EMS Anxiety

EMS (Supply) Anxiety

By Alan Perry

February 29, 2016

What causes EMS supplies to be stockpiled on your medic or in your station? Is it insecurity or anxiety about a procedure? An unreliable EMS supply system? Lack of communication? A fear of an MCI event? In the ideal EMS supply system all units carry the same equipment and supplies, stocked at pre-defined levels, to assure that units can remain functional without unreasonable delays in restocking them. Unfortunately the practice of EMS supply hoarding, whether on the medic or in the station, confounds this goal. It drives up the cost of consumable items by increasing inventory levels while taking them out of circulation where they frequently become damaged or expire. That creates some of the very problems that the hoarding strategy seems to be trying to avoid, namely unpredictable stock levels or out-of-stock items.

I believe fear can be a factor, although an irrational one, it seems some of the supplies most likely to be overstocked are related to ALS procedures (ET tubes), infection control (masks, gloves, etc.) and trauma supplies (kling, tape, bandages). Could it be that somehow having more of these items allows us to handle those situations more effectively, or are they serving as a security blanket?

Communication is also an important factor; if the apparatus get checked off every shift, supply orders are placed every shift as well. If the supply system is not responsive, and fails to fill the orders as they are received, it can easily lead to duplicate (triplicate, quadrupled…) orders unless providers communicate what orders they have placed to each other. If supplies are not kept in specific locations in specific quantities this will lead to items being kept in multiple locations in variable quantities. The system should define what, where and quantity for items stocked on each piece of equipment. In most Fire-based EMS systems and volunteer systems, there is also a high degree of staff variability on each transport unit, frequently only a single shift assignment a month or pay cycle. In that situation you have little ownership of the apparatus or continuity in its care and restocking, both of which further confound the issue.

Most EMS systems now have dedicated resources they can rely on for MCI events. While a medic may be sacrificed in some instances to manage an MCI incident the majority of units will be used for treatment and transport of single patients. There really is no need to equip each ambulance with enough nasal cannulas, ET tubes and 12x30 trauma dressings to treat a dozen victims –that’s an irrational fear.

The reliability and of an EMS supply system will affect its efficiency. If your providers know the supply system is reliable and responsive to their needs they will be far less likely to set up individual stashes of these precious commodities on the medic or in the station. Providers should be aware of the consequences of these actions, which increase the cost to the organization, have a negative impact on its reliability as well.

Be safe,

Alan

Team-Based EMS

Team-Based EMS

By Alan Perry

November 4, 2015

Introduction

What do you want to call it? “High Performance EMS”, “Pit Crew EMS”, “Code Team”, “insert cute name here”, it really doesn’t matter, these terms all convey the same meaning; an organized and efficient approach to patient care. Regardless of the name, it won’t just happen without some effort on the part of the system and the providers. I would like to explore some ways of dissecting it from a team and teamwork perspective. I am going to discuss the ideas and practice in this article in three phases; Understanding the idea and how to visualize it, Defining the priorities of scene and team management, and Illustrating application of the idea when applied to any given crew configuration. I want to present it this way so the material can be presented and absorbed in a way that builds from concept to technical skill, with the final product being integrated into a flexible and effective system.

Concept

Why a team approach is needed

Cardiac arrest treatment has become much more technical and precise; the data behind modern resuscitation tools and skills is solid and still building. Sudden Cardiac Arrest is one of the most studied pre-hospital medical emergencies. Building a solid team approach will allow your organization to maximize the use of your team, and the resources available to them, to improve patient outcomes.

The Coach and Players

All teams need a coach and players that are familiar with the game and the responsibilities and capabilities of their team mates. An EMS/Fire crew is no different. Coaches are strategist, know the strengths and weaknesses of their team, the disease process and the tools and tactics required to succeed.  Players know their area of responsibility and what performance goals must be met. Both are committed to the team’s success and a good outcome for the patient.

Planning to win

When working a code we should have a specific goal in mind, in the past we would be happy with simply regaining a pulse, we resigned ourselves to the likelihood that most would not survive, that is changing. It is becoming increasingly likely with our new tools and tactics, that victims will survive, not only survive, but remain neurologically intact and live normal lives. In some places survival rates from witnessed cardiac arrest are near 50%, clearly they play to win. Planning to win means that you are willing to commit your team to training with the tools and tactics that are proven to work, it will require going beyond simply knowing what to do, you must bring all the elements together multiple times and in multiple scenarios to build your teams confidence and competence. You will know you are there when the team can function calmly, flawlessly and smoothly in even the most difficult circumstance.

Building your play-book

To reach the level of play required for an elite EMS team, we will have to improve the way we train, deploy, act and recover. Training is not just something we do to deploy a new device, tactic or skill, it is something we must do constantly so the team can build routines, muscle memory and fine-tuned personal interactions. Deployment of new tools, tactics and skills must be preceded by training, reinforced and evaluated, to determine if the material has been delivered and retained. When we respond and act, we must practice that team-based approach that brings all of the technology and skill we possess into play to produce the best possible outcome for the patient. When we recover from these calls we must extol both the good and bad when we debrief, learning from both and discovering new ways to improve.

Technicalities

Understanding the Priorities during Cardiac Arrest

#1 Safety:        

From dispatch through recovery, you cannot help if you don’t get there or you or your crew is injured.

#2 CPR:          

By-stander CPR followed seamlessly by high quality uninterrupted CPR by EMS is proven to be the most beneficial action for patients in sudden cardiac arrest.

#3 Airway

Controlling the airway includes opening and sealing the airway with an ITD to improve circulation in cardiac arrest with CPR

#4 Defibrillation:

Cardiac arrest from ventricular fibrillation can be resolved quickly with counter shocks delivered as early as possible.

#5 Ventilation

Not a priority during the first 2 minutes, but necessary beyond that, delivered with BVM and capnography to guide patient care.

#6 IV Access & pharmacology

Also not an initial priority, establishes a route for IV fluids and pharmacological agents if indicated.

#7 Rule outs (H’s & T’s)

Finding and treating the cause of the arrest is at least as important as reversing the arrest to prevent re-arrest.

#8 Post care

The jobs not over after the patient regains a pulse; perform a 12-lead, employ pharmacology and electrical therapy to manage this very unstable patient, employ therapeutic hypothermia if permitted and indicated.

