Navigating Ambulance Deserts and Their Impacts on Public Health

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*Begining 

Jazlyn Gallego:

Hi. Welcome and thank you so much for joining us for Georgetown’s public policy review podcast. Today we are joined by Rob Lawrence, the executive Director of the California Ambulance Association and chair of the American Ambulance Association State Association forum. Welcome Rob. Thank you so much for being on our podcast today. Please feel free to introduce yourself and tell us about your first exposure to emergency response in public health.      

Rob Lawrence:

 First of all, don’t let the accent fool you. I am doing all of these things here in the United States so I originally started in the UK where I’m from I was my first career was an army officer in the medical services, and then ended up moving into the National Health Services in the UK, where I was the chief operating officer service in the UK, and then the call came to the United States, and I ended up in Richmond Virginia for 10 years, where I was the Chief Operating Officer of the Richmond ambulance authority, and then subsequent moves lead me to the the West Coast and to doing sort of the two things I’m doing right now which is being the Executive Director of the California Ambulance Association, which is the association looks after all the private ambulance services across California and also Allied to that with the American Ambulance Association in the state Association forum, which is really bringing together all of the states with all of their own respective ambulance associations in order really just as hunters of a pack, because as we discuss in the next few minutes, I’m sure, we know we’ve got some really meaty significant issues to get it into.

The question, however, why did I get in the public health, while I I’m a firm believer, that EMS and public health are one in the same thing that. EMS particularly right now is that last great health and social care, safety, net, and actually being allied with public health we have a lot of data, alot of information we can generate a lot of local intelligence, and obviously working with our epidemiologists in public health departments. We can work very closely together, identify the problems maybe look at rootcauses certainly during. My time in Richmond every summer, I always had a public health intern. Because we have that one thing, the public health interns love and that’s data and lots of it but obviously we can come up with hypotheses. We could come up with problems and would allow our interns to go and work and come up with some pretty cool solutions, and in the end oversee some academic reports, papers, posters, and obviously improve the lot, so I am an absolute public health fan. When I go around and talk as I do, one of the one of the first questions I ask is hands up in the room if you if you don’t know the name of your public health Director and I’m always shocked and awed that a lot of people just don’t know. My first question well go away, meet them, introduce yourself to them, and work with them.

 

Gallego:

That’s actually, something that I don’t know so I will immediately have to follow up and see who my public health director is and introduce myself and say hello also see what they’re working on in my community. Because a lot of as you said public health is local, it starts locally and there’s a lot that we can learn within our local communities that’s super interesting and I would love to jump back into that data point later on in our discussion.

 

 

Lawrence:

 I’ve got a story that illustrates it beautifully.

 

Gallego:

 I’m sure! There is a lot to be said from that data. One thing I really wanted to touch speaking of data is there are over 4 million people in the United States that currently live in ambulance deserts. talk about a data point that really stood out to me! but not many people know what ambulance deserts are..do you mind defining an ambulance desert and telling us why you believe this goes so unnoticed?

 

Lawrence:

I think the technical description, if you like, is that an ambulance desert is a place where an ambulance response to an ambulance station or a point of which an ambulance can originate from is more than 25 miles from where you live and so ambulance coverage is the issue there and as we get into hopefully in the conversation, there are many reasons right now where ambulance services are shuttering and closing. Volunteer ambulance organizations are literally running out of volunteers and therefore becomes challenging to provide services.

Now, of course, a lot of this is happening in rural areas, and so not only are we seeing the ability of ambulance coverage, but also a lot of local regional hospitals closing as well and so you know the ambulance station may always have been in the same place but actually, the hospital is now closed and therefore the next hospital along is much further away and so you know you have these situations where if you have a rural community in particular and you have one or two ambulances based there.. well, if you’re the first or the second patient that’s fine you get the ambulance. What happens if you are the third patient? because the ambulances are now on a loop to the hospital which is a considerable distance away so there’s a number of compounding factors that go on that they make the ambulance desert even makes the desert even drier right and so it’s it’s an issue and because it may well be in rural areas, may well be in tribal areas, tends to go unnoticed. It may well be in states to have it at much smaller population and so these things tend to get kind of brushed over by the bigger ticket items but nevertheless, when someone’s having an emergency, they need an emergency response if there’s not one there, than the outcome can obviously become quite dire and obviously we need to get into educate public health.

