I had missed dinner and was heading in for my first of three night shifts. I made excellent time on the highway, and pulled into a local strip mall just several blocks from the hospital to grab a bite to eat before tackling my shift. Off along the curb a quarter mile back along the state highway was a local ambulance. The lights were flashing, the doors open, with a paramedic chase truck having clearly stopped the vehicle to assist with a patient in the rear. Where the ambulance was stopped is literally less than one mile to the Emergency Department entrance. Expecting the paramedic to have climbed aboard of the ambulance and to be off in moments, I entered the fast food establishment, grabbed my sandwich and soda and sat down to eat. Fifteen minutes later I exited and the ambulance was still sitting there. With New Jersey Highways being the way they are, the only way to assist would be to drive another half mile down the road, find a jug handle, wait for a light, drive in the opposite direction and find another jug handle to return. With only minutes to the start of my shift, I figured I would find out soon enough what was going on.
I arrived at the hospital, put my bags down, hung up my coat, and proceeded to receive sign-out from the dayshift doctor. After receiving report, I asked if the department had been alerted via HASTE for any inbound ambulances. I explained that there was a unit along the road a mile or two back with a MICU unit behind it for a least twenty minutes. At that moment, the squad rolled through the door. An approximately 60 year old was sitting upright on the stretcher, apparently quiet comfortable, wearing a 100% non-rebreather mask, smiling, and looking around. I asked if this was the same unit stopped on the state highway just up the road. The squad gave report of the various treatments and interventions initiated in field curbside along the highway.
Southern New Jersey has a very unique two tier EMS system which, after fifteen years, I am still getting use to it. It is predominantly a volunteer BLS system with ALS being provided by “chase-units”, consisting of Ford Explorers. The ALS units have no transport capability. Typically, the medics would climb aboard the BLS ambulance and provide higher level of care when needed or provide such on scene. Unfortunately, this system has lead to several issues, including the one addressed above.
The opening vignette, in my experience, is not at all unique. Prolonged transports from nursing homes only two or three miles down the road from one of the hospitals I work at for respiratory and cardiac arrests or from neighboring residential developments is not uncommon. There is a very strong motivation to provide advanced life support on-scene care despite the close proximity of a fully staffed Emergency Department. The concept of “scoop and run” by BLS units when close proximity to hospital care is at hand is often mistakenly misplaced for delayed scene times to await the arrival of ALS.
Another product of the two-tier system in New Jersey is a dangerous race of emergency vehicles and civilians in a long, “vehicular parade” to the hospital. The ambulance is followed by the paramedic chase unit, which is often followed or lead by a police car or two. Racing up the rear is usually family in their car despite being told not to try to follow the ambulance to the hospital. Other drivers, when hearing the sirens, usually only expect a single emergency vehicle. Two vehicles, especially if driving fairly tightly behind one another, can easily be unanticipated by motorists. With families trying to keep up with “the parade,” the potential for additional injuries is very real.
With state economics being what they are, funding to advance New Jersey volunteer crews to having ALS level of care is limited. The ideal would be to bring all squads up to the capacity of having a medic available for all runs if needed. Fewer rescue vehicles on the road would have the financial benefits of lower costs in equipment, fuel, and insurance for cash strapped municipalities. This system has been proven to work in New York State for decades. Nassau and Suffolk Counties in New York provide financing to train their volunteers to ALS level of care and limit the number of vehicles on the road for any individual call. Prolonged scene times are a rarity. Meanwhile, New Jersey has not managed to learn from it’s sister states how to manage within the constraints of finances to advance its volunteer EMS system and limit public risk.
I suspect the current system in New Jersey, with the paramedic chase units, represents a product of local politics, limited funding, billable ALS care by these chase units, combined with a hold over from when New Jersey was predominantly farmland with long distances between medical facilities. Southern New Jersey is increasingly not rural. As such, the current system is only adding to the financial costs to townships.
I invite others who read this blog to discuss their volunteer systems. Specifically, how do your systems manage to keep the public safe, provide ALS care, while dealing with the economic austerity affecting all municipalities today?
Comments from paramedics I work within this system are pending. At their request, I will post their thoughts regarding this blog’s subject matter anonymously and without editing.
ADDENDUM: All comments received have been posted provided objectionable language was not included. I have made every attempt to answer as many of the comments posted as I can.
Thank you to everyone who has contributed!