In response to my request for evidence that corner posting improves clinical outcomes, High Performance EMS author Dale Loberger writes:
Jersey City Medical Center has presented a case correlating decreasing response time with increasing ROSC showing that quick response saves lives.
I applaud the good work done by John Washko’s company and the people administering EMS in Jersey City. It seems to be working well. Response times are certainly one factor leading to success, but not the only one. At some point they added LUCAS devices and induced hypothermia to their treatment arsenal. Correlation is different from causation, and the argument that corner posting causes better response times, which cause increased survival, is still a stretch based on the information presented.
Jersey City also use a relatively small number of paramedics who, according to the JEMS posting webcast, see a lot of sick patients. In his July article, however, Washko wrote that he believes correlating survival with the number of paramedics in a system is absurd. It seems to be working with a small number in JC, but again, correlation is different from causation. It is also a densely populated city, which makes their model similar to others with high survival rates in Seattle and Boston. Other low subsidy/corner posting systems use paramedic/EMT ambulances for every call type and cover a larger area. Success with posting in JC may not apply elsewhere.
There is a distinct, palpable difference between companies that place some priority upon the health, happiness, and quality of their crews — in other words, they value their people — and those who simply view them as interchangeable certificates. The attitude that ANY business benefit to posting units in arbitrary locations is good enough, because there’s NO downside (because human considerations aren’t even on the table) is a red flag.
Dr. Parasite follows with:
Posting on street corners sucks. especially in ambulances with exhaust leaks or ones without fully functioning AC or heat, or for agencies that won’t let you run the truck when you are posted.
I feel you guys. I’ve been there in those trucks. I’ve posted near open air drug markets. Badly planned posting schemes are one symptom of a much bigger problem. I’ve been replaceable, so by my choice, I don’t work for that service anymore. Neither should anyone else. The EMS free market can fix a lot of this. Send me an email if you’d like to learn more about where I work now.
Dr. Parasite also writes:
Responding from a central station allows for an entire shift to eat together. it helps build camaraderie. it aids in communication. they can all watch a football game together, leaving when they have a call. Fire departments have been using stations for years.
Careful Dr. Running 24 calls in 24 hours out of a fire station is just as bad as the worst corner posting scheme. I did not attack Mr. Washko’s article promoting the minimum subsidy, revenue driven, corner posting model because it is necessarily bad, but because he sited no evidence to support it. If an EMS trade magazine ever published an article presenting the Fire-Service Based EMS Advocates positions as a best practice, I would use the same references and attack it just as violently.
Before arguing that stations are better, how does your service do with the things that matter? How many critical patients does each paramedic manage? How many advanced airways does each one place in a year? What is your cardiac arrest survival rate based on the Utstein Criteria? What is the 911 call to balloon time for STEMI patients? What is being done to make it better? We need to spend time between calls figuring this stuff out.
Skip Kirkwood writes:
So, I gotta ask. Every day, police officers get in their cars and spend their shifts on patrol. They don’t complain that they should be in a different environment.
Police officers do spend a lot of time in their vehicle patrolling. They catch the erratic drivers we try to avoid, and look for out-of-place vans in driveways. They also get bored, especially at night in bedroom communities. Cops in my area come from all over to go to a burglar alarm, just to get out of the car and hang out. We used to sneak away from our corner assignments to visit other crews on calls for the same reason.
The biggest difference I see is that cops have a career ladder. There are dozens of lateral and promotional career opportunities that get them out of the car if they wish. In EMS we don’t have that – yet.
The Unwired Medic asks:
Does anyone know of the rates of injuries for SSM EMS versus hybrid-systems EMS versus station-based EMS?
We don’t reliably track injury rates for any EMS workers, let alone by service type. I would look for something from NAEMT on this soon. They are doing great things with their safety course, event reporting tool, and fitness initiative. They could also use your help and membership dues.
Unwired goes on to ask:
How much cost savings is lost on vehicle maintenance, wear-and-tear, and fleet replacement in comparison to maintaining a station and not having to run a truck 24 hours a day to maintain the environment and charging the electrical systems.
Vehicles are disposable, just like people at some of these services. They are cheaper to replace than to construct, maintain, or rent buildings at strategic locations. If you’re looking for an argument against posting, that one will lose. Ditto about posting in dangerous areas, because nothing bad about it has been publicized about it – yet.
Sleep is important for shift workers. Police, fire, EMS, and emergency medicine. We need to be incorporating naps into our schedules. Lack of sleep may result in the wrong medication going into the patient’s veins.
Unlike Mr. Washko, he even has a reference for this. Corporate productivity consultants also promote time for napping and exercise into 8-hour work days for people. Since we are never more than 10 minutes from being thrown into the middle of hell, short naps are a good thing. When we must work at night when our body think we should be sleeping, maybe they should be a bit longer. Just don’t do it while posted in Crack-fina.
Short naps should not be hard to sell. If anyone has a problem with napping on duty, ask them to close their eyes for 20 minutes and think about it. On the other hand, too many EMS people expect to sleep for a significant portion of their shift. This serves us instead of our communities in a number of ways. Whether it is to go to another job or because of poorly designed shifts, it hinders us from growing as a profession. There’s too much work that needs to be done between calls to make EMS better.
What we need is to collect data and scrutinizing every delivery model. We need to look at what actually gets delivered to each patients, measure how effective it is, and work backwards to figure out the best way to get it there. It must not be clouded by any prexisting beliefs or idelogies. Right now we just have a lot of expert opinions with little evidence to support them.