Agenda 2050 transparency question

To: emsagenda2050@redhorsecorp.com

Good morning, 

I attended the first Agenda 2050 meeting in Silver Spring. Since then I have been curious about the comments submitted by my peers about this project. I am unable to find any documentation or summary of those comments. As they are essential to the development of this Agenda, is there a plan for, or an already existing repository for them? As a suggestion, it might be useful to create an unbiased survey to document the responses to your questions in a transparent and open way so all can benefit from the experience.

Thank you,

Comments on the revised EMS 2050 Straw Man

Responses to the EMS Agenda 2050

revised Straw Man Document

Alan Perry

1/14/2018

What is your vision for ems in 2050, and how do we get there?

I think we must all first recognize that my vision for my organization and myself, in my socio-political environment, will likely be entirely different from the vision of another. The reality is that this Nation is made up of individual states, cities, towns and communities with vastly different resources and needs. I don't view that as a negative as the authors of this document seem to believe. EMS, as I believe we should call it, has evolved with, and adapted to, this diverse landscape. The larger changes to the healthcare system brought about by tort law and the affordable care act have pushed primary care relationships between physicians and patients to a new low. As a result EMS has been compelled to fill the void, a cycle this document will perpetuate. We have not yet achieved the goals of the original EMS agenda and should be working to close those gaps while recognizing the professionalism of those who choose this profession with greater support and recognition.

Will the vision and guiding principles in the straw man help steer the ems profession in the right direction?

It would be more like a hard left, socialized medicine to be specific. The hard-line on "social equality", which I believe EMS has always striven to achieve, seems very much like redistribution of resources. The reality is that each community can choose now what level of EMS services that want, need and can afford. This seems like a segway for the Federal government to gain greater control over the healthcare system and EMS.  The document does contain some positive ideas for preserving and promoting the workforce that are long overdue relative to hours, compensation and safety. But ideas are just that, without a clear mechanism to overcome outside influence, tradition and politics, it cannot be achieved. The document condemns volunteers outright and recommends their replacement with paid staff that most rural communities cannot afford. This will necessitate either redistribution of resources or new taxes to fund those positions.

Integrated and Seamless

Which recommendations are most important or won't help achieve the vision? What is missing that must be included?

Integration with the rest of the healthcare system has been a long standing need. In a monolithic organizational environment that can be easily achieved. In communities where several different hospital systems and EMS agencies operate it becomes much more complex. In the meeting I attended I noted that no hospital or healthcare system administrators where present. What is missing are the stakeholders.

Socially Equitable

Which recommendations are most important or won't help achieve this vision? What is missing that must be included?

I believe each citizen, community, city & state should be free to choose where they live, what taxes they will be subject to, what level of EMS service they desire and how they choose to staff and fund it. Redistribution of wealth and resources is a game in which the losers will be taxpayers, providers and patients. EMS in my experience has always provided the best service possible with the resources available without bias.

Inherently Safe

Which recommendations are most important or won't help achieve the vision? What is missing that must be included?

I suggest that it is impossible to make an emergency inherently safe. The predominant injury pattern for EMS providers are back and extremity injuries secondary to lifting and moving patients. The very nature of the EMS environment necessitates manual lifting and moving of patients in some circumstances. To the greatest extent possible mechanical devices such as powered stretchers and loading systems must be employed. This is not yet a universal occurrence, it should be a priority until it is through enforcement of existing OSHA guidelines and availability of grants to fund up-fitting these devices. There are many cultural barriers to achieving inherent safety as well, many organizations still require "lights and sirens" responses even though the practice has no proven benefit.

  

Sustainable and Efficient

Which recommendations are most important or won't help achieve the vision? What is missing that must be included?

Provider compensation, as well as professional recognition are key factors to creating a committed, professional, mobile and long-term workforce. Public education is also a frequently overlooked/neglected component. Both of these require significant cultural change in the way the provider and the public are viewed by EMS administrators. The keystone in all this is funding, who will pay for it?

Reliable and Prepared

Which recommendations are most important or won't help achieve the vision? What is missing that must be included?

Fire-based EMS and third service EMS are usually the most reliable, but volunteer systems are more scaleable when disasters strike (yet this document seeks to abolish them).  Evidence-based practices are quickly becoming the norm already, its the hospital systems that are lagging. This section itself is a little redundant as these subjects are closely related to system efficiency. The idea of permitting EMS provides to function across the hospital/pre-hospital divide is a good one, but once again where are the stakeholders that can make that happen?

