Optimizing Demand Forecasts

Improvement of your deployment operations requires that you understand where your services will be needed and how to get the available units into the most suitable positions. Then, once you are prepared to respond, it is also critical that only the most appropriate assignments are made for each request to preserve your ability to respond to the next call as well. Traditionally call assignment was a simple “closest unit” consideration with all your resources being equal. That task has now become increasingly complex with a recognition of a growing diversity in call acuity and the increasingly common tiered capabilities of your immediately available resources. This second step of appropriate dispatching toward operational efficiency will be the subject of a future blog post to focus this article solely on demand forecasting.

A common practice for emergency services that have grown beyond a single central depot has been a simple distribution of their resources geographically in the hopes of being able to serve anyone at any time. Without an abundance of crews, this is not typically a successful strategy since neither population nor risk are ever uniform. To make matters even worse, most agencies are experiencing an increase in their volume of demand while also facing some of the most serious challenges in decades to simply maintain staffing levels. Emergency medical services across the country are reporting employee turn-over rates of around a quarter of their staff annually. This trend suggests that there are not only fewer providers per call but less experience on each transport as well. Dispatch centers across the nation also face challenges with an average of 20% of their staff positions routinely left unfilled during the past few years. These difficulties underscore the importance of making good decisions quickly.

Figure 1

Disproportionate access to services is difficult to resolve with fixed stations and often results in increased service available outside of the intended district. To adequately populate this geographic coverage model requires an excessive workforce.

So, are you accurately forecasting demand to help improve your operations?

Is your current demand forecasting process recognizing trends throughout the day and week to allow for effective decision making in response to any predicted demand patterns? Without some certainty in your predictive capabilities, it is impossible to effectively trust the recommendations of any decision automation. A potential lack of credible information makes the choices of unit movement more difficult at the same time they are becoming even more critical to the agency. And a lack of credibility also encourages the freelancing of decisions outside of the control of your administration.

Seasonal variation

When reviewing your own annual call history, you should notice the seasonal variation that distinguishes not only the volume of calls within or between school calendars, but the very nature of the calls themselves tend to follow a pattern. During the summer months, personal schedules tend to be increasingly variable with more adventurous outside activities repeatedly lead to more traumatic events. Once school is in session, most families have less-flexible schedules and the shorter, cooler days often make individuals more vulnerable to acute medical conditions.

Even shorter temporal variation

On a shorter scale of time, differences are also recognizable by day of the week or even hour of the day. Higher call volumes typically occur toward the start and end of the traditional work week. The early morning hours of these business days also exhibit patterns found with early waking habits and the increased vehicle traffic and population movement. The pattern repeats itself later in the afternoon, but the locations of people are quite different than in the morning. The unique business hours and personal behaviors on the weekend also make these days unique from the rest of the week. An unequal distribution of people throughout space and time leaves discernable patterns in the location of requests as well.

Figure 2

Sample data demonstrating ALS (green) and BLS (blue) call volume comparisons by hour-of-the-day and day-of-the-week. Notice the similarity in daily patterns although total volume (represented by 90th percentile) is unique.

To create a useful model that honors all these variations, the operational period to be described in a forecast must generally be shortened while simultaneously extending the pool of similar examples to achieve the required statistical precision. The more similar the forecast of demand is to the current moment in time, the more useful it will be in guiding effective decisions. If the intention is to describe demand during the next hour or two, the historic records queried should reflect a comparable timeframe.

Fortunately, your call history is proven to contain many useful clues about the future. It is not merely a matter of extrapolating a progression of time or an assumption that the same request will come from the same caller again. The real-world is complex, yet we all tend to live, work, and associate with individuals that are more like us than the overall population. As a result, each previous request is an indicator of the types of requests likely from our unique population cohorts. The successful technique is in the allocation of the right populations within the right timeframes to sufficiently forecast the future demand. This is accomplished through the way incident records are selected in a dynamic query to represent a time-based forecast and even more importantly, how those results will be spatially aggregated.

