EMS MEd Blog

The Pros and Cons of Degree Requirements for Paramedics: Kazan and Moy debate

Should paramedicine require a minimum degree? In this post, two EMS physicians, Clayton Kazan (Medical Director for LA County Fire Department) and Hawnwan P. Moy (Medical Director for ARCH Air Methods in Missouri) , debate the Pros and Cons.

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CON: Raise the Roof, Not the Floor.

by Clayton Kazan MD FACEP FAEMS

Far be it from me to knock the benefits of higher education.  It was always one of my narcissistic goals to achieve more letters after my name than in it, and, with the addition of FAEMS this year, I have finally achieved it.  I think that the “associations,” as they describe themselves in the PEC published joint statement (NEMSMA, NAEMSE, IAFCCP), are going about this the wrong way, and the detrimental effects on paramedic programs, particularly fire-based programs, will be severe. [1]  I have been involved in training EMTs and paramedics since 1995 (again with the narcissism), and I would be a huge supporter of this concept if I believed that this was the gap between poor and good (or good and great) prehospital clinicians…that, if only they had fulfilled the general education courses needed to finish their degree, they would be given the tools they need to build strong clinical skill.  By the same argument, I am a better physician today because of the undergraduate coursework that I completed at my alma mater (UCLA).  So, linguistics (my textbook was a freaking dictionary), psychology (rats given dopamine will forego food and sex to get it), art history (pyramids at Giza = cool) are really part of the fabric that makes me an amazing clinician (yup) today?  Even my science courses had very limited applicability…unless the human body has a xylem and phloem, or I am ever asked to synthesize a perfume that smells like bananas.  If you think that these types of courses would not be required of our paramedics, then I invite you to review the A.S. requirements of a junior college. [2]  I took the EMT course as a sophomore specifically because my coursework had NO relevance to my chosen field, and the rest is history.

The issue we have as we strive to develop an EMS profession is not the prerequisites that our paramedics bring as they start their careers, it’s that it is a dead end.  Requiring an A.S. degree does not change that.  The position statement states that 60% of paramedic programs already offer an Associate’s or Bachelor’s degree program is misleading because, using their source, only 1.6% currently offer Bachelor’s. [3]    If you want to take those Associate’s Degrees and use them toward a Bachelor’s, how many of the universities are giving course credits for the paramedic program and not requiring the students to start from scratch with introductory biology, physiology, etc.?  In California (because the west coast is the best coast), the answer is zero.  Thus, the Associate’s is a dead end, and that is part of the reason why many students do not continue their education to finish their degree. 

What is missing in our prehospital clinicians is the opportunity and encouragement to be lifelong learners, to stay in EMS, and to advance past paramedic.  Build the degree programs so their paramedic certificate is worth something to them from a career advancement perspective.  Requiring an A.S. of everybody may raise the floor, but it definitely does not raise the ceiling.  Build bridges within the house of medicine to use that credit towards a nursing, PA, or, dare I say it (I dare, I dare), a medical degree…so our providers don’t feel chained to their ambulance or squad for the duration of their career.  Rather than knocking our current programs back to EMT-I (BTW not recognized in Cali), build an advanced paramedic level with an expanded scope of practice, as we have for our flight programs.  What our profession needs is a carrot, not a stick.

Lastly, I want to comment (rant) on a statement made near the end of the article… “From an economic standpoint it is almost certain that degree requirements will restrict the supply of available paramedics to some extent.”  For fire-based EMS systems, this represents a disastrous, unfunded mandate that will severely affect the supply of available paramedics.  They are right that it creates an upward surge in salary, but their argument that this money will come from third party payers and local governments is ludicrous.  Requiring paramedics to have degrees will not squeeze one penny out of health insurers, local government budgets are nightmarish without this.  To me, “the associations” have not clearly thought through what stream actually fills this imaginary pool of money they think will pay for this.  As huge constituents of the schools and employers of the graduates, it is essential that fire-based EMS provider stakeholders have a voice in the future direction of paramedic programs, and I urge our membership to read their reply.4

References

1.     Sean M. Caffrey, Leaugeay C. Barnes & David J. Olvera (2018) Joint Position Statement on Degree Requirements for Paramedics, Prehospital Emergency Care, DOI: 10.1080/10903127.2018.1519006

2.     Illinois Central College. www.icc.eduhttps://icc.edu/academics/catalog/associate-in-science/associate-in-science-degree-requirements/.  Accessed January 5, 2019.

3. Programs CoAEMSP. Find a Program 2018; Selected Paramedic, Accredited, All States and Provinces with boxes checked for associates, bachelors and masters compared to all chek boxes (inclusive of certificate and diploma). 2019. Available at: https://www.caahep.org/Students/Find-a-Program.aspx. Accessed January 5, 2019.

4. Fire Service EMS. www.fireserviceems.com. http://fireserviceems.com/joint-position-statement-opposition-to-proposed-degree-requirements-for-accredited-paramedic-programs/. Accessed January 7, 2019.





PRO: A Good Build Starts with a Strong Foundation

by Hawnwan P. Moy, MD FAEMS

I’ll start by stating that Dr. Kazan and I are friends.  Like all traditional friendships, we embrace our similarities and poke fun at our disagreements.  I dare not break tradition. While Dr. Kazan MD FACEP FAEMS #SpoiledinCali (sorry @PEMEMS) believes that requiring further education for paramedics is all for naught, I believe this is a crucial step in creating a better trained, more prepared and well-rounded paramedic. 

Critical thinking is essential to practicing excellent paramedicine.  What defines a great paramedic is NOT what procedures they can do, but how they think.  No offense to any 12-year-old, but we can teach any 12 year old how to intubate.  But to teach a 12-year-old when to intubate, when to anticipate a bad airway, or whether they should intubate requires critical thinking.  “Critical thinking is that mode of thinking — about any subject, content, or problem — in which the thinker improves the quality of his or her thinking by skillfully analyzing, assessing, and reconstructing it.” [4] Paramedic educators have the responsibility to teach the fundamentals of paramedicine.  Yet they rarely have enough time to build a foundation for critical analysis. This is where creating education requirements for paramedics is paramount.  

In order to engender critical thinking, a solid foundation must be established beyond high school education.  A foundation of critical thinking has to be broad to expose the mind to different ways of thought. So while I agree that linguistics (I can’t believe you took Latin @Clayton_Kazan), psychology (Maslow’s Hierarchy of needs is important, but listen to Ginger Locke’s Hierarchy of needs here!) and art history (pyramids, schmyramids...The Great Wall is so much cooler) have a low correlation to actual clinical medicine, the underlying benefits of challenging the mind to think differently, to understand the world from different viewpoints, to learn from history’s lessons, to understand different ways to achieve the same goal, provides an invaluable foundation to critical thinking.  

 Let me utilize someone from Dr. Kazan’s beloved California as an example, Steve Jobs.  Yes, Steve Jobs didn’t finish college. However, he did enroll in at least a year of college where he had to take general basic courses that had nothing to do with computers.  One such course was calligraphy (see Steve Job’s Standford Graduation Speech).  In the 70’s, the world of computers only had Atari-like block font.  Yet it took someone like Jobs who had experience in calligraphy, an appreciation for design, and the critical thinking to apply calligraphy to computers to revolutionize the world of technology.   Just look at this very webpage you’re reading. All those different fonts evolved from Steve Jobs’ influence. As he said, “…you can’t connect the dots looking forward; you can only connect them looking backward.  So you have to trust that the dots will somehow connect in your future. You have to trust in something your gut, destiny, life, karma, whatever.” So while I agree that taking general education courses may have little relevance to the field of medicine, they do create a foundation for critical creative thinking and may even create unique solutions. 

On that note, I do not believe that an associates degree is a dead end, but a beginning of a journey.  Dr. Kazan is correct in that the sources he cited, only 1.6% of programs currently offers Bachelor’s degree.  Technically speaking requiring a Bachelor’s degree would provide a stronger base, but for those who face real-life challenges where time is not a luxury, a two years Associate’s degree is a good start.  30/50 states have some sort of guarantee of transferring credits to a Bachelor's degree.  

Nonetheless, Dr. Kazan speaks some truth.  Encouraging a love of learning in your paramedics and paramedic advancement are key to job satisfaction.  I think it is great when paramedics gain additional medical training beyond paramedicine to become a physician assistant or physician, but not all paramedics want to leave the job - and we don’t want them to.  I know plenty of paramedics who are in the field because they love what they do and don’t want jobs that take them within four walls. I agree paramedics should have a career ladder. However, that ladder should be based not only on experience but education.  Just look at our fire brethren who require further education - a Bachelor’s (or Masters!) in Fire Science-for advancement in their career. You’re right Dr. Kazan, paramedics do need a carrot and our paramedics deserve to be paid more for their work. That can be justified by a required education needed to become a paramedic.  Nurses did it with their profession. [3,8]  Why can’t we?  

To follow up on the supposed financial catastrophe that the number of paramedics will fall precipitously due to education requirements, let’s look at other states who have paramedic education requirements, Kansas and Oregon1.  Those states have enacted education requirements and guess what?!?!  EMS continued to march on. Yes, change is scary. We have every right to be anxious.  Maybe this will initially affect the number of paramedics enrolling in our systems. Yet looking at these two states as examples, proves that a possible decrease in paramedics will not last indefinitely.  

In the end, Dr. Kazan and I are two sides of the same coin.  Despite our differences (one of the main ones being I’m better-looking :P), we believe in education and care deeply for the future of paramedicine and paramedics.  He works in a successful EMS system and is one of the grittiest, dedicated EMS medical directors I know. I do not fault his comments. In fact, I encourage it. I thank him for it.  It creates thoughtful conversation, a lively debate, and dare I say it a valuable viewpoint that forces you, the reader, to critically think about your own thoughts on education requirements for paramedics.  See what I did there? So, Dr. Kazan, I raise my glass to you and I just have one thing to say to your impending retorts. I know you are, but what am I?

To hear a lively debate about this very issue, check out our PEC podcast discussion here!


References

  1. Caffrey, Sean M., et al. “Joint Position Statement on Degree Requirements for Paramedics.” Prehospital Emergency Care, vol. 23, no. 3, 2018, pp. 434–437., doi:10.1080/10903127.2018.1519006.

  2. JoshuaG. “Steve Jobs Stanford Commencement Speech 2005.” YouTube, YouTube, 6 Mar. 2006, www.youtube.com/watch?v=D1R-jKKp3NA.

  3. Kutney-Lee, Ann, et al. “An Increase In The Number Of Nurses With Baccalaureate Degrees Is Linked To Lower Rates Of Postsurgery Mortality.” Health Affairs, vol. 32, no. 3, 2013, pp. 579–586., doi:10.1377/hlthaff.2012.0504.

  4. “Our Concept and Definition of Critical Thinking.” Our Conception of Critical Thinking, www.criticalthinking.org/pages/our-conception-of-critical-thinking/411.

  5. “PEC Podcast.” Prehospital Emergency Care Podcast - the NAEMSP Podcast, pecpodcast.libsyn.com/pec-podcast-6.

  6. “Prehospital Emergency Care Podcast Ep. 58.” Prehospital Emergency Care Podcast - the NAEMSP Podcast, pecpodcast.libsyn.com/prehospital-emergency-care-podcast-31.

  7. “Resource Title:50-State Comparison: Transfer and Articulation Policies.” Education Commission of the States, www.ecs.org/transfer-and-articulation-policies-db/.

  8. Smith, Linda S. “Said Another Way: Is Nursing an Academic Discipline?” Nursing Forum, vol. 35, no. 1, 2000, pp. 25–29., doi:10.1111/j.1744-6198.2000.tb01175.x.

