Ambulance Staffing in Fire-Based EMS

Ambulance Staffing in Fire-Based EMS

By Alan Perry

December 25, 2013

The growing sophistication of pre-hospital medical care is driving the use of better research and the adoption of evidence based measures for patient care. It also relies on high quality data, and a greater degree of consistency and teamwork from providers, perhaps pushing the limits of the conventional two-man Medic. It may be time to break this tradition and begin deploying EMS assets the same way Fire assets are deployed, with a clear crew structure that is only to be broken up in extreme circumstances. I'm talking about a Medic Company, a senior EMS provider as the company officer and a ALS/BLS crew of two. Fielding this type of unit is both practical and revolutionary, allowing the team to perform at a higher level and reducing the instances of deploying multiple additional assets to "assist" them. Instead of a medic being a dreaded shift assignment a crew/officer would be assigned to it providing the same continuity and familiarity with the apparatus that engine assignments currently enjoy exclusively (this is called ownership).

The advantages of having more than one provider in the back of an ambulance for an ALS transport should be obvious and indisputable. Yet I still encounter resistance to the practice among my co-workers. I work in a Fire-based EMS environment with EMT-staffed ambulances and ALS providers on the engine companies. Not all engine companies have 4-person staffing, and they are not all in close proximity to a hospital. There are two possible outcomes depending on the Company Officer’s attitudes toward EMS services.

A)  The Company Officer moves all of the paramedics gear to the ambulance, takes one provider off the medic and moves his/her gear to the engine, the ALS provider rides the call in alone with the EMT driver. The engine company returns to service BLS, Once the patient is turned over and the unit is restocked the provider is brought back to his/her station, transfers their gear and returns to the engine.

B) Depending on the staffing level and proximity to the hospital; the Company Officer does not re-arrange personnel or gear, leaves an additional provider on the medic to assist with the "ALS" patient, follows the medic to the hospital remaining on the call, or goes out of service until the ALS provider is returned to the station.

These two options represent the cultural divide in thinking in an organization that puts Fire Protection above Patient Care. To better illustrate all of the variables let me break it down into Pros and Cons with a couple of stipulated facts:

*ALS patients are by definition more likely to need multiple and/or invasive procedures to assess, monitor and treat.

*The ability to record timely and accurate information aids in treatment. improves the accuracy of documentation and usable data collection.

     * One person cannot reliably perform multiple interventions, assessment, documentation and communications in a <15 minute transport.

To put this in its proper perspective we have to acknowledge that we are primarily an EMS service that provides Fire and Rescue services as well. We document the value of the property we save but rarely consider the value of the lives we impact. This may eventually change, like our ways of thinking.  let’s do what is best for the patient.

Thanks,

Alan

Back Injury Basics, Apathy & Education

Back Injury Basics

Apathy & Education

By Alan Perry

November 26, 2013

Spinal immobilization is a basic EMS skill that every provider should be intimately familiar with. The skill is part of most State EMT tests, as well as the National Registry practical exam.  Motor vehicle accidents (MVA’s) are responsible for the majority of back and spinal cord injuries[i].  MVA’s present unique challenges for extrication of patients while maintaining some degree of immobilization to protect the spine and spinal cord from further injury. Traumatic spinal cord injuries occur at a rate of 12,000-20,000 per year[ii]. The efficacy of spinal immobilization is debated and currently being investigated, some have even suggested that in the case of patient extractions from MVA’s it would be better for the patient to remove themselves with only a c-collar to prevent unnecessary spinal manipulation[iii].

Providers must make several decisions when confronted with a MVA patient complaining of back pain. First, consider the Urgency; is the patient’s condition critical? Will they suffer additional harm if not removed and treated immediately, such as for a major bleed? Are they in immediate danger from fire or drowning?  If the answer is yes, then spinal immobilization concerns become secondary and the patient must be removed in the most expedient way possible until immediate life threats are resolved (if they ever can be). Then choose your method; if the patient’s condition and environment are stable then you have to decide what method is best, in most places this will be determined for you by local protocol, in a few places it is left to technician discretion. Most localities have the option of using a regular long backboard (LBB) and short board or Kendrick style extrication device (KED) as their primary tools.

We are taught that with a stable patient and stable environment (the majority of MVA’s), that the KED is the most effective way to remove a patient from an automobile that has only minor damage[iv].  All too frequently this tool is left disheveled in the back of the backboard compartment in favor of the more expedient and less time consuming trauma roll onto a LBB. Why is this? I suspect a number of factors are in play; education & training, expectations & communication, laziness and complacency, leadership, and especially in the fire service, culture. While the academic world debates the efficacy of the procedure, it is important to note that the textbooks, protocols and certification processes still define what our standard of care should be.

Can you tell where I’m going with this? I’m not worried much about what a lawyer thinks about my patient care because everything I do for my patients is based on what is best for that patient and the current standard of care that I am expected to provide. This includes routine use of a KED when indicated. Can you say the same thing about your patient care? Where you even aware this might be a problem? Think of it this way; do you want to be responsible for causing a catastrophic spinal injury to a patient that otherwise might have walked home from the hospital just to save some time or because you forgot how to use the KED? When was the last time you trained with it? When was the last time you suggested using it?

The KED is but one tool of many that may be used to manage a back-injured patient. MVA’s cause the most spinal injuries, and the KED is uniquely useful in removing seated patients from automobiles which explains why it is the standard of care for these patients. Many of the tools on the medic or engine are designed for a specific purpose, the KED is no different. Take advantage of the tools you have, your correct use of the KED could make a huge difference in your patients’ outcome.

