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Justin Duncan

Chief Executive Officer, Washington County Ambulance District

The changing face of emergency medical services (EMS)

 

I’ve worked in healthcare for my entire adult life. I started volunteering when I was 16, and my plan was to go to medical school. By 18, I was working full-time on an ambulance and haven’t stopped. I started on the west coast and worked throughout the country as a paramedic, critical care paramedic, flight paramedic, clinical educator, quality manager, and now CEO. In addition, I serve as the president of the Missouri Emergency Medical Services Association which represents EMTs, paramedics, and ER folks. We’re their voice from a prehospital clinical care standpoint.

 

I’ve spoken at conferences about the changing world of EMS and how ambulance work is only half of what we do. We also embrace the concept of mobile health care providers and mobile healthcare clinicians. And we don’t only treat patients in emergency settings anymore, we treat them in non-emergent, routine, follow-up care settings as well.

 

We’re only reimbursed as an ancillary service for transportation, not for the clinical care we provide. The push now is to show we do two very distinct things. We take care of patients — we just happen to take care of them in their living rooms, bedrooms, or side of the highway. And then transportation is sometimes a part of it.

 

There have been some silver linings hidden in COVID, and one that’s come to light has been when we’re told, "Please don’t bring us patients. Try to keep people out of the hospital if they can." So, we sit here and go, "Okay, I’ll play ball with you. We will rise to the occasion, adapt and overcome. But, if we’re good enough to do these things during a global pandemic, we should be good enough to do these things when we’re not in the middle of an emergency." It’s time for reform on how EMS agencies are viewed and reimbursed. We are mobile healthcare, and our mission and purpose is actively evolving right in front of us.

Discovering the desire to be a leader

 

At my first job, I didn’t even know who my boss was. Never met him before. Couldn’t pick him out in a lineup. Later in my career, I worked for a humble servant leader who would show up on an ambulance when things were busy or at two in the morning and go, "You guys are tired. I’m going to drive you to the hospital." And I thought, "I respect that. That’s what I want to do with my life." 

 

I once worked for somebody who was not clinically focused or focused on the patients but on the numbers and the business and the money, which are also important. Then I worked for somebody completely opposite who said, "You take care of the sick people. We’ll support you and figure out all that other stuff in the background."

 

I wanted to be that leader who was like, "We’re going to do what’s right by the patients first and foremost. We’ll deal with everything else later." I try to keep as much of that burden off of my crews as possible: "You guys do what’s right for sick people. I’m going to support you. I’m going to go to battle for you. Just let me know when you think you screwed up ’cause I’ll eat crow a lot easier that way." 

 

Really, I just stumbled into this position. I never wanted to be the boss. Now I can’t imagine doing anything else, honestly.

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Challenges of caring for COVID patients

One of our biggest challenges is that COVID is out there and there is so much misinformation. Social media helps to stack the cards against us here in the United States of America. We now live in a time when there is not a noticeable difference between an opinion or a blog and a peer-reviewed journal article with support and data. I never thought in my entire career that I would have to argue with non-scientists about science. I tell people all the time, ‘I’ve dedicated my life to being a healthcare provider. I would not argue with someone who builds roads

because I don’t build roads. I don’t build bridges. I don’t fix cars. But I know science. And I know data. And I know review processes. And, unfortunately, public health and a global pandemic are real and they have been politicized. It’s not one or the other.

 

As of this point in time, 80% of our emergency calls for service, non-emergency calls, transfers, wellness checks, and in-home care are either COVID-positive confirmed, COVID persons under investigation, or ruled out based on symptomatology and presentation. That means on 80% of calls, my folks are wearing heavy levels of PPE. You’re walking around in a surgical mask all day long, but if we’re having to do anything considered an aerosolized generating procedure or getting invasive, that’s a plastic gown in 100-degree heat with humidity. That’s an N95 or a P100 mask, that’s a face shield, that’s two sets of gloves. And on really sick people, that’s a Tyvec suit.