BSI, Scene Safe: Debating the Personal Protective Equipment of Today

by Noah Tyler, EMT-P

Peer Review by Aurora Lybeck, MD

We’ve all seen the news stories and videos: Mass shootings, violent gang activity, and targeted assaults on first responders are on the rise.  Fortunately, bullet and stab resistant vests have been effectively protecting most of our law enforcement officers for years.

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Today, we see EMS personnel wearing ballistic armor to every call.  But wait a minute… we’re medical people, not one of those proverbial sheepdogs who protect the flock.  Is this overkill for EMS?  Are we addressing a blatant disregard for scene safety with a quick fix instead of education?  Are “tactical paramedic” ambitions jousting towards Don Quixote’s windmills?  Aren’t most violent or weapons-related responses contained and controlled by law enforcement long before paramedics step foot on scene?  They are in Lubbock, Texas… we call it “staging” in the area.  So why are we wearing ballistic vests for body armor?

A little history: A few years ago, our hospital-based EMS recognized the increasing rate of violence within Lubbock and began considering options to protect our EMS personnel without impeding patient care.  Our agency acknowledged that just like in the rest of the country, there were shootings, stabbings, and mass casualty threats within our city of nearly a quarter of a million people.  That said, we also had a strong, dedicated police force to keep us safe and we worked well together. 

Now jump ahead to 2018 --- Our hospital purchased ballistic vests for every field EMT, paramedic, and supervisor within our service.  It was not a strategically-planned and targeted weapons attack that brought about this change in protection.  There was no conflict or concerns about police protection for our staff.  Instead, it was the enormous rise in synthetic cannabinoid and bath salt abuse from 2013-2017 and the subsequent rise in calls for excited delirium, where we were confronted with patients who could not even be controlled with our standard sedation drug, Midazolam (Versed).  Small foil packets of tainted grass and other dried vegetation - something innocently named “Scooby Snax”, “Breeze”, or “Mr. Happy Potpourri” - sold for just $5 at the local smoke shop were presenting risk of serious injury to not only patients, bystanders, law enforcement, but our EMS personnel as well. 

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Intramuscular ketamine quickly became our medication of choice to protect and tame the patient, as law enforcement was not always deployed for our scene safety needs as these 9-1-1 calls may have come in as an unknown medical, vomiting, seizures, or check welfare.  We saw a need for ballistic vests to protect ourselves from the weapon threats usually involved in these patient encounters. 

With multiple raids on smoke shops, improved legislation on synthetic cannabinoid sale and prosecution, and targeted efforts by Lubbock police working with state and federal agencies, the synthetic epidemic finally tapered down.  But Lubbock’s population was increasing and as with any growing city in the US, the rate of violence was on the rise.  Two of our EMS stations were shot at in a single night – fortunately, no one was injured.

Improved dispatch algorithms for EMS and law enforcement evolved and police were responding to the suspected weapons calls and now more potentially-violent excited delirium patients.  2018 seemed safer, so again, do we really need all of that expensive body armor?

The ball was already rolling through the finances department and UMC approved the purchase of the armor.  Our EMS staff started wearing the lightweight ballistic vests for those just-in case encounters with a violent, armed patient or questionable scene.  While the past history of violent events led to body armor use, we soon discovered a previously-unrecognized benefit in our daily meat-n-potatoes type responses.

One of our frequent 9-1-1 requests is the “check welfare” call where a friend or family member has not heard from an elderly parent, college-age son, or friend with an extensive medical history in several days.  Most of these concerned callers are living in another city or state and can’t just drive and check on the individual.  Or, a home medical alarm company contacts EMS for an elderly person who has fallen and is unable to stand back up.  These encounters are usually not a safety threat and we prefer to preserve our law enforcement resources for more pressing needs. 

There is something unique about Texas though, and particularly in the western part of the state: It seems that just about every man, woman, and child owns a gun.  Yes, even in Texas, a child can legally own (but not purchase) a gun.  Most individuals are responsible gun owners, and it’s not uncommon to walk into a home and see a locked steel gun safe weighing hundreds of pounds sitting in a corner of the bedroom.  But, Texas paramedics and EMTs don’t suddenly run out of the house screaming, “scene safety!” --- in contrast, it usually spurs a conversation about the gun collection and an exchange on the latest wisdom about hunting rifles.  Having trouble with small talk for assessing decisional capability?  Start with a few words about the upcoming deer season or wild hogs tearing up the farm fields and you won’t have to say a word.  Your patient will do all of the talking.

So, going back to body armor: Are these hunters trying to kill our paramedics?  Absolutely not.  Instead, the ballistic vests find their value in the unexpected encounters.  For example, we responded to a “check welfare” call where the out-of-state son was concerned about his father with recently-diagnosed mild dementia.  His father is highly-functional and lives at home with occasional visits from friends and community health partners.  The son frequently calls his father to check up on him, but this time he did not answer the phone so the son called 9-1-1.  We arrived on scene and knocked on the door, which happened to be unlocked --- another west Texas behavior.

While entering the residence, we announced ourselves as EMS and heard no response, so we cautiously continued into the home.  As we entered the hallway, a frail elderly man was found frantically rolling his wheelchair down the hall.  His eyes were fixated on the doorway behind us and he wouldn’t respond to our questions.  He didn’t seem to understand our role or purpose and instead was intent on pushing past to the door behind us.  As I glanced behind me, I saw exactly what he was driving towards: A double-barreled shotgun resting on the door post.  He was exerting every effort towards getting his hands on that weapon because in his mind, two intruders were in his home and they were the threat. 

Dementia is a horrible disease.  His case was supposed to be mild, but when coupled with an acute urinary tract infection that altered his mental status, he was doing exactly as we should expect him to do.  He was protecting his life and his home, responding instinctively as any normal Texan would confronting a home invasion.  I was able to secure the weapon before he reached the doorway and eventually calmed him, but what if his hands got to it first?  What if shots were fired just as we entered the doorway earlier?

Another response involved a call for diabetic complications out in a more rural area of the county.  In this case, we arrived to find the front door wide open and obtunded patient sitting in the hallway.  His blood glucose level was 30 mg/dL, and while occasionally agitated, he didn’t appear to be an immediate threat.  Just your standard-issue hypoglycemia call near the “passed out” stage with a known diabetes history.  While administering the IV dextrose solution (D10W), I noticed that house was in disarray, in need of a lot of repair, and it looked like candy was scattered across the floor --- he must have been aware that his blood glucose was dropping but couldn’t fix it on his own soon enough.

My partner was looking for a medical history or medications list in the house, and he stepped out of the nearby bedroom saying, “You need to see this”.  We changed places and as I walked into the bedroom, I saw well over 80 bullet holes in the ceiling, walls, and furniture.  Handguns and rifles were strewn across the bed and floor.  I immediately requested law enforcement and as they arrived, the patient regained most of his mental status.  He was calm, confused about our presence, but then remembered: He knew his blood glucose was dropping and dropping fast.  Decades of his difficult-to-control diabetes also taught him that he’d soon lose his ability to make sound decisions and didn’t want to harm anyone.  He emptied his weapons, but by that time, his brain chose the most unconventional method. 

Guns and other weapons are not the only threat.  The human body is a formidable weapon in itself.  The ballistic vests have protected our personnel from injuries that previously were once accepted as “part of the job”.  Physicians, nurses, and emergency center staff know these risks and injuries well.  Hypoglycemia, stroke/brain injury, medication effects, or drug/alcohol abuse can turn an otherwise pleasant individual into a kicking, screaming, biting, fighting weapon of pain.  Trying to bathe a cat would be a breeze in comparison.  The ballistic vests perform remarkably well in blunting the kicks, fists, and even bites towards our core.  These are the potential injuries that can be most disabling for us on scene and risk our safety. 

I offer the experience and scenarios not to boast on “war stories” or to instill fear towards every patient encounter.  But as we’re taught in our EMS classes and usually soon forgotten, every response has a potential for violence – intentional or not.  Complacency can be fatal, but at times we also face situations where the risks will never be discovered until it’s too late. 

The individual decision to use body armor is a personal one.  Some of our personnel see it as important as donning gloves with every call.  Others bring their vests into the ambulance every shift as required by policy, but only wear them during known weapon-involved calls.  While every paramedic or EMT is entitled to their own decision to use or not use their vest, it must be an informed one.  Body armor’s role is more than protection from bullets and knives during a targeted attack.  It’s the everyday calls: The daily hypoglycemia response, substance abuse, brain injury, or even delirium from untreated acute illness. 

As experienced providers and mentors, we should instill a culture of safety that embraces the wisdom offered by author and speaker Simon Sinek: “Leadership is absolutely about inspiring action, but it is also about guarding against mis-action.”  The action is convincing decision makers that body armor investment for EMS personnel is necessary, while mis-action leads us to assume it’s only valuable for known weapon calls.  Consider alternative scenarios to protect yourself and your partner from preventable, disabling injury that in just a moment of time, could destroy your career and livelihood if not life itself.

 

Response & Commentary

Mark Philippy, EMT-P

I read with great interest the article regarding the wearing of ballistic and protective vests in EMS.  This is something of a timely topic, as one of the committees I serve on in New York has this on our agenda as an item of discussion.  We have wrangled with the notion of creating a best practices document to help EMS agencies in our state address the need for, and deployment of, ballistic vests.  Some areas of the state have been able to move ahead in various ways to provide partial deployment, mostly of threat-level four plate-carrying vests for tactical environments, but few have delved, officially, into daily-wear vest systems.

First, I’d like to be transparent about some of my own biases and experiences. 

Among the proudest and happiest days in my life were the first day I put a bullet-resistant vest on – my first day out of the police academy, and the last day I took it off – the day I retired from police work.  For 23 years I wore the vest religiously, even though, at the time I started in 1990, it was not required for daily wear as a police officer.  There were those in my department who resisted mandatory vest wear, despite the fact that they carried a firearm into every single encounter they ever had with a citizen – a weapon that could potentially be turned against them.  Yet by the time I left, it was not even a second thought – the vest went on before the uniform.

Having said that, I hated it, too.  It was hot, bulky, stiff, and any time I got into any kind of tussle, I spent a good 20 minutes trying to get it seated right and getting my uniform tucked back in (I’m a bit challenged in that regard, I admit).  When agencies such as the Chicago Police Department first started testing the outside vest carriers that looked like uniform shirts, I cheered, hoping it would someday make it to my department (it didn’t, at least not before I retired).  I worked bicycle patrol for a number of years and I lost more weight from sweating than I did from the exercise.

Now look at the EMS side of things.  In the time that I worked in the City of Rochester, my ambulance had been shot at twice, I had been punched, kicked, bit, and threatened with stabbing, all the while (stupidly, I agree) walking right in with the local police on things that today, we’d stage down the block for until cleared into the scene.  At the same time, I scoffed at those medics who wore bullet-resistant vests.  Why?  Because it was my observation that those who did, immediately seemed to get into more trouble than they had before.  Likewise, it seemed the people who got into trouble were the first ones to put a vest on. 

By trouble, I mean those few (and we all know them) who managed to rile up every patient with a mental health issue, seemed to draw crowds around themselves at inopportune times, and got more than their fair-share of personnel complaints.  These were often the folks whose chest seemed to puff out a little too much, and who seemed to feel they could take on the world single-handedly.  I worried for them, and about their partners, all the time.

Fast-forward to 2019.  I cannot agree more with the author that things are violent and dangerous.  I don’t know that I would agree they are any more so than 30 years ago, when crack cocaine was rearing its ugly head, and excited delirium was still called “cocaine psychosis.”  But we are more aware, and we are busier, and so are our law enforcement partners.  So the danger may be more visible, in-your-face, not to mention we may be much more aware of it through social media and information sharing.  So where is my concern?

