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A Short Take on Long Boards

The National Association of EMS Physicians and the American College of Surgeons Committee on Trauma have made their Position Statement on spinal immobilization for EMS publicly available.  So, now what?

It is hard to argue with their findings:

  • Long backboards are commonly used to attempt to provide rigid spinal immobilization among emergency medical services (EMS) trauma patients.  However, the benefit of long backboards is largely unproven.
  • The long backboard can induce pain, patient agitation, and respiratory compromise.  Further, the long backboard can decrease tissue perfusion at pressure points, leading to the development of pressure ulcers.
  • Utilization of backboards for spinal immobilization during transport should be judicious, so that the potential benefits outweigh the risks.

I know that I have been torn in my own mind while strapping an octogenarian to a rigid long backboard when the only indication for such treatment was that she slipped on the floor of a rest home.  Neurologically she may appear completely intact with a normal level of consciousness (GCS of 15), no complaints of numbness, lacking any spinal deformation or distraction injury.  However, our protocols say she must be strapped to a rigid device without padding and subjected not only to the jolts of our handling, but every bump of a threshold as the stretcher is wheeled outside and then she continues to suffer the uneven pavement between the Emeritus Senior Living facility and the hospital.  If she wasn’t sore due to the fall, she will definitely feel it by the time she is seen by a physician.  I know I am protecting myself from any potential injury lawsuit, but am I really protecting my patient?

The Prehospital Emergency Care statement suggests criteria where use of a long backboard would not be indicated.  Part of that definition includes the following recommendation:

  • Spinal precautions can be maintained by application of a rigid cervical collar and securing the patient firmly to the EMS stretcher…

While I can imagine the greater comfort for my patient and even see the potential for improved spinal protection, it remains just a thought until the concept is adopted by my Medical Director and written into our protocols before I can actually change my behavior.  While I applaud the new recommendations in this position statement, I feel powerless as I continue to apply a non “evidence-based” treatment to my patients.  The primary restraint to change is not medical evidence, however; it is a lack of confidence that the field EMS personnel can make proper judgement calls on when the treatment is indicated or not.  What I fail to understand is how it would be significantly different as we are already given specific latitude to make that call only it is constrained by a far more conservative set of criteria.  Here is hoping a change can happen soon.

 

Posted in Administration & Leadership, EMS Topics, Fire Prevention & Education, Fire Rescue Topics, News, Patient Management, Rescues, Training

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17 comments Posted by on June 7, 2013

Second Thoughts on ‘Scene Safety’

In addition to my regular job, I continue to proudly serve as a medical first responder in my home community.  But, now, in the wake of a Christmas ambush of firefighters last year and yesterday’s hostage situation during a fake medical call, I am thinking back on the doors I have rushed through attempting to offer my help to someone in need.  When I respond to that late night page, I review in my head the details given to me by the dispatcher and construct my index of suspicion regarding the medical condition I will likely encounter and never suspect I am entering any sort of trap.  Just like you, I was taught to say “scene safe” during my drills and exams, but that was in a classroom setting which is far different than I have ever experienced in the field.  Now matter how good your imagination, that fluorescent lit room full of desks and chairs never becomes the cramped, dimly lighted bedroom down a narrow hallway.  So, how do we relate the real-world idea of safety concerns into practice in the field?  Back in school, we have simulators for patients that can respond to treatments providing feedback on my care and mock-ups of ambulances that even make noise to disrupt the use of my stethoscope, but where is the effort to really teach recruits caution before entering a home?  Or even how to deal with the dangerously irate family member once we reach our patient?  Maybe we need to go down the hall of the community college and ask the theater students to join our tidy little scenarios as grieving relatives.

And it doesn’t always have to be the setup of a deranged psychopath to present a danger, there are times I have simply gone to the wrong address.  And in my state, a homeowner is justified in using “deadly force” on anyone who “was in the process of unlawfully and forcefully entering a home.”  Hopefully by announcing myself and asking who called 9-1-1, I can argue the “unlawful” part if logical debates were possible in those late night situations.  Fortunately, I have never found myself in a situation where my life was truly in danger.  But I suspect other responders have felt that same casual assurance before things went sideways for them.  Arming medics is also not the answer.  My “concealed carry” training was very good, but it doesn’t begin to help me understand how to react in a hostage taking situation even assuming my hands weren’t already full of equipment when entering the room.