Be Safe,

Alan

---

[i] Mayo Clinic Website article on spinal cord injury

http://www.mayoclinic.com/health/spinal-cord-injury/DS00460

[ii] CDC website, statistics for spine injury

http://www.cdc.gov/traumaticbraininjury/scifacts.html

[iii] NIH study on backbording MVA patients

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2691505/

[iv] Limmer, O’Keefe; Emergency Care, 10^th edition; Pearson Education, Inc. Upper Saddle River, NJ 07458

Only Two Attempts

Only Two Attempts

You and your airway kit

By Alan Perry

My agency only permits two attempts at endotracheal intubation by a provider before compelling the use of an alternative airway such as a King airway. In a cardiac arrest situation an ET tube becomes secondary. Most medics do not have sufficient exposure to the skill itself in the field and training for intubation skills is sparse if available at all. Never-the-less the skill is an important one that should be mastered and practiced as often as possible to be certain it can be done properly when needed. The equipment needed for the procedure is no different; it must be kept organized, clean and ready for a variety of patients and circumstances much like Your Physical andMental Jump-bag. In my position I frequently get the opportunity to examine jump-bags and intubation kits. What I frequently find is that the kits are mostly complete, but are clearly only a passing concern to those checking them off; after all it’s a single check box on the check off sheet.  My concerns are multiple, most of which my contemporaries will dismiss as being minor only because they do not understand the full effects and implications of this equipment being in sub-par condition. I will also make it clear that this is not an isolated or universal statement; there are providers with sufficient pride and knowledge that do maintain the equipment as best they can. This article will address the knowledge and expectations for properly maintaining airway equipment specifically, and all of your EMS equipment generally.

Why is it important

Equipment that is maintained in a state of contamination and disrepair is subject to accelerated wear and frequent malfunctions. Airway failures are more often than not blamed on equipment failures. I wonder why? Contaminated equipment can be responsible for (pre) hospital acquired infections and death. It is a very tragic thing for someone to survive a major trauma or illness only to be killed by a pathogen carelessly introduced by a provider unaware of the consequences of their actions. Now you are aware.

The Provider

Each intubation attempt begins with the provider’s knowledge and confidence in the procedure. If intubation is a defined part of your skill set it is your responsibility to maintain that skill, and find opportunities to practice and validate your competence. If you are unable to do this on your own contact your training division for their resources, a nearby agency that may have the resources or find an airway lab you can attend at a symposium, community college or medical facility. Recommendations for the number of actual intubations required to remain proficient vary widely, I have worked with agencies that keep several airway mannequins in their day room for providers to practice on at the beginning of each shift, they also have intubation as a required skill at least once a year as part of a skills drill to demonstrate competency. When was the last time you practiced?

The intubation or airway kit bag

The inspection of your airway kit begins with the exterior of the kit; the bag should be clean and free of stains and other evidence of contamination, the zipper and other closures should function properly. Once opened the bag should be arranged in such a way that the contents do not explode or fall out of the bag, elastic or Velcro should firmly hold all blades, handles and accessory items in place. The interior compartments should be clean, free of contaminants and stains, and open and close properly as well. Bags should be cleaned regularly; bags that are in poor condition should be replaced.

The ET tubes, stylettes and other consumables

I find open ET tubes and stylettes in intubation kits with alarming frequency; I believe that most providers are not aware of the risk of introducing pathogens into the airway by this route, so this is mostly an education issue. The blades we use are only required to be clean, but the ET tube and Stylette, like anything else inserted into a body must be sterile. Taking an ET tube from a stained package with a hole in it does not meet that standard, nor does the use of a stylette left floating around in the kit out of its package. ET tubes, Stylettes, NG tubes, NPAs and suction catheters including the yankauer should come from clean, unbroken packages if they are going to be used on living patients. Other items in your kit like tape, water soluble lubricant and securing devices should also be clean and in good condition.

The intubation blades and handle

We are not required to sterilize our re-useable intubation equipment so all blades and handles are “cleaned” after each use, it appears that in most cases the best they get is a wipe down. There are two problems with this; its effects on patients and its effect on the equipment. As mentioned earlier we don’t want to inadvertently introduce any new problems in our patients, blood and bodily fluids routinely make their  way onto our intubation equipment, and when not properly decontaminated impregnate our entire kit with unwanted materials. These same contaminates will migrate into the cracks and crevices of out intubation handles and blades causing flickering lamps, dim lamps, poor fit and function. That’s because this corrosive goo gets into and between the contacts and pivot points. A stainless steel intubation blade should be bright and shiny no matter how old and dinged up it may be, every crevice should sparkle, the light should be uncomfortably bright to look at. I have found that soap, water and a small scrub brush will do wonders and solve a variety of problems with dirty handles and blades.

Catch your breath

Before you consider respiratory arrest, consider your skills, the condition of your equipment and what is best for our patients. Make a more thorough examination of that kit part of your mental preparation for the event and your contribution to improving your agency’s performance in these high profile events. You certainly won’t get any awards for having a clean, working intubation kit, but when the time comes it will work for you and may save your patient.

Loyal Customer Program

Loyal Customer Program

for

Your Emergency Medical Services & Fire Department

By Alan Perry

October 21, 2013

Introduction

Most EMS agencies & Fire Department's are aware of the growing momentum of changes affecting the delivery of pre-hospital EMS as a result of general healthcare reform and specifically the Patient Protection and Affordable Care Act. These departments would like to begin working on solutions that are easiest to achieve and can be accomplished without major changes to existing policy or major program development. They realize that the healthcare environment is becoming more dynamic and that their organization, and any new ideas, must be flexible and adaptable. EMS systems are frequently misused and abused by a small portion of the patient population; the premise of this program is that this unnecessary and unproductive behavior can be easily corrected without any major changes to the normal operational pattern by simply providing a little patient and public education among this target group. Ideally this program will include the voluntary cooperation of the loyal customer, their primary care physician and the EMS provider. It will incur no additional cost for the EMS agency, and may actually prove to save money by avoiding unnecessary and un-billable transports. It will have the added benefit of being an anchor point for validating efficacy through research allowing expansion of the program if needed to address hospital re-admission rates and other targets of the Patient Protection and Affordable Care act.

