Category Archives: Command & Leadership

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.

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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.  

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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.

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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. 

 

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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

 

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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. 

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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.

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Dynamic Risk for Intelligent Fire Move-Ups

Planning for the placement and staffing of fire apparatus, either in a fixed location or for a temporary move-up position, involves the comparative evaluation of community risk for each alternative. Unfortunately, our typical understanding of risk is skewed and outdated. Basing operational decisions on inadequate data leads to choices that can be inefficient, ineffective and legally indefensible.

Of course, there are many factors that combine to influence the danger of a fire response. There must be some estimate of fuel load along with the exposures and barriers to a potential fire spread. For the most part, existing studies get this right – even if only rudimentarily. But it is the most significant single impact on fire frequency that is modeled the poorest. Kasischke and Turetsky stated in 2006 that “(people) are the dominant source of ignitions except in sparsely populated regions.” Our troubled standard for measuring population is the decennial US census. Prior to the twenty-first century, these federal statistics were clearly the most consistent available figures that were widely accessible.

Census population data, which is often the basis of many comprehensive fire plans, have several logical failures for their use in local community risk evaluation. The first problem is the age of the data. The census is taken only every ten years and the values of intervening years are estimated through algorithms. At this present point in time, the 2010 population estimates have been statistically massaged for the past 7 years. Add to that, the fact that the census only counts “night-time” populations by estimating where individuals “live” (or spend the majority of their sleeping time) rather than accounting for their patterns of movement outside of the home. The time away from their census-defined abode can often be the better part of each 24 hour period, yet the nineteenth century agrarian idea of home is the value most studies use to consider the number of humans at risk in an area. Still another major problem is the aggregation level of these population estimates. The census ‘block group‘ is the smallest numerical unit that the US Census Bureau reports to the public. By definition, the block group typically consists of a neighborhood of between 600 and 3,000 individuals where estimates of its values are extrapolated through reports from a representative fraction of the area. Finally, in a 2015 study on population density modelling in support of disaster risk assessment, the authors conclude that “block groups are not fine enough to be suitable for specific hazard analysis.” While many planners attempt to break down these manipulated night-time population estimates by factoring a simple percentage of an area, there is no statistical support for such assumptions. In fact, the foundation of the referenced work by Tenerelli, et. al. describes specific ‘downscaling techniques’ using intensive proxy attributes to give clues for any justifiable disaggregation of coarse population statistics. Most of these techniques are far more involved than percentages and have value only when no other population measure is present.

Today, the near real-time visualization of population surges that quantify the urban influxes at the start of the work day and their subsequent retreat into suburbia for the evening are becoming a reality. Dynamic population movement can now be mapped using anonymized mobile phone data. According to a 2017 Pew Research Center Fact Sheet, it is estimated that “95% of Americans own a cell phone of some kind” (and well over 75% have devices that are classified as “smartphones”.) Since every one of these devices must regularly ‘ping’ a tower in the cellular network, these signals open bold new opportunities for tracking, visualizing and even analyzing population movement forming an important layer in the dynamic risk of any community with a fidelity far greater than the census block group.

Generic population measures are a great start, but not all people are similar when factoring risk. Some populations are more vulnerable than others. Families that live in flood zones, for instance, have a greater exposure for both life and property loss during heavy rain events. Those who live in large housing complexes with limited egress may also be unfairly disadvantaged during a significant event that requires evacuation. Socioeconomic factors can also limit access to current information or an individual’s ability to react to it. Beyond raw numbers of bodies, we must be able to classify groupings of individuals and label their vulnerability.

There are many other sensors in a community that can also be leveraged in modelling the dynamic nature of risk. The risk for flooding is dependent on a source of water input. Rain gauges within your watershed can define the amount of water added over a measure of time. Stream gauges measure the depth of water in a channel and can inform you of the likelihood of imminent flooding. Increasingly, these sensors are becoming part of the Internet of Things (IoT) that allow remote access of real-time data. Even layers of data that are often considered to be static can have variability capable of being modeled. A school, for instance, is usually categorized as a ‘high risk’ asset, but is it always at the same risk level? The actual risk experienced is far lower during summer months or on weekend evenings. Conversely, its risk status may go even higher than normal on certain Friday evenings when the home team is playing a championship game and entire families gather in addition to the normal student population. Similar to pre-plan floor layouts or construction analysis, the use patterns of a building can be noted and input to a dynamic risk model. The increased effort of data collection should be more than repaid by the acute knowledge gained for steering protection decisions.