 

I’m sure many people have seen a lot of pictures of negative pressure rooms in hospitals, and they are horrible conditions to be working in. Well, think about how we take that same patient on a ventilator with multiple drips hanging and put them into a boxed ambulance that was not ever designed for negative pressure. Hospitals have negative pressure rooms. They have ways to close doors to separate people. Nurses can have drips and monitors right outside the rooms. They don’t have to go in and out and put on all that gear. My coworkers and I don’t have that luxury.

 

We were never taught how to prone a patient, how to put them on their belly to make it easier to ventilate when moving them from point A to point B. We don’t have negative pressure ambulances, so you can’t isolate the driver. We put two or three people in the back because these COVID patients are so sick, and you’re sitting next to them with your knee touching their hand. They’re intubated, ventilated, sedated, pain managed, and probably paralyzed chemically so we can take over lung functions. And we’re thinking, "I hope we don’t hit a bump and that filter comes off between the tube in their throat and the ventilator. I hope I don’t break the seal on my mask."

COVID is happening at the same time as everything else that sends people to the hospital - they are not mutually exclusive issues

 

I don’t take care of patients very often, but I do remember one COVID patient early on who’s been forthcoming with asking me to tell his story. He was so, so, so sick that he went to a supercritical place called ARDS secondary to COVID pneumonia. We see it in our pneumonia patients at times. But, they usually spend days in the bed and go into ARDS, and they are then hard to oxygenate and ventilate. This guy was intubated and in full-blown ARDS from COVID in a matter of hours. And conventional techniques just don’t work. I was one of two EMS clinicians sitting in the back of the ambulance with him going to DePaul Hospital because that was the closest availability for an ICU bed we could get, which is a long way from Washington County.

 

So we were cruising up the highway, and I just sat there and looked and him thinking to myself, "I’m not sure he’s going to make it. But we’re giving him a shot. And I really hope we don’t turn a corner too hard." I dropped my glasses, because I leaned over trying to do something, and I was sweating. I instinctively went to pick them up and then I go, "Oh, crap. I shouldn’t pick them up. Don’t touch your face. Don’t put them back on." Those are just things we weren’t used to thinking about. After a COVID transport, we have to decontaminate and air out.

 

In the last few months, we’re at a 50%, sometimes 70% volume increase. My crews last night took a patient 150 miles one way to Columbia to find them a bed. Folks have forgotten that, yes, COVID is real and it’s scary. There are lots of very sick people. However, we still have a behavioral crisis and an opioid epidemic on our hands. In my area, methamphetamines are a huge issue. And we have people who don’t manage their sicknesses, so they’re in and out of the hospital. People still get in car accidents and still have strokes and heart attacks.

 

So when folks say, "I’m fine. I don’t think I’m going to get COVID," or, "I think I’ll be fine if I get COVID," I go, "Fantastic. But if you get in a car accident, I don’t know if we’re going to have a home for you. If you have a heart attack, I don’t know if I’m going to have a home for you. We might have a home for you, but it might be in Columbia." Do you think somebody from Washington County wants to be so far from their family and everything they know? Those are conversations we have with folks.

The value of people and partnerships

One of the blessings this county had early on was that we decided we were going to band together when COVID first hit. I remember the first positive case we had. We all sat in a room and went, "It’s here." And then there was the first death. Shawnee Douglas is an awesome human being who said it so eloquently: "These numbers? Those are people. When we see over 50 deaths for a community our size — a county of 25,000 people — those are 50 human beings and hospitalizations and positivity rates." 

 

And we know that those are low numbers. We know people aren’t reporting. We know they get the self-test at Walmart and are not reporting, or only one person in the household gets swabbed. So are numbers accurate? No, they’re not.

