Complexity

EMS Perspectives: An OpEd Page on the History and Future of EMS

By Clayton Kazan, MD, MS, FACEP, FAEMS

So we are about 54 years into the pilot project that is EMS and paramedicine.  That we would even exist, much less thrive, years later, was viewed by many as highly improbable at the time.  The EMS system, in its inception, was a complicated system with a lot of moving parts.  It wasn’t simple, but it was fairly linear.  Call was made to the Fire Department (or EMS, as 911 did not exist), a response was dispatched, units arrived on scene, they provided whatever assessment and treatment were appropriate (rudimentary by today’s standards), they notified the hospital, and they transported.  The system of today has moved from complicated to extremely complex, affecting each of the steps above. 

One of the notable exceptions, at least until recently, was the 911 system.  We reduced the number of phone numbers down to a single, 3 digit number.  This is a terrific example of system leadership advocating to reduce system complexity.  911 is in place throughout the US and enables you to access the appropriate local resources without knowing the local telephone numbers.  From rotary phone to iPhone, the 911 system remained simple to the user.  Now, with the advent of 988, we are reintroducing system complexity, and not just by giving the public a second number to dial.  Bridges between the 911 and 988 system need to be developed to appropriately move traffic when the public dials the wrong number.  But, I digress, because at every other step above, through system entropy and evolution, we have introduced complexity exponentially.  From emergency medical dispatch to tiered dispatch to specialty response units to sophisticated assessment tools and new treatments, to new methods of hospital notification, and to the hyperspecialization of receiving hospitals, our system has become quite a wonderful beast.  With every layer of complexity that is added, we create new ways for the systems to fail, but we have also created an infinite way for the EMS system to aid.

So, with all of that said, the question that I have been pondering and what drove me to my laptop on my day off was this…has the complexity of our operations failed to keep up with the growing complexity demanded of it by the communities we serve?  We keep being asked to do more than EMS, to the point that EMS and prehospital care do not even seem to be the appropriate terms for what we do anymore because, so often, the E does not apply, and not all care that we provide should be prior to arriving at a hospital.  Really, what we have become is mobile health, with traditional EMS existing as a service line under that umbrella.  Nothing made this clearer than the pandemic response.  EMS (or whatever we decide to call it) rose to the occasion and demonstrated amazing resilience and adaptability when so much of the healthcare system crumbled around it.  We were the innovators.  Why?  Because we are still a pilot project.  Traditional healthcare has been around for 2400 years, and it is more rigid, yet brittle.  54 years in, EMS is still trying to find and define its niche, which is why the adage, “if you’ve seen one EMS system, you’ve seen one EMS system” applies.  You can’t say that for hospitals, Emergency Departments, clinics, etc.  They’re more like Starbucks…pretty similar but not exactly identical and very expensive to visit.

So, what do I mean by this complexity gap?  The cracks exposed in our healthcare system from the pandemic are far from repaired, and it remains to be seen how traditional healthcare will morph as it recovers.  But, we have true crises of mental health, substance use, homelessness, aging population, and eroding access to all forms of scheduled medical care, and I do not use the word “crisis” haphazardly.  We have more care facilities, of all kinds, calling us because they can’t get access to other forms of healthcare and are unwilling to shoulder the liability of watchful waiting when a free solution (at least to them) exists just three digits away.  Our pace of innovation to meet these needs has been unable to keep up, and the end result has been more and more call volume driven, mostly, by low to medium acuity patients.  As we seek new solutions, we run into perpetual problems with funding, reimbursement, and outright pushback other medicine stakeholders, who lack any granular solutions, seeking to contain any perceived expansion of the mobile health mission and scope.

Complexity can definitely be problematic, but it also generates a broader repertoire of solutions.  We need to take advantage of our relative youth, amongst the rest of the house of medicine, with all of the optimism and adaptability, and keep advocating for innovative solutions, new connections to care, new treatment modalities, new delivery models, and new transport destinations.  The going will be hard, but the alternative is the unfettered crumbling of our existing healthcare system and its growing inability to meet the needs of its constituency.  We have come a long way in 54 years, but we have a long, hard road in front of us as well.

Website Layout and Graphic by EMS MEd Editor James Li, MD

EMS Burnout and Mental Health

EMS Perspectives: An OpEd Page on the History and Future of EMS

Authors: David Wright, PA-C, NRP, FAEMS; Kate Randolph, PA-S;  Kim King, FNP

Introduction

Mental health and wellness are on the forefront of everyone's minds these days, and the past few years have been an exceptionally challenging time for healthcare workers around the world.  During a time when EMS systems were already understaffed and overworked, COVID decided to make an appearance.  The world became unsure of what was to come with this new virus, seemingly creating a plethora of sick patients, with no real treatment in sight.  Then the explosion of EMS calls across the nation.  Throughout this time, we never stopped serving our residents, our neighbors, our communities.  If 911 was called, we responded.  But did we ever stop to consider the harm that we were experiencing, even without getting physically ill.

Frequently, EMS clinicians face extremely stressful situations that other clinicians may never even fathom to experience in their careers.  These situations can be anything, from the 17th sick case of the day to a mother running at you crying with her dying infant in their arms.  These stressors are real and cause long term consequences to those that serve.  In this post, we are looking at some situations that frequently cause an increase in provider stress and burnout.  We will also look at some possible predictors of burnout that leaves our coworkers with a higher affinity for negative mental health experiences and burnout.

Call it EMS bingo… call them extreme calls… whatever you call it, we all have a list of calls we never want to run.  Pediatric cardiac arrests, Mass Casualty Incidents, building collapses, death notifications, entangled patients, suicides, homicides, critical pediatric calls, the list goes on and on. Everyone is impacted by these high stress, critical calls, but most people don’t know it immediately.  Eventually these stressors surface either as mental, physical, or emotional distress. 

Stress and Burnout

Occupational stress is known to lead to multiple adverse health effects including psychological disorders, cardiovascular disease, GI complications, weakened immune system and specific disorders such as hypertension, obesity, stroke, and diabetes. (Hashmi, 2015)  Post-traumatic stress disorder (PTSD) can also contribute to high rates of suicide, job-related burnout, clinical depression, and can manifest in physical conditions resulting in EMS clinicians no longer being able to perform their jobs. (Mountfort & Wilson, 2022)

Burnout among EMS providers has been linked to higher absenteeism and turnover which eventually will lead to a shortage of healthy, trained EMS professionals. A study was performed evaluating the relationship between burnout and job-related demands/resources among emergency medical services (EMS) professionals (Crowe, 2020). EMS professionals facing high job demands and low job resources demonstrated significantly higher odds of burnout. Within this study, an initiative to improve coping mechanisms was addressed, but often this places the responsibility on the victim. Of all the challenges that EMS clinicians face, being under constant pressure to make vital clinical decisions and perform lifesaving interventions creates the strongest impact on burnout.

As EMS professionals, exposure to various occupational hazards, such as exposure to death, grief, and injury, is part of their daily routine.  Increased stress and burnout were also noted in those who perform death notification, with an increase in burnout every time notification was made. (Campos et al) Facing highly stressful and critical situations is one of the core risk factors for EMS. EMS personnel have been identified to be at a higher risk of suicide than the general population with 6.6% of Fire/EMS professionals reporting a suicide attempt in comparison to 0.5% of the general population (SAMHSA, 2018).

EMS professionals often perceive high levels of emotional exhaustion and depersonalization with low levels of personal achievement. In one study, frequently reported coping strategies included talking with colleagues (87.4%), looking forward to being off duty (82.6%), and thinking about the positive benefits of work (81.1%). (Almutairi & Mahalli, 2020) Targeted training and feedback has the potential to negate a portion of these negative effects experienced by clinicians. (Crowe RP et al) While this can be beneficial for some, it is not the solution to all stress and burnout related problems presented.

One concept that must be considered is that of repetitive trauma.  Providing focused education and resources to our emergency medicine prehospital providers on this topic is something that is seldom performed in many regions. (Jahnke, 2016) While single traumatic events can be impactful, singular events are commonly manageable.  Persistent exposure to multiple traumatic events can lead to increased risk of mental health disorders, including PTSD, insomnia, among others. (Do et al., 2019) Compounded over a 20-30 year career, it is almost inevitable that EMS clinicians will be exposed to repetitive trauma.