We need to get back into educating the public on what to do next and that could be anything from knowing how to stop the bleed, knowing how to initiate CPR, knowing how to make somebody just feel a little bit better until somebody or something arrives and of course more importantly, having a call center at the end of that 911 number that is properly equipped with the folk that have the medical knowledge or the medical information to impart upon the caller to actually tell him what to do next and believe it or not, that doesn’t happen across the country either.

You may will have a call center that is operated by sheriffs department, who has no notion of the medical side of things. That also is an issue so there’s a whole set of golf bag of problems here but of course ambulance deserts- if we’re not there, we can’t get to you. That’s the bottom line upfront I guess.

 

Gallego:

Yeah, and what’s really serious about this issue. Now what I’m hearing is that a lot of these are populations that also statistically speaking have a lot of health issues, and it makes sense now that you are drawing out this picture for us that these are communities without the infrastructure for a good public health system, and they have gone unnoticed. They are communities that are historically under represented like tribal communities, or rural communities where there aren’t huge populations that really need people to speak up and really shed light on this issue. It’s super serious because as we’re thinking about ambulances and the critical nature medically of getting someone that medical response that they might need they might need that response within an an hour to 35 minutes and if that time can totally change, depending on where you live, that could really be the difference of how quickly they get medical care and that’s really…at the end of the day, the difference of someones life. Ultimately, it’s a really serious issue of how quickly can we get someone care, how can we make sure that not only we get someone care quickly, but that it is appropriate quality care too.

 

Lawrence:

Yeah, indeed, and across the range of reasons of people called 911 of course, only a small percentage of those are truly life-threatening. In other words, If we don’t do something immediately, that person is in danger of dying, and of course, I’m talking about cardiac arrest, or some sort of penetrating trauma, whether it be a gunshot wound, or you know, be it an agricultural accident the amount of rural areas where there is sort of agricultural incidents and accidents, I’m just sort of picking on one category to give you an example but you know, those things could be quite significant and so you know if you don’t have that service in place then you need to be prepared to tell the patient what to do next or to tell the bystander what to do next whether it’s somebody initiating initiating CPR as I’ve said or somebody applying a tourniquet or something looking like it to stop the bleed.

At the blunt end, if you like or the sharp end, it’s actually quite severe. We need it. It’s a major issue. Now, a lot of 911 calls are urgent and not emergency. In other words if you’ve had, you know, (for example) I’ve had pain in my leg for the last four days, you’re probably not gonna die but you’re probably need to have someone come and see you and because if you know, I would argue that if there’s no ambulance system there, there’s probably no primary care there either because these things tend to go hand in hand. You know there’s primary care deserts, there’s food deserts, everybody’s got a desert these days, right? I don’t mean to be flippant or talk it down, but these are major issues and certainly certain areas because of course, ambulance services, primary care services, it comes back down to reimbursement right? if they’re not getting funded to do it then they can’t afford to do it and they’re not there and so it compounds the problem and compounds, you know, the need to actually try and fix this really.

 

Gallego:

Absolutely. It sounds like it’s systemic and not only is the issue compounded when it’s an emergency, or early on in life when we’re not doing preventative care for that person, but that example that you just gave us, if someone has a leg that has hurt a couple of days maybe it’s not an emergency then but that’s only going to get worse later on if it’s not taken care of. Its a matter of also that upfront prevention, but also making sure that the quality of care when we are providing it in medical care is high-quality so that we are preventing issues later down the road too. Super important.

Flipping gears here a little bit, Virginia has the largest number of volunteer EMS professionals in the country. How are certain parts of the US seeing such huge volumes of emergency response filled with volunteerism? Can you give us a little bit of historical context on where this comes from and whether or not, this has always been the case?

  

Lawrence:

Well, I’m glad you said Virginia because of course, as you’ve heard, I spent my first 10 years in the US in Virginia, in the city of Richmond, but also involved in a lot of state, EMS boards and associations and as the Virginia Association of Governmental EMS administrators, I was their Vice President, so I was able to really take in the expanse of how EMS is organized in Virginia and so here’s the history of it…of course EMS…

Back in the day and I love that American phrase back in the day, was, you know, local communities, local towns, local small cities, villages, whatever you wanna call them. Of course, all had their own volunteer fire department that volunteer fire department then kind of naturally morphed into the Volunteer emergency medical response/ambulance department. And it was a matter of pride that people would then volunteer their spare time to pay back into their community to pay it forward if you’d like, and so Virginia actually was not only the first, but had the most volunteer rescue squads and of course that becomes a traditional thing to be a part of the squad. The way that they raised the money was to stand outside the local food line. If you’re in Virginia, with the boot raised, shake the boot, and people come along, and donate.

