Category Archives: EMS Dispatch

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 ‚ÄúClosest Vehicle Dispatch: A Primer for Fire‚Ä? 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 ‚Äúcloud servers‚Ä? (although they are quite terrestrial) while others may be hosted privately on local government networks and available only to ‚Äútrusted client‚Ä? 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 ‚Äúimpedance.‚Ä? 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. ‚Äú’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. ‚ÄúSpatial Decision Support Systems for Vehicle Routing‚Ä?. 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.

‚ÄúResponse-Time Considerations.‚Ä? 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. ‚ÄúWhy the Shortest Route Isn‚Äôt Always the Best One.‚Ä? 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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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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Still Solving Problems in Lexington

An awful lot can happen in five years. I know that my own understanding of EMS deployment has deepened a great deal in that time. It was that long ago that I wrote a post about The Cost of Saving Money using Lexington County, SC, as an example. The county EMS Director, Brian Hood, and the now-retired county GIS Manager, Jack Maguire, made a huge statement about how EMS and GIS can work together and achieve incredible results. At that time, Lexington County EMS credited technology with giving them an advantage that helped them plan and respond better.  Even though they were experiencing an average annual growth rate in calls-for-service of about 7-1/2 percent, they had gone over 4 years without adding a single new truck to their fleet. The close relationship EMS had developed with their GIS group also benefited everyone by improving the quality of their street data for all county users. I have repeated this story over the years but when I revisited them recently for a follow-up, I was amazed to learn how much we had both matured.

Chief Hood began by stating that¬†ten years ago their average response time was 11 minutes. Since then, growth in demand for services has continued to range anywhere between 3.5 and 11 percent annually. Still, they have not added a new ambulance to their fleet, but through continual improvement they have that same average response time of 11 minutes today. Their goal is 12 minutes at the 90th percentile. However, pending legislation in the state of South Carolina known as R.61-7 may require times at the 95th percentile for Advanced Life Support (ALS) response. Guaranteeing service at that level can be a daunting challenge for any manager. The response of Chief Hood was to develop a process to address the demands¬†as well as the¬†realities¬†of his agency. At the core of that process is MARVLIS Deployment Planner (a tool for asolvingproblemsutomating system status management) and MARVLIS Deployment Monitor (a live view of current resources and demand with real-time¬†recommendations.) These tools give the Chief and his staff the information they need to know for scheduling and dynamically deploying resources. “If you took these tools away from me, I could not do my job,” said Hood. “History absolutely repeats itself and this system is frighteningly accurate.”

In addition to facing increasing demands and tighter response times, Lexington is facing a lack of paramedic resources the same as many other areas of the country. It is recognized that sending ALS level resources to every call can be expensive and even wasteful of these limited resources when record reviews show that 70 percent of responses only require a Basic Life Support (BLS) level of care. The new solution they have just begun testing is a tiered approach where calls are being triaged based on nearly 200 determinate descriptors to categorize the initial response level. To prevent dispatching high acuity resources to low priority calls, it is not always the closest unit that is assigned to a call by dispatchers. The lowest categories of Alpha and Bravo level are only sent BLS providers in a vehicle that could otherwise provide ALS care. Rather than requiring an ambulance intercept in the event an upgrade of care is required, command staff will arrive in a quick response vehicle to supplement the care available and effectively transform that ambulance into a full ALS unit.

They are also looking at improving provider safety by questioning the use of lights and sirens on most calls. Just as calls can be categorized for the level of responders, they can be categorized for “cold” and “hot” responses that can limit the dependance on lights and sirens. This is still very much a work in process, but key to making it successful will be in the support of county commissioners. The goal of arriving on scene to the highest priority calls on-time 95 percent of the time will mean that other calls designated in the lowest priority responses will take¬†longer. It’s just common sense that decisions must be made when a system has a defined budget with limited resources to get an important job done. The vision to see the larger picture and to achieve the greatest good for all who are involved is the hallmark of real leadership. Problems never really go away, the list just keeps changing and they¬†keep solving them.

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What If We're Wrong About Response Times?

Anyone who follows my posts here, or on Twitter, will recognize that I consistently argue for the value of prompt responses by¬†emergency vehicles to nearly all incidents. However, this post will be different thanks to an inventive challenge through EMS Basics asking bloggers to consider an opposing view to their favorite topic. You can read about the challenge and link to other participating blog posts in The Second Great EMS What-If-We’re-Wrong-a-Thon.