Looking for Solutions

In an ideal world, EMS leadership (supervisors, command staff or medical directors) would be able to identify specific calls that predispose EMTs and paramedics to increased risk of stress and burnout, but it is understood that this is a difficult, multi-faceted task. 

While there is no currently identified list of critical calls that will definitively effect EMTs and paramedics, it is reasonable to note that commonly stressful situations such as death notification, critical pediatric calls (including cardiac arrests), mass casualty incidents, suicides/homicides and incidents involving other public safety workers are a potential starting point. As leaders in the EMS field, it is our responsibility to start looking out for our own.  Leaders should be looking at crews that run these high stress calls and performing targeted intervention in an attempt to decrease the long-term impact of these types of calls.  While the gold standard of intervention has yet to be identified, it may include debrief, discussion, and support provided in a safe, judgment-free environment.

Resources

Almutairi, M. N., & El Mahalli, A. A. (2020). Burnout and Coping Methods among Emergency Medical Services Professionals. Journal of multidisciplinary healthcare, 13, 271–279. https://doi.org/10.2147/JMDH.S244303

Campos, A., Ernest, E. V., Cash, R. E., Rivard, M. K., Panchal, A. R., Clemency, B. M., Swor, R. A., & Crowe, R. P. (2021). The Association of Death Notification and Related Training with Burnout among Emergency Medical Services Professionals. Prehospital emergency care, 25(4), 539–548. https://doi.org/10.1080/10903127.2020.1785599

Crowe RP, Fernandez AR, Pepe PE, Cash RE, Rivard MK, Wronski R, Anderson SE, Hogan TH, Andridge RR, Panchal AR, Ferketich AK. The association of job demands and resources with burnout among emergency medical services professionals. J Am Coll Emerg Physicians Open. 2020 Jan 27;1(1):6-16. doi: 10.1002/emp2.12014. PMID: 33000008; PMCID: PMC7493511.

Do, T. T. H., Correa-Velez, I., & Dunne, M. P. (2019). Trauma Exposure and Mental Health Problems Among Adults in Central Vietnam: A Randomized Cross-Sectional Survey. Frontiers in psychiatry, 10, 31. https://doi.org/10.3389/fpsyt.2019.00031

Hashmi, Muhammad. (2015). Causes and Prevention of Occupational Stress. IOSR Journal of Dental and Medical Sciences. 14. 98-104. 10.9790/0853-1411898104.

Jahnke, Sara A. et al. ‘Firefighting and Mental Health: Experiences of Repeated Exposure to Trauma’. 1 Jan. 2016 : 737 – 744.

Mountfort, S., & Wilson, J. (2022). EMS Provider Health And Wellness. In StatPearls. StatPearls Publishing.

SAMHSA.First Responders: Behavioral Health Concerns, Emergency Response, and ...May 2018, https://cectresourcelibrary.info/wp-content/uploads/2021/07/First-Responders_-Behavioral-Health-Concerns-Emergency-Response-and-Trauma.pdf.

Editing by EMS MEd Editor James Li, MD

Should Waveform Capnography be in the EMT Scope of Practice? (Part 3)

What’s the Big Picture?

By Adrien Quant LP,  Hashim Q. Zaidi MD

As discussed in Part 1 and Part 2, current EMT standards of lung auscultation and pulse oximetry have critical limitations in the evaluation of ventilation and perfusion (Brown et al., 1997; DeMeulenaere 2007; Chan et al., 2013). However, the introduction of waveform capnography to the EMT scope of practice would largely resolve these issues. The introduction of waveform capnography is necessary to promote the evidence-based nature of EMS healthcare, and improve prehospital care in regions of the United States where EMTs are the highest level providers. 

Skill - Airway/Ventilation/Oxygenation (Modified)
Source: National EMS Scope of Practice Model 2019
https://www.ems.gov/pdf/National_EMS_Scope_of_Practice_Model_2019.pdf 

In the emergency department, waveform capnography is the gold standard to determine whether an airway intervention has been effective. In fact, the technology is repeatedly endorsed by the new NAEMSP Airway Compendium, particularly for non-invasive positive pressure ventilations (Carlson et al., 2022; Harris et al., 2022; Lyng et al. 2022). When the National EMS Scope of Practice Model (2019) was constructed, the Expert Panel placed waveform capnography in the ALS scope of practice. Why was it left out of the EMT scope of practice?

Incidentally, the Expert Panel did consider placing waveform capnography into the EMT scope of practice (National, 2019). During the development of the guidelines, the Expert Panel considered placing supraglottic airways into the EMT scope of practice. Since supraglottic airway placement requires waveform capnography confirmation, the panel also considered including waveform capnography into the EMT scope of practice as well. However, the panel ultimately decided against supraglottic airway implementation, citing concerns that supraglottic airways can harm patient outcomes if improperly placed by an EMT. In addition, the cost of supraglottic airways could be cost prohibitive to many EMT educational programs. As such, the panel decided against including supraglottic airways into the EMT scope of practice due to clinical and financial concerns. Unfortunately, when the panel decided to exclude supraglottic airways, the panel also decided to exclude waveform capnography. This was a curious decision. Whether supraglottic airways are dangerous or cost prohibitive for EMTs is a valid concern for separate discussion; however, the extensive benefits of waveform capnography justifies its cost. The exclusion of supraglottic airways from the EMT scope of practice should not have facilitated the exclusion of waveform capnography. These are separate technologies with different costs and risk/benefit ratios. Arguably every EMT level airway intervention (manual airway maneuvers, bronchodilator and epinephrine administration, supplemental oxygen administration, CPAP administration, and positive pressure ventilations) could benefit from waveform capnography validation.

Under new regulation KBEMS-E-39, Kentucky now mandates supplemental training of non-invasive qualitative and quantitative waveform capnography for EMTs.
Source: Kentucky Board of Emergency Medical Services & David Fifer
https://www.facebook.com/KYBoardEMS 

Fortunately, improvements are on the way. On August 11, 2022, the Kentucky Board of Emergency Medical Services expanded waveform capnography to the EMT level (Kentucky 2022). Under new regulation KBEMS-E-39, Kentucky now mandates supplemental training of non-invasive qualitative and quantitative waveform capnography for EMTs. Under this new order, EMTs will be trained to utilize waveform capnography to evaluate the quality of their BLS interventions. In our opinion, this is a critical first step towards improving patient care across the state. The United States should follow Kentucky’s evidence-based change. 

In closing, waveform capnography should be included into the national EMT scope of practice. As stated by the National EMS Scope of Practice Model (2019), “depending on a patient’s needs and/or system resources, EMTs are sometimes the highest level of care a patient will receive during an ambulance transport.” As such, many patients, especially in rural parts of the United States, are being treated by EMTs who are ill equipped to appropriately evaluate their airway and breathing interventions. Lung auscultation and pulse oximetry are simply not enough. In order to empower our EMT providers and elevate our patient care, we must include waveform capnography in the EMT scope of practice. 

