Category Archives: EMS Health & Safety

EMS Today 2018 Highlights

The EMS Today conference is always filled with interesting content both in the classrooms as well as the show floor. My live Twitter feed during the conference referenced highlights of the educational sessions I attended ranging from the Operational category to Advanced practice and even some Basic courses. The complete experience shared by everyone is permanently archived with the official #EMSToday hashtag. 

I traveled the exhibit hall several times last month looking for innovative and practice-changing technology. There was plenty to be found and the “best” will always be subjective. While these are some that I felt were worth sharing, others may have found significant gems I missed. If you were also there, please feel free to use the comment section below to add your own impressions of what you see as important in changing the practice of our field of EMS. 

One of my favorite sessions at any national EMS conference is when you can find a gathering of even a small number of “Eagles” (the top Medical Directors from around the country.) The lightning round of “The Eagles Unplugged” presentations in Charlotte was on February 22, just a week before the huge international Gathering of Eagles in Dallas. One of the first topics requested by the audience was on “spinal immobilization” (or in deference to my friend Rommie Duckworth, the proper term should arguably be “spinal stabilization”.) There was certainly no love in that packed room for most techniques or devices currently in use. In fact, the emphatic consensus statement was that there is simply no literature that shows any benefit to current spinal motion restriction while there are plenty of documented complications. 

In regards to spinal stabilization, everyone in the room agreed that the long spine board is gone and immobilization currently consists of just a collar. However, there was no consensus on what that collar should look like while there was no shortage of complaints for what is currently on the market. One of the JEMS “Hot Products” from EMS Today in 2017, however, was the SIPQuik vacuum cervical splint from Care 2 Innovations which I only got to play with this year. Basically, it is a collar-shaped bag filled with tiny styrofoam beads and a generous velcro strap. It has several advantages in that it fits a wide variety of patients and will conform closely to the shape of the neck to provide gentle support in any position. Unlike rigid collars that require the head to be placed in the neutral position for stabilization, the SIPQuik can wrap around the neck and be secured comfortably snug with the strap before the collar is molded to support the head while the air is vacuumed from the collar. The beads are held tightly in place to provide support that minimizes the possibility of further injury. Removing the manual pump without locking the air tube will allow air to reinflate the collar for easy removal. 

Several sessions, and exhibitors, included discussions of safety for care providers while working on the road. In America, we tend to love the large square box we call the patient compartment in our Type I and Type III transport vehicles. The size of the box and position of supplies and equipment requires a significant range of motion and most providers roam about unrestrained. Traditional safety belts are already available in every seat, however, they are just too cumbersome to apply and too restrictive to be used. At least this was my thinking until I placed by arms into the new 6-point “Back Pack” belting system on the EVS2160BPB from Emergency Vehicle Seating, Ltd. Unfortunately, the Back Pack system is not advertised on their website yet, but if you are interested, they will know what you are asking about if you contact them. 

The shoulder straps were as easy to apply as simply slipping my arms through the loops.  But the range of motion was incredible and allowed me to stand up fully and reach clear across my imaginary patient to where I would expect cabinets to be on the other side of the room – while still wearing the shoulder straps and even the lap belt! As I return to the seat the straps automatically tighten and should the vehicle have an accident, the belts would immediately tighten to prevent my head from crashing into those same cabinets across my patient. This quick and easy seat belt access is certified to meet all safety standards of FMVSS and SAE while providing maximum flexibility for the care of my patient. Two EVS1790 captain’s style chairs in place of the typical bench seat also allows comfortable and safe crew seating or can be rotated and tilted forward to allow the transport of a second patient on the non-skid back surface of the seats. Clearly, EVS has been giving plenty of thought to where we put our butts.

Another one of the hottest topics in prehospital treatment of trauma has to be the use of tourniquets and binders. I really thought that the poplar military-style tourniquet had not changed significantly from the belt and windlass configuration of decades ago, but there have been innovations here as well.

The S.T.A.T. Tourniquet is probably the greatest revolution in design. It comes in both a pediatric and adult size, but immediately conjures up the ubiquitous zip tie. It is wrapped around the limb above the injury and the end is inserted and pulled as tight as needed (in 2mm increments) to easily adjust. Although it looks like a zip tie, it is anything but what you find in the hardware store however. It is a wider design to prevent cutting into the skin and the material is a stretchier rubber to hold fast and evenly to secure blood flow. It also has a simple timer that can be activated when applied to measure half hour increments up to a max of 2 hours. Like the common zip tie it resembles, it can be used in combination to create a larger band or used in a series for splinting too. One major difference from the traditional zip tie is that this model also has a release tab to remove the tension. The simple design and lower cost compared to a traditional windlass system makes it ideal for public use in an MCI situation as part of a hemorrhage control kit. S.T.A.T. Medical Devices even sells them preloaded on a carabiner in a quantity of 25 tear-off tourniquets.