Program Development

·         Quantify the problem

·         Identify the stakeholders

·         Develop a policy, procedure & infrastructure

·         Conduct a pilot study

·         Analyze the data

·         Get stakeholder feedback

·         Monitor the results, seek continuous improvement

Quantifying the problem

We all have our suspicions about the number of patients that routinely misuse and abuse the 911 EMS system, we know their names, where they live, and what their primary complaints are. In order to prove that a change in our system is having the intended effect we must know exactly what the problems is, the number of transports, the number of patients, the primary complaints must all be documented and analyzed to identify a problem. Typically most EMS systems do not do anything about this type of problem until it becomes a major issue. Due to this and the changing shifts and personnel the problem may be greater or lesser than imagined. A quick and dirty way to accomplish this might be to conduct a retrospective analysis of EMS calls identifying specific addresses, patients and chief complaints to produce a good starting point. A better way would be to add a few targeted questions such as: Do you have a pcp? When were you in the hospital last for this problem? Do you have any means of transportation? These examples of questions could be used to flag your potential loyal customer for review.  

Identifying the stakeholders

You, your providers, the patient, the patients physician, your OMD, the hospital systems and your chief officer are all stakeholders in this immediate process. They should be heard before a plan is developed, again after it is finished, and ongoing as it is implemented and refined. For this to work, everyone needs to be happy with the process and the intended results. There may be other parties you will need to involve such as public and/or mental health and your state or regional EMS office. You must explain in basic terms what you hope to accomplish, a reduction in misuse and abuse of the 911 EMS system, and ask each what your agency can do to achieve that goal that can fit within the confines of a public and patient education program.

Developing policy, procedure and infrastructure

After quantifying the problem and collecting stakeholder input you can begin the process of creating an outline of your program’s policies, procedures and infrastructure needs. Your research will identify what the specific problems may be, your program should be targeted to achieve improvement in those specific areas and also seek to improve the experience for patients and providers.  A mechanism must be in place to fully record and document the presenting problem, what interventions were done, and ultimately whether or not the situation improved. Privacy policies and law will need to be examined to determine what data can be used to identify loyal customers and track their progress. Voluntary participation of the patient and the patient’s primary care physician will likely be needed to avoid any legal problems. The role of the provider will most likely be that of a health coach, monitor and recorder working in partnership with the patient’s physician and/or your OMD. A schedule or process must be created and supported for providers to perform routine or PRN health checks and follow-up. The same data used to identify your problem will be used to document its effectiveness.

Do a Pilot Study

Start with a small area, a single station or district with a clear problem that this program should be able to address. Train your personnel, identify and enroll your patients and physicians and kick it off. This is a good time to be hands-on, check with the providers and see how it went for them, with the patient and make sure it was a positive experience, and with the patients physician. They all must be satisfied with the way it is working or it must be modified. Document every contact with your usual PCR. Collect all the relevant NEMSIS data and any pertinent data relevant to your program objectives.  Once you have worked the bugs out of your program in the pilot (3-6 months minimum) you should have enough data to determine if it can be applied to the rest of your system or expanded to others.

Analyze the Data

Within 3-6 months you should have enough data to determine if your program is having the intended effect, and you may have identified several new target populations/sub-populations as well. If your program is producing the intend result you must be able to prove it with the data before expanding or continuing with it. If the results are mixed or show no/negative change try to identify why, this is a good time to go back to those stakeholders to discover where the program may have failed and get good suggestions about how to improve it. Make sure you are measuring the right metrics, any improvement in patient outcomes, healthcare experience and cost reduction are meaningful and positive results.

Stakeholder Feedback

Go back to your original stakeholders and any new ones you may have discovered, revisit the initial objectives of the program of reducing EMS system misuse and abuse by your loyal customers. Are there any concerns now? Are there any suggestions for improvement? Are there any unforeseen outcomes or consequences? Is everyone happy? Any concerns or negatives here must be addressed  before the program can grow, your stakeholders will remain your primary source of feedback about the performance of your program, they will be of great value in maintaining the program’s responsiveness and relevance as circumstances change.

Monitor the results, seek continuous improvement

Once your program is up and running you will still have to go through much of this process again as new information becomes available allowing you to tailor your approach to each new patient, refining and validating new approaches that produce better or more efficient results. If successful you will hopefully draw the attention of our healthcare partners who may seek to involve you with their patients as well or borrow ideas from your program. Keep in mind that it must be a dynamic program that can adapt to the needs of the patient, the providers and the requirements of local, state and federal law. Continuous Quality Improvement (CQI) will keep your system effective, efficient and popular with your stakeholders.

Summary

A Loyal Customer program is an easy to achieve first step for 911 EMS systems that are not sure where to go or what to do next in the face of healthcare reform and the Patient Protection and Affordable Care Act. Instead of waiting around for healthcare changes to be forced upon us, it seems prudent to start taking some positive action that will improve the quality of our service and the outcomes of the patients we serve. A by-product of positive action is public support, goodwill, and increased pride among your workforce for being proactive. 

