EMS public education reboot: Call it MIH

Public education reboot: call it MIH

By Alan Perry
June, 24, 2018

The best illness or accident that ever happened is the one that was prevented right? Sure we are there to cover the ones that come to fruition; we manage them with skill and care, making the best of a bad situation. Can we make a larger impact by increasing our prevention efforts for illness and injuries? There are plenty of free (or nearly free) resources out there, from the Federal Government to private insurance companies, covering everything from substance abuse to firearm and pool safety. As an example of how fruitful this can be, let’s look at the progress the fire service has wrought on the incidence and severity of fire events over the past 100 years; Fire events were once one of the largest single threats to any population, causing extensive damage and major loss of life. The fire service developed and committed resources to the idea of fire prevention. Fire marshals, inspectors, fire codes, and life safety programs all have a dramatic effect on the effects of fire events, reducing both incidence and severity. 

Why can’t we do the same thing on the EMS side of the house? Some departments do, but have we committed a reasonable level of resources to truly have an impact on the incidence and severity of illness and injury? Do you have EMS public educators? Do you have a MIH program that performs home visits? Do you offer home and business inspections that address common injury and illness patterns that are performed by your fire and EMS personnel? Do you have EMS open houses and do EMS school demos? Do you have a public message in print, media, and an internet presence that coveys and reinforces illness and injury prevention? The potential savings in lives, improved quality of life, and the expense of treating chronic illness and traumatic injuries is enormous! The cost savings to agency operations and the tax burden to the community are an added benefit. Commit to marketing illness and injury prevention to your community, it will enhance the resilience of your community and your public image.

Be Safe,

Alan Perry

No More Agendas

No More Agendas

Alan Perry

January 17, 2018

EMS Agenda for the Future vs. Agenda 2050

Having read and studied the original EMS Agenda for the Future, as well as the subsequent implementation guide. I observe that most EMS systems still have not achieved those goals, I am finding this new attempt at creating a vision for EMS suspect. The Agenda 2050 is heavy on "social equity" but has thus far only produced fantastical ideas for how EMS could be with no clear or realistic pathway to complete the original agenda or this one. Perhaps it just an "Agenda" that does not have the welfare or effectiveness of EMS as the primary objective. One question asked early on was "does EMS describe what we do?”. This was in the context of all the new variations of EMS spawned to deal with increasing call volumes, decreasing resources, and the "care gap" created by the ACA and the current political, legal and social climate. The idea that EMS is part of the broader healthcare industry is concerning to me, as it should be to you. The first word is EMERGENCY! EMS is an essential public service just like Fire and Police spawned to react decisively in times of crisis. Mobile integrated Healthcare, Community Paramedicine, and anything else not dealing with true emergencies rejects that idea and places the service in the realm of public health and social work. I'm not belittling those professions, but EMS needs to be good at one thing, as do Police, Fire, Public Health and Social Services.

Fantasy vs. Reality

The addition of new and existing technology to the arsenal of EMS could indeed produce fantastical change in the way EMS is managed and applied. If only cost, tradition and politics where not barriers. Who will pay for it? How will the cultural changes occur?, Who will be willing to give up power and influence to make it happen? It seems that most of the envisioned changes do not consider these obstacles, in fact we were told to disregard all obstacles while developing the ideas for this initiative. The first reality is that EMS systems are diverse with widely varying needs, populations and resources. The second is that getting all of the stake holders, even within a small region, to agree on standards of care, staffing, compensation, and funding streams for these far-fetched visions, will be next to impossible. The only way I can see this occurring is by compulsion through legislation and or compensation from a larger political body (ie: Federal Government). This will inevitably come down to wealth redistribution, higher taxes, and more Federal involvement in EMS to achieve "social equity". Is this really what we want or need?

