A History of Public Service

From their roots in the 19th century horse drawn ambulances of the Boston City Hospital, through the emergence of the innovative modern EMS system with its joint medical and public safety roles, the EMT's and paramedics of Boston EMS have consistently demonstrated their commitment to public service. The evolution of EMS as we know it was reflected, and in part fueled, by Boston EMS. The agency, along the way, earned a reputation as a committed, peer-driven, high quality provider of emergency medical services.
  Looking Forward

The commitment noted can be expected to be carried forward into the future as the BPPA/EMS Division continues to adapt and expand to meet the needs of the citizenry of the city of Boston. Exploring advanced training, special operations, expanded scope of practice issues, and above all, increasing community involvement, will be avenues on which the EMS providers of Boston will continue to apply their principles of public service.

In an atmosphere of growing societal emphasis on health promotion and on the prevention of injuries and disease, an opportunity exists to apply new strategies to traditional public health efforts. That the special needs of vulnerable populations in particular would be addressed by the proposed strategies, makes their exploration all the more consequential. For although proven tactics exist to address many public health problems, they have not always been adequately utilized for those who need them the most.

Boston EMS is in a unique position - by virtue of its associations with the other public safety agencies, the medical community, and the Public Health Commission - to realize the potential for EMS systems to be "the intersection of health care, public health, and public safety" as noted by the National Highway Traffic Safety Administration (NHTSA). The EMS professionals of Boston EMS are already deployed across the city, are well-respected, and come into frequent contact with sectors of the public most in need of many public health efforts. Thus among the most practical future initiatives for Boston EMS will be an evolving community outreach program involving: identifying needs, initiating referrals, providing education and training, presenting prevention messages, mitigating environmental impacts, furthering research and data collection efforts, and participating in public campaigns to further the agenda of health promotion and safety.
 

Public Health and EMS

The traditional EMS role has been a reactive one, focused on the post-event stage. It is evident that moving into the pre-event phase, EMS providers could identify risks that lead to "accidents". Injuries due to car crashes, shootings, burns, drownings, and falls are often non-purposeful yet preventable events. Actions such as securing window guards for families with young children or encouraging car-seat use are examples of potential EMS contributions. In the case of intentional injuries, particularly domestic violence, EMS providers can assist in providing individuals with options ranging from immediate safety considerations to referrals for further services. Additionally, the data that is routinely compiled by EMS providers could be used to identify patterns and trends (e.g. increased violence, particularly dangerous intersections). Traditional prevention strategies emphasizing environmental and behavioral components could be enhanced by EMS identification and educational initiatives. Furthermore EMS providers could address needs in terms of such issues as access to care, early intervention, and data collection that are currently unmet.
 

Building on the Traditional EMS Role

The Centers for Disease Control (CDC) has called for increased agency referrals and community coalitions, a need that could be addressed by combining existing programs with the proposed expanded scope of EMS responsibility. As health care professionals, EMT's and paramedics are already mandated reporters for abuse and neglect of children and the elderly. An expanded referral program would merely involve building onto an existing framework so that significant, though less acute, problems could be addressed. The possibility to benefit people by connecting those providing preventive services with those most in need is evident.

The idea of using the existing EMS resources and applying them in an expanded fashion can be easily applied in the settings of schools and community sporting events. EMT's already provide first aid education and are present at many community events. It would be a simple adjustment to use these existing resources - the EMT's - to address preventive needs. Appropriate training and guidelines are prerequisites for such efforts, but would not be prohibitively costly or difficult to undertake. Additionally, such programs would afford another opportunity to directly address populations at high risk.

The CDC recognizes the usefulness of school-based education in affecting health-risk behaviors. EMS resources can be useful in reinforcement of these messages. Furthermore the CDC refers to drop-outs, runaways and the homeless as benefitting from the recommended community coalitions. Improving agency referral systems for such citizens is a prime need identified by the CDC, and is a function that Boston EMS personnel - who not infrequently interface with this population - are well positioned to assume.

Among the unique contributions EMS providers can make is application of the ability to augment public-health surveillance of problems by documenting data obtained at incident scenes. Interpersonal violence and vehicle crashes are good examples of situations where information regarding mechanism of injury - information available only to trained observers actually at the scene of the event - can be of short term benefit to a patient's care and can be used in long term efforts to mitigate problems. An example is the ongoing collaboration of Boston EMS and researchers at the Boston University School of Public Health analyzing data accumulated by EMS providers to assist in planning traffic safety initiatives. The potential for EMS providers to play a role in the implementation of comprehensive strategies and to assist in environmental response planning is virtually limitless.

An Integrated Network

The Institute of Medicine of the National Academy of Sciences recommends improved training, communications, planning, evaluation and research (and funding) geared toward significantly reducing the "enormous and tragic toll of serious injury and illness" by developing integrated networks - including EMS systems. The city of Boston is poised to take advantage of this vision.

As noted above, in proposing future directions for emergency medical services, NHTSA in its "EMS Agenda for the Future", refers to EMS as the intersection of health care, public health, and public safety. The expanded EMS role being explored in Boston incorporates the positive aspects of all of these elements. Benefits have been recognized in delivery of safety messages and community relations initiatives by police officers and by firefighters. As has been noted, EMS providers operate in a medical as well as a public safety capacity. Given the fact that both health care providers and public safety officials are, in certain contexts, perceived as acceptable sources of information, EMT's and paramedics are in a unique position to capitalize on the credibility they possess as representatives of both the health care and public safety communities.

The NHTSA EMS Agenda for the Future puts forth a vision of EMS as:  "community-based health management that is fully integrated with the overall health care system. It will have the ability to identify and modify illness and injury risks, provide acute illness and injury follow-up, and contribute to the treatment of chronic conditions and community health monitoring integrated with other health care providers and public health and public safety agencies. It will improve community health and result in more appropriate use of acute health care resources. EMS will remain the public's emergency medical safety net."

Thus the agenda for EMS dovetails with the needs of public health practitioners, public safety agencies, and ultimately with the needs of the public.
 
The Public Health Referral Initiative: A First Step

It is clear that Emergency Medical Technicians and paramedics routinely encounter circumstances which are ideally addressed by the public health community. Therefore an important initial step in a proposed collective approach is the institution of a formalized referral program. This step has been taken in Boston. The Public Health Referral Initiative of the Boston EMS Community Outreach Program is an alliance of the city of Boston's EMS system with agencies of the Boston Public Health Commission and the Boston Medical Center. EMS providers, in what amounts to a small extension of the public service they are currently dedicated to, offer invaluable assistance simply by connecting those in need of services with those providing the services. It is notable as well, that the most vulnerable populations, including urban children, the elderly, and victims of domestic violence, stand to gain the most from this EMS/public health collaboration.

The existing outreach programs instituted in Boston, and the proposed future directions, are examples of the EMT's and paramedics of the BPPA/EMS Division building on a proud tradition with a vision for the future.