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