Adaptable and Innovative

Which recommendations are most important or won't help achieve the vision? What is missing that must be included?

The ideas put forth in this document regarding education across the EMS spectrum, including leadership and administration are all good ones, as is the concept of both educating providers in and funding research in EMS. The authors must consider the diversity of organization types, and the significant obstacles and resistance that entrenched systems such as the fire service will have to this type of change. Leaders and administrators in these organizations are typically promoted from within without regard for any specific training or expertise in EMS.

What is the Agenda?

What is the Agenda?

By Alan Perry
September 27, 2017

The first regional meeting for The EMS Agenda 2050 to discuss the Straw Man Document created by a panel of subject matter experts (SME’s)was held on September 26, 2017 in Silver Spring Maryland. The EMS Agenda 2050 is very public and intended to be as inclusive as possible, literally anyone can provide comment on the Straw Man Document or the process by e-mailing mtaigman@redflashgroup.com .

The meeting structure was different; there were about 12 tables with seating for 6-8 at each table with one moderator per table.  Each table would convene for 25-30 minutes to discuss the future of EMS based on a specific question related to the “guiding principles” identified by the SME’s (who served as the moderators). The SME’s would then record any new ideas that seemed viable to them. I do not claim to have heard all the ideas or discussions, but I believe I was able to sit with nearly everyone that attended at some point. Most who attended where EMS chief officers, EMS industry writers, government officials both state and federal, VAOEMS, HHS, NHTSA, DHS, DOT, industry representatives from the IAFF, NAEMSE, consulting firms and EMS educators. It is notable who was not there; there were no representatives there from allied health professions, legislators, the hospital systems, insurers or Medicare/Medicaid.

The keynote speaker was Dr. Ric Martinez, one of the authors of the 1996 EMS Agenda for the future, who made some points to get us thinking. To paraphrase his comments, he asserts that EMS is fragmented and suffers from the ill effects of isolation and insulation. He notes that EMS is deployed locally while Fire is deployed nationally. That EMS should be declared an essential public service, that we need the think exponentially not incrementally. It was a short but effective inspiration.

The subject of social equity appeared in many of the early questions asked of the groups, initially was not concerning until it became the predominant theme in the round of questions we worked through that morning. In its normal context that would imply that there was some concern about the equity of the treatment of patients, that was not the case. The concern was refined via feedback from the moderators which seemed to make it more of a concern about disparity among EMS systems affecting entire populations falling inside differing EMS systems that have developed locally.

We were repeatedly asked to think about how we would see the future of EMS if all the boundaries and restrictions did not exist, some of us have a hard time with that, but after a few practice sessions even an old paramedic can become creative. Rather than describe each individual workgroup, the question and reaction, I will try to describe the ideas that seemed to bridge all the questions and which became better refined because of their resonance as the exercise progressed.

Integration- The vision includes the ability to treat more patients where they are found or to transport them to the most appropriate resource to improve care, reduce cost and improve resource utilization. EMS must have better integration with the rest of the healthcare system, public health, mental health and social services if it is to meet this agenda goal. It includes sharing access to patient records and treatment plans to guide care, removing artificial boundaries limiting where providers may practice and where patients may be treated.  The most significant barrier appears to be communication and a willingness of the identified partners to engage in a meaningful way without some inducement. 

Education- The vision involves placing paramedics and other providers with higher levels of education into the mix to assist in filling the gap between hospital and pre-hospital care. It suggests greater public involvement which will have a public education component. The integration component will require education of those we wish to integrate with as well as legislatures and insurers.  It also addresses changes to the core material taught in paramedic level programs to include healthcare management, research, injury prevention, and the development of paramedic post-graduation programs. At every point in the discussions it became more evident that EMS will be used to fill a gap in the healthcare system left by the exit of the traditional family doctor. Paramedic education and practice would evolve to the level of the physician extender or nurse practitioner. Public education came up in almost all discussions as a way to improve public reaction and involvement in healthcare events.