Team Roster

Safety-                      Individual (and entire team); senior officer, maintains scene security and safety, serves as patient and family advocate.

Coach-                   Team leader; senior paramedic or EMS supervisor – directs code after determining nature of call and indications for resuscitation.

Compression team- At least two persons to alternate compressing the chest wall, initially may be an individual until additional resources arrive, will alternate with airway team every 2 minutes.

Airway team-           At least two persons to manage airway and ventilations, initially can be an individual who secures airway seal with ITD until additional resources arrive, will alternate with Compression team every 2 minutes.

Defibrillator-          Specialist; exposes patient and applies defib pads, charges defibrillator, applies electrical therapy on command from lead once patient is cleared, connect capnography lead, applies additional electrodes and non-invasive monitoring tools when possible and acquires 12-lead if indicated.

IV access-                 Specialist; set up and establishes IO access, administers fluids and drugs PRN on direction of team lead. Assist with obtaining glucometry.

Pharmacology-        Specialist (ALS); assists team lead, obtains, draws, constitutes indicated medications, mixes drips, assist IV position with administration.

Integration

A model for initial team assignments

Position assignments are a tool that can assist your team in accomplishing complex tasks. In a work environment that frequently includes overtime and swing assignments with apparatus and crews we may not be familiar with. Standardized position assignments can help personnel and the organization achieve a higher level of performance in spite of staffing issues, and more complex treatment goals. One goal is to minimize the shift/station/apparatus variability that occurs as a normal process when crews find what works for them. This is fine if you know you will always be working with the same people on the same piece of equipment, but that seems to be the exception now rather than the norm. Another goal is developing a system for deploying and delivering more advanced tools and skills consistently and effectively. Consider that the practice of team-based EMS is already promoting teamwork and assigned roles in dealing with critical medical events like cardiac arrest. Because of the advantages, it seems reasonable that we could start practicing that way on every call to improve our performance and patient outcomes. We already apply these pre-assigned roles for firefighting activities, it should not be much of a stretch to apply it to EMS as well. Below is an outline model of how it might look, again it does not replace good decision making and must remain adaptable.

The Model Assignments for initial interventions

Alpha              (Officer)

•           Scene safety/Command/Communications with EDC

•           Patient/Family advocate

•           Assist with collecting patient information and history

•           Assist with staging equipment and manpower

•           Assume #2 CPR position during resuscitation if needed

Bravo               (Jumpseat)

•            Lead EMS provider- first to patient – marks patient contact

•         Deploys with Tablet and monitor

•         Assesses patient and determines need for resuscitation

•         Primary patient assessment/interview/determine nature of call

•         Directs care of patient by crew

•         Documents interventions with accurate time stamps

•         Develops and communicates treatment plan to team

•         ALS performs procedures outside others scope of practice

•         Communicates with patient’s family and med control PRN

Charlie             (Jump seat)

•         Forcible entry if needed

•         Deploys with blue & red bags

•         Assumes #1 compressor position during resuscitation

•         Obtains patient vitals & physical exam

•         Procedures as directed by lead within scope of practice

Delta                (Driver)           

•         Deploys with drug & IV boxes

•         Assumes control of airway during resuscitation

•         Secure scene for incoming resources

•         Stage patient moving equipment

•         Procedures as directed by lead within scope of practice

ALS                 (any position)

•         If an ALS provider is assigned to a position other that Bravo/lead EMS provider, they will assume the role of the Bravo/lead EMS provider if the patient is presumed, or found to be in need of, ALS care and/or evaluation.

Summary       

Emergency medical services are increasingly driven by outcomes and the application of tools and skills with proven benefits. Delivery of these devices and skills requires greater organization and communication to produce favorable outcomes. The adoption of formal crew assignments and a team-based approach to EMS can produce more efficient and effective care and thereby improved outcomes. It is a new way of thinking for most but not one we are unfamiliar with.  Our daily activities, finances, team sports, card games and hunting all require strategy and tactics to produce a successful outcome. We can apply teamwork, new tactics and technology to deliver our services to save more lives and improve quality of life for survivors.

Ready? Set? Practice!!

Wake up call

Wake up call

By Alan Perry

October 11, 2015

The Fire department acknowledges that it’s EMS SOP’s largely have not been updated since the consolidation of its Fire & EMS Divisions nearly 20 years ago. The rapid changes to the practice of EMS, including high performance EMS, crew resource management and position assignments brought a group together to re-evaluate and create operating guidelines for EMS, as well as develop training, deployment and feedback mechanisms. Our current guidance comes from the old SOP’s, a handful of Medical Directives and the regional EMS Protocols. Most other departments rely on these same mechanisms locally, nationally, there seems to be a tendency to develop agency/system specific protocols and SOG/SOP’s by agencies that find this lacking. This Department is pushing into new territory with its EMS activities, rapidly adopting practices and methods that have proven success with the goal of saving as many lives as possible with the latest science and technology. The regional protocols have not kept up, and the complexity of EMS operations has increased as well. The field forces are expected to keep up with these changes and be prepared to apply these new skills without any additional training resources being made available. The Department hopes that developing their own resources (protocols/ SOP’s/etc.) will give those in the field the resources they require to reference and be prepared to use these new tools.

A quick internet search reveals that there are many good models of EMS and agency specific protocols/ SOP’s & SOG’s. What I find lacking is training plans for communication to, instruction of, and feedback for providers. In fact it seems many departments, while communicating the requirements of maintaining certification and/or licensure to their providers are quite forthcoming, there is no reciprocal statement defining the agencies commitment or responsibility for training to its providers. While I am happy to embark on that task, I feel it will be futile since any attempt to compel even a willing organization to commit funding & staffing at any defined level will likely not be supported.

So, before I attempt anything like that, I ask that anyone with a similar circumstance take a moment and reply with their experience (especially if successful) so I can at least move forward with reasonable expectations.