Check out Part 1 and Part 2

References:

1.     Brown LH, Gough JE, Bryan-Berg DM, Hunt RC. (1997). Assessment of Breath Sounds During Ambulance Transport. Annals of Emergency Medicine, 29(2), 228–231. https://doi.org/10.1016/S0196-0644(97)70273-7

2.     Chan E, Chan M, Chan M. (2013). Pulse oximetry: Understanding its Basic Principles Facilitates Appreciation of its Limitations. Respiratory Medicine, 107(6), 789–799. https://doi.org/10.1016/j.rmed.2013.02.004

3.     DeMeulenaere S. (2007). Pulse Oximetry: Uses and Limitations. The Journal for Nurse Practitioners, 3(5), 312–317. https://doi.org/10.1016/j.nurpra.2007.02.021 

4.     Carlson J, Colella M, Daya M, De Maio V, Nawrocki P, Nikolla D, Bosson N. (2022). Prehospital Cardiac Arrest Airway Management: An NAEMSP Position Statement and Resource Document. Prehospital Emergency Care, 26(sup1), 54–63. DOI: 10.1080/10903127.2021.1971349

5.     Harris M, Lyng JW, Mandt M, Moore B, Gross T, Gausche-Hill M, & Donofrio-Odmann JJ. (2022). Prehospital Pediatric Respiratory Distress and Airway Management Interventions: An NAEMSP Position Statement and Resource Document. Prehospital Emergency Care, 26(sup1), 118–128. https://doi.org/10.1080/10903127.2021.1994675

6.     Kentucky Board of Emergency Medical Services (2022). Statement of Emergency, 202 KAR 7:701E. https://apps.legislature.ky.gov/law/kar/titles/202/007/701/ 

7.     Kentucky Board of Emergency Medical Services (2022). Thank you to our Medical Oversight Committee on commanding and guiding this regulation change. Facebook. https://www.facebook.com/KYBoardEMS 

8.     Lyng J, Harris M, Mandt M, Moore B, Gross T, Gausche-Hill M, Donofrio-Odmann JJ. (2022). Prehospital Pediatric Respiratory Distress and Airway Management Training and Education: An NAEMSP Position Statement and Resource Document. Prehospital Emergency Care, 26(sup1), 102–110. https://doi.org/10.1080/10903127.2021.1992551

9.     National Highway Traffic Safety Administration. (2019). National EMS Scope of Practice Model. https://www.ems.gov/pdf/National_EMS_Scope_of_Practice_Model_2019.pdf

Editing by EMS MEd Editor James Li, MD (@JamesLi_17)

Should Waveform Capnography be in the EMT Scope of Practice? (Part 2)

The Benefits of Waveform Capnography for Patient Care

By Adrien Quant LP, Hashim Q. Zaidi MD

As discussed in Part 1, under the National EMS Scope of Practice Model (2019), EMTs are expected to initiate several critical airway and breathing interventions for a variety of medical and traumatic conditions. However, in order to evaluate ventilation and perfusion, EMTs must currently rely on lung auscultation and pulse oximetry - both of which have critical limitations (Brown et al., 1997; Chan et al., 2013; DeMeulenaere 2007). The limitations of lung auscultation and pulse oximetry can be addressed by the introduction of waveform capnography to the EMT scope of practice (Brandt 2010). Here, the benefits of waveform capnography to EMTs and their patients will be discussed. 

Benefits of Waveform Capnography: 
Waveform capnography is a non-invasive tool that provides a quantitative measure of expired CO2 throughout the respiratory cycle. A small end tidal carbon dioxide (ETCO2) sensor is placed at the patient’s nose or mouth. During inhalation, the ETCO2 sensor reads a baseline CO2 partial pressure. During initial exhalation, the CO2 partial pressure rises sharply as CO2 rich gas arises from the alveoli. As exhalation continues, the CO2 partial pressure plateaus, and then returns to baseline upon inhalation. In a healthy patient, this physiological process produces the usual “table-shaped” waveform with plateau readings of 35-45 mmHg. Lower respiratory system and V/Q abnormalities cause deviations from the expected “table shape” that are easily recognizable and clinically useful.

Nasal cannula with ETCO2 sensor. Source: Adrien Quant LP. Original image (special thanks to Neil Chopra AEMT)

BVM with ETCO2 sensor. Source: Adrien Quant LP. Original image 

Once trained in capnometry interpretation, EMTs would gain valuable information that other vital signs cannot quickly provide. Here are three quick scenarios demonstrating the potential benefits of waveform capnography during common EMT-level interventions.

• Monitoring Respirations:
  An unresponsive patient has been loaded onto the ambulance by EMTs. Prior to leaving the scene, normal pulse rate and adequate respiration rate and depth are confirmed. Pulse oximetry reads 92%, so the EMT manually opens the airway and places the patient on supplemental oxygen via nasal cannula. On route to the hospital, the EMT notices that the patient’s SpO2 is slowly dropping. The EMT switches to a non-rebreather with an airway adjunct, and increases the amount of oxygen, but the SpO2 continues to drop. The EMT begins to count respirations, and finds the chest rise and fall very shallow. Upon auscultation, they are not sure if they can actually hear any lung sounds over the driving noise. The patient’s heart rate begins to drop, and the EMT promptly begins positive pressure ventilations. If the EMT had access to end-tidal capnography, they would have noted the patient’s drop in respiratory rate and depth almost immediately, minutes before the delayed notification from the pulse oximeter and falling heart rate.

• Monitoring Positive Pressure Ventilation:
  A patient is unresponsive due to heat stroke. Respirations are inadequate, so one EMT begins positive pressure ventilations while the other cools the patient. Although the EMT sees adequate chest rise and fall, the pulse oximeter reads “low.” Unsure if they are ventilating the patient adequately, the EMT begins squeezing the BVM more forcefully and ventilating the patient at a faster rate, inducing barotrauma and gastric inflation. If the EMT had access to end-tidal capnography, they would have known whether they were adequately ventilating the patient. Furthermore, they would have observed that ventilating the patient more forcefully was not improving alveolar gas exchange, reducing the likelihood of continued overventilation and patient injury.

• Monitoring CPAP Therapy:
  An elderly patient is experiencing difficulty breathing. Due to the patient’s medical history, physical presentation, and vital signs, the EMT concludes the patient is experiencing a COPD exacerbation. The EMT administers an albuterol treatment and places the patient on CPAP. Throughout transport, the patient continues to experience respiratory distress, and their SpO2 slightly increases from baseline. If the EMT had access to end-tidal capnography, it may provide clues for the etiology of the patient’s respiratory distress. Capnography could also reveal impending complications such as cardiovascular collapse or pneumothorax. It can help monitor patient response to bronchodilator and non-invasive positive pressure ventilation treatment.

Waveform capnography (modified). Source: Sketchymedicine.com. https://sketchymedicine.com/2016/08/waveform-capnography/.
Permission from the artist for education purposes (https://sketchymedicine.com/using-images/)

In these scenarios, lung auscultation and pulse oximetry provided the EMTs with insufficient ventilatory information, leading to patient deterioration. However, proper utilization of waveform capnography would have provided the EMTs with the critical information needed to better monitor their patients. Waveform capnography provides a non-invasive, accurate assessment of a patient’s ventilatory status. While the technology is already extensively utilized by ALS prehospital providers, in many rural parts of the United States, an EMT may be the highest level of prehospital care that a patient receives. Why should waveform capnography be limited to ALS providers? Considering its numerous benefits, should we include waveform capnography in the EMT scope of practice? 

Check out Part 1 and Part 3

References:

1.     Brandt P. (2010). Current Capnography Field Uses, JEMS. https://www.jems.com/patient-care/current-capnography-field-uses-sup/ 

2.     Brown LH, Gough JE, Bryan-Berg DM, Hunt RC. (1997). Assessment of Breath Sounds During Ambulance Transport. Annals of Emergency Medicine, 29(2), 228–231. https://doi.org/10.1016/S0196-0644(97)70273-7

3.     Chan E, Chan M, Chan M. (2013). Pulse oximetry: Understanding its Basic Principles Facilitates Appreciation of its Limitations. Respiratory Medicine, 107(6), 789–799. https://doi.org/10.1016/j.rmed.2013.02.004

4.     DeMeulenaere S. (2007). Pulse Oximetry: Uses and Limitations. The Journal for Nurse Practitioners, 3(5), 312–317. https://doi.org/10.1016/j.nurpra.2007.02.021 

5.     Meenahc, D. (2013). Why CO2 Monitoring in EMS is Expanding. https://www.boundtree.com/university/capnography/why-co2-monitoring-in-ems-is-expanding

6.     National Highway Traffic Safety Administration. (2019). National EMS Scope of Practice Model.https://www.ems.gov/pdf/National_EMS_Scope_of_Practice_Model_2019.pdf

Editing by EMS MEd Editor James Li, MD (@JamesLi_17)

Should Waveform Capnography be in the EMT Scope of Practice? (Part 1)

The Limitations of Lung Auscultation and Pulse Oximetry

By Adrien Quant LP,  Hashim Q. Zaidi MD

“Depending on a patient’s needs and/or system resources, EMTs are sometimes the highest level of care a patient will receive during an ambulance transport”

National EMS Scope of Practice Model (2019)

Under the National EMS Scope of Practice Model (2019), EMTs are expected to initiate several critical airway and breathing interventions for a variety of medical and traumatic conditions. Currently, in order to evaluate ventilation and perfusion, EMTs primarily rely on two tools – lung auscultation and pulse oximetry. Both tools have critical limitations.  