I read of states like Iowa and New Jersey that are having trouble recruiting volunteers and in some cases offering incentives for service.  I have always felt that EMS is a calling however.  We don’t just need more bodies in uniform, we need the right people to care enough about helping patients.  We also need to do a better job of protecting the professionals (including volunteers) who give of themselves already.  We must use the CLIR E.V.E.N.T. database to share experiences of how to make EMS safer and better for responders as well as patients.  Take the recent events that have happened and let them make you more aware, not more afraid.  Work with others to help them understand the real-world of “scene safety” and practice it in every call.  Let your “index of suspicion” always include your own safety, because we need you back doing this job again tomorrow!

Posted in Command & Leadership, EMS Dispatch, EMS Health & Safety, EMS Topics, Firefighter Safety & Health, Funding & Staffing, In the Line of Duty, News, Training, Training & Development

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No comments Posted by on April 11, 2013

What is “Performance” in EMS? Part 4

This particular series began with the new year in thinking about the characteristics that make and keep an EMS as an efficient, “High Performance” system.   The previous criteria were all focused on factors including “Response Time,” “Effective Care,” and being “Community Connected.”  Each of these criteria obviously affects patient care either directly or more indirectly as part of the community, but in order for a high level of performance to be sustainable in an agency, it must take the welfare of the providers themselves into account.

Part 4: Provider Culture

Protocols and Standards of Care are documents that describe what should be done for patients, however these actions must be implemented by the people who work for a service.  Since the quality of care (and even patient satisfaction) is exclusively implemented by these individuals, often in extreme conditions, it seems counter-intuitive that the jobs they fill are regularly listed in surveys of The 10 Most Underpaid Jobs.  Part of the reason the pay remains so low for a position that is so widely recognized as being critical by the public is that it is still seen as a vocation taught at community colleges and even high schools rather than as a profession.  In some cases, EMS is even treated as a certification that simply becomes a gateway to another job.

The demands on Emergency Medical Technicians (EMTs) and Paramedics is strenuous both physically and mentally.  Some statistics I have heard suggest that one in four EMS workers will suffer a career ending back injury within the first 4 years of service while others may last only 5 years before the accumulated stress becomes almost intolerable.  Those who make it longer often become jaded and cynical due in part to monotony or exposure to patients who seem to routinely abuse the system.  It is important that the culture of a highly performing EMS service not view an employee seeking help in dealing with stress as being weak but rather look to support that comrade through their feelings.  There are resources readily available to help EMS personnel facing burnout Learn to Cope with Stress.  From a very practical perspective, it is typically cheaper to retain a senior employee, even one facing issues, than it is to train a new hire in the organizational way of thinking.

Another real fear that EMS agencies should understand is the problem of complacency.   Disengaged employees cost the US economy around $300B year.  And worse yet, for EMS agencies, this behavior means lawsuits, bad press, patient dissatisfaction, and employee retention problems.  A service culture than promotes performance encourages positive role mentors at all levels.  It is important to pay attention to the characteristics of new hires and to personally examine what type of personality you bring to your organization.  The chart to the right highlights some important character traits to look for in potential employees as well as yourself.

There are two ways to look at the problem of employee satisfaction: is your service hiring the right sorts of people and are you the type of person that the service you actually want to work for is actively hiring?  If you don’t know what the criteria of a good employee are, here are 8 Qualities To Look For When Hiring A Responder.  But again, the other consideration is whether your service is a place with whom professional minded individuals are interested in working.  Here are  6 Culture Building Principles for Your Response Team that promote professional performance and loyalty within the organization.

Leadership is key to authority in any group.  Unfortunately, the only form of authority that can be confirmed on anyone is just “command.”  The role of “leader” must be earned.  True leadership comes from developing respect, not demanding loyalty.  It is developed through an understanding of the job you request others to perform and an appreciation for the way the tasks of that job are carried out.  A high performing EMS promotes a “just culture” where positive behavior is rewarded at least as much as poor behavior is reprimanded.

Just as their is no single “correct” model for EMS delivery, there is no single pattern of employee relations.  Professionally minded employees must find the right service provider culture for them.  Similarly, agencies should demand high performance from those who wear their uniform in order to instill pride both ways.

Posted in Administration & Leadership, Command & Leadership, EMS Health & Safety, EMS Topics, Funding & Staffing, Line of Duty, Training & Development

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2 comments Posted by on March 25, 2013

Quick Thoughts from EMS Today 2013 Conference

Since the EMS Today conference for 2013 started a week ago I know that my thoughts at this point can hardly be considered “quick” any longer. However I wanted to share my experience of the highlights from this event anyway.  JEMS has always been known for putting together a great product whether in print or performance and this show was not a disappointment.  While I have not heard about attendance figures, it did seem just a little smaller in Washington, DC this year compared with Baltimore last year.  I also had a hard time capturing a single shared mood or tone for this year.  Perhaps it was the cancellation of my pre-conference course and inability to get registered into any others that may have set me off on the wrong foot.  Especially easy to do after a day of work followed by an evening Con Ed class and an all-night drive to beat the forecast “Snowsquester” that was sure to shut down DC.  But it didn’t take long to begin catching up with colleagues and realize there were fewer flakes than predicted.