Thanks,

Alan

Fire based EMS Position Assignments

PROPOSAL

Model Position assignments for fire units on EMS calls

By Alan Perry

October 7, 2015

Purpose

Position assignments are a tool that can assist your team in accomplishing complex tasks. In a work environment that frequently includes overtime and swing assignments with apparatus and crews we may not be familiar with, standardized position assignments can help personnel and the organization achieve a higher level of performance in spite of staffing issues and more complex treatment goals. One goal is to minimize the shift/station/apparatus variability that occurs as a normal process when crews find what works for them. This is fine if you know you will always be working with the same people on the same piece of equipment, but that seems to be the exception now rather than the norm. Another goal is developing a system for deploying and delivering more advanced tools and skills consistently and effectively. Consider that the practice of high performance EMS is already promoting teamwork and assigned roles in dealing with critical medical events like cardiac arrest. Because of the advantages, it seems reasonable that we could start practicing that way on every call to improve our performance and patient outcomes. We already apply these pre-assigned roles for firefighting activities, it should not be much of a stretch to apply it to EMS as well. Below is an outline model of how it might look, again it does not replace good decision making and must remain adaptable. Feedback welcome and encouraged, especially if you are already practicing some form of this.

The Model Assignments

Alpha             (Officer)

·       Scene safety/Command/Communications with EDC

·       Patient/Family advocate

·       Assist with collecting patient information and history

·       Assist with staging equipment and manpower

·       Assume #2 CPR position during resuscitation

Bravo              (Jumpseat)

·       Lead EMS provider- first to patient – marks patient contact

·       Deploys with Tablet and monitor

·       Applies defibrillator and directs resuscitation efforts during resuscitation

·       Primary patient assessment/interview/determine nature of call

·       Directs care of patient by crew

·       Documentation

·       Develops and communicates treatment plan to team

·       ALS performs procedures outside others scope of practice

·       Communicates with patient’s family and med control PRN

Charlie                        (Jumpseat)

·       Forcible entry if needed

·       Deploys with  blue & red bags

·       Assumes #1 CPR position during resuscitation

·       Obtains patient vitals & physical exam

·       Procedures as directed by lead within scope of practice

Delta               (Driver)          

·       Deploys with drug & IV boxes

·       Assumes control of airway during resuscitation

·       Secure scene for incoming resources

·       Stage patient moving equipment

·       Procedures as directed by lead within scope of practice

ALS                 (any position)

·       If an ALS provider is assigned to a position other that Bravo/lead EMS provider, they will assume the role of the Bravo/lead EMS provider if the patient is presumed, or found to be in need of, ALS care and/or evaluation.

Summary                       

Emergency medical services are increasingly driven by outcomes and the application of tools and skills with proven benefits. Delivery of these devices and skills requires greater organization and communication to produce favorable outcomes. The adoption of formal crew assignments can produce more efficient and effective care and thereby improved outcomes. It is a new way of thinking for most but not one we are unfamiliar with, team sports, card games and hunting all require strategy and tactics to produce a successful outcome. We can apply these tools to the delivery of our service, save more lives and improve quality of life for survivors. 

Debilitating Decision Delays

Deliberating Decision Delays

The performance pitfall perils of procrastinating for proof

By Alan Perry

3/8/15

In the era of evidence based best practices for the EMS and Fire services, we are beginning to accept that this ideal as the norm rather than the exception. Those holding the purse strings and writing policy are more often compelled to act based on evidence and proof of value before allocating resources. This is of course the most responsible and practical thing to do, but should this rule be applied to every decision we make? Is there still value in making decisions based on reasonable expectations? Does every project have to have some specific, measurable and obtainable outcome to have merit? If we are bound by this dictum we would all be hemmed up in a hopeless feedback loop of indecision every time we tried to do something new and unproven for which no “proof” exists. Someone actually has to do something before any proof or positive results can be found, and occasionally the outcome is not what we expect even if it is a positive one.

A perfect example is public education; fire prevention programs have a proven and documented history of success as declining fire events and related injuries can attest. Why then, do we have to prove that an injury/illness prevention program will work and establish a set of metrics to analyze it? The benefits of education and prevention programs go far beyond reducing injuries and illness, although those would be primary goals. The benefits generally translate into greater public support, better reactions to emergencies and participation in community health and safety, things that can be difficult to measure but can have a profound impact on the community’s resistance to emergencies of all types.

The same logic can be applied to integrating healthcare services and incorporating EMS systems into the patient care continuum. Start where you stand, do not be blinded by the wide array of possibilities. I assure you, that while you are doing your research and developing evaluation methods to measure your success, someone will be acting. EMS is not alone in this arena, hospitals, public health, health care systems and insurers are all looking for ways to improve their bottom lines while improving the quality of care for patients as mandated by the Affordable Care Act. Most traditional Fire and EMS systems are ill prepared to step into this fast paced arena using old management philosophies and insufficient resources compared to the other players.

In areas where diversity in delivery models is significant, consensus is the enemy. I’m not saying cooperation isn’t desirable or even preferred, I’m merely pointing out that while trying to mesh too many disparities it will be difficult if not impossible to reach a decision that will enable all parties to benefit and maximize the use of the resources they have. I have seen such attempts last for months if not years with no tangible results or even progress. Sometimes you have to take the tools you have, the resources you have, and use them to start pushing the ball forward.

The word I’m looking for is responsibility; as public safety professionals we have a responsibility to the citizen taxpayers to provide responsive and caring service, keep up with the state of EMS & Fire sciences, adopt and develop the most effective care and delivery practices, dedicate sufficient and appropriate resources to training and equiping our providers, and act with purpose when we know our system needs work. We can ill afford to attend another unproductive meeting or continue to conduct business as usual when that is not producing the change our services desperately need.

We have known for several years that routine back-boarding of patients is of no benefit, and can actually be harmful, why do we still do it? Narcan, in the hands of a first responders or bystanders saves lives, why don’t we permit it? Fire and EMS personnel are injured every week in vehicle accidents even though the evidence indicates priority responses have no proven relationship to patient outcomes, why do we run two, three or four vehicles lights and sirens to any EMS call? We know integration of healthcare and EMS benefits patients and the EMS systems involved, why have we not yet acted? These are just some examples of best practices that are delayed by our traditional decision making process. It is broken, it may be time to re-evaluate our command structures and seek a leaner more responsive model that is made possible by using modern communication tools.