Through Demand Monitor, MARVLIS users can not only update forecast parameters based on their local knowledge, but they can monitor both the accuracy and precision of each dynamic forecast. Using a default configuration, most services should find that approximately 80% of the actual calls received are in an identified hotspot recognized by a current demand forecast. With some effort, that average can often be raised to over 90% of future requests are correctly forecast by the hotspot zones. Simply raising accuracy, however, could be easily accomplished if precision is not considered. By including the whole jurisdiction within a hotspot, an accuracy of 100% would be the result. While technically valid, this type of forecast would provide absolutely no assistance in pre-positioning responders to improve outcomes. The forecast area must be maintained as small as possible while increasing the predictive capabilities of a demand query. Currently, this is recognized by comparing incoming requests over time to the effective forecast when each call was received.

Demand Monitor allows analysts to define multiple query strategies for simultaneous execution and evaluation. If each of these queries is validated against reality, the distinct forecasts can be quantitatively compared and improved over time. The result is a continuous quality improvement that requires some regular review to maintain.

Best practices in Demand Monitor

A recommended best practice for modeling demand is reviewing and modifying the demand queries at least twice a year to coincide roughly with the school calendar. It is not necessary to be precise in modelling academic dates, it is the mindset of schedule regularity that is driving the demand pattern. Jack Stout, the father of the System Status Management concept, suggested using a floating 20-week period based on the size of the spreadsheets he used, but this often crosses the known seasonal variations discussed earlier. To minimize the impact of influence from outside the current season, the number of weeks can be shortened. Reviewing only 5 weeks before and after the current forecast date cuts that total number of weeks in half. It is possible to maintain the number of records of the longer period by including the same weeks from a previous year to mitigate the reduction of number of samples while maintaining seasonality. However, the addition of too many years may have a detrimental affect by increasing the influence of older neighborhoods since newer subdivisions would have less representation across the years. Experience suggests looking back no further than 2 previous years in most circumstances. For most agencies, that keeps the records reviewed within the post-pandemic experience as well.

Another successful strategy to control for the temporal pattern can be to query a fixed seasonal timeframe rather than a floating period. If you want to model the school year, setting fixed dates of mid to late August through mid-May will clearly eliminate the effect of any summer dates. A downside to this method would be the necessity of changing the query period once school begins or ends for the year. Automating the model of both strategies simultaneously can allow for each query option to be graded separately to discover the best alternative for your jurisdiction.

It is difficult to argue against modeling each day of the week individually, but when it comes to the finer segmentations of the day, there is legitimate debate. Again, Jack Stout recommended modeling each hour of each day for a total of 168 unique timeframes of the week. Part of his justification is the average busy time of a unit being about an hour and to simplify the calculation of a Unit Hour Utilization (UHU). Demand Monitor is typically automated to execute every 5 to 10 minutes to minimize the amount of change between each forecast while allowing the predictions to subtly adjust more frequently. It is also common for ambulances to be busy longer than an hour in our post-pandemic world.

Once a query definition is set, it can be tested in Demand Monitor to see how many records it will return. Ideally, the number of records for any sample query should be measured in the hundreds, but less than a thousand. If you need to adjust your parameters, altering the number of years will have the greatest impact followed by the number of weeks and finally the number of minutes which will have the smallest influence.

The experts at BCS have decades of experience bringing real-time analytics to the real-world. If you require any assistance in customizing your Demand Monitor queries, please contact your support representative.

How is Your EMSWeek?

Elsewhere on social media this week I have seen a call to “protest EMS Week 2023”. The logic suggests that the free meals and cheap trinkets are far less than the long-suffering and under-paid providers deserve. While I whole-heartedly agree, “we” have made EMS Week what it has become, not what it was intended.

The EMS Week 2022 proclamation reads “I call upon public officials, doctors, nurses, paramedics, EMS providers, and all the people of the United States to observe this week with appropriate programs, ceremonies, and activities to honor our brave EMS workers and to pay tribute to the EMS providers who lost their lives in the line of duty.” I read nothing in there about free drink coosies and pizza. While there is nothing wrong with a “company BBQ” to get together outside the ambulance, we are wasting the opportunity we were given as a national spotlight. It feels good to bask in that glow for the moment, but we could be grabbing the microphone while we’re there.

