Fire Service EMS training and evaluation

PROPOSAL

EMS Deployment and Training

By Alan Perry

October 19, 2015

Introduction:

The Fire Service can improve on its deployment of new EMS technology and skills, by improving the training and evaluation mechanisms available to its providers. To accomplish this, the following practices may be considered to produce a reliable and consistent system for delivering new information, ongoing training, and evaluation of knowledge and skills competency. This can be done in a way that does not commit new resources. It will improve the performance and consistency of EMS services and satisfy the continuing education requirements of the providers. It consist of a single change in the character of the position of the EMS supervisors on each shift and a three part mechanism for delivery, training and evaluation.

The system change:               EMS Supervisor role

Changing, or placing more emphasis on the role of the EMS supervisor as an educator, is a simple and effective way to improve the system as a whole. Directing the EMS supervisor to periodically conduct Company training using standardized lesson plans, cognitive exams, skills evaluation and a course/instructor evaluation will bring Fire Service practices in-line with accepted standards in EMS education and evaluation. This is a proven system that will provide the mechanism for delivery of the category 1 and 2 CEU’s required for providers to re-certify. Ideally, Companies would attend a 1-2 hour training once a cycle while out-of-service, in a comfortable location away from the station, but within their own district, such as a library or community center. Senior EMS providers can and should assist with the delivery of these programs.

The three-part mechanism: Initial training

Initial training programs for new skills, new devices and/or changes to existing practice should always precede the deployment of these skills and devices in the field. Providing the initial training to the supervisors and providing them with the proper training materials will allow them to quickly and effectively deliver the necessary training, evaluate and document delivery, and assess skill competency before deployment occurs.

                                               PI driven training

PI driven training can be delivered as an individual, Company, District, Shift or System tool to remedy specific PI driven concerns. It can cover one topic or multiple topics dependent on audience and needs. PI driven training should be dynamic and focus on the most critical, severe or most costly identified deficiencies first.

                                               Annual/semi-annual protocol and skills evaluation

Protocol and skills evaluations are nothing new to EMS, all providers took exams and performed practical skills as part of their initial certification. At least once a year providers should be required to pass a basic protocol test appropriate to their level of certification, as well as a random skills evaluation based on The National Registry of Emergency Medical Technicians Practical skill sheets. This is both a preventive and maintenance measure, which will assure that providers remain current in their knowledge and skills. Providers who do not perform well can immediately be retrained and re-evaluated, or the collective results used to conduct PI driven training in the future. Any critical skill deficiency must be corrected before the provider is allowed to continue practicing at his, or her level of certification.

Summary

Formal deployment, training and evaluation programs are part of most other high risk professions. Other agencies and regional systems within the Commonwealth and across the Country already use a formal training and evaluation system. The Central Shenadoah EMS Council requires quarterly skills reviews for all providers in their system. The Lord Fairfax EMS Council requires an annual skills review. Considering the Fire Service's initiative in bringing forward thinking practices to the region, codifying a proactive and aggressive training policy seems like a logical and obtainable goal. This goal can be achieved with a minimal investment of on-duty time and effort from the existing EMS supervisors. It will add to both the competence and confidence of our providers, as they deliver the best responsive and caring service possible, to our citizens and guests. It may be advisable to add an additional EMS supervisors position to allow supervisors to rotate training, while leaving at least two in service while spreading the administrative functions out, allowing for adequate preparation and follow-up in training. Ultimately the implementation of this plan will require a commitment from the Organization, the Administrative Staff, the Training Division, EMS Supervisors and the individual providers. Developing a culture of proficiency, competency and innovation starts at the top.

Criminal MCI Calvary slide presentation

Slide presentation: Who is the Cavalry in Criminal MCI's?

Danger Everywhere

Danger  Everywhere

By Alan Perry

I came across an article on the NFPA website titled "Firefighter Injuries in the United States", the article summarized some dry data, but I was able to pull a few interesting take way points from it for you to consider.

54% of injuries occur in places other than the fire ground. While fire ground injuries still account for the largest single venue for injury, the majority are occurring elsewhere in training, non-fire events and responding to and from calls.

Since 1981, total fire ground injuries have fallen, but the number of injuries per 1000 fire calls has remained nearly the same.  This demonstrates little improvement in fire ground safety.

The total of non-fire injuries have increased during the same period, with the number of injuries per 1000 non-fire calls declining; an improvement it would seem.