Good hunting,
Alan

Your Physical and Mental Jumpbag

Your Physical and Mental Jump-bag

By Alan Perry

September 19, 2013

The jump-bag is the one item you should always take into any EMS call, it must be equipped with the basics needed to save a life and start treatment for a variety of illnesses and injury. Your brain, mental preparedness and training are a similar set of tools, equally important, requiring your daily check-off and replacement and repair of expired or damaged items. Occasionally old items are removed to make use of new tools with proven efficacy or updates. The tools in the jump-bag should be those needed to deal with true emergencies and routine patient assessment while remaining highly portable, easy to carry, and easy to navigate. We all know this is not always the case, we also know that the information and training we have accumulated is perishable and needs to be organized in our head so that we can access it quickly and reliability. The next time you are checking off your jump-bag do a little mental check off; do you have all of your protocols memorized? Is your knowledge of basic A&P sufficient to determine what illness or injury may be present and how best to treat it? Do you know the indications, contra indications and side effects of the drugs in your drug box and common prescribed medications? Do you have tools in your head that need cleaning, repair or replacement? Have you taken action to correct it through study or repair/replacement through your training division?

I know you have grabbed a jump-bag at some point in your career and found that some critical item, perhaps oxygen, or a stethoscope was either missing, empty or broken, preventing you from doing what is required for the best patient care. It happens, and we do the best we can with what we have until we find someone else with what we need or we gain access to our back-ups. In our minds, if we draw a blank, forget or are unsure of what to do our back-up is the protocol book. I am not an advocate of “cookbook” medicine, if the protocol book has become your source for patient treatment options you are doing the equivalent of leaving your jump-bag in the truck. My “take-home” message is that you need mental preparedness just as much as physical preparedness, if not more. 

Doing a mental check-off, like doing an equipment check-off, requires some type of check-off sheet to identify the required items, there condition, and status if out for repair or on order. For a provider you can look at your protocols, pharmacology, certifications and education requirements; if you had to test out again today, would you pass? I would avoid simply meeting the expectations of your employer, agency or the public, this leads to complacency. You should be prepared to deal efficiently and effectively with every possible patient and scene presentation within, and maybe slightly beyond, your scope of practice. You didn't get into this business because it was easy, so let the fun begin.

Be Safe,
Alan

Trials of September 9-11-01

The Trials of September

by Alan Perry

September 11, 2013

September 11, 2001:

I was only four years into my career as an EMS provider on September 11, 2001. I received my Paramedic certification the year before and had joined a State EMS task force in preparation for some natural disaster. My EMS affiliation was with a volunteer agency, the Kempsville Rescue Squad in Virginia Beach, so I was working my day job running my auto repair shop. We normally listen to the morning news on the radio so we heard the first reports filtering in on the news wires, we quickly found it on the TV as the major news networks chimed in. I knew what would come next, I told my daughter I would have to leave, went home a started packing for a deployment. I had barely started when I got the call from the task force wanting to know if I was available, I let them know I was already gearing up and would be there well ahead of the planned noon departure. About that time the first tower collapsed. A chill ran through me, what a cold and calculated attack this was, clearly whoever planned it knew exactly how to bring these buildings down, civilians! Husbands, wives, children, all snuffed out to make what point? It was sickening, but nothing I could do except help pick up the pieces. VAOEMS task force 2 was deployed first to the VAOEMS headquarters in Richmond, then ultimately to Fredericksburg to backfill for their crews who were working the Pentagon site in Alexandria. We didn’t really do much, but we had to do something. What I recall most vividly is how quiet it got everywhere, when I stepped out of my shop in a busy industrial park to go pack my gear what I noticed first was the silence. It was as if the whole world was taking a giant gasp of disbelief. The second thing I noticed was how vacant the skies were, every single flight had been grounded, there was nothing flying in the air. It all seemed so surreal, nothing like this had happened for several generations, not since Pearl Harbor, how many had we lost today? This is all history, but let us not forget those we lost, and the spirit that makes this country so great, our ability to come together as a family and stand up for what is right, help each other, and continue to build and rebuild.

God Bless America.

Summary of September, 2013 NEMSAC meeting

Summary Report

from the September 5&6, 2013 meeting of the

National EMS Advisory Committee

By Alan Perry 9/7/2013

I embarked on a journey to Washington D.C. this week for the September NEMSAC meeting. I was really interested in finding out what was going on at the national level with all the recent changes facing EMS, and I wanted to get the information from the source, unfiltered and without editorial spin. I ponied up the time and the money to make this happen and cover my expenses for the two-day meeting. Please keep in mind that what I am presenting here is largely what I heard, not necessarily an absolute account of the events or statements made. I have tried to the greatest extent possible to be inclusive and factual in my accounts, and have made some of my own personal thoughts known as well. The meeting agenda, which is determined by the Designated Federal Official (DFO) and the committee chairman, was published about ten days before the meeting and included items that both my agency and the regional EMS council have been struggling with for some time. Since the council consists of a broad spectrum of EMS players, all considered experts in their field, it seemed like the perfect place to get the best answers and understand how Federal agencies NHTSA, FICEMS and HHS will be likely to respond. As it turns out it is a good deal more complicated than that, so I will start buy trying to explain this bureaucracy to you. The information I gathered in the meeting is useful if it is taken in context, but this organization does not operate like a fire department, rescue squad or business, has no real authority, and is only permitted to act in an advisory capacity to NHTSA, HHS & FICEMS. All discussions, decisions and information gathering must be done in a public forum to assure transparency, which is a good thing, but it does slow things down.

Prior to the first days meeting the DFO, Mr. Drew Dawson, introduced himself to me and welcomed me to the meeting, I found out rather quickly that getting any comment about pending legislation either officially or as a personal opinion was not likely to happen from a government official. Mr. Dawson, and the chairman Aarron Reinert, maintained a fair and even hand throughout the two-days of the meeting and represented DOT, NHTSA and NEMSAC very well. Other officials in attendance, but not directly involved with the committee, were a bit more forthcoming and even offered assistance to my agency or personally if additional information was needed. All of the council members, federal officials and organization representatives in attendance were very approachable and eager to provide their insights if asked. Other members of the NEMSAC included representatives from volunteer EMS, EMS research, EMS educators, EMS practitioners, EMS medical directors, consumers, trauma surgeons, hospital administrators, local EMS directors, emergency nurses, air medical, state highway safety, 911 dispatchers, private EMS, emergency physicians, state EMS directors, data managers, public health, fire-based EMS, state and local legislature, hospital based EMS and pediatric emergency medicine. There were others in attendance from the IAFF, NAEMT, NREMT, IAFC, NASEMSO, HHS, NHTSA-EMS, DHS, DOT, DOD, local fire departments & myself who were there to present, observe and comment.