EMS Week was designed with a daily focus on service, not just for accolades to passive providers, but as a chance at the microphone to tell our individual stories. Unlike our brothers and sisters in law enforcement and fire protection, we are generally not considered “essential” because the public has not yet seen our value. We can’t point the finger at them and say they need to wake up and look harder, it is up to us to proclaim and demonstrate that value. That doesn’t happen when our mouths are full of free food, only when we provide the free “food” of empowerment to others. So, why aren’t we teaching free classes that build community awareness?

Face it, we suck at coordinated political action. We can’t agree on educational requirements, collective bargaining, titles, or even whether you can provide good care from a red truck. Most of us still honor personal anecdote over research and blame volunteers or federal reimbursement for low pay. We all have different ideas to solve the mess. However, we do share a common power and it is in the personal interactions that we are best at demonstrating our medical knowledge and concern for the welfare of individuals. The same individuals that we are asking to fund us with their taxes.

We could be using this week in service above and beyond instead of using it as a chance to rest. Empowering the public is the best way to gain trust. Show what we know and ask for help in improving outcomes. We need their help to keep a cardiac arrest patient viable until we can arrive and resuscitate them. Make them a part of the team, not outsiders. Learn to install a car seat and help new parents prevent an accident. Build the relationships that use our strength when people are in distress and they will see us as a necessary component of the community, not an add-on.

Many of the pieces of the puzzle to fix EMS are beyond our immediate personal control, but if we actively make the community a partner, they will support us and even demand change on our behalf. Don’t protest the monster we created, tame it for our better purposes.

Advice From an FTO

As we begin to wind down on the pandemic-level of constant 911 calls and the endless hours waiting on a room in the ED, we find ourselves in a time to reflect a little before our next call. Like so many services, we have a new influx of eager young professionals. Recently, a new student asked me, “how do you guys keep doing this day after day?” Not an unusual thing to ask lately, and my reply was this:

“determination and our perseverance to make sure our patient gets the definitive care and treatment they need.”

COVID-19 has really stretched us thin, not just with staffing, but with supplies, training, willpower, and people who actually WANT to learn. Training new hires and students can be tedious and frustrating if you don’t have the opportunity to learn and adapt along with them in addition to teaching them what they need to know. You must become extremely patient and place yourself into their boots. If you don’t empathize, you risk placing yourself in the position of doing harm. Not only to your student, but to the patient, and most likely our profession as well. We need to be resilient and steadfast, showing them the ropes and thoughtfully placing them into the patient care position supported with good proctoring and mentorship.

Minority Report or Moneyball

I have often heard comparisons on the automation of System Status Management to the 2002 Spielberg movie starring Tom Cruise called “Minority Report” loosely based on the 1956 short story by Philip K. Dick. This science fiction action thriller is set in the year 2054 when police utilize a psychic technology to arrest and convict murderers before they commit their crime. The obvious comparison there is to the forecast of future call demand and the eerie accuracy of the reports that allow the right resources to get there in time to make a difference in the outcome. Sometimes in the movie, as in real life, there is a considerable cost to achieve that goal as well. It is easy to get wrapped up in the technology, particularly the virtual reality user interface that Detective Anderton (Cruise) uses to make sense of the premonitions and quickly locate the scene. I like to end the analogy there before we learn the darker side of the way the technology works and can even be manipulated to put a stop to the whole project. Perhaps some EMS providers think they see a similar inherent darkness and hope for an eventual collapse of the whole dynamic deployment paradigm as well. This may be where the art of a story and our reality diverge, especially considering the current economic dynamics even given the admittedly sporadic successes. This may also be why we need a different analogy.

Improving EMS Deployment Performance

I work regularly with agencies that are looking to improve aspects of their operations. Some casual readers may be surprised to know that the focus of those discussions is not always about cutting response times. While response is a simple and common measure, it clearly does not evaluate EMS well and certainly fails to encapsulate many of its complex needs and values. Still, I feel the necessity to address the time objective briefly before going on to other important aspects.  