First of all, what is the purpose of wearing ballistic or edged-weapon protection?  I’m loath to bring up what events transpired in my region some not-so-distant years ago (particularly since it involved a friend and colleague), but in that instance, ballistic vests would not have been of benefit.  Yet immediately after that incident, fire departments around the region and the country started talking about buying ballistic vests.  My question then as now is, why?  When will you wear them?  Will you put them on under your turnout gear?  Will you wear them on every call all the time?  If you’re a career firefighter or EMS provider will you wear it all the time, over or under your uniform?

What does that mean for you, and for your practice?  Because I see a good number of people (and police officers now, which irritates me to no end) wearing outside-carry vests festooned with pockets and carry points.  So the uniform is no longer the first thing a patient sees.  It’s the ballistic vest.  We might no longer present the image of primary caregivers, but perhaps be easily mistaken for police.  They are bulky, catch on things, and yes, you can take them off, but they still get hot when they’re on, which for practical purposes, should be most of the time.

Let’s talk about under-uniform vests then.  For threat-level II or III (and their progeny, IIA and IIIA) vests, under the uniform wear makes sense.  It is less intrusive, less visible, and depending on what style is purchased, can be integrated with stab-resistance and water repellency.  They are also hot, stiff, and make movement about inside an ambulance, or incident scene, challenging.  Uniforms will be untucked and it will be annoying, but you can work through that.  The thing to watch out for is the feeling of increased protection morphing into a sense of improved invulnerability.  And thence, potentially, increased risk-taking.

What else?  Cost.  Who bears the brunt of that?  The author was fortunate to have a hospital system than was progressive and financially positioned to purchase these, but what about municipal, commercial, not-for-profit, and volunteer agencies?  Medicare reimbursements being what they are, we are all holding on by a thread just to upgrade aging cardiac monitors and keep ambulances running.  While taking care of our people should be foremost in company leadership’s mind, does that extend to providing this level of protection?

In the law enforcement world, the National Institutes for Justice realized early on that the benefit of protective bullet-resistant vests warranted federal subsidy.  For every year that I was on the job, my vest was partially, and in some cases wholly, funded through federal grants.  Are those same grants or funding streams available for fire and EMS personnel?

The author points out that it is important for people to make informed decisions about wearing vests.  So let’s talk about some limitations and considerations.  If you have to buy a vest, I return to the question of what threat level?  What are you protecting against?  Small arms, rifles, close range, far away?  Of much more concern to me is, frankly, edged weapons.  However most bullet-resistant vests do not protect adequately from stabbing, thus Corrections’ use of SpectraTM and similar materials in stab-resistant vests.  There are those manufacturers who incorporate both (I had one for Bike Patrol) but they are increasingly expensive.  So cost and type of protection are key factors in this decision.  And I submit few EMS providers, let alone agency leaders, are knowledgeable enough to make these choices, so if you are considering it, best do your research or find yourself a subject matter expert to help.

What about moisture?  KevlarTM and TwaronTM fabrics, which make up the bulk of bullet-resistant vest manufacture, are susceptible to becoming soaked through, at which point they lose some or most of their ballistic integrity.  This was one reason I chose to use a combined Spectra/Twaron vest for bike patrol.  EMS providers are often in the rain, and sweating in cramped, semi-conditioned environments, so how effective will your protection be when the time comes?  As a police officer, I had the luxury of being able to go back to my station and swap carriers, keeping my car air conditioned, and making darn sure I wore a raincoat when I was outside for a period of time (most of the time, anyway).  That has not always been the case as an EMS provider.

What about training for the intended user?  How much training do EMS providers have in the limitations, care, and replacement of bullet-resistant vests?  I was acutely aware of the fact that I had a huge open area under my armpits that was not protected.  It was never so apparent as when I wore a short-sleeve shirt in changing weather, and could feel the cold air rush up my arm while in a standard bladed stance addressing a potential adversary.  Do EMS providers know how to stand to maximize their ballistic protection?  Do they know how far down the vest goes, or doesn’t go, to protect their abdomen, and their sides?

Up to this point I’ve somewhat danced around the issues of why we should wear the vest, and written about the challenges and considerations.  I don’t think anyone can argue, with any kind of standing, that there is not a place for bullet-resistant and edge-weapon protective vests in the EMS environment.  I do believe that there are a good number of considerations that must be addressed before anyone lays a hand on one, or picks up the thread to start obtaining them.  The author makes excellent and valid points about the ancillary protective benefits of the vests, from blunt attacks to motor vehicle crashes.  I know of a friend who avoided a serious spinal injury during a crash because his ballistic vest acted much like a KED.  But when we talk about “lightweight ballistic vests,” let’s make sure we’re talking apples and apples, and not Kevlar and Spectra.

Finally, I agree with the author that there is a particular lack of situational awareness (Oh, how I hate that term!) in EMS today.  It is getting better, and there are a number of good programs across the country trying to improve not only provider safety awareness, but EMS defensive tactics (shout out to Kip Teitsort and the folks at DT4EMS).  I posit that we should be spending our hard-won funds in this area before we invest in protective vests.  Then, and only then, can we fully understand the threat, and address the use of protective equipment effectively.

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EMS MEd Editor, Maia Dorsett MD PhD (@maiadorsett)

ET3: Perspectives of a Paramedic and PA

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As both a Paramedic and an Emergency Medicine Physician Assistant I commend those who made the announcement of the Emergency Triage, Treat and Transport (ET3) payment model a possibility.  This is by far, one of the biggest steps in the advancement of modern EMS.  This historic payment model could finally bring an end to the “you call, we haul” motto that has plagued EMS since its inception.  One of the most beneficial sections of this new payment model is that it allows current EMS providers the option to transport to hospitals, urgent cares, primary care offices, or, when necessary, to “stay and play”, allowing EMS professionals to provide treatment in place with qualified healthcare providers, via telehealth when necessary.  While I feel this is beneficial to the EMS community as a whole, it begs the question what does this mean for the day to day provider?

As a paramedic, I am thrilled that this may curve the overwhelming amount of calls that do not require trips to the emergency room.  I can recall many trips for simple requests, such as  prescription refills, cast removal, cold and cough symptoms, or suture removal that would be placed in triage and often still be sitting in the same seat when I returned with the next patient.   I often thought to myself that there has to be another way - that trips to the ED were not always the answer, but if only we could take them to their primary care office, or utilize technology to communicate with their provider.  Then there were the many calls I would run that would end without any transport at all.  Often there would be treatment provided on scene, but then would come the refusal of transport.  For paramedics, these are also some of the highest risk refusals, but that’s another topic on good documentation.  I feel that the lack of access to healthcare was the basis of many non-transport calls, people whose only reliable way to see a provider was to call 911.  A perfect example is the underinsured patient with diabetes.  Patients who needed their blood sugar checked, were hypoglycemic, received treatment and when alert again, would sign the refusal of transportation form.  These trips would often end with a call to a medical control provider but would yield no payment to the EMS service.

For years, we have fought to be recognized as a valued part of the medical team, and this new service model has the possibility of being a giant leap for EMS kind.  Not only does this require the implementation of quality metrics for EMS service but provides paramedics a platform to shine.  EMS providers are now able to highlight their mastery of pre-hospital medicine, human pathology, knowledge of medical protocols, and dedication to patient care, no matter where that care may be delivered.  This is our chance to prove to the world that paramedics and EMTs are capable of quality, evidence based prehospital medical care, and not just basic transport.  With increased power comes greater responsibility and thus the responsibility of advanced education now falls onto the shoulders of my EMS family.  Advanced education, in the form of college degrees or specialty certification, is paramount for providers making definitive decisions for patients, and as professional healthcare providers, we should not fear this change.  At this time, paramedics are faced with the ability to be valued members of the medical community, it is time we seize this moment to bear the responsibility, to ourselves, our patients and our communities.

 As a PA, the ability of alternative (more appropriate) destinations brings the obvious benefit of a decompressed ED waiting room.  Many of my patients are there because they have no other avenues to see a provider.  This new payment model is a way to allow for a more efficient and effective pre hospital triage, and subsequently improved treatment of the 911 patient.  Paramedics in the field would now be able to utilize urgent cares and primary care providers to facilitate the most appropriate level of care, while having the ability to be paid for the services they provide.  It also allows for a closer collaboration opportunity between in-hospital providers and pre-hospital providers via additional resource utilization, such as telehealth.

 Overall I think this is a great leap in the right direction for EMS and the future of our profession.

This new reimbursement model creates standardized benchmarks for the EMS providers.  The goal of which is to improve the quality of care, while decrease the overall cost of healthcare.  It is our responsibility as EMS providers to show that we are worthy of this opportunity and seize it with overwhelming care, compassion, and efficient care for our patients.  It is also our responsibility to make assure we have the education, knowledge and the skills to advance the EMS profession and allow ET3 to be the giant leap forward EMS so desperately needs.  This may also allow for new relationships between EMS providers and hospitals in the region to be formed. It is my hope and belief that this announcement will improve the effectiveness and efficiency of prehospital medical care and allow the continued growth of MIH programs nationwide.

 

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Can ET3 push the field of medical direction to where it should be?

by Melissa Kroll, MD and Hawnwan P. Moy, MD

 Introduction

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The Center for Medicare and Medicaid Services’ (CMS) passage of the Emergency Triage, Treat, and Transport model (ET3) not only recognizes EMS as part of the health care system but is a significant step in developing a mature EMS system.  But what does this mean for the EMS medical director?  It is unlikely that we will be notoriously ignored like the 1973 EMS System Act of old. But will it help propel the office of the EMS medical director from an often unpaid (or underpaid) position struggling to fulfill the needs of the EMS system to a widely recognized and valued component of the healthcare system? Before we attempt to answer these questions, let’s review what the ET3 model hopes to establish.

What is ET3?

A new model for prehospital care that allows for increased flexibility and efficiency.

 The ET3 Model is a voluntary, five-year payment model aimed at increasing the flexibility and efficiency of prehospital systems. Essentially, with this trial period, CMS has agreed to pay EMS services for the following:

 1) transport an individual to an emergency department or other destination covered under the regulations

 2) transport to an appropriate destination (such as a primary care doctor’s office or an urgent care clinic)

  3) or provide treatment in place with a qualified health care practitioner, either on scene or connected using telehealth.

ET3 hopes this model will encourage cooperative agreements between local EMS systems and surrounding dispatch systems, hospitals, clinics, local governments, etc. This system also allows for increased accountability of systems through monitoring of programs through specific QI/QA metrics.

 

Feb 14, 2019. Emergency Triage, Treat, and Transport (ET3) Model. https://www.cms.gov/newsroom/fact-sheets/emergency-triage-treat-and-transport-et3-model

Feb 14, 2019. Emergency Triage, Treat, and Transport (ET3) Model. https://www.cms.gov/newsroom/fact-sheets/emergency-triage-treat-and-transport-et3-model

 What does this mean for the Medical Director?

Not just a “sign here Doc” system.

 If we ask any lay person what a good fire or police chief can do for their community, they may not answer with specifics, but they implicitly understand the role of such leadership positions.  If you ask them what a good EMS medical director can do for their community, you’re probably going to get a blank stare. Perhaps we have been too complacent in advertising what it is that a good EMS medical director can do for the EMS service and community.  Let’s take the opportunity now to highlight what a good medical director can do to ensure the success of ET3 and improve community health.   

  1. At the heart of it all, a medical director is a physician first.  Physicians have duty to ensure that the patient remains at the center of the system -an active medical director ensures that the patient is always number one.

  2. With the ET3 expansion of EMS systems there needs to be increased involvement and oversight by medical directors. As experts in the medical direction and having an intimate knowledge of how hospital systems operate as physicians, medical directors are a required leader for connecting the hospital, EMS systems, local governments, and other entities in a collaborative partnership.