It was a great program having a lot of equipment raised for charitable donation or through donation from the local board of supervisors. Now of course, fast forward to the modern era, in the last 5 to 10 years, time has become a challenge for people and so the volunteers volunteering and volunteerism is becoming more challenging to get people to come to work. So what happens then is that the volunteer rescue squad to go back to the local board of supervisor and say “Right, we don’t have as many volunteers as we used to, but what we need you to do is to pay someone to come in and fill the gaps when we can’t come. So for example, I’m a volunteer firefighter. I work my regular job in the daytime. I can come to the station overnight. You need to find people now to come in and pay them to sit there in the daytime.”

So it now becomes a challenge because up until that point fire an EMS have been free in the local community and now you have to go back to the local board of supervisors. You have to go back to the taxpayers into the electorate to say

“Actually now by the way, I need to put a levee on your local property etc. because now we gotta pay for EMS.” and they’ll go

“What!!! I’ve never paid for EMS in my life!!! I’ve never paid for fire in my life! what is this?!”

“Well because the volunteers are not volunteering anymore!”

So that now becomes a challenge that it’s unfounded mandate and people are having to realize that it actually costs something to have this emergency service which is an essential service on standby and so it kind of answers the question of why so many places are responded to by volunteers – because the volunteers were there first. It’s been traditional to have them in the communities, but now local governing bodies, board of supervisors, etc. are having to dig into the budget maybe raise taxes in order to put a more permanent and professional, I’m not saying that volunteers are amateurs, but you know what I mean – a full-time.. paid… service.. in to fill that gap and that is a challenge because this was always – this was never funded, now it is and so that’s where we are right now in fact.

  

Gallego:

That’s really interesting how there was initially a notion of paying it forward, initially public service was such a cultural thing that this is something that people willingly wanted to do – and still do! I guess my biggest question right now is how is the training different?

 

Lawrence:

There’s no difference. In order to be an emergency medical technician, or a paramedic or a firefighter one or a firefighter two, you still have to work to the same curriculum you have to take the same set of exams. For example, in Virginia, you have to – as a paramedic or EMT – you have to challenge the national registry test, so the national registry of EMTs sets the education standard, convenes the tests, you go to local testing centers, and so to be awarded your EMT or your paramedic certification, you still have to do the same thing.

There is not a difference just because I’m in Stanton, Virginia versus Vienna, Virginia, right? You still gotta do the same level of training, the same level certification because of course, the public needs to know that you are able to do the job that you’ve been trusted to do.

 

Gallego:

 Yes.

Lawrence:

And of course, that becomes a challenge as well because the training pipeline for a volunteer rescue squad, whereas if you join a full-time service, you could probably do a month course Monday to Friday eight till five and then you emerge as an EMT. Whereas, the volunteer, that could be a Monday night for the next 10 months or whatever.

It takes a while because you’re not gonna go to full-time community college you know, the local rescue squad will have EMT instructors that will take you through on a night of the week or a weekend day to go through the curriculum in order to challenge the test in order to become qualified and certified so it’s not time volunteering to be on the ambulance its actually time volunteering to get qualified, certified and ready. We ask a lot of our volunteers and those that do give up a heck of a lot in order to be there and be there ready for you.

 

Gallego:

That is super incredible. How how much time do people commit to volunteerism?

 

 

Lawrence:

Well…You know, we have this fantastic phrase in EMS and people are squirrels, like their little bushy tails go up they get excited about being a part of the crew, and so some people could spend every night of the week there when they’re not working, so there are incredibly dedicated volunteers, but like all things volunteered, you know, it’s what you can give to your community whether it’s a week or month or whether it’s every night of the week there is a whole range, I’m sure, and I met people that fit in both ends of that spectrum, but nevertheless, they in their own time went through the training in their own time go to the station, go to the meetings in their own time become part of the fundraising effort, you know, outside the food line, shaking the boot, in order to raise the money, so you know, its an incredible thing that these people do whether you’re a volunteer firefighter, volunteer EMT in your community and it’s not just you know the tours of the truck, it’s all that stuff that sits around it. And of course, if somebody stops doing that, then it becomes challenging and you see, certainly during Covid – we lost a lot of volunteers during Covid because of course what were asking you to do when it’s not your full-time day job, is to come in and see what potentially are really sick people and possibly get really sick yourself so we saw a demise sadly in volunteers, in the volunteer ranks during the pandemic. I can’t honestly blame them for it. My day job isn’t to do that. But those that are still there, they’re still doing an amazing job, but I think they are unfortunately a diminishing return right now.