There actually are some valid¬†arguments against rapid responses, so let me begin with pointing out the lack of a recognized national standard. If a short response was really an evidence-based practice, there should be some¬†agreement on exactly what a “short response” means. The NFPA and NIST standards suggest response times for all hazards, but are really focused on requirements for structure fires and have more to do with the central placement of stations than the speed of fire spread in a structure. The nature of this fixed deployment strategy becomes even more problematic for medical responses as there tends to be far fewer ambulances in comparison to fire suppression apparatus.

A shortage of resources is therefore, a compounding problem. Ambulance response time goals often vary tremendously by locality and type of service. Response time goals become a result of compromise matching community expectations with financing – not the science of resuscitation. Often contracts with private services are drafted to simply improve on the current response times rather than meet an objective goal with a defined clinical outcome.

The clock is an easy measurement device that is more easily understood than many other proxy measures of the quality of our service. And pushing for more (faster) response makes a contract negotiator look like a winner. Unfortunately, there is a heavy cost to pay to chase these ever increasing goals. And for services who cannot meet these objectives, there is either embarrassment, financial ruin or the flexibility built in to the start and end times for the clock. In other cases, there are rules for simply ignoring exceptions to the goal as outliers. Without standards on measurement, why do it?

Trends are showing a¬†higher¬†demand for services which translates to an increased demand in resources which in turn raises system costs unnecessarily. Recent studies have also shown that response times do not improve clinical care in the vast majority of cases. In fact, there are a significant number of responses that don’t even require an ambulance at all. Proper emergency medical dispatching through improved triage at the call taking phase can reduce the effective number of emergent calls that demand immediate responses.

Finally, there is also a growing awareness lately to the safety of providers. Studies show that the use of lights and sirens are risking the lives of responders and even the public. Ambulances driving at excessive speeds for most calls is just illogical and unsafe.

I would like to thank Brandon Oto for issuing this writing challenge. Viewing a problem from a new perspective is quite a liberating opportunity. I believe that in this case, there clearly is still a good reason to debate the need for rapid responses. However, I will continue that debate in a follow-up article from my own perspective.

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We're More Like Police Than Fire

fireemscopWhen EMS professionals complain, the justification often includes an¬†appraisal¬†of¬†how our family in the ‘big red trucks’ do (or sometimes,¬†don’t do) things instead of comparing ourselves to our brothers and sisters that¬†make up¬†that ‘thin blue line’. The choice of comparison is most likely swayed by¬†the fact that somewhere around half of us working in EMS do so while wearing a fire-based uniform during our time on the ambulance. In addition, the vast majority of us spend more of the¬†time that we are off the rig inside a fire station than in a police station. However, when we look critically at the tasks we perform, it becomes quite¬†apparent that we may actually relate more closely to law enforcement activities than we do fire suppression operations. Obviously, we do not enforce any laws. In fact, it is easy to¬†argue that we spend our time trying to break¬†the laws of nature; however,¬†I am talking about something more fundamental here.

A firefighter responding by himself to a scene is of little value. His normal operation is always as a part of a team. The introduction of only a second firefighter on the scene of a structure fire also has a minimal value. Even though they are trained to enter structures as a pair, these first two going in depend on another two staying outside. In reality, a dozen or more firefighters can be required in order to be effective in controlling even a small structure fire. Additionally, all of these firefighters require support from specialized apparatus including fire trucks with ladders, fire engines prepared to pump large quantities of water, and rescue vehicles containing other heavy equipment. As their operations begin on scene, their first goal is protecting the public from that scene. The next goal is to suppress the active conflagration in an otherwise inanimate building in order to minimize a calculated loss. There is never any intention to restore the premises, but simply to minimize what is sacrificed. And in certain circumstances, the best course of action may be to simply protect other structures while allowing that one to be completely consumed. Their work rarely relies on the awkward, or even self-serving, social interactions with the public to obtain situational awareness. Firefighters intellectually study the smoke and building basing judgments on previous plans for exactly this situation in a building that they have likely already studied and know by plan. They also operate within a legal jurisdiction that permits them complete legal control of a property in order to definitively negotiate an acceptable outcome that weighs certain losses until control can be safely transitioned back to the actual owner in the end.