Where Do We Go Next?

To know where our increasingly limited emergency resources will be needed next, we need to understand where future requests for service will originate. If we knew exactly where the next call would come from, we could proactively dispatch a resource there even before it is requested (watch the movie “Minority Report” for an idea of how that might work.) Unfortunately, the nature of emergency response is not nearly that easy, but that is not to say it is impossible to recognize useful patterns across both time and space. While the 2002 Spielberg movie was set 50 years into the future, it correctly predicted the use of several new technologies that have become reality in less than twenty years. And although we don’t use “precogs” in forecasting demand, the ability of data to show future patterns that effectively influence deployment is also now well established within some agencies.

No one can tell you who will be that very next person to dial 9-1-1; however, it is imperative for the effectiveness of deployment that we concede that people and events often follow certain predictable patterns. Let me explain how this works in just a few steps. First, consideration of the repeatable nature of the temporal distribution of calls has been used for years in making shift schedules. The following chart represents the daily call volume from a specific study, but without a scale along the vertical axis, it could easily be representative of almost any agency regarding their relative hourly volumes.

The daily behavioral routine of individuals perpetuates the collective pattern for the larger community. These daily patterns not only replicate over the years, but across various types of political jurisdictions according to a 2019 Scandinavian study on the �Use of pre-hospital emergency medical services in urban and rural municipalities over a 10?year period: an observational study based on routinely collected dispatch data.� The following graphs from that study represent the relative call volumes of rural, small and large towns, as well as medium and large cities over a decade showing the reproducibility of call volume forecasts by hour of the day.

If we segregate the total call data by weekday, we can capture variations by the hour-of-the-day within each day-of-the-week. The chart of call volumes by day over a twenty-week timeframe, shown below, displays the commonly repeated variation throughout each week. It is the reproducibility of these volumes that allows us to schedule adequate crews to cover these anticipated call volumes.

The next step is to adequately distribute those available resources spatially to address the variation over the geographic area by time which requires an even deeper understanding of the call patterns. The fact that we, as social creatures, often live or work in communities that share similar and predictable risk factors allows us to generalize assumptions of individual activities over larger community groups. Corporations have used targeted demographic profiles to understand local populations for many years. Community profiling has even been recognized by the World Health Organization as an essential skill for all health professionals to help understand the specific and detailed needs of focused populations. (See �Community Profiling. A Valuable Tool for Health Professionals� published in Australia during 2014.) Beyond predictable human variables that focus primarily on medical emergencies are the physical characteristics of our built environment that determine the repeatability of traumatic accidents. A 2009 publication by the Association for the Advancement of Automotive Medicine looked specifically at �Identifying Critical Road Geometry Parameters Affecting Crash Rate and Crash Type� to aide road safety engineers with the challenge of addressing safety issues related to the shape of motorways. The existence of identifiable causes explains the ability to properly forecast the vicinity of calls in addition to their timing.

The following animation demonstrates several spatial demand forecasts in quick succession that are normally separated in the real world by hours. Your existing historical CAD records contain the necessary information to build such dynamic views in real-time.

The demonstrated reliability of demand forecasts, both spatially and temporally, is well known to MARVLIS users and proven to provide the critical information necessary to make decisions in prepositioning resources to reduce the time of emergency responses and limit the distances travelled in emergency mode to enhance the protection of crews and citizens. Furthermore, the Demand Monitor has the capability of grading demand hotspot calculations specific to your service by comparing actual call locations � as they are being recorded � with the forecast probability surface to highlight both the accuracy and precision of our demand forecasts over time that is specific to your agency data and query parameters. The following screenshot shows comparisons of various forecast models.

The percentage of calls that correspond with each shaded area over the selected timeframe quantifies the query accuracy while the hotspot size denotes the relative precision. Accuracy could be increased easily by enlarging the hotspots, but this would be at the cost of precision. A well-balanced query should result in a relatively small-sized hotspot that properly captures a significant portion of actual calls.