 

We gave thousands of vaccines in drive-through clinics here for people all over the region. My agency started doing house calls and giving shots to people who couldn’t get out. A lot of other places are doing it as well. But I have a 760 square mile county that’s rural and socioeconomically poor with high comorbidity rates. We want to get every shot in an arm that we can.

 

Science tells us, "Let’s protect those people." A lot of them don’t have access to transportation. They can’t make it to a clinic. So we take the vaccine to them. We’ve decided we’re going to try to manage disease processes at home for certain people who we can as well.

Pandemic politicization and battlefield medicine

It’s super disheartening that we, the United States of America, in 2020, we were running out of personal protective equipment for healthcare providers. Everybody was talking about the ventilators and how we’re not going to have enough vents. I think you can build all the vents in the world, but you’re not going to have people who know how to use them. You don’t take a nurse, paramedic, physician’s assistant, or doctor right out of school and throw them into an intensive care unit expecting them to be

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rockstar clinicians. It takes years of on-the-job training and mentoring and specialty certifications to be competent and skilled in rendering care to critically ill patients.

 

And what are you seeing in the headlines? ‘This job is not fun anymore. Provider fatigue is real.’ One of the things that weighs on my brain is that, on top of all of this, people are mean. They’ve taken a political stance. It’s on both sides of the aisle. I’m so sick of hearing about the red hats versus the blue masks. I don’t care who you voted for. We should be embarrassed as a society and as a country. We’re supposed to be the light in the darkness, and there is just this huge divide.

 

Before you pass judgment, before you form an opinion, just walk a mile in the shoes of a healthcare provider. I don’t care if it’s rounding in an ICU, rural hospital, emergency department, medical-surgical floor, or EMS or mobile healthcare system. Just walk a mile. Because we’re all having to do things we never dreamed we would be doing.

 

My system is not built around sending patients to Columbia or Cape Girardeau on interhospital transfers. Critical access hospitals in Missouri were not designed to house intubated, ventilated patients for days at a time. Historically, you would wait a couple of hours for a bed, and out the door they went. We’re sitting at days in rural community hospitals without ICUs, physicians, and nurses. It is not good for patient care. We are doing battlefield medicine. This is triage.

 

I talked to some colleagues around Springfield before it got bad in our area and they were transferring patients as far as Dallas, Texas, trying to find beds for their patients. I talked to providers at medium-sized hospitals begging for an ECMO bed. And it just doesn’t happen. So people just before they ever have a chance. And we deal with death every single day, but we always gave them a chance. And now? There are days we look at patients and know, ‘They’re going to die before they ever get a bed somewhere else. They’re going to die before they ever even have a shot.’

The practice of medicine

I like a healthy debate. I like to have differences of opinion. I respect it. But that doesn’t mean you get to be mean and tell us that this pandemic is fake or it’s a hoax. Come and see with your own eyes. If it’s not COVID, I don’t know what it is. I really don’t care what you call it, because it’s not standard pneumonia. People are horrifically sick, and we don’t even know the downstream effects.

 

People say we’re living in a giant science experiment. And I say, "Absolutely." We’re going to study this in years to come. But right now, we’ve made a hypothesis and a plan, and we’re moving forward. Medicine is a practice. The public forgets that it is not hard, fast rules. I can’t tell you how many times in my career we make a diagnosis for a patient, start down a treatment path, and hit a brick wall that says we were wrong. Then we try something different. That’s just what we do.

Healthcare worker exhaustion and team support

What I see among my coworkers is physical exhaustion. We’re thankful to have an active part-time pool of employees. You see leaders stepping in and taking patients, running calls, doing transfers, coming in to work on their days off. You’re seeing teams of healthcare providers in hospitals and in the field coming in from out of state. That should cause concern for people. I make sure to leave my huddles with, "Just take care of each other. We will do the best we can."

