EMS NEWS

Tidewater EMS news, August 26, 2013

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

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

AP

Synthetic Recreational Poisons

Death by NBOMe

By Alan Perry

Introduction

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

The Victims

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

The Treatment

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

Looking Forward

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

Be Safe,

References:

NBC12 Richmond, VA. News article:

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

Website marketing this product:

http://www.buyecstasypills.com/

and another:

http://www.pills4party.com/

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

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

Erowid drug information website:

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

Mercy Emergency services:

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

Bartlett Regional Hospital Statement:

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

Wikipedia:

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

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

"I Hate EMS"

"I Hate EMS"

By Alan Perry
August 6, 2013

I walk into a station and overhear the Officer say “I hate EMS” at the dining room table in front of both the oncoming and off going personnel. It is an attitude I know is well rooted in some fire services, but it is not always so audible. In many tradition-bound fire departments that still think its primary mission is putting out fires, the decisions that are made with regard to personnel and monetary resources frequently bear that out. This of course affects everyone’s attitude toward any activity that is related to providing EMS to the community. From the new recruits first day in the station, and probably much earlier, these unofficial messages are sent and received, having their intended or unintended effect. It is not surprising that the EMS equipment in stations where these attitudes are the strongest are often in the worst state of readiness, would it be any less surprising to find the standard of medical care and customer service also lacking? Such statements and attitudes may appear harmless, delivered in a humorous tone, but they are indicative of a problem.

What can we do? we could just ignore it and be happy that we have a job (which I am), not rock the boat and just play out our careers dealing with whatever we are asked to do without question, which is apparently what all of my contemporaries have decided to do. You see everyone can see the same problem I see, they seem to have come to terms with it and simply accept it as the way things are. Perhaps I am looking at it wrong (again), the officer’s expression of dislike does not come from his dislike of providing this service to the public, and it is more a dislike for the way in which it is delivered. As I stated earlier these departments are tradition-bound and very slow to react to changes. They have not kept pace with current effective practices, management and training in EMS operations. I fear this is likely the case in most fire departments that provide EMS transport service. For the fire service to remain effective at providing EMS services we will have to change our attitudes and methods beginning at the top.

If you were to ask, or simply listen to the grumbling, you would find that there are at least two common problems. The first is public education; providers frequently encounter patients who do not know what an appropriate use for a 911 ambulance is, and are unaware or have no other options for care. The second are inefficient paperwork requirements; providers are frequently dealt substandard and/or outdated data collection tools and software, the least expensive option is often purchased, something that would not occur if buying a fire truck. Add long hours and inefficient staffing models to the mix and you can see why the frustration is there. All of these circumstances can be resolved by reallocation of resources and the acknowledgment that EMS is the primary service provided by the fire service today. So why not fix it? Create a first-rate EMS public education program that mirrors the fire prevention side of the house to educate, inform and involve the public in your EMS services. Purchase equipment and software that makes data collection easy and efficient, is the newest version available and will be upgraded regularly. There is absolutely no reason the same data should ever have to be entered twice. Provide GPS or good quality maps, the days of hand drawn maps are long gone.

For our EMS systems to perform and have providers who truly enjoy their work we should consider demonstrating commitment to making the system the best one possible. Aside from the obvious morale implications, and improved operational efficiencies, fire administrations must consider the ramifications of the Patient Protection and Affordable Care act (Obamacare). This legislation will begin exerting force on healthcare and transport organizations, Medicare, and insurers to reduce healthcare cost by providing more appropriate and cost effective care. This should end the era of everyone going to the ER whether they need it or not, and provide a means to bill for other more appropriate treatment and transport. Failing to recognize a problem such as poor attitudes or sweeping EMS system changes in the pipeline will spell disaster for the organization, and ironically hating EMS won’t be an option anymore because we won’t be doing it.

Making some of these changes and showing commitment to the idea of a first rate EMS system will go a long way toward changing the negative culture surrounding EMS in the fire service. Positive attitudes flow from the top down, I realize many senior officers are late in their careers; many senior firefighters are similarly excluded from having to provide EMS and have lost touch with it. The fact remains that EMS is still the predominate service offered by fire departments that provide it, therefore participation and embracing of the EMS mission is no longer an option, it should not be the reluctant burden as it is currently portrayed. Of course not every system, officer, or administration has this problem, many have already overcome it, but for those that still have this issue the time is getting short.

Be Safe,