Still, knowing when and where to anticipate calls is not enough in itself to determine resource deployment. Some number of outlier calls will likely occur outside of the forecast hotspots, so it is critical to also develop a strategy for managing the risk of covering demand versus geography as weighted factors in any deployment decision. Where we need to be next is well beyond the simple strategies we typically employ now and must fully leverage the depth of our data for deeper understanding and action.

Examining the 2020 Vision of EMS

The NHTSA Office of EMS released a significant document last year called the EMS Agenda 2050 that was carefully crafted to set a bold vision for the next 30 years of paramedicine by clearly differentiating the focus of care from its original definition in the 1996 EMS Agenda for the Future. Now, after just a few months of a COVID-19 pandemic, we have seen these modern precepts being challenged. As with any such vision of the future, a bit more perspective then just the immediate quarter is required. Before stepping toward the future, it is important to know exactly where we are today. To provide that update, NASEMSO released a new National EMS Assessment this past April to provide a measure of emergency medical response personnel and their agencies in this pivotal year of 2020. Although the latest survey is only updating the original work of a decade ago, there have been such dramatic changes that direct comparisons, even over this relatively short time frame, are difficult. To help bridge that gap for comparison, the folks over at ZOLL did a quick blog to reflect on the evolution of the EMS industry since 2011. Still for many, a little more context on how we got this far may be helpful before we can truly understand the significance of these most recent discussions regarding the future of EMS.

It was only back in 1960, that President John F. Kennedy made the statement that “traffic accidents constitute one of the greatest, perhaps the greatest, of the nation�s public health problems.” The automobile was well entrenched in the new American dream by this point as ribbons of smooth highway were unrolling across the country that facilitated speeds of travel much greater than the safety aspects of the car would afford. Yet it wasn’t until 1966 that the National Academy of Sciences ‘white paper,’ officially titled “Accidental Death and Disability: The Neglected Disease of Modern Society,” that ambulances began to transform from a side business at funeral homes into our modern Emergency Medical Systems of today. This initial milestone report, delivered during the Vietnam War, stated that �if seriously wounded � chances of survival would be better in the zone of combat than on the average city street.� So, the signature of President Lyndon Johnson provided federal funding through the National Highway Safety Act of 1966 that not only provided for the establishment of EMS programs, but thoughtfully placed the system within the federal Department of Transportation. Although the Omnibus Budget Reconciliation Acts of the 1980’s under President Ronald Reagan transformed direct federal EMS funding into state preventive health and health services block grants, federal guidance remained within the National Highway Transportation Safety Administration.

The numbers 9-1-1 were added to the American experience by AT&T in 1968 and it grew slowly across the nation as more communities demanded Emergency Medical Services. The most effective recognition of out-of-hospital care throughout the 1970’s came as the result of a television show simply called “Emergency!” This drama highlighted the results of efforts by early cardiologists like Drs. Lown, Zoll and Pantridge in having developed portable devices capable of disrupting the lethal dysrhythmias of v-fib effectively parlaying paramedicine from a focus primarily on trauma to include chronic medical conditions within the home as well. Pediatric trauma would not be officially recognized until 1984 with an Emergency Medical Services for Children study leading to a report finally published in 1993. The patchwork quilt of EMS continued to grow with increasing interest and even more piecemeal funding. Economist Jack Stout led a revolution in economic modeling of EMS systems during the 80’s and 90’s in response to the imbalance of demand and financing that had already fractured EMS into a kaleidoscope of models from fire-based, public safety to “third-service” public utility models to for-profit integrated healthcare businesses. 

It is certainly no accident that our industry has ended up in the position we are today. As W.E. Deming has taught the world, “every system is perfectly designed to get the results it gets.” And we proudly embrace the philosophy that states “when you’ve seen one EMS, you’ve seen one EMS” because we still believe that each service knows the particular unique expectations of their individual community while allowing insurance companies to dictate reimbursement rates. As a result, there is little federal standardization beyond a minimum national level of competency and few local agencies that are funded as “essential services”  even though the NAEMT has advocated this position for years. 

