Category Archives: Dispatch & Communications

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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Analyzing Routes and Response Times

This is a second preview chapter of a new book in the Primer series from Bradshaw Consulting Services to be titled “Closest Vehicle Dispatch: A Primer for Fire� to be released in time for the FDIC 2017 at the end of April.

Whether you are held to the standards of NFPA 1710, which addresses predominately career fire department responses in the US, or NFPA 1720, which deals specifically with volunteer departments, the challenge of meeting these response time standards is increasingly difficult for many reasons. Higher demands on limited resources and increasing performance expectations from the public are just a couple of those forces opposing response efficiency. Another elementary factor that critically impacts our response times is the route we choose in order to arrive at an incident. In most cases, there is not always a single route that is consistently the best choice at all times of the day or week. These differences can also include seasonal variations or be complicated by special events which may be planned or unplanned (Demiryurek, 2010). The subjectivity of route selection is further complicated by dynamic characteristics such as traffic or weather in addition to the extent of the mental map we develop of a service area or what that map may be lacking in adjoining or mutual aid areas (Spencer, 2011).

Most of the considerations that we process as we consider a potential path of travel in an emergency vehicle are often made subconsciously through personal experience and knowledge. While there is no legitimate argument against knowing your service territory well, the question becomes do we have sufficient awareness to consistently make the best route choices?

According to U.S. Fire Administration statistics for 2005, responding to alarms accounted for 17 percent of firefighter on-duty fatalities (Response, 2007). Deaths in road vehicle crashes are often the second most frequent cause of on-duty firefighter fatalities. In 2014, this percentage dropped to only 10 percent with a total of just 7 fatalities. Although the change is positive, it is too early to consider this to be a trend since it is only the second lowest number of crash deaths over the past 30 years (Fahy, 2015). While these accidents are not all due to their route choice, it can be argued that there are times where crews were clearly in the wrong place at the wrong time. Furthermore, the shortest path is not always the quickest route, and the fastest one may not have the simplest directions either (Duckham, 2003). Given the technology and data available today, there is little doubt that we can make strong decisions provided that we understand how we make these choices and what information may improve them.

In selecting a route for any particular apparatus, we may consider the physical or geographic characteristics of the roadway that determine the maximum speed of travel based on the maneuverability and size of our apparatus. Similarly, we must consider the likelihood of traffic congestion and also the safety of our crews as well as the public. As we increasingly rely on algorithms for making driving decisions, it is important to appreciate the mechanics of how the technology components function together. The Global Positioning System (GPS) is often credited with providing guidance to vehicle operators, but this is not exactly true. The satellite constellation that makes up the American-operated GPS (and similarly the European GLONASS) simply sends accurate time signals by radio waves to our portable receivers who detect the length of time each signal has traveled through space and then triangulates a position based on the calculated distance from those man-made stars (Hurn, 1989). The accuracy of the position that your GPS unit determines is based on the quality of those signals received and the precision of the local clock used to compare the time encoded in the signals. These satellites have no concept of transportation networks or traffic congestion on earth. It is Geographic Information Systems (GIS) that model the street networks and also track the vehicles using them. Unlike the limited number of GPS-like constellations in space that help us derive our position, there are a multitude of GIS-based computer services that offer routing recommendations. Some of these services, like the consumer-based routing applications available on your smartphone, are located on “cloud servers� (although they are quite terrestrial) while others may be hosted privately on local government networks and available only to “trusted client� applications on your Mobile Data Terminal (MDT).MARVLISiOSinFD

Each of these GIS services has unique embedded algorithms for recommending directions or to estimate arrival times (Keenan, 1998). As users of these systems, we become subject to the specific assumptions inherent within their design leaving them far from being equivalent to one another (Psaraftis, 1995). For instance, network models must account for the elevation differences of overpasses in relation to the roadway below in order to prevent suggesting that a vehicle take a turn off of the side of a bridge. The cost of that ill-fated maneuver would be insurmountable, but other legitimate turns have minor costs associated with them because the apparatus must slow down to navigate the curve safely. A traffic light, or oncoming vehicles, can add further to that turn delay. Accounting for these delays requires logic in the GIS routing algorithm as well as valid time estimates coded into the street network data at each intersection.

The most basic feature of any transportation network model, however, is the cost of movement along a road segment in either direction which is known as its “impedance.â€? Many systems will assume the speed limit over the distance (impedance_time=speed/distance) between intersections to derive a similar “drive time” in both directions. Real world conditions (including traffic, terrain, and weather) will prove that speed limit-based assumption to be overly simplified and can lead to poor routing decisions because of unrealistic impedance values in the model (Elalouf, 2012). Crews will quickly recognize these failures and the lack of trust that these errors engender can compromise the entire routing program. Realistic impedances should be variable based on the time of day or day of the week in addition to the direction of travel.