  3. Many systems will be creating new processes, such as 911 triage, processes for determining optimum patient destination and who can best be treated in the home. New protocols requiring in-depth physician input will need to be developed, trialed, updated, and re-trialed.

  4. Constant quality improvement and quality assessment will need to be completed.  Continuous quality improvement, quality assessment, and timely feedback by the EMS Medical Director are required to ensure the safe medical care of the patient.

  5. Results will need to be published, presented, and discussed allowing for programs to learn from each other. Medical directors will need to be present, both in discussions at a higher level, but also on a ground level where practical application occurs to ensure a smooth maturation of the EMS system for the safety of our patients and still receive valuable data.

  6. ET3 allows for treatment to occur in the home in coordination with a qualified healthcare practitioner. Behind every prehospital provider that completes an in-home evaluation, there is the medical director who has provided focused, up to date education, training, and consistent quality assessment.

  7. In order to provide treatment in place, there will need to be a conversation with a qualified healthcare practitioner. For many systems, this will be a conversation with their medical director. This medical director will need to be accessible for consultation.  

 As a subspecialty of medicine, EMS should optimize the opportunity provided by ET3 to move EMS medical direction from “what is” to “what should be”.   We would be remiss not to recognize that unfortunately the term “medical director” currently describes a wide range of physician roles – from rubber stamp signatures on paperwork unknown personally to frontline providers to those who are involved in all aspects of patient care provided by an agency. The reason for this spectrum in medical direction is multifactorial.   EMS as a medical subspecialty is rather young, although EMS subspecialty fellowship training is working to build a larger base of involved EMS physicians.   At the state, agency or regional level, EMS medical directors are often excluded from decision-making. In addition, many medical director positions remain un- or under-funded and full time or majority time EMS physicians are few among us. Reimbursement rates for medical direction (the cost) largely do not acknowledge the value that an involved medical director can bring to the healthcare system.  This will be even more evident as we consider treat in place and alternative destinations which will better align patient needs with the current financial incentives of the healthcare market. 

 

The Future

The pilot will end. What needs to happen to make the future successful?

 Will a change in reimbursement structure such ET3 be the nidus to move medical direction to where it should be?  We think it can.   Fundamentally, systems that have relied on rubber stamp physicians will not be able to function in this expanded model.   EMS physicians will need to step up to both this challenge and responsibility.  Hopefully this new model provides a financial means to support them in doing so.

The ET3 is a 5-year pilot project. Which means it will end. In order to make this a sustainable option in the future, medical directors will not only need to be careful trackers of data, allowing for cost analysis of the impact, but leaders who demonstrate wisdom, integrity, and the expertise required to navigate the unique world of healthcare both in and out of hospitals while keeping an ever-vigilant eye on maintaining patient-focused care.  Let’s become the EMS Medical Directors we all strive to be.  

 

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Mentorship Matters.

By Christopher Galton, MD NRP

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When we start our EMS careers, the path forward seems easy.  You want to run every great call there is to run and you tell yourself that the path to becoming the best paramedic or EMT is through sticking tubes into people, covering up holes in the chest, and driving fast down the road.  After a few years, most of us realize that longevity in this career comes from being satisfied with the less sexy calls.  I was recently standing around with a group of EMS colleagues and we were talking about how the people that stay in this career don't depend on the drama to keep them going.  This discussion got me thinking about the value of mentorship.

My three.

Three very important people in my career shaped the paramedic and physician that I am today.   These three people helped guide me toward a healthy EMS career and are a large part of why I continue to work in EMS even though the cost to my personal life is frequently high.

My first medical director was one of the early Denver General paramedics.  After a long paramedic career, he went on to be a very successful emergency physician and eventually the EMS medical director of Colorado.  Arthur Kanowitz was the physician that introduced me to the idea that EMS patients don't need to suffer.  He believed that EMTs and paramedics had the ability to make positive impacts on the lives of every patient they interacted with.  In the late 1990s, the mindset in EMS was that pain medications were potentially dangerous and should be used in only the worst cases.  Dr. Kanowitz challenged that idea and pushed back against many powerful and prominent physician EMS leaders.  He did research on the use of prehospital analgesics and demonstrated both safety and efficacy.  He took that information to his colleagues and fought for what he believed in.  His passion for looking past the "emergency" part of what we do and treating ailments without regard to circumstance, continues to change EMS minds across the country.  Art is the reason that I am so passionate about treating pain and the reason that I will not stop preaching his vision until our collective performance is at a high level.  

The first "ALS chief" I ever worked for was another early Denver General paramedic named Jeff Forster.  Jeff was a legend in Denver as one of the best paramedics they ever turned out.  He was the type of guy that people turned to when things were going bad, and he was the paramedic that every other paramedic wanted to be, including a baby paramedic named Galton.  He was a legend for a variety of reasons, and he taught me an immense amount about not only EMS, but how to treat employees, how to lead by example, and the meaning of being a leader instead of a manager.  One day, when the world was blowing up, he hopped on an ambulance and we went on a call together.  After the call, he cleaned the back of my ambulance better than it has ever been cleaned before.  I told him that I was happy to clean up after myself and asked him why he not only cleans the floors of my ambulance so diligently, but still rides at all hours of the day taking any call that came his way.  He looked me square in the eyes and said one of the most impactful things I have every heard.  He said "never ask someone else to do something that you are not willing to do yourself."  He led by example, and of all the great people I have met over the course of my professional life, he stands out as someone that worked hard everyday to earn, and then maintain, the respect from those around him.  It did not matter whether they were the chief medical director, entry level paramedic, or housekeeping staff cleaning up at the end of the day.  He was always happy to help anyone do anything just to demonstrate that he valued them as much as we valued him.  To this day, if he called me for help, I would claw my way through a brick wall to help him without even a thought.  

Finally, I want to end with the person that had the most significant impact on the way I operate as a paramedic today.  Thom Hillson (aka Thom Dick) is a columnist for multiple different EMS magazines and journals.  He has written books about caring for patients and fellow EMS colleagues.  To this day, I have never met another human being that cared more for every other living sole in this world.  I started off my EMS career working the night shift for eight years, and I loved it.  One of the drawbacks of the night shift is this creeping cynicism that becomes suffocating because of the typical clientele that make up your regular call volume working in an urban/suburban EMS system.  I had the pleasure of working with Thom for 4-5 years early in my career when I was an impressionable paramedic.  I remember thinking he was a wise old sage that had been everywhere and seen everything.  The two of us developed a wonderful relationship and he ended up writing me the best letter of recommendation for medical school that I have ever seen.  

One day Thom pulled me aside and asked me to go grab lunch with him and he was the type of guy that you wanted to be around all the time, so I was thrilled.  While we were out eating, he asked me if everything was all right.  Initially I thought this was just banter, but he continued to say that he was worried about me.  He had noticed a deterioration in my typically positive, upbeat attitude.  I told him about being a little depressed lately because of some bad outcomes and how I was likely going through a period of burn out, but I really just tried to blow it off.  He did not let up and we proceeded to have lunch weekly for the next few months.  During those lunch meetings, Thom and I talked about a wide variety of things, many times not mentioning EMS at all.  It was at one of these meetings that he used a phrase that has stuck with me to this day and is ever present when I am working in EMS.  We were talking about customer service in EMS and why I was worried that I stopped caring about my patients.  He specifically challenged me by saying "why not."  What he meant by that was much more complicated than I initially appreciated.  He was really asking why I was not willing to go the extra mile anymore to take care of people and why was I staying in this job if that was the case.  This was the point that I realized that a career in emergency services is not about you, it's about the people that need you.  This is when I finally understood that being an EMS professional was not about the person that could put an endotracheal tube in upside down with a patient stuck in a car that was hanging off a cliff in a snowstorm.  It was about knowing that someone is calling 911 because they need your help.  That might be taking them to the hospital because they are having chest pain, but it also might mean helping them clean up after falling on the way to the toilet.  You don't get into this career because you want to help an elderly person change out of urine soaked clothes and then start a load of laundry.  You do stay in this career because you realize that those are the patients that need your help the most and you are the person that they turned to in their moment of need.  I would encourage you to take Thom's advice and ask yourself "why not"if you ever have a question about customer service and the needs of the citizens that we are charged to care for in their time of crisis.

 

Finding the Right Mentor

My mentors are a large part of why I have been able to achieve professional success and reach goals that I would have thought were out of reach.  Most high level leaders at Forutne 500 companies insist that their employees have mentors and embrace those relationships while accepting the lost time required to build them.   They know that they will get more out of their employees in the long run when mentees have goals, purpose, and guidance. 

I’m sure you have all heard the phrase “it’s not what you know, it’s who you know.”  Your mentor is the “who” in that expression that is capable of opening doors and making connections on your behalf.  My mentors have frequently made phone calls, sent emails, and made personal introductions to connect me with the right people.  That is how business is done and you should not be embarrassed to take advantage of those connections. 

Hopefully I sold you on the value of having a mentor in your professional life.  The first hurdle is finding the right mentor for you.  I think you need to start by identifying the personality traits that you want to emulate.  In EMS, those traits might include unconditional empathy, a calming demeanor, a driving desire to learn, or an altruistic belief in serving the community.  Your mentor should be someone who has established a benchmark for you to work towards.  

The second step is identifying people that you already have a connection to, that are 2-3 steps above you in the pile.  For instance, I am one of the Deputy Medical Directors of Monroe County.  If my professional goal was to become a Chief Medical Director of a county or region, then I would start by identifying people in those positions who would serve as good benchmarks for me.  They are doing the job that I want to have, and are consistently demonstrating  their success in that position.

Step three is approaching the potential mentor.  You anxiety level should be pretty low.  This is not asking someone out of your league on a date or walking into your boss’s office to ask for a raise.  I’ll let you in on a little secret, any good mentor will be flattered that you have asked them to help you grow in your career.  By asking them, you are saying that you think they are doing something right and that they have the ability to guide you to success.  That is a pretty impressive compliment and if they don’t see that, then they are probably not a good mentor for you anyway. 

The final step is developing that relationship.  A potential mentor needs to know that you will value their input and put their advice to good use.  You are asking them to give up their valuable time to guide your forward in your career with little direct benefit for them.  Kathy Caprino, a columnist for Forbes, recently tackled the issue of finding a mentor and she takes it to the next level by saying that a potential mentor has “to like, trust and believe in you already.” She goes on to ask the question, “are you somebody you yourself would like to mentor?”  If you cannot answer yes to that question, then you need to work to become that person before you consider engaging a mentor.  

Mentorship should not be forced.  The relationship needs to develop organically without it being coerced.  This usually occurs during the initial few meetings where your mentor will start to help you set some goals and work on the things that need to occur for you to meet your goals.  A great mentor is someone who can inspire you when you need to be inspired and can put you in your place when you need to get leveled out.  If the relationship is not that strong, then that is not mentorship.  Your mother can be your cheerleader.  Your mentor fills the role of coach, cheerleader, friend, leader, and follower based on what you need, when you need it.  It is a special relationship that should be cherished.

 

 

A Productive Mentor-Mentee Relationship

So, now that you have a mentor, how do you turn that into a productive relationship?

When I work with my mentors or I have mentees, I always start with a face to face meeting.  This can be as simple as meeting for coffee, lunch, or some other informal setting.  Before you commit to this, you need to analyze the type of relationship you have or will have with your mentor/mentee.  I think the relationship between a medical student and the dean of the medical school would be different than the relationship between an EMT working through paramedic school and their paramedic preceptor.  Some meetings should happen during normal business hours in a traditional office setting, while some will happen in the corner pub after a long shift.  Where to meet up has a lot to do with the type of relationship that will develop.