Today, it is heart disease that has overtaken the American consciousness as waistbands expand across the countryside demanding more from our organs than the body was designed to provide. In addition, we face new biological and socio-economic challenges for delivering healthcare in the field. We’ve needed a new road map like the EMS Agenda 2050, but we can’t just sit back and wait for it to happen. As professionals, we all need to educate ourselves on topics like Emergency Triage, Treatment, and Transport (ET3) and health information exchanges that are being piloted at select services. We must be the change we want to promote. 

 

See What Others Can't

Ever since I was a kid, I wanted a superpower of some kind. Little did I know that one day my wish would actually come true. 

For anyone who is a serious user of Geographic Information Systems (GIS), it is not news that this week is the 2019 Esri User Conference. If you are not one of those people, the “UC” is an annual gathering of around 20,000 people who share an interest in applying geospatial technology to solve real-world problems from optimizing business to saving the environment. I was particularly inspired by the theme this year, “See What Others Can’t.”

At its core, GIS is a spatial database for the analysis and visualization of information. When it is used in EMS, it can take a deep dive through your call history and come up with an estimation of the likelihood of the location of calls for service within the next hour. Because it can be an automated process, this forecast can be repeated every few minutes to give you a constantly updated view of the near future regarding where you are most likely to be needed. Some users of MARVLIS Demand Monitor compare it to a weather map that shows the changing conditions in your service area. But knowing where you need to be is only a part of the problem of optimizing the delivery of emergency medical services.

To really be efficient, you also need to know where you are and where you can be within your response time allocation. To answer this question, you need a model of the street network and an understanding of both the daily patterns of travel as well as the unique driving conditions right now. Many counties across the US have dedicated GIS staff to maintain these navigation and addressing models, but commercial vendors can also provide a good base layer of data. TheAddresser is another product from BCS and it can be used to measure or even improve the quality of your geographic data to improve its ability to turn an address into a proper coordinate where a crew can physically respond. The digital road network that is used to calculate a route can be improved by modeling how fast vehicles in your fleet have traveled along each road segment in the past, divided by direction, and lumped into various traffic time periods. The MARVLIS Impedance Monitor automates the mining of your Automated Vehicle Location (AVL) history to generate these unique travel times to understand exactly what area can be covered even as an ambulance is moving. For the immediate hazards along the way, MARVLIS can leverage the events logged by Waze users in real-time to enhance your own road network data through MARVLIS Central. Together, this gives you the best understanding of the reach your crews have at any given moment.

The real trick is in how you choose to post ambulances to meet your specific objectives. If a fast, safe response is most valued, ambulances can be directed to uncovered hot spots which will minimize the distance they must travel to the next call. If cutting response times across the board, or minimizing post moves is preferred, a weighting can be applied in the MARVLIS Deployment Planner to optimize the geographic coverage area. Regardless of how the criteria are balanced, an hourly, prioritized posting plan can be generated based on your service objectives. That plan can then be automated through the live connection in MARVLIS Deployment Monitor that can not only see where ambulances are located by their status, but also directly viewing where calls are currently active from the Computer Aided Dispatch (CAD) software. It can then even make specific recommendations on reassigning units to automatically optimize your coverage criteria.

Together, these intrinsically GIS-based tools can provide an unparalleled insight into the operational world of EMS with timely automated recommendations on how to improve service according to your community’s values. The suite of MARVLIS applications give any EMS manager a view to “see what others can’t.”  To see clarity in the everyday chaos of EMS operations, GIS can give you genuine superpowers. 

-Dale Loberger

 

tl;dr but commenting anyway

I’ll try to be brief. As an EMS blogger, I have always believed in the potential that social media possesses to change the dynamics of how we interact and grow professionally. The promise of the democratization of information and the timely access to news and research on-demand should only be making us better at our prehospital jobs. It is my experience, though, that we have simply become more efficient at sharing opinions than we are at actually communicating useful information. Worse yet, many individuals continue to abuse social media resulting in a stifling of their own professional development. Dave Statter terms this phenomenon as “Social Media Assisted Career Suicide Syndrome” (with plenty of examples.) But probably most disturbing is that we, as healthcare professionals, are hardly any more progressive in our knowledge or use of social media than the general public.