As a test, try asking one of those questions of the person next in your chain of command. If you have a responsive and nimble organization that person should be able to answer the question directly and have the ability to effect an immediate change if needed. If you do not have a responsive nimble organization you will have to wait for an answer from the ivory tower, if you ever get a reply at all, it will likely not result in any change or further discussion of the matter. You can’t hold an individual responsible for that type of problem, it is cultural in nature, it is no wonder that when leaders of such organizations gather to address the need for change and new challenges facing them, they are hopelessly mired in the apparatus of consensus and “chain of command” decision making.

I don’t like putting stuff like this out there without trying to point us in the right direction for solving it, so here it goes;

·                       - Flatten the command structure.

·                        - Use the freed-up resources to allocate sufficient personnel to training and organization                          development.

·                        -Spread out authority and accountability for decision making.

·                        - Don’t be afraid to do the right thing.

·                         -Do it now

The Heart of High-Performance EMS

The Heart of High Performance EMS

By Alan Perry

3/10/2015

What makes a High Performance EMS system work? It’s not just the mechanics of the operations and program development, but also its culture –the people and attitudes that make it work. It is not new and innovative practices, advances in the field of mobile healthcare, a charismatic Chief Officer or a dedicated OMD. These are influential, however I doubt any system could effectively support that type of change and progression without the firm foundation of a strong and supportive organizational culture. If you examine the most proactive, progressive and respected organizations providing EMS in the nation; such as MedStar in Fort Worth, Texas, or The Richmond Ambulance Authority in Richmond, Virginia, you notice something very special right away. No one sitting in easy chairs watching TV, No sloppy facilities, everyone embraces, and can articulate the mission, goals and achievements of the organization, what is this? It is pride, empowerment and accountability, all things born out of a positive organizational climate. This is the foundation these organizations build upon to be leaders and innovators in Emergency Medical Services.

This is not an idea that can be mandated as a performance criteria on an evaluation, it must be supported throughout the organization by effective leadership, administration, training, logistical support, public relations, public education, medical direction and healthy relationships with allied professions in hospitals, public health and nursing. Several of the most effective systems sprang from collapse of failed delivery models, taking the opportunity to rebuild the EMS delivery system from the ground up to be focused on performance and delivery of quality care. Common features include an organization focused solely on delivery of EMS services and related health and public education programs, Dedicated dispatching facilities, training facilities on par with a good community college, a full-time OMD(s), In-house vehicle maintenance, supplies and logistical support, use of system status management and call prediction software, and a nearly flat organizational structure with liberal and frequent lateral communication. Such a design promotes rapid response to any threats or opportunities that present themselves, allowing the organization to be nimble and proactive in meeting the needs of the public and its providers.

These organizations value efficiency as their responsibility to patients and the general public. Efficiency improves patient care as much as it makes effective use of public funds, if they are used at all. Every aspect of EMS system design and delivery has been carefully thought through and implemented to maximize utilization, reduce waste, and maximize the use of precious resources. Providers are supported with adequate training, field support, and career progression. There is accountability and questions/problems are solved or addressed quickly. The cost of providing this type of service to traditional, Fire-based EMS or EMS-based Fire systems is not a monetary one; it may be the dismantling of existing command and management structures, and drastic changes to the organizational culture. This is the future of EMS, high-performance EMS is here to stay and is what the public and providers deserve.

Be Safe, AP

MedStar 911

http://www.medstar911.org/

Richmond Ambulance Authority

http://www.raaems.org/

Wake County EMS

http://www.wakegov.com/ems/Pages/default.aspx

King County Medic One

http://www.kingcounty.gov/healthservices/health/ems/MedicOne.aspx

Hidden Fire

Hidden Fire

Unseen threats to Emergency Services

By Alan Perry

February 11, 2015

Many a life and countless millions in losses can be attributed to the effects of hidden fire. These fires spread undetected, concealed in walls, floors and utility chases, destroying the structure and spreading to remote locations with catastrophic consequences. It is a threat every firefighter should know well and aggressively seek to identify, locate and extinguish before declaring a fire under control. This principal is an easy one to understand but also easy to overlook in the heat of battle. Many emergency services have similar threats to their ability to achieve their primary purpose and mission due to hidden threats within and outside the organization. Many appear well on the outside only to collapse under pressure when the underlying structure fails due to these “hidden fires”.

 The structural integrity of your organization can be compromised by inadequate training, poor morale, lack of public or political support, overextended resources, poor communication or any number of other threats and weaknesses you can name. The critical needs of the organization can be overlooked while distracted by ancillary programs, new services and trying to keep up with new trends. Some organizations seek out new responsibilities, programs and stature, enticed by State or Federal funding, setting up new services at the expense of those critical needs. I will argue that emergency services should do more to prepare for large scale events, integrate with more effective healthcare or cultivate needed specialized resources. These are all part of the public expectation and our mission just as the core services we provide are, there must be a balance between these “nice to haves” versus the “must haves”.

Identifying the threat or existence of the hidden damage is not difficult if you are in-tune with your organization. Objective quality control monitoring of your resources, human and physical, will give you the best and quantifiable evidence. Structural collapse rarely occurs without giving some evidence or clues to a developing problem, that’s why we sound floors and look for smoke and heat where it should not be. Similarly, problems within your organization will reveal themselves if we use common management tools to evaluate failures in our equipment, processes and personnel. Long standing problems will compound and accelerate the damage, like a hidden fire in a structure already weakened by termites.

To locate the source of this insidious damage we have to look at data, ask questions, and sincerely want to improve the situation without fear, or presumption, of what will be found. How effective are your firefighting operations? How reliable is your apparatus? How frequently do your providers deviate from operational or EMS protocols and SOP’s? Are there training issues? Funding issues? Do your personnel have the right tools and resources? Do they function well as a team? Are all concerns heard without reproach? These questions may reveal the symptoms; the cause may be well removed and must be located before it can be corrected and the damage stopped.