The data does not differentiate EMS calls within the non-fire emergencies even though these account for upwards of 80% of the call volume in most municipal fire departments these days. That may explain the increase in the total non-fire injuries but further study is needed.

My point, if there was one, would be that while Improving safety on the fire ground is still a priority - we need to consider safety and injury prevention in all our actions. On a purely curious note; why does the fire service continue to frame every study in terms of fire ground vs. non-fire if over 80% of our activity is EMS. Why not just add EMS call related injuries? Perhaps it would skew the intended message.

Be Safe,

Alan

Reference:

Firefighter Injuries in the U.S., M. Karter Jr. & J. Molis, October 2013, NFPA

Brotherhood Lost

Brotherhood Lost

By Alan Perry

February 9, 2014

The Fire Service like many other organizations claims a brotherhood among its members, this brotherhood is not elective; it is an expectation. Brotherhood is defined[i] as “the state or relationship of being brothers” and “An association of men united for a single purpose”. In the Fire Service this relationship is (or should be) extended to all members male, female, full-time, part-time and volunteer. Like any familiar relationship there will always be times of disagreement and strife amongst us, if we follow this code we will remain faithful to our brothers and sisters and support them unconditionally regardless of our disagreements. At the core of this belief system are respect, duty, sacrifice and honor. We are good people, how do we avoid human nature and make our brotherhood more than just a word?

I am fortunate enough to have a biological brother, like any set of siblings we have had our disagreements, feuds and physical confrontations, our relationship is stronger because of it, as is our respect and admiration for the path the other has chosen. We would each provide whatever we can to help the other succeed or get through a tough situation without ever the thought of doing anything to harm or diminish the other. This is the standard or lens that I view the Fire Service Brotherhood through. In my career I have had the opportunity to observe the Fire Service Brotherhood from outside and within. I have seen it shine brightly and its name invoked in very dark ways. Like any organization formal or informal our brotherhood will be what we make it, and simply calling it a brotherhood does not make it so.

Unfortunately my first experiences with the “brotherhood” were not positive and made little sense to me. As a volunteer EMS provider I was frequently spoken down to and dismissed by professional firefighters who seemed to view me as somehow less professional in my qualifications and abilities as themselves. I was doing a job they did not want to do, but somehow I was considered a threat to them and deserved little if any respect. In my own department I have found myself on the wrong side of issues supported by this brotherhood and found myself ostracized. While representing my department voluntarily during a national incident I witnessed this brotherhood conducting itself outside its assigned area of responsibility in questionable ways and threatening its members with retribution if they reported it. These were not proud moments, and certainly not what I think our family should be.

These acts persist today; we still treat volunteers and part-time staff like second class members. There is no justification for it. We are all here for the same reason; we cannot assert that a member who volunteers or works part-time is somehow less committed than a full-time person. They frequently do the work we don’t want to do for less or no money and no benefits. We thank them by treating them with disrespect and outright contempt. How can we assert that we have an honorable brotherhood when we treat our co-workers with such blatant malevolence? This may be the exception rather than the rule, but I think that if it occurs even once it is too often and must be corrected swiftly and severely if we are to hold to our true values. Doing otherwise is passively condoning the practice and will undermine the legitimacy and influence of our brotherhood.

So who are our brothers and sisters? Do we limit inclusion to our crew, professional firefighters, our fire department, part-time staff, volunteers, administrative staff, those we like, those that share our faith & beliefs, our race, our church, our lifestyle or all public safety workers? It has been my experience sadly that we tend to find ways to exclude more often than we seek inclusion. This is human nature; we seek and associate more comfortably with those like ourselves. Our challenge is to get away from these narrow definitions and begin thinking more broadly as a “family” instead of a “brotherhood”, including brothers & sisters as well as all others that help us achieve our mission. Treating anyone in our department as something less than a full and equal member is a divisive and reprehensible act. It does nothing but diminish and denigrate the organization and profession as a whole.

Brothers, Sisters, and all of our public safety family, I challenge you to look at your organization. Do you see everyone being treated fairly and equitably without regard for employment status, tenure, rank, who they know, their religion, their lifestyle and skin color? Does everyone have the same opportunity to grow personally and professionally within the organization without regard for these insignificant variations? Does everyone have a mechanism and opportunity to become involved in the discussion and decision making process so their voice and concerns are heard? Does everyone in your family have the support of the organization when things get tough personally and professionally? You must speak for those who are not being treated fairly, disrespected or excluded. By doing so you are representing what is good and honorable about brotherhood and family and can restore faith in it.  