The next step is preparing for your meeting.  In my case, that means developing a list of things I want to talk about in the weeks prior to the meeting, and then writing it down on a scrap sheet of paper that lives folded into my wallet until meeting time.  Your list does not need to kill a tree if you are smart enough to use your smart phone.  Maybe it is an email sent ahead of time or memorized if you did not get hit on the head with an oxygen bottle too often.  Even if your mentor makes fun of your list (mine does every time), having a list demonstrates that you value their time and you want to be productive during your meeting.

During your meeting, what type of things should you discuss.  In my mind, this meeting is broken up in three parts.  The first part is usually spent catching up with my mentor on a personal level.  Frequently I speak with my mentor or mentee about how things have been going because this is a relationship so it’s OK to invest into it and be human.  Any good mentor wants to know that their mentee is maintaining adequate priorities and perspective with everything going on, especially when things are getting really busy.  The second part is a review of the previous meeting and progress on the subjects that you discussed at the last meeting.  The premise of this relationship is based on the mentor providing guidance to the mentee, so they certainly want to hear about how you advanced the ideas that you both spoke of previously.  The final part is the new material and this is typically where the list comes into play.

In this busy world, everyone’s time is valuable.  By the time my meeting hits, I have usually thought through what I want to say about the previous subjects as well as the newer things I want to talk about.  It is OK and expected that your ideas are not refined, that is why you have meetings with your mentor.  Part of their role is to help you refine those ideas into viable actions.  A meeting should not be one sided and the mentor expects to have ideas bounced off them.  You should expect them to critique and suggest things that you had not considered.  Along those lines, it is OK to take notes during your interaction.  Any mentor should be flattered that you are writing their ideas down.  It shows that you value their opinions enough that you do not want to risk forgetting.

I have benefited greatly from having positive mentors in my life.  I continue to have multiple mentors today who both directly and indirectly inspire me to be the greatest paramedic, physician, medical director, anesthesiologist, intensivist, coach, and friend that I can possibly be.  If only they could help me find some time to sleep …

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The text above first appeared as a three part series in the University of Rochester Division of Prehospital Medicine Newletter.

 

 

This is why we do advocacy

by Ritu Sahni, MD, MPH, FAEMS

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On the Friday before this past Thanksgiving, the President signed HR304, otherwise known as the Protecting Patient Access to Emergency Medications Act.  In a year in which dysfunction would have been an improvement in the political world, this important legislation was passed in a bipartisan manner.  As EMS physicians, we have a unique view.  We look at our population as a whole – not necessarily individual cases and certainly just unique disease processes and specialties.  We are not responsible for one patient at a time but an entire community. This is why advocacy matters.  We have a responsibility to do what is right for our patients and as system-thinkers, we have a unique responsibility to do what we can to enhance the system.  This is especially true when it comes to advocating on behalf of our patients and our system and this is why we helped create and advocated for HR304.

In January of 2015 I was completing my term as President of NAEMSP.  We had been discussing issues regarding the management of controlled substances in EMS for years.  The only consistency was inconsistency.  In some locales, EMS Medical Directors were required to get a separate DEA license for every location that stored controlled substances of any variety.  Some EMS agencies were required to get a distributors license because they “distributed” controlled substances among their various rigs and stations.  It was in this context that the Drug Enforcement Administration’s policy/regulatory section approached the EMS community proposing to create a set of rules specific to EMS.  We were pleased that there would possibly some consistency and excited to hear that the DEA was reaching out to the EMS community.  During the NAEMSP meeting in New Orleans we had the opportunity to meet with the DEA’s policy personnel  As we sat in my presidential suite in New Orleans it became increasingly clear that we had a problem.   The DEA’s authority comes from the Controlled Substances Act.  The CSA was written two years before Johnny and Roy premiered on television (for you youngsters – Johnny and Roy are a reason many of us ended up in EMS).   The law didn’t anticipate the use of controlled substances in a mobile environment and without a physician present.  Ultimately, the DEA stated that the CSA had some very specific guidelines as to when controlled substances could be delivered.  The crux was this, all orders for controlled substances had to be “patient-specific.”   There couldn’t be a “standing order” that allowed non-physicians to deliver controlled substances without an order given to them directly by a physician in real-time.  When we suggested that the new EMS rules could allow this, the DEA representatives appropriately pointed that they could not write a rule that was counter to the requirements of the statute.  The only way to get rules that made sense was to change the law.

NAEMSP had seen the importance of advocacy many years earlier.   Dr. Richard Hunt correctly identified that EMS had been left out in the cold when there was a large increase in preparedness funding following the attacks on 9/11.  Law enforcement and operational fire had received specific funding lines.  Medical preparedness was focused on hospitals, who controlled local distribution of federal funds.   He asked a staff member of his local congressman why was EMS left out and the answer was simple: EMS had no one at the table when decisions were being made.  NAEMSP realized that caring for our patients required being involved when policy was made.   A spot at the table requires resources, which NAEMSP was unable to afford by itself.   As a result, Advocates for EMS (AEMS) was born.

Advocates was born from a desire to be provide a “Generic EMS” advocacy arm.   NAEMSP sought to bring the “alphabet soup” of EMS organizations together to provide a patient-focused advocacy outlet separate from some of the issues that may divide us in EMS.   Early on, the National Association of State EMS Officials (NASEMSO) was a key partner.  Later on, the National Association of EMTs (NAEMT) was the major partner.  This allowed the organizations to pool resources and invest in professional lobbying along with a more strategic legislative focus.  AEMS adopted many strategies as it strove for relevance.  Early on, AEMS sought to ensure that “report language” and grant requirements included EMS.  It was successful in these endeavors and some small victories were helpful to the EMS community.   Ultimately, AEMS attempted to get more aggressive and developed the EMS Field Bill.  This bill was large and meant to be impactful.  It called for a formal Federal “Home” for EMS that was in Health and Human Services (not NHTSA).  It led to significant discussion and even controversy in the EMS community – but did not achieve passage. Ultimately, trying to run an “Association of Associations” can be difficult. Each association has a slightly different “twist” on EMS issues and more importantly, different processes when it comes to setting legislative goals.  As this became more difficult, AEMS had to come to end.  This does not mean AEMS was a failure.  In fact, it was quite the opposite.  EMS associations realized that “You must be present to win.”  Having a presence in Washington, DC is imperative or national policy will roll right over you.  Based on this experience, NAEMSP decided that it needed to invest its resources into a permanent presence in Washington.

This brings us back to the DEA.  Shortly after NAEMSP formalized its own government affairs plan by creating an Advocacy Committee and contracting with Holland & Knight as our DC representation, it became apparent that any regulations regarding controlled substances would negatively impact patient care.  This is not because regulations are inherently bad, but because the CSA was not designed for prehospital use.  Because of the lobbying experience available to us from our Holland and Knight partners, we were able to identify a Member of Congress willing to listen to us and take up our fight.  Representative Hudson from North Carolina heard us and, as a result introduced the Protecting Patient Access to Emergency Medications Act.  We tried our hand at Advocacy.  NAEMSP members starting contacting Congress.   Additionally, we quickly partnered with ACEP and NAEMT – both of whom activated their membership on the issue.   NAEMT agreed to make the bill a priority on EMS on the Hill and members of the EMS community walked the hall of Congress to advocate for a bill in which NAEMSP led the development.  Our issue almost got done in 2016 – which would have been amazing.  But politics prevailed, and the bill didn’t pass.  Representative Hudson didn’t give up and he reintroduced the bill in the House and Senator Cassidy introduced the bill in the Senate.  This time, the pieces fell into place and the bill was passed by both the House and the Senate, and signed by the President.  To some it was a small thing, but using protocols or “standing orders” for EMS to deliver controlled substances was now legal.  Presence in Washington would have a direct and positive impact on the provision of care at the patient’s side.

What next?

NAEMSP strives to continue to be a force in healthcare policy development, especially as it relates to time-critical emergencies and high quality prehospital care.  As we move forward, the issue of medical oversight and its value to the system and role in driving quality care is key.  High quality medical direction improves patient outcomes and the system should acknowledge that and fund it.   NAEMSP plans to lead this discussion.  Your membership in NAEMSP helps fund this.  Additionally, NAEMSP has decided to form a political action committee or PAC.  Unfortunately, neither George Soros or the Koch Brothers can fund this PAC.  Only NAEMSP members can fund the PAC.  Why do we do this?  It allows NAEMSP to do it what it can in an aboveboard and ethical manner to support legislators who are open and supportive to EMS.  How can you help?  Here are a couple of things:

  • Donate money to the PAC (www.naemsppac.com)
  • Attend the NAEMSP Government Relations Academy on April 10 (Space available on First come, First Serve Basis, Click here to RSVP)
  • Attend the NAEMT EMS on the Hill Day on April 11 (https://www.naemt.org/events/ems-on-the-hill-day)
  • Get involved in local politics
  • Be present at local and state meetings, especially when EMS issues arise.
  •  Serve on local and state policy committees that impact EMS
  • Here’s the crazy one – RUN FOR OFFICE.  Imagine a world in which your county commissioner is an actual EMS physician?   It could be a game changer.  We can provide information but only when holding the levers of power can you truly make change. 

In EMS, we are system-thinkers.  Our primary objective is to improve the care of patients in our entire community.  We cannot assume that lawmakers will understand the intricacies of the care we provide or the barriers we face in achieving our primary objective.  We must be at the table. 

 

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We Gave an Inch, They Took a Mile

by Clayton Kazan, MD MS

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EMS Physicians need to be drivers of the EMS system and recognize that we are a Mobile Community Healthcare Provider and not providing medical direction to a fleet of glorified Ubers.  This seems like a total “no-brainer,” yet we find ourselves grappling with problems like Ambulance Patient Offload Delay (APOD, aka Ambulance Wall Time) that we should never have allowed to happen.  If, in your system, APOD is not a problem, then I suggest you stop reading this and migrate over to your Facebook account because you must be the Medical Director of the Shangri-La EMS system.  For those of you who share my system’s difficulties, I am going to blow your mind…we often blame the hospitals for APOD, but the fault lies with us because we depended on the hospitals to fix a problem that they have little incentive to address.  Meanwhile, despite the fact that EMTALA gives us firm legal ground to hold hospitals accountable, our inaction on the issue has led the problem to fester to the point of ridiculousness. 

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EMTALA is quite clear about who bears responsibility for patients that present to Emergency Departments.  The 250 yard rule has always been a bit difficult for me to understand, especially when it means that my ER is responsible for a “patient” in the Burger King Drive-Thru across the street.  Regardless, there is no question that a patient belongs to the hospital the minute the ambulance wheels stop.  So, the ambulance enters the ER doors, passes through the gauntlet of parked ambulance gurneys  a volley of offcolor remarks from our inebriates, and vomiting in stereo from our flu patients, and our patient finds their way to the triage nurse.  With the state of ED’s these days, it would be laughably unrealistic to expect them to have a space for our patient, but when did this become an EMS problem?  Our shared experience is that the triage nurse, in true pirate captain form, shanghais the ambulance crew and sentences them to hours on the wall as unpaid members of the ED staff.  Part of this comes from a mistaken belief by some that the patient remains the responsibility of the EMS crew until such a time as the ED is ready to accept the patient, and part of this is sheer desperation at paralyzed ED and hospital throughput.  But, again, when did this become an EMS problem?  If the EMS call volume was ever too high, would it be OK for us to kidnap 2 ER nurses and put them on an ambulance?  Why is the opposite any more reasonable or palatable?  Is this a game of chicken with the hospitals to see how long our crews will wait on the wall until we direct them to start leaving?