Stopping the destruction will require correction of the identified fault. It may also involve correcting other faults propagated elsewhere secondary to the origin. As with hidden fires, there will likely be extension to other parts of your organization. Your organizational culture can help you manage these shortcomings, or it may be decayed and damaged by the process itself. As with structures that are hopelessly corrupted by fire, the only solution may be demolishing it and rebuilding.  That would be an extreme outcome that will permanently alter the persona of the organization, but it would certainly give it the opportunity to rebuild the organization as it should be and on a solid foundation. An alternative that may be more appealing would be targeted restoration of affected components, like remodeling a kitchen, retaining the existing structure while upgrading the area in need, taking care to carefully examine other parts of the organization for weakness. So what kind of "house" do you want to inhabit? One with a solid structure, but perhaps without the fancy kitchen and showers, or a showplace that has cracked walls and creaking floors. Choose wisely.

Be Safe,

Alan

Salvation or Salesmanship?

Salvation or Salesmanship? A closer look at Impedance Threshold Devices.

By Alan Perry

January 30, 2015

Cardiac arrest science and outcomes have been changing at a rapid pace. New procedures and equipment have radically changed the way we approach these cases and have significantly improved the outcomes for victims in some locales. Techniques and equipment that are proven to be effective require training for the pre-hospital provider to apply them correctly and consistently. The Impedance Threshold Device (ITD) is one such tool. Although the device is deceptively simple to use, its basic function and correct application are not well understood by providers who have simply been instructed when and where to use it. ITD’s are not universally accepted as being effective or safe. Questions have been raised by independent researchers and the Federal Government about the validity of the claims of the manufactures supported research, implying that errors in study design, data collection or bias may be involved. It would seem that the ancient caveat of “buyer beware” still applies.

The basic selling point for these devices is that in the setting of cardiac arrest, the use of the ITD improves the return of blood the heart, thereby improving preload and stoke volume induced by effective CPR while reducing ICP. The mechanics of this are fairly simple; once the ITD is in place passive inspiration ceases due to the effective occlusion of the airway by the ITD, When the chest is compressed effectively the pressure expels blood from the heart and air from the lungs, when the chest recoils air cannot return to the lungs, this produces negative pressure within the chest wall which can assist blood in returning to the heart. In effect it sacrifices respiration for circulation. This would seem to be quite effective in a previously well oxygenated patient since the circulating blood presumably would still be carrying enough oxygen to postpone permanent damage to organs.

Questions about the research on, and use of ITD’s, are mounting and have merit. The Food and Drug Administration (FDA), in a draft document published May 6, 2014 to its Circulatory System Devices Advisory Panel posed questions about the research data, safety and effectiveness of the device. Among these questions some fundamental problems with the research were cited with the statement that the research does not support the assertion of improved survival if used alone with standard Cardiopulmonary resuscitation (CPR). The FDA’s Data Safety Monitoring Board (DSMB) found that the studies were not effectively blinded, that they excluded non-cardiac etiologies, and Emergency Medical Services (EMS) providers were not blinded at all. Additionally, the document asserted that the development of pulmonary edema was 30% more likely with ITD use, and that the manufactures should consider labeling to further define which patients are appropriate candidates.

Before we jump to any conclusions about ITD’s, whether they are effective, or just the latest gadget we have been sucked into buying, I think we should examine and consider what we know now. If you think it through, considering the evidence, what we know about the pathophysiology of cardiac arrest and the various co-morbidities, I think it can still be an effective tool if we consider the totality of our patient’s presentation and history and become more selective in the application of this tool. In the setting of a witnessed cardiac arrest, presumably a myocardial infarction or arrhythmia, the selection of the ITD to improve the effectiveness of CPR would seem to be beneficial, provided effective compressions and airway management are also present. Conversely, it would seem that a victim of cardiac arrest secondary to some other event such as a drug overdose or pulmonary edema which was primarily respiratory in nature would more likely benefit from aggressive ventilation with effective CPR to correct the hypoxia that precipitated the event.

Unfortunately, the ITD is not currently marketed or deployed with these considerations. I believe manufactures must be more diligent in conducting/supporting research that promotes patient safety over sales. The government regulators must be more diligent in reviewing the research and outcomes. Those responsible for applying new technology, devices, practices, protocol and training within the local jurisdiction must do their own research on them as well. We are taught from an early age to hear both sides of an argument before reaching a decision, to beware of products that sound to “too good to be true”. A thorough evaluation process that involves the providers who will be using these devices as well as a training program that imparts an appropriate level of understanding of the pathophysiology and mechanics of the devices is a must.

A more refined set of indications, contra-indications, and a better understanding of the pathophysiology involved by providers, as well as better refined protocols should led to more successes when using these devices and fewer complications for patients. I offer this example for consideration:

To bring it home, we have to ask ourselves about new things that are presented to us, evaluate them carefully and validate any claims made by any manufacturer or salesman. Be aware that shrewd companies may suppress negative information about their products or services on the internet, so information from this source may be unreliable or downright misleading. 

Be safe and do your research,

Alan

References:

Food and Drug administration, Data Safety Monitoring Board website:

http://www.fda.gov/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/CirculatorySystemDevicesPanel/default.htm

A trial of an impedance threshold device

http://com-emergency.sites.medinfo.ufl.edu/files/2013/02/A-Trial-of-an-Impedance-Threshold-Device.pdf

American Heart Association

http://circ.ahajournals.org/content/130/Suppl_2/A248.short

Is diversity a good thing?

Is diversity a good thing in public safety?

Alan Perry

December 2, 2014

Diversity is defined as “The fact or quality of being diverse; difference; a point or respect in which things differ; variety or multiformity”, according to The American Heritage Dictionary. Having a diverse workforce has clear advantages, but what purpose does diversity serve in determining how to best treat a patient or mitigate an emergent situation? Is it just the way it has always been done, do “best practices” really matter, or is it that we just think our way is the best and that’s that? Why does every station, agency, municipality, region and state have a different set of policies, procedures and structure? I would argue that some degree of diversity is necessary to accommodate variations in resources and the needs of the public, but that only goes so far. We have gone to great lengths to establish national standards for EMS & Fire training, certification and best practices for activities in these realms, yet we are slow to adopt and implement them uniformly. We work in positions of public trust, as such we should move aggressively toward earning and retaining that trust by providing services that are prudent, proven and effective.