Technology/Innovation- This was the most interesting and amusing of the topics covered, participants came up with ideas as frightening and wonderful as implantable chips to identify and hold patient healthcare data, monitor lab values, and provide other biometric data to healthcare providers. PSAP, dispatch, patient and hospital communications systems that could function as easily as a smart phone and provide real-time audio, video and biometric data to call takers, responders and receiving facilities to guide response, size-up, treatment and transport decisions in real time. Defibrillators that fit in your pocket. High-Tech lightweight bulletproof, puncture proof, thermally resistant PPE with built in biometrics. Drone technology dispatched with units to give advanced 360 scene size-ups & patient assessment. Use of AI to assist or autonomously respond to, assess, monitor, treat and transport patients more consistently and safely. Use of live universal standards of care based on the most current evidence.

Workforce retention and development-  There was quite a bit of discussion surrounding the workforce, the various levels of care, the considerations for paid, volunteer and fire-based systems, and the effect of higher education standards on an already stressed system. Most acknowledge that burnout, long hours and low pay are factors in retaining people and preventing EMS from being a viable career path for most. To place EMS on par with other healthcare professions there must be transparency about the career, established career paths, progressive education programs from EMT-PhD, professional recognition and better wages, benefits, resources and working conditions.

System development /Sustainability- Understanding that EMS is a separate essential public service like the Fire service, Police or public education could be a pathway to resolve funding concerns and bring diverse systems across the nation into agreement on what minimum level of service and standard of care is acceptable without limiting the localities in their freedom to choose the design and make-up of the service. Encourage innovation, eliminate that which does not add value and self-inflicted obstacles like tradition. Understand your data and use it to find and demonstrate value, tie performance to requests for resources. Address top management stagnation with use of term limits, requalification or selection every few years instead of lifetime positions.

Closing

The parties with the largest influence on the outcome are not present. For any real integration to occur this must change, if it does not the effort will be severely limited and we will revert to the highly localized solutions we are familiar with.

Higher education, better technology, wages & deployment of all the suggested improvements will take investment. Most systems already struggle with funding, the first things to be cut are the very things the agenda seeks to implement, how can that be fixed? EMS will be asked to fill the gap left in healthcare with no means to achieve it if major legislative or economic pressure is not brought to bear to correct funding gaps. If EMS is identified as an essential public service with minimum standards of service and care defined, as with Fire Service or Public Education, or if EMS service can be scored like the Fire Service for insurance purposes, it will create the political and economic pressure necessary.

This exercise appears to be driven by Federal agency concerns to encourage collaboration borne out of the ACA. The ACA encourages the development of Accountable Care Organizations (ACO’s) and ties reimbursement levels to performance of the system. It seems that this mechanism left out any collaboration with EMS or we would have seen the ACO’s (hospital systems) in the room ready to talk.

Public education programs such as those employed by the Fire Service have had a profound positive effect. Fire losses were once a grave concern for the nation prior to Fire Service public education programs and fire codes. The decline in fire related losses and deaths dramatically declined. This is a lesson EMS has been slow to learn, spending a fraction of the resources up front on public education can save big on the service delivery end. It is the best way to improve public health and be responsible with the resources we have.

I got concerned when I heard from several groups that volunteer systems were an obstacle to progress and promptly set them straight. EMS in the United States came to be largely by volunteer systems that arose to address the need. The fact is that most of the United States is served by volunteer firefighters and EMS personnel. It is a great and valuable tradition in this nation, one I will not seek to discourage. Involving the public in the solution is also key to improving our situation whether encouraging volunteerism or simply providing the public education to allow the public to participate as a partner or better understand what we do.

Good luck,

My views on the EMS 2050 Agenda Straw Man Document

My take on the EMS Agenda 2050 Straw Man Document

By Alan Perry

September 21, 2017

In preparation for the first meeting to discuss what the EMS Agenda 2050 should be, I read the Straw Man Document published on September 20. First, thank you to the members of the Technical Expert Panel for constructing this instrument designed to get the discussion going. It worked, my head nearly exploded. Keep in mind that I am only a lowly paramedic with less than 20 years of experience. I feel my input in this process is critically important for myself, and my organizations, if our voice is to be heard as we chart the path for the next thirty years. I may have a different point of view than a hospital administrator or Fire/EMS Chief, I hope I can provide the street-level provider a voice in this process.

The overall theme is that EMS (if we will still call it that) should be people centered. This contrast with the old concept of being “patient centered” in that it considers the needs of not just the patient but also the family and the provider, a change I find refreshing. It disputes the validity of tradition, assumptions and organization priorities in meeting that goal. The document is based on six guiding principles for EMS systems; Integration, Equitability, Safety, Sustainability, Reliability and Adaptability. I will get into each of these later based on my experience and how they will affect the organizations I have knowledge of.