 

In case that style of tourniquet design is just too revolutionary, the folks over at SAM Medical have evolved the traditional tourniquet design by adding TRUFORCE Buckle technology to auto-lock the tourniquet during application. Slack in the tourniquet is the main cause of application failure requiring extra time twisting the windlass or even restarting the application. The SAM XT is designed to

require 33 pounds of force to engage two pegs that hold the strap before it is Velcro-ed together and the windlass can be engaged to stop the bleeding. This makes application easier and quicker. They also have a junctional tourniquet to stop pelvic hemorrhage. And my favorite model is the SAM Pelvic Sling II to comfortably apply the correct force to stabilize pelvic fractures. The design looks similar to the SAM XT tourniquet, but uses a patented AUTOSTOP buckle instead that ensures that the optimal compressive force is reached to confirm correct application. It is more expensive than a hospital sheet, but it provides confidence and comfort in a professional design.

I was also impressed by the Water-Jel Burn Dressings which provides a cooling gel (that is water-based, bacteriostatic and biodegradable) that actually stops the burn progression by actively cooling the skin and relieving pain rather than simply covering the wound to protect against airborne contamination. These dressings come in several different sizes and have a shelf-life of 5 years. The other great feature of these dressing is that each dressing has a Total Body Surface Area (TBSA) icon that indicates approximate total body surface area covered with the use of that particular dressing to improve your estimates of the body area covered.

Finally, to reduce medication calculation errors in pediatric patients, CertaDose provides syringes printed with color bands that match the Broselow tape used with younger patients. These syringes are clinically proven to reduce critical dosing errors by labeling the correct dosage directed on syringes labeled by the medication to be administered. Simply select the correct drug, match the color zones according to the Broselow tape and draw up the correct dosage.

I should also mention StethoSafe as another highlight from the floor of the show because I rely on their product to protect my stethoscope, but I did a whole other blog on the StethoSafe earlier.

Leave a note about what you found most interesting.

 

 

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Are You an Ambulance Driver Too?

One of the fastest ways to piss off almost anyone in the emergency medical services community is to call them an “ambulance driver.” It has become a triggered response as reliable as setting off the tones for a call. We bristle at the fact that driving an ambulance is such a small part of what we are trained to do – even though “high-flow diesel” can be an effective, legitimate treatment for certain patients. Retired FD captain and bestselling author of Rescuing Providence, Michael Morse, wrote an article last year on accepting the title of “ambulance driver.” His reasoning was due in large part to the variety of nuanced titles that we stubbornly cling to including Paramedic (which is reserved only for “those who can intubate”), EMT, Basic, EMT-I, or AEMT as well as several permutations of NREMT. Quite frankly, we simply do not accept any generalized term for “EMS workers” that is as easy to understand and say as doctor, nurse, firefighter, or cop. And for those who are offended at being lumped into the cadre of “first responders,” at least the term “ambulance driver” does distinguish one of our unique capabilities.

“Ambulance Driver”

While I agree that Morse has a legitimate argument in his assertion that we have made this predicament ourselves, there is another salient point that comes to my mind from the news multiple times each month when an ambulance is involved in a serious wreck. A local Minnesota news channel investigation discovered that the requirements for operating an ambulance in emergency traffic while carrying a sick patient and an often unrestrained paramedic in a moving emergency room is far less than is mandated for a “truck driver hauling a semitrailer load of beer.”

With a shortage of paramedics, more EMTs are being hired to fill out crews. With low starting wages, it is often people who are still too young to legally rent a car by themselves that are put behind the wheel of a 14,000 pound vehicle costing nearly a quarter of a million dollars and loaded with the most vulnerable of human cargo after just a day or two of experience driving a cone course!  

Recently, NHTSA analyzed 20 years of data and found that the nation averages 29 fatal crashes involving an ambulance each year. Furthermore, these accidents result in an average of 33 fatalities annually. For a group of individuals dedicated to saving lives, this should be an unacceptable statistic. Rather than being indignant that the name describes so little of our training, we need to adequately train for the job of driving an ambulance for proficiency just as we train for our skills as a medical clinician. The lives of our patients (and our partners) depend on that skill every bit as much, if not more, than our medical skills.

