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

Motivation

Motivation

By Alan Perry

Every now and then the need for motivation arises from complacency, boredom, frustration, or repeatedly being passed-over, beaten down and punished for your well-intentioned efforts. It happens in all our personal lives, or career, finances and relationships. Motivation is literally what moves you. We often get so mired down in the routine events, successes and failures, and distracted by mere survival, that we forget this. It is the desire, and why, We do things. Our pure vision of a desirable goal will get bent, damaged, and sometimes replaced with something we never intended. We must acknowledge that we only have limited control of events affecting us that involve other people. We will be tempted to accept outcomes that are not ideal or even reasonable, we will be asked to sacrifice our ideals and principals in the interest of other agendas hostile to our own vision.

Be strong, have hope and don’t give up. The most important battles are never won easily, but the one who stands on the other side uncorrupted, and able to realize their vision, will not need the validation of others. I believe determination is by far the quality most required to achieve that outcome. It is measurably easier to obtain ones goals and remain motivated when you can experience some measure of success even if it is only incremental. Being smart is nice, but having a plan is better, and it has a greater chance of working. Remember what your motivation is? Write it down as clearly as possible! Make a plan to achieve that goal, break it down into achievable steps and work your plan!

Your ability to motivate yourself is important, your ability to motivate others is absolutely critical in achieving goals that involve others. Be it your family or your co-workers, most significant accomplishments involve getting tasks done through the cooperation of others. You must be able to translate your motivation into something others will identify with as well.

The truth is, life can be cruel, not all plans are good ones, and not all good ideas will survive. It may not be the right time, it may be the wrong audience, and there may be factors you have no knowledge of that will affect the reception of your ideas and plans by others. Being realistic will go a long way toward relieving your stress and prevent ineffective use of your limited resources. The old adage “choose your battles wisely” applies here, but does not mean you should avoid fighting for legitimate and just causes when they arise. Failing to fight for something just, ethical and smart, that will have significant positive impacts for others and will redefine who you are in a negative way.

Confused yet? I am.

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

EMS Pub Ed program outline

EMS Public Education Program

Program length: 1 Hour

Program format:            Informal lecture, handouts, power point, question and answer

Target Group:               Teens-Adults

Preferred venue:           Public/private group meetings of 12 or more

Target Groups: Civic organizations, Houses of worship, Clubs

Program development timeline:

·        Review and approve course syllabus and curriculum.

·        Solicit interest among target groups & schedule presentations.

·        Collect feedback, analyze and refine program.

·        Develop interest list for additional/related programs.

Resources needed:

·        Room with chairs

·        Computer with projector and screen for ppt

·        Related program handouts

Course description:

            This is a one hour presentation provided by the  Fire department for the purpose of encouraging greater public understanding and support for the mission of their emergency medical services(EMS) system. The activities of the Fire Department in prevention, emergency and non-emergency responses, will affect nearly every citizen at some point in their lives. Most do not require direct services with any frequency however, all benefit from and observe our actions in their daily lives. This presentation seeks to inform the participant of the department’s goals, practices and activities, and solicit discussion and active participation in improving the quality of EMS within the city.

Course Outline:

·        Introduction

·        Audience experiences

·        Overview of current EMS response

o   Reaction to event

o   Call taking/Dispatch/Response

o   Treatment/Transport

·        The role of citizen participation

o   Preparation, recognition and reaction to EMS event

o   Pre-arrival treatment and preparation

o   Treatment/Transport

·        Potential gains with citizen involvement

o   Improved outcomes

o   Quicker/Appropriate response

o   Less friction between responders & family

o   Less time on-scene/More accurate information=Better treatment

·        Other available programs

o   Hands-only CPR

o   Basic first aid

o   SCAN

o   File of Life

o   CARE

o   Project Lifesaver

Presentation:    

Introduction

·        Introduce presenter (name, rank, position)

·        Introduce and thank host/host organization

·        Thank participants for their time and interest

Opening

·        Good morning/afternoon/evening,

·        My goal here today is to convey information to you about your EMS system.

·        I also hope provide you with some tools and ideas you can use in a medical emergency.

·        I hope to address any questions you have about the Fire Department's activities, as well as our practices and goals in our delivery of service.

·        I will inevitably use a term or expression you may not recognize. I apologize in advance, please stop me and I will gladly explain.