As author Stephen Covey has aptly pointed out, “the biggest communication problem is we do not listen to understand. We listen to reply.� Like the responder who keys the microphone before thinking through the data that needs to be transmitted, many of us share a stream of thought from our beliefs in place of observing facts that may serve to lift the conversation. What becomes all too apparent in the rush to comment is the lack of depth in our training instead of the width of our understanding. It amazes me how many readers of an article will post comments based on the title of the piece without reading the text itself. The acronym “tl;dr” sums up the very problem at its heart because the person writing the comment is admitting the post was “too long; didn’t read.” 

To prove that this is not simply an opinion letter, I’ll submit a Pew Research Center study from earlier this year that demonstrates how differently various age groups receive their news. Hardly anyone younger than a Baby Boomer will dirty their fingers by thumbing through an actual newspaper any longer as social media finally edges out this traditional printed news in popularity. Even digital newspaper websites are declining in readership while television manages to retain its lead as the most popular medium (also propped up in large part by older generations.)  It is apparent that, independent of its source, more Americans prefer watching stories to actually reading the news. In fact, the most interesting insight from the survey is that the top two platforms for news among the college-aged crowd is Facebook and Snapchat.

My greatest fear has now become the “democratization of information” because of how much of the internet is fake. Not just “fake news,” but fake businesses, fake metrics, and even fake people. Artist Donny Miller, known as much for his typographic-based prints as his politically astute comments, noted that �We don’t communicate anymore. We just talk.� He is also the one who popularized the quote: �In the age of information, ignorance is a choice.� However, the internet has become much less than we thought it could be. And even using it becomes more of a challenge to mine information than simply find information.

As a sign of the decline of printed news in the prehospital arena, PennWell Corporation discontinued printing the Journal of EMS earlier this year and has opted for a digital approach to disseminating news. Whether JEMS, or its competitors at EMS1 and EMSWorld, can navigate the new reality of news is still to be seen. But it is clear that “readers” are demanding more interactive content that includes engaging visual infographics and flashy videos. One of the bright spots on the web to me as a professional has been the appearance of FOAM (the Free, Open Access Medical educational resources.) But this collective has many challenges as well. Some of the ethical issues that need to be analyzed and resolved are outlined in this article which also posted this handy summary graphic.

 

A few years ago, someone posted a question to a Reddit forum pondering, “If someone arrived from 50 years in the past, what thing would you have the hardest time explaining?” George Takei shared the reply of a very astute observer of society who answered, “I possess a device, in my pocket, that is capable of accessing the entirety of information known to man. I use it to look at pictures of cats and get in arguments with strangers.”

Although I am not fan of New Year’s resolutions, my personal plan for this coming year is to continue to educate myself (going beyond the bare minimums of ConEd classes) by actually reading more research and commenting my opinions on the news less often. We will have to see what happens to this blog as well as my Facebook and Twitter pages as a result. Happy New Year. 

What Starman is Saying About the Future of EMS

We have seen the last photo to be transmitted directly from the cherry red Tesla Roadster belonging to the electric car manufacturing CEO, Elon Musk, that is being driven through space by a dummy named Starman while listening to David Bowie tunes. That is clearly the sort of historic snapshot that will not fade any time soon. More importantly, it is developing a new picture in my mind of an image that belies the future of EMS here on earth.

This �PR stunt for the ages,� as the BBC put it, was conceived by Elon Musk who is also CEO of SpaceX, a private American aerospace manufacturer and space transport service. He is a South African-born billionaire entrepreneur and founder of Paypal (in addition to Tesla and SpaceX) who has manufactured the most powerful rocket on earth as a stepping stone for carrying cargo and passengers to colonize Mars. And almost as if to show his prowess, he designed his rocket to have parts that land upright on targets after separation from the main rocket so they could be reused in future launches. In case  there was any doubt before, Musk can definitely claim to be a space visionary now. Until earlier this month, all of these ideas were considered to be the indisputable domain of science fiction. So what is the connection to EMS? Bear with me.