Limitations of Lung Auscultation:
Lung auscultation may help measure quality of ventilation, but it is deceptively complex, especially in the pre-hospital environment (Arts et al., 2020; Hafke-Dys et al., 2019; Brown et al., 1997). Lung auscultation can be negatively affected by the following factors:

• Provider experience

• Provider hearing ability

• Stethoscope quality

• Abnormal patient anatomy

• Ambient noise

Where They Expect You to Use A Stethoscope

Source: Free to Use Photo by Pixabay from Pexels https://www.pexels.com/photo/bed-empty-equipments-floor-236380/

Where EMTs Actually Practice Medicine

Source: Free to Use Photo by Pixabay from Pexels https://www.pexels.com/photo/concert-at-night-258804/

Limitations of Pulse Oximetry:
Pulse oximetry estimates peripheral perfusion, but clinicians are often unaware there is a significant time delay between changes in the patient’s ventilatory status and changes in peripheral perfusion. Furthermore, unknown to many clinicians, pulse oximeter accuracy can be negatively affected by the following factors (DeMeulenaere 2007; Sinex 1999; Chan et al., 2013): 

• Arrhythmia

• Weak pulse (low QRS amplitude)

• Significant hypoxemia/hypoxia

• Significant hypotension

• Patient motion (seizure, shivering, Parkinsonian tremors, etc…)

• Patient’s peripheral temperature

• Sickle cell vaso-occlusive crisis

• Inhalation of carbon monoxide

• Carboxyhemoglobinemia

• Methemoglobinemia

• Peripheral edema

• Anemia

• Sepsis

• Bright ambient lighting

• Patient skin color

Studies have shown black patients are nearly three times more likely to develop undetected hypoxemia than white patients (Sjoding et al., 2020).

Source: Free to Use Photo by RODNAE Productions from Pexels https://www.pexels.com/photo/people-inside-an-ambulance-6520213/

Patient skin color can affect the accuracy of the pulse oximeter readings. The accuracy of pulse oximetry was originally validated in patient populations lacking racial diversity, and recent literature has revealed critical shortcomings (Jubran & Tobin 1990; Bickler 2005; Sjoding et al., 2020). If pulse oximetry alone is utilized for patient monitoring, Black patients are nearly three times more likely to develop undetected hypoxemia than White patients (Sjoding et al., 2020). This unacceptable racial difference necessitates the utilization of other diagnostic tools, such as waveform capnography, to better assess patients during prehospital care. 

In addition to the inherent limitations of pulse oximetry, many clinicians misunderstand and misuse pulse oximetry data when making clinical decisions (Elliot et al., 2006). Pulse oximetry is not a measure of ventilatory status. However, often unaware of this fact, many EMTs may use pulse oximetry data to justify inappropriate clinical decisions. EMTs often use pulse oximetry to determine the adequacy of a patient’s breathing, even though pulse oximetry is an insufficient tool to fully assess this issue. In addition, novice EMTs will often over ventilate patients with low pulse oximetry readings, incorrectly believing that this will improve ventilatory status and instead causing harm (Mumma et al., 2018). Such errors are partially due to lack of training, but they are also indicative of the critical need for a better assessment tool - such as waveform capnography. 

Summary:
Under the National EMS Scope of Practice Model (2019), EMTs are expected to initiate several critical airway and breathing interventions; however, lung auscultation and pulse oximetry are often insufficient to assess ventilation and perfusion properly. Both techniques have critical, inherent limitations. Furthermore, many EMTs may misunderstand pulse oximetry data, which can lead to poor clinical decisions. Under the National EMS Scope of Practice Model (2019) utilization of waveform capnography is considered an ALS skill. However, considering the critical limitations of lung auscultation and pulse oximetry, should we include waveform capnography in the EMT scope of practice? 

Check out Part 2 and Part 3

References:

1.     Arts L, Lim EHT, Van de Ven PM, Heunks L, Tuinman PR (2020). The Diagnostic Accuracy of Lung Auscultation in Adult Patients With Acute Pulmonary Pathologies: A Meta-Analysis. Scientific Reports, 10(1), 7347. https://doi.org/10.1038/s41598-020-64405-6

2.     Bickler PE (2005). Effects of Skin Pigmentation on Pulse Oximeter Accuracy at Low Saturation. Anesthesiology. 102(4), 715–719. https://doi.org/10.1097/00000542-200504000-00004

3.     Brown LH, Gough JE, Bryan-Berg DM, Hunt RC. (1997). Assessment of Breath Sounds During Ambulance Transport. Annals of Emergency Medicine, 29(2), 228–231. https://doi.org/10.1016/S0196-0644(97)70273-7

4.     Chan E, Chan M, Chan M. (2013). Pulse Oximetry: Understanding its Basic Principles Facilitates Appreciation of its Limitations. Respiratory Medicine, 107(6), 789–799. https://doi.org/10.1016/j.rmed.2013.02.004

5.     DeMeulenaere S. (2007). Pulse Oximetry: Uses and Limitations. The Journal for Nurse Practitioners, 3(5), 312–317. https://doi.org/10.1016/j.nurpra.2007.02.021

6.     Elliott M, Tate R, Page K. (2006). Do Clinicians Know How to Use Pulse Oximetry? A Literature Review and Clinical Implications. Australian Critical Care, 19(4), 139–144. https://doi.org/10.1016/S1036-7314(06)80027-5

7.     Hafke-Dys H, Breborowicz A, Kleka P, Kocinski J, Biniakowski, A. (2019). The Accuracy of Lung Auscultation in the Practice of Physicians and Medical Students. PLOS ONE, 14(8), e0220606. https://doi.org/10.1371/journal.pone.0220606

8.     Jubran A, Tobin MJ. (1990). Reliability of Pulse Oximetry in Titrating Supplemental Oxygen Therapy in Ventilator-Dependent Patients. Chest, 97(6), 1420–1425. https://doi.org/10.1378/chest.97.6.1420

9.     Mumma JM, Durso FT, Dyes M, dela Cruz R, Fox VP, Hoey M. (2018). Bag Valve Mask Ventilation as a Perceptual-Cognitive Skill. Human Factors: The Journal of the Human Factors and Ergonomics Society, 60(2), 212–221. https://doi.org/10.1177/0018720817744729

10.  National Highway Traffic Safety Administration. (2019). National EMS Scope of Practice Model. National Highway Traffic Safety Administration.https://www.ems.gov/pdf/National_EMS_Scope_of_Practice_Model_2019.pdf

11.  Sinex JE (1999). Pulse Oximetry: Principles and limitations. The American Journal of Emergency Medicine, 17(1), 59–66. https://doi.org/10.1016/S0735-6757(99)90019-0

12.  Sjoding MW, Dickson RP, Iwashyna TJ, Gay SE, Valley TS. (2020). Racial Bias in Pulse Oximetry Measurement. New England Journal of Medicine, 383(25), 2477–2478. https://doi.org/10.1056/NEJMc2029240

Editing by EMS MEd Editor James Li, MD (@JamesLi_17)

Addressing the Greatest Harm: Diagnostic Safety in EMS

by Maia Dorsett, MD PhD FAEMS

When we teach about patient safety and medical errors, we put up pictures of the Swiss cheese model (1, 2) and demonstrate how harm occurs as errors fall through serial holes of imperfect systems.  When I examine this model, in many ways it rings true for the examples it is most often used to illustrate, including medication error.  But I do not think it works as well for the more common errors that are occur every day with greatest impact on patient care: Diagnostic errors.

 What is diagnostic error?  Diagnostic error, defined as “the failure to establish an accurate and timely explanation of the patient’s health problem or communicate that explanation to the patient” accounts for the greatest proportion of harm to patients in our system.(3) On the surface, this makes sense.  With the exception of emergency stabilizing measures, such as treating respiratory failure with assisted ventilation, the failure to make an accurate diagnosis in a timely manner decreases the chance that treatments provided are tailored to the correct problem.  Diagnostic error is increased in situations of high uncertainty, unfamiliarity with the patient and in conditions of high stress, workload and distraction (4), making the practice of EMS medicine particularly susceptible.

