This is a transcript of a presentation/interview at the NAMSP annual meeting (Jan 10) where Colby Miller (CEO, MedStar of Michigan) critiques EMS reliance on response-time metrics and argues that widespread use of lights-and-sirens and multiple-vehicle responses increases risk and costs without benefiting most patients. He describes MedStar (900 employees, 11 counties, ~200,000 patients/year), his roles (paramedic since late 1980s, chair of state EMS Safety Committee), and the motivation for hosting a multi-stakeholder EMS Safety and System Design summit beginning in 2022 after a joint position paper (Cooper/Kupas). The summit brought clinicians, system leaders, elected officials and dispatch advocates together to discuss evidence showing limited clinical benefit from universal rapid responses and harms from emergency driving practices; attendance and engagement grew from 40 to 60 across the first two years.
Chapters
All right, welcome everybody. It's January 10th. It is the NAMSP annual meeting. So many of us are out here in San Diego, but the show must go on, and this one is going to be very important for many of us. How did this come about? Colby Miller is someone that I've gotten to meet over the years. Recently was up in Michigan and we got to have dinner with him and his team. But then he put a post up on LinkedIn, which I'm sure he'll get into, where he talks about where in 2012 where he was telling people that response times aren't all that, that he was mocked and fast forward many years and it turns out he's right. And I said, hey, Colby, but I'd love to have you come on the webinar and talk about this exact topic. So colby is the CEO of MedStar of Michigan. He's been a paramedic, been in the field, he's done it all, and now he's an executive and he's an administrator up in, in Michigan. So without any further ado, Colby, thanks for joining us and very looking forward to your talk.
Thanks, Peter. Happy to be here. Happy to have the conversation wherever we can. As you said, a little background on me. Paramedic worked in public and private and now not for profit. EMS since the late 80s. I'm sure everybody can figure the math out on that one. It's probably time to be on a sailboat somewhere. But yet here I am, fortunate to lead the largest EMS provider in Michigan now, MedStar. We have about 900 employees in 11 counties, serving just under 200,000 patients a year through the ground in an air medical program. I've worked a little bit with our ambulance association here in the state, a couple terms as the president, and I'm currently the chair of the state EMS Safety Committee as a subcommittee of the state EMSC Steering committee. Safety Committee was an ad hoc committee until 2024. We started to put a lot of effort into some of our safety practices and the state made it a standing committee.
As Peter said, you know, as an, as a paramedic, it started to occur to me pretty early into my career that some of the stuff we were hustling around town for just didn't need the hustle. And as, as I grew in my organizational responsibilities and some of the system roles that I had, I began to notice that the only metric we reported on or the only discussion that we really had about our performance and, and sometimes from a competitive perspective, we, different agency types would step to the mic and kind of beat their chest and the only thing they'd really talk about is response times. And it started to occur to me, and I'm not a scientist, I'm not a researcher, I'm, I'm an ambulance guy, it started to occur to me that we're spending a lot of time, a lot of money, a lot of risk and a lot of unnecessary time and effort discussing a metric that really doesn't seem to affect most of the patients we respond to. And in the ones where it does, we might actually be working against ourselves by designing our system to meet everybody's need in the same time frame. The first presentation was at the Zoll Summit conference in I think it was 2009. Half the room left, got up and left presented at an American Ambulance association conference. There were some people from varying departments there, different agency types, and almost type by type, some of the attendees got up and left, some pretty loudly threatening, indicating that we were going to be killing people if, if we didn't respond. Red lights and siren with seven vehicles to every request. So as, as my role at MedStar and my engagement in the Michigan EMS system has developed, I kind of took on a little bit of a personal mission here to at least start the discussion. And I thought it was important to include all of the EMS stakeholders rather than what I saw as the EMS agency leaders going back to all of their stakeholders and telling the story about how an EMS system works. I kind of thought the story was being told with a little bit of a self serving bend. And again, I'm a paramedic. I've told the story myself. I'm not exempt from thinking that what we've always done is always the right thing. In my presentation, I always start with a slide that has a picture of a KED board, an EOA airway, a jaw screw and a demand valve resuscitator and a backboard. And I point out that when the data showed us that these things weren't valuable anymore, we got rid of them off our ambulances faster than you can say 7, 11 or lunch. But when the data shows that response times and the system structure built around response times might not be all that, we've got 101 excuses to not make changes. And it's, it's funny how the things that physically affect us, that we kind of don't like, we get rid of really quick. The things that enable us sometimes and that, and that we've always used as the foundation of our value proposition or, or how we report