The reason we do not make more effort to realistically model the threat to our communities is not because it is difficult, but because we simply have never done it that way before. The technology to visualize changing demand and automate recommendations for responding to it has long been proven in the EMS world. The rebuttal is often that the fire service is different. However, simple modifications of existing software provide mobile access to risk as a spatial surface of probability on a user-selected basemap of imagery, topography, or cadastre for incident management or support in apparatus move-up decisions. Modification of the dispatch software to recommend not just the closest ambulance but the most appropriate response package of apparatus based on incident reporting is also being made. The Mobile Area Routing and Vehicle Location Information System™ (MARVLIS) by BCS is leading the movement to change the management of fire apparatus, not just as another point solution, but a significant new platform for visualizing your community and better protecting it.

“Risk” is defined in the Business Dictionary as “the probability or threat of damage, injury, liability, loss, or other negative occurrence.” The threats that face any neighborhood (or fire planning zone) are never constant. We must re-evaluate these time dependent risk factors and re-imagine the information flow used in making decisions that respond to knowing the time-dependent threat. If you only report call history as daily averages, you are ignoring the role that reality plays in your responses. Action as simple as viewing call demand by the 168 hours of each week will provide a clearer image of the routine daily patterns that exist. And these patterns are likely to be different during each season of the year or, at the very least, in comparing the months when school is in session against the months it is not. I recognize commuting changes in my own neighborhood the very day school opens and again on the day after it closes each year. If you can see that too, why are you not making efforts to adjust response potential to these realities?

While public safety is not a traditional ‘business’, it can learn a great deal from business leaders like Warren Buffet who said, “part of making good decisions in business is recognizing the poor decisions you’ve made and why they were poor.” We can do better and that is exactly why we should.

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What 'Level Zero' Really Means in EMS

Rampart, Medic 13 with an incoming patient report.”

Go ahead, 13.”

I have a patient with a pulse of 120. ETA less than 10 minutes. Over.”

Well, this sort of report certainly leaves something to be desired. What is the age of the patient? For an infant, this may be a normal rate, but in a geriatric person it could be a bigger concern. Has the patient been involved in any physical activity? If the subject just completed a marathon it may not be a concern, but if the patient had been sitting on the couch watching TV and the pulse suddenly spiked, it could be a legitimate emergency. In any of these cases, we still need more information. The patient’s blood pressure would be another good measure along with age. Some OPQRST or SAMPLE would be enlightening too. A treatment, let alone a diagnosis, cannot be advised from this single piece of data.

In a very similar vein to our pulse example, there have been several articles written lately bemoaning the dangers of any particular EMS system having hit a ‘Level Zero’ situation some number of times in the last however many months. For instance, there is an article where San Bernardino firefighters attack AMR. Don’t misunderstand my point, not having any ambulances available can definitely be a serious situation, but how long does the situation last in each occurence? In any significant service area, its bound to happen at some point even with proper planning and normally adequate staff. My concern is the media attention over this single measure of an emergency health system. It may be that reporters finally got the message that response time was not a good defining metric by itself. But just like our bodies, an EMS organization is a complex system of interoperating systems. Performance is not defined by any single measure. Although individual metrics, however, can cause us to want to look deeper to understand the likelihood of potential serious problems.

A case in point is a story last year on Paramedics Plus in Sioux Falls, that revolved around two specific cases where an ambulance was not available for patients in distress. While this is not ever a desirable position, the compliance of the ambulance provider in question was 95% and even the investigative news reporter found that EMS arrived before the fire department’s own ”first responders” in 25% of cases. Perfection is simply not easy to maintain. While not making light of any potentially serious situation, my intention is to place this measure within some context, just as a sole pulse reading is only a singular measure of performance and one that is not meant to be interpreted by itself.

The MARVLIS application, in use by almost every member of the AIMHI (Academy of International Mobile Healthcare Integration) organization (formerly known as the Coalition of Advanced Emergency Medical Services or CAEMS) is often viewed as a tool for improving response times. While it has proven to be beneficial in achieving that goal, that is not the only reason these “high value” systems use it. Improving individual response times also improves compliance. Consistently short response compliance can also have clinical value if the times are low enough in the right situations. Jersey City has correlated a response time near 4 minutes to improved ROSC. But other benefits are improved value in post moves. Not moving ambulances for the sake of changing posts, but in positioning units closer to their next call with fewer moves. This also means fewer miles driven with lights and sirens to improve crew safety. Mobile Medical Response (MMR) credits MARVLIS in their annual report with reducing their costs associated with unloaded miles driven. As a collection, these improvements mean more than any single measure.