You may recall a story of an ancient city called Bable, its tale is told in the Hebrew Bible in the book of Genesis, chapter 11, verses 4-9. In this story a great civilization arose (public safety) and sought to meet their god in person (a perfect world). To accomplish this they all collaborated to construct a great tower (policies, procedures, etc.). As it were, the Lord had reservations about this and sought to thwart their efforts and thus confused their communications via creating many languages (diversity) where there was once one, thus preventing them from obtaining their goal. While our goal is somewhat less lofty, I find it perplexing that we ourselves have imposed this confounding practice of diversity on our organizations willingly. To be fair, we did have to develop our own systems before any of the best practices were yet discovered (with the exception of our stubborn indifference to the EMS Agenda for the Future and its subsequent reiterations.). This does not absolve us from the responsibility of setting things right. We must now deconstruct our defective structures and rebuild using sound and proven practices.

I understand the pessimism some of you have about the ability of these leaders to put aside business as usual and turf battles to create a true regional system. Doing so could transform public safety into a much better integrated and responsive framework that can serve the citizens, and the professionals that have chosen to serve, in a much more efficient and effective manner.  These leaders may be justifiably concerned with control of resources and allocation of those resources to the communities they are charged with protecting. Some, if not all, of these localities are already stretched thin on some key assets such as ambulances and paramedics. Will the region take the next step and begin reallocating resources across boundaries to solve response issues?Regionalization is an attainable goal but should not be used to solve individual department’s shortcomings with staffing and resource allocation.

The cost of change is significant, but if done collectively could produce significant improvements in efficiency and effectiveness that will outweigh and justify the cost. We are a long way from national EMS protocols or standard staffing models, but state and regional models are already in place that should serve as examples for Fire and EMS systems as they move toward a more integrated and uniform approach to providing services. Imagine if every firefighter and EMS provider was trained to employ tools and methods that were proven to work and adopted as a best practice by NFPA and/or NREMT (or for that matter VDFP and VAOEMS). The need for agency specific operational policy and protocols would be minimized instantly. Training, logistics and administration could be streamlined and regionalized with little difficulty. It might even be possible to fill those staffing holes with some of the administrative staff that would be out of work.

 Happy days indeed,

Alan

Add PEP to your EMS public education

Prevention, Education and Participation (PEP)

An EMS Public Education Proposal

By Alan Perry

October 14, 2014

 

 

Abstract

This proposal reviews new practices for public education in EMS, elaborates on the benefits of these practices to the public and the organization, and contrasts these with current Fire prevention activities. Consideration is given to public awareness, and public education in first aid, CPR and AED use as a starting point for improving community reaction and knowledge of these events. It also suggests topics for internal training and action that affect perception of our activities by the public relevant to patient family advocacy, and relationships with patient care partners. The goal desired is a more efficient, and effective system, that seeks community involvement and support for the mission of the Fire Department.

Introduction

The power of public education has been demonstrated by the results of Fire Safety and Prevention programs nationally. It seems reasonable to conclude that the same methods and tactics can be applied to Emergency Medical Services (EMS), with similar results. Advocacy and collaboration in the field of EMS are a stated goal of the National EMS Management Association's Strategic Plan (NEMSMA, 2010, p. 4) , and others (IAEMSC) (NAEMT) (NHTSA, 2006, p. 8) (VAOEMS, p. 5) who have conducted recent research toward improving EMS system performance. Many systems have already documented the effectiveness of such programs in improving patient outcomes (Neumar, 2011), reducing nuisance calls (Johnson, 2011), improving public reaction to medical emergencies, improving employee morale, and reducing costs. Any one of these benefits is desirable and seems to justify exploring the concept. No national standard currently exists for EMS public education although it is clear the field of EMS is headed in that direction. A proactive approach to EMS system management will place the organization in a positive light with all stakeholders, and demonstrate to the public and employees, that the Department is best capable of providing this service.

This document represents the first installment of a plan for comprehensive EMS system improvement which will bring the organization in line with the best practices in EMS across the country. As with any major change, it is best managed incrementally, it must be supported by the administration, line officers and individual providers. All stakeholders will benefit from the effort. Additional programs will need to be developed to address other related system issues (appendix), improve employee morale and improve system efficiency. Some related areas of concern are; efficient and effective use of technology, improving EMS v. Fire cultural differences, staffing and system management issues, healthcare system integration, quality control and quality improvement, and employee retention and training.

 

What is EMS public education?

EMS public education is a tool; a tool which will accomplish the goals of improving patient outcomes, system performance, system efficiency, provider morale and public awareness. Through education the organization's goals can be communicated clearly and consistently to the public. The key components of EMS public education are awareness of the function, capabilities and needs of the EMS system, proper reaction to EMS events, and how to participate in and facilitate the operation of the EMS system. Through such programs the community may become involved to whatever extent each individual is comfortable doing so, while building trust in, and understanding of the organization. Such education is preferable to the speculation, rumor and disinformation that may fill the void in the absence of a solid public education program. Fire and Life Safety programs do not fully accomplish the goals of EMS public education.

 

How will EMS public education benefit the patient?

Patient outcomes are directly linked to treatment throughout the continuum of care, from the initial public recognition and reaction to the event, through discharge from the hospital and beyond. EMS public education should seek to add the general public or layperson to that healthcare team, and thereby improve the quality, and efficiency, of the delivery of care. By doing so, recognition and appropriate reactions are achieved, and initial care is provided within the critical window required for survival from the most serious medical events. Even in less serious medical emergencies, the time to an initial intervention has an effect on morbidity and mortality (National Highway Traffic Safety Administration, 1996, p. 37).

 

How will EMS public education benefit the public?

The public has a vested interest in the performance of the municipal EMS system. This system affects the quality of life in the city, intermittently touching the lives of nearly every citizen. A system that can operate efficiently and produce superior outcomes is an asset to the taxpayer, both as a resource and an investment. EMS public education programs provide a benefit to the public, and simultaneously improve the performance of the system. The significant potential monetary and human cost savings that can be realized should be considered when calculating the cost of providing public education programs and determining the level of support they receive.

 

How will EMS public education benefit the Department?

Encouraging citizen participation in the system, gives the public a shared stake in its performance. The benefits of greater community involvement extend beyond the effect on outcomes and efficiency. Greater understanding of the EMS system, its challenges, needs, and goals, by the public, will lead to greater support on a wide range of issues. An effective EMS education program will inform the public, and garner their support for the goals of improving patient outcomes and overall system efficiency. With this knowledge, they will be able to exert influence and take ownership of their EMS system when decisions are being made by local government, or when legislation at the state or federal level is presented that affects delivery of EMS services. A positive public image and informed public will improve provider morale and lead to more responsible and appropriate use of the system.