Mr. Dawson opened the meeting by stating that he was impressed with the council’s performance and reminded attendees that the council will affect planning at FICEMS. Mr. Reinert stated FICEMS is expressing great interest in the activity of NEMSAC and is looking for 3-5 specific items to work on. Terms for some members are about to expire, new and different members need to step up and bring new issues to light as they are found. He reminded members of the three core values of NEMSAC; Visionary, Strategic and Diligent. After the initial introductions and housekeeping were out of the way the agenda kicked off with the federal updates from DOT, DHS USFA & HHS.

Federal Updates

DOT-  Keith Williams spoke briefly emphasizing that EMS extends beyond NHTSA, the purpose of the Federal Highway Administration (FHWA) is to reduce injuries and fatalities on all public roads with prevention being key in the design of the State Highway Safety Plans (SHSP’s) and includes EMS in the four E’s enforcement, engineering, education & emergency medical services. Mark Kehrli, Director of FHWA, showed a brief video and explained the importance of getting all highway workers including police, fire, and EMS and recovery services on the same page when it comes to safe and efficient scene clearance. FHWA has a new traffic incident training program out with the goal of training 50,000 responders within 3 years. This program is already being offered in southeastern Virginia.

DHS- Bill Sector, DHS liaison of the NASEMSO, suggested that the NEMSAC continue to look for practical solutions to known problems and continue to be the voice for EMS including support for community paramedicine. There is a need for greater integration among fire/police/EMS at major events such as mass shootings, a problem well known in southeastern Virginia. Common problems are still with communications and lack of knowledge of other services terminology and tactics. There may be a need for EMS to start entering scenes in less than ideal circumstances if lives are to be saved, perhaps adopting the philosophy of fire-fighting where more risk is acceptable where lives can be saved. Human trafficking is becoming a greater problem, EMS is in a unique position where they may be the first to identify it, a new program called the “Blue Campaign” is attempting to address this, it can be found online at DHS.gov\bluecampaign.

USFA- Mike Stern; NFA is developing more courses for EMS recognizing that EMS is 80% of what most fire services are doing. Since the NFA is not a traditional supplier of EMS education perhaps the council can push the information out, the classes are free. As courses pick up EMS instructors will also be needed as well as ideas for useful new EMS courses.

HHS- Greg Margolis; Referenced the innovation white paper relating to increased EMS demand incidents (MCI?). He introduced web resources for public heath emergencies (phe.gov) and the Hospital Preparedness Program (HPP). Announced operation bioshield, which is an EMS countermeasure involving stockpiling of WMD medications (similar to MMRS?), he reminded the council that preparation for major incidents both hospital and pre-hospital remain woefully inadequate. A reminder was given that the PPACA provision for open market health insurance opens October 1^st.

Stakeholder reports

DHS- Bill Seifarth; discussed the need for changes in how EMS approaches mass shootings and IED’s, the activities of Police/Fire/EMS need to be better integrated and new tactics such a tourniquets, hemostatic agents and the use of body armor need to be considered more fully. Response and incident management training, NIMS standards, plans and exercises need to occur to prevent interoperability failures. The traditional role of EMS staging until the scene is “safe” will cause significant loss of life and increased injury severity in mass shootings and IED events due to the nature of the injuries, there needs to be dialog to resolve this. Chief Sinclair, representing fire-based EMS, commented that the NEMSAC should lead the change in doctrine and policy related to these events. The Chief’s remarks and the concerns of DHS echo the concerns I reported to my agencies command staff after a school shooting exercise we conducted several years ago. In those comments I suggested adopting the same doctrine we apply to a fire incident where risk is based on the probability that lives will be saved, put simply we risk a lot to save a lot, we risk nothing to save what is lost.

NASEMSO- Dia Gainor, representing the National Association of State EMS Officials, provided information on EMS workforce guidelines. There is a new publication titled National EMS workforce data definitions which identifies the characteristics of the EMS workforce as well as those seeking EMS education or employment.

DoD- Marion Cain stated there is difficulty transitioning EMS providers from the military into civilian EMS upon their separation from the armed forces. Correcting this problem will improve employment opportunities for veterans. Gaps exist in the training provided by the military and civilian EMS, the goal of the proposal is to provide gap training and there are currently 280 in a pilot program. Bridging this gap and allowing these veterans to transition to civilian employment in EMS is a priority of the White House and the First Lady. Military EMS training is not accredited and recertification is not required, DoD will be looking at fixing these issues so personnel have recognized credentials.

White Papers

The next segment of the NEMSAC meeting was presentation of white papers, contracted by the NEMSAC, for the purpose of getting expert and unbiased information on topic of concern to the council. The white papers commissioned were; Pre-hospital EMS as Public Good and Essential Service, Research in Pre-hospital Care: Models for Success, Emerging Digital Technologies for EMS and 911 Systems and Efficacy of Pre-hospital Application of Tourniquets and Hemostatic Dressings to Control Traumatic External Hemorrhage.