More complex online routing services now offer near real-time traffic updates. While this traffic feedback can be invaluable to most drivers, its practicality to emergency vehicles appears limited in general. If our task was to deliver pizzas, we would be constrained by normal traffic regulations. Knowing where traffic congestion is at any given moment would allow us an opportunity to seek an alternative to bypass a congested intersection. This is a common type of need for drivers and therefore many consumer routing apps seek to address that specific function (Ruilin, 2016). But when our duty is to respond to the accident at that same intersection that is causing the delay for others, these typical consumer routing applications may fail our unique requirement. This objection is especially valid where emergency vehicles are not strictly constrained by the driving patterns of other vehicles on the roadway. In certain situations, it may be allowable for an apparatus to use the road shoulder for travel or even cross a median to use an on-coming traffic lane or to traverse a one-way street in the wrong direction (Harmes, 2007). The only reasonable exceptions to this generality are those dense urban areas where congestion is excessive and these “open” lanes or roadway shoulders simply do not exist to allow apparatus to circumvent that traffic. In a recent trip to New York City, I visited a fire station in downtown Manhattan. They received a call and exited the station with red lights and sirens blaring, but even the air horn was unable to move traffic. The engine sat at the traffic light behind the rest of the cars until the intersection cleared enough to allow drivers to create a path up to the next intersection.

In general, when we look to leverage technology for our unique demands in public safety, a system would ideally be able to learn our peculiar patterns of travel and record typical impedances based on how our own fleet resources travel. Additionally, these impedances will likely be different during certain hours of the day or on specific days of the week and vary even further seasonally based on whether school is in or out of session. These cyclical patterns will have a huge impact on actual drive times and any route recommendations must account for them accordingly. Current consumer routing applications are continually improving their ability to recognize and address the needs of passenger cars or ordinary delivery trucks, but this still does not necessarily translate to better routing of emergent public safety vehicles in most cases.

Finally, the last critical piece of route selection is a review after the call. Comparing the actual route traveled with the recommended path is an important feedback mechanism to both ensure that the system is operating as intended and to build confidence within your crews that encourage them to trust the system. This is not to suggest a blind obedience to technology, but constructing a learning process for everyone in developing tools that function to improve overall performance. No technology is perfect in the real world, just as no person has ultimate knowledge at all times. But cooperatively, we can learn to make improvements in either the computer or human systems as needed to enhance awareness in the other. The most successful implementations of routing assistance create cooperative relationships between responders and the GIS staff responsible for maintaining the data. Failures discovered in any system should not be used to condemn an otherwise useful technology, but seen as opportunities for improvements in either the algorithms behind it or the data that fuels it.

One of the critical outcomes of route selection, aside from arriving safely, is the total time of travel. No matter when the clock starts for measuring your response time, it is the minutes and seconds that the wheels are rolling that often consume the majority of it. The longer that time or distance, the higher the cost. A cost that can be measured both in actual vehicle operating expenses as well as the risks associated with its operation; not to mention the losses adding up on scene prior to your arrival. In general, the shorter the time (and distance) between dispatch and your safe arrival on scene, the better it is for everybody.

 

References:

Demiryurek, U., Banaei-Kashani, F., Shahabi, C. “A case for time-dependent shortest path computation in spatial networks.” GIS ’10 Proceedings of the 18th SIGSPATIAL International Conference on Advances in Geographic Information Systems. ACM, November, 2010; 474-477.

Duckworth, M., Kulik, L. “’Simplest’ Paths: Automated Route Selection for Navigation in Spatial Information Theory.” Foundations of Geographic Information Science. (2003) 169-185. Berlin: Springer-Verlag.

Elalouf, Amir. “Efficient Routing of Emergency Vehicles under Uncertain Urban Traffic Conditions.” Journal of Service Science and Management, (2012) 5, 241-248

Fahy, R. F., LeBlanc, P., Molis, J. Firefighter Fatalities in the United States-2014. NFPA No. FFD10, 2015. National Fire Protection Association, Quincy, MA.

Harmes, J. Guide to IAFC Model Policies and procedures for Emergency Vehicle Safety. 2007. IAFC: Fairfax, VA.

Hurn, Jeff. GPS: A Guide to the Next Utility. (1989) Sunnyvale: Trimble Navigation.

Keenan, Peter B. “Spatial Decision Support Systems for Vehicle Routing�. Decision Support Systems. (1998);22(1):65-71. Elsevier, Salt Lake City.

Psaraftis, H.N. “Dynamic vehicle routing: Status and prospects.” Annals of Operations Research (1995) 61: 143.

“Response-Time Considerations.� Fire Chiefs Online. ISO Properties, 2007. Web. 20 May 2016.