 

Gallego:

Wow, and have you seen that gap start to grow back of the volunteers that were lost during the pandemic? Do you feel like there’s now the rise again in volunteerism?

 

Lawrence:

I don’t know the answer to that. I don’t have a sort of finger on that pulse. But of course, what we were seeing is that in the regular ranks of EMS paramedic EMTs, a lot of people because they’ve been on the front line 24/7 365 all throughout the pandemic actually got to the point where you know they’ve gotten sick, gotten Covid, seen people sadly pass away, Had to deal with some fairly, you know, horrific – I mean, it’s back to the job where you’re gonna go to somebody that maybe has a gunshot wound or someone’s having a cardiac condition or whatever you know – that’s one of those things to come along but during the pandemic places like New York City – that wasn’t a once a week or a once in a career event, it was a once an hour event, and you wonder why people really – it literally filled them up emotionally and drained them and so we lost a lot of people. “Out of EMS into working in hospitals where I’m gonna get off on time. I’ve got a regular shift schedule. I don’t have to drive here, there, and everywhere.” and so what it created was actually a paramedic and EMT shortage and so we are seeing some major problems now around the country where we’re currently competing now and so people left and of course, I’ve just described describe the pipeline of how you become a paramedic.

For example, you go through your EMT class that you go to community college. Its a two year Associate degree over time and so we have a bit of a capability gap at the moment which means that everyone’s looking for paramedics, I can’t think of an EMS system that’s fully up to strength right now and that’s whether it’s a fire base EMS system, an ambulance company, volunteer rescue organization they don’t have their full compliment, certainly of paramedics, you know, they don’t have their full compliment probably of EMTs – and an EMT is relatively easier to train because of the length for training and so that’s also having a real time problem right now

What does it mean you have enough people? It means you don’t have enough people to man the vehicles to man the ambulances, and that which means that there’s gonna be inevitably a shortage of vehicles available to respond, and then of course those vehicles, then get stuck in the hospitals are in the same boat, so they have a staffing issue as well, particularly in the ED, so understaffed ambulance crews go to hospitals with understaffed hospital staff. They can’t take the patients off the back of the truck there. Therefore, you have ambulance queuing at hospitals and they can’t get back into service in order to service the next patient and so we have this awful situation where we have some areas where which we have amazing delays at hospitals and therefore, that means we can’t get back to the next call so it’s kind of, you know, I think a mess is a great word to use at this point in the podcast.

 

Gallego:

Right it sounds like the emergency medical response overall, it’s still making its way back from the pandemic. But also, one thing to note here. we’re talking about overall response and how do we get to the next step of moving forward in this issue? When we earlier were talking about the volunteers and what they do, whats really interesting on this note of the conversation topic is that their response is filling an immediate need, but its also a long term response. You noted that they also take part in fundraising to make sure that we don’t have this problem in the future and other things along with being able to complete that emergency response gap that might be needed community.

I think that’s really important to also look at and see how people can be engaged in all parts of the issue because it’s goes deeper than what I imagined and how I really thought about this playing out because I knew going into this conversation that there was a shortage of ambulance responses, and that we had just gone through pandemic, and many people are just now coming back into the medical field, but really thinking about how the different sectors really affect one another is really, really, really intense to think about and there’s a lot that quickly jumps into a cycle. The public health field overall is something to think about like an ecosystem, you take one part of it, and then the rest of it sort of falls..