Wednesday:  Improvisation is a primary characteristic of both EMS professionals as well as politicians.  Fortunately, both implemented plenty of it on Wednesday during a modified “EMS on the Hill Day” event sponsored by NAEMT in conjunction with the conference.  While not as many elected representatives were available as hoped due to a weather-related shut down, there was opportunity to explain the impacts of legislation such as PPACA (“ObamaCare”) and the Field EMS bill on our industry to those who knew where it was happening.  (An awareness shared by those attendees who participate in social media at conferences.)  This is an important annual day of advocacy open to all EMS professionals who register in advance and one that everyone should be involved in supporting.  As representatives were found to be available, they were visited by attendees on your behalf.

For those of us attending the impromptu hotel meeting, we heard several good speakers on topics passionate to them. Matt Zavadsky of “MedStar Mobile Healthcare” (formerly “MedStar EMS”) discussed his agencies view of changes to the industry saying “we are not Emergency Medical Services (any longer), we are Unscheduled Medical Services.” Others, like Chris Montero, spoke on our increasing role in public health and promoting community paramedics.  One easy example was assisting with ”mobile immunizations” for the community (or what was jokingly termed “drive-by shootings”).  Later in the evening JEMS announced the “EMS 10″ Award Recipients for 2012 at a special gala event recognizing those who drove the EMS profession forward.  It is definitely worth reading through the accomplishments of these individuals and agencies and commit to continue their work nationally.  LeFlore County EMS located in “super rural” Oklahoma, just as an example, improved their save rate from 6% to 40% and has not failed an intubation in 3 years.

Thursday:  By far the busiest day with endless concurrent sessions.  I tweeted as many of the pearls of wisdom that I heard live as fast as I could.  Whether you are attending a conference or not, the ability to share knowledge through social media at an event like this is incredibly valuable.  For those at home or on the job, it was their first opportunity to hear even pieces of great lectures and those in the same room get to hear what resonates with others immediately.  One of the key points I took away from this day of courses was that as an industry, we need to communicate that EMS response is more than a measure between receiving a call in the dispatch center and the wheels of an ambulance hitting the curb at the scene.  It is also important that we “take stock of our dysfunctions in order to embrace the change that means improvement for the benefit of our patients.”

Representatives from the “Gathering of Eagles” presented in a forum session where several “sacred cows” of pre-hospital care were lined up for the slaughter.  Such controversial ideas as: “IVs being the only method to administer drugs is becoming an antiquated idea”; “to save patients as well as money, focus on driving safety and alternate endpoints for treatment”; or ”where are the papers that support the benefits of the backboard?”   Cervical collars, it was argued to the delight of the crowd, properly strapped with patient on a stretcher can be safer than a “slip-n-slide” (i.e. “backboard” which can add to compression/decompression injuries during transport.)  I know many of us are watching intently for the paper coming soon on new ideas for spinal immobilization. In short, the best summary of the “Eagles” session was ”everything is changing.”

Another informative and challenging session was “What EMS has Learned from the Iraq and Afghanistan Battlefield” with Peter Taillac. Much of this presentation focused on the return of the tourniquet.  This device, according to Tallic, got a bad rap because there was historically no evacuation plan once applied, but more recent research shows that survival rates for patients are 96% if a proper tourniquet is applied before signs of shock are present while rates decrease rapidly to only 4% when it is used only as a “last ditch effort.”  The other challenge to traditional thinking was stated clearly in the thought that ”‘only a doctor can remove a tourniquet’ is “bullshit.”  Medics should apply tourniquets early, as indicated, but reassess the need for a tourniquet during transport and remove if possible.  One warning, however, is that if blood pressure increases after removal, the likelihood of “popping a clot” increases too.  However, he contends that the goal of an IV is to prevent shock by maintaining perfusion not returning normal blood pressure in the field.  Tallic also praised topical hemostatic agents when used properly but chastised the industry in general saying that typically “EMS sucks at pain control.”

The opening ceremonies on Thursday night had all of the requisite pomp and ceremony to make any fire-based EMS service feel comfortable.  But it was all pure EMS history as Dan Swayze of the Center for Emergency Medicine in Pittsburgh (CEM) led the audience through a dramatic trip of historic ”pre-hospital medicine firsts.”  I know I had personally wondered where some practices came from, but it was definitely thought-provoking when Dan asked, “so, you are the first person to ever attempt increasing blood flow with direct intravenous fluids, how do you do it?”  Following this presentation, the exhibit hall was officially opened and I got to attend the premier of the latest Code STEMI video in the inspiring FRN series taped this time at the world’s busiest EMS service.  Take a look and share it as part of the “Community Connected” initiative I mentioned in my last post.

