Elmhurst EMS Must Avoid ALS Saturation

Emergency Medical Services (EMS) has become a contentious issue in the city of Elmhurst. Yet the inner workings of EMS remain an enigma to the public. I hope to give the citizens and leaders of Elmhurst insight and provide guidance for their EMS system.

Metro Paramedic Services provides Elmhurst with two advanced life support (ALS) ambulances that are each staffed with two paramedics along with an ALS SUV staffed by one paramedic. When compared to other high-performing EMS systems across the country, this is more than enough ALS. There is a desire to outfit the Elmhurst fire department to provide ALS services on its trucks. But do more paramedics and ALS resources on the scene of a medical emergency truly improve patient outcomes? In many cases it does not.

When supporting the notion of adding ALS capabilities to Elmhurst Fire Department, the members of the Annie LeGere Foundation cited the death of 13-year-old Annie LeGere. Their stance suggests that they believe more paramedics would have changed this teen’s outcome. There are concerns that possible paramedic incompetency was responsible for her death. But without an investigation that is transparent with the findings to the public, this is not a rational approach. There are better questions to ask. Local 3541 President Steve Talaski touted that the fire department goes “to 100 percent of the calls.” So where were they when Annie LeGere’s suffered a fatal allergic reaction? Acutely ill patients must simultaneously receive basic life support (BLS) with ALS. Firefighters and EMTs play a role in rendering BLS (CPR, manual ventilations, extrication, etc.) and driving the ambulance when two paramedics need to attend to a patient. But the idea that increasing the number of paramedics on scene is proportional to better patient outcomes is not well supported. Systems like Boston EMS and King County Medic One have the lowest paramedic to population ratios in the USA. Yet they have superior clinical capabilities and better patient outcomes in cardiac, airway, and trauma care compared to most EMS systems.

Consider where the Elmhurst fire union is coming from. In the Emergency Medical Services: A Guidebook for Fire-Based Systems (2003), the International Association of Firefighters (IAFF) claims that fire-based EMS is superior to other forms of EMS like private and hospital-based entities. Yet they do not demonstrate better patient outcomes. The fiscal studies that they use to justify single-tier, all-ALS systems do not address the monetary implications of overtreatment. Most low acuity patients with low-grade back pain, an ankle sprain, or mental health troubles could easily be transported to the ED via Uber, let alone a BLS ambulance. But the risk of overtreatment increases when you increase the number of paramedics in a system. All a paramedic needs to do is place them on the heart monitor or start an IV for whatever vague reason, and the amount that the EMS entity can bill the patient doubles even though they may have done nothing to help the patient clinically. This isn't to indiscriminately bash the IAFF- King County Medic One is a member of Local 2595, and they have one of the highest performing EMS systems in the country. But they abide by evidence-based medicine, not the subjective standards and status quo that tend to eclipse them.

To assume that outfitting two fire rigs with paramedics and ALS equipment while also maintaining those resources for a single five-figure cost is asinine. Even if the department already has paramedics, they must perform 100 hours of continuing education every four years and submit a renewal fee to recertify their license. Does the city plan on paying for this expense if they do not already? What about paying firefighter-paramedics an extra salary for rendering ALS? Equipment is not cheap. Heart monitors alone are a five-figure expense and require upkeep. Single use-equipment like advanced airways, ECG electrodes, IV catheters, fluids, and medications need to be replaced after use. They come with expiration dates, so one cannot store them indefinitely for patient use. Who is supposed to pay for potential overtreatment and excess equipment costs? The patients and their families? Taxpayers?