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None of this speaks to the ethics of a formalized handoff of patient care.  I certainly understand the importance of providing critical care, and I recognize that sometimes ED’s need a few minutes to rein in their chaos.  I do not suggest that ambulance patients be placed on luggage carousels in the ambulance bay to be claimed inside (or not), but the kindness and patience of EMS crews has clearly been taken advantage of.  EMS and ED work is a team sport, but the ED has become a Kobe Bryant-like teammate, that takes all the shots and glares at any dissent.  When did 10-15 minutes of acceptable waiting become 4 hours?  When did the priorities of the ED outweigh the importance of insuring that someone shows up when communities dial 911?  Perhaps the root of the problem lies in our background as hospital workers and our sympathy to the ED. 

So, I cannot raise a problem without proposing a solution.  The answer truly is fixing hospital throughput, and I spent 4 years on various hospital committees championing just that, with uninspiring results.  How about if the hospitals hire their own EMTs to hold the wall with these patients…the standard of care is the same, but, at least the hospital bears the cost and the community gets its ambulance back.  The hospital can carve roast beef in the ambulance bay if it wants to, but their overcrowding and failure to address their throughput issues really isn’t an EMS problem.  Until we hold the hospitals’ feet to the fire, they have no incentive to fix the problem. 

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So, when people ask you how much APOD time is acceptable, the answer is zero.  This is a hospital problem that demands a hospital solution.  We wait out of courtesy and support for our ED partners, but our patience is wearing thin.  The day we start walking out when our clock runs out or when it hits the hospital’s pocket book is the day the hospitals will engage.

EMS: The Best Kept Secret in Healthcare

by Maia Dorsett, MD PhD

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At the end of my third year of residency, I was in the process of solidifying my decision to pursue a fellowship in EMS.   I was on rotation in the Medical ICU and we were having an informal conversation about plans following residency.   When I stated that I planned to pursue an EMS fellowship, the ICU Attending asked what it was. 

My response?

EMS is the subspecialty of medicine that encompasses provision care beyond the borders of the hospital, at the level not only of individual patients but the entire community.  That the care was not limited to 911 response in the traditional sense, but also public health, community education, disaster preparedness, provision of continuity of care following hospital discharge and in fact, to every critically ill patient transferred to his very own ICU.   From then on, I pulled up available EMS records on every admission to point out the critical and often life-saving interventions provided to patients before they entered the hospital borders. My mission was to highlight the scope and importance of care provided by EMS providers. 

I am not sure if this ICU attending – and the countless others who stated that they have never heard of an ‘EMS fellowship’ - were unaware of what EMS stands for.  I think that they did not recognize the term in the context in which it was presented; they did not recognize it as a physician subspecialty, let alone a practice of medicine.  I’m sure that those who did not recognize the term ‘EMS fellowship’ would expect a prompt and competent medical response if they were to call 911 from their living room or public place.  In the grand scheme of things, EMS is relatively new.  Accidental Death and Disability, which spurred the development of both EMS and Emergency Medicine, was only published a half century ago.   EMS was only approved as a physician subspecialty in 2010, with the first board certifying examination offered in 2013.   Like many developments that are also relatively young– the internet, cellular data network - EMS has become an assumption of peoples’ lives.   Much like the delayed knowledge translation window between quality research and change in practice, moving the behemoth of the house of medicine to change the way it thinks is a long, arduous and inefficient process.

When it comes to recognition of EMS as a practice of medicine, we need to speed things up.  Advocacy for our specialty is advocacy for our patients.  

The reason? 

Failure to recognize EMS as a practice of medicine stunts the growth of the specialty towards the model set out in the EMS Agenda for the Future:

“Emergency medical services (EMS) of the future will be community-based health management that is fully integrated with the overall health care system. It will have the ability to identify and modify illness and injury risks, provide acute illness and injury care and follow-up, and contribute to treatment of chronic conditions and community health monitoring. This new entity will be developed from redistribution of existing health care resources and will be integrated with other health care providers and public health and public safety agencies. It will improve community health and result in more appropriate use of acute health care resources. EMS will remain the public’s emergency medical safety net.”

While small steps have been made, the defacto situation is that EMS is reimbursed as a taxi service, mobile integrated healthcare programs are stunted, EMS providers are disrespected and underpaid, national certification of EMS providers fails to be 100% nationally accepted, EMS research is still underperformed and underfunded, hospitals fail to share outcome data and operational metrics rule assessments of EMS quality. 

There are many different approaches to changing the status quo.  EMS physicians and providers with significantly more experience and knowledge than me are pursuing those routes.  But as someone new to EMS (a lab nerd turned emergency physician who caught the EMS bug mid-residency), I can tell you that part of every approach needs to be explaining the specialty of EMS not only to the public and lawmakers, but to our colleagues in medicine.  I have now given talks on the principles of and barriers to Mobile Integrated Healthcare in a limited number of venues – three different EM residencies and a conference on healthcare overuse.  In every situation, audience members have been surprised and inspired by how EMS can be used to provide patient-centered care with decreased healthcare utilization.  They have been similarly frustrated by the payment by transport model.  They have shared in our vision for a truly integrated healthcare system. 

For our healthcare system to meet its potential to improve the health of our communities, it must be transformed.  Many of us became EMS physicians because we wanted to be part of this transformation.

Those of us who took the EMS Boards in September are anxiously awaiting exam results.  Many if not most of us put ourselves through the exam not for better pay or a new position, but because of dedication to the specialty – to the knowledge that we can positively influence the lives of an incredible number of people by improving the quality of care they receive on a system-wide level.  It’s time that our colleagues in medicine understood what we actually do.

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Quality Assurance in Innovation: Drug Shortages, Cost and the Tale of Check & Inject NY

By Melinda Johnson, EMT-B

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One could say that MacGyver is the patron saint of EMS.  Prehospital professionals pride themselves on innovative solutions to patient care.  Most frequently this takes the form of the work that goes into delivering a packaged patient to the right hospital in a timely manner no matter where, what time of day, and in what situation they originally presented.  Less frequently, but no less importantly, this takes the form of innovative solutions to patient care on a system-level.  Occasionally, this requires modification of a scope of practice limitation caught under statute or regulation. 

Anaphylaxis is a potentially lethal multi-system allergic reaction triggered by an exaggerated immune response.  The signs and symptoms of anaphylaxis include bronchospasm, urticaria, pruritis, angioedema, gastrointestinal symptoms (diarrhea, nausea, cramping), cardiac arrythmmias and hypotension [Figure 1].  These symptoms occur on a clinical continuum and can develop over time.   Most anaphylaxis occurs in the prehospital environment.

Source: Simons, F. E. R., Ardusso, L. R., Bilò, M. B., El-Gamal, Y. M., Ledford, D. K., Ring, J., ... & Thong, B. Y. (2011). World allergy organization guidelines for the assessment and management of anaphylaxis.  World Allergy Organization Journal ,  4 (2), 13.

Source: Simons, F. E. R., Ardusso, L. R., Bilò, M. B., El-Gamal, Y. M., Ledford, D. K., Ring, J., ... & Thong, B. Y. (2011). World allergy organization guidelines for the assessment and management of anaphylaxis. World Allergy Organization Journal4(2), 13.

Many studies have demonstrated that the treatment of choice for anaphylaxis is epinephrine [1]. Death from anaphylaxis occurs either through respiratory compromise or circulatory collapse.  The treatment of anaphylaxis is about as time-critical as it gets.  In a study of 202 patients who died of anaphylaxis in the UK from 1992 to 2001, onset of symptoms to death took 10-20 minutes for medications, 10-15 minutes for insect stings, and 25-35 minute for food exposures [2].  In two cases series comparing near-fatal and fatal anaphylactic reactions, a > 5 minute delay in epinephrine administration from time of onset of significant symptoms was closely associated with death [3,4]

Ideally, epinephrine is self-administered by patients via auto-injector as soon as severe symptoms occur.  However, in many cases, patients either do not have their auto-injector or are having a first allergic reaction and need EMS to provide this potentially life-saving intervention.  In the National Scope of Practice model, EMTs are allowed to help patients administer their own medication, but administration of IM epinephrine is left to the AEMT level. Studies published after these guidelines demonstrated that EMTs can administer epinephrine under appropriate circumstances given adequate training [5].  In 2011, NAEMSP published a position statement supporting administration of epinephrine by BLS providers, citing that it “is imperative that EMS providers have the capability to administer epinephrine in a timely fashion.” [6]  

While the majority of states allow BLS providers to administer epinephrine, they require that it be administer in the form of an epinephrine auto-injector (EAI).  Here in New York, the exponentially increasing cost in epinephrine auto injectors made it difficult for agencies to keep them stocked on their emergency vehicles.  Despite the financial challenge posed by EAI, we knew that we couldn’t absolve such a lifesaving drug from our medical supplies.  It would be unethical and harmful for our patients.  We needed a solution (pun intended).

The Check & Inject NY project was born out of an increasing need for an alternative to the epinephrine auto injector.  Several other states had used a lower-cost solution to the epinephrine auto-injector problem: syringe injectable epinephrine. A 2016 survey of all 49 states (excluding Texas because of variability in practice within the state) identified 13 states that allowed BLS providers to draw up epinephrine from an ampule and administer it by syringe [7].  At the time of the survey, 7 other states (including New York) were considering instituting training programs.

The idea of having basic EMTs draw up epinephrine seemed to be the best solution to the auto injector price hike.  After reviewing the syringe-injectable epinephrine project developed by King County Medic One in Seattle Washington, we decided to have a specialized syringe manufactured to prevent dosing issues.  We worked with CODAN Medical ApS, a company based in Denmark to develop a syringe with just two gradations on it, one for pediatric patients and the other for adult [Figure 2].  With this simple change, we avoided dosing errors throughout our project.

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We quickly realized that given the distribution size of this project, it was unrealistic to put together and distribute all these kits ourselves.  We entered a partnership with Bound Tree Medical to keep up with the demand for our kits state-wide.  Through this partnership, we also provided a seamless transition to prevent further delay for our agencies to obtain the cost effective Check & Inject kits. 

In EMS (and medicine in general), an intervention is only as useful as the training and quality assurance that accompanies it. The Check & Inject NY team created several different tools to be able to make this project successful.  We created an entire training program for each agency participating to ensure each provider was refreshed on the use of epinephrine and when to choose adult over pediatric dosing.  This training included a skills station in which each provider familiarized themselves with the syringe, the process of drawing up epinephrine, and the process of intramuscular administration. Additionally, students were provided pre and post tests, whose purpose was to evaluate the training and not necessarily the provider’s knowledge of the learning objectives.  This was to ensure completeness of the training program so that we were able to provide uniform education not just to local participating agencies, but to agencies statewide. 

As quality assurance was a key component to our pilot program, we established a physician phone line that enabled us to have an on-call physician 24/7 for each administration during the pilot program.  Once the provider used the syringe epinephrine kit, they were to call this phone line to discuss with the physician about the administration process as well as potential concerns.  The physicians then entered the data to a Research Electronic Data Capture database (REDCap) allowing the agency to maintain HIPPA compliance.  Additionally, the phone alert itself, triggered a replacement kit to be sent to that agency at no additional cost.

In the active demonstration project phase, 638 agencies participated across the State.  There were 83 administrations of check & inject epinephrine.  All administrations were deemed indicated by physician consultation and none resulted in injuries for the patients or providers.  It was found that kit usage was also utilized for asthma exacerbation.  This lead our team to add asthma exacerbation as another Check & Inject kit indication.  Interestingly, a provider reported that a patient stated that the syringe epinephrine kit was a less painful than an EAI as a method of receiving the medication.

On May 24, 2017, the project was formally adopted by the New York State Department of Health Bureau of EMS and Trauma (BEMSAT) with the support of the Commissioner of Health through the issuance of Policy 17-06.  This was a tremendous achievement and expansion of the BLS scope of practice in New York State. The Check & Inject NY demonstration project is the largest of its kind ever undertaken in the State’s history, requiring collaboration on the part of many individuals. Many other states across the nation have inquired about our project and are looking to start ones of their own.