The primary tools of the police officer, on the other hand, mainly include the items attached to their utility belt or what can be carried in their hands or head. They often operate individually, or in very small ad-hoc groups of their peers. While they are keen observers at the scene, their size-up of the situation relies heavily on interviews with the public. This highly subjective investigation is the first step in resolving a complaint that intends to make the situation as whole again as possible. Statements are confirmed or denied based on physical evidence that can be discovered by the officer. The resolution, like the problem that makes it necessary, is seldom known beforehand which makes prior planning nearly impossible. At times, a definitive resolution cannot even be accomplished on scene. In those cases, individuals must be transported to magistrates who will make the final judgments that ultimately determine the outcome. Law enforcement officers play an important role of gathering information on situations that range from the mundane to the extreme. A continuum of dynamics that can change quickly from one to another as they continue to interact with the personalities involved.

In much the same way as a law enforcement officer, the paramedic controls the situation through their presence and professional demeanor as much as by any task they perform. The situation, always involving both medical as well as psychological aspects, can improve or destabilize based on the confidence that participants place in that individual leader. The situations they encounter are of an endless variety and the severity of the situation is equally dynamic while often not being as obvious to everyone else involved. The actions of both the officers and medics are tightly constrained by specific protocols due to the fact that they deal directly with people and are constantly subject to internal, and even public, review. They both prefer to develop and work through the consent of those involved rather than compulsion. While the nature of calls for service can vary widely, medics train constantly for the worse cases such as STEMI, stroke, cardiac or respiratory arrest. It is in these incidents, where moments matter, that their skill and training distinguish them. Fortunately, these life-critical situations requiring an immediate response are seldom what they encounter. Too often though, they allow the infrequency of demands on these skills to lull them into a level of complacency and a desire for normalcy. Like our law enforcement counterparts, we must always prepare our minds for the worst case scenario involving our patient.

Along those same lines, we must consider how we are deployed. The fact that there are typically far fewer EMS resources than any other emergency services branch, and that they can be necessary on scene without delay; it is more logical to consider their deployment to be dynamic in a similar way to police resources. The need for large numbers of personnel and heavy equipment on the fire side make fixed stations more logical in order to ensure adequate response times to stationary real property assets. However, people (our patients), are dynamic. They move about and either cluster or disperse in recognized patterns that can easily be modeled. Consequently, our similarity to law enforcement operations in dealing with people requires us to think in many ways like these officers and admit that our jobs differ more from firefighters than we might like to think.

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Stop Dissing Response Times and Start Dissecting the Argument

It is not hard to find an article that bashes the industry’s insistence on measuring response time as a performance goal. The latest one I saw was published just today in “Don‚Äôt let response times overshadow the role of EMS” by the respected author Arthur Hsieh. The flow¬†of his article follows the traditional pattern of claiming that measuring time is an outdated historical artifact of EMS without any basis in science, followed by the inevitable¬†near-contradiction confessing that¬†time is critical is only a limited number of cases before¬†finishing by imploring¬†future leaders to take a courageous stand against the uneducated politicians who simply fail to understand our modern evolving business. Hsieh is certainly not alone in making this well-worn, if not self-serving and short-sighted, argument.

Assuming my readers are familiar with the clinical EMS process of assessment, let me present a reasonable differential¬†in terms we can hopefully appreciate. First, what bothers me in the common¬†debate is the assumption that what we see is the totality of the problem. The¬†ingrained reflex¬†of our ABC mnemonic is only¬†for¬†the initial impression, not the final diagnosis. We must resist the urge to simply treat the surface¬†presenting problem¬†and investigate even deeper for an underlying pathophysiology. Our assessment should probe whether the response time concept itself is really the source of the disease, or is it possibly the uncomfortable idea of a formulaic approach to system “compliance” underlying the measure that makes us protest so loudly? Are we taking our frustrations of prescribed protocols out on one single measure when it is actually any measure that attempts to pit arithmetic against our artistic judgement and the free expression of our healing knowledge? Another idea of an underlying cause may be that we equate good response times with unsafe speeds or the very real growing risk of ambulance-involved collisions from excessive speeds and increasingly inattentive drivers.¬†Or could it be a frustration, often expressed as “running hot to a stubbed toe,” that suggests we are simply expending extraordinary efforts on the wrong cases altogether because current EMD processes are not adequately refined in order to triage our limited response options to the unworthy types of calls we are seeing lately?