Education of front line providers is a common theme, even venturing into requiring additional post-graduate education and certification. With the additional educational requirements, compensation and retention questions arise, and the acknowledgement that paramedics and RN’s function at a similar level. More important than the level of care is perhaps the consistency of care, a topic not specifically addressed, but which is a considerable problem.

Many of the ideas put forward are well outside my realm of influence and/or experience. Several are things I have promoted for some time. Most involve significant structural and ideological change to all organizations involved in the larger vision of pre-hospital and integrated care. These structural and ideological changes I feel will be the biggest challenge to progress. Most of the recommendations will require significant changes to the workforce including education, training, staffing, scheduling, compensation and professional recognition. These workforce changes have been needed for some time and should be considered the “low hanging fruit”.

One of my ongoing concerns, as with MIH proposals, has been that we may be trying to expand the role of EMS into areas traditionally filled by a PCP or Health Department to the detriment of our core role in Emergency Medicine. I am apprehensive about all the new education, skills and responsibilities pushed into the realm of EMS to fill the gaps in the healthcare system. This is after all how we got here in the first place. Between our legal system (tort law), insurance companies (profit driven), and government mandates (ACA et al) EMS has been left to pick up the pieces as those parts of the system with greater influence cherry pick what services they will provide.

I also have concerns for the providers, while this proposal does address compensation and working conditions, I fear it will turn into a “if-then” equation. Our providers are already stressed, working ridiculous shifts, have little support and are the lowest paid in the healthcare system. Making an argument that providing these additional services and skills may improve our situation is insulting. Those choosing a career in EMS should know that their education and experience will have the same value wherever they go (professional recognition), and that their compensation is on par with other highly trained healthcare professionals. If that is not corrected it will continue to be considered a temporary occupation for the best and brightest.

The Principles

Integration- Creating a healthcare system that is contiguous, with communication and coordination, which appears as a single system from EMS, Hospital, PCP, Public Health and Social services. EMS partners in healthcare should work to understand the role of EMS and form partnerships with EMS. Integration of EMS with other community resources and removal of legal boundaries. Real time access to patient medical records. Equip EMS with better diagnostic tools in the field to guide treatment and transport decisions. Create inter-professional education systems to improve collaboration. Make paramedicine a specialty of nursing.

I live and work in an area with volunteer, paid, fire-based and third service EMS systems, four disparate hospital systems and multiple home health organizations. Recent attempts at obtaining consensus to move a MIH program forward failed. I believe this was due to the diversity of the region and the competing interest of the actors. I still arrive at hospitals and must explain the protocols we follow in the field to nurses and physicians accepting my patients. The vision is a good one that will require collaboration at the highest levels among Chief officers, Hospital Administrators, Public Health officials, Local and State officials.

How do we overcome the individual players interest to create a uniform, cooperative system?

How will we create the motivation, or demonstrate the need for these parties to cooperate?

What role will OMD’s play in this process?

Should they lead it?

Equitability- Access and quality of care will not be affected by race, language, sex, disability, age or socio-economic status. Providers will be confident and capable of caring for all patients. More training for patient advocacy and end-of-life care. National Scope of practice and clinical guidelines. Disclosing risk/benefits and cost of ambulance and air transports.

Access to service is still a problem in rural areas, as is the availability of qualified healthcare resources in general. Provider education in my region is highly variable when it comes to pediatrics, special needs and geriatrics. More training can improve the provider’s knowledge of special populations and/or seeking proficiency in a second language.

-Should the public accept that where they choose to live will affect their health care options and outcomes?  Needs of many v. needs of few

Safety-  An inherently safe system that minimizes exposure to injury, illness, infection and stress to patients, providers and the public. Evidence -based patient & provider approach to safety. Standardized drug formularies. More education to providers in safety & mental health. Address the effects of shift length and other factors on fatigue.

For me this should include a severe reduction in the use of “lights and sirens” responses and transports, avoiding invasive procedures not required by the patient’s condition and improved general housekeeping habits. Provider injuries should be examined closely and engineering controls put in place to continue their reduction.

Sustainability- Efficient EMS systems with adequate resources, that are fiscally responsible, that compensate providers with a living wage, and creates an environment that allows providers to enjoy their work. Create PSAP’s that can effectively triage patients and redirect to appropriate resources other than EMS. Change reimbursement models to reflect other more appropriate destinations or treatments. Invest in public education to explain the role of EMS and the cost involved in providing service. Find ways to decrease the documentation burden through technology.