Patient care starts with basic life support and should not be limited by the outrageous and unnecessary hikes in medication cost.  Rising drug costs, shortages, and evidence-based medicine require us to change our practice in order to do what is best for our patients.   The importance of training and quality-control cannot be underestimated as we advance practice to ensure that our best-intentions are realized.

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References

1.     Kemp, S. F., Lockey, R. F., & Simons, F. E. R. (2008). Epinephrine: the drug of choice for anaphylaxis--a statement of the World Allergy Organization. World Allergy Organization Journal1(2), S18.

2.     Pumphrey, R. (2004). Anaphylaxis: can we tell who is at risk of a fatal reaction?. Current opinion in allergy and clinical immunology4(4), 285-290.

3.     Sampson, H. A., Mendelson, L., & Rosen, J. P. (1992). Fatal and near-fatal anaphylactic reactions to food in children and adolescents. New England Journal of Medicine327(6), 380-384.

4.     Yunginger, J. W., Sweeney, K. G., Sturner, W. Q., Giannandrea, L. A., Teigland, J. D., Bray, M., ... & Helm, R. M. (1988). Fatal food-induced anaphylaxis. Jama260(10), 1450-1452.

5.     Rea, T. D., Edwards, C., Murray, J. A., Cloyd, D. J., & Eisenberg, M. S. (2004). Epinephrine use by emergency medical technicians for presumed anaphylaxis. Prehospital Emergency Care8(4), 405-410.

6.     Jacobsen, R. C., & Millin, M. G. (2011). The use of epinephrine for out-of-hospital treatment of anaphylaxis: resource document for the National Association of EMS Physicians position statement. Prehospital Emergency Care15(4), 570-576.

7.     Brasted, I. D., & Dailey, M. W. (2017). Basic Life Support Access to Injectable Epinephrine across the United States. Prehospital Emergency Care, 1-6.

 

EMS MEd Editor: Maia Dorsett, MD PhD (@maiadorsett)

Are Emergency Physicians the EMS experts that many think they are?

by Clayton Kazan, MD MS FACEP

I suppose I am biased.  Like many of the readers, I got my start in medicine working as an EMT on the UCLA EMS ambulance in college, and, I entered medical school with the intent to become an Emergency Physician.  I have been actively involved in EMS since I was first bitten by "the bug" (yikes, 23 years), and I have always seen my understanding of the local EMS system as fundamental to my Emergency Medicine practice.  When I was in residency, my classmates used to tease me (rightfully) as an EMS geek, but I always viewed EMS personnel as an extension of the ED, and knowing their protocols and practice was akin to knowing how our ED nurses manage our patients.  EMS providers are as much a part of my treatment team as the ED nurse, tech, secretary, radiology, lab, etc.  So, why don't more of our ED colleagues feel the same way?  Why don't more of them take an active part in understanding the basics of the local EMS system in which they practice: scope of practice, treatment protocols, destination criteria, etc?

The American Board of Emergency Medicine (ABEM) and NAEMSP have taken the critical step of establishing a Board Certification in EMS, and I realize that our subspecialty is still in its infancy.  Many of our physician colleagues, and, unfortunately, many of our fellow EP's still do not know that EMS Board Certification exists.  What frustrates me is the lack of understanding by EP's that this whole knowledge set exists. 

As an example, consider the interfacility transfer for STEMI patients.  Our EMS system in Los Angeles County has had STEMI centers for more than 10 years.  Since very early in our STEMI program, we recognized that our ED's could not get a private transport ambulance quickly enough to get STEMI patients to the cath lab quickly, so, by policy, they are permitted to call 911 to facilitate transfer to STEMI centers.  Yet, we often find that our ED physicians start nitroglycerin and heparin drips on these patients prior to calling 911; with a clear lack of understanding that our paramedic scope of practice does not allow for such interventions. 

Los Angeles County also allows for "911 re-triage" of trauma patients under specific circumstances in order to get them emergently evacuated from non-trauma hospitals to Trauma Centers.  Despite the very clearly defined criteria, only about half of the calls we receive for 911 re-triage actually meet criteria.  And, for the patients that do, we often find them receiving blood transfusions or IV infusions (propofol, etc) which are out of our scope of practice.  When we share the EMS Agency policy with the ED administration, it is often apparent that they have little to no idea of its very existence. 

Unfortunately, this lack of understanding is apparent even from California ACEP.  In December 2015 and January 2016, Cal ACEP went on the warpath against Community Paramedicine and Alternative Destination projects citing a lack of data around their safety.  Their stance was that people who call 911 are "actively seeking access to emergency care, where their EMTALA rights can be realized."  But, Cal ACEP also noted that its mission is "to support emergency physicians in providing the highest quality care to all patients and to their communities."  But, we (EMS Physicians) are Cal ACEP members and emergency physicians too, and these are our patients and communities.  Prior to making its stance, Cal ACEP did not reach out to its EMS constituents for comment or input, and their stance demonstrates a lack of appreciation for the challenges faced by the EMS community.  To their credit, since its publications, Cal ACEP has begun to engage with the EMS physician community.

So, how do we solve these issues?  As the trailblazers in this new subspecialty, we need to pound the pavement and advocate for EMS.  If we don't, then the Emergency Medicine (EM) groups will remain our proxy. We need to engage with groups on all sides and demonstrate the value that we bring to the table.  This includes the EM groups, but also primary and urgent care, fire chiefs, firefighters, EMS groups, law enforcement, political groups, etc.  We can have a loud voice, but only when groups remember to think of us, and they remember to think of us when they see us out there...so get out there and show up at meetings...until people start asking, "who is that guy that keeps showing up and eating our cookies and drinking our coffee?" 

I was wrong.  EMS is far more than an extension of the ED into the community.  EMS is a mobile, community healthcare provider with its own patients, challenges, and values that sometimes transports sick patients to the ED.  We care deeply for the communities we serve and the integrity of our EMS safety net.  We fill a complex niche in community health that is completely distinct from the EM system.  I am proud of my EMS Geekdom!

It's Time For Us To Call a Code Green

by Clayton Kazan, MD

We all know about the various codes they call in the hospital: Code Blue, Code White, Code Pink, etc.  We have even made up a few codes of our own, aka Code Brown.  But, not enough of us know about Code Green.  It's not a new name for patients on 4/20 or from Colorado or California.  It's about recognizing the leading cause of active duty death in our First Responders...suicide.

I have come to believe strongly that we train ourselves and our EMS brothers and sisters the wrong way.  When I look back on my training as an EMT (and Medical School and Residency), I received exactly zero training in mental resilience and zero preparation for the calamities I would bear witness to.  In fact, my department followed a now discouraged practice of forcing us to see a psychologist for a debriefing after any traumatic call.  Hopefully none of your departments still require critical incident stress debriefing since we now know that forcing it upon our folks can be counter-productive.  But, what can we do, because we need to do something...the data is staggering.

According to the Firefighter Behavioral Health Alliance (FBHA), from 2014-2016, there have been 374 suicides among active duty firefighters, compared with 268 Line of Duty Deaths (LODDs).  This data likely understates the problem, since data for suicides is shared voluntarily while LODDs are reported mandatorily to NIOSH.  Research has shown that first responders' rate of suicidal ideation is 10x that of the general public, while firefighters' rate is more than 12x.  The risk of suicide attempts is 13x higher for first responders and 30x higher for firefighters.  The risk of successful suicide is more than 2.5x that of the general public.  And, unfortunately, the data is not much better for us Medical Directors because Emergency Physicians also have an increased risk of suicide, though not as bad as the first responders.

I think that the problem boils down to 2 cultural issues we need to face.  First, we need to reconsider the whole way we think about the horrible things we experience.  We all carry with us the memories of the horrific tragedies we have cared for, the mistakes we have made, the times we have been threatened or assaulted, and we have all experienced having to suppress our emotions for the sake of moving on to the next patient.  We see things and experience emotions, quite often, that the lay public never experiences.  No matter how resilient you may be, these exposures leaveboth temporary and permanent impressions upon your soul.  

What do we do to prepare our folks during their training, and how good are we at monitoring our crews throughout their careers?  The military, faced with a suicide epidemic, has incorporated resiliency training to soldiers preparing for deployments, and they have seen some decrease in post-traumatic stress disorder (PTSD).  While EMS has embraced many military technologies and practices into everyday care, resiliency training has lagged behind.  There are many healthy ways we use to cope every day, including the tight comeradery among us.  Many of our departments, mine included, have incorporated Peer Health Counsellors, Chaplains, and access to Psychologists, but it is still largely dependent on self-referral.  Unfortunately, beyond the comeradery of our profession, the culture also includes some worrisome practices.  Substance abuse is high, especially with the work hard-play hard mentality.  The same comeradery that binds us can lead folks that need help to be afraid to ask for it because they are afraid of being ostracized, thought of as weak, of being laughed at, or of being fired.  And so, they laugh at our jokes and sit quietly during our stories, and they begin to isolate themselves.  After all, they signed up for this, and working in EMS becomes more than your profession.  It becomes who you are, and what if you don't know if you can continue to be who you are anymore?  

The other cultural problem that we need to face is the way we treat errors.  This is not unique to EMS and is true throughout the practice of medicine.  I think that we all tire of the analogies to the airline industry, but the success of their cultural change around safety has been remarkable.  In my own department, if we avoid serious mistakes 99.99% of the time, then we will still commit 36/year...a number that most critics would argue is far too high.  But, can anyone really expect even that level of performance from human beings?  We need to get out of the cycle of our name, blame, and train approach to performance improvement.  No system punishes its way to greatness.  In fact, only a poorly designed system would ever allow a single, unchecked mistake by a provider to lead to a patient catastrophe.  Our culture of punishing for mistakes only leads to their concealment for fear of reprisal, and so our system remains stagnant rather than getting safer.  We set such unrealistically high expectations for our folks, that the guilt of a mistake reaps a terrible toll on our folks, and they practice in fear.  In the words of Jeff Skiles, the lesser known co-pilot of the USAir plane that landed in the Hudson River, "It is vastly more important to identify the hazards and threats to safety than to identify and punish an individual for a mistake."

So, what are the answers?  We need to educate ourselves and our folks about the warning signs of our brothers and sisters in crisis.  We have to educate them early in their careers and renew it often, and we need to maintain a culture that encourages members in crisis to step forward.  We must build layers into our systems to protect both our patients and our caregivers, because no individual error should ever lead to catastrophe.  That way, the crews on the front lines can step forward and help us build a safer system rather than practicing in fear of making a catastrophic mistake.  Lastly, let's mobilize behind the critical work of organizations like the Code Green Campaign, FireStrong, etc. and make sure that our folks all know that they are out there.  

We must all remember that we are all vulnerable to mental illness.  The burden of our deceased brethren was not unique to them.  Sometimes it just takes one bad experience to put us over the edge.  It happens to folks in the beginning, middle, and end of their careers, and it can progress rapidly.  There are often warning signs, and there may be an opportunity to intervene and get them the help they need.  What sets them apart is not their circumstance, it's that we did not recognize their crisis and respond to them in time.  Suicidal ideation is a treatable illness, and suicide is preventable.

Please check out these excellent and important organizations:

Code Green Campaign

Firestrong

 

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The ER system is a sinking ship, EMS can be part of the solution.

By Clayton Kazan, MD, MS, FACEP (@clayton_kazan)

The ER system is a sinking ship, EMS can be part of the solution.

In the late 1960's, most pre-hospital care was provided by primary care physicians.  As hospital care became more sophisticated and Emergency Medicine began to develop, the focus began to shift to transporting patients to hospital Emergency Departments, and EMS began to provide emergent treatment in the field as an extension of the ER.