Without exception, everyone that brings this topic up recognizes at some point that there are clearly instances where time is actually critical. STEMI, stroke, and¬†anaphylaxis are usually among the list of obligatory concessions. Still, we seem way too willing to just “throw the baby out with the bathwater.” In the fire service, there is a well-known motto that says, “train like you fight, fight like you train.” To me, that translates to always practicing the things that are important even if it doesn’t make a difference every single time. There are often instances when (whatever “it” is) genuinely saves a life (whether your own or that of a patient). Sometimes, the “it” is time. There may not be any magic in “10 minutes” (or whatever your standard may be) or even the “golden hour” itself, but there is inevitably an “expiration” on our efforts. There is a time limit when the value of all our interventions diminish to the point that they can no longer buy back the life of our patient. A short response time gives us more time to consider options. It is no longer a question of “stay and play” versus “load and go”, but always to “think and act.” The anxiety of our patients and their family or friends at the scene are measurably lowered by our professional presence. If that is not your experience, then you may actually be correct in believing that your response time truly does not matter.

Just as we do our assessments, we can’t stop at the first symptom of a problem and treat it in isolation. We must often dig deeper to understand an underlying cause that needs to be treated more importantly than just the first observed sign of it.¬†Hsieh¬†is correct in saying that “It’s really time to move on and get with the times,” but ¬†not by neglecting the value of our response, rather¬†in addressing the underlying objection to having it measured. Politicians are never likely to admit to understanding our disagreement to measuring response times because they do not account themselves to us, but to the public that demands our prompt service that keeps them in office. If we insist on expending energy to attempt change, direct that energy in the most productive way it can be used. This begins by recognizing the root problem and the limitations of our interventions to affect change in it.

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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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HP-EMS Profile: MedStar Mobile Healthcare

As¬†I was going to be in Dallas for the Fire Rescue conference, I decided to go a little early and pay a visit to MedStar Mobile Healthcare (the renown “birthplace of Mobile Integrated Healthcare”) just over in Fort Worth, Texas. ¬†For anyone who may not have been paying attention to the industry during the last few years,¬†community paramedicine¬†has become a hot topic at conferences for¬†EMS systems that are looking to fill a gap in the healthcare needs of the community. ¬†Significant savings can be realized just in reducing transport demand, especially by “loyal EMS customers”, but additional cost avoidance is available to the hospital in preventing re-admittances. ¬†If you are looking for¬†additional information about implementing a similar program,¬†Matt Zavadsky,¬†director of public affairs at MedStar Mobile Healthcare,¬†has written an excellent description¬†of¬†Community Paramedicine and why it‚Äôs the future of our profession. medstarparamedicwithclient

There is really no doubt that EMS as a practice is changing. However, Paramedics and EMTs will always be critical in responding to emergency calls for service, but MedStar has helped show that they can also be effective in using their skills far beyond that traditional role. While it was the MedStar reputation for innovation in delivering high performance EMS related services that enticed me to visit, I was really most impressed by the back-end systems that keep the care providers on the road and doing their job effectively. Community Care Paramedics like Jimmy Aycox, pictured here with his Panasonic Toughbook, rely on the MARVLIS Client software not only for accurate routing information but also patient details presented from the CAD for filling out patient care reports.

MedStar System Status Controller Stacey SokulskyBut what makes it all work in the field actually starts in the dispatch center, whether the calls are emergent or scheduled. ¬†Technology is a critical piece used to¬†find the right resource and route the closest paramedics to the right call. ¬†In many routing systems, the travel impedance (the factor that tries to model¬†the real-life movement of a vehicle) is based simply on speed limits to calculate the time required to move from one intersection to another. These systems are static and do not account for various traffic patterns throughout the day or any seasonal variations such as school being in or out of session. ¬†Then there is also the issue of planned road closures or closures due to accidents that can also significantly affect navigation. In this news story about MedStar, the problem with traffic and road closures is highlighted along with their response in employing new technology to account for these issues. During my visit, System Status Controller, Stacey Sokulsky told me that their “older GPS technology could be up to 2 minutes off [in predicting drive times], but I have not seen MARVLIS be off by more than 10 or 15 seconds.” This can make a big difference in selecting which vehicle to dispatch.

Having the right tools makes the job much easier and allows progressive systems like MedStar Mobile Healthcare to do more outside of the traditional role and thinking. Thanks for letting me get a peek at the heart of your system.

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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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