 

How will EMS public education be paid for?

Cost is understandably an obstacle in the current economic climate. These programs may not require any additional funding. As written, they will require some collateral duty assignments which could be voluntary, or assigned to specific positions suited for that role. A no, or low cost method of putting these into play, without taking away from existing fire and life safety programs, could be achieved by assigning these duties to individuals, engine companies, and EMS supervisors willing to perform the task on-duty. Positive results may support funded positions when fully implemented, these costs may be completely or partially offset by system efficiencies, and a measurable improvement in patient outcomes. As a temporary solution some funding may be available through VAOEMS, DHS, and other federal legislation such as H.R.3144 (GovTrack.US) if passed. A less attractive method would involve using volunteers from CERT or FireCorps programs, or even volunteer career staff. The choice will be dependent on the level of commitment the Department is willing to make.

 

What EMS public education is appropriate for your department?

Public education in EMS comes in many forms; some are directed solely at the public, others involve educating our healthcare partners. The two areas of focus that may be most beneficial, easiest to implement and least expensive are directed at the general public and are the primary subject of this proposal:

• Awareness programs for communities, civic organizations, and businesses
  

There are many communities and civic organizations that would welcome any form of EMS education we are willing to provide. Assisted living facilities, Girl/Boy Scout troops, Churches, businesses and other City departments are likely target groups. The information we can share could include injury prevention, simple operational information, and how to receive basic first aid and CPR training for their members or staff. A successful program would bring these groups to bear in the community as our allies. Through this type of outreach and public relations effort, the goals and practices of the Department will be better understood by the public. This improved understanding and knowledge should induce a better reaction and cooperation during actual EMS events in the community. CERT and Citizen CORPS (FEMA) programs could be an extension of this type of program.

• Community first aid, CPR and AED training
  

The public is not integrated into our current EMS system. Most see an ambulance for the first time when they call 911, or are on the receiving end of our services. Very few know CPR or basic first aid, which makes them less likely to react properly, or be willing to follow CPR instructions effectively, if at all. Training in these skills will instill proper reaction to these events, and effective intervention by the lay-public prior to our arrival. An involved and educated public can improve patient outcomes and reduce unnecessary calls. Many agencies, including King County, Washington (Seattle & King County EMS, 2011), Boston EMS, and FDNY (New York City Fire Department), have already demonstrated the effectiveness of this training. Several organizations; Medtronic, Leardal, and the American Heart Association (AHA), offer programs and resources to accomplish basic first aid, hands-only CPR and AED training.

• EMS family advocate
  

In addition to public education there is a demonstrated need for provider education within the department. The easiest and most beneficial programs are EMS family advocacy and EMS liaison training. Our providers and Officers should be trained to act as family advocate on critical calls where family need emotional support, explaining the care being given, the necessity for treatment, and the need for cooperation during a significant event involving a loved one. By providing kind and compassionate care for the family as well as the patient, the department will enhance its public image and avoid causing undue distress to friends and family of the patient. Other agencies, such as King County, Washington (Neumar, 2011, p. 2900), have demonstrated the effectiveness of treating significant EMS incidents much like a fire incident, with assigned roles, and a command structure which would include a family advocate position, and tracking of benchmarks.

• EMS Liaison for health care facilities
  

Many facilities we deal with on a daily basis are not aware of the capabilities of our system or the needs of our providers when they request patient transports. This leads to misunderstanding, frustration, and inappropriate use of resources. For a relatively small investment in time, our patient care partners could be educated to understand our needs when receiving a patient for transport, and the available non-emergency transport resources. This type of interaction with our counterparts will establish a good starting point for bringing greater healthcare system integration as suggested by the IAFF (IAFF-Department of Emergency Medical services, 1997, p. 18). Such a program also compliments suggested changes proposed by The EMS agenda for the Future (National Highway Traffic Safety Administration, 1996, p. 10).

 

How will EMS public education be implemented?

The implementation of these initiatives should involve personnel that embrace the EMS mission and the goals of this education program. Making duty assignments for personnel otherwise inclined will inhibit, if not prevent, the success of the programs. The message should be pushed out, promoted, and implemented as quickly as possible to maintain momentum and achieve measurable results in a reasonable time. The entire process needs to be open, keeping in mind that the cooperation, and involvement of the members of the department, is as important as that of the public. EMS public education may need to be completely separated from existing fire prevention programs, including fire truck demonstrations and station tours, to avoid being marginalized or lost in the more dramatic and colorful fire prevention and life safety messages. Perhaps with time this perception and promotion issue will abate. NHTSA (NHTSA, 2006) has published an implementation guide for the EMS Agenda for the Future, which contains specific recommendations directly related to this issue. Other resources include the Public Information, Education and Relations in EMS (PIER) manual, also published by NHTSA. This proposal incorporates many of these recommendations and suggests this outline for the programs proposed:

Web-Based Prevention, Education and Participation (PEP) program

1. Develop and publish online resource for PEP.
2. Link to developed local, state, federal and private resources that are already developed.
3. Provide locale and service specific information and contact points.
4. Solicit feedback, Monitor and update frequently.
5. Use as contact tool for direct programs & volunteer opportunities.

Awareness program

1. Identify qualified and committed personnel.
2. Develop a general information program about our mission and validate it.
3. Create list of potential organizations without prejudice (include all).
4. Make contact with community, provide information, and offer services.
5. Schedule presentations and dedicate time to complete program.
6. Give presentation, encourage feedback and record comments.
7. Provide report, need for re-contact for training.

Community first aid, CPR and AED programs

1. Identify qualified and committed personnel.
2. Adopt or develop curriculum and validate it.
3. Promote the program within the community.
4. Create target group list, use contacts from awareness program.
5. Make contact with organization, explain and schedule the program.
6. Conduct class on schedule without interruption.
7. Issue certificates, publish roster in local paper.
8. Create database of attendees for follow-up.