But, the pendulum has swung way back.  85% of ED patients are discharged home, and, while many of those patients benefit from an ED work-up, there is also a large subset of patients presenting to the ED that could be worked up in other, less costly arenas.  Research from ACEP has shown that the vast majority of patients that present to the ED are justified to be there, but that just does not jive with my experience over the past 15 years. 

The problem is that the needs of the healthcare system and the financial incentives of the hospital/ED physicians are not aligned.  The healthcare system needs minor patients to be managed in a cost-effective manner, but ED budgets and ED MD salaries are driven by census.  I used to try to educate my patients on the appropriate use of Emergency Services, but it is a fruitless endeavor to try to educate millions of Americans, and it lacks any financial incentive for the stakeholders on the hospital side.  Instead, ED census continues to rise faster than new beds can be added, reimbursement per patient is falling, and the only answer is to improve ED bed efficiency.  But, efficiency has its limits, and, unless financial incentives are realigned, the ED system as we know it is a sinking ship. 

The ideal hospital ED needs to be reconsidered, and triage needs to be able to route patients along a spectrum of tracks.  We cannot expect patients to stop coming to the hospital, but patients with less acute problems can be triaged to the appropriate level of care, including Fast Track, Urgent Care, and Subacute Care.  Emergency Departments can be much smaller and can be a service line in a spectrum of services offered by the hospital.  Until financial incentives are realigned however, there is no incentive for hospitals to stop routing all patients through the ED, and board certified resuscitationists will continue to bill to see patients that could have been managed in a less expensive venue.

If EMS systems do not evolve, then we are part of the problem and are destined to go down with the ship.  This death spiral begins with increasing ambulance wall time and ED diversion.  But, unlike the ED system, the EMS system is financially incentivized to change its practice.  The mobility of our service puts us in the position to offer community based medical care unlike any current hospital or healthcare system.  Payers are highly incentivized to reduce the cost of unnecessary EMS transport and ED visits, and they are very open to working with us on innovative new models.

We need to stop viewing ourselves as EMS providers and start viewing ourselves as delivering mobile healthcare, with EMS being a service line in a spectrum of care we can offer.  Physician Assistants and Nurse Practitioners can be utilized to provide simple interventions in the field setting and redirect patients back to their medical homes.  In addition to contacting patients through the traditional EMS system, we can also partner with payers' nurse advice lines to evaluate patients that cannot wait for next day appointments.  While none of this is cheap, it is far cheaper than our current practice of EMS transport and ED visits, it saves EMS resources for true emergencies, it can reduce ambulance wall time and diversion, and it can provide a better patient experience.  Payers can also partner with us to provide urgent follow-up resources, which are far more cost effective and sufficient for many of our patients.  There are may ways that different departments are using mobile healthcare resources in innovative ways to reduce hospital readmissions, perform safety checks on high risk patients, etc.

This is the biggest watershed moment in EMS since John Gage and Roy DeSoto went to paramedic school.  This is our opportunity to become a stakeholder in the future of healthcare delivery rather than just an extension of the Emergency Department.  This is our time to become an indispensable provider of cost effective mobile healthcare. 

Medicine in Public: Messaging is a Core Skill in EMS Education

Sabina Braithwaite, MD, MPH, NRP, FACEP

The current EMS Fellowship curriculum emphasizes clinical skills needed to be a competent EMS physician.  In addition to medical knowledge, prehospital patient care, and systems-based practice, there are milestones for team and patient centered communication. These milestones focus on communication between EMS physician and EMS providers, EMS physician and patient, but do not expressly focus on communication between EMS physician and the public in general.

But unlike many other subspecialities of medicine, EMS is largely performed in public venues, now under the ever-watchful (and recording) eye of social media.  When taking care of complex patients in a complex system, it is guaranteed that bad things will happen. When that day comes (and it will), EMS physicians must be prepared to be questioned privately, in public, on TV, in front of a county commission hearing, and who knows where else, about what their role in the EMS system is and why that bad thing happened. 

Knowing this, we must make sure to prepare postgraduate EMS physicians with  additional communication skills that are at best under-emphasized in the current curriculum.  These skills are absolutely central to success as an EMS physician specifically, but also more broadly in any administrative role taken on.

One of these key skills is “messaging.”  A message is a brief, value-based statement aimed at a targeted audience that captures a positive concept.  This means that even when addressing a negative subject, the message should be positive.  Without a firm grasp on messaging, it is pretty easy to get into trouble in any of a number of ways when bad things happen.

So how do you become effective at messaging?  Here are my Top 6 tips: 

1.      Proactively work to get a positive public image.  This isn’t too hard to do: EMS are the “good guys” that help people in need.  But get that positive message out in front of the public, the funders (county / state government), and whoever else needs to know BEFORE the bad thing happens.  Develop a positive relationship with your print / TV media so they know they can call on you for facts when “it” hits the fan.  Get a reputation as an accessible expert who is part of a large team of folks there to help the public.  Volunteer to do a piece on heat exhaustion in the summer when it gets hot, pool safety for Memorial Day weekend, etc.  Every TV station in the land does those same pieces every year, and they will love you for not making them hunt someone down.  That way when you almost inevitably end up in front of a microphone / camera on a bad day, at least you will have done it before under non-confrontational circumstances.

 

2.      Always force yourself to write down the two or three bullet points that are the major message you want to get across.  You have time to do this no matter what, and it will keep you focused so you don’t wander off down some rabbit hole.  Have a “hook” that you can go back and rephrase, reiterate and come back to during the interview to emphasize your point.  Remember the KISS principle (Keep It Simple, Stupid).  Have a couple strong facts to support your points.  Anticipate the negative questions you will likely be asked and have an answer ready.  And shut your mouth and stop making sounds when you have made your point.  Resist the urge to over-explain.

Example:  Your system plans to start field cease resuscitation for OOHCA.  The public’s biggest concern will be that patients aren’t getting as high a level of care as they would if they were in a hospital [negative].  So create a positive message:  We want the public to know that we are taking a new approach to cardiac arrest similar to other progressive EMS systems [of course your system is progressive, right?], and we are now bringing everything the patient would get in an emergency department right to your home, where a whole team of professionals will try to help your loved one survive neurologically intact, starting with the dispatchers who will help you start CPR, which is one of the most important factors in helping your loved one survive ….. [you get the picture, team effort, everyone is there to help you, we are bringing it all to you, your job is to do CPR when we tell you, etc. Then explain when you will transport patients to the hospital.]

 

3.      Tell a story that illustrates your point.  This works particularly well with legislators and government officials, because it makes it personal and helps explain the problem or issue in a way people can relate to.

Example:  when explaining change in approach to cardiac arrest to the county commission, do a demo of your new “pit crew” approach, bring a survivor along, and tell them how many more people are surviving and going back to work (not a nursing home in diapers!) because of the great teamwork approach your system is using.  

 

4.      Be energetic, authoritative, and human.  Don’t hide behind doctor-speak - use straightforward language.  You know your stuff – show everyone!  For in-person interviews, be very mindful of the nonverbal messages you send and be sure they are in sync with what your voice is saying.  If doing a phone interview, stand up and walk around, it gives your delivery more energy and inflection.  Be sure the interviewer knows your name (spelling), title, and role in whatever you are being asked to comment on.  Feel free to educate them on what a medical director is / does, and also feel free to offer them some questions they can ask you when you are doing a public relations-type piece, so it is more likely that your major points will get across. 

 

5. The microphone is always on.  Corollary:  there is no such thing as “off the record.”  And remember, the 10-20 seconds that ends up on the evening news can be any 20 seconds out of the 5-10 minutes you talked, so don’t stray off message and have comments that can be taken out of context.

 

6.  Most importantly, KNOW YOUR AUDIENCE.  Be sure you are tuned in to station WII-FM – “what’s in it for me?”.  If you can anticipate what your audience wants to know / is worried about / can connect with and incorporate that information into your message, you can be sure that the message you think you are sending out is also the message they actually receive.  For the public, they want to know they are getting the best care possible.  For legislators, they want to know that the public isn’t going to complain to them, and that they can truthfully tell their constituents that public funds are being expended wisely, and possibly even that they have supported some fabulous thing that you are doing in your system that has improved patient outcomes.

 

EMS is a uniquely public specialty of medicine.  It is therefore of paramount importance that EMS physicians – in –training are taught how to navigate medicine in the public eye.   It not only has the potential to save them a lot of heartache, but also prepare them to be more effective advocates for themselves – and most importantly – the patients we serve.

 

Interested in learning more?

If you ever get the opportunity to go to the Media Training offered by ACEP at Scientific Assembly or at the Leadership meeting, definitely do so, it will really open your eyes and give you valuable pointers.  There also is considerable in-depth information on this subject in the chapter in the NAEMSP textbook Vol2 Ch15:  EMS Physicians as public spokespersons.

 

EMS MEd Editor: Maia Dorsett

Now Is the Age of EMS: It is Time to Revolutionize Our Practice

David K. Tan, M.D.

            Growing up, one of my favorite TV shows was “Emergency!”  I suspect many of our readers with a few grey hairs share my fond memories of watching Johnny and Roy gallantly saving lives every week while receiving sage advice from Dr. Brackett and Dr. Early when they brought the patients to Rampart ER.  It is fascinating to watch the portrayal of the early paramedics and what was necessary to become the first physician surrogates during the birth of EMS.  Training was a few weeks long, online medical control was required to defibrillate VF patients, every IV started in the field required permission as well as a 24-hour follow-up report, and an EOA was considered their advanced airway. 

            Fast forward to today, and look at how times have changed!  We now expect paramedics to interpret Sgarbossa’s criteria on a 12-lead EKG and, in some locales, initiate thrombolytic therapy for it, perform surgical crics, calculate cardioactive pharmaceutical drip rates, and engage in community paramedicine as part of the continuum of medical care.  EMS no longer merely brings patients to health care.  EMS is health care.    We continually pile more and more expectations onto EMTs as well as paramedics, yet we still treat the profession as a vocational tech skill as opposed to a practice of Medicine.   Paramedicine is not skilled labor.  It is a medical practice deserving of the requisite training and education worthy of the trust that citizens place in our abilities and, more importantly, our aptitude for decision-making and critical thinking.  Such capabilities require an entirely new paradigm in EMS education, yet if anyone dares mention that paramedic licensure should be via a college degree pathway instead of a “certificate,” prepare for an onslaught of naysayers! 

            Something else that struck me about Johnny and Roy is that they had a personal relationship with their medical control physicians.  Dr. Brackett did not abrogate his responsibility to teach and mentor his medics to a staff member.  He spent time with them, taught them his approach to patient assessment, gave feedback to the crew, and imparted his sense of the sacred trust between a caregiver and the patient.  Merely by the tone of their voice over the radio, either party instinctively knew if something was awry or if a patient was going to be particularly ill or a situation particularly difficult.  EMS Physicians must find time to break away from the desk and jump on the box or the apparatus, respond unannounced on scenes as a resource and teacher, and spend time in the classroom imparting knowledge impossible to glean from books. 

            As such EMS agencies must recognize that EMS, as a practice of Medicine, requires a compensated physician, ideally board-certified in EMS Medicine, with the requisite time and infrastructure to realize the new reality of this unique practice of Medicine.  Government, from local to state, must support medical oversight including having a functional state EMS office and a state EMS Medical Director. 

            Now is the most exciting time to be an EMS provider in the age of Mobile Integrated Healthcare, recognition by the proverbial House of Medicine as a bona fide subspecialty, and the growth of evidence-based protocols and practice where EMS can actually influence hospital policy.  It is a quantum leap from where Johnny and Roy started, and we now must begin treating this new frontier with a new vision by demanding more from ourselves and each other.