Agendas vs. Best practices

High quality, high-performance EMS systems of various designs exist out there already. They developed independently of anything other than local need and available resources. We need look no further than organizations such as the Richmond Ambulance Authority, Medstar-Fort Worth, Mecklenburg's MEDIC or King County EMS to see what localities can do when they engage in proactive measures to improve the quality of emergency medical care available to their citizens. Most of these are our shining examples of how we should proceed –let’s call it our evidence base. The majority of EMS systems are locally based volunteer, third service, non-profit or fire-based. Each entity, and their management team, has a vested interest in maintaining control over their piece of the pie for political or monetary reasons. Many, especially municipal and fire-based systems, have no pressing incentive to change practices. There is no competition and until the public demands more there is little incentive to, or consequence for failing to change. Shaking EMS free of this traditional feudal system will be the biggest challenge in my view, and our greatest obstacle to implementing evidence based practices for managing and providing Emergency Medical Services locally or regionally.

Private, third service or Fire service?

System design is only one component of the broader concerns for EMS. It is one that is driven by the needs of the locality, region and the States. I do not believe there is any one perfect design, only an ideal combination of resources provided to providers and the community that will make it efficient and effective. We know what providers need; support, training, reasonable hours and compensation that is fair. The community needs; Good stewardship, effective, efficient and compassionate care. Resources are a big part of the puzzle. In rural areas with a small tax base a volunteer system may be the only option the community can muster. Large metropolitan areas may be served by a fire-based system or have regional agreements with taxing authority than can acquire and maintain significant resources. It should come as no surprise then, that there will be significant differences in the design and capabilities of EMS systems across this nation which reflect the collective personal choices of those within those borders. The disparity of these two extremes is a major theme put forth by the facilitators of the EMS Agenda 2050 which portrays this as social inequity. Our forefathers, and I believe most sensible adults of all creeds and colors, would agree that each of us is entitled to live and work in a place of our own choosing, taking into consideration things like quality of life, accessibility to resources we think we need, tax burdens and government influence on our daily lives. It’s called freedom not social inequity.

Connecting the dots

If you are reading this article you are biased. You probably work in EMS or a related field or are in school pursuing a career as a provider. You already know how to fix EMS where you are, the truth is that most people have no idea what the big deal is because it typically does not affect their daily lives. When they do intersect with EMS it is usually brief and at the worst time in their life. Hollywood has not done us any favors but they probably reflect what most people think EMS is. Who’s fault is that? Like any other distorted story it starts with a lack of real information, when information is lacking the imagination takes over, public education can solve that problem. Healthcare is big business, EMS is at the bottom of the food chain, just ask any nurse or Medicaid billing specialist. It’s yet another perception problem from those we should consider our peers. We need to stand up, speak up and start the long process of educating the public and our allied healthcare partners. Before you do that though, do a gut check. To be considered a professional, you and your organization must look and play the part. You will get nowhere fast if you can’t demonstrate value, commitment and professionalism in everything you do. Study the research, do your own, and look at other systems and what works for them. Find your weaknesses and strive every day to improve your service. Set goals and reach for them, remember that they must be realistic and achievable.

Be Safe,

REFERENCES:

EMS Agenda for the future (1996)

https://www.ems.gov/pdf/2010/EMSAgendaWeb_7-06-10.pdf

EMS Agenda Implementation guide (1998)

https://www.ems.gov/pdf/advancing-ems-systems/Provider-Resources/EMS_Agenda_Imp_Guide.pdf

EMS Agenda 2050 Straw Man version 2 (2018)

http://emsagenda2050.org/wp-content/uploads/2018/01/EMS-Agenda-2050-Straw-Man-Version-2-January-2018.pdf

EMS and Home Healthcare (NAEMT)

https://www.naemt.org/docs/default-source/community-paramedicine/mih-cp-toolkit/ems_homehealth.pdf?sfvrsn=2

What is EMS (NAEMT)

http://www.naemt.org/docs/default-source/about-ems/what-is-ems-for-web-04-17-2017.pdf?status=Temp&sfvrsn=0.46038588091233634

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.

Non-Invasive Monitoring Pearls

Non-Invasive Patient Monitoring

Purpose:        

Non-invasive patient monitoring includes ECG’s, blood pressure, pulse-oximetry, capnography and blood CO levels. It is an essential tool for the initial assessment of patients and for ongoing evaluation and treatment. It is desirable that there be a consistent and reliable method of applying these tools to the patient in the pre-hospital environment as well as a common understanding of the limitations of these devices. This guidance seeks to provide a reference for all providers to assist in the consistent application of these tools and a resource for trouble shooting common problems.