Love, Honor & Respect

Alan

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[i] The American Heritage Dictionary, 2nd College Edition, Houghton Mifflin Co., Boston, MA.

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

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.

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

Another White Paper

Another White Paper

By Alan Perry
August 18, 2013

In case you missed it, the two government bodies that are most affected by proposed changes to the delivery of emergency medical services (EMS) have recently weighed in with their joint assessment of the situation. On July 15, 2013 the National Highway Traffic Safety Administration (NHTSA) and offices of Health and Human Services (HHS) released a joint statement in the form of a draft white paper entitled Innovation Opportunities for Emergency Medical Services. The document does not contain any new data, but expresses the desire of these two organizations to promote their vision of health care reform as it pertains to EMS, and proffers a generic model of cost savings that can be realized by making a few changes that have already been identified in other publications by the Institutes of Medicine (IOM) and NHTSA. While the paper certainly focuses on the cost savings and the strategies required obtaining them, it leaves the process in the vague hands of a number of “possibilities”. As we have seen from the activity following the previous attempts at reforming healthcare, and EMS in particular, this falls short and. The final conclusion being that Americans deserve a better system that saves money improves care and creates less of a burden on critical resources…. Duh.

As an industry, EMS recognized over a decade ago that our delivery model is inefficient; this is confirmed in this white paper and identifies by name the root source of the problem which we have known for years, it’s the federal government. Medicare and Medicaid reimbursement schedules are driving the inefficient allocation of EMS resources by only paying for patients who get transported to a hospital, which is not always a reasonable or cost effective choice. The paper goes on to address the specifics of the potential cost savings in what it characterizes as a conservative methodology, identifying the potential savings to be somewhere in the range of half a billion dollars. Since we live in a democratic capitalistic society it should come as no surprise that the biggest incentive for change will always be a monetary one. From my perspective of relative ignorance, I must conclude that the quickest and most effective way to change the system would be to change the way it is paid for.

Unfortunately individual EMS systems lack the clout to confront the Centers for Medicaid and Medicare Services (CMS) and challenge the current fee for service schedule. This process is typically worked out between CMS, physician and large healthcare organizations. Equally unfortunate is the Patient Protection and Affordable Care Act (Obamacare) which does not acknowledge the fee for service  problem directly, but instead offers incentives based on cost savings to encourage larger healthcare systems to prove a different model works better. The combination of these two circumstances favors large for-profit healthcare organizations with the clout and money to have their preferences considered. I fear it will leave many public safety organizations at a disadvantage in having their concerns heard since few have the resources to effectively form and fund an Accountable Care Organization (ACO) that can deliver the required savings to get paid. We will be left to work out whatever deal we can with a much larger organization if we are to survive at all. The Federal Government, through Obamacare and CMS, has effectively shut out all small and moderate size public, private and non-profit EMS providers out of the process and the discussion.

Our best hope at this point is the Field EMS Quality, Innovation, and Cost Effectiveness Improvements Act of 2013. This bill is currently in committee with 10 sponsors, it will move the national office for EMS to Health and Human services, which more accurately reflects the realm in which we operate, it acknowledges and incorporates the concepts and goals of the EMS agenda for the future, addresses the concerns of the IOM report EMS at the crossroads, provides funding for study and implementation of new delivery models, and directs CMS to include field EMS models in their testing. This bill will provide the needed framework, funding and focus needed to move EMS forward in a logical and responsible way without depending on Obamacare, ACO’s or some other magic pill. This bill will achieve many of the goals of Obamacare and healthcare reform in general as they pertain to EMS functions, but it will also add the stability needed for 911 EMS systems to plan and sustain operations while making these needed changes without selling them out. The draft white paper produced by NHTSA & HHS does not articulate a strong desire to maintain 911 EMS capabilities or identify how to accurately account for its cost although other NHTSA publications, such as the EMS System Performance-based Funding and Reimbursement Model by the National EMS Advisory Council do. Perhaps once all realize that EMS is both public safety and public health we can realize some progress.