Depending on the type of organization, this can be a big deal. The Fire-based model is rife with staffing inefficiencies but creates a reasonable work environment, sans the 24-hour shifts. Volunteer and Third-service systems are typically lean or under staffed and consequently have fatigue and retention problems. Both have different funding mechanisms and staffing goals.

Funding for EMS is based on insurance and state/federal reimbursements and/or local taxes. It is very sensitive to cost pressures, labor cost are a predominant concern. In this environment, how do you increase your investment in your people, training programs, and staffing models that reduce long shift work to make the job endurable much less enjoyable?

Reliability- A system that is prepared, consistent, evidence-based and scalable. Increase training and understanding of data collection and analysis. Make EMS a more attractive career option through better pay, benefits and career paths. Improve paramedic education to include residency programs. Improve and add to degree programs in EMS and EMS education. Improve succession planning and leadership education. Educate the public in proper reaction to emergencies. Enact the Recognition of Emergency Medical Services Personnel Licensure Interstate Compact. Allow flexibility in the settings in which credentialed EMS providers may practice.

Individual organization leadership, Federal grant targeting and organization type affect preparedness. Consistency of provider skill across organizations is variable which adds to the problems facing the augments for professional recognition. Tradition and OMD engagement are factors that affect adoption of evidence based practices. The Fire service has an advantage in scalability however its engagement in FEMA programs can cut into that capability for concurrent events.

Adaptability- the system will meet evolving needs, continuously evaluate new technology, system designs and educational programs be best meet the needs of the community. Promote innovation from individuals and organization to test effective new ideas and programs. Refocus paramedic education to include research and discovery of the evidence base to improve the standard of care. Increase support for research and pilot projects that have the potential to improve outcomes and/or reduce costs.

This is an important new concept for most, it is no longer static, it is a living breathing thing that requires constant attention. There should also be increased support for research and pilot programs that can improve provider/patient safety, reduce fatigue, improve job satisfaction and retention.

I’ll See you on Monday

Reference:

EMS Agenda 2050 Straw Man Document

http://emsagenda2050.org/wp-content/uploads/2017/03/EMS-Agenda-2050-Straw-Man-September-2017.pdf

EMS Agenda 2050 ideas? Questions? Concerns?

Good morning,

The first public meeting to solicit feedback for the EMS Agenda 2050 project is on September 24, 2017. This project was contracted by the NHTSA Office of EMS for envisioning bold and innovative possibilities for EMS advancement over the next three decades. I will be attending this event as a stakeholder and citizen to share my concerns and ideas and hear what other new and innovative ideas are out there. I am offering to bring any questions, concerns and suggestions you have the table, if I am able, and bring back firsthand information for our region. If you are willing just send me your notes by email and I will incorporate them into my talking points. If you do not wish to be credited with the ideas/comments you provide please state so in your reply.

Respectfully,

Alan Perry

Missing the "High" in High Performance CPR?

Missing the “High” in High Performance CPR?

Alan Perry

July 30, 2017

High Performance CPR is a generic term associated with various methods now used in the setting of cardiac arrest aimed at improving the survival rate and long-term outcomes of victims beyond outcomes obtained by standard AHA/ACLS guidelines. It is achieved by improving the quality and consistency of CPR and maximizing the effect of efficacious actions taken during the process.

High performance does not occur by accident or by writing an SOP, It takes education, practice and teamwork. It is a complicated process in which every team player must understand the whole process, what their area of responsibility is and how to best perform each task. It also takes leadership and communication. A gap in any area will decrease performance and potentially have a negative effect on the patient’s outcome.

Education on any high performance variant of CPR will likely require your agency to develop its own system with the approval and participation of your OMD(s). Since High Performance CPR is a skill every operational member of your organization must have for the system to work. Initial and on-going training programs should be put into place that convey the necessary knowledge, skills and abilities.

Because it is a team-based function it will also require regular practice and competency/skill verification. In most systems, providers will not always be working with the same crew members. Practical exercises across shifts/stations/battalions, with members functioning in all roles they might normally fill, will produce greater consistency of performance across the organization.

Teamwork can be difficult to achieve when you are not always working with the same members. This is where training to a standard and having all members of the team knowing the whole process pays off. There can be little variation across shifts/stations/battalions if you want everyone to work collaboratively in this fast-paced and stressful situation.