Exercise 1- show of hands……questions will be answered later

·        How many of you have been exposed to a emergency medical services call in the past 5 years?

·        How many of you had questions about the process?

·        How many are comfortable with their ability to react properly to a medical emergency.

·        How may are willing to participate in the preparation for and response to a medical emergency?

Here is the way our system currently operates

·        Keep in mind that this is a continually evolving process that is driven by the city budget, State and Federal regulation, ongoing research and the input of the public.

·        A medical emergency occurs

·        Someone calls 911

·        Dispatcher collects information, dispatches appropriate resources

o   Ambulance, ALS or BLS

o   Closest Engine company for ALS calls, accidents

o   EMS supervisor, as closest ALS or for complicated calls

o   ALS unit, co-responds with BLS ambulance for ALS calls

o   Squad truck, Battalion chief, helicopter, sky is the limit if needed

·        Personnel collect ringdown, find address on map

·        Apparatus rolls out the bay (goal is under 2 min. longer at night)

·        Apparatus arrives on scene (goal is 6min.)

·        Personnel and equipment arrive at patients side (8-10 min)

·        Patient is assessed,  treatment begins, patient is packaged for transport, personal health information, history and list of medications are obtained if possible (20 min. elapsed)

·        Patient is transported, treatment continues, hospital is contacted en route

·        Patient arrives at ER, turnover to RN (30 min.)

·        Ambulance is restocked, patient care report completed and left with hospital (1 hr.)

·        Ambulance returns to service

·        Did any part of that process surprise you?

Community preparation and reaction can have dramatic effect on the system’s performance

·        Preparation

o   Well marked address

o   Keeping list with Med Hx and medications in accessible location

o   Taking first aid and/or CPR class

o   Knowing what to expect (todays class)

·        Recognition of medical emergency

o   Check if unsure

o   Call sooner rather than later (stroke/chest pain)

o   Be sure of situation and location

o   Do not approach violent people

·        Reaction to a medical emergency

o   Call 911

o   Render aid and/or follow dispatcher instructions

o   Collect relevant medical information for EMS (Hx, Meds, ID etc)

o   Assist by clearing path to patient and removing obstacles

These critical actions will save lives and improve patient outcomes

·        Patient outcomes are directly linked to the time it takes to receive initial care and definitive care

·        Patient care can begin with the lay-rescuer, by following dispatcher instructions and/or attending CPR and first aid training.

·        Stroke/Heart attack/Cardiac arrest….all very time critical

·        Witnessed cardiac arrest……Brain death in 4 min. without bystander CPR most will die. Some communities have achieved survival rates of better than 40%

·        A quick and appropriate response by the public reduces miscommunication and enhances the efficiency and effectiveness of the EMS response.

·        Better understanding of the system leads to better communication during emergency

·        Better communication means more accurate information and better patient care

Resources available

·        Hands-only CPR classes

·        Basic first aid

·        SCAN program

·        File of Life program

·        CARE program

·        Project Lifesaver

Questions?

Foundation Building

Foundation Building

By Alan Perry

I made my presentation for an EMS public education program to my chain of command some 8-9 months ago, after a brief conversation I was given permission to move forward with the project with a few limitations. Basically there would be no funding from the department, no overtime could be used, and any activity on-duty could not interfere with station duties and/or calls for service. I really did not expect any more than this; I was just hoping to get some buy-into the concept from the administration. That was almost a year ago, my life and other department assignments have kept me from moving forward with the project…until now.

The complete plan that was developed was a comprehensive program involving, public awareness training & outreach, community CPR, first aid & AED training, marketing and research. It is clear the ambitions of the initial proposal will have to be pared down. This article addresses that process; I intend to chronicle the adaptation of key parts of the program that one or two individuals can achieve with limited resources and time. Hopefully in this process some public and department interest will be generated, some positive changes will occur and more support for the program can be found to achieve the primary goals of improving patient outcomes, public satisfaction and system performance.

The nucleus of the program is public education; this seems like a good place to start. By developing and refining a short program that generates public interest and support I believe the program can begin to gain traction. The initial proposal included a 15 minuet power point presentation that outlines the emergency response process, the need for public involvement and proper reaction, and resources available to the public from their fire department and other sources. This presentation will be offered to small groups, clubs, community organizations, church groups, scouts, schools, etc. I am sure it will need a few tweaks depending on the presenter and the audience but it is basically ready to go as-is, I just need to find audiences and presenters.