Prehospital clinicians begin with undifferentiated patients and, through an iterative process of information gathering, integration and interpretation, develop a working diagnosis that guides their treatment and optimizes subsequent care.  The iterative nature of this process is what makes the Swiss cheese model less suited to describe diagnostic error.  As clinicians, we integrate prior information into our decision making process, thus creating the conditions for diagnostic momentum, where a prior diagnosis is accepted without sufficient reassessment or skepticism. Diagnostic error thus more closely resembles a game of dominos than slices of Swiss cheese. As the point of first medical contact, prehospital clinicians therefore have a critical role to play in ensuring diagnostic safety.

As both an EMS educator and a medical director invested in quality improvement, diagnostic error has occupied my thoughts a lot lately.  From a quality improvement perspective, many of our metrics evaluate performance once a diagnosis has been made (e.g. did you perform a blood sugar in a suspected stroke?, what was your scene time for the STEMI?), but as our perspectives have broadened, particularly through examination of care disparities, we can begin to see how the greatest harm can come from diagnostic error, including the failure to consider the diagnosis in the first place.  From a system perspective, interventions to improve diagnostic safety have centered around approaches such as diagnostic support tools, but diagnostic support tools still rely on the clinical judgment of the clinicians who use them. (5)

As medical directors and educators, one of our roles is to support EMS clinicians in developing practices that improve diagnostic safety.  So how do we do this? There is not a lot of strong evidence in this area, but certainly some good ideas.  Here are a few.

Value thorough patient assessment… and reassessment

My favorite quote from James Clear’ book Atomic Habits is “your outcomes are the lagging measure of your habits.”(6)  Nowhere does this ring more true for me than in the arena of clinical care and why we aspire to build systems that promote safer habits.  When we think about safe habits, we picture rig checks, checklists and crosschecks.  But approach to patient assessment is also a habit that we build.

There is growing concern that as technology takes on an increasingly prominent role in medicine, that the “traditional” components of patient assessment receive less attention.  We have all witnessed the error of focusing on and treating a monitor rather than the patient.  As part of initial EMS education, we focus on the differentiation of “sick” vs. “not sick” as part of the general impression.  But the reality is that in emergency services, “obviously sick” is a rare general impression and the largest population falls into the “maybe sick” category.  As an emergency physician practicing in an often overcrowded ED with long wait times, it is not the obviously sick patients that feed my anxiety, it is the unknown, “maybe sick” in my waiting room.

So how do we begin to sort out the “maybe sick”? Fundamentally, it is the patient assessment.  Our iterative diagnostic pathways rely on a series of inputs, and if those inputs are woefully incomplete, the accuracy of our conclusions will be compromised.  Time critical diagnoses such as stroke, acute coronary syndrome and sepsis may present as non-descript complaints such as dizziness, weakness, lightheadedness or fall.  It is thorough patient assessment, including history and exam, that lets us sort through our clinical probabilities of significant illness and potentially change a patient’s trajectory through the system.  However, these patients are less likely to have a thorough assessment performed than the obviously sick and have a subsequent diagnostic delay.  As medical directors, this needs to be reinforced in our trainings, quality improvement activities and our actions.  Indeed, what you measure often reflects what you value.  Which of your quality metrics address patient assessment? How do you identify diagnostic errors more systematically? We need to assign as much or more value to the assessment and diagnostic skills of EMS clinicians as their ability to perform and execute specific actions used to define their scope.   

Teach clinicians to balance their intuitive and analytic processing abilities.

The dual process model of clinical reasoning asserts that problem solving, such as development of a working diagnosis, is the result of an interplay between intuition and analytical reasoning.(7)  Intuition develops as a result of unconscious application of previously developed mental models in response to recognized patterns or cues.  In prehospital medicine, this enables rapid translation of recognition into action and forms one component of the development of expertise.  Intuition is accurate until is not; It is at this point that analytic reasoning, a conscious and deliberate approach to solving problems, becomes necessary.

As medical directors and educators, we need to not only foster intuition by closing the loop with follow-up on patients with a wide-variety of clinical presentations (and working to integrate the system in so that this becomes more seamless), but also teaching cognitive forcing strategies to help them recognize when heuristics can lead to diagnostic error. (4, 5, 8, 9)  Such cognitive forcing strategies include identifying patient populations or clinical presentations where our structured biases leave us a high risk of diagnostic error.  It also includes helping them develop the habit of patient reassessment and transition to analytical reasoning when gathered data does not fit with their intuitive impression, including when patients do not follow the expected clinical trajectory or respond as expected to intervention.  Teaching metacognition may be as important a learning objective in simulations and case discussions as the pathophysiology involved in the individual cases themselves.

Instill the value of learning from failure

Optimizing our intuitive processes requires opportunities for recalibration of mental models.  To be able to optimize clinical judgement, we need to know when we are wrong and value errors as opportunities to improve performance.  Indeed, one of the greatest barriers that exists to improvement in diagnostic safety in EMS is the difficulty in getting patient follow-up.  I often tell my paramedic students that patient follow-up is some of the most valuable feedback you can get.  Yet even with existing difficulties of getting regular follow-up on patient diagnosis and outcome, there remain squandered opportunities for learning and improvement when diagnostic errors are identified because error is seen as failure, but failure is not reframed as opportunity. There are leaders who prefer to tell stories of their successes, but it is actually more important to share what you have learned from failures. (10) This models not only that it is safe to share your mistakes, but also the process for how learning can occur – for the individual and the system – as a result of an openly discussed error. Critical examination of diagnostic errors is something that can be practiced during open case reviews and simulations. In practicing this, we succeed developing the skills and culture for continuous improvement.  

The iterative nature of the diagnostic process places enormous responsibility upon EMS clinicians and dynamic environment they work within.  Addressing diagnostic safety is complex and simple at the same time.  Diagnosis is complex, textbook presentations much rarer than the alternative, but the human art of patient assessment, reassessment and re-evaluation, remains central.  While technological tools and system-based solutions can help, I cannot foresee a future where the role of the clinician is completely eliminated. For those practicing in the realm of EMS medicine, that’s a challenge to which we will always need to rise.    

References:

1.                   J. Reason, Human error: models and management. BMJ. 320, 768–770 (2000).

2.                   T. V. Perneger, The Swiss cheese model of safety incidents: are there holes in the metaphor? BMC Health Serv Res. 5, 71 (2005).

3.                   Committee on Diagnostic Error in Health Care, Board on Health Care Services, Institute of Medicine, The National Academies of Sciences, Engineering, and Medicine, Improving Diagnosis in Health Care (National Academies Press (US), Washington (DC), 2015; http://www.ncbi.nlm.nih.gov/books/NBK338596/).

4.                   M. L. Graber, S. Kissam, V. L. Payne, A. N. D. Meyer, A. Sorensen, N. Lenfestey, E. Tant, K. Henriksen, K. Labresh, H. Singh, Cognitive interventions to reduce diagnostic error: a narrative review. BMJ Qual Saf. 21, 535–557 (2012).

5.                   R. L. Trowbridge, G. Dhaliwal, K. S. Cosby, Educational agenda for diagnostic error reduction. BMJ Qual Saf. 22 Suppl 2, ii28–ii32 (2013).

6.                   J. Clear, Atomic habits: An easy & proven way to build good habits & break bad ones (Penguin, 2018).

7.                   P. Croskerry, Clinical cognition and diagnostic error: applications of a dual process model of reasoning. Advances in health sciences education. 14, 27–35 (2009).

8.                   P. Croskerry, Perspectives on diagnostic failure and patient safety. Healthc Q. 15, 50–56 (2012).

9.                   P. Croskerry, Critical thinking and decisionmaking: avoiding the perils of thin-slicing. Annals of emergency medicine. 48, 720–722 (2006).

10.                 C. G. V. Coutifaris, A. M. Grant, Organization Science, in press, doi:10.1287/orsc.2021.1498.

A version of this article was originally published in NAEMSE’s Educator Update (July 2022).

Error reduction starts with putting down the hammer

by Clayton Kazan, MD

We live in a scary time in the practice of medicine, though I am not sure that there has been a time in which medicine was relatively un-challenged.  We make a lot of errors, and those errors hurt a lot of people.  It’s as true in EMS as anywhere else in the house of medicine.

