the proposal new impetus with the release of an “Issue Brief” titled Back to the Future: An Agenda for Federal Leadership of Emergency Medical Services.
The United States Fire Administration (USFA) is a subunit of the Department of Homeland Security (DHS). The goal of USFA is to improve the quality of fire protection within the United States. The USFA’s organizational structure is broken down into four components to match the agency’s major roles: fire statistics and data; fire education and training; public education; and fire technology.
The USFA does an exceptional job in meeting all four goals for the collective U.S. firefighting community. Not surprisingly, inclusion of the USFA in the Department of Homeland Security has heated up the discussion of establishing a National EMS Administration as well. The argument goes somewhat as follows: In the emergency-response world as well as in the homeland-security world the availability of a cadre of responders who can provide lifesaving care, immediately and on the scene of a disaster or terrorist incident, both to the public and to other responders can mean the difference – literally – between life and death. (This is why many SWAT teams and rescue units have specially trained paramedics on their teams.) The importance of this role should be reflected in the type of support and resources provided at the federal, state, and local levels.
What Is EMS and Why Is it in DOT?
EMS, simply put, is a system devised to provide medical care while transporting sick or injured people to the hospital. During the early age of EMS, ambulances were run by mortuaries and often served double duty as hearses, very little if any medical treatment was provided, and the “ambulance” was simply two strong backs and a ride. After the publication of the National Academy of Science’s (NAS) White Paper Accidental Death and Disability: the Neglected Disease of Modern Society, ambulances moved forward from the two-strong-backs stage to a model for providing first aid at the scene. The NAS White Paper pointed to accidents as the major cause of death among the young and suggested that many of these deaths could and would have been prevented if simple lifesaving care had been provided prior to arrival at the hospital.
Because the white paper’s principal focus was on car accident fatalities and injuries, the federal role in EMS has always been assigned to the Department of Transportation (DOT) – more specifically, to the National Highway Transportation Safety Administration (NHTSA). This first-aid model has grown to encompass the entire scope of emergency medicine. Paramedics now provide medications on the scene and carry out various lifesaving techniques both on the scene and in the back of the ambulance on the way to the hospital.
An important divide within EMS has always been emergency versus non-emergency. Emergency or 911 ambulance work is just what it sounds like: transportation from the scene of the emergency to the hospital. Many patients are too fragile, though, or are bed-bound, and/or require too much care to travel home from the hospital – or to other ancillary treatment facilities – in anything but an ambulance. Today, this is the realm of the non-emergency ambulance.
Despite this distinction, these two functions are regulated in the same way and, to perform in either realm, the ambulance must have the same equipment and staffing. Often the same ambulance will perform both roles within the community.
The other important ways in which EMS is divided as a community is similar to those within the firefighting community – volunteers vs. paid career staff; municipal government agency vs. third-party; and the varying types of units involved.
A Vital Component of the First-Responder Mix
“Why all the commotion – it’s just ambulance drivers [who are involved]?” That is a question that is frequently asked (here it should be noted that the term “ambulance driver” is considered by most in the EMS community to be pejorative). Why? The answer is that, because almost everyone needs emergency care and a fast ride to the hospital at some time in his or her life, the kinds of emergencies that the DHS was created to prepare for require trained medical staff significantly more than the “normal” emergency does.
Consider one of the principal events that led to the creation of the DHS – namely, the terrorist attacks of 11 September 2001, and specifically the attack on the World Trade Center (WTC) in New York City. Emergency medical technicians (EMTs) and paramedics rushed to the scene of the disaster along with firefighters and police officers, carrying out their role of providing patient care in the plaza surrounding the WTC – until they were chased from their positions by the falling towers.
It is indicative of the dedication of these professionals that, like their police and firefighter counterparts, they dusted themselves off and walked back toward the plaza after the collapses. At that point, the New York Task Force 1 Urban Search and Rescue Team (NYTF-1) moved in to join the search for survivors in the moonscape of WTC; the paramedics and EMS physicians were an integral part of that team, and continue to serve in that role today.
The simple answer to the question is the same for the WTC collapse on 9/11 as it is to the two-car accident on the highway: Patients do better when they are provided early care.
One of the major distinctions between the fire, police, and EMS communities is that, although there are some for-profit EMS agencies, there are very few for-profit police or fire agencies. This distinction is often pointed out in the form of a question: “Should we [i.e., the state, federal, or local government] be funding the training of the staff of a for-profit agency?” A partial answer is that “we” already are. According to the Journal of Emergency Medical Services (JEMS) “JEMS 200”, an annual survey of the EMS systems of the 200 most populous cities in the United States, 35 of the nation’s 100 most heavily populated cities use one or more private carriers to complement their own 911 ambulance systems.
Many other cities and municipalities not large enough to make the list of 100 most populous cities also contract out at least some of their EMS work. In addition, many hospitals provide EMS services to the communities surrounding them. Many of these contractors and hospitals provide non-emergency transport as part of their day-to-day operations, and many also follow a plan that allows them to use all of their ambulances for either 911 or non-emergency calls.
As a result of this dual role (911 and non-emergency), there is no way to exclude those that do not make emergency runs from any agency that has responsibility for 911 calls. More important, however, is that during a catastrophic emergency even non-emergency ambulances will almost certainly be pressed into service. There was, in fact, a line of 25-30 non-emergency units on West Street, above the WTC, on 11 September 2001, and Yamel Merino, a MetroCare EMT, was lost that day as a result of answering a response assigned by the 911 system.
Why a NEMSA?