The reality is that our profession is fundamentally changing. We are coming from an EMS world where measurements of specific vital performance are evolving into a diagnosis of value. Just as good vitals indicate good health, positive measures of performance will be interpreted as higher value. In the same way that a general impression should guide a clinician in measuring vital statistics, the evaluation of an EMS should also be guided by a broader vision of value rather than a microscope trained only on specific measures.

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Lights and Sirens and Safety

lightsandsirensThe use of  lights and sirens is supposed to clear traffic by warning drivers or pedestrians that a public safety vehicle is approaching in emergency mode. The expectation is that the use of warning devices increases the safety of both the patient and provider by reducing travel time in responding to a scene or while transporting a patient to the hospital. Conceptually, this visual and audible cue is requesting that other nearby motorists yield the right-of-way to the approaching ambulance.

While lights and sirens are a fundamental cannon of every agency’s standard operating guidelines, their efficacy has never been proven to positively impact patient outcomes. To the contrary, there are examples nearly every day of the failures of these warning systems to provide a safe transport. Just last night there was an accident as an ambulance broke an intersection in Orlando and a few days earlier another crash was reported in Chicago. And literally as I was writing this post, an ambulance from a small town in New York was also hit at an intersection. If warning devices worked, why do we see so many accidents?

In our current age of evidence-based clinical practice, it is more than fair to question operational procedures as well. Studies have shown full use of lights and sirens decrease hospital transport time by only 18 to 24 seconds per mile when the ambulance trip is less than five miles – and there is virtually no time savings at all when the transport is over five miles. Additionally, studies show that the operation of ambulances with warning lights and siren is associated with an increased rate of collisions.

According to a 2010 report on EMS Highway Safety by the National Association of State Emergency Medical Services Officials, “no evidence-based model exists for what ‘mode’ of operation (lights and sirens) should be used by ambulances and other EMS vehicles when dispatched and responding to a scene or when transporting patients to a helicopter landing zone or hospital. A New Jersey based EMS provider, MONOC, has produced a video that aims to protect EMS providers through creating a culture of safety and limiting the times that warning devices should be used. We do know accidents happen when lights and sirens are used. We also know they save very little, if any, time in transport. But no one wants to completely eliminate them. They are in about the same position as the long spine board. We shouldn’t use them as much as we do, but they seem to still have a proper limited space of operation.

In attempting to limit their use, we can come up with some crazy ideas. A new protocol affecting 15 West Michigan counties calls for the use of emergency lights and sirens only to “circumvent traffic,” primarily at intersections, by ambulances transporting patients with life-threatening conditions. Once traffic has been circumvented, lights and sirens are to be turned off. This seems potentially dangerous  as drivers have less warning of an approaching ambulance leaving less time to react. In my experience, drivers are already confused on exactly what they should do when they finally realize we are in a hurry behind them. My other personal concern would be the impression left with drivers when the lights and siren are switched off after “circumventing the traffic.” Will the public incorrectly view the situation as an abuse of the “privilege” to run emergency traffic just to clear traffic? In researching some of these questions, I ran across a serious question from the public asking “if the guy dies do you turn off the siren?” We have failed as an industry to teach the community what we do and how we do it.

The article, “Why running lights and sirens is dangerous” discusses not only the issues faced, but proposes steps that should be taken to reduce the risks associated with driving ambulances “hot.” One objective for safer operation is to reduce the miles that ambulances travel under lights and sirens. The Michigan protocol attempts to accomplish this objective by requiring them to be switched on and off throughout the trip, but another alternative is to change the starting point of an ambulance prior to responding to a call. Many services already accomplish this through dynamic deployment to hot spots of forecast demand which has shown to be effective in reducing both the distance traveled in emergency mode and reduces the overall response time as well.

Carefully consider, within your protocols, when to use the warning devices available to you. Never assume that they “grant you” any right-of-way, as they can only request motorists yield it to you. It is always your obligation when operating an ambulance to drive cautiously for your own safety as well as the public. You can change the culture of ambulance operations to prevent accidents and be safe!

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