As I was growing up, I followed the Apollo missions between 1961 and 1975 that ended up taking humans to the moon. Okay, I wasn’t actually born until 1964, but even as child I could recognize the historic importance of that “one small step” Neil Armstrong took that eventually slipped mankind beyond the surly bonds of earth during the Space Shuttle program of the 80’s. Long before video games supplanted the imagination of childhood, my friends and I rode a nearly-fallen, old tree poised perfectly to take young dreamers into the stars to explore unknown worlds. Our only hope of reaching the inky black of space was to be an astronaut. And it was NASA that held a monopoly on those dreams.

The world is very different today and so is NASA. The government space agency is no longer the only game in town. In fact, since the retirement of the Atlantis shuttle in 2011, NASA has been hitchhiking space rides with the Russian government and private companies. The government employees that met President Kennedy’s challenge “to do the hard thing,” with less computing power than I carry in my pocket, has now been upstaged by a billionaire blasting his own sports car into space for a unique photo op. It wasn’t supposed to be like that. Space is about science. It is about the good of all humanity. The private sector is not supposed have the right stuff! Had NASA let me down?

Now. Let’s talk about EMS models. Sure, “if you’ve seen one EMS, you’ve seen one EMS”; but the common thread is that we serve the public. And only the public sector has the best interest of all people at heart, right? Wait, or it is only the fire service with their selfless devotion to helping others that can claim the legitimate right to save lives? Or, maybe it can only be the volunteers who truthfully don’t do it for the money. It certainly can’t be the minions of a for-profit company. Their only motivation is greed. “You call, we haul, and that is all.”

I used to think there was a right answer for modelling an EMS, a single best practice that universally applied. With all that we have experienced, there had to be a right answer. However, one thing Starman helped me see is that our answers don’t always fit when we ask the wrong question. Space travel is simply a means to an end. The goal Musk set for his SpaceX team was not to just build a record-setting rocket, but to design a means to build a human colony on Mars. The goal that President Kennedy set was not to beat Russia into space, but to put a man on the moon. Given these great missions, I am disappointed by the level of discussions we often have in EMS. We focus on the details of programs to get them right – often to the exclusion of a coordinating plan. We expect that working out these details will lead us to the right end.  

Do we have a “moon shot” challenge in EMS? Hopefully it is more than building new programs or perfecting existing models of delivery. Every EMS organization has a mission statement, but is it something that can really guide us or is it simply something to make us feel good about what we already do? Does your organization share a vision of what we truly hope to accomplish through improvement and lay out how different we want our service to look when our tour is over? Building a community paramedicine program works is some settings, but shouldn’t necessarily be owned by EMS everywhere. To some agencies, the thought of patients being dropped off at the ED by an Uber rideshare is a serious threat. For others, the core challenge is CMMS reimbursement rates.

When we focus on program details we find more differences with other services than commonalities. Where we lack an understanding of an actionable vision, we find very different goals depending on specific employee roles. Successful businesses share a common, actionable vision and each individual learns how their tasks help to make that vision a reality. Ultimately, our daily job is really little more than touching the lives of patients. The moon of our shared quest, therefore, is not a model for deployment, is not the creation of a universal program, it is really about the effective care we give to each and every patient. The details of the programs must grow from that understanding. The vision must be set to allow every provider to correct the course of change rather than focus on blindly applying protocols. 

I used to think there was a simple formula, a best practice that universally applied, but then I took a look for the moon of our profession. Like Neil Armstrong said in July of 1969 when he stood on the surface of his dream and gazed back toward earth and said, “I didn�t feel like a giant. I felt very, very small.� Just a few years later, Alan Shepard had his turn on the lunar surface. His remark was, “when I first looked back at the Earth, standing on the Moon, I cried.� But probably the best statement came during an interview with Apollo 14 astronaut, Edgar Mitchel, when he said �from out there on the Moon, international politics look so petty. You want to grab a politician by the scruff of the neck and drag him a quarter of a million miles out and say, �Look at that, you son of a bitch.��

What Starman is teaching me is that any dummy can ride in an expensive rig, the trick is to go somewhere important and do something meaningful.