 

Lawrence:

Yeah…It interlocks and it overlaps, and so I sort of talked about the hospital issue that we have with delays, of course, looking how we overlap and interlock with public health.. You know, one of the largest reasons that we have 911 calls right now is for the opioid situation and ketamine and drugs and the fact that the cartels are clearly winning the distribution war, right? and so everybody – we are seeing people overdosing in ever increasing numbers and that’s an ambulance problem. It’s definitely a public health problem. It’s a situation that we can’t seem to find a way out of and so that’s where EMS and public health can particularly can work together to identify, using data, where these things are occurring actually to work, dare I say, now with the medical examiners office to identify – in certain, we did a project – this is one of those moments where my public health intern was absolutely essential –

 

Where we worked with the medical examiners office to identify those overdose deaths that we’ve had in a given period of time. We then went back into our data to see how many times we’ve been to that person that had suffered that overdose because normally we can administer Naloxone or Narcan. Both names are one and the same thing and save the patient that time. Did that patient go onto eventually die? Yes, that patient did and what happened was because the times that we’ve been to that person in overdose, someone had found them. Or t hey were doing it in a space where people could see they were overdosing. The one time that they overdosed and died, they were at home and away from other people so we were able to start looking at the correlation of what’s causing overdose death, is it in a public place? Is it in a private place? and that’s a great use of data between the medical examiner and public health and ambulance services.

 

That response to overdose, drug addictions, substance misuse is now a massive use of EMS time and that’s another thing that..it was there, but not the point now..where dare I say this, good old-fashioned heroin was one thing but now of course, the additives that you have in all your opioids, now you just don’t know what’s in there. Of course, the ingredients make it more lethal to the user and we certainly saw cases… we could always tell through data when there was a new strain of something on the street because it would take more Naloxone to revive the patient.

 

We could almost see if you’re putting you know, 10 mg in instead of the usual two, there’s something in that drug that’s more effective and more deadly and so again, we were able to use that as kind of a surrogate almost for you know, what was on the streets.

 

And it’s a fascinating topic but one that’s causing massive increase in the ambulance use. Obviously an admission to the hospital increased death and that’s the public health conundrum that we’re in right now and where we all have to work together in that particular arena.

 

Gallego:

Absolutely, the opioid epidemic is very, very serious and as you noted, it’s really important for us to take a look at those trends or those trends that you see the trend in the public health data, and to be able to raise a flag and indicate where there are increased needs that are on the rise to be able to create the solutions before those events come up and so definitely very important, that data piece, to be able to mitigate emergencies.

 

Can you tell us looking now to the public policy lens, about what the American Ambulance Association is currently working on and how we can combat this EMS work for shortage or anything else that’s on your radar?

 

Lawrence:

Well, it’s the three Rs, actually. It’s recruitment, retention, and reimbursement. And so one of the things that we’re working to do is to seek federal funding to seek state funding in the states in which everyone is operating to maybe have training grants.

 

For example, Texas last year allocated I think $20 million for recruiting and training of new entry emergency medical technicians and obviously upgrading to paramedic courses so legislating to get funding in order to restore the workforce and that’s a major issue right now and you’re listeners may be surprised to know that one of the taps that’s opening from a workforce perspective is Australia and every Australian university has a paramedic program because it’s a great initiative and Australia overproduces paramedics. Can you believe that?

 

They’re actually four year RN registered nurse paramedics and they can’t get jobs in Australia and so we’ve just gone through the process now of opening up the E3 visa program to having a reciprocity or ability to challenge the national registries of EMTs test in order to bring these folk in on sort of a two year, three year work visa to come and get first hand experience and obviously help us out so we’re trying all angles, international as well in order to fix recruiting so that’s the first R, retention.

We have to look at ourselves very closely to see the problem of why are people leaving? Actually, it’s because nowadays working in for example a fast food restaurant gains as much income as being on an ambulance and being on an ambulance is a very noble thing to do, but actually the hourly rate when somebody is like “do I need to be out here in the cold, the wet miserable,  the snow? – 10 foot of snow that’s just falling here in Truckee California- or would I rather be in a nice warm location and so we have to be able to pay to retain people.

The problem is the third R, reimbursement and of course, ambulance services only receive income when they transport patients and so the income comes from two major sources: source number one is the government: whether its Medicare, Medicaid, or in California Medi-Cal. There’s a government federal reimbursement, but that’s at a set rate. Right?

So it’s gonna be for an ambulance journey to a hospital which is probably $250 lets that say that. Now, it actually costs more than that to do the journey but why does it cost more than that for a simple ride?