 

I think it takes engaged leaders to recognize when enough’s enough to say, "Time out. It’s time to call in reinforcements," whether that reinforcement is me or my command staff or off-duty people. In addition to our emergency and non-emergency work, we did over 100 rapid COVID swabs out of the side of my building in the last three days. I feel like that’s doing our part to try to help folks recognize we have access to testing, no questions asked. Thankfully, we have access to a rapid tests swab machine through a local partnership. From a preventative standpoint, if I can quarantine one family before they go walk through school or Walmart, maybe we saved lives in the long run.

 

This business has always historically been reactive, but now we’re taking proactive approaches to things like when we do mobile shot clinics. And we’re trying to follow up in home settings with our chronically ill patients to prevent them from going downhill, too.

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New relationships and going the extra mile

I never dreamed we would be getting peoples’ antibiotics called in, coordinating dental services for them, and keeping them home versus taking them to the hospital. I never dreamed we would be taking boxes of vaccines and sitting in people’s living rooms to vaccinate them during a global pandemic. I never thought I would be teaching my staff to do nasal swabs to detect communicable diseases.

It’s meant reaching out to partners in the care team that weren’t partners before. Ambulance

and hospital folks have always had a weird close bond because you work together in the trenches, but we never really hung out. I mean, we would smile and nod and say, "Hi, how are you?" But through this, I mean, I walk into the Washington County Health Department building and I know every one of those ladies’ names. They’ve been in my building helping us do clinics, and we’ve been in their building swabbing congregate settings for them.

 

Also, our rural health clinics are Federally Qualified Health Centers, and we had never worked with those clinics before. Well, now we do. I’m proud that in little Washington County, Missouri, we’ve all been coming to the proverbial table to try to do what’s right by the patients. That’s the only goal. Yesterday, we got a call from our local health department: "We’re all worried about Mr. and Mrs. Smith. We called to check up on them, but we’re just worried." "Okay, cool. We’ll send somebody in an SUV." From a proactive standpoint, I’d rather send one person to go check on a patient versus that patient waiting until they feel really bad to access the emergency system. Being proactive may give us the opportunity to catch a patient before they’re in crisis and now it’s an emergency.

Public misconceptions about EMS

I don’t think the general public realizes how much any of us healthcare professionals do. There were things I didn’t know about public health, and I’ve been in healthcare my whole life. I didn’t know the sheer number of patients that FQHCs and rural health clinics see on a regular basis. What they provide is not just about vaccine clinics. Iit’s WIC programs, back-to-school shots, lead testing, water samples, soil samples.

 

Is there a misconception about my business and EMS does? Absolutely. People think they call 911, we show up, and drive real fast to a hospital. Yes, somebody has to drive, but that is a licensed clinician in the State of Missouri. A paramedic has the same basic timeline of school as a registered nurse. We arrive, we assess, we do a working diagnosis, we initiate care, we do stabilization, and then we make transport decisions based on patient need, request, acuity, and then there’s the operations of the system.

 

EMS systems are diverse, too. If you call 911 in Downtown St. Louis, there are large facilities with every service imaginable all around. And it doesn’t take very long to get to them, whereas my folks have to make those decisions on the fly based on the needs of a patient: "Do I go 15 minutes to a local rural facility, 35 minutes to an ICU capable facility, or 45 minutes to one of the big houses?"

 

People don’t realize the number of resources that we have either. Our cardiac monitors do multi-lead EKGs for diagnosing heart attacks. We draw lab samples in the back of the ambulance and run some. We have portable ultrasound devices to look inside chests and bellies. And that’s just in emergency situations. We can take inner-facility transfers of critically ill patients and move them to large-scale facilities while keeping them stable ot stabilizing them. So just like hospital systems and services are not all created equally, it’s the same for EMS.

Justin Duncan

Chief Executive Officer

Washington County Ambulance District

NOTE:  Justin shared his story in fall 2021. Some information about COVID case rates and the pandemic response have changed since that time. 

Storytelling and photos by:

Humans of St. Louis / Ava Mandoli