Friday and Saturday: Continued more sessions and time in the exhibit hall as well as annual favorites like the JEMS Games and the Cook-Off Challenge.  Unfortunately, I had to leave before the closing ceremonies and last session, “Gaining and Keeping the Public’s Trust” by a popular and entertaining speaker, Gordon Graham.  I do look forward to next year though and hope to see you there.

 

 

Posted in Administration & Leadership, EMS Topics, News

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1 comment Posted by on March 14, 2013

What is “Performance” in EMS? Part 2

With the new year upon us I began to ponder what really constitutes a “High Performance EMS” and came up with several criteria.  I started this discussion by posting on “Response Time” and now want to bring in a second topic.

Part 2: Effective Care

While being effective in our care of patients should be an automatic criteria, I believe there is still plenty to say on the topic.  The American Heart Association re-evaluates its approach routinely to cardiac care every two years.  How often do we truly examine our practices in the “out-of-hospital” emergency care profession where we know that patient demand and provider skills are constantly changing?  In the past several months, I have seen articles challenging standard practices toward intubation and c-spine immobilization – basic tenets of our practice – but how many agencies have made any significant investigation toward change in these protocols?  For its part, The Army Awards Follow-On Contract for Autonomous Airway Management to Energid Technologies to create robots that can perform endotracheal intubation.  Before we answer the question of whether robots or people are better at ETI, shouldn’t we answer the question regarding efficacy of the practice for the patient or refine the scope of practice regarding it?  Similarly, other detailed questions are being raised like Is the 6-12-12 adenosine approach always correct?  Is the closest facility really the best facility and who is allowed to make the call of an appropriate destination when EMS strategy change gets heart patients faster care?  Is public perception or even financial reimbursement a more important driver?  Please don’t think I am just being cynical, I believe that the return of the tourniquet is a good example of evidence-based practice in practice.  While we don’t want to see protocols change like fashions, we need to avoid viewing them as sacred writings as well.

This next point may need to a separate topic altogether, but as an example of considering all parties involved, lets look critically at a new protocol that has been introduced at many agencies including the service where I work.  For cardiac patients requiring CPR, it is now to be done on-scene for at least twenty minutes or until ROSC.  If resuscitation attempts are ended, the body is left.  Just last night, I departed a scene of the cardiac arrest of a mother leaving her cyanotic body in the home with her husband and 5 yo daughter.    I admit that I was relieved not to have to transport, but I was equally mortified to leave the grieving family in that way.  Perhaps there isn’t always a good answer, but do we communicate the reasoning behind the decision or just the alteration of the  protocol itself?

In my mind, EMS personnel are consummate professionals.  But how does the system view these providers of emergency care?  I was involved in a serious debate recently over whether EMTs are qualified to place the pads for 12-lead ECGs to be transmitted for interpretation at a receiving facility.  I was surprised to find that there was any serious question.  Are we more concerned over maintaining a strict division of labor skills for the benefit of the provider even over the needs of a patient?  Think of the combined experience out there.  There are many innovative EMS personnel, who out of necessity (or extreme practice) create better “mouse traps” such as the REEL Splint or WauKboard for example.  Paramedics, EMTs, and even Medical First Responders must not be viewed simply as automatons that can only repeat protocol standards, but capable of some judgement within the limitations of their qualifications and skill level.  But whether it is the fault of EMS personnel who attempt to skate by with minimal effort or the cautious medical director who sees the wide disparity in knowledge (or more accurately “wisdom”) in the staff, many good professionals are being short changed.  It is our responsibility, whether an EMR or MD, to teach and even police, “our own”.  We must hold each other up to the standards we want to examined by and to guide our profession.

You are required to bring about the next generation of EMS, the so-called EMS 2.0 revolution by your actions.  EMS World recently published a article to help you move in that direction in their Quality Corner: How to Make Better EMS Providers.  Don’t view “professional” as a title, but as a calling to service in always providing “effective care.”