Be Safe,

References;

EMS Agenda for the Future, NHTSA 1996

http://www.nhtsa.gov/people/injury/ems/agenda/emsman.html

EMS Agenda for the Future- Implementation Guide, NHTSA 2010

http://www.nhtsa.gov/people/injury/ems/agenda/

EMS at the Crossroads, National Institutes of Medicine 2006

http://www.iom.edu/Reports/2006/Emergency-Medical-Services-At-the-Crossroads.aspx

Innovation Opportunities in EMS- A Draft White Paper, NHTSA/HHS 2013

http://www.ems.gov/pdf/2013/EMS_Innovation_White_Paper-draft.pdf

H.R.809 - Field EMS Quality, Innovation, and Cost Effectiveness Improvements Act of 2013, 113^th U.S. Congress 2013

http://beta.congress.gov/bill/113th/house-bill/809

EMS System Performance-based Funding and Reimbursement Model, NHTSA, National EMS Advisory Council 2012

http://ems.gov/nemsac/FinanceCommitteeAdvisoryPerformance-BasedReimbursement-May2012.pdf

Apathy and the Art of Apparatus Maintenance

Apathy and the Art of Apparatus Maintenance

By Alan Perry

How does your organization manage vehicle maintenance? Do you fix it as it breaks, a system driven by complaints and failure? Do you let an independent or municipal shop manage it, a system frequently fraught with excessive cost and repair delays?  Do you manage it yourself, or some combination of the three? I have been working on machinery, cars & trucks professionally since I was seventeen years old. I have been certified as an ASE master auto and truck technician multiple times. I managed my own shop for 25 years, performed fleet maintenance on ambulances, and served as logistics officer for my rescue squad. As my interest in emergency services grew so did my interest in emergency vehicle service and maintenance practices. There are three primary goals when managing a fleet of emergency vehicles, safety, reliability and controlled cost. All of these goals are important and directly affect patients, providers and the organizations stability. I hope to convey to you some practical thoughts that can guide you to development of a rational, efficient and cost effective vehicle maintenance program that will suit your organization’s needs.

I have been exposed to all of the aforementioned strategies, some can be good, and some must be avoided. How do you decide? The person responsible for apparatus maintenance does not have to be a mechanic although a background in that area would be helpful, access to an honest and respectable technician or shop owner would be a reasonable alternative. The pitfall here is that the individual managing your fleet may not be up to speed with modern apparatus, vehicle engineering and effective maintenance strategies. Motor oil does not need to be changed every 3,000 miles anymore, buying cheap tires does not save money, preventive maintenance is not an oil change and tire pressure check, in other words what works for your mom’s car does not work for emergency equipment.

So what does an effective emergency apparatus maintenance plan look like, and what should you know going into this process? It will depend on your circumstances, climate, geography and type of equipment. You will need a thorough understanding of your equipment, the manufacturer’s recommendations for service, and the meaning of the terminology used. Record keeping plays an important role in tracking and identifying recurring needs and potential failures in your maintenance program, these records must be kept in sufficient detail to make the data useful. Simply keeping all the receipts in a folder will typically meet government requirements, but you need to go well beyond that if you are serious. A simple spreadsheet will usually suffice, at a minimum it should track fluid services such as engine oil, transmission fluid, coolant, brakes, tires and electrical system checks and repairs documenting the date, mileage, cost and reason for each service. If you collect the data for a period of several years you will notice patterns in certain types of failures, in this way you can predict both service life of certain components and potential costs involved. If you apply this data you will be able to schedule your services in advance of equipment failure reducing both cost and downtime, improving reliability of your equipment.

I have found that the 3,000 mile traditional service interval usually used for emergency equipment is excessive, it is frequently referred to as preventive maintenance, but very few actually adhere to the definition of that description with predictable failures occurring between scheduled PM’s routinely. So how do you fix that? It’s really very simple; you use the historical data for each unit and you change the nature of your PM to fit the definition. Change the maintenance interval to 5,000 miles, create a check list that the technician responsible for servicing the truck must complete, include all of the items that would normally be inspected during a state vehicle safety or DOT inspection on the sheet requiring documentation that each item is not only good, but will remain serviceable until the next inspection. This must include checking all the tires, brakes, lights, suspension, fluids and the electrical system. Any item that is not likely to remain functional and safe until the next service gets replaced right then and there. The overall goal here is to keep all of your equipment in the best shape it can be, improving reliability and reducing cost. I applied this very system to a fleet of 6 type I & III ambulances and saw a 20% reduction in overall repair costs each year for two years. Initially all the trucks rotated through the program took a little additional work to bring them up to speed, but the results were exactly as expected and the reliability of the fleet improved noticeably.