Ruilin, L., Hongzhang, L., Daehan, K. “Balanced traffic routing: Design, implementation, and evaluation.” Ad Hoc Networks. (2016);37(1):14-28. Elsevier, Salt Lake City.

Spencer, Laura. “Why the Shortest Route Isn’t Always the Best One.� Freelance Folder, November 2011. Web. 7 December 2016.

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Toward a Better Understanding of Dynamic Deployment

I recently had two articles published by EMS1 as a couple of “mythbusting primers” on the topic of dynamic deployment. The articles were Dynamic deployment: 5 persistent myths busted and Dynamic deployment: 5 more persistent myths busted. My intention was not to convince anyone of a position that opposes their current EMS world view pertaining to deployment models, but I had hoped to extend the work Dave Konig began in The EMS Leader defining the terms of EMS resource deployment in 2013 and to have an open discussion about it. My hopes of engaging in dialog fell somewhat short of my expectations. But after watching the presidential debate last night, I understand that the idea of a robust “give and take” may be more difficult to achieve in public interaction than simply setting a stage with opposing actors.

One comment I received the first week after publication of my articles was a posting that basically just left a link for an article by Dr Bryan Bledsoe from 2003 entitled “EMS Myth #7: System Status Management Lowers Response Times and Enhances Patient Care.” The assumption being that the topic was settled long ago. While I have great respect for the man who calls himself “The EMS Contrarian” and his robust body of writings (including by first EMS textbook), I respectfully disagree with the finality of some of his assertions. A great deal has changed in the past 13 years. Some readers may actually recall that MySpace debuted the same year that his opinion was written. For those who do not recall that social media phenomenon, MySpace was a precursor to Facebook that was once the largest social networking site in the world – even surpassing Google as the most visited website in the US. This was also a time when almost every patient was administered high-flow O2 because it was considered safe, even if not always effective. Fortunately, the evidence-based movement in EMS has caused many practices to be re-evaluated both for inclusion as well as exclusion. And computer technology has also made great developmental strides from the 2003 introduction of the first wristwatch cellphone named the Wristomo. At that time, engineers were still thinking of wearable technology as a cross between the 2-way wrist radio device that became iconic for Dick Tracy in the 1940’s comic strip and the modern flip phone of the day. Naturally, the device was designed to be easily unclipped in order to hold it to the ear like a traditional cell phone. It even offered an optional cable allowing it to exchange data with a computer. The development of Bluetooth freed designers to reconsider how a smartwatch could interact in an entirely different way with a user’s smartphone. The evolution of dynamic deployment has followed a similar trajectory.

Gartner_Hype_Cycle.svgThe Gartner Hype Cycle is a graphical and conceptual presentation that describes the maturity of emerging technologies through five common phases. Each year, the organization follows several technologies through this consistent cyclical journey. While EMS deployment was not one of these tracked technologies, I would submit that the initial technology trigger in the case of dynamic deployment would have certainly been the work of Jack Stout on System Status Management in the 1980s. His publications in the Journal of Emergency Medical Services (JEMS) throughout the decade inflated the expectations for performance returns. Implementation issues however, contributed to it sliding down into the trough where many disillusioned system providers left it for dead around Y2K. But the story doesn’t end there. The combination of his economic theory with Geographic Information Systems (GIS) provided a new operational view of both demand as well as current positions of available vehicles reported in near real-time with growing bandwidth. The advancement of computer processing has allowed some of these same Stoutian concepts to now be performed in real-time. With practice in modifying the parameters, the concept of Dynamic Deployment has become, as one comment to the article stated, effectively SSM 2.0. The benefits are no longer theoretical or even limited to Public Utility Model services, but are being realized by both public and private EMS providers climbing the slope of enlightenment or who are content with the productivity gains they have already reached.

JCMCresponsetimevROSCOne of Stout’s assumptions that has changed since the Bledsoe article is the “20 week” rolling window for analysis. This is too broad of a query that effectively combines different seasonal impacts throwing off focused projections not improving them. Experience shows that just a few weeks backward or forward from the current date for only a few previous years gives the best demand  forecast. Tests conducted at BCS show that MARVLIS correctly forecasts 80-85% of calls in the next hour by identifying hotspots that are limited to approximately 10% of the overall geography. Going back too many years, as Bledsoe was led by a consulting statistician, can actually unfairly weight more established neighborhoods while undervaluing newer communities. The clinical significance of shorter response times is not always in the “37 seconds” that are saved or even in meeting an arbitrary response goal, but in reducing response to a meaningful 4-minute mark. Achieving this milestone has had a proven impact on ROSC in New Jersey for instance. And beyond clinical significance is contractual obligation. Like it or not, EMS is often judged (and even purchased) similar to fire protection – by compliance to a time standard. Software makes a difference in meeting those goals. Running a system so that it performs well in most cases means it is more likely to perform well in the cases where it really does matter to the long term health of the patient.sedgwick_compliance

The increase in maintenance costs of 46% as claimed by Bledsoe has also been disproven with services showing a reduction in the number of unloaded (non-reimbursed) miles driven and even a reduction in the number of post-to-post moves in favor of post-to-call dispatches. By reducing fines for late calls, some services have found significant cost savings compared to previous operations.