In addition to my personal credentials as a professional (both in EMS and GIS), I am a fire vollie, a backpacker, an instructor, and an amateur historian. While none of these monikers describe the entirety of my personality, none of them offend me by limiting the description. Why should I be insulted for being recognized for a critical function in safely operating an emergency vehicle? I do not hear doctors being offended by not being identified by their specialty or even by being lumped in with a PhD outside of the medical community. The sad fact is that we just don’t have an agreed generic term for the collection of people with which we share our profession. Although the term “ambulance driver” does not fully define me as a person, or even as an emergency medical professional, I will proudly accept the title as my personal commitment to safely operate my ambulance for the benefit of the public, my patient, my partner, and myself. To any other “ambulance driver” out there, let me thank you for all you do for the public beyond the safe operation of your rig.  

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What Starman is Saying About the Future of EMS

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

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

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

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

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

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

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

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

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

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

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More Reasons to Support Dynamic Deployment

The “Leverage Real-Time Data for Improved Ambulance Response Times” article that Zoll posted on their blog site did a good job of explaining response times and even the benefits of System Status Management (SSM) planning to the patient. But there is still more to the story that we have learned over the years since Jack Stout first introduced it.

Of course, it is best for the patient (and the service) when an ambulance arrives to the scene in a short time. The media often picks up on poor response times with stories like†the GSW patient dying in Clevelandsurrounded only by police and fire personnel. Even the doctors at JAMA can’t resist publishing an article showing response times as an inherent failure of EMS in certain cases. Unfortunately, many will read the solution as medics “speeding” to the scene, yet we have learned that lights and sirens have little impact on times and may even prevent some patients from calling for an ambulance in the first place. However, when the deployment of ambulances is responsive to the dynamic demand patterns throughout the day, ambulances can literally be moved closer to the scene even before they are dispatched. Literally hundreds of High Performance EMS agencies across the US have significantly reduced their 90th percentile response rates through technology. Forecasting the future does not involve magic, at least not for predictable phenomenon like emergency calls for service. Not only can we forecast the quantity and types of calls we will receive (necessary for adequate staffing), we can determine where they are likely to originate from with significant accuracy as well. Shortening the distance that an ambulance must travel is a safer alternative than asking a crew to speed in order to achieve the same result.

Another positive impact of shorter response times is patient satisfaction. There are many reasons that healthcare providers should be†using patient satisfaction surveys, both for the benefit of the patient as well as simplifying the accreditation process for your service.†Beyond safety, satisfaction and simplification; proper SSM can improve finances. Some services have recognized marked reductions in the number of post moves for crews and ultimately reduce the total number of unloaded (read unreimbursed) miles driven which saves on vehicle wear and tear in addition to fuel costs. Other agencies, particularly those who contract their services, can reduce financial penalties for “exceptions,” or late calls beyond the target response time.

Frankly, the public often expects performance measured in minutes. Whether we approve of the measure or not, we are often graded and compared based on response times. Whether the penalties for missing targets are financial, patient satisfaction, or driven by bad press reports, being late simply hurts. Until EMS is designated and funded as a critical service for government, it will be dependent on political funding allocations and insurance reimbursements. As long as performance is measured by how long it takes to be on scene, response times will be critical to the financial well-being of services. The least we can do is perform to the highest safe standards possible.

 

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Innovation Review: StethoSafe

Have you ever broken a stethoscope on the job? I have. Rode a wheel of the loaded stretcher right over the connection from the tubing to the bell. It was a clean break. Very neatly decapitated my old friend from EMT school. It was one of those clear and obvious signs of death such as decomposition or rigor mortis. I didn’t want to show it, but my heart was crushed too. But it wasn’t like I was without a scope to do my job. There was always the one that hung on the crash webbing at the end of the bench seat. You know the one, it hangs right above the trash can for anyone too poor to have their own equipment to use. I’ll admit that the idea of inserting other folks ear wax into my own canals grosses me out, but the point was that I didn’t have MY stethoscope. So, before I even finished the PCR, I was on the web buying myself a brand new set of ears. While my new and improved (and yet to arrive) stethoscope would have my name engraved in gold letters right on the tubing, I still wanted my old one repaired. To their credit, Littmann offered me an identical replacement scope for less than the cost of the repairs I required. I won’t tell you what happened to the old broken pieces of “my first stethoscope,” but suffice it to say that I am sentimental.