In contrast, let’s look at the typical municipal or private garage that is overworked and under budget constraints which frequently cause cost avoidance via delay or omission rather than an attempt to control cost via effective management of maintenance programs. Typically you schedule your PM, the truck goes in and gets the oil changed and if you’re lucky the primary fluids checked, you pick it up, and a week later you notice the state inspection is due, when you take the truck back they discover the rear brakes need to be replaced and the parts have to be ordered because they don’t keep them in stock. You pick up your truck a week later, it requires a jump start when you pick it up but keeps working for another week before the alternator burns up trying to accommodate the bad batteries. You see where I’m going with this? This is the typical result when the personnel or facility maintaining your equipment does not have a vested interest in truly maintaining the safety and reliability of your equipment; in fact they actually spend/make more money this way.

Your logistics officer or whoever is responsible for managing your maintenance program must be committed to a program that is proactive instead of reactive, and this individual must have the support of the organizations leadership to implement this type of program. You cannot manage ambulance maintenance like your personal vehicle or a garbage truck, there is too much at stake, the safety of your staff, the outcome for the patient, and the costs to the organization’s reputation and finances are at risk.

Happy motoring,

Fire Based EMS Advantages

Advantages and Strengths of Fire Based EMS

By Alan Perry 7/12/2013

Introduction

I have frequently questioned the commitment of the fire service when it comes providing emergency medical services (EMS). I have observed through my own experiences that the fire service has reluctantly accepted provision of this service as a necessary evil in order to secure funding for its own programs and preservation of career firefighter positions. I am a career paramedic/firefighter in a large municipal fire department, my initial training as a paramedic was obtained while I was a volunteer in a neighboring city because my city did not encourage volunteerism. I eventually sought employment in my home town as a paramedic/firefighter and was given some preference in hiring due to my paramedic certification. My department began as separate EMS and Fire divisions which merged before I was hired with separate career paths for fire and civilian EMS personnel. Over the years through attrition the numbers of civilian employees have dwindled to but a handful with the majority of supervisory EMS positions being filled by aspiring Fire company officers who have not given up their ALS certifications. The EMS command structure falls completely under the Fire chain of command with no parallel structure or career path for EMS. Our current staffing model is dictated by the Fire Administration’s desire to have one ALS provider available in each station, ambulances are staffed with two BLS providers, ALS is available by simultaneous dispatch or requests for an ALS provider via an engine company response. In this way the best use is made of the departments limited ALS resources. There are many other models used in the fire services ranging from this extreme to all ALS apparatus and systems where even officers are expected to do some time on the “box”. If anything, we are flexible. We almost universally, as part of our fire based culture, play down and degrade the value and importance of the EMS services we provide. We portray this duty as a punishment or undesirable assignment even though it accounts for over 80% of the services we provide. These observations aside, I believe the fire service is in a better position to provide EMS services due to the culture, resources and stability the fire service possesses.

The fire service culture

Normally I would count this as a negative, but I have come to realize that the fire service does many things right when it comes to producing an atmosphere of cooperation and teamwork. There is also the mentality that no job is too daunting or extends beyond the capabilities of the fire service. These attitudes have been tested, and although applied slowly to the practice of EMS, it is changing. The fire service has the correct mind set needed to take on the challenges facing changes in EMS that are occurring now and those on the horizon, the test will be if it can react with sufficient agility to maintain control of its own system.

The resources of the fire service

The nature of the fire department is to handle any emergency, of any kind, at any time. We train for every conceivable type of scenario. Because of this fact the fire service is the best prepared to handle any type of patient presentation, and equipped to begin treatment immediately even in the most difficult circumstances. The additional training and equipment available allows for safer and more effective treatment of patients and minimal risk to providers. One of the biggest strengths of the fire service is its ability to organize and mobilize resources both physical and human. Through unions and public goodwill we frequently can convince both the public and government officials that our needs should be met in the public’s best interest if our cause is a just one. The fire service can bring extreme amounts of physical and human resources to bear when disasters occur locally, regionally or nationally. The agility of the fire service will be tested in the near future, challenging our ability to improve and keep up with changes in EMS. The political power of the organization can be used to improve EMS systems or expended trying to maintain the status quo.