In trading station lounges for the cramped cab of an ambulance, there has been a genuine cost to the paramedics and EMTs. However, the argument they make is not about fixing the plan, but rather it becomes an attempt discredit the foundation of that plan completely. Consider the fact that most field providers in a closest vehicle dispatch operation describe a “vortex” that traps them in an endless cycle of calls if they do not escape it in time. They find ways to try to beat the system rather than suggest that recommendations account for the unit hour utilization by vehicle and allow busier units to leave the high call volume area and move to less call prone posts to complete paperwork and recuperate. It is not that the strategy is inherently evil or wrong, but is designed to support a business philosophy that is not properly balanced, so the outcome becomes skewed. It is time to stop challenging the core notion and focus on specific concerns of the implementation that will make the system work better for all participants. As long as we demonize the idea, we will not be able to impact how it works.

Much like the polarization of the presidential debates, I have learned from experience that when we perceive only bits and pieces of the world around us, our minds fill in the blanks to create the illusion of a complete, seamless experience, or knowledge of a system in this case. Sometimes that interpolated information is no longer correct and it can keep us from participating in the crafting of a solution that truly works for everyone.

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The Fallacy of the "First Due" Area

The following is a preview of a book coming soon from Bradshaw Consulting Services to be titled "Closest Vehicle Dispatch: A Primer for Fire" which is a follow-up to "Dynamic Deployment: A Primer for EMS".
Watch for the new release in time for the FDIC 2017 conference at the end of April.

The modern legal definition of response zones can be found in the Code of Federal Regulations, which states that the “first-due response area is a geographical area in proximity to a fire or rescue facility and normally served by the personnel and apparatus from that facility in the event of a fire or other emergency.â€? (44 CFR 152.2) This banal definition glosses over some very interesting history in the development of modern professional fire departments. In the mid-nineteenth century, there were frequent, and often bitter, disagreements over territories that sometimes resulted in physical confrontations. In fact, the politically powerful New York City volunteer fire companies of that era were known to send out runners ahead of the engine in order to claim the right to fight a particular fire and thereby receive the insurance money that would be paid to the company who fought it. While the monetary incentives are not nearly so direct today, there is still a great deal of pride invested in being the “first responders” to an incident. It would not be a difficult argument to make that we haven’t changed as much as we would like to think in regards to response.
A retired fire chief recently relayed a story to me about an engine crew that raced through a residential neighborhood in order to beat another engine that had been dispatched for mutual aid since the “first due� engine was out of quarters returning from another call. The need was so great to be the first responding company in “their own area� that they willingly disregarded the safety of the public that they had sworn to serve simply to avoid the embarrassment of being second to a call that was “rightfully theirs.�
The concept of the “first due” area is a strategy to automate a century-old manual concept of pre-assigning the closest resources to specific structure addresses within a fixed response area. The thought that a central station will have the closest apparatus to any potential fire in their district is simple, but with the increasing complexity of urban transportation networks, it is also an increasingly simplistic idea. The reality is that traffic patterns, and increasing traffic congestion, can dramatically change response times, particularly in high density population areas.
Public safety vehicles, even those running emergency traffic, can sometimes struggle to reach the posted speed limits at certain times during a shift. Alternatively, a lack of traffic at other times will permit the discretion of rates above the normal traffic speed. These periods of diverse congestion levels exist not only for intermittent periods of time but can vary dramatically by the direction of travel as well. Additionally, these temporal and directional impacts are confounded by the fact that station locations are often inherited positions that were designated many years earlier when housing, demographic and development patterns were very different from today. In most areas, fire station placements have grown through ‘incrementalism’, often tainted with political influence. In some jurisdictions this inheritance may go back over a century or more. Not all current station locations are the result of some forward-thinking intelligent design. The result of fixing address assignments to these past growth patterns may, or may not, represent who will be able to arrive first on the scene with the right resources. Furthermore, the common overlap of nearly a third between each of multiple urban engine companies means that when they are each dispatched from quarters, the next few arriving fire units, under normal conditions, will likely have a similar response time to that of the “first dueâ€? apparatus.

 

The “effective service area� of any station will vary during different times of the day based on traffic congestion. On a typical morning, as most traffic is heading toward a downtown business district, an urban station located at the city center will be able to travel outward toward the suburbs with relative ease. At the end of a normal business day, that same station will find that it can no longer travel as far in the same direction in the same length of time. Any sort of break in the normal business routine will further alter that pattern. These exceptions can include weekends, holidays, or special events. Most areas will also experience seasonal changes to traffic as a result of adding school buses or tourists to the roadways. The result of traffic is the evolution a unique “first due� area for different hours of the day and days of the week during different months of the year. A “fixed�, or “average�, first due area must either ignore, or at the very least, generalize the pressures of these growing realities.

