The dispatcher had said, "21-year-old male, trouble breathing." But when paramedics Russ Bryant and Mike Haley arrive on the scene in North Philadelphia a few minutes later, the man is breathing just fine.
"What's going on?" Bryant asks him gently. "I tried to eat a whole stick of butter," he says. "On a bet. For a thousand dollars. I've been sick since then."
Haley checks his blood pressure and blood-oxygen levels. Butter Boy's vitals are normal. He's simply having an anxiety attack.
"You want to go to the hospital?" Bryant asks, his face betraying no hint of his frustration.
"Yeah," Butter nods. And off we go.
"You call, we haul" is pretty much policy for the city's emergency medical service (EMS) units, a means of covering the agency's ass while everyone else's butts hang out in the breeze. Already tonight, a heart-attack call was handled by a distant ambulance because nearer units were tending to nonemergencies. But at least that person survived: In Philadelphia, two 22-year-old men died from heart attacks after 20-minute waits for help that should have arrived in a fraction of that time.
"Some cases make the papers," Bryant tells me later. "But things happen all the time, and you just never hear about them."
None of this is unique to Philly. Nationwide, EMS units have become tasked with far more duties than they have the resources and leadership to handle — far more, in fact, than they were ever intended to handle. This has given rise to a whole host of risks, including sleep-deprived EMS crews, long patient wait times, and an entire field of emergency workers who lack the training to deal with a large-scale catastrophe, be it a chemical attack or another Katrina.
The exact depth of America's EMS problem is unknowable: Federal patient confidentiality laws limit the amount of information made public, and immunity statutes minimize the number of lawsuits initiated by families. But several years ago, a study commissioned by USA Today reached a startling conclusion: The researchers conservatively estimated that 1,000 cardiac-arrest victims die in the United States each year, in part because of slow EMS response. And that's for just one type of 911 call.
In Cincinnati, the brass running EMS admit that they often have more customers than ambulances, so people have to wait after they dial 911. "The phenomenon of 'no ambulances available' is becoming more and more common throughout the country," says Bryan Bledsoe, D.O.
Dr. Bledsoe is a clinical adjunct professor of emergency medicine at the University of Nevada school of medicine and has been the director of two emergency departments and 13 ambulance services. He literally wrote the textbooks on which the principles of paramedic care are based, making him an exceptionally good guide for navigating the issues facing the industry. He says that because of simple neglect on the government's part, EMS is a ragtag collection of private companies, volunteers, and city and county agencies unprepared for even the more mundane, day-to-day tasks.
"Some rural areas are really on their own," Dr. Bledsoe says. "And nobody thinks about it until they have to call for help."
This crisis could be particularly devastating for men. According to national traffic-safety statistics, men are killed twice as often in road accidents as women are. They also die far more often from the "unintentional injuries" the EMS system is supposed to respond to. And data from the Centers for Disease Control and Prevention shows that men are less likely to recognize the signs of a heart attack, resulting in a deadly delay before they even think of dialing 911.
The EMS emergency
Most state constitutions mandate such "essential services" as law enforcement and fire suppression, but make no provision for EMS. One reason for this, says Dr. Bledsoe, is that their constitutions were written long before EMS even existed. And given stretched state budgets, they're unlikely to take it on now. In the absence of government support, salaries for EMS personnel are low. In Montana, an emergency medical technician (EMT) makes as little as $14,000 a year. Most full-fledged paramedics in Oklahoma make less than $33,000.
"Rendering EMS a nonessential service is one reason the salaries are so low," says Dr. Bledsoe. "It's set up as a kind of job for young people who can live on the salary it affords. But once they want a family of their own, they have to leave the field." And leave they do. According to a December 2007 national survey by EMS Magazine, just about every state is short on paramedics and EMTs — some critically so.
People also leave the profession because of the ridiculously long hours — another result of budget shortfalls. The most recent survey of EMS providers published in the Journal of Emergency Medical Services found that 24-hour shifts remain the norm. This, the authors wrote, "raises serious concerns about safety for crews and patients."
No kidding. A 2008 study in Sleep Medicine found that moderate, repeated sleep deprivation is comparable to a blood alcohol concentration of .08 percent. "That's the legal limit for noncommercial drivers," says Brian Maguire, Dr.PH., a clinical associate professor of EMS at the University of Maryland at Baltimore County. That means if the man or woman who comes to treat you is nearing the end of a shift, he or she might as well be drunk.
To complicate matters, all these issues intersect: Low base pay and short staffing act as enticements to work more hours. As Bryant in Philadelphia says, "You can have pretty much as many hours as you want. There are always shifts available."
Broadly speaking, there are two classifications of EMS professionals: paramedics, like Haley and Bryant, who are trained to provide advanced life support (which includes administering medications); and EMTs, who are trained to provide basic life support (which mostly means CPR) and safe transport to the hospital.
