Non-Emergency Ambulances

The Glue that Holds Healthcare Together

Ambulance
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We all know that ambulances respond to 911 calls, rushing down the street with sirens wailing and lights flashing. The paramedics are on the way to save lives. When they arrive at the scene, they'll take control of the situation and find the solution to the problems. The patient will be stabilized and transported to an emergency department for definitive care.

There are plenty of images of ambulances in the media.

Paramedics and emergency medical technicians (EMTs) are usually portrayed as the rescuers in the emergency. But treating emergencies is not the only way paramedics and EMTs contribute to healthcare. In fact, it's probably not the most common way they care for patients.

Ambulances bind modern healthcare together. Without them, many of the cost-savings found today wouldn't be possible (yes, there are efforts to address costs in healthcare).

Separation of Patients

Hospitals started out as simply group housing where doctors could treat multiple patients in one place. Prior to the widespread use of hospitals, physicians almost exclusively visited patients in the patients' homes. Hospitals allowed patients of limited means the ability to be seen by physicians.

Eventually, hospitals became one-stop shops, where patients could find all sorts of services. Even small hospitals in rural areas could deliver babies and do surgery.

Whether a hospital had few beds or many, the range of services would be similar even if the quality varied greatly. A patient could seek help for any number of conditions.

Hospitals evolved into complexes of wards, large rooms with multiple patient beds. Often, the wards of the hospital would be split into branches by gender and by type of patients: Labor and Delivery, Medical, and Surgical were some of the more common wards used.

Later, emergency wards (or rooms) would develop. Some would also have a separate area for pediatrics.

Healthcare Silos

Even though hospitals had patients separated into wards, they still all came to the same building. In modern healthcare, that's not always the case. As patient care gets more specialized, it makes sense to consolidate patient types into hospitals dedicated to specialties.

There are surgical hospitals, where only scheduled surgical procedures are performed, such as hip replacements or cosmetic surgeries. Emergency or unscheduled procedures associated with acute conditions like appendicitis or trauma are saved for hospitals with more traditional general services or for other types of specialty hospitals.

There are now hospitals dedicated to women and children, trauma centers, cardiac hospitals, stroke centers, cancer centers; even septicemia. Each can be centered on a floor of a hospital or in an individual facility with everything physicians would need to focus on one subset of patients.

How to Move from Place to Place

This form of specialization is important to large healthcare systems with diverse patient populations. To serve patients, these organizations have to have a number of general hospitals where patients can seek help, but also the ability to move those patients to the proper level of care in a way that doesn't compromise patient care. How does the hospital move patients from place to place? 

Ambulances.

The history of ambulances focuses on their use as rapid transportation of the sick and injured for emergencies. Ambulances didn't start off responding to emergencies independently. They were sometimes sent out to collect those with diseases (leprosy and the plague, for example) and take them against their will for treatment and isolation.

When ambulances were used for emergencies, they were often operated by hospitals as a service to wealthy patients. The use of ambulances for emergency transportation evolved in the military. The most widely touted story comes from the development of the ambulance services in Napoleon's army.

In the early use of ambulances on the battlefield, the wounded often waited until the fighting stopped for the ambulances to come get them. Napoleon's Surgeon General realized that if ambulances were sent in earlier, they could save more lives, thereby reducing losses from battle. Improving survival among soldiers wasn't a humanitarian effort; it was inventory control.

Not Just for Emergencies

Since the beginning, ambulances haven't been just for emergencies. Picking up a patient to take him or her to the hospital is only one of the uses for an ambulance. Ambulances can also move—and have always moved—patients from point to point in non-emergency situations. 

Some of the oldest ambulance services today got their starts doing something other than responding to calls for help. Many were based in a particular hospital and were used to move patients to and from other hospitals, which is still the most common use of an ambulance. Today, this type of transport is called an inter-facility transfer (IFT). Over time, some of the ambulances evolved to provide specialty care themselves.

There are ambulances for critical care patients that use a nurse instead of (or in addition to) a paramedic.There are neonatal ambulances that are designed to transport pre-term babies. Some ambulances have teams of caregivers that combine nurses, doctors, respiratory therapists, nurse practitioners, paramedics, emergency medical technicians, or all of these.

Continuum of Care

Instead of responding to emergencies, ambulances that perform IFTs provide a continuum of care from one facility to another. During the transport, the patient is monitored to make sure his or her condition doesn't change. 

That doesn't mean that some inter-facility transfers aren't extremely important. In many cases the patient is being moved from a facility that can't provide the needed specialty care to a facility that can. In some cases, essential treatment is continued throughout the transport to make sure the patient makes it safely and is ready to receive care at the new hospital.

The staff on an IFT ambulance is an integral part of the patient's treatment. They're part of the healthcare team as much as the hospital staff is. Without this vital service, patients in modern healthcare wouldn't get the treatment they need from the specialists who can provide it.

Training Deficiencies

Despite the fact that ambulances are holding all of healthcare together in a world where healthcare providers are stuck in silos of specialties; and despite the fact that IFT ambulances far outnumber the ambulances that are responding to 911 calls (or respond to both types of requests), education and training programs for emergency medical technicians and paramedics are still focusing almost exclusively on emergencies.

Emergency medical technicians are taught splinting, bleeding control, CPR, rescue breathing, and how to extricate patients from vehicles after an accident. Paramedic education focuses on treating heart attack and stroke patients. Everyone learns to manage a scene during a multiple casualty incident (MCI). All of this is extremely important training that can't be minimized, but in the IFT setting, it doesn't translate.

Certainly, an EMT or a paramedic must be able to react appropriately to a patient whose condition deteriorates suddenly during a transport, regardless if that transport started from a hospital or from the patient calling 911. Like an airline pilot trained not for flying on autopilot, but for when the autopilot fails and the plane is in crisis, paramedics and EMTs must be ready for the unexpected.

But the pilot is also trained for flying with the autopilot. She is well-versed in the expected as much as the unexpected. The EMT never gets that training—at least not as part of a national standard curriculum. The EMT isn't taught how to do the very thing he will likely spend the first few years of his career doing.

Changing Expectations

As much as ambulances are called upon to move patients from one facility to another, patients should demand that the staff making the move is comfortable doing the job. If something goes horribly wrong, the EMT is ready to jump in, but what about making sure the care from the first facility is continued seamlessly at the second?

EMTs come out of their initial training ready to save lives and stamp out disease. They are trained heroes-in-waiting. They are poised to run in while others are running out. But that's not the role they will play—not at first. The new EMT is going to do IFT, not because it's not important. They're going to do IFT because it's boring. It's not driving "hot" with lights flashing and sirens blaring to pull a victim from the burning car.

IFT is not sexy; at least not to a new EMT.

That can be changed. With proper education focusing on the importance and technique of IFT, EMTs and paramedics will embrace the new role. They will do it and do it well as long as they know what to expect and have the tools to do the job.

Patients will benefit from a stronger healthcare system, where the ambulance crew really is an integral part of the team and moving from facility to facility does not present a weak spot in patient care.

Sources:

The History of Hospitals and Wards. (2016). Healthcaredesignmagazine.com.

The influence of Dominique Jean Larrey on the art and science of amputations . (2016). Sciencedirect.com.

Kulshrestha, A. & Singh, J. (2016). Inter-hospital and intra-hospital patient transfer: Recent concepts. Indian Journal Of Anaesthesia60(7), 451. doi:10.4103/0019-5049.186012

Samuels, David J, et al. Emergency Medical Technician-Basic: National Standard Curriculum. (1997). US Department of Transportation.

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