 

Generalizations of Effective Service Areas as Impacted by Primary Traffic Patterns
Morning                                                                     Afternoon

Rzones1      Rzones2

During a typical morning “rush hour� period, the heaviest traffic may be to the north and west as in the left example making response in that direction relatively more difficult than moving to the south and east. Consequently, the effective response zone represented in gray around two example stations will compress moving with the traffic and elongate against that traffic. In the afternoon, this pattern will reverse since the heaviest traffic would now be moving away from the downtown area making response to the south and east slower as compared to the morning pattern and therefore reforming the effective service area in the opposite direction.

The dispatch of a theoretical “persistently closest resource� is made even more difficult when we consider that an increase in call volume makes it increasingly common for an apparatus to be dispatched when it is already out of its assigned station, either on or returning from another alarm. With an increase in call volume, the chances of another call leading to a dispatch before a unit has returned to its station are only increasing. These moving vehicles will have a significantly different effective service area and a different proximity to an incoming alarm when compared to an apparatus that is currently parked in a given “first due� station. Additionally, the “chute time� in preparing the crew to respond is completely eliminated when the dispatched vehicle is already moving. In this case, the effective response area is larger when considering response time than an apparatus that is parked at its station. However, this dynamic nature of the responding vehicles can also work against the efficiency of a traditional “first due� response. Consider that an apparatus may be available after clearing an alarm at some extreme point within its district when a call is received from an opposite extreme location. The mere fact that the responding vehicle is moving may still not overcome the greater distance that places it significantly further from that next alarm than an apparatus that is parked elsewhere. In this case, the closest unit may well be one outside of the assigned primary response area.

Impact of Increasing Call Volume on Effective Service Areas

Rzones3

When an apparatus clears a call, it becomes available in a different location than the station and although it is capable of responding with a “zero chute time”, its distance from the station will impact its effective service area possibly putting it further away from the “next call” than a neighboring station “in quarters”. As call volume increases, the likelihood of being dispatched while returning from another call only increases.

These changing logistical dynamics significantly alter the performance realities for modern fire stations from simple planned service delivery to a complex system of matching dynamic resources to increasing demand. Meeting the expectations of your community requires more than the historical paradigm of “first due� scenarios assisted by mutual aid to that of a cooperative system approach designating primary and secondary response functions on-demand and independent of an arbitrary enforcement of outdated patterns of convenience. Fire departments must literally become dynamic fire services requiring an intelligent coordination of these mobile resources.

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Consumer Apps in EMS

The tools used in EMS are constantly changing, but one of the most powerful devices available to nearly every ambulance is the smartphone. However, the vast majority of these devices are owned personally by the crew assigned to any rig. While this may be acceptable to the employee who retains control over the personalization of their own device, it can lead to many potential problems for the organization. The advantage for the agency, however, is not having to purchase or support these devices. A trade that many services are apparently more than willing to take as my own non-scientific Twitter poll failed to discover any services that specifically ban the possession of personal phones while on duty. What did surprise me was that only 15% of respondents stated specific policies were already in place regarding their use.

 

SmartphoneTwitterpoll

 

Over the last few years, the number of medics with personal smartphones has only increased. This is due, at least in part, to an evolving workforce integrating the millennial generation that never knew a world without personal communication devices. Over those same years there have been several good articles that describe the potential of using them at work including “10 Apps Every Paramedic Should Have” or “EMS Apps Make Life Easier“. Many of these apps are focused on patient interactions such as drug identification or calculations, language translators, or a digital version of your protocols. Some, like the Northwest MedStar Alert app, are actually designed for operational improvement at the system level. This particular app allows a GPS coordinate from the phone to be sent directly to the flight communications center and even sets up a secure dialog between responders and hospital staff. (One of the best features to that app may be having an accurate ETA for the helicopter!)

padOther authors are more excited about the near future, such as in “How EMS will benefit from smartphones and connected vehicles“. There are multiple studies currently going on regarding the potential of  bringing a virtual physician presence to the scene in order to evaluate a patient. The article “Mobile Devices Speed and Streamline Pre-hospital Care” identifies one of these telemedicine projects targeting stroke. The evolving mobile eco-system has also given birth to some new private businesses. Medlert is just one example of an app built specifically to optimize patient transport schedules using smartphones.  As EMS agencies become increasingly comfortable with leveraging more cloud-based services, there will be more development in the market.

Use of any of these apps (and the personal devices they depend upon) comes with certain caveats and risks. Many apps commonly state disclaimers about their use, particularly in emergency services, so it is worth reading the fine print.