My new stethoscope, a Burgundy Cardiology IV, was an definite upgrade from my previous faithful Royal Blue Littmann Select. Although the price difference made me a little short of breath, I decided my career was worth it. But from now on I would have to be even more cautious. And my new scope had two diaphragms instead of just the one to protect. In the meantime, I began to examine some of those listening devices hanging back in the patient compartment of trucks I’ve driven. I have noticed cracked or bent diaphragms and even some that appeared to be trying to escape their captivity. Knowing that the quality of our assessments can be impacted by the quality of our equipment, I wanted to ensure I was always prepared. But how much can we really do though? Any equipment we use in the field and routinely stuff into bags is subject to damage and there is little we can do to protect our equipment, right? Wrong.

A couple months ago I heard about a nifty invention from Paramedic Greg Sumner†called the StethoSafe. While it is not designed to prevent the type of ‘beheading’ I executed, it is made to protect the sensitive diaphragms on your head. As it states on his website, “Itís like a helmet for your stethoscope.

At $9.95 (plus $3.00 first class postage) for just one, I could have some piece of mind. While I don’t consider myself a ‘whacker,’ I do like innovative stuff. I bought one in blaze orange, stuck it on my head and stuffed it in my go bag. After carrying it around a while, I began to wonder exactly how much protection it afforded my equipment. A friend of mine, who knew Greg, asked me to give it a good test. I wanted to, but didn’t want to break mine, so he contacted Greg to send me another to put through some paces. That left me free to really test it out.

Over the last couple of weeks, I have been intentionally abusing my original StethoSafe. This video review†on YouTube is only my latest attempts to ‘crack this case.’ There were many, many more before what you see. Even after all of that, I am still using the same case on my shifts. It does have some obvious scratches now and some discoloration near the joints (you can see circled in the photo) that I assume are the precursors to cracking, but no actual cracks yet. Since this is a 3D printed part (correction: only the prototype was printed, my production review item was injection molded), I wondered about chemical abuse, so I poured isopropyl alcohol on the plastic and it eventually all evaporated with no sign of damage.

I have been very impressed by the ability it has to keep my sensitive parts safe. I did notice, however, after constantly clicking my stethoscope into the case that it was beginning to leave some residue on my bell. But this powdery residue came right off with a simple wipe. It was not actually scratching my bell, just wearing the plastic down every so slightly. My scope fits snuggly in the case (even after plenty of testing.) In fact, it fits so tightly that I worried about pulling on my tube to get it to release. I found myself in the habit of grabbing the metal tube connection very near the bell to pull it out. But with a little faith, I have found that the case will release with a tug from further down the rubber tubing without any damage to the equipment. The lanyard would be very convenient if I had a D ring inside my equipment bag so I could just pull it out when needed. My habit, however, is to leave my stethoscope in the cab (often on the dash) or hanging around my neck. My StethoSafe is never any problem regardless of where that I keep it and I can feel confident that it will prevent me from losing another friend any time soon.

 

 

 

 

 

 

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Split-Second Destination Decisions

This past Sunday night about 2245 hours, a Detroit police officer was shot in the head while responding to a domestic violence call. The Detroit Free Press,†in an article identifying the shooter, reported that the incident happened at an apartment complex in the vicinity of the 10000 block of Joy Road near Wyoming Avenue on Detroitís west side. According to Channel 4 News in Detroit, Rapid Response EMS was dispatched and arrived on scene in less than 60 seconds. The officer was transported, with a police escort, to a level two trauma center,† as reported by another local news source,†with the patient being handed over within 22 minutes of the original dispatch. Now, Detroit Police Chief†James†Craig is asking why the injured†officer “wasn’t taken to the closest hospital.”

These are the facts as I have been able to glean them from multiple news reports and summaries. I have no inside knowledge of this particular incident or even any great understanding of Detroit in general, but I believe there are several interesting questions worth a larger discussion here from the perspective of a complete outsider. For those who may have more inside information of this situation, I will point out that I have no interest in any past conflicts that this particular EMS provider has had with the Detroit Fire Department or a memo now resurfacing from an incident last October specifying that injured “Detroit firefighters will be transported by Detroit EMS only.” That is a totally separate matter that relates potentially to medical care, not destination decisions.

A FOX 2 news article made a statement that they are “still looking into why a critically wounded Detroit police officer was taken to a hospital in Dearborn– when there were two hospitals that were closer.†At least one of the hospitals that was passed up is better equipped to deal with a gunshot wound to the head [emphasis added].”†Another article, updated during my research today,†has since made a correction stating, “This story has been updated to clarify that an ambulance driver [sic] did not pass any hospitals while transporting a wounded Detroit police officer.”