The reasons why many senior officials at every level of government say a National EMS Administration (NEMSA) is needed are much the same as those that drove the creation of the United States Fire Administration – i.e., the need for national EMS statistics and data; for the education and training of EMS personnel; for a public-education program in the EMS field; and for a national center for the advancement of EMS technology and science. Perhaps the most important reason, though, to shift federal EMS authority into the Department of Homeland Security through creation of a NEMSA is to give this critical first-responder community the ability to compete for training and federal funding within the overall federal bureaucracy.
Today, many local EMS agencies are unable to fulfill their domestic preparedness training needs in a meaningful, effective, and cost-effective, way. In reality, most of them simply do not have the resources needed to support responder-training or public-education programs on their own. There are some exceptions, of course, such as a few of the major municipal EMS agencies – the EMS agencies in New York City and Seattle, for example, have a wealth of experience and data about what they do. However, most other cities and towns throughout the United States are protected by relatively small, often volunteer, organizations.
Even a small local department may be able to develop an exceptionally good program focused on a single need or requirement – usually, though, because it has someone who is both knowledgeable and experienced in that particular field. The same department, though, may be out of date and/or lacking expertise in many other areas. A national-level program would allow all EMS departments and agencies to pool their expertise to meet a significantly varied menu of needs and priorities, contributing when and where they can to other departments, and drawing from those other departments the expertise and experience they may be lacking.
EMS Statistics and Data
Although there are many studies that indicate one medical treatment may be better than another, few address the specific needs of the pre-hospital environment. Moreover, the same studies often are driven by a manufacturer’s need to demonstrate effectiveness and safety. A national data program could not only study specific treatments, but also look at the national EMS system as a while, in the same way that fire statistics collected by USFA look at firefighting as a whole.
One might ask why and how it helps to compile data “without a focus and a goal.” The answer is that extraordinary findings often emerge when data is compiled over a large system and for a considerable length of time. That is why the USFA compiles fire data. In short, because unknown, and often unsuspected, patterns emerge from such data, and questions can be raised that might otherwise never have been asked. Most local EMS agencies do not do the volume of work required to allow them to look at the data collected in a statistically significant way. By spreading the data collection nationally, the volume of information compiled rises to a relevant level rather quickly.
A National EMS Technology and Science Center; The Education and Training of EMS Personnel
In addition to the collection of data, there logically should be a way to promote the creation and/or improvement of technology based on that data. Most comparisons of equipment and techniques within the EMS community are either funded by an EMS manufacturer, or occur as a side effect of a program supported by a national organization, or are set up in an ad hoc fashion to meet the needs of a specific EMS entity. There is no current federal entity assigned to review, support, and/or promote EMS science and technology.
There also is no national EMS training center. There are, though, a number of national emergency training centers – among the most notable are the National Fire Academy (NFA), the Emergency Management Institute (EMI), the Federal Law Enforcement Training Center, and the FBI Academy – and a number of contractor facilities focused primarily on homeland security and first-responder training.
Although some federally funded training programs address EMS issues, most do so as a tangential task, and not as the main focus of the program. As a result, EMS participants in such programs frequently gain additional knowledge (about a fire issue, for example) but have to meld that information into their EMS work. The problem with this approach is that each individual processes the information in a different way, based on his or her experience and other training, and this leads to an inconsistent and often incoherent final result.
A national EMS training center would provide the same benefits to emergency first responders in the EMS world as it does to those in the fire and law enforcement worlds.
A More Equitable Distribution of Resources
The main reason why many realistic advocates support creation of a NEMSA is to put EMS on an equal footing with other first-responder communities in terms of their respective positions within the federal bureaucracy. Currently, EMS receives only about four percent of the DHS budget. Considering that there are approximately the same number of EMS workers as there are policemen or firefighters – and that, as noted earlier, many of the same structural divisions exist within each of these communities – this is a somewhat troubling statistic. An examination of what is termed “call volume” finds that police departments generally receive the most calls, followed by EMS agencies, and then fire departments. There are a number of reasons for this disparity – including, of course, the praiseworthy effectiveness of the USFA both in promoting fire-prevention programs and in compiling fire data.
In short, what EMS lacks is a strong advocate agency that can compete at the federal level. Fire and police departments have – and both need and deserve – grant programs that help cover their normal operating costs. But the EMS community does not. Expensive pieces of fire apparatus can be purchased with grant funding, moreover, but EMS equipment usually cannot.
The bottom line is that, if EMS is ever to receive the recognition it deserves as one of the nation’s primary first-response communities – and, as a result, be funded and supported more equitably than it now is – it must have a federal advocate agency focused primarily on EMS. If and when enough citizens realize that their own survival, in times of national disasters or other emergencies, including terrorist attacks, depends primarily on the abilities, experience, and dedication of the EMS personnel on the scene, the current inequitable distribution of funding may change. Until then, the EMS community will continue its status as a second-citizen.
Joseph Cahill is the director of medicolegal investigations for the Massachusetts Office of the Chief Medical Examiner. He previously served as exercise and training coordinator for the Massachusetts Department of Public Health and as emergency planner in the Westchester County (N.Y.) Office of Emergency Management. He also served for five years as citywide advanced life support (ALS) coordinator for the FDNY – Bureau of EMS. Before that, he was the department’s Division 6 ALS coordinator, covering the South Bronx and Harlem. He also served on the faculty of the Westchester County Community College’s paramedic program and has been a frequent guest lecturer for the U.S. Secret Service, the FDNY EMS Academy, and Montefiore Hospital.