First, we have to acknowledge that error is inevitable and cannot be completely eradicated.  The attempt to eliminate all error is a fruitless endeavor as long as we have human beings acting at the point of care.  That’s not to say that we cannot reduce the rate of error by incorporating best practices, but we need to learn to expect error to occur and to turn our energy to inhibiting the impact that the inevitable errors have on patient outcomes. 

The first step is that we have to reconsider our system designs in ways to minimize the risk of errors.  For example, we know that medication errors in the prehospital setting are common, and there are all kinds of contributing factors to those errors.  Our personnel work in the most austere of settings; with low light, copious distraction, fatigue, and countless other challenges.  We are often reminded by our personnel that they don’t work in the “pristine setting” of our emergency departments.  But, hospitals recognized the harm potential of critical medication errors many moons ago, and so mandatory double checks for critical infusions like blood transfusions and thrombolytics are the standard.  It’s ironic to use hospitals as the standard for medication safety mere weeks after a nurse was found guilty of negligent homicide for a medication error, but there is no question that mandatory double checks have reduced the risk of medication errors.  So, we have to look far and wide to incorporate best practices, and, where they don’t exist, we need to invent them.  We need to insert enough layers of Swiss cheese between  potential errors and our patients so as to make the probability of an error reaching the patient near zero.  I write this passage while flying on a jetliner, wholly confident that I will safely reach my destination because, decades ago, the airline industry looked at error exactly this way.  Of course, if my plane crashed, you’d never know that this article existed anyway.

What we are bumping up against is culture, and that will inhibit this effort in two ways.  First, we have to stop punishing our people for committing errors.  The punitive culture around error is the biggest impediment to improving patient safety because it disincentivizes our providers from openly sharing their errors.  Without that critical information, we will never really know where to even begin.  If punitive action actually led to better accountability, error reduction, and better outcomes, then why are we still having this conversation?  We need to build a just culture in which the manner that errors are reviewed is transparent, and punitive action is reserved for malicious misdeeds or repetitive at-risk behavior.  As EMS Medical Directors, it is not our job to be the referee for our teams on the field…it’s our job to be their coach.  What team thrives when the players on the field are afraid of being benched or traded when they commit an error?  Only after we  have established a just culture can we hope to build a reporting culture in which it is expected for safety issues to be shared, and a learning culture that embraces the educational opportunities. 

The second cultural challenge that we will face is the inertia of “the way we’ve always done things.”  Stale tradition is the death of innovative system design.  Even a perfect system design, with dozens of layers of glorious Swiss cheese, makes no difference without system adoption.  In the battle between system design and culture, culture always wins.  Classically in healthcare, it takes physicians an average of 17 years to change our practice based on sound medical evidence, and the magic of 17 years is that it represents, approximately, half of a career.  In that time, half of our physicians will have retired out and been replaced by a new crop of physicians, trained in the new system, that know no other way. 

While we have to be patient, because culture changes do take time, we owe it to our patients to be persistent and to be the beacon that lights the way for the departments that we lead so that we can stop sacrificing our patients at the altar of “the way things have always been done.” 

About the Author: Clayton Kazan is the medical director of Los Angeles County Fire Department, President of the California Chapter of NAEMSP and Chair of NAEMSP Communications & Social Media Committee.

Breaking Down the Wall

by Clayton Kazan, MD, MS, FACEP, FAEMS

About four years ago, I wrote an opinion piece for the NAEMSP blog entitled, We Gave an Inch, They Took a Mile about ambulance patient offload time (APOT).  So, now that the problem is solved, we can move on to more pressing issues, right?  I can’t comment about your system, but APOT in my system is the worst it has ever been.  I saw situations during pandemic peaks that I never thought I would, and I hope I will never experience again…walking up and down rows of parked ambulances at our hospitals, occupied with dying patients and no place to put them.  Like so many other things, the pandemic exacerbated existing EMS system weaknesses.  In December 2020, we had two patients surpass 24 hours on the ambulance wall.  In the winter of 2021-2022, the Omicron surge exploded and impacted EMS workforce to the point that, in combination with APOT, we were routinely queuing calls for available ambulances and transporting patients in paramedic squads, law enforcement vehicles, and fire engines just to get them to the hospital.

This is a two-pronged problem.  One, we have to own, and the other, the hospitals must own.  First, we have to stop allowing the ED to be the triage point for all patients reaching out to the EMS system.  It is an unsustainable bottleneck, and the fact that we have come to expect a multi-hour wait in the ED is a prime example of normalization of deviance.  In 2019, we were able to launch and expand a pilot for select mental health patients to be transported to psychiatric urgent care centers (PUCCs).  It’s noteworthy because we had lobbied for this, at the state level, since 2018, only to be successfully resisted by, among other groups, California ACEP and the California Nursing Association.  We managed to get our pilot approved in 2019 and a law pushed through in 2020 (AB1544), ironically with Cal ACEP support, creating a framework for transporting patients to PUCCs and sobering centers, but this is just scratching the surface of where we need to go.  A 911 call should not, necessarily, have to result in an EMS transport and ED visit.  We have multiple opportunities from dispatch through transport to offload appropriate calls to alternate levels and forms of care.  We have to continue to advocate and innovate for our patients to be evaluated upstream of EMS transport and treated in the most appropriate place, at the right time, and at the right cost.  The capacity to care for our high acuity patients demands it, and, we cannot reasonably expect our hospital and ED colleagues to actively lobby for fewer patients.  We have to carry the torch.

The other prong lays squarely with the hospitals, and that is APOT.  On this issue, with EMTALA squarely behind us, we are in a position of strength.  Patient care responsibility transitions from EMS to the hospitals as soon as they are made aware that there is a patient on their property seeking care in the ED.  (Great article from EMS1 on this topic) Responsibility does not transition at the point that the patient is moved to a hospital stretcher or the hospital staff are willing to accept a turnover report.  Once we arrive with our patient and lock eyes with hospital staff, patient care responsibility has transferred, whether it has been accepted or not. In countless stakeholder meetings on the topic, the consistent message from the hospitals is that they are handcuffed by a broken healthcare system with APOT as the inevitable result.  As an emergency physician, of course I am sympathetic to the plight of the hospitals and our ED colleagues, but we cannot allow hospital throughput dysfunction to consume the 911 system…which it surely will if we do not actively defend it.  We have to advocate for patients in the streets that cannot get timely critical care because our units are held up at the hospitals.  We argued, pre-pandemic, that, if our EMTs could watch hospital patients on the ambulance wall, then hospital employed EMTs could do the same.  We could not get hospitals to hire their own EMTs for this purpose until, during the pandemic, the state sent EMS personnel to decompress the hospitals by offloading EMS patients, and guess what?  It worked swimmingly at reducing APOT.  We need to keep the lines of communication with the hospitals open, but we also need to advocate with regulatory agencies to hold hospitals accountable to their EMTALA obligations, which includes managing patients on their ambulance walls with acute life-threatening emergencies and not allowing a patient to see a second day dawn before being placed in an ED bed.

About the Author: Clayton Kazan is the medical director of Los Angeles County Fire Department, President of the California Chapter of NAEMSP and Chair of NAEMSP Communications & Social Media Committee.

Wishes from my Garden: Let Us Be Antifragile

By Maia Dorsett, MD, PhD, FAEMS

Editor, @EMS_MEd

One week ago today, I had my family move out of my house and in with my parents who live around the corner.  I had read the data about healthcare workers bringing the virus home, and I could not bear the thought of bringing it home to my parents who moved close to me when they retired this year.

In this time I’ve realized, probably like a lot of other people,  that I am a much more social person that I thought I was.  I have a renewed appreciation for direct human connection – for hugging my children tight, preparing meals for my family, for going out for a cold beer and warm food with my colleagues after a long shift in the ED. When I am not at work in the ED, answering calls from my EMS agency or responding to COVID-19 emails, I feel quite lonely.  I always thought that if I had some time to myself at home I could be so much more productive, but I have found that my productivity on anything non-COVID-19 related has basically come to a halt.  My mental processors are so overladen trying to make sense of a daily torrent of changing information that I find myself cognitively slowed and unable to push through on any of the projects that I had only wished for the time to work on before.