 

 

According to a recent Pew Research Center study, 74% of adults use a smartphone for directions based on location. Another Twitter poll that I’ve conducted shows that using a smartphone app is fairly common for “ambulance drivers” as well. But how good are these routes when we are in an ambulance, especially one that is driving “emergency traffic”? If an agency can provide its own web service based on road data that it controls, the routing can be very good. With MARVLIS Impedance Monitor, an agency’s data can be automatically modified to reflect the travel times common to a fleet during specific timeframes and on certain days and for different seasons learned from actual emergency traffic experience.

There is less control when a commercial routing service is used through a consumer app. Google Maps has an option to show real-time traffic and Waze boasts being the world’s largest community-based traffic and navigation app where drivers share real-time traffic and road information. Waze is interesting in that it was created as a social navigation tool for passenger cars. So, if you plan to use it on an ambulance trip, it would be best not to “share your route” with friends or other contacts. For that, there is a “Go Invisible” option you must choose in order to keep any potential identifying data private.

wazewindowIs simply “outsmarting traffic” really what we need to be doing, though? Apps like Waze are great to help you avoid the congestion created by an accident that is tying up traffic. But when the traffic accident IS your destination, avoiding it is not a recommended route for you to take. For most vehicles, commercial routing and real-time traffic is hugely valuable. But for an ambulance, not so much. Routing normal cars and trucks is relatively simple because there is a set of rules they must abide by in motion that can be easily modeled. Emergency vehicles, including ambulances or fire apparatus, often break those rules by traveling along the road shoulder or even crossing a median into the oncoming lane of travel. The normal direction of one-way streets can also be ignored at times.  No regular commercial app takes these routing options into account. It requires you to track your own vehicles and learn patterns from those operations only. A final consideration is how you may, inadvertently, influence the decision-making on a social routing app for others by including your behavior with all of the other vehicles on the roadway.

There is no question that you will be using, or allowing the use of, smartphones for a wide variety of purposes. What you need to do is be sure your staff are using the right apps for the right applications. We often like to think we are different, and in many ways we are very different indeed from most “consumers.”

We are interested in keeping this conversation going with your experience and ask that you share what apps have you found to be useful on the ambulance, or cautions about them, in the comment section below.

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What is CAEMS and Why Should I Care?

Two weeks ago, we started a Community of Practice to discuss EMS Deployment. The larger issue of deploying resources is all about efficiency and effectiveness in care, those are also the aims of any High Performance EMS group. However, that message is too often confused with meaning simply “better, faster, cheaper”, when in practice it must be rooted in “doing what is best for the patient” in order to be anything of lasting value.

In the following episode of ‘Word on the Street’, an EMSWorld podcast hosted by Rob Lawrence, representatives of the Coalition of Advanced Emergency Medical Systems (CAEMS) chat about the professional association and exactly what makes EMS systems “high-performance.” Give it a listen (or even download it) here: http://www.emsworld.com/podcast/11327832/word-on-the-street-coalition-of-advanced-emergency-medical-systems.

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How To Perform CPR: The Crucial Steps You Should Know (and Share!)

This important article (and the associated graphics) is reprinted as a guest blog with permission from Monica Gomez, a freelance health and healthcare writer. Originally published at http://carrington.edu/blog/medical/how-to-perform-cpr/.  The animated GIF images alone are worth sharing!

Anybody can and anybody should learn how to perform CPR (Cardiopulmonary resuscitation): According to the American Heart Association, a stunning 70% of Americans don’t know how what to do if somebody is experiencing a cardiac emergency because they don’t know how to administer CPR or they forgot the exact technique. This is especially alarming since almost 90% of cardiac arrests occur at home — where patients depend on the immediate respiratory care response of their family members. In brief, knowing how to perform CPR can save the life of a loved one someday. CPR-How-To CPR-How-To-AdultsCPR-How-To-ChildrenCPR-Cats-and-Dogs

While 400,000 cardiac arrests happen outside of hospitals each year in the U.S. alone, hands-on CPR can actually double or triple an adult’s chance of survival. However, you need to act quickly. At four minutes without oxygen, the patient will suffer from permanent brain damage. At eight to ten minutes, the patient can die. Almost 90% of cardiac arrest patients die because no one performed CPR at the scene.

Before You Start CPR

First of all, check if the patient can respond by tapping them on the shoulder and shouting “Are you okay?� If they don’t respond, call for medical emergency services immediately. If others are around, instruct them to call 911 and if you’re alone, do it yourself. If the patient is an animal, call the closest animal hospital. If you happen to be near an AED (defibrillator), read the instructions and give one shock to the patient (this applies to humans only).