Pre-hospital EMS as a Public Good and Essential service- This draft White Paper was authored by Mike Milligan of the National Academy of Public Administration from a purely economic viewpoint. It did not translate to the common conception of terms such as “good”, “club” or “public”. If that was not confusing enough the author took a round-about way of getting to his conclusion at one point suggesting that EMS was a common good, police service a public good, and fire service a club good. This understandably confused and in some cases angered those in attendance. The conclusion of the paper was that EMS is a Public Good and an essential service, and identified how some public administrators may view it. It was the consensus in later discussions that the paper needed some clarification to avoid the possibility that some portions of the paper could be taken out of context and be seriously damaging to the causes of both fire and EMS services.

Research in Pre-hospital Care; Models for Success- This draft paper, authored by E. Brooke Lerner and funded by NHTSA and the EMS for Children Project, centered on the correct way to conduct clinical trials and the obstacles that must be overcome. Some identified barriers include; funding, consent, ethics approval, training of EMS providers and researchers, lack of relationships, political & social risk, reliance on EMS providers and/or hospital staff, other researchers. The paper is well written and would make a good resource for anyone considering an EMS research project. The author provided this additional resource; clinicaltrials.gov.

Efficacy of Pre-hospital Application of Tourniquets and Hemostatic Dressings to Control Traumatic External Hemorrhage- The authors recommend a systematic literature review, the military and PHTLS already recommend and include these tactics in their TCCC curriculum but civilian evidence and research are lacking. The efficacy of TQ’s compared to pressure alone, the efficacy of specific TQ products, the efficacy of hemostatic dressings compared to standard dressings and the efficacy of specific hemostatic products all need to be studied. These will be looked at by the authors with an additional report forthcoming and the results will be made available to field EMS providers and EMS physicians. This is one of several exercises, which to me; indicate some detachment of this committee with other researchers and fields of practice. TQ’s and hemostatic agents have been proven in the specific areas of concern, namely IED’s and mass shootings, by the military and are the basis of their inclusion in the TCCC program. My concern is that the committee may be expending precious resources by duplicating the efforts of others.

Emerging Digital Technologies in EMS- Benjamin Schooly and Thomas Horan co-presented this paper and asked the NEMSAC to provide feedback before the paper is published. The authors inform us that new technology has reached the level described in the EMS Agenda for the Future with application in injury prevention, response, treatment, training, education & communication. There are significant application and expansion gaps that need to be filled. A common view among EMS systems is that integration needs to occur with other public safety and healthcare partners to fully develop this potential. Solving this issue will have positive health benefits but new skills must also develop to manage the new technology. All stakeholders must work toward creation and adoption of common data elements and information systems so the entire EMS event can be captured and studied. Some of the obstacles that are present include privacy concerns, technology costs, integration and infrastructure; there is no guarantee that new technology will save money.

I found this portion of the meeting to be very informative, at times also frustrating and confusing. Hearing well compensated private and federal officials stand up and declaim some of the same ideas I and others have advocated for years, makes me wonder if the only ideas that are ever heard are the ones proffered by those having influence and authority regardless of the quality of the idea. This makes me question if what I have to say will ever make a difference. Don’t get me wrong, this type of organization must exist, those acknowledged as experts must speak and provide an outlet and connection with policymakers, but it also sorely needs more public participation and scrutiny by EMS providers.

Public Comments

The brief public comment period before the sub-committee meetings occurred with several speakers; Mr. Linde representing the NAEMT stated that there needs to be more dialogue between fire and EMS. A representative from NOAA asked the council what other products they should work on that could be of value to responders other than heat indexes and air quality. A representative from Latrobe University in Australia stated that EMS in the United States could learn a few things from Australian EMS and offered to facilitate some discussion.

Sub-Committee meetings-PPACA

I attended the sub-committee presentation and discussion on the Patient Protection and Affordable Care Act (PPACA). This meeting was led by Chief Sinclair, with NHTSA representative Noah Smith in attendance. The two biggest issues for this sub-committee were the untoward effects of the PPACA on volunteers and integration of EMS into the healthcare system via community paramedicine, mobile integrated healthcare, or some other vehicle. Chief Sinclair asserted that this sub-committee will likely need to be a standing committee to facilitate the still developing effects of PPACA on EMS, and that the focus of the committee should be bi-directional addressing both the effects on the EMS systems as well as the effects on employees and volunteers. The committee discussed at length the transition challenges to mobile healthcare, the effects of healthcare consolidation, and issues with tax liability and/or penalties for volunteers due to PPACA. Many questions were generated with an obvious need for follow-on discussions once the needed information is obtained.

Discussion (Saturday September 6, 2013)

 The morning before the committee reports I ran into a federal official at a coffee shop, I took the opportunity to ask (again) for some comment or opinion on HB809 and some aspects of the ACA. The response was solidly in support of NHTSA retaining its relationship with field EMS out of concern for retaining existing relationships within the federal government and preserving the highway safety and response characteristics of EMS in vehicular accidents. The lack of structure the PPACA provides in the development of new EMS systems was also acknowledged. I also found source material to present to the PPACA sub-committee authored by the AHRQ (Agency for Healthcare Research and Quality) titled Community Paramedicine Evaluation Tool, which our council is using as a template to develop a CP program of our own and may be useful and trump the need of this sub-committee to write a best practices document.

White Paper discussions:

EMS as an essential public service- General discussion by members;       

• EMS has characteristics making it both an essential public service and a public good (economic definition). It does require public funds to operate effectively. 
• This is primarily due to the need for preparedness and services provided without payment. Two distinct cost factors; readiness and marginal, which can be funded separately as a more logical way to provide funding. 
• Some exceptions noted in the report which separates fire and ems improperly and classifies them differently. Economic definitions v common definitions can be misleading to the public and may send the wrong message. 
• The document is helpful in that it provides a better understanding of EMS functions in economic terms which are the language of government and financial entities, but it does need more work in both detail and depth of comparisons. 
• The paper also needs to recognize that various EMS systems operate in different realms of the economic models presented and cannot all be lumped together as a homogeneous group. 
•  The fire service is improperly classified as a club good, not a public good, the fire service is largely tax funded and therefore is clearly a public good and also an essential service. The fear is that the document, which is considered to be incomplete and inaccurate, if published will damage both fire and EMS goals immediately and could be used as a tool by those wishing to push other incompatible agendas.  
• The document will be available on ems.gov when complete.