The stability of the fire service

Fire departments are paramilitary organizations that rely on rigid command structure both in emergencies and routine operations. Because of this fire departments are able to produce more consistent and reliable results, personnel at all levels are held accountable for their actions. Individual preferences, variations and freelancing are minimized, safety procedures are followed, and most actions other than local EMS protocol are based on established national standards creating little variation from one department to the next. Fire departments are publicly funded, they are required to submit and adhere to budgets and long-term plans. The finances and activities of the fire department are very public. Fire departments do not get into trouble quickly or without the public’s participation. These facts make fire departments inherently more stable and free from the vacillations in financial and leadership performance often plaguing non-profit and volunteer organizations engaged in providing EMS services. This stability in leadership, oversight and financial affairs make fire departments much better suited to provide a stable environment for the improvement of EMS service and system development.

Conclusion

I believe that in spite of my past experience with the fire service, it is far better suited to take on the challenges facing EMS at this time. Those in the fire service have become acclimated to EMS as much more than a “box” that takes people to the hospital. They realize it is an important service that greatly affects the lives of those we serve. The fire service possesses all the resources needed to confront the changes EMS is facing now and in the foreseeable future. My hope is that we will be able to do so with the agility and efficiency required, after all the fire service as a whole is a huge organization, it has traditionally been very slow to change. The only obstacle remaining is the Fire Service Culture, if we can change our attitudes toward EMS across our organizations from the top down, no one will dispute our ability.

Be Safe,

Limitations of Web-Based Instruction

The Limitations of Web-Based Instruction

By Alan Perry

Online and web-based instruction have become very popular over the years due to the limitations of individuals time and resources. Many public safety organizations have discovered its benefits due to shrinking training budgets and greater personnel resource utilization. Without on-line and web-based options many individuals and organizations would have no other alternative to provide necessary and frequently required training. But where does this leave us as instructors and students? We all know the cognitive, affective & psychomotor domains of education, how can this satisfy them all? I am not alone in my concern for the outcome of this situation.

The risk is that online and web-based training options may be used to completely replace other forms of training. This presents a problem when it comes to training that requires conveying a technique or psychomotor activity. Take intubation as but one example; you can discuss the anatomy, the procedure, look at videos of it being done, and answer multiple choice questions to get your airway CE. We all know that does not work, how does this get passed-off as somehow being adequate? For some providers that is as close as they will get to performing an actual or simulated intubation. No wonder our skills are declining.

Most of us as providers recognize that the training we receive at times is more of an exercise to satisfy some administrative requirement than a true attempt to impart a meaningful and beneficial education experience. We take it upon ourselves, for our patient’s sake, to obtain and maintain the required skills and knowledge that will benefit them. I take my EMS training seriously; I do not rely on my organization to provide all the education I need to do my job and stay on top of my profession.

As an instructor and education coordinator I know how challenging it can be to find good quality training offerings, especially for large organizations. The ease and consistency of on-line programs is tempting, however the training must match the needs of the providers, especially when QI programs indicate a need for specific training such as intubation. It may be necessary to collect the necessary training equipment, find the space, and schedule hands-on training for your staff. If you know that a problem exist and you fail to effectively mitigate it you are culpable for the failure of the system and the provider when things go wrong. My advice: don’t wait till then.

For those general refresher topics, and routine procedural reviews web-based training is an excellent choice. You still need to do your homework and make sure the program you select is relevant for your service, mirrors your protocols, and is not prone to errors and omissions. Don’t assume that the flashy training website has reviewed the material for accuracy and consistency, that’s your job. Providing online training that is confusing, irrelevant or incorrect will only make things worse and sour your staff’s attitude towards it in the future.

EMS and EMS training are both changing rapidly, not all change is good so we still need to do our homework whether we are the trainer or the trainee. Always remember that your skills can and will make a big difference in the outcomes of your patients. Staying on top of developments in the practice of EMS as a profession and of training opportunities available for your staff will always be a challenge, but that’s why you got into this business in the first place, right?

Be safe, do good work

Community Paramedics

Community Paramedics in Virginia

By Alan Perry

Description and Goals of Community Paramedicine

Many patients with chronic illness lie in a no-man’s land between emergency medicine and primary care. Community paramedicine was devised for the purpose of caring for these individuals who frequently become “super users” of EMS and emergency room services. Community paramedicine can also be used to address public and patient education and improve the quality of healthcare in underserved populations. The main goals of Community Paramedic programs are to decrease hospital readmissions by “frequent flyers”, decrease EMS and emergency room workloads, reduce the overall costs of healthcare and improve access to preventive care by “at-risk” populations. I have described this type of solution in my first publication “EMS Manifesto” which looks at the broader cooperation needed across all healthcare disciplines that are needed to make this work.