CPR Steps For Adults and Children 9 and Older: Hands-Only CPR

  1. Lay the patient on their back and kneel next to their neck and shoulders.
  2. Place the heel of one hand on the center of the patient’s chest.
  3. Place the heel of your other hand over the first and lace fingers together.
  4. Keep your elbows straight and align your shoulders directly over your hands.
  5. Begin compression:
  • As hard as possible
  • At least 100x/minute
  • Allow the chest to rise fully between compressions.

TIP: Give compressions to the beat of disco hit “Stayin’ Alive�!

CPR Steps For Younger Children and Infants

  1.  Tilt the head back a bit and lift chin to open the airway and check for breathing.
  2. If there’s no breathing, give either of these two rescue breaths:
  • Child: Pinch the nose shut and make a complete seal over their mouth
  • Infant: Make a complete seal over their mouth and nose.
  1. Blow in for one second, so the chest visibly rises and repeat this once.
  2. Give 30 chest compressions (100x/minute):
  • Child: Push with one or two hands about two inches deep
  • Infant: Push with two to three fingers about 1.5 inches deep.
  1. Repeat these steps three to four times.

 

Pet CPR – For Dogs and Cats

[Follow these CPR instructions for puppies]

For Animals Under 10kg/22lbs:

  1.  Use the one-handed technique, wrapping the hand over sternum and chest.
  2. Give 30 chest compressions (100-120x/minute).
  3. Allow the chest to fully recoil between compressions.
  4. Give two mouth-to-snout rescue breaths after each set of compressions (30:2).

For Medium to Giant Dogs:

  • Position the animal on its side.
  • Use the two-handed technique, placing your hands over the widest part of the chest.

For Deep, Narrow-Chested Dogs Like Greyhounds:

  • Use the two-handed technique, placing your hands directly over the heart.

For Barrel-Chested Dogs Like English Bulldogs:

Place animal on its back and use the same positioning and technique as for adult humans Whether you perform CPR on an adult, child, infant, or pets, DO NOT STOP unless:

  • The patient starts breathing
  • An EMS or another citizen responder takes over
  • An AED is ready to use
  • The scene becomes unsafe
  • You are physically incapable of continuing

Make sure to practice and/or brush up your CPR abilities today, so you’re ready to potentially save someone’s life in the future! Furthermore, if you’re interested in making it your profession to help people suffering from respiratory conditions like asthma, bronchitis, lung cancer, heart attack, stroke, chronic obstructive pulmonary disease (COPD) or sleep apnea, you should look into Carrington College’s respiratory care program. This two-year program combines classroom lectures, laboratory instruction, and clinical experience in order to prepare you to work in a variety of healthcare settings. If you’d like to assist and educate people regarding respiratory health concerns, our training program is the ideal fit for you!

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Static v. Dynamic: A Continuum of Cost

In our recently published book, “Dynamic Deployment: A Primer for EMS“, John Brophy and I established a dichotomy between the standards of static deployment and dynamic deployment in the very first chapter.  Fortunately, that strong polar perspective has spurred some interesting discussions for me. While the check-out lane analogy was effective in distinguishing some of the differences of static and dynamic deployments, its simplicity only recognized the extreme ends of the spectrum and failed to acknowledge what I would describe as a “Continuum of Cost” between them.

Few systems (at least those with more than just a few ambulances) probably function exclusively at either extreme. The static model will necessitate some flexibility to provide “move-ups” to fill holes, just as dynamic systems will have reasons to keep specific posts filled as long as enough ambulances are available in the system. The reasons for moving, or even fixing locations, may have something to do with demand necessity or even the political expedience of meeting community perceptions.

While there are many differences between static and dynamic deployments that we could discuss, there are also some elementary misconceptions. For instance, dynamic deployment does not mean vehicles are constantly in motion. The term dynamic refers to the nature of their post assignments which can vary between, and even within, shifts. As alluded to in the book, proper post assignments also reduce, not increase, operational expenses. In at least one example we stated, the dynamic deployment strategy was shown to significantly reduce the number of unloaded miles actually driven, which in turn increases the percentage of overall miles that can be billed. This situation not only increases revenue while simultaneously reducing expenses, it also reduces fuel costs and wear on the vehicles (and crews) too which potentially extends their useful life. All this is still in addition to reducing response time and improving crew safety by positioning ambulances closer to their next call so that fewer miles need to be driven under lights and sirens.  The inherent efficiency of this management strategy allows a system to achieve response compliance at the 90th percentile with the smallest possible fleet.  To achieve the same compliance level with a static deployment of crews and posts, the fleet must grow significantly larger. Another recent sample calculation showed that both staff and fleet size would need to grow by well over double in order to reach the same goal. The resulting cost continuum, therefore, clearly shows that a static fleet has operational and capital expenses multiple times the costs of the dynamic deployment model without burning crews out with excessive and unhealthy UHU figures.