There are clinical consequences of ALS saturation. If one needed cardiac or brain surgery, would they want the surgeon who regularly performs these surgeries, or the surgeon who seldomly does them? Most would prefer the former. Critically ill and injured patients are a small proportion of the patients that EMS encounter. But paramedics must be on their A-game when treating sick patients. When a system has too many paramedics, they encounter acute patients even less frequently. It’s problematic for performing high-risk, low-frequency skills. Do you want a paramedic decompressing your chest, titrating your vasopressors, intubating you, putting an IV in your neck, or drilling into your bone if they haven’t done it on a live patient within the last year? That becomes reality in an ALS-saturated system. Multiple studies show a correlation between the number of times a paramedic performs a vital intervention, the success rate of such intervention, and patient survival. One may try to counter with an oversimplified stance; they wrongly assume that the hospitals are so close that these concerns do not matter, or that training can substitute for real-life experience. These claims are dangerous and will shortchange Elmhurst’s citizens in their most dire moments.

Instead of spending money on an ALS-saturated system, the city should consider the other aspects of EMS. Fund higher training for EMS. Mandate that all city paramedics carry certifications like ACLS, PALS, PHTLS, TECC, and Difficult Airway Course. Require staff to attend quarterly training and morbidity & mortality rounds. Send a cohort of paramedics to obtain critical care training. When it comes to quality over quantity, expand the paramedic scope of practice to allow for better patient care. Does Elmhurst’s paramedics have second generation airway adjuncts (RSI, video laryngoscopy, cricothyroidotomy), prehospital ultrasound, a prehospital sepsis program that includes lactate monitoring with broad spectrum antibiotics, or prehospital blood? If not, I would endorse spending in these areas instead. These are innovations in the EMS profession that many systems can afford when they do not overindulge in the other ALS expenditures.

I realize this Mrs. LeGere is devastated by the death of her daughter. Being asked to drive the ambulance to the hospital was nuclear-grade bonkers. Should the leadership have conducted a review as to whether the EMS crew had a clinical deficit? Absolutely. Should Metro Paramedic Services and city leadership have had a plan in place for critical calls to have multiple BLS providers to assist the two paramedics? Absolutely. But what the Elmhurst fire union and Annie LeGere Foundation are proposing is absurd. Perhaps it is time to rethink how the region renders EMS in general. Earlier in March, a Patch article by David Giuliani addressed EMS mutual aid between Elmhurst and surrounding municipalities. Maybe they should collaborate by merging their EMS systems and creating a multi-tiered, BLS-ALS system that is outfitted for the region’s needs. We need to develop new, efficient, and creative ways to render quality prehospital care using evidence-based medicine. Using a tragedy where not all of its aspects are disclosed is an inappropriate method of conducting public policy.

As a final remark, I want to stress how important it is for the city to weigh efficiency with EMS performance. Not everyone who calls 911 requires an ALS-level crew; to send one to every patient is a waste of resources in a profession with staffing and fiscal issues nationally. But those patients who require ALS deserve a high quality of care. The city has a level II adult trauma center and primary stroke center at Elmhurst Hospital, but keep in mind that it is about a 10-minute transport time from the city center. The closest level I trauma, burn, PCI, and comprehensive stroke centers are outside the city. The nearest pediatric trauma center is at least 25 minutes away at the John H Stroger Hospital. These transport times may increase depending on traffic and what part of the city a medical emergency takes place. Keep this in mind before assuming “the hospitals are so close that we do not need to consider how well paramedics perform.”

Additional reading:

• https://www.emsairway.com/2020/08/13/optimal-prehospital-airway-management-depends-on-ems-system-efficiency/
• https://www.jems.com/operations/too-many-medics-debating-a-tiered-response-vs-all-als-ems-system/
• https://usatoday30.usatoday.com/news/nation/ems-day1-cover.htm
• https://www.ahajournals.org/doi/pdf/10.1161/CIRCOUTCOMES.115.002317
• https://pubmed.ncbi.nlm.nih.gov/18584496/#:~:text=Conclusion%3A%20These%20data%20show%20a,risk%20skills%20are%20performed%20infrequently.

Disclosure: this article does not reflect the views of either Canton Rescue Inc, Brewster Ambulance Service, or Eascare Ambulance Service.

-Marty "MacFly" Pelletier

mepelletier@cantonfirerescue.com