Comments on Corner Posting


My attack on the July cover story of JEMS generated some pretty passionate comments about corner posting, and got even more after Rogue Medic’s post.  Here is my response to some of them:

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.

Brandon Otto, from EMS Basics writes:

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.

On his blog, Rogue Medic writes:

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.

Mr. Washko asked for feedback, good or bad, about his July article on Twitter.  He has been personally attacked on other websites. I only attack arguments on mine.  I  NEVER make personal attacks on anyone, nor would I tolerate any comments that do.   He is welcome to join this conversation, along with anyone else from JEMS who signed of on his article, to defend his positions. 

Let’s all get to the bottom of this to figure out the best way to serve our patients.

Comments

  1. I would just add that the particular vitriol for Mr. Washko is probably for a simple reason: this issue pertains to our job happiness. In other words, we don’t want to sit in the truck all day.

    Because we don’t want that, it’s tempting to try to translate what we want into more businesslike terms, and come up with reasons why other people should care — and many such reasons may exist. But I think it’s worth acknowledging that a big slice of the opposition does come from that simple, entirely personal and subjective source. And it’s not good or bad, it’s what it is, but blending that motivation with the real objective factors can make it hard to understand the issue.

  2. While I have been pondering where we should have exactly this type of informed debate, Bob made it happen. So thanks to both Bob and also Brandon for comments that help to keep this very necessary debate focused on the issues.

    I would like to suggest we move forward by parsing the problem. One of the difficulties I have seen in the larger debate referenced throughout this posting is the problem of dissecting the various pieces of this issue. First, the question is not “corner-posting” versus the “traditional Fire-based station” model. The latter is going away regardless of what other model replaces it. To support that statement, we had an intentionally provoking session at Pinnacle pointing out many of the reasons that government can no longer afford to support the status quo. Check out the #Pinnacle2012 tweets from two weeks ago or read my very brief synopsis at the end of my post at http://highperformanceems.com/2012/07/18/quick-thoughts-from-pinnacle-ems-2012/#more-1018. If you still need more evidence, read the grand jury report my friend Scott (@MedicSBK) shared with me on “Fighting Fire or Fighting Change?” at http://www.scscourt.org/court_divisions/civil/cgj/2011/FDResponse.pdf which details the problems caused by the evolving demands. What we must discuss is what do we want next, not how do we keep things as they are.

    Second, I would prefer we allow for some separation between the idea of “posting” in general from the “corners” that can be used in certain posting plans. While they obviously do exist together in many plans, it is not a requirement of “posting” to be placed at an “open air drug market” (although that will be a likely place for a next patient.) Posting can actually be effectively done at “stations” since posting is merely a method of moving scarce resources to maximize their impact. I would rather we discuss how to measure the efficacy of a posting plan considering not just response time, but whatever other objectives we want to optimize. My quote correlating ROSC to response time from Jersey City was actually validated statistically by Mt Sinai as being significantly causal, but I will concede it still leans more anecdotal than basic primary research because it was not an actual controlled study. However, regardless of how we might feel about the “golden hour”, I hope we will not debate the fact that shortening the time for definitive treatment in life-threatening circumstances is key to an improved outcome. While it is fair to question how often that really happens, it does occur a significant amount of the time (nationally averaging around 5-15%) and I don’t believe that more routinely practicing good response is detrimental to those limited instances. The question is really more about the cost (in dollars and even employee satisfaction) to achieve or maintain an acceptable response. What should we measure and how do we weight those factors? If we are looking at building a new response model, I also think it is fair to bring in the subject of advanced triage of calls before dispatch. Not all calls require a Delta level response. Are we doing our systems justice by treating every call the same? Are we doing our patients any favors by always transporting them to the closest hospital ED? Posting is only part of the solution.

    Another common complaint I hear about “posting” that I would like to distinguish is about being woken up just to move posts. Napping is critical to maintaining performance during long shifts. If the concern is consecutive rest (sleep time), shouldn’t we question the wisdom of the shift lengths as well as the wisdom of a plan that recommends constant re-posting without improving patient care? At Pinnacle I heard Sedgwick EMS say they were able to reduce post moves by approximately 25% and Jersey City almost eliminated it completely through the ability to create better posting plans. In EMS, we have watched many life-saving technologies develop from merely adequate assistance to become recognized as essential tools. Before we simply write posting off as a lost cause, I suggest we look at what is really working already and what needs to improve so together we can help develop the technology that we can live with in our jobs rather than simply fighting the change.

    Of course, pieces always work great in a vacuum and eventually we will need to bring it all back together as a system, but for tuning I think there is value in isolating distinct pieces of the problem.

    • emspatientperspective says:

      Thanks Dale! My long comments one someone else’s blog usually turn into a post here. EMS needs people with your unique perspective to bring common sense to this debate.

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