Because of course, the ambulance service has to be there 24/7, 365. It’s not just there for that one call. They’re there all the time and that’s what we call “the cost of readiness.” Right? It’s the cost of having – if you’re in Richmond, Virginia – for example, I can talk about this until the cows come home: at the peak of day, we had 27 ambulances on standby deployed in the city and of course you think it’s 27×2 crew x 24 hours. You start to add all that up, the cost of actually being there runs into the millions of dollars. Yet for that one transport journey, you might get $250 back from the federal sources. If you’re privately insured, then the other conundrum we have is that despite the fact that the cost of readiness is x dollars, the insurance will say “oh yeah, our rate is this, and this is what we’re gonna pay you..” and what happens then is that you get into this kind of situation where the patient may pick up what’s called the balance bill: the difference between what the cost is to deliver the call and the cost that the insurance will pay out.

Now, of course, there’s legislation that’s coming in now, certainly in California, where where the patient is actually taken out of the middle of that situation, the balance billing, and actually its now directly between the ambulance company and the insurance company, but reimbursement is a major challenge. Because the cost of readiness and the cost of doing business in many places now is more expensive than the income they get from doing the job and that then, and now we’re gonna go full circle in fact, because if we don’t have an enough income to sustain the service… the service will close and then we get back to an ambulance desert, so I’m just taking you on a full circle journey round back to – this is one of the reasons we have ambulance desserts because recruitment, retention, and reimbursement.

 

Gallego:

This is definitely a really, really good look at the full scope of issues and how we can definitely increase the quality and longevity of the workforce in emergency response, as well as the ability for people and communities across the nation to have care. So it’s definitely very important that we look at those three Rs: recruitment, retention, and reimbursement.

So I know that there’s Medicare ambulance relief support for rural and urban areas as well as other items being supported by the American Ambulance Association —

 

Lawrence:

Yup – in our parlance, we’re looking to extend the extenders, so there is some relief. There is extra payment for being in rural areas. In super rural areas, there’s obviously calculations that go with that. You’d think that would be a permanent thing, but every few years we have to go back to re-legislate to say we need to continue these Medicare extenders to allow us to – because again, in a very rural area, you have to cover a lot of ground you need this cost is more cost to doing it so therefore, if you need to have a little bit more income in order to continue to maintain that service, so that certainly something that is were working on legislatively.

We’re certainly working on, in fact coming up, not only the American Ambulance Association, but the National Association of EMTs, which is another major lobbying Association in our industry.. very shortly we have what’s called EMS on the hill coming up. We will take paramedics, EMTs, EMS workers up to Washington DC. We divide them off into their state groups to both sides of the Hill. They get to meet their elected officials.

They get to actually identify the good work they’re doing and obviously we have a chance then to identify our own legislative needs, of course take the Medicare extenders clearly being one of them, and obviously any other issues that we want to actually put forth and so, you know, things like we’re trying to smooth the pathway for military medics to actually come into our workforce at the end of their military service if you are, a medic employed in an army unit, for example, we know it’s gonna be a much easier pathway to come through to join an EMS system without having to start all over again and do the classes and the courses that you have probably already done or they have a military certification attached to it, even though theoretically, the same thing so working on some topics, such as are absolutely critical to us as well.

 

Gallego:

 Yes, definitely that’s a really interesting response there. I’m addition to that, I know that the association you’re a part of, the American Ambulance Association has had some recent success. Your earlier mentioned the balance billing piece, so can you share what you believe leads to some successful advocacy with some of these issues? What’s some key advice that listeners that are listening to this podcast can really walk away with thinking about their advocacy in terms of public health issues?

 

Lawrence:

 I think the thing I tell everybody is that I was first asked the question, “who is who is an advocate? who is a politician? who is politically involved?” Right?

And the answer is everybody! because we all probably voted somebody into office, whether it’s your local board of supervisor person in your town, whether it’s somebody into your statehouse, and of course, whether it’s somebody into the White House, or the Senate. In another words, you all have actually taken part in the process.

Take that that one stage further and that person was put into office by you and therefore if we have a campaign that’s going on, if we have an initiative, we have an idea: like smoothing the way to bring Australians in by smoothing the visa process, for example. You can actually write to your local elected officials and say “Hey! I wish to seek your support in this.”

And of course, the beauty of having national associations, in our industry in our space, such as the National Association of EMTs, such as American Ambulance Association, International Association of Fire Chiefs, Chief International Association of Firefighters because we have legislators that can then assist our members in getting their message, and their voice heard on the relative hill, whether it state Hill federal Hill, local Village Hill, wherever.