As a mental health break, I have been going outside to puddle around in my garden. The cognitive silencing of cleaning out garden beds and weeding is strangely rejuvenating.  But more so, in my garden, I have found a sense of hope.  As I have raked away the leaves and trimmed dead stalks, everywhere there is new life emerging.  The ridiculous number of bulbs and perennials that I, after compulsively internet ordering in the wee hours of the night after ED shifts, planted in the Fall are emerging after surviving the harsh Rochester winter.  These plants did more than survive the Rochester winter, they used the cold weather to break down seed coats and start biochemical processes so that they could make their comeback stronger and more beautiful than they were in the previous year.   It is my garden that has instilled in me this wish as we enter this tidal wave: let us be more than resilient, let us be  Antifragile.  On the other side of this, whenever that may be, let us build a system better than we have today.

In recent weeks,  I have felt like I am being eaten from the inside out by frustration.  By relaxing PPE regulations that are more a response to shortage than science. By the inability to test for the disease. By wading through a sea of unknowns and feeling like everything is blurry when I want it more than anything to be clear.  By wishing I could do more to change the course of what is to come.   But I hope that we are like the perennials in a garden, taking this time to sew roots that will make us stronger and better in the future.   Let this be a time of great innovation and recognition of the importance of emergency preparedness and public health.  With a proverbial winter upon us, I see the signs of these fragile roots emerging all around us: recognition of EMS as frontline healthcare, alternative destinations, hospital cooperation to reduce ED volumes, change in production lines, adaptability and more.  

While it feels lonely with my family out of the house, I have also never in my career felt a stronger sense of togetherness – of a shared purpose with amazing, dedicated and selfless people who truly care for those around them.

The weight is heavy, but we will lift it together.  Let us be stronger on the other side.

Maia Dorsett is an Emergency Medicine and EMS Physician, wife, daughter, sister, mother of 3 and fellow human being residing and working in Rochester, New York.  Priorities not in that order.

EMS Physician Assistants: Are They the Next Paramedic Practitioner?

David Wright, PA-C, NRP & Bridgette Svancarek, MD, FAEMS

“There should be a paramedic to Physician Assistant (PA) fast track!”

“PAs and paramedics do about the same job!”

“Isn’t a PA doing the same job as a paramedic, just in the hospital?”

“Paramedics are just as good as nurses”

“Why don’t we [paramedics] get paid like nurses””

Over time, I’ve heard it all. The questions, the comparisons, the ideas of a fast track curriculum to ultimately go from Paramedic to Physician Assistant (PA). It seems a natural progression. Back in 1965, the first class of PA’s was established by a physician at Duke University. [10] The class was composed completely of Navy Corpsman with substantial medical training. This is the same place we get military medical training from today. Years later there have been many EMS professionals that have left EMS to go to PA school. Personally, as a paramedic who went to PA school, I can offer some insight in to this line of thought. Today it is difficult for some of our paramedics to make the transition. While paramedics are trained to be effective Emergency Prehospital Medical Providers, they are often not required to take the advanced sciences, such as Organic Chemistry, Biochemistry, Physics, statistics and psychology, among others. For paramedics to be able to transition to a PA, there needs to be additional training provided, in addition to PA school.

Let’s take a dive into the idea of having EMS PAs, who Dr Mark Escott (Medical Director of Austin Travis County EMS) has appropriately named, Paramedic Practitioners.

Current EMS Education

Today, EMS education is primary classified as a technical career. Most paramedic programs are required to be accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP). CAAHEP accreditation is recommended by The Committee on Accreditation for the EMS Professions (CoAEMSP). CoAEMSP currently does not require a college degree as part of their minimum standards for accreditation. In 2013, the National Registry of Emergency Medical Technicians (NREMT) transitioned to a national standard of 4 separate types of emergency medical provider [2,3,13,14] :

Emergency Medical Responder (EMR) - EMRs complete approximately a 48-60 hour course that trains them to provide immediate life saving care to critically ill patients. They are trained to treat the immediate threat while awaiting additional EMS resources. They can perform basic interventions with minimal equipment.

Emergency Medical Technician (EMT) - EMTs complete approximately a 150-190 hour course that trains them to provide out of hospital emergency care and transport of the critical patients. They have basic skills and knowledge designed to stabilize and transport patients in both the emergency and non-emergent setting. They can perform interventions with basic equipment on an ambulance.

Advanced Emergency Medical Technician (AEMT)​ - AEMTs complete approximately 150-250 hour course that trains them to provide basic and limited advanced emergency care and transportation skills for the critical patients. They have additional training in comparison to EMTs and can perform basic and advanced interventions with both basic and advanced equipment normally on an ambulance.

Paramedic ​- Paramedics complete approximately a 1000 hour course that trains the allied health professional to provide advanced emergency care for critical patients. They have complex knowledge and skills to provide quality patient care and safe transport. They can perform both basic and advanced interventions and can utilize basic and advanced equipment found on an ambulance.

Specialty Paramedics are a relatively newer concept. They further specialize in specific types of care. In some states, there are certification courses and examinations that exist for specialties such as tactical medicine, community paramedicine, and critical care paramedicine. [3]​ There are no defined national standards regarding these specialty paramedics. While there may be a certification exam that is available, it may not be required to be obtained prior to practicing in that field. Without national standards, there is a lot of variation in the teaching and education of these types of providers. Some are short courses that could be offered in a weekend, while others are months or longer in duration.

Current PA Education

Table 1: Accreditation, Certification and Licensing Bodies for Paramedics and Physician Assistants.

Physician Assistant Education, on the other hand, is accredited by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) and is typically a masters of science degree, with program length averaging 24-36 months. Currently most PA programs focus on general medical knowledge, such that pertains to primary care. [6] During the clinical portion of the program, multiple clinical rotations are complete in various specialties. These specialties include Emergency Medicine, Pediatrics, Obstetrics/Gynecology, Family Medicine, and Surgery. Many programs also allow for the student to have input in their clinical time and have a “student directed” clinical rotation, where the student can revisit a previously completed specialty, or experience something they have a personal interest in.

Once the professional program is completed, students are eligible to sit for the Physician Assistant National Certifying Exam (PANCE) exam. This exam is provided by the National Commission on Certification of Physician Assistants (NCCPA) who acts as the certifying body for PAs. NCCPA is to PAs what NREMT is for EMS professionals [Table 1].

Comparison to Nursing

View fullsize

Table 2: Proposed comparison of nursing education to EMS education. Currently, in most states, paramedic is not currently an associates degree and there is no bachelor’s degree requirement.

Often our EMS profession is compared to the age old profession of nursing. While the concept of nursing has been around for a long time. The American Nurses Association was created in 1896, compared to the creation of EMS in 1966. [7,11] Today nursing has a hierarchy that can be compared to that in EMS, but EMS seems to comparatively fall short in education requirements. Nursing has placed value on formalized post secondary education. Nursing organization starts at Certified Nursing Assistant (CNA) and continues to Licensed Practical Nurse (LPN), Registered Nurse (RN), Bachelor of Science Nursing (BSN), Masters of Science:Nursing (MSN). This organization is very similar to EMS from EMR, EMT, AEMT, Paramedic and the proposed Paramedic Practitioner.

A proposed example comparing the Nursing education to EMS education is outlined in Table 2.

Proposed Educational Requirements

In 2018, the National Association of EMS Educators (NAEMSE), the National EMS Management Association (NAEMSE), and the International Association of Flight and Critical Care Paramedics (IAFCCP) released a joint position paper supporting the advancement of paramedics from a technician level program to a degree profession. [9] In 2013 NREMT changed the title of the Paramedic from EMT-P to Paramedic, in an effort to enhance the title by removing the technician label. [13]. In 2010, CoAEMSP recommended that all accredited paramedic programs be offered college credit of 30 credit hours. [12] This eases the transition from a technical program to degreed profession. Today there are many colleges/universities that currently offer Associate's Level degrees (usually Associate in Applied Science or Associate of Science) in Paramedic Care. According to the National Association of EMTs (NAEMT), there are currently only about 25 EMS four year degree programs or higher. [8]

Below is a proposed degree pathway for each of the level of EMS providers allowing smooth transition from paramedic to PA:

View fullsize

Table 3: Proposal for future EMS Degree Pathway

Logistical Considerations for Requiring EMS Degrees

View fullsize

Table 4: 2019 Salary Comparison between Nursing and EMS providers (All data sourced from Salary.com, average annual yearly salary)

Of the largest hurdles to requiring degrees for EMS education, time and money are at the forefront. NAEMSE has published a position paper stating on-line/distance education is one potential solution. [15] With the immersion of technology in the educational world, online programs are becoming more popular, and there are less challenges faced when moving these “additional courses” online. This would allow for them to be completed in a flexible, asynchronous manner, to anyone with a computer. This style of learning, would be able to accommodate the abnormal scheduling of many EMS providers.