In some jurisdictions, separate agencies handle these different functions. In a single ride-along with a municipally run EMT-level squad in Cherry Hill, New Jersey, the potential for fatal errors in this system was more than evident. The crew was first on the scene for two separate calls — an older man experiencing a heart attack and an aged man suffering a stroke. Though in both cases paramedic-level care might have benefited the patients, the Cherry Hill EMT unit had assessed the men, loaded them into ambulances, and prudently taken off for the hospital by the time the advanced life-support unit, carrying paramedics, arrived.
What this means for patients is chilling to contemplate. "In situations where we can transport the victim to the hospital before the paramedics would arrive on the scene, we don't always wait for them," says Randall McCargar, chief of emergency medical services for Cherry Hill. "Have some of those patients died? Yes."
Cops announce big busts with press conferences. Hero firefighters command the evening news. But paramedics toil in relative obscurity, largely because federal laws prohibit the release of patient information.
There is some irony here. If you look at the numbers, the political importance and public profile of EMS should be rising while the primacy of fire departments wanes: The number of fires in this country has decreased by half in the past 30 years, according to statistics from the National Fire Protection Association. Between 1994 and 2004, emergency-room visits have increased 18 percent.
You probably didn't know that at least seven EMS providers died alongside America's other heroes on 9/11, and many who worked the rubble pile now suffer from the World Trade Center cough.
Of course, the paramedics who respond to 911 calls are supposed to rescue us in the event of another terrorist attack.
But all the evidence suggests that they are woefully underprepared for just such an event.
A life or death situation
A recent study in Prehospital and Disaster Medicine discovered that less than 12 percent of the EMS responders in the United States are equipped to help victims of chemical weapons, leaving us faced with "avoidable civilian and EMS responder illnesses and deaths."
They are underprepared in another way, as well: "Though EMS providers are roughly equal in numbers to firefighters and law-enforcement officers," states a 2005 report from the George Washington University Homeland Security Policy Institute, "they received only 4 percent of the first-responder funding allocated by [the Department of Homeland Security]."
Here's one reason why: While the U.S. Justice Department represents law-enforcement agencies around the country, and the U.S. Fire Administration (under the U.S. Department of Homeland Security) serves as an advocate for America's fire departments, no federal administration exists to further the cause of EMS in Congress. The U.S. Department of Transportation comes closest to a federal presence, but its primary job is limited to setting the curriculum and minimum standards for the nation's EMS providers.
"Paramedics and EMS as disciplines don't have the same political clout as fire departments and law-enforcement units have," says Gregg Lord, a senior policy analyst for the Homeland Security Policy Institute. "It's incredible, but it's as if no one's been paying any attention to what's happening to EMS in this country."
For all the problems, solutions are being explored. For instance, some fire departments have noted their own decline in "business" and taken over EMS operations as a supplement. In Seattle, for instance, personnel are cross-trained to perform firefighting as well as EMS duties.
"They are good marriage partners," says Lori Moore-Merrell, Dr.PH., an emergency-response systems analyst for the International Association of Firefighters. "We believe that communities should take advantage of resources — vehicles and staffing — that are already deployed for rapid response to fire emergencies. These resources are equally useful in responding to medical emergencies."
Still, such marriages can work. Dr. Bledsoe says that when fire departments take on EMS care, their call volumes change so drastically that they become, essentially, EMS agencies. "They do 70 percent EMS on average," he says, "and 30 percent fire. And when they embrace that and support EMS, as they do in Memphis and Seattle and some other places, it works out well for everyone."
Of course, merging with fire departments won't settle the issue of federal leadership. A whopping 310-page book published in 2007 by the Institute of Medicine illuminates many of the problems cited in this story and calls on the U.S. government to create a lead agency for EMS at the Department of Health and Human Services. This would equate our nation's medics with fire and police personnel and wrest control from the Department of Transportation.
Having a new federal boss oversee EMS shouldn't interfere with mergers of ambulance services and fire departments. "The two federal agencies would just have to cooperate," says Dr. Bledsoe. "Fire departments and law enforcement work together just fine on issues like arson."
But so far the recommendation for a new federal home with authority over EMS has yet to be advanced by any politician, and no legislation is pending. Maybe that's why some people think emergency medical services will have to get worse before they can get better. After all, if the public isn't up in arms yet, if the politicians aren't calling for change now, what will it take to reverse the damage?
Scot Phelps, J.D., M.P.H., a paramedic and an associate professor for emergency and disaster management at the Southern Connecticut State University, thinks he knows precisely what the field needs. He even authored an essay on the subject for a trade-oriented magazine, Emergency Medical Services, in which he claimed that only a total system collapse can save EMS now.
That word, "collapse," seems to clearly describe the current state of the profession. But Phelps has a definition fit to stop all our hearts. "Collapse," he says, "means people dying to the point that the public just won't tolerate it anymore."