Don’t think that you are such a small cog in this great machine that it doesn’t matter because it does because your vote put that person in there and then for when we’re going up to legislate, we want to take our associates with us in our case our EMTs, our paramedics, etc up to the hill and say

“These are the guys that are doing an amazing job. These are the guys that are actually saving lives out there & here’s why you should listen to them & support initiatives that we have because we’re trying to make their job a lot better.”

You can apply that to public health as well. That is a public health is part of that great health and social care safety net that we have right now working with EMS working with prehospital emergency services and so don’t be afraid to have your voice heard. Don’t be afraid to make a statement. Don’t be afraid to get involved in letter writing. If someone says “we’ve got an issue going on and a campaign going on” – and these days there’s actually IT systems that you put in your name, your ZIP code, and it identifies your local elected official and a letter of support for the campaign that you’re involved in goes to that person. Then you get a nice letter back, saying thank you very much for enrolling in this process and we note that you are for or against or whatever.

To put it simply, don’t be afraid to get involved, get involved, and actually get your voice heard.

 

Gallego:

Excellent advice! Excellent advice! I think we all need a reminder that we might just be one person, but there is so much strength in all of our voices, especially collectively. There is strength in numbers. When I was in college, I interned at my United States senators office, and I would log calls of who came in calling about certain issues, and what ended up happening at the end of the week, there was a report that went out about how many people called about each thing, and so the senator received a report on what folks were calling in about, and all those individual calls ended up being something that made it to his hands, and said, “this is what the people want.”

Even if you’re just taking two minutes out of your day to make that phone call, it’s going to end up as something very tangible, and can end up something very tangible in terms of change, and we all need to do our part especially if it’s something that we care about, and impacts our lives so, so deeply.

So, as we close off this conversation, what is one thing that you wish people knew about ambulance, deserts, and public health emergencies and how can we bring awareness to such issues?

 

Lawrence:

Well, first of all, please remember my three p’s, right because that’s the thing that we’re working on…

What from a public health perspective should we be thinking about? It’s the fact that if we can’t be there because we can’t get the people and we can’t get the infrastructure, then we need to start thinking about how we have the citizenry help themselves and whether that’s everybody needs to learn CPR. Everybody needs to learn what to do in an emergency. Everyone needs to learn what to do to stop a bleed, because actually lifesaving is either restoring breathing or stopping hemorrhaging right? at its very basic and so, everybody should be able to do that.

You mentioned Virginia, there was a law that was passed 8 or 9 years ago . .but without a CPR certification or at least CPR training, there is no high school diploma. At the high school level, everybody leaves school at least knowing how to do CPR. And so having some sort of preparedness in the community and this is a great public health initiative is that if you don’t have local legislation that says everyone needs to learn CPR before high school or every vocational course should have a CPR module then that’s something that the public health official could do and its relatively inexpensive and actually the reward is huge when that life is saved in the same way stop the bleed stuff there might be some fundraising to get equipment but quite simply I could teach anybody to do CPR in two easy steps: push hard and fast call 911.

If you can do that, actually you’re doing something. A lot of people will say “ah yes, but what if I break a rib?” But what would you rather have somebody not alive or a broken rib? I used to bring out cardiac arrest survivors with broken ribs who would say “I’m glad my ribs broken because I’m here to talk about it.”

So that is a very quick and simple fix to help the population when we’re in the desert.

 

Gallego:

Wow. Yes absolutely and I love that you brought that back to local change and things that we can implement not only locally but in our every day lives, in our personally lives, and that just made me remember that when I was in high school, I got CPR certified but I don’t know that I remember how to go ahead and give CPR, so that’s definitely something I’m going to look into!

But if all else fails, push hard & fast, call 911.

 

Lawrence:

Yeah and I’m just gonna go back on that because a long time ago when somebody called 911 and there was a cardiac arrest going on, the call taker would ask you to give rescue breaths to blow down into the into the patient and of course the  people said “ooo I’m not gonna do that..” and so we now have compression only CPR.

So what we ask the citizen to do is to push hard and fast, because actually by doing that, by depressing and allowing the chest to rise, air is going in anyway. But actually, the key thing is to prime, pump, prime the heart. Right? and so therefore we’ve made it easier for somebody, anybody to do CPR by simply pushing hard and fast.

Obviously, call 911. There will be somebody on the line telling you what to do next, but the key thing is push hard and fast and get further help.

 

Gallego:

 Amazing. What keeps you hopeful, as you think about the future and the future of public health specifically?