Policy:            

The following procedures will be used when applying non-invasive monitoring tools to patients.

Procedure:

General:

·         All equipment will be in an organized condition suitable for immediate deployment.

·         All exterior surfaces and lead sets will be cleaned and disinfected after every use

ECG’s:

·         All ECG’s will be obtained using undamaged electrodes from a sealed package.

·         4 lead ECG’s will utilize limb leads and be placed on the extremities on the inside of the wrists and ankles so as to avoid muscle and fatty tissues.

·         12 lead ECG’s will be obtained using both limb leads and standard 12-lead placement on the chest wall.

·         Clothing will be removed as required to obtain correct lead placement.

·         ECG quality will be best if performed in a stationary location with the patient as still as possible.

Blood pressure:

·         Obtaining a manual blood pressure for reference is desirable but should not delay patient assessment or care.

·         Correct cuff size is important both in width and length, the correct cuff can be fastened securely around the upper arm without extending into the armpit or covering anticubital fossa.

·         In cases where the upper arm cannot be used due to size and/or anatomy, the lower arm or thigh may be used. If an alternative location is used it must be documented with the blood pressure.

·         Limbs which are injured, amputated or contain fistulas should not be used.

·         While blood pressures are being obtained the patient should remain still and the cuff  and tubing should be free of any pressure points.

Pulse-oximetry/CO monitoring:

·         Never delay treatment to obtain pulse-oximetry

·         Finger probes shall be applied to clean, uninjured digits without fake nails and/or nail coatings.

·         Pulse-oximetry will not be reliable in patients with decreased peripheral circulation due to hypovolemia, shock, or temperature.

·         Environmental light sources may interfere with the device, blocking the light source by placing a wash cloth or towel over the probe may improve the quality of the signal.

·         If the patient has cold hands, placing a hot pack in the hand may improve the circulation and the quality of the signal.

Capnography:

·         All patients with an altered LOC, respiratory distress, suspected shock/sepsis and traumatic chest injury should receive capnography.

·         All patients who are intubated, have an advanced airway or receiving ventilatory support should receive capnography.

Another Patient Refusal

Another Patient Refusal

By Alan Perry

September 22, 2015

You arrive on the scene and approach the patient, before you can speak your partner ask “do you want to go to the hospital?” For many providers out there this has become a standard and acceptable line of questioning, intended to cut to the chase, but putting emphasis in the wrong place. I’m sure your partner is adroit at creating EMS reports that describe these calls in sufficient detail (or lack thereof) to avoid drawing attention. As a group we have hammered home the message of creating good documentation to defend against unwarranted claims of poor patient care. This type of event is one that should concern all of us as professionals, ideally we took this job and accepted this role because we care for people and want to do what is best for them. Unfortunately some are compelled to act in this role because of changes in the work environment, or out of necessity, without the presumed desire to do this work, creating a serious lack of empathy and/or ethics when dealing with another person’s health issues. Other explanations might include laziness or burnout. Whatever the cause, it must be corrected. Patient refusals where the patient does not express a total unwillingness to go to the hospital without prompting, encouragement, or coercion should be rightly classified as provider initiated patient refusals. If we are honest about how often these occur, the potential and real effects of these refusals to the patient, and our reputation as a profession, we should all conclude that as professionals our first question to the patient should not be a decision to refuse. The best approach is always to gather information, chief complaint, history and vitals so you can at least form an opinion of the patient’s condition before you even ask if it’s ok for you to take them to the hospital. A refusal should be the exception, not the norm.

Be safe, do good work

Criminal MCI Calvary slide presentation

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

EMS Public Education presentation for Fire/EMS

slide presentation: EMS public education

Hearing loss....what did you say?

Hearing Loss...what did you say?

by Alan Perry

October 1, 2014

Why do fire trucks have headsets? Is it so you can talk to each other? Communicate with the dispatcher? do they just look cool? A federal Q-siren produces 123 decibels of sound pressure, according to most sources this is enough to cause immediate pain and permanent hearing loss within seconds, add a 140 decibel air horn too that mix and you create a dangerous situation for both your crew, and the general public, without substantial hearing protection like that provided by a properly sized and maintained headset. You have hearing protection on the engine. That is good, what about the medic and the other response vehicles? Does the guy in the convertible trapped in traffic in front of you have any protection? Does the small child playing in their yard? 