Money is another limiting factor for EMS degrees. Many opportunities for assistance with finances for degrees are available, especially for those who currently do not hold a degree. Examples of such funding include Federal PELL grants, workplace assistant, community based scholarships, school based scholarships. Each one of these requires a small amount of work on behalf of the student, but there are many available opportunities for those willing to look for them.

When the salaries between nursing and EMS providers are compared [Table 4], it appears that in the technical programs (CNA vs EMT), our EMS providers are making 14% more than CNAs. An even smaller pay gap was identified with the Master’s Level providers (ED Nurse Practitioners vs the ED Physician Assistants) at 3%. Meanwhile the Associate’s Degree ED nurses compared to the technical program Paramedic had a significant pay gap with a 78% pay difference in the nursing favor.

Can an EMS Practitioner be a reality?

In short, YES! It is possible that today, an EMS Paramedic Practitioner be a reality, in fact, there are some systems utilizing PAs in EMS at this time. Yet, there are still some challenges before a well defined pathway may become available nationwide. Currently, many of these Paramedic Practitioners are former Paramedics who continued on with their schooling to become a Physician Assistant. A master’s degree PA with a Bachelor's degree in EMS can easily be the paramedic practitioner of the future. Another option is to customize a current PA program into having more of an EMS focus. Instead of having the aforementioned “student directed” clinical experience, this is then substituted for an EMS rotation. In place of the multiple rotations in family medicine, there would be greater emphasis on emergency and unplanned medicine.

Having this defined pathway may lead to viable, life long careers with advancement options for EMS providers. This could help combat the long standing feeling of the EMS profession having limited career progression.

It is likely to see more of these ideas emerging. With the implementation of programs like Emergency, Triage, Treat and Transport (ET3) model and alternative transport destination protocols, along with an increase in ED volumes, and increased wait times speciality care paramedics and paramedic practitioners are going to be playing a more critical role. As these programs grow and mature, there will be an increased need for these levels of EMS providers. Implementation of the above proposal can ease their transition into these roles.

There is no better time than now to reflect and decide in what direction we want our profession to head.

View fullsize

References

1. Committee on Accreditation for the EMS Professions (2019) CAAHEP Standards & Guidelines. Accessed from: ​https://coaemsp.org/caahep-standards-and-guidelines#1

2. National Highway Traffic Safety Administration (2007) National EMS Care Content. Accessed from: https://www.ems.gov/pdf/education/EMS-Education-for-the-Future-A-Systems-Approach/ National_EMS_Core_Content.pdf

3. International Board of Specialty Certification (2020) Tactical Paramedics. Accessed from: ​https://www.ibscertifications.org/roles/tactical-paramedic

4. International Board of Specialty Certification (2020) Community Paramedics. Accessed from: ​https://www.ibscertifications.org/roles/community-paramedic

5. International Board of Specialty Certification (2020) Critical Care Paramedics. Accessed from: ​https://www.ibscertifications.org/roles/critical-care-paramedic

6. Physician Assistant Education Association (2013) Physician Assistant Educational Programs in the UInited States. Accessed from: https://paeaonline.org/wp-content/uploads/2016/10/27th-Annual-Report.pdf

7. American Nurses Association (2020) The History of the American Nurses Association. Accessed from: ​https://www.nursingworld.org/ana/about-ana/history/

8. National Association of Emergency Medical Technicians (2019) Degrees in EMS. Accessed from: ​https://www.naemt.org/about-ems/degrees-in-ems

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

10. American Academy of Physician Assistants (2020). History of the PA Profession. Accessed from: ​https://www.aapa.org/about/history/

11. National Highway Traffic Safety Administration (1966) Accidental Death and Disability: The Neglected Disease of Modern Medicine. Accessed from: https://www.ems.gov/pdf/1997-Reproduction-AccidentalDeathDissability.pdf

12. Committee on Accreditation for the EMS Professions (2010) Articulation Agreements: The Path to Offering College Credit for Your Accredited Paramedic Program. Accessed from: ​https://coaemsp.org/?mdocs-file=1368

13. National Registry of Emergency Medical Technicians (2013) Transition Policy. Accessed from: ​https://www.nremt.org/rwd/public/document/policy-transition

14. National Highway Traffic Safety Administration (2007) National EMS Scope of Practice Model. Accessed from: ​https://www.nhtsa.gov/people/injury/ems/EMSScope.pdf

15. National Association of EMS Educators, Position Paper on the Use of Internet Based Distance Learning in EMS Education., Pittsburgh, PA, 2003. Accessed from: https://cdn.ymaws.com/naemse.org/resource/resmgr/Docs/DLPositionPaper111003.pdf

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

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

CON: Raise the Roof, Not the Floor.

by Clayton Kazan MD FACEP FAEMS

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

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

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

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

References

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

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

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

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

PRO: A Good Build Starts with a Strong Foundation

by Hawnwan P. Moy, MD FAEMS

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

by Noah Tyler, EMT-P

Peer Review by Aurora Lybeck, MD

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Response & Commentary

Mark Philippy, EMT-P

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

ET3: Perspectives of a Paramedic and PA

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

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

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

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

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

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

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

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

 Introduction

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

What is ET3?

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

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

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

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

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

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

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

 What does this mean for the Medical Director?

Not just a “sign here Doc” system.

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

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

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

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

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

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

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

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

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

The Future

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

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

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

Mentorship Matters.

By Christopher Galton, MD NRP

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

My three.

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

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

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

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

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

 

Finding the Right Mentor

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

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

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

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

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

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

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

A Productive Mentor-Mentee Relationship

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

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

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

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

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

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

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

This is why we do advocacy

by Ritu Sahni, MD, MPH, FAEMS

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

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

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

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

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

What next?

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

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

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

We Gave an Inch, They Took a Mile

by Clayton Kazan, MD MS

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

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

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

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

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

EMS: The Best Kept Secret in Healthcare

by Maia Dorsett, MD PhD

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

My response?

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

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

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

The reason? 

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

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

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

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

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

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

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

By Melinda Johnson, EMT-B

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References

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

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

3.     Sampson, H. A., Mendelson, L., & Rosen, J. P. (1992). Fatal and near-fatal anaphylactic reactions to food in children and adolescents. New England Journal of Medicine, 327(6), 380-384.

4.     Yunginger, J. W., Sweeney, K. G., Sturner, W. Q., Giannandrea, L. A., Teigland, J. D., Bray, M., ... & Helm, R. M. (1988). Fatal food-induced anaphylaxis. Jama, 260(10), 1450-1452.

5.     Rea, T. D., Edwards, C., Murray, J. A., Cloyd, D. J., & Eisenberg, M. S. (2004). Epinephrine use by emergency medical technicians for presumed anaphylaxis. Prehospital Emergency Care, 8(4), 405-410.

6.     Jacobsen, R. C., & Millin, M. G. (2011). The use of epinephrine for out-of-hospital treatment of anaphylaxis: resource document for the National Association of EMS Physicians position statement. Prehospital Emergency Care, 15(4), 570-576.

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

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

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

by Clayton Kazan, MD MS FACEP

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

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

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

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

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

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

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

http://c.ymcdn.com/sites/californiaacep.org/resource/resmgr/docs/Lifeline/2016/Lifeline_Magazine_December_2.pdf (Page 4-6)

http://c.ymcdn.com/sites/californiaacep.org/resource/resmgr/docs/Lifeline/2017/Lifeline-Magazine_January_20.pdf (Page 10-15)