For the sake of validating my argument, it is unfortunate that these examples are from private ambulances companies who do not wish to openly share details of their calculations at this time for competitive reasons. It would be safe, however, to assume from these competitive reservations that these results are not automatic, but dependent on proper management and the use of good tools. There are certainly numerous examples of poorly managed systems or ineffective operational tools. To achieve similar positive results in your own system requires certain knowledge, an underlying reason for having written the book in the first place, and an assurance that the deployment tools are proven to be effective.  Just as managers should have references checked during the hiring process, vendors of operational deployment tools should be able to provide ample references for successful implementations of their technology in comparable systems to your own. It is also important that any solution be able to address a continuum that includes your specific objectives to find a balance between geographic coverage with anticipated demand coverage at an acceptable workload and schedule for your staff.

There is no “magic bullet” to achieving operational nirvana, but the combination of effective management with operationally proven tools has shown that cutting costs while improving performance is an achievable goal in most any size system. It is also fair to say that performance can be enhanced with less skill through the application of significant sums of money; but honestly, who can afford that sort of strategy in the competitive arena of modern mobile integrated healthcare.

It is our desire to produce yet another, even more extensive, volume on the topic of dynamic deployment to make the achievement of efficient and effective high performance EMS a reality for more systems. Stay tuned for future details!

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Could Busier be Better?

There is plenty of talk about “evidence-based procedures” in EMS lately. Well, today I read an interesting article that shows a link between being busier and better patient outcomes.

Okay…, now after reading that statement, what just happened to your heart rate? Was your automatic response to click the link in order find fault so you can dismiss the finding, or did it pique a genuine interest to read the article and find what might be of value to you personally in hopes of possibly achieving a better understanding of even one aspect in a very complex patient/care giver dynamic? It is interesting to see how we respond to “evidence” we don’t necessarily like, or evidence that contradicts with our own longstanding personal stereotypes.  I know that whenever I talk about Dynamic Deployment, or System Status Management, I immediately hear complaints from those who work in the field that it is all about the numbers and is often driven by greedy consultants forcing “snake oil” math on all too willing administrators who have forgotten their “street experience.” I usually try to combat the stereotype perception with facts about more progressive experiences with creating high performance systems, but I will admit right here that everyone is at least partially right – it really is about the numbers. However, it may not just be the same numbers you are thinking (but I will stick to my assertion that the logic is probably much less nefarious than suspected.)

Time is an easy thing to measure, but in itself, it is seldom very important. In fact, it can be much like a single vital statistic from a patient taken out of context. Still, time is a pretty fair proxy measure of performance on the aggregate.  And, like good base line vitals, it becomes especially useful when combined with other numbers.  Now, before writing your comment, please note that I never said anything about a 7:59 response standard, I was only talking about measuring time in the abstract.  I believe the argument over response time standards is very similar to arguing that everyone should have a BP of 120/80. Sometimes it is the right goal, but for others, or depending on the situation, the target may be higher or lower.

Each of us measures our work shift in terms of hours.  System Status Management extends that basic idea by measuring everyone’s time in a shift along with the work they accomplish and balance it against the public’s perception, reasonable risk, and the actual needs of individual patients and their providers.  There are plenty of bad examples out there and I refuse to justify them, but at the same time there are good examples of systems that are improving and taking the right measures into account.

The key is not UHU, TOT, response times, compliance, ROSC, patient outcomes, employee satisfaction or budgets – it is all of those things and much more. Those numbers are no more definitive in themselves than BP, pulse, O2 sats, capnography, skin condition, ECG, GCS or anything else we measure is a truly accurate indication of a person’s overall health. Similarly, it is no less fair to view SSM as a static group of measures than to believe the components of our patient assessment are unchanging. If some medic had overly emphasized, or even ignored, some measures in an assessment, that specific experience should not condemn a process that has been proven valuable in many other cases.

It may seem that I have ventured pretty far from the question with which I started this post about how busy we should be in order to be most effective. You may have even thought I was promoting an idea to maximize every minute.  As for the clinical interpretation of the answer, I will leave that to the authors of the particular study I referenced.  Instead, I will suggest that we all must be a little busier in understanding how our collective time and actions impact the performance of the systems in which we work. It doesn’t matter if your service is private, non-profit, fire-based or whatever; money and resources are always finite while demand and expectations are often increasing.  I would ask that you don’t simply rely on the assessment from “vitals� of SSM taken years ago, but reassess with an open mind and set aside the prejudices of previous assessments. After all, very little in our business is truly static. Like a “routine� interfacility transport, we can assume nothing has changed regarding the patient’s condition, or we can get busy and engage in our profession looking to have a positive impact on potential outcomes. Don’t leave leadership to the administrators, but take initiative to at least understand, if not improve, your corporate mission. You may be caring for patients, but the care of your career is part of your job too. Get even busier and improve that outcome for yourself.

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