Leadership is important but not as much dependent on rank as where you find yourself. What is important is that the person taking the lead be competent and communicate effectively with other team members. This is no place to fuss over who’s going to lead, make the call and fall into line. If this falls apart the whole process can implode into utter confusion.

Communication is probably the most important skill. It requires both effective delivery of messages as well as good listening. A closed-loop communication model is best so that critical procedures and information can be tracked accurately by both the sender and receiver. This type of communication also helps keep the whole team aware of where they are in the resuscitation process.

It has been proven that effective CPR delivered early in a witnessed arrest and preceding defibrillation of VF produces the greatest possible benefit for the patient. It has also been proven that minimizing gaps in CPR created by analyzing rhythms, charging defibrillators and switching compressors improves outcomes. This is an excellent place to hone the communication and teamwork.

It should go something like this:

Scribe/Timekeeper:        Approaching 2 minutes CPR

ALS team leader:            Prepare for rhythm check and compressor switch.

                                      (Charge defibrillator)

                                      Switch compressors, clear the patient.

                                      (Examines rhythm, shocks if VF/VT) 2 seconds max.

                                      Resume compressions.

Scribe/Timekeeper:        Records actions/defibrillation/rhythm.

                                      Restarts CPR clock.

Looks simple right? Try this with a crew you have not worked with before, or with providers who have not practiced or don’t remember the process. It won’t be so simple.

Enjoy,

Alan

Resources:

http://www.resuscitationacademy.org/downloads/HPCPRToolkit110309.pdf

http://www.aedchallenge.com/articles/highperformancecpr.php

http://www.ems12lead.com/2016/06/14/high-performance-cpr-performance-not-protocol/

Healthcare in America

Healthcare in America

June 26, 2017

Alan E. Perry

Life, Liberty and the pursuit of happiness, as well as several other “civil rights” are afforded by our constitution. Nowhere does it say we will all have healthcare, or for that matter pick-up trucks, big bank accounts, or a reasonable IQ.

Our lives are shaped by our circumstances and how we react and adapt to move ourselves where we want to be. Each person selects their own priorities and accepts the risk and rewards of those decisions. Some plan, make good decisions, accept responsibility and do better. Some are short sighted, irrational and blame others for their misfortune. Granted some get handed circumstances that are inherently more difficult to manage than others purely because of chance, but this is the exception.

Individual health is affected largely by personal choice. There are exceptions to this, but again this is the exception not the norm and not the subject of this discussion. That being said; there are actions individuals can take to manage certain known risk such as hypertension and diabetes. But back to the issue; individuals must accept the responsibility for their health buy treating their bodies with respect, exercising, staying physically active, eating properly, managing their known conditions and avoiding risk that are not necessary.

The assertion of the “universal healthcare” concept is that everyone has a right to exactly the same healthcare, and that those who cannot afford it will receive it at the expense of those who can. This is the definition of socialism; will it stop here? I think not. This “universal healthcare” idea provides no incentive for (in fact punishes) those who take care of themselves and make wise decisions about their body and provides reward for those who squander their own resources and health. As an example, take a 50-year-old male who has taken care of himself and has no medical problems; he used to be able to get health insurance (if he chose to get it at all) at a very reasonable rate based on his age and absence of risk factors. Another 50-year-old male, who has been reckless, excessive and generally abusive to his body and sedentary has multiple medical problems and disabled as a result. Do they both get treated fairly? The healthy one sees his insurance rates and deductibles go up and he is no longer able to save for his retirement. The unhealthy one gets free healthcare and a disability check.

In 1935 President Roosevelt and the Congress legislated the Social security act which created a financial safety net. In 1965 Medicare and Medicaid where added, Medicare provides financial assistance for healthcare to those 65 and over, Medicaid provides financial assistance for healthcare for low income families and individuals. These programs addressed the need for the elderly and the economically disadvantaged to have access to basic healthcare as a safety net, it never intended to put them on par with those who opted for more extravagant treatments and could afford them. Our government has programs to assist those who have trouble obtaining food, housing, medical care and education. It does not guarantee these. NGO’s have typically also assisted with these basic human needs, but again no guarantee.

By guaranteeing universal healthcare we are opening a very large can of parasitic worms and diminishing the value of personal accountability and self-determination. It will not take long before the authors of this malignancy begin demanding that everyone is entitled to a three-bedroom house with a garage, a new pick-up truck, free cable TV and an all-expense paid vacation semi-annually. Look closely, it’s already happening.