on our good work. When the data and the research and the, the sometimes obvious information works against that belief, there's a lot of us don't want to talk about it. So, so my effort was to bring people together. MedStar as the sponsor. We looked for a little bit of sponsorship from some of our vendors, but, but we shouldered most of it. And when the paper came out in 2022 from Dr. Kupas, this is the presenter lineup for the third annual summit that we're going to talk about in a bit. But I'll, I'll walk through the, the history of these summits. In 2022, when the first joint position paper came out from Dr. Cooper, Dr. Kupas and and all of the other EMS system stakeholders across the country, we decided to hold this EMS safety and system design summit immediately on the heels of the paper being released. And we introduced the concept that red lights and siren were dangerous. Multiple vehicles responding, red lights and siren were dangerous. The belief that we've always held in our systems that everything is an emergency, everything has to be responded to with multiple vehicles and lights and sirens was more the juice was not worth the squeeze. And Dr. Kupas does a great job presenting data on the risk associated with the red lights. And 7 responses as well as the clinical outcome and the clinical data about the patients that we're serving. Jerry Overton presented at that conference and we talked about how dispatch could play a key role in helping us sort the right vehicles, the right personnel, the right level of response to the right patient and kind of started the idea that maybe we think we're doing something that's good, but we might be costing our systems a lot of money not benefiting the patients, we might be working against some of our patients in this. Everybody has to have the same thing model. And most importantly, we're putting our personnel and the public that we're supposed to be serving at risk while we run this apparatus and EMS vehicles all over town. Lights and sirens.
In the first session in 2022, there were 40 attendees. It was a one day conference. We held it at the Detroit Athletic Club, gave everybody lunch, good representation of emergency medicine, physicians, EMS system leaders, agency folks elected and appointed people, mayors and supervisors and city managers and then administrators from some of our health systems. So a good cross section of the EMS stakeholder group. And we presented, you know, Dr. Dr. Kramer, recently retired from Washington at the time, talked about system design. His history is here in Michigan. Dr. Fales is the state EMS medical director. Dr. Kupas reported on the paper. Jerry talked about the ability of proper emergency Medical dispatch to make a difference. And Matt Zavatsky from then from MedStar in Fort Worth talked about EMS systems around the country that weren't what everybody thought we're always supposed to be doing running lights and siren to everything. Interestingly, there was a lot of good feedback after the meeting, immediately after the meeting, standing around the room. It was an hour and a half after the meeting ended that the attendees left because the, the conversations were so robust and it's an interesting breakdown and I, I point the breakdown out because with each successful, with each passing summit we see some of the same comments. The health systems and the docs in the room said, you know, this makes sense to us. We didn't know that you responded to every patient, lights and siren as if they were all the highest security. The elected officials in the room said, wow, this is really interesting. You know, we've been told by our EMS leaders and our public safety leaders that everything you do is life threatening and response times are critical on all these calls. And this is, this is really surprising that lights and siren are risky. We don't gain that much time anyway and the time that we do gain doesn't matter to 98% of the patients. The EMS and fighter people in the room kind of said, well, you know, this, this data is really interesting and we recognize that there's some smart people in the study, but this is the way we've always done it. And then the public expects it and, and then the, you know, the, the unending stories of what if and what about and these, these odd one offs that everybody wants to talk about. And it, it was very interesting to me to see the, it was almost like a political divide between the groups of attendees and how they separated after the information was presented and how they kind of internalized it.
A year later we got everybody together and we said, all right, it's been a year now. We didn't invite, we invited the same general group, some of the same people attended. We had some different attendees from different organizations and it grew from 40 to 60 in the second year. As we brought the second year together, we talked more about the changes that were taking place around the country in different response models. Agencies going away from red lights and siren agencies, going very public with their local elected, saying that, you know, this response time thing is, is a crushing burden to our EMS system that might not be benefiting all of our patients and kind of bringing the Michigan group up to speed, that what we talked about a year ago is now starting to gain traction in EMS agencies. And systems around the country. Dr. Kupas updated US on the feedback that he'd gotten through the various organizations since the paper was first published. Matt presented again on, you know, the, the other agencies around the country. And we started this theme that the, the topic or the concept that we introduced in the second meeting was if we think that lights and siren and.