 

Lawrence:

 What keeps me hopeful is the fact that we have the answers. We can see that we have an amazing amount of information and amazing amount of data. We can see the way that things are going in order to help shape policy so you came in from a policy perspective and of course, the way that we change things is to present compelling evidence that there is a need and a reason for change.

And so we have all of that public health information and if you’re going to become future public health directors, get in touch with your locally EMS system because they are the front line of all of this and have all of the information. It’s there. They’re seeing it every single day of the week and so that information is generated into intelligence and intelligence, generating into action action, then develops change, and so that’s what the public health folk can do to actually ensure that we know the next iteration of healthcare is better because we have the proof and of course your average politician who changes the law reacts yes, to the phone calls, but also to absolute data that says that if we don’t do this, its going to get worse not better.

 

Gallego:

Yes, absolutely and I think that’s so important for everyone listening, mostly those that are educators and students that are doing research day in and day out that are knee-deep into data to be reminded that this data is truly saving lives and that there is a lot that needs to be done in terms of policy and not just on Capitol Hill, but also being able to create compelling research that tells a story about the need of people and how we can go ahead and create, a better future for our communities.

 

Lawrence:

Absolutely, and one final story if I may before we go and you may choose to put this in, you may choose not to.. so I had a public health intern and we had a theory that we had a Latino community in the South part of the city that just weren’t calling 911 – was very, very obvious call desert. Of course we went through the data and there was definitely a lack of calls in one certain area that was allied to the Latino community.

Of course, what we discovered was folk had associated 911 with ICE immigration deportation issues and so they wouldn’t actually use the service, so what do we do with that information? We then got involved with LULAC of the league of Latino association with a public health department Proteros, public health, lead Spanish language clinics. We started to work to let them know that “listen when you call 911, we’re not immigration folk. Honestly, we don’t care where you’re from. We want to be able to be there to save you so we were able to encourage that community to use the emergency service in an emergency, and not be fearful of some sort of policing encounter because it’s absolutely not at all.”

and so a good use of information led to an identification of a problem, and then actioning a solution. That’s where public health really comes into this.

 

Gallego:

That’s amazing! I really I appreciate you telling that story because a theme throughout this conversation has been a lot about underserved communities, not receiving adequate care for one reason or another. Perhaps funding or perhaps being overlooked and in this case, it was not examining the pattern that was there and creating a response.

That’s something that you were able to do and I truly, truly do appreciate that because it led to obviously, a community that needed healthcare being able to be more comfortable with being able to reach out and ask for what they needed and that’s just so incredibly important, especially as we look at public health numbers of Latin communities that are disproportionately at higher risk for chronic illnesses and things like that. It’s really important that we bridge those gaps and say “Okay, where can we reevaluate? where can we see what needs to be re-examined? or see why we’re not reaching folks..”

There are definitely different reasons but when we were examining those patterns, were able to really think about new solutions and also bridge together with community groups as you mentioned, if you’re not an expert in something, maybe you can reach out to other community groups and see why. You were able to reach across to somebody else that was a leader in that community and say “hey what’s going on? This is what I think is happening, but can you help me figure out how to bridge this gap and make sure that these people get care?”

And that’s also really important, if we’re noticing a pattern of something going a miss, we’ve got to reach out and see how we can go ahead and create a solution that’s adequate, that’s culturally sensitive, and make sure that we get people the care that they need.

 

Lawrence:

Couldn’t have said it any better myself.

 

Gallego:

amazing.. thank you, Rob. Are there any final notes that you want to end on?

 

Lawrence:

 No. Thank you. I think we’ve had a great conversation which covered a lot of areas and really identified the importance of EMS and public health working hand in glove all the time.

 

Gallego:

Hand in glove indeed! Well, thank you so much. Rob, it has been an absolute pleasure discussing all things public health with you. I feel like I truly learned a lot throughout this conversation, and I feel like I am learning more and more about the bits and pieces, the cogs in the machine that go into public health every time that I interview someone for a podcast but I truly appreciate how many tangible solutions that you had for us to be able to think about and think about how we can act on somebody different things to be able to enhance care, so I hope that this is our final conversation. I hope that we stay in touch and I hope that we continue to scheme about all the ways that we can save the world.

 

Lawrence:

Great. Thank you for having me. I’ve enjoyed the discussion.

 

Gallego:

I’ve enjoyed it as well.

*End