So that is where I am with this, it’s time to put it out there. I will contact the administration and seek permission to solicit within the department for interested personnel to present the program and seek to have the program publicized on the city/department web pages. I suspect that getting the program off the ground will require getting on the phone or hitting the streets to secure presentations until the program can gain some recognition. I will not be able to do this alone, and anyone attempting this outside my department should consider asking for help as I am here. All I can promise you at this point is a chance to get into this program early and help develop it into something very useful.

Full program proposal can be found here:

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

Is it clean? or just disinfected?

Is it clean? or just Disinfected?

By Alan Perry
rev 10/14/2017

     Your employer, EMS instructor, training officer or partner has told you all that you need is to wipe down the equipment, handrails and cot with the de-funkicide wipes in the cabinet and everything will be fine. That might be, but your unit certainly won’t be clean. Actually cleaning all of the surfaces and equipment in your rig will require the use of something a little stronger along the lines of a commercial cleaning product like 409, dish soap and water, Simple Green, or my favorite industrial degreaser - Purple stuff. That grey-black greasy crap stuck in the folds of the vinyl seats, armrest, floor and other dingy looking areas harbors not only filth, but also the very bacteria and viruses the funky-wipes were supposed to kill. They are still there because they are now protected within that gooey mess and may actually be sustained by living in it. A good degreaser will break that stuff down and allow you to more completely clean not only the pathogens away but also years of accumulated crud.

      Most anti-bacterial wipes, bleach solutions and other “disinfecting” cleaning products that we use for making our EMS equipment safe do in fact kill nearly all bacteria and viruses that can potentially infect us or our patients if used consistently and appropriately. It is nearly impossible to apply such products to every possible surface that may be contaminated after every single call, add to that the fact that the majority of these products contain no detergent properties and you end up with a gradual and perceptible buildup of oils, dead skin, hair, dirt and organic matter on floors, walls, seats and crevices. I’m sure you have all seen it, that brown-grey material that builds up in the lines and seams of the vinyl seats, that grey-black dusty looking stuff built up under the hinged arms of the stretcher arm rest, and the stuff around the floor plates where the stretcher wheels rest. It is also present in some places we don’t always look like the radio microphone, steering wheel, monitors and stethoscopes.

     Let us also consider some other overlooked special hiding places; How about tape? Leaving it hanging about all during the shift(s) acting like some kind of microscopic fly trap catching little bits of dirt, airborne contaminants, germs and bacteria is just not a good idea. Neither is taking it from its resting place and placing it in close proximity or contact with a fresh wound our IV site. There's also the residue left on rails and seats that most providers seem content to leave were it is because its hard to clean off. This residue also collects the same contaminants that the grey goo does. It usually takes a hydrocarbon based cleaner like mineral spirits or Goo-Gone to remove it, but it really needs to go. Back of the truck clean? check! Now how about the cab and the compartments?  These areas deserve the same scrutiny the patient care area receives for the same reasons as well as your personal welfare.

     So I sound like some kind of clean zealot right? This isn’t just about EMS acquired infections, it is also about pride in what you do and caring about how your customers, the families and other public safety personnel view you. I believe you can tell a lot about an individual’s character and values by how well they maintain their professional work environment; it speaks to their commitment to doing a good job and presenting themselves and the organization in a positive light. It should not matter how old and well-loved your equipment is, it will certainly look better if it sparkles, and so will you.

Be Safe,

Intra-Governmental Communication

The value of good Intra-Governmental communication

By Alan Perry

Most branches of your local government probably function very well as independent units such as Police, Fire, Public Health, Sheriff and EMS, but do they all work together effectively?  It has been my experience that development of close lateral communication systems and the management of programs to attain common goals are frequently lacking. This is only my own perception based on my own experiences, and might well be due to a failure to communicate and share these processes with all affected by them.

A recent example I will use to illustrate my concerns involves a class a police department was conducting for new officer candidates, for which a fire department was requested to provide medics in case of injury. The subject of excited delirium came up in the context of apprehending subjects, the dangers of that situation to both the officer and suspect where explained clearly enough, but there was an information gap when it came to what the EMS personnel’s expectations and capabilities were. After discussing the observation with the training officer I was able to present a brief explanation of the EMS protocol to the candidates, how we can help reduce the risk to officers and suspects with proper use of chemistry, and the exact procedure, limitations and expectations of the medics. This brief summary generated another 15 minutes of discussion of the subject. Unfortunately only the candidates and instructors present benefitted from that discourse, hopefully the instructors will carry that information with them for future classes.