 

Posted in Administration & Leadership, Command & Leadership, EMS Health & Safety, EMS Topics, Funding & Staffing, News, Opinion, Patient Management, Training & Development

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1 comment Posted by on January 30, 2013

What is “Performance” in EMS? Part 1

It is that time of year for resolutions and reflection.  As I ponder this thought, the topic that sticks out to me is about what really constitutes a “High Performance EMS”.  As we look back over the past year of the High Performance EMS social network (including our Twitter and Facebook feeds as well as this blog) one of the recurring comments that disturbs me is that “response time doesn’t matter”.  This causes me concern in two ways – first, that the primary measure of performance is overwhelmingly always “response time” and the other is that this simple measure is deemed to not really be important.  So, for the next few posts, I will discuss various characteristics that I feel do matter in becoming a truly high performing EMS system.

Part 1: Response Time

This past February, Elsevier published an excellent newsletter (EMS Insider, Volume 39, Number 2) focused on EMS response times and included articles such as “The Great Ambulance Response Time Debate Continues” in which the author, Teresa McCallion, laid out many of the facts.  For instance, the article recites the “MedStar example” from Super Bowl XLV suggesting that “very few EMS calls” in that prospective two week study actually “required an immediate response.”  It is important to note that this statement did not go so far as to say that response time is meaningless in all cases – just that it is far less limited in most.  Then as counterpoint to dismissing response times altogether, the public conflict at EMSA in Oklahoma City was brought up where at least one politician complained of the number of excluded calls required in order to reach a 90% response time compliance rate.   (more…)

Posted in Administration & Leadership, EMS Dispatch, EMS Topics, Fire Dispatch, News, Opinion, Social Media, Technology & Communications, Vehicle Operation & Ambulances

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9 comments Posted by on December 30, 2012

Excellence Through Challenge

Everyday on the job is a competition for EMS workers against the forces of nature (and sometimes even stupidity).  Staying sharp and ready for these challenges can be daunting – especially when you are not asked to exercise all of your skills.  Following that logic, friendly competition can help make you better as a emergency care provider.  That is why I wanted to post this following announcement from Mike van Mil on the upcoming Paramedic Competition this April.  Plan to improve!

11th Annual Paramedic Competition

Think you’re the best at what you do? Do you have the skills to beat out all others? Do you like to show off those skills? Come on up to Oshawa, Ontario Canada and prove it!

Teams compete in one of three divisions:  Advanced Care Paramedic, Primary Care Paramedic and Primary Care Student.  For competitors unfamiliar with those terms, ACP may likened to EMT-P while PCP may be considered to be EMT/EMT-I/etc.  The scope of practice for each paramedic level may be found by reading the National Occupational Competency Profile (updated 2012) created by the Paramedic Association of Canada.  If you are unsure of which division you should be competing in, please contact us to discuss your situation.

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Posted in EMS Topics, News, Patient Management, Training, Training & Development

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1 comment Posted by on December 3, 2012

A New Danger in EMS?

I read an article this morning where Winnipeg declared Cellphones off limits for firefighters, paramedics with only some surprise.  Sure there are the embarrassments like the Texas Firefighter Charged With Taking Secret Bathroom Pics who need to be drummed out of the system.  And I understand that new technology can be a scary thing – especially from a legal perspective, but our reaction to any sort of potential change is always predicated by our view of the staff we employ.  If staff are viewed only as automatons, they need constant micromanagement even at the most basic level.  If they are viewed as professionals, they need only to understand the tools they have, the overall mission they are given, the latitude of their autonomy, and the impact of their misjudgment.

Businesses in the private sector have struggled for many years over the risk and rewards of giving employees increased access to sensitive corporate information from mobile devices.  Once the technology was finally embraced, the initial result was huge expenditures for company-owned devices that quickly became outdated.  As a result, many organizations have now embraced a BYOD (“Bring Your Own Device”) policy to leverage the employee’s willingness and need to provide current mobile technology for use outside of the office.  While it certainly increases the workload for corporate IT professionals to support and secure these devices, it has been determined that the improved productivity, increased job satisfaction, and in some cases even lowered equipment cost outweigh the investment.  The risk of exposure is still there, but when employees are properly treated as professionals they become empowered allies instead of floating liabilities.  In some ways the case is much easier for EMS. (more…)

Posted in Administration & Leadership, EMS Health & Safety, EMS Topics, Technology & Communications

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2 comments Posted by on November 1, 2012

Late for the Future

My friend Mike Ward, who I met as “FossilMedic“, asked a question in a blog post back on September 10 wondering aloud “What will the fire service look like by September 11, 2021?”  Well, a few of my fellow EMS bloggers took the challenge of answering that question.  In his blog post on the subject, Greg Friese presented a mixed bag of specific predictions as he also extended the question to include EMS as well as Fire in the query.  The gadget geek known as “UnwiredMedic“, or just Christopher Matthews to some, also quickly took up the challenge focusing on the advances in technology as he usually does in his post on “the closure of another anniversary“.  Finally, Bob Sullivan focused on his trademark patient perspective in discussing provider skills and training that will be common in his view of “EMS on 9/11/2021“.  I am quite late to the fray, but hope to join these friends in making my own prognostications from my own unique vantage point on improving the efficiency of EMS.