Active Shooter/IED's-    

• Training is needed; it is a tactical issue more than an operational one and as such should not be dealt with by this council.
•  The use of TQ's in some situations is prudent, but needs further refinement. Again this organization should not be concerned with field protocols.
•  The initial discussion yesterday also recognized the weakness of the relationship between police-fire-ems regarding terminology and operations at multi-casualty incidents and ems recognizing that the scene safety component may become more variable with some risk needed to save lives in MCI circumstances.
• The council was reminded that this issue was brought forward by the deputy director of FEMA; there may be a need for this council to look above the specifics and start looking at the cooperative aspects of the problem rather than the specific tactics and protocols.

Sub-committee meeting reports:

NEMSAC Process sub-committee- endorsed NEMSAC process document which is a guiding document for the council defining how the committee will operate to both members and the public.

EMS education Agenda for the future sub-committee- The sub-committee will develop a document requesting suggestions for minimal updates needed to reflect the new education standards, federal legislation, and the EMS education agenda document.  The sub-committee will ask for all comments without restriction openly, and will be making request at all stakeholder meetings this fall. This sub-committee will review these at the December meeting and make recommendations to NEMSAC based on the current state of implementation. A motion to have the Chair draft a letter requesting suggestions from stakeholders, and review responses at December meeting, allowing public comment and discussion, was approved.

PPACA sub-committee- The sub-committee created a group to research best practices in community paramedicine, and will bring forth best practices to be published as an advisory. The sub-committee recognized the work of previous councils in addressing concerns with CMS and the need for repeating/duplicating work. The council may need to re-evaluate the work of the previous finance committee recommendations for EMS funding. The council should create an advisory to IRS on effects of PPACA on volunteer EMS. Much discussion ensued regarding the effects of PPACA on EMS, and the desire by the council to here from some federal partners on the specific effects that may be felt by EMS. It is recognized that the law, and the practice of EMS, will be evolving and ongoing. Chair request input from all about any good material relating to this topic. 

EMS Agenda for the future sub-committee- This was a formative meeting.

Safety sub-committee- This sub-committee is waiting for the publication of a new safety position paper, it will be reviewing that and meeting with stakeholders to gain consensus on the next steps. The safety problem is not quantified and the sub-committee will need data to base its decisions on. We may need to work on education as a primary means of obtaining results. NREMT is pushing team and resource management training as a potential solution. IHST is joint federal/HEMS effort to improve safety, and can be used as model for improving EMS safety.

Public Comments:

IAFF- A representative of the IAFF requested that the NEMSAC discard, abandon or defund the White Paper titled Pre-Hospital Emergency Medical Services as a Public Good and Essential Service citing the potential for harm to the collective goals of both EMS and FIRE services if published.

NAEMSO- The NAEMSO is working on legislation that will grant professional recognition of EMS certifications across state lines. The final draft should be available in early 2014.

NAEMT- Supports the activities of the NEMSAC, there is a need for EMS research training.

NFPA- Suggested the use of social media to get people more involved in the activity and discussions of the council. Reminded the council that NFPA-1917; Ambulance standards, is being updated. The final standard should be published in March, 2014.

NVFC- The White Paper titled Pre-Hospital Emergency Medical Services as a Public Good and Essential Service needs to be more straight-forward in language. The inclusion of fire and police in the report is not helpful and creates distinctions between the three public safety branches.

General public & NEMSAC member comments:

·       The White paper titled Pre-Hospital Emergency Medical Services as a Public Good and      Essential Service needs work.
·       NEMSAC needs to facilitate Mobile Integrated Healthcare Practice (MIHP) discussion.
·       Medical Directors need to be involved in MIHP discussion and can help facilitate it.
·       The AARP support EMS public education, MIHP & PPACA
·       NEMSIS data is growing, what are we going to do with the data?
·       EMS education is moving toward better critical thinking and less cookbook medicine.
·       MIHP education needs to start occurring now.
·       As a result of PPACA more agencies are using part-time employees. What are the ramification for EMS professional development and workforce retention?
·       Out of hospital roles of EMS providers will be changing, more involved in general healthcare and public education.
·       Suggestion that the duration of NEMSAC meeting be increased to accomplish more, acknowledging the complexity of the decision making process.
·       Suggestion that the NEMSAC look at Israeli EMS practices as a model for response to mass-shootings and IED events.
·       NEMSAC must initiate conversation on EMS evolution.
·       There is a need for EMS provider population analysis.
·       There is a shortage of EMS providers in Hawaii; the state offers incentives to EMS providers.

The meeting concluded following these closing statements. Overall I found the experience very informative. I also found it very supportive of the ideas I already have and those I am working on in my own agency. I suspect any organization attempting to influence policy at this level will be slow to act, often working on a parallel tract with proactive EMS systems across the country. The council should recognize that and seek to get ahead of the local movements and encourage federal actions that can facilitate it. It is clear no one will be able to fully predict the effects of PPACA, but this legislation is poised to completely change the way EMS is funded as well as its basic function. The NEMSAC is developing its position slower than the changes are occurring. It may consider having a more concentrated focus at future meetings to get ahead of it. I look forward to continued interaction with the NEMSAC; it has the potential to be more influential in advocating for responsible EMS policy if it can become more focused.

