As someone entrenched in quality and process improvement; patient, worker, community safety and healthcare; I seek to understand first, what the problem is that we are trying to solve to ensure that the work being done matches the work that is needed. I can’t help but realize that we have missed the boat in a major way with our traditional Paramedic, Fire and Police Services.
We have and continue to fail those with mental health and social issues. The emergency response system as it is designed was never designed to deal with the complexities of the underlying psychological trauma and pain that leads to the varied behaviours which result in the application of force or instigating a revolving door in the emergency department or criminal justice system. It’s no wonder these problems are escalating. We are making every issue a nail and approaching it with a hammer.
As one safety expert says so much more eloquently, ”You can’t meet pain with pain”. -Todd Conklin
As an advocate for higher education in the Paramedic profession I often articulate the needs for tertiary education as entry to practice for Paramedicine on the basis of introducing critical decision making and expanded abilities to synthesis evidence in application of practice. One the the things I have repeatedly said for many years is that those going into an emergency response profession should have a basis in their undergraduate education in psychology and social work.
Sure, I received a couple courses in abnormal psychology and basic training in de-escalating a person in a mental health crisis, but that has never been deep enough or consistent across educational institutions. And definitely not to a university level of understanding.
Not only that, but often there is a pervasive attitude engrained that this type of response is beneath the responders and not worthy of their time. Before we get upset about this statement, let me explain, education for emergency service is all about the worst case scenario. The big heroic events that test the skills and knowledge in medicine, crime or major fires. That of course is what we signed up to do. It’s not reality.
Building such expectations upfront creates a dissonance between the realities of the job and the expectations. I don’t have any scientific evidence to share now, but I’m of the opinion that this also contributes to burn out and occupational stress injury.
So what am I getting at?
What if we flipped the approach and the education to address the most abundant needs of the community and de-emphasized the high risk, low frequency events. I’m not suggesting that we change the standards for those events, but time and effort in entry to practice be aligned with the reality. I see this now, a full university course in psychology in my area will only get a Paramedic 0.5 hours of CME credit.
As the 911 system evolved and the public was encouraged and trained to call for any and all emergencies, our quality metrics left out a large area that has not been adequately addressed. We track things like cardiac arrests, strokes, intubation attempts, time to treatment with respiratory distress, break-ins, car thefts. Then typically under one umbrella there is a single category for mental health or social problems; there are no quality outcomes to being measured.
This public education changed the landscape of what 911 emergency services respond to in the modern era. It is a product of successful public education and marketing. But more importantly, it highlighted a need and demand that has existed for a very long time and was kept behind closed doors. In my opinion, we have failed to adequately adapt to the new evidence and understanding of what drives many community issues through the underlying psychological and social problems.
What if and how do we engage the experts in these areas?
The work on the mental health and social issues however comes from a smattering of agencies spread across hospital, regional community support systems and their funded public and private agencies. A relatively uncoordinated effort in acute situations that still lets people fall through the cracks. And ultimately provides little emergency support to front line emergency services dealing with acute mental health and social crisis. There are occasional models that pair a social worker with a police officer, but most are ad hoc, limited regionality and don’t operate 24/7 like other emergency services.
Personally, I have been involved in what is called the “HUB” model of social justice intervention. Spearheaded in Canada out of the University of Saskatchewan and adapted from Glasgow Scotland. This model brings agencies together, Police, Paramedics, Fire, Schools, Social Services, Hospital, Volunteer agencies and more to address the complex needs and help people stay out of the criminal justice system. It creates alternative pathways to police intervention before the problems escalate. This is a great model, but it still does not get the experts at the front-line at the initial time when things have escalated beyond this preventative at-risk model.
We put money, time, effort and expertise into developing all kinds of specialty programs within emergency services; things like a High Acuity Response Team (HART) a UK model that trains Paramedics in accessing patients in adverse conditions and rescue situations. We have Paramedics trained in tactical SWAT scenarios, there are Police marine units, fire department auto extrication teams, hazardous materials teams, and more.
Many of these specialty teams are designed to work in a specialized vehicle, have a diversity of experience, maintain standard skills and training in addition to their specialized training. And work a mix of “normal” responses while being readily available for their specialized duties when needed.
What I am saying, is that it is time for a social services emergency response agency. An agency response with the skills, knowledge and authority to intervene in these emergency situations that are primary psychological or social in nature. It’s a cooperative effort, certainly a need for police for safety and security and paramedics for clinical medicine. But let’s be straight up here, the current response agencies don’t have the expertise and depth of knowledge or connection within the social services system.
I’m not going to go as far as to outline wether this should be stand alone or partnered with one agency over another. I for one can see a specially trained emergency response social worker partnered with an advanced practice paramedic on a response car responding independently or to backup an ambulance and police on a call that is primarily psychological or social in nature. Perhaps other agencies have the capacity in their volume of response and training budget to consider bringing on social workers who want to cross train in other areas. Perhaps this is a practice of Community Paramedicine in as it evolves.
Let’s re-imagine solutions to problems with the right resources. Locality of problem solving makes a big difference in communities, but we also need to consider some scalability and reproducibility when we find a model that improves outcomes. And, let’s expand out our quality measurements. Let’s truly try to track specific types of issues and expand our capabilities of providing the right tools and resources. Most importantly, we need to break the budget silos and cycles that isolate services from being creative in problem solving and protecting the institutions that are simply hammering at problems as if they are all nails.
Talk to me about how to drive the solutions and change.