Warning devices are only one concern, there are many others; chain saws, power tools, PPV fans and pump panels are all dangerous too. Hearing loss occurs from brief exposure to intense sound pressure as well as routine exposure to levels as low as 90 decibels, which is the ambient sound pressure inside an engine or medic just driving down the road normally. Does your Department have a hearing protection policy? Are earplugs available when not in your apparatus? Do all of your response vehicles have headsets like those on the engine and ladder? 

Like respiratory and cardiac injuries we sustain as a result of complacency with the use of other PPE, hearing loss is no different. We injure ourselves in all these ways due to our culture of peer-pressure, not wanting to look weak, and because of lack of enforcement for existing policies and State and Federal regulations. There are two possible explanations for allowing yourself to be injured in these ways; one is ignorance which you can no longer claim at this point, the other is stupidity which I am not equipped to correct for you. 

Don't wait for the hearing loss to occur, if your employer is still able to justify not providing the necessary protection you should provide your own, sustaining a hearing injury or any other injury is never worth making a point. Tradition can be hard to change as can be an organizational culture to presents roadblocks to protecting employee health. New data and studies of the various health effects associated with emergency services are readily available to help organizations and individuals create safer and healthier workplaces, it will be an ever evolving process. We work in a risky profession already, we should remove those risks that we can reasonably control.

Be Safe,
Alan

What's the Future of EMS?

Mobile Integrated Healthcare and the EMS provider

By Alan Perry
9/24/2014

The EMS Agenda for the Future identified the need for Emergency Medical Services (EMS) seeking a broader and more integrated role in the healthcare system. Many variations of that vision have been pursued successfully and are now known as Community Paramedicine or Mobile Integrated Healthcare (MIH).EMS systems are exploring the application of these concepts locally, recognizing that all affected parties; EMT’s, paramedics, firefighters, nurses, doctors, EMS agencies,  healthcare systems & public health, will want to have input in its design. As a provider I have embraced the concept since I first witnessed its practical application some years ago and began to study it intently. I found that the goals of these programs are consistent with the outcomes I want for my patients and provide the tools I need to improve the performance and effectiveness of my EMS system.

Prevention is a key strategy employed by these programs, reducing or avoiding accidental injury, improving recognition and reaction to strokes and chest pain, and linking your patients with the resources they need to remain healthy and reduce both the severity and incidence of hospital admissions. This is the “low hanging fruit” for us; virtually all of these are within our grasp and require no new legislation, regulation, policy or SOP to get them up and running. Those of us that are also in or around the fire service are well aware of the effect of prevention programs on the incidence and severity of fire events over the last 100 years, greatly reducing the incidence and severity of fire events through education, engineering and legislation. The goals of MIH are very similar, if we can achieve even a small fraction of the success of the fire prevention programs it will be a huge success.

As I think about my daily practice, I would much rather spend a little time at a school or senior living center providing this information, than responding to and transporting someone who is injured, or waited too long to call for help. I’m there to help, that’s why I sought this type of work, my goal should be to educate my customers and provide them with resources that will enable them to avoid injury and poor outcomes. Building a new culture within EMS to make this a reality will require changing the way we think about our service delivery and our role as educators. As these programs mature other changes within the health care system are also likely, our role as an emergency resource will remain and our role as educators will expand, beyond that I do not know exactly what our program will look like, but I have a good idea it will be a win-win for everyone.

Be Safe,

AP

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

---

[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.

Loyal Customer Program

Loyal Customer Program

for

Your Emergency Medical Services & Fire Department

By Alan Perry

October 21, 2013

Introduction

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

Program Development

·         Quantify the problem

·         Identify the stakeholders

·         Develop a policy, procedure & infrastructure

·         Conduct a pilot study

·         Analyze the data

·         Get stakeholder feedback

·         Monitor the results, seek continuous improvement

Quantifying the problem

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

Identifying the stakeholders

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

Developing policy, procedure and infrastructure

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

Do a Pilot Study

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

Analyze the Data

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

Stakeholder Feedback

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

Monitor the results, seek continuous improvement

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

Summary

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

Good hunting,
Alan