AP

EMS NEWS

Tidewater EMS news, August 26, 2013

The Tidewater EMS council hosted a meeting of local EMS agency managers and providers for the purpose of discussing the potential of community paramedic programs in our region. Most of the participants were well aware of the concepts and goals of such a programs but only one local agency has taken these ideas and implemented them in the field albeit in only a very basic way.  On the national stage these programs have been in place for years, several States have enacted legislation recently to enable this practice, the Affordable Care Act has accelerated the adoption of these programs as a way of both improving the quality of care and reducing healthcare costs. According to the Virginia Office of EMS (VAOEMS), Virginia has no such legislation pending, and they are not aware of any legal obstacles to implementing such programs. It was rumored that the home healthcare industry may be preparing a legal challenge to the concept but VAOEMS has no information supporting that allegation according to their representative.

The integration of field EMS into the objectives of the Affordable Care Act is necessary to achieve the long term goals of the act, the changes to EMS will occur, the council is rightly taking the role of facilitating the participation of field EMS agencies in designing their own future. The issue is very complex and requires the involvement of multiple healthcare entities, Local, State & Federal regulators, physicians and providers. The group acknowledged the complexity of the issue and looked at some short term goals. All agreed that public education for loyal customers would be a perfect place to start, one program is already in operation and others could be implemented with little work or need for any major program development. The second was that the group would convene again in a month to discuss what additional goals are desirable short term, realizing that the next steps in the process will be largely data driven. Next week (Sept. 5&6), the National EMS Advisory Council will meet in Washington D.C. The discussion there will be related to this topic as well. I hope to bring you more useful information about these developments as they occur…stay tuned.

AP

Synthetic Recreational Poisons

Death by NBOMe

By Alan Perry

Introduction

I recently had the opportunity to treat three young women, in separate events, within a week for some very strange symptoms that were very concerning. All three refused to (or were unable to) disclose what they had taken. It seems likely that it must be some variation of a substance known as 25I, N-Bomb or Smiles. The chemical name is 2-(4-iodo-2,5-dimethoxyphenyl)-N-[(2-methoxyphenyl)methyl]ethanamine. It can be supplied as a powder or liquid, snorted or applied directly to the mucous membrane, there are also reports that it is being marketed as legal LSD and dispensed on blotter paper. There are only a handful of states that have made this product illegal (Virginia is one of them) but it is still widely available elsewhere in the U.S. and abroad. It can be purchased online, from “tobacco” shops and local dealers. Various reports on the drug identify it as a stimulant, hallucinogenic and serotonergic. Its effects have been documented to last up to 48 hours.

The Victims

All of these young women presented with a lack of gross motor coordination, hallucinations, paranoia, dysphasia, tachycardia and hypertension, one had reported seizure activity. Initial concerns with these patients where directed toward the cardiac effects of the drug. There had been a reported case of a young female dying from a cardiac event a week earlier leading to speculation that this may have been a possible cause. Richmond Virginia had a rash of similar events in February 2012 with reported brain injuries and one death associated with the drug. It is extremely potent with and onset of effects within 5 minutes of ingestion. The effects on the patient are highly variable, pupil size and response may be unaffected, respiratory depression or hyperventilation did not occur with any of these patients during the Prehospital phase, one patient vomited, one had seizure activity, two presented in SVT, all had hallucinations, two exhibited paranoid behavior. Other reports have documented violent behavior and multiple deaths since its debut in 2010. This drug is not currently part of routine drug screening therefore its use will be difficult to confirm.

The Treatment

EMS treatment of drug overdose/effects are typically based on toxidromes specific to a class of drugs such as narcotics (opiates), stimulants (cocaine) and muscarinic (organophosphates). The problem with most designer drugs such as NBOMe is that they produce effects relevant to multiple toxidromes and therefore do not fit neatly into one class, we are frequently left to attempt treatment of the most urgent presenting problems with incomplete or no data on efficacy or untoward interaction with the substance involved. As an example, many of these patients present with tachycardia-frequently SVT-if we only treat the sign without considering the totality of the circumstances we could be led to attempt to cardiovert the patient. Such an action might prove injurious or fatal to the patient with an unknown ingestion of 25I-NBOMe. A more reasonable approach might be consultation with your medical control, and the subsequent administration of a benzodiazepine to blunt the sympathetic nervous system response to the drug, provided the patient is otherwise stable. A definitive treatment algorhythm has not been established and research is very limited and commercialized.

Looking Forward

I am unaware of any free, easily accessible data sharing on the topic of emergency treatment of any of these new designer drugs. It seems prudent that the CDC, the American College of Emergency Physicians or the state departments of health develop a free, easily accessible resource for providers to access, reference for the purpose of informing providers of the existence, prevalence and treatment for overdoses/poisoning from these substances. Ideally this could also be used to identify new substances quickly as they are modified and hit the street so providers are better prepared to handle them appropriately.

Be Safe,

References:

NBC12 Richmond, VA. News article:

http://www.nbc12.com/story/16964534/kids-overdosing-on-new-drug

Website marketing this product:

http://www.buyecstasypills.com/

and another:

http://www.pills4party.com/

Severe clinical toxicity associated with analytically confirmed recreational use of 25I-NBOMe: case series. Hill SL, et al. Medical Toxicology Centre, Institute of Cellular Medicine, Newcastle University, Newcastle, UK.

http://www.ncbi.nlm.nih.gov/pubmed/23731373

Erowid drug information website:

http://www.erowid.org/chemicals/2ci_nbome/2ci_nbome.shtml

Mercy Emergency services:

https://www.mercyemergencyroom.com/25I-NBOMe.html

Bartlett Regional Hospital Statement:

http://www.bartletthospital.org/news/docs/Statement%20on%2025I-NBOMe.pdf

Wikipedia:

http://en.wikipedia.org/wiki/25I-NBOMe