By Eric DuBois,
I will start with a question that came up in conversation with Soovin after our most recent lecture. Is it better to base our emergency response system on the type of patient that is most common or the type of patient that is least likely to survive?
My research for a long time since arriving at UW-Madison has focused on ambulance response during severe weather. One of the chief problems that needs to be considered in this context is the expected survival of different patient types. If someone is going to have to wait an extra 20 minutes during a blizzard for an ambulance, it had better be someone who isn’t likely to suffer any long term ill-effects.
On a normal service day, by far the most common patient is a trauma victim. Yet, here’s the rub: The vast majority of studies show that prehospital response times are not a very good indicator of trauma patient survival (For more see [1-3] below). Further, “most ambulance services report that less than 10% of their calls are true life and death situations.” So clearly our system is over-serving the vast majority of patients.
On the other hand are those few patients in dire need of medical attention, for whom a timely response can be critically important. With survival rates of less than 6%, surely cardiac arrest patients deserve our concern too? It is these very patients that have driven much of the literature and the current expectation that service times are so critically important.
Even if we decide it’s better to find the efficient solution for patient survival, this does nothing to answer the overall question of equity. Worse yet, just because we have the theoretical resources to best serve cardiac arrest patients, doesn’t mean that we will actually serve them any better. Sanghavi, et al found that the more advanced ALS ambulances actually did worse than BLS . So just having the equipment and people in place may not be enough.
Now there are plenty of non-causal reasons that this could occur. For instance, ALS usually serve worse patients than BLS, and it is only possible to control so much for the actual severity of the patient with the data usually available. Additionally, it should be considered that if the paramedics and EMTs aren’t well practiced in using advanced life support, due to the infrequency of such calls, trying them on such time-sensitive patients could just make the situation worse.
Beyond the question of what we view our ideal to be is the practical realities of the situation. The American public expects to receive speedy service whether they have a cardiac arrest or a broken leg. It’s something we expect and it’s something for which we hold our leaders accountable. If we are to be honest with ourselves, it’s hard to argue that we wouldn’t want the quickest response possible when we are the ones dialing 911, no matter what the objective research says on the matter.
As with most questions in public OR, there is no simple answer to this one. With multiple stakeholders and unclear measures, it is up to us as a community to develop best approaches. I look forward to diving into these complex issues this semester and hope you’ll come along. So what do you think? Is there a better way to handle EMS calls than we currently do? More importantly, is such a way practically implementable?
 Blackwell, T. H., Kline, J. A., Willis, J. J., & Hicks, G. M. (2009). Lack of association between prehospital response times and patient outcomes.Prehospital Emergency Care, 13(4), 444-450.
 Newgard, C. D., Schmicker, R. H., Hedges, J. R., Trickett, J. P., Davis, D. P., Bulger, E. M., … & Brown, T. B. (2010). Emergency medical services intervals and survival in trauma: assessment of the “golden hour” in a North American prospective cohort. Annals of emergency medicine, 55(3), 235-246.
 Pons, P. T., Haukoos, J. S., Bludworth, W., Cribley, T., Pons, K. A., & Markovchick, V. J. (2005). Paramedic response time: does it affect patient survival?. Academic Emergency Medicine, 12(7), 594-600.
 Sanghavi, P., Jena, A. B., Newhouse, J. P., & Zaslavsky, A. M. (2015). Outcomes after out-of-hospital cardiac arrest treated by basic vs advanced life support. JAMA internal medicine, 175(2), 196-204.