We live in a nation founded on the principals of personal responsibility, self-determination and respect and tolerance for those with differing views. It worked then, as it should now, because each person knew with certainty that if they worked and took responsibility for their actions they would have a much better chance of succeeding than those who choose to sit in the bars or street corners and refuse to contribute or better themselves. We raised our children to understand that if you did not become vested in your future and provide for your family there would be undesirable consequences.

As voters and taxpayers what are we to do when the numbers those receiving this ever-growing list of entitlements exceed the numbers of those paying for them. This Nation will collapse if this occurs, and it will be violent. We must find a way to get healthcare out of the corporation’s hands, out of the government’s hands, and back into the hands of the providers and the patient. We must also look at the broader problem that got us here in the first place and acknowledge that while we are all created equal, our decisions, actions and efforts will determine the amount of resources we will have as individuals and a Nation. as Thomas Jefferson put it " Free men are not equal".

The Three-man Medic Company

Three-man Medic Company

By Alan Perry, June 21, 2016

Congratulations on your promotion! Your new assignment is lieutenant on a Medic Company!? It should come as no surprise that the busiest piece of equipment, with the most at stake in the daily performance of it's duties, has finally been elevated to the company level. You and the other personnel assigned to your Medic Company are taking a huge step forward for Emergency Services. Thanks to this new concept your organization will be able to more efficiently and responsibly provide necessary emergency medical services to the public you serve.

“How did this happen?” you ask. Your City Council and the City Manager have been systematically looking at all city department functions looking for ways improve efficiency, reduce costs and improve retention of ALS personnel. The traditional Fire Department staffing model and even its name could be re-aligned to reflect what it actually does. After conducting an “operational effectiveness and efficiency” study and looking at evolving practices in staffing and deployment, the city manager and the interim Fire Chief determined that a major re-alignment of physical and human resources needed to occur. This included adding Company Officers on medics, Field Medical Officer Captains for each battalion and shift, a EMS Duty Chief for each shift, and a Division Chief of EMS.

With nearly 80% of the calls for service being related to medical emergencies, and only 5% actually involving any type of fire, the name has been changed to “Emergency Services”. Every station will have at least one three-man Medic Company in addition to a four-man Engine Company, and every Medic Company will have at least one ALS provider. These Medic Companies can handle 80% of EMS calls without the need for additional resources.

Second run engines have all been replaced by Rapid Response Companies, a three-man company in a medium duty truck equipped for firefighting and rescue operations without a pump or water. These trucks co-respond with Medic Companies on high acuity EMS calls for manpower, and function like flying squads for fire and rescue calls. They are much more cost effective to operate compared to the engines and ladders that were used before, each district has two. Engine Companies are staffed with four, safe levels of staffing are still maintained since Medics Companies co-respond to fires as well.

You noticed the changes in the promotional process you just participated in. The increased emphasis on EMS practices and operations in the process was not random. The City Manager and Fire Chief both realized that promotions within the organization need to reflect the current role of the Department as well as the need for a change in the culture of the organization.

The money your City is saving is being re-invested in a new training facility for public safety (EMS/Police/Fire), and an aggressive public education program focusing on health and safety issues through the Community Risk Reduction Division (formerly Fire Prevention). The Chief has indicated recently that the Department will be moving to correct pay compression issues due to consistent budget surpluses and possibly even provide a second set of turnout gear. As an added bonus, those who choose the EMS assignments receive a 10% salary differential.

In the Fire service these changes might seem radical, in business and politics they can't come fast enough. Many Fire Departments across the country are developing new and innovative ways to provide the public with the best return for their emergency services dollar independent of any industry guidance. At the national level there seems to be some lag in even acknowledging the need for realignment. The NFPA and IAFF are quick to protect the future of the fire Service and the employment of Firefighters but have not seriously addressed the need for any realignment of personnel or resources other than to protect the control and influence of the Fire Service on public safety. The diversity of Fire Service organizations and localities has a great deal to do with the difficulty in developing a recommendation that will work for us all. I think that if we seriously consider what the public both expects and needs in emergency services we can do what we do best, fix the problem so we can get the opportunity to be the heroes we want to be.

Sweet dreams,

https://www.ncbi.nlm.nih.gov/pubmed/10163385

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