EMS family advocate

1. Create curriculum for EMS PIO course, validate.
2. Consider making the curriculum part of regular recertification requirement for all providers.
3. Identify who must assume this responsibility during calls.
4. Require this course for all EMS supervisors and company officers.
5. Create SOP or directive to address responsibility and performance expectations.    
6. Follow up on any questions not answered during presentation.

EMS liaison for healthcare facilities

1. Identify qualified and committed personnel.
2. Identify issues and create talking point list, validate.
3. Create list of facilities to contact.
4. Include hospitals.
5. Schedule visits and dedicate time for meeting.
6. Listen to their needs and present our concerns.
7. Develop plan jointly to improve performance.
8. Create facility point of contact list.
9. Follow-up on issues, work toward resolution.

 

Conclusion

These proposals are ambitious; there will undoubtedly be some push-back until everyone understands the full scope, goals and benefits of these programs. With time a perceptible change in attitudes toward EMS, and EMS education within the department, and among the public should be observable. This can be enhanced and reinforced by making the other necessary system changes as well. The Department's position as EMS provider for your city may already under scrutiny; many systems across the nation have been dismantled, or reorganized, because of failure to adapt to changes in the field of EMS system deployment, resource management, and patient care standards. Your department should consider the merits of these programs and develop them for the good of the public, the providers, and the organization.

References

AHA. (n.d.). Hands only CPR. Retrieved March 18, 2012, from American Heart Association: http://www.handsonlycpr.org/

FEMA. (n.d.). Citzen CORPS. Retrieved April 4, 2012, from http://www.citizencorps.gov/index.shtm

GovTrack.US. (n.d.). H.R. 3144: Field EMS Quality, Innovation, and Cost Effectiveness Improvements Act of 2011. Retrieved April 8, 2012, from Govtrack.us: http://www.govtrack.us/congress/bills/112/hr3144/text

IAEMSC. (n.d.). IAEMSC-homepage. Retrieved April 8, 2012, from International Association of Emergency Medical Services Chiefs: http://www.iaemsc.org/

IAFF-Department of Emergency Medical services. (1997). Emergency Medical Services-Adding Value to a Fire-based EMS system. International Association of Fire Fighters.

Institute of Medicine of the National Academies. (2007). Emergency Medical services at the Crossroads. Washington D.C.: National Academies Press.

Johnson, K. (2011, September 18). Responding Before a Call is Needed. Retrieved April 4, 2012, from New York Times: http://www.nytimes.com/2011/09/19/us/community-paramedics-seek-to-prevent-emergencies-too.html?_r=3

NAEMT. (n.d.). NAEMT-Mission Statement. Retrieved April 8, 2012, from National Association of Emergency Medical Technicians: http://www.naemt.org/about_us/our_mission.aspx

National Highway Traffic Safety Administration. (1996). Emergency Medical Services Agenda for The Future.

NEMSMA. (2010). National EMS Management Association Strategic Plan 2010. Retrieved April 8, 2012, from National Emergency Medical Services Management Association: http://www.nemsma.org/AboutNEMSMA/StrategicPlan/tabid/420/Default.aspx

Neumar, R. e. (2011). Implementation Strategies for Improving out-of-hospital Cardiac Arrest in the United States: Concensus recommendations From the 2009 American Heart Association Cardiac Arrest Survival Summit. Circulation: Journal of the American Heart association, 2900.

New York City Fire Department. (n.d.). CPR to Go program website: http://www.nyc.gov/html/fdny/html/general/registrations/cprtogo/index.shtml. New York, New York.

NHTSA. (2006). National Highway Transportation Safety Administration; Implementation Guide- EMS Agenda for the future. United States Department of Transportation.

Seattle & King County EMS. (2011). 2011 Annual Report to the King County Council, p32. Seattle & King County, Washington.

VAOEMS. (n.d.). Virginia Office Of Emergency Medical Services State Strategic and Operational Plan 2010-2013. Virginia Department of Health.

 

 

Appendix I

 

Prevention, Education and Participation (PEP) program website

 

 

Vision

A universally useful and effective website for all individuals, groups and organizations needing information, materials and resources related to EMS services, improving outcomes, injury prevention and reaction to emergencies. A resource so compelling and engaging that it affects public perception, reaction and health behaviors. A continually evolving and dynamic resource that is recognized by the community and the broader health professions as a model for public education.

 

Purpose

This website will convey information via web links, video links and text on a variety of topics affecting public knowledge, perception and reaction to medical emergencies and injury prevention. It will integrate with online resources of the Fire Department, the Virginia Department of Health, The National Highway Transportation Safety Administration, and other resources that provide useful information supporting this message.

 

Organization

 Ideally the webpage will located through the Fire Department website-Public Education, being a distinct and separate from Fire & Life Safety. It needs to depart from the usual and traditional to be effective. The site will be very interactive and engaging, provoking reaction and engagement by the user. The webpage should be easily searchable and discoverable by both internal and external users searching relevant terms.

 

Website Outline

 

Public Education Resources-linked externally via keywords

            EMS System

                How our system works-video

            Reaction to emergencies

                Chest pain recognition and reaction    

                Stroke recognition and reaction

                Mental Illness

                Other emergencies

                    In the home

                    In Public

                    On the road

                Additional training resources

                    Hands only CPR

                    First aid

                    Babysitting programs

            Injury Prevention

                Fall Prevention

                    Severity of the fall problem

                    Self-assessment

                    Home survey

                    Other resource links

                Bike Safety

                    Rules of the road

                    Helmets and helmet laws

                    Other resource links

                Boater Safety

                    Water safety

                    Safety equipment

                    Water sports

                Hunting & Firearm Safety

                    Hunter Safety programs

                    Firearm safety programs

                Motor vehicle safety

                    Motorcycle safety & awareness

                    Seat belts & car seats

                    Towing and hauling

 

Pool & water Safety

                    Pool safety

                    Learning to swim

                    Other resource links

                Poisons and chemicals

                    Poison Control

                    Safe handling

                    Disposal

                Powered equipment

                    Tractors and mowers

                    Power tools

                Head injury & concussion

                    Consequences of repeated head injury

                    Recognition and grading tools

                    Avoiding head injuries

                    Other resource links

            Request a home survey

            Request a presentation for your group

            Sponsor a community event or prevention program