Every city department and public safety organization has its own structure, policies, procedures and directives which guide the internal operations of that unit. If we all operated alone that would not present a problem but the reality is that we frequently come together to resolve public safety issues and more often than not, the more serious the event the more interaction and cooperation is required. I recall a school shooting MCI drill I was asked to observe and critique a few years ago which involved local police and fire departments, the community college and the state police. This should have been your typical MCI 101 exercise but it went sideways from the start with multiple command structures, duplicate communications systems and major terminology problems. There were fire company officers refusing to send their personnel in with police rescue teams because the scene was not “safe”.  I can’t help but think that better training integration from the start would have produced a better outcome. That was my recommendation; I produced a presentation for the public safety command staffs. To my knowledge that was never presented, and no subsequent training has occurred to address the problems.

From an even wider perspective consider the delivery of health care in general; EMS, Public Health and Hospitals all function in their own spheres. This is another area that can benefit from greater integration. For the most part the relationships are good here but we still run into the problems of expectation mismatches, poor communication and teamwork. Are we driven to improve based on revenue, legal liability or improved patient outcomes? I think we should really start looking at the coordinated care concept and find a way to apply it to EMS in that setting, but that’s a whole other discussion.

For now let’s focus on intra-governmental communication. It is a simple concept; those that commonly work together in the field or office should train and develop operational policies together so interoperability is seamless and requires little, if any, additional thought. OK, it’s probably not going to be that easy but I don’t think it would be that hard either. Personal influence and control will be the biggest obstacles. Public safety should be viewed as a single functional unit for the purpose of establishing training goals, policies and procedures. In my dream world I would like to see police, fire, EMS and hospital staff training together doing CPR, Hazmat awareness, MCI, HIIPA & Bloodborn pathogen classes together. In that type of environment important lateral relationships can be built with other public safety personnel before they show up on the same scene together. Take it a step further by conducting joint NIMS training, having joint policy development and review sessions by both command and field staff. Have an open training environment by sharing instruction resources and pulling subject matter experts from each other so everyone will always be on the same page. Have open communication channels at all levels which foster and encourage lateral information sharing. We all have one goal and amongst ourselves we possess all the tools we need to effectively and efficiently handle just about anything. It should no longer be so segmented and territorial, petty turf battles are for tyrants, dictators and children. Let’s grow up and move on.

Be Safe,

ALS or BLS?

ALS or BLS? Who decides?

By Alan Perry

Your Department’s circumstances

There are many types of EMS delivery systems operating in the United States and around the world. No two systems are exactly alike but many share one of several delivery models, I’m not so much talking about system structure; Fire based, third part, public utility, etc., as I am staffing make up. Some systems are all ALS, some all BLS, most fall somewhere in between with a combination of levels of education, training and certification. One common question that arises in these diversified systems can be the determination of the appropriate level of care required for a particular patient in a specific circumstance. We all know that not all such decisions are clear cut, and frequently those that appear to be, fool us the worst.

ALS shortages

Becoming an ALS or BLS provider has been increasingly more difficult over the last twenty years. ALS providers in particular require a significantly greater commitment, many paramedic programs are now 2-year college degrees and maintaining certification requires over a hundred hours of CE over the course of two years. Understandably the ranks of paramedics have thinned. The EMS systems that employ them are having more difficulty recruiting and retaining them given budget pressures to reduce costs. Many systems are finding themselves in the position of having to shuffle their staffing models to make sure they have ALS providers available for the most serious calls that require them. This has produced some interesting models and a degree of increased pressure on those providers, and systems to make it work.

Competence of all providers

In our Brave New EMS World, all patients would be provided with the best care and best trained provider for the circumstances. Let me be clear that in most cases that may be a competent BLS provider or an ALS provider who is competent providing BLS care. Not every patient requires an ALS provider to give appropriate and effective care. Any provider should aspire to handle any call clearly falling within their scope of practice, if they do not feel competent and confident in doing so; it is incumbent upon the provider to seek out training and experience that will accomplish that. The ALS provider should recognize subtle signs, symptoms and circumstances that are reliable for determining the need for ALS care, as well as the comfort level of other providers. This is a very difficult balance point because either provider will have reached a conclusion about the level of care needed independently. I always encourage discussion of the facts, observations and rationale if a consensus is not evident. If an impasse exist one should always err on the side of caution and the needs of the patient; which is us providing the best care possible as a professional and competent team.