The way I see it, in another ten years we will be past most of the in-fighting we currently experience between firefighters and paramedics about who does what more effectively or efficiently.  I hope that by the 20th anniversary of the terrorist attacks we will finally recognize that the public is both the focus and financier of our efforts outstripping our desires for shiny equipment or promoting blind union allegiance.  We face the pressures today of a changing environment where a lack of volunteers is necessarily being replaced by paid staff increasing provider costs and an aging and increasingly unhealthy population is placing more demands on emergency resources.  All while, the very foundation of the heath care system is continually being overhauled with changes to well-established financial reimbursement incentives.  The fundamental change we will witness regarding the structure of provider agencies in coming years will not be a linear progression from today, but the enhanced variation of a “punctuated equilibrium” driven predominately by rising costs and demand that are clearly out of line with our commitment of resources.

The first ten years since 9/11/2001 saw unprecedented spending in public safety at every level raising debts nationally and locally.  Now we face an economy that cannot sustain current spending patterns and will demand increased efficiency along with the increasing efficacy of evidence-based treatments.  To get more from less, we must do better.  I believe we will see the advances in technology and education that others have predicted because it will prove to improve service, but we will also see consolidation of agencies along with increased specialization.  Medically focused professionals will handle the majority of medical calls.  Savings will be realized by integrating these medical responses with advanced medical providers given incentives to improve long-term health outcomes.

A future we need and can live with.  What do you see?

Posted in Administration & Leadership, EMS Topics, Funding & Staffing, News

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2 comments Posted by on September 19, 2012

The Default Solution is Always More

My wife announced that there wasn’t enough money in the checking account again.  The obvious solution to her was that I simply needed to add more money to it each month and that the problem would then go away.  Any attempts on my part to question where the money is being spent is considered completely offensive simply on face value.  There are so many details that I would just not understand.  After all, I simply need to know that we are talking about meeting the needs of our family.  How could I even consider not addressing those needs?  Do I want a child to go without an education?  Without shoes or food?  It could happen she warns, if the funds are not provided.  Oh, and I can’t reduce the family size either by letting any of the kids (or even my wife) go.  Alright, maybe I took that analogy to an extreme there at the end, but replace my wife with the fire chief or union leaders, my kids with union firefighters, and make me a politician or simply the public and the story is replayed all over the country and even across the world.  ”If we don’t have more money, someone could die!”

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Posted in Administration & Leadership, EMS Topics, Firefighting Operations, Funding & Staffing, News, Vehicle Operations & Apparatus

1 comment Posted by on August 28, 2012

MCIs and “The Downwind Walk”

I never really considered doing book reviews on this blog or writing about specific horrific incidents either, but I finished reading “The Downwind Walk: A USAR Paramedic’s Experience after the Terrorist Attacks on September 11, 2001” by Steve Kanarian just hours before the shots rang out at a movie theater in Aurora, Colorado.  Let me say upfront that this will also probably not be the sort of book review you might expect, but I doubt the book will be what you expect it to be either.  The book at least, is much more than it appears.  Steve is a Paramedic, a retired FDNY EMS Lieutenant, and now I am happy to call him my friend as well.  He has given me a gift through his pain and I hope you will take it as well.

From the title I was expecting a journal of the messy details written by a “Forrest Gump”-type character who was always in the right place at the right time and would take me into the depths of the response that day.  What I discovered was an even more real experience than I imagined.  It was his exact experience including the hours and days of simply waiting to be of use.  Most surprising was that the greatest interest of the book for me became the continuation of his story long after the actual event and even after his final day working at ground zero.  It was the story of every first responder who is called to action at (more…)

Posted in Command & Leadership, EMS Topics, Firefighter Safety & Health, Mass Casualty Incident

4 comments Posted by on August 2, 2012

Quick Thoughts from Pinnacle EMS 2012

Last year one of the Pinnacle attendees was quoted to say it was ”the most innovative and thought-provoking event of the year.”  This year I will have to admit that this truly has been one of the best conferences I have attended in a while for the quality of the discussions and relationships it has initiated.  From the pre-conference power seminars to the keynote and concurrent general sessions, attendees have consistently been challenged with new ideas relating to the future direction and operations of EMS.