Challenges and Obstacles

The protocols and training used in current EMS programs were not created for the purposes of Community Paramedicine; it is a new concept which will require modification of current practices if not an entirely new program. It will need the cooperation of all involved parties including EMS, hospitals, public health departments, social services, private providers, insurers & Medicare. Funding for Community Paramedic programs will be a problem; private insurers and Medicare have been slow to recognize treatment provided by Community Paramedics. Through cooperation and the adoption of alternative treatment and transport possibilities it may be possible to establish a Community Paramedic program in Virginia.

Legitimate questions

Community Paramedicine intersects several areas of medicine including EMS, Public Health, Primary care and preventive care. Because of this fact it seems to be re-writing the definition of what a paramedic is. Does this shift the responsibility for primary care? Is this a reaction or consequence of the lack of primary care? Will this further enable users of the system making them more dependent? How does this differ from the other options currently available such as home health care and clinics? These are all powerful questions that can significantly alter how a program is implemented or stop it completely. The reality is that the gap in service has been identified; the question remaining is who will fill it.

How to Proceed

Last year I queried the director of Public Health for my city about her position on greater cooperation and collaboration in the realm of EMS and forwarded to her my “EMSManifesto”, her initial reaction was positive, but we have yet to sit down and discuss it further. This is but one of many discussions that need to be had, ultimately it should probably be initiated at the regional level and involve the VAOEMS, hospitals, Public Health Departments, primary EMS agencies, Billing and insurance representatives, TEMS and providers from the region. The Scope of practice will need to be defined, new protocols established, a medical control plan put in place, and a means to recover the costs of the program. I would be happy to do further research on this for our region and work to collaborate with the other stakeholders to craft a plan that works for all parties.

Be Safe,

References:

Red River EMS project, New Mexico

http://www.srph.tamhsc.edu/centers/rhp2010/html/access/ems/redriver.htm

Western Eagle County Community Paramedic Program Guide

http://www.communityparamedic.org/

NAEMT, community paramedicine

http://www.naemt.org/about_ems/CommunityParamedicine.aspx

Brave New EMS World, EMS Manifesto

http://bravenewemsworld.blogspot.com/2013/05/ems-manifesto.html

Our Western Brethren

Commonalities of the approach to EMS by our western brethren

Bend Fire & Rescue

By Alan Perry

Where I got my information

I have visited Bend, Oregon on several occasions and found it to be a beautiful community with many natural resources, a pleasant climate and breathtaking vistas. In short a community I would love to live in. I came across the Bend Fire & Rescue Deployment Plan for 2011-2013 while perusing the department’s web site. It is a comprehensive and detailed document available to the public prepared with the help of ICMA data, and the department’s historical data to determine their compliance with NFPA 1710 . It is a document used by the state government to assist departments with identifying their circumstances and creating plans to help them remain viable.

About Bend Fire & Rescue

Bend Fire and Rescue serves a population of approximately 100,000 in an area of 165 square miles much of which is sparsely populated. The City of Bend has a population of 77,000. The annual call volume is around 8000 with 82% of calls being EMS in nature. Their staffing consists of 88 career personnel, 4 part-time and 5 volunteers. The chain of command contains a Chief several Deputy Chiefs including the Deputy Chief of EMS, a Battalion Chief for each of the three shifts, a Captain for each of the five stations on each shift, 6 engineers per shift and 6 ff/medics per shift. The department uses a flexible staffing model were engines and ambulances are at each station, and staffed based on the nature of the call. All-in-all, a very lean operation.

About us

Fire Departments in Southeastern Virginia tend to follow the old school east coast fire service model. It is a well-tested institution known for a strong and rigid structure which does a good job of protecting lives and assets and the jobs of firefighters. We have enjoyed both public and political support, supporting well-staffed  and well-equipped career departments in most major cities. The approach to providing EMS service is widely variable ranging from only providing a first response to being a primary EMS transport provider. In this mix there are also widely varying degrees of support for the EMS mission ranging from treating it as a necessary evil in order to maintain public support and funding, to embracing it, making innovative changes that are needed and addressing public education in EMS.

