Saturday, February 28, 2009

Something to Celebrate (Marin IJ)

It’s hard to keep track of all the holidays we have in this country. This month alone, according to, we have already celebrated No Socks Day, National Candied Orange Peel Day and Lumpy Rug Day. And even though May has been designated National Hamburger Month and National Salad Month, today is “Eat What You Want Day.” Last week, in case you missed it, was Wildflower Week. It is no wonder that with all this random celebratory noise, most of you will not observe National Emergency Medical Services (EMS) week, May17th-May 23rd. This is a shame. Some readers have been around long enough to remember a time when EMS, as we now know them, didn’t exist. But for the rest of us, perhaps the best way to fully appreciate today’s efficient pre-hospital services is to turn back the clock.
Imagine it’s 1967 and Thurston Howell III (anyone remember Gilligan’s Island?) has crashed his Cadillac Fleetwood into the center-divide of a suburban interstate highway. He is pinned inside his car and suffering from multiple injuries, including a lacerated spleen. Assuming there are other cars passing by, Howell’s accident will be easy to detect, but EMS notification will not be so easy. Nowadays, Americans are taught from childhood to use their cell phones to dial 9-1-1 in an emergency, but in 1967, cellular phones were merely theoretical and there was no such thing as 9-1-1. Emergency phone numbers existed, but there was great regional variability. For example, in the 1970’s, in the eight counties of the Kansas City metropolitan area, there were 78 different emergency phone numbers for 45 different ambulance companies. So, for a passing motorist to summon help for Howell, he or she would have to drive to the nearest town, thumb through the phone book, and hope to pick the right number. And then, the real confusion would begin.
In 1967, dispatch was even less efficient than notification, primarily because there was little region-wide coordination. As for Howell, it might be hours before the jurisdiction is sorted out and a transport vehicle dispatched. Meanwhile, he’s bleeding and the clock is ticking.
Consider Howell’s horror, after waiting three hours for an ambulance, to see that a hearse has been sent instead. He might think that he is dreaming, or perhaps residing in purgatory, but really he is receiving the standard ambulance care. In 1967, ambulance transport was essentially an unregulated industry and as Dr. Merlin Duval told a gathering of emergency medical personnel in 1971, it was “entirely possible for an individual or an organization with a station wagon or other similar vehicle to install red lights and a siren and initiate an ambulance service.”
Thus, in the late 60’s and early 70’s, an estimated 12,000 morticians supplemented their incomes by using their vehicles, sometimes converted for medical use, sometimes not, as “horizontal transport” for injured patients. Even the most advanced of these ambula-hearses lacked space for a second attendant, let alone a cardiac monitor or oxygen tank. A 1968 study in Iowa reported that undertakers provided 60% of the state’s ambulance services, a figure likely representative of the rest of the nation. Most of these morticians had no training in first aid and had neither the skill nor equipment to assist seriously injured victims. In fact, nationwide, out of 200,000 or so ambulance and rescue personnel, less than half were trained in first aid. Today, on the other hand, many of us demand first aid certification from our dog sitters.
Getting back to Mr. Howell III, let’s speculate that a mortician has arrived on scene and somehow extricated Howell from the Cadillac, loaded him into the back of a hearse, and turned on the rooftop siren. As the hearse speeds down the interstate, Howell is alone in the back, without anyone to check his blood pressure, give him oxygen, or offer words of reassurance. If he’s lucky, he will soon find himself at a hospital rather than the morgue. But, if he does get to a hospital, it is extremely unlikely that the doctors there will have heard about him ahead of time.
Communication between rescue vehicles and emergency departments was about as standard as cruise control on a Model T. “Although it is possible to converse with astronauts in outer space,” noted the National Academy of Sciences in 1966, “communication is seldom possible between an ambulance and the emergency department it is approaching.” This was because most rescue vehicles didn’t carry radios and those that did usually only allowed for contact between the driver and the dispatcher. In sum, the emergency medical transport approach of the era was focused on delivery – scoop the victim off the pavement and haul him or her to the nearest hospital. “The function of the ambulance driver,” wrote Digby Diehl in his 2000 anthology The Emergency Medical Services Program “was to deliver victims to the nearest hospital quickly, lights flashing and sirens wailing. The crucial question – whether the closest hospital was the best medical choice to treat the patient – was never asked, but all too often the answer was no.”
Today, we have a rapid, highly trained and communication-enabled emergency response system. The paramedics that staff this response can perform procedures, administer drugs, consult with a base physician and give cogent medical advice. This is something to be thankful for. It is also something to be respectful of. Emergency medical services are not infinite and they are not cheap. With that in mind, here is a plea from an emergency medical provider; use EMS liberally when you need it, but don’t abuse it when you don’t. Heart attacks need ambulances, hangnails do not. Not even on National Hangnail day.