On Monday, I attended the session on “Effectively Using Social Media” with Greg Friese, Carissa O’Brien, and Skip Kirkwood.  Even though I work with social technology every day, I still heard many practical and well thought out approaches such as learning to leverage social technology internally first before trying to promote it outwardly – especially as a large organization.  Aetna was a great example of how some organizations are really doing social right.  Relating it more directly to EMS services, there was talk of developing not just a social media “policy” of “dos and don’ts” but a “strategy” of what you hope to accomplish with it.  Social is also not something you simply assign to the young intern because they might be comfortable with technology, but must be directed as a strategic corporate resource.  Listening is the best way to begin, but this is not just how you need to get started in social media, but more importantly how you stay engaged.  There are several listening tools that can help you know what is being said about you and to help you take appropriate action which may, or may not, involve a “social” response.  There were several other points I found worth noting and they can be found in my Twitter feed going back to July 16.  Opposite this session was the wildly popular “Community Paramedicine” session facilitated by Kevin McGinnis, Chris Montera, Anne Robinson, Brent Myers, and Gary Wingrove.  This was clearly a topic of interest to many throughout the week.

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Posted in Administration & Leadership, Conferences, EMS Topics, Training & Development

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3 comments Posted by on July 18, 2012

A Bibliography on EMS in a State of Change

Most scientists agree that earthquakes are difficult to predict, but last Thursday should have been a “gimme” regardless of how the Supreme Court would have ruled.  Independent of your perspective on the ruling, we now know how health care reform will play out – at least until the next major shift changes the landscape again.  There are some fine articles that have looked specifically into the basics of U.S. healthcare, reform and the high court, or How Health Reform Could Hurt First Responders, even What the Supreme Court’s health care decision does—and does not—mean.  Also, hospitals are seeing the healthcare ruling as a new challenge and suggest that Federal Proposals Would Limit Aggressive Hospital Collections Practices.  So I have no intention to try to argue any of those contributing factors.  There are still many other factors affecting the future of emergency health care delivery that aren’t getting as much press attention even though their impact is at least as important.  Make no mistake, reform is coming to EMS!

Steve Whitehead at The EMT Spot blogged on the 7 Myths About Fixing Our EMS Systems.  It is a well-thought out article focusing on how to improve the system, but doesn’t approach the underlying causes.  From my perspective, one of the most important influences I see making an impact is politics.  In the article Ambulance debate rough road: Government could grow, it is clear that local politics specifically regarding government is driving too many decisions.  The Mayor of Columbus appears to be favoring a significant initial investment along with an annual subsidy to expand the local fire department rather than award a contract to one of the service providers claiming no subsidy would be required.  This also brings to mind the case in Utica, New York where the city sees an opportunity to actually generate municipal revenues through an ambulance service even though they could not certify a need as the Revised bill on ambulance plan still a bad policy opinion article suggests.  Which brings me to my second primary factor of money.  There are too many differences in how EMS is funded.  Unlike the fire and police department, which are so-called “free” services paid completely through your taxes, most EMS agenices charge for their services, going through your health insurance where they can.  Some operating costs are also covered by various combinations of property taxes, usage fees, or subscription fees without any consistency between jurisdictions.  There are many ongoing debates including this one by Letter: Emergency Medical Services In Great Neck.  But as long as there are such diverging funding schemes, (more…)

Posted in Administration & Leadership, Dispatch & Communications, EMS Dispatch, EMS Topics, News

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3 comments Posted by on July 6, 2012

Demystifying the Current Drug Shortage Problem in EMS

The following post is co-authored by two special guests:

Jonathan D. Washko, BS-EMSA, NREMT-P, AEMD and Scott Matin, MBA, NREMT-P

In a recent meeting held in Washington DC, sponsored by the Department of Health and Human Services (HHS) and the Assistant Secretary for Preparedness and Response (ASPR), the EMS industry and other key industry players were invited to learn more about why the current drug shortage situation exists. Those that attended the meeting were fortunate to be addressed by a panel of experts from the FDA, HHS, drug manufacturers, drug suppliers and a variety of EMS providers and industry trade Associations.

How did we get into this situation?

It became quickly evident that the problem being experienced by the EMS industry along with other emergency health service providers is due to a variety of unmanaged but tightly integrated series of manufacturing, regulatory, supply chain and end user processes and practices that have come together in a perfect storm to produce the situation we find ourselves in.

(more…)

Posted in Administration & Leadership, EMS Health & Safety, EMS Topics, News, Patient Management

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3 comments Posted by on May 21, 2012

Quick Thoughts from the EMS Today 2012 Conference

This was my first time at the EMS Today conference produced by JEMS and I have certainly not been disappointed by the promise of quality education, networking, and new products.  The ride-along with BCFD EMS, described in my post yesterday, help set the tone for a genuine learning experience.  Whatever your level of experience or interest in EMS there was something for you here in Baltimore.