Common threads to our approaches to EMS

The most common thread among fire departments that have taken on EMS as part of their service mix is the high percentage of our total calls that are EMS in nature. Of equal importance and contrast is that most firefighters do not enter this career with the primary desire to transport the ill and injured on an ambulance. Culturally I think this is a common thread among fire-based EMS systems, one that creates the climate for poor attitudes when making decisions and long-term plans for these systems.

Where we differ

A few highlights of the Bend Fire & Rescue program jumped out at me as being very proactive and engaged in improving the quality of their EMS system; They conduct monthly EMS case reviews with their two physician advisors to include patient outcomes. EMS protocols are updated annually, A service survey is sent out for every 15 EMS calls, They have an EMS public education program even though it is limited to senior communities only at this time. The concept of flex staffing maximizes the effectiveness of a small staff allowing a smaller group of responders to handle a variety of calls whether EMS or fire. Despite the staffing limitations the department has an average response time within the city of 7:33. They have a dedicated training staff and a training facility.

How can Fire-based EMS improve

Bend Fire & Rescue appears to be doing well with the resources they have available but are clearly pushed to the limit in their current circumstances. Like many other departments they are having difficulty with being fully forthcoming about the nature of the fire services relationship with providing EMS. The financial data conveniently lumps both fire and EMS operations costs under one heading and does the same with revenue, this approach could be considered an attempt to minimize the higher operating costs for fire services and the revenue produced from the EMS activities. Being open and honest about these circumstances will better allow the management and the public to make good decisions. Their portrayal is not unique, it is a common tactic used in the fire service. We in the fire service, as public servants, should be more honest with the public and ourselves, the lack of clarity will affect our integrity ultimately. Fire-based EMS systems must look at our perception of EMS and be certain that we are embracing it, constantly looking for ways to improve upon it, and deliver the service as effectively and efficiently as possible.

Link to Bend Fire & Rescue Deployment Plan

http://www.bendoregon.gov/Modules/ShowDocument.aspx?documentID=6919

Size up

The Importance of Size-up

One of the most important things the first arriving unit must do at an emergency incident is to provide an accurate and informative size-up for other responding units, this is the first essential step in taking command and gaining control of an incident. The initial report should contain a statement of fact; the situation as you see it through the windshield, what has happened, what is happening now, and what is likely to happen as other units arrive. This report is critical for other responding units to hear and understand; it is the foundation on which the incident will be managed. Hazards must be identified whether it is an angry crowd, a downed power line, a tree or wall that may be ready to collapse or a hazmat situation. Advise incoming units of specific actions they may need to take to avoid the hazard. This can be as simple as advising them to stage at a safe location or take a specific route to get to the call.

Initial Scene Size-up:

What is involved?

□    Building, size, type, use

□    Vehicle, size, type, contents

□    People, number, nature of injuries

What is the nature of the emergency?

□    Fire

□    Explosion

□    Vehicle accident

□    Structural collapse

□    Natural disaster

Where is the problem occurring?

□    Specific location

□    Inside/outside

□    A/B/C/D side

□    Above or below grade

Is there a life safety issue?

□    Victims needing rescue

□    Entrapments

□    Potential hazards to the public and/or responders

Are other structures and assets at risk?

□    Exposures

□    Containment

□    Hot zone/cold zone

Are there any immediate needs that must be met by incoming units?

□    Water supply

□    Control utilities

□    Exposure protection

□    Traffic and crowd control

□    Additional assets such as squad truck, hazmat or EMS

Once a brief, concise initial size-up has been provided, the first in asset must take command, give it a name and declare an initial strategy. The name should be simple and descriptive. The initial actions can range from investigation, victim rescue or offensive attack. Determine if additional resources not yet dispatched required. As you are immersed into the scene clarify what needs to be done and why. As the incident develops you will be responsible for looking at the overall direction it is taking, apprising units of changing conditions and tactics, as well as scene safety and accountability for all units on scene. You must understand what is driving the incident and take deliberate steps to control it with the safety of responders and the public as the priority. You must evaluate the need for additional or special resources, you must identify and request them in anticipation of the need, do not wait until the incident forces you to request them. Until relieved of command by a superior you are responsible for continually updating your size-up and assigning incoming units to specific tasks to mitigate the situation or to staging until they are needed. Scene control is paramount; a poorly controlled scene will rapidly become congested, confused, ineffective and potentially hazardous.

Good Luck