The needs of the organization

Each EMS organization has different needs, budgets & resources, the staffing model chosen will reflect this. We must remember that ultimately we are there for one purpose, and that is to provide the best patient care possible with the resources the organization can provide. Our jobs, and those of our co-workers, depend on our stewardship of these resources.

The needs of the patient

In all our actions and decisions we should keep the welfare of the patient paramount. The patient’s outcome will be directly affected by our words and actions, keeping a professional, caring attitude and working as a team to appropriately manage each patient should be our primary goal when making decisions regarding the appropriate level of care.

Medicare’s role

Of course the State and Federal governments will have a say in the way the EMS service gets compensated for calls, there are guidelines for what qualifies as an Emergency, the need for transport, and the definition of BLS or ALS care. This is for the accountant to worry about; you must focus on what is right and appropriate for the patent. Of course you need to be worried about proper record-keeping, make sure your report is accurate, making false statements to garner payment as an ALS transport may result in substantial monetary, civil & criminal penalties.

Opportunities to educate and grow

When disagreements about level of care arise it should be handled professionally and respectfully with the highest level of care provided for the patient as the default. Once the call is completed, and the patients disposition ascertained, a debrief should occur to determine what the nature of the conflict was and how to best correct it. If patterns emerge where patients are routinely over or under treated it must be addressed immediately to ensure the safe and efficient operation of the system. This should be managed like any other good QI program, providers need to feel free to express themselves and be free from punitive actions, when additional training is indicated it will provide an additional venue for ALS & BLS providers to interact and understand one another.

How will it all turn out?

The EMS profession continues to grow and develop, I view these new challenges and the additional responsibly they place on us as a further maturation of the profession. We need to accept that change will be a large part of our future as we grow, as professionals we need to conduct research and advocate for what is best for our industry and the public we serve. As long as we maintain a positive attitude and commit to moving forward intelligently and cooperatively our lives, the lives of our patients, and our industry will benefit.

Be Safe,

Professional Recognition

The Benefits of Professional Recognition
6/3/2013

By Alan E Perry

Any organization -Fire or EMS -career, paid or combination should value the life experiences, training and professional experience of its members if the organization is to get the most from them and foster a healthy work environment. Most other professionals within the medical community and other major occupations engage in the practice of professional recognition, a principle that acknowledges the qualifications and experience of the individual regardless of where these assets were aquired. This recognition carries across all regional, state and governmental boundaries allowing the employee greater choice and mobility in pursuing their career goals, and permitting the organization to find the best candidate for its vacancies. Fire and EMS organizations appear to ignore the obvious benefits of this practice and compel their members to start all over every time they begin a new job, senior officer positions in large departments are one possible exception.

As an example; consider an electrician, a physician, or a lawyer. Any one of these occupations can simply leave one job, go to the next and expect to be fully recognized and compensated for their experience and training. A firefighter, EMT or Paramedic on the other hand can expect to be treated like a new employee, repeat basic training programs and start all-over again at the bottom of the organization. Experience, training and qualifications are frequently disregarded.

If we are going to progress as public safety professionals we need to adopt the concept of professional recognition. The practice of granting opportunity based on time-in-service instead of qualifications is self-defeating. It denies professionals access to good jobs they are qualified for and it can prevent the organization from putting the most qualified individual in a position. Progressive organizations will make all of their opportunities competitive, based on the right combination of experience, training, education and competence regardless of where these assets are obtained.

How many unhappy employees do we retain by locking them into seniority based systems where they know that they cannot leave without fear of losing everything, even though they may have grown to dislike the job? What does this do to morale, our performance and public perception? Does our seniority based system truly produce the most qualified and appropriate filling of vacancies? Would a more mobile workforce create organizations with better dynamics and performance? Just a few questions we need to think about.

I know this flies in the face of the organizational culture predominate in our industry for the last century. I see hints of change everywhere, especially in small and new fire departments that do not have the impediment of tradition to hold them down. Time will of course eventually bring about change. I only question why we have to wait.

Be Safe,

Alan