The pre-conference courses began on Tuesday and the ones I observed were excellent varying from the “Back to Basics Skills Lab” by Bill Justice that was attended by many young, new EMS professionals to the “EMS Field Training and Evaluation Program” led by Troy Hagen and Skip Kirkwood that opened up many new questions for me about how EMS functions today and what we need to do to improve it.  Others I would have liked to attend included Advanced Airway Management, EMS Street Survival, and a workshop on best practices for delivering and tracking training by Greg Friese with CentreLearn.

The “Global Climate of EMS” session led by Jerry Overton was a great way to start my day yesterday by forcing me to take a hard look at how our EMS systems are designed in the US and how they compare to the rest of the world.  Some of the sobering statistics can be found in my past tweets by @hp_ems or by searching the #EMStoday hashtag.  But more importantly, Overton challenged the core model of EMS based on a 7:59 response time and automatic transport to the hospital ED created as a result of the 1965 Medicare legislation.  Some of his suggestions included “Alternate End Points” for appropriate care and nurse triage in the PSAP to determine response alternatives.  While the legal concerns surfaced quickly, the reply from places doing it cited cost savings and more appropriate care as a positive return.  This was a discussion that continued with a lively dialog over lunch at the EMS Leadership Lunch & Learn.  Interestingly, the session I attended between these talks was on “Culture Change from the Ground Up” by Fire Chief Gary Ludwig who had a very different premise.  (more…)

Posted in Conferences, EMS Topics, Training & Development

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No comments Posted by on March 2, 2012

A Country EMS in The Big City

Last night I was fortunate enough to have been given the opportunity by Baltimore City FD to ride-along with one of their EMS crews as part of the EMS Today 2012 conference.  My desire was to learn some of the many differences between their service and the more rural EMS service back home.  While there clearly were definite differences, the thing that struck me more than anything else was actually how similar we all are, not how different.

I anticipated the promise that each tone held to expose me to some uniquely urban situation.  And while the individuals I met were clearly unique, the choreography between us all was mostly a repeat.  This is exactly how we are trained in EMS.  We take whatever situation is given to us and we bring a defined order to the chaos.  We seek sameness in purpose and outcome.  The empathy I felt for the apparently homeless patient with the self-induced alteration in LOC and the young woman facing a possible miscarriage was no different here than anywhere.  I simply wanted to help.  The public attitude toward EMS leading to abuse of the system and the painful inefficiencies it causes was also no surprise.  We face the same issues everywhere even if the proportions change.

It was witnessing the banter between calls that told me I wasn’t back home.  The teams and even the sports were different, the union issues too.  But then then there was the discussion of changes in protocols, the latest findings in medicine, the issues faced in home life.  Maybe I am not so far from home after all.

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Posted in Conferences, EMS Topics, Training

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1 comment Posted by on March 1, 2012

The Role of Response Time in EMS Performance

Several months ago Rob Lawrence of the Richmond Ambulance Authority started a thread on the High Performance EMS Group of LinkedIn by asking “So what does the phrase ‘High Performance EMS’ mean to you?”  This innocent sounding question sparked immediate debate even within the small group at that time.  Benjamin Podsiadlo of AMR quickly tied the quality of EMS performance to “experience” and “outcomes” stating further that “response time is not an evidence based factor in ALS performance.”  He later backed up his assertion by writing that “the catch 22 of pushing the workforce to be responsible and accountable drivers while simultaneously achieving narrow response time goals to the vast majority incidents that have no medical need for such high speed driving is also a bizarre and irresponsible contradiction.”  This is a point that even Lawrence admits could foster the “mentality of ‘arrive on time and the patient dies – good outcome, arrive late and the patient lives – bad outcome’” that has already been affecting common sense both in the UK and increasingly in the US since NFPA 1710 set response time standards several years ago.

While there were other good comments, I would like to focus on the specific assertion that measuring response time (a well established practice today such as at Huron Valley Ambulance’s public web Performance Dashboard) is not an “evidence-based” practice.  There are many specific accounts of individual lives saved that I have heard mentioned by different agencies, but I will concede that the plural of “anecdote” is not “data”.  However, one of the best stories of response time saving lives was made on February 9 when Richard Sposa of Jersey City Medical Center EMS discussed an interesting finding in a recent webcast.  The chart reproduced here shows a correlation between (more…)

Posted in Dispatch & Communications, EMS Dispatch, EMS Topics, Opinion, Rescues, Technology & Communications, Uncategorized, Vehicle Operation & Ambulances

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1 comment Posted by on February 21, 2012