The question we in EMS are often forced to answer is what facility is “closest,” however that question does not always have a static answer from every incident. One of the first articles I read on this case printed a thumbnail map (since removed) similar to the image on the left (which you can enlarge by clicking on it.) What immediately struck me was that the shooting occurred at the center of a triangle formed by the three “closest hospitals.”

If we consider distance to be “as the crow flies,” or perhaps more appropriately, “how the medical helicopter flies.” We will get one set of distances and travel times. Here, Henry Ford to the east appears closest in straight-line distance followed by Sinai-Grace to the north and finally Beaumont in Dearborn to the southwest. If we consider road miles of the shortest path, the order changes with Sinai-Grace at 4.8 miles, Henry Ford at 5.6 miles and lastly again, Beaumont at 6.8 miles. However, if distance is measured in drive-time, specific values change (according to my tests using Google Maps) depending on the amount and direction of flow of traffic. In all of my time tests, Sinai-Grace came in dead last due to the number of local street segments traversed and I suspect a large number of traffic signals. These typically narrower streets and signaled intersections are not only slower to travel, but more dangerous when traveled using red lights and sirens (some studies will show this is especially true with a police escort.)

The travel times in my daytime investigation during a typical work week varied with the other two destination hospitals and probably would still be different from a late drive on a Sunday evening. Of some significance in comparing the “best routes” is the number and direction of turns. As a general rule, right turns are safer than left turns which must cross opposing lanes of travel. The other consideration is the speed limit of the roadways. While I assume the ambulance was travelling above the posted rate going code 3, it is the faster roads that are built to a higher level of safety and will more easily accommodate higher speeds with fewer traffic control devices (lights or stop signs.) The route to Beaumont had the highest number of miles on restricted access highways that have the highest speed limits in any city. Consequently, this may have been a very good choice based on actual travel-time as well as safety considerations.

The call was still a judgement one and I will not defend one or the other as the best choice given my lack of knowledge in Detroit, but I will defer to the judgement of crews that travel these streets regularly both as emergent and routine traffic.

The other consideration in this call was the trauma rating of the hospital. As I understand it, both Henry Ford and Sinai-Grace are level 1 while Beaumont is only a level 2 facility. Given the severity of the wound, some deference would likely be given to the better equipped hospitals. However, the real difference between these levels is typically whether there is a teaching and research program available. The surgical capabilities should actually not be significantly different.

With drive times so close to being similar, I can sit comfortably in the safety of my arm chair typing that the choice of Henry Ford would have been quite practical; however, I may well have made a different choice myself as I place myself behind the wheel (as I will be doing tonight.) That immediate “split-second” decision of east versus south west is much more difficult in the moment. And this is exactly the type of situation where I would be grateful for the input from the MARVLIS in-vehicle client that sorts destinations choices by distance and provides an optimal path based on time-of-day with turn-by-turn driving directions.

 

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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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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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EMS Today 2016 Review

It was my privilege to have been selected as the Official Blogger of the EMS Today conference for 2016. Like my predecessor, Tom Bouthillet at¬†the¬†EMS 12-Lead blog, I took that role very seriously and visited as many of the sessions, vendor exhibits, and even socials (they are definitely part of the experience) as I possibly could. Throughout the conference I posted my impressions live on Twitter through my¬†@hp_ems account using the hashtag #EMSToday2016. But I know many people either couldn’t, or simply didn’t, watch that whole feed over the four days that I was tweeting live, so I felt a summary blog of the highlights was definitely in order. If you were there, I hope I saw you and that my remarks will echo your own experience. But I would also like to ask that you include your own impressions as comments at the end of this post. If you weren’t there, you missed a lot. And hopefully for you, this article can provide justification for you to make the trip to Salt Lake City next year for EMS Today 2017.

The very first time I attended an EMS Today conference, I arrived on the first day of the show only to discover that I was actually more than 24 hours late. By not arriving early, I had missed tons of great content presented during the pre-conference sessions the day before. While they definitely add an expense to attending the meeting, they also add anywhere from 4 to 8 hours of detailed content (as well as CEH) that you just won’t get in the faster paced 60-minute sessions of the rest of the conference. This year, I opted to attend an afternoon cadaver lab hosted by Teleflex. Training with manikins and simulators is great, but it can only take your skills so far. But flushing a proximal¬†humerus IO access¬†with the chest cavity open, allowed me to witness first-hand the short vascular distance from the infusion point to the heart compared with femoral access. In addition, we had plenty of time to practice ETI with various devices on¬†many different patients. I also had the chance for my very first surgical cricothyroidotomy. While the practice of these skills was highly valuable, the opportunity to simply hold the lungs while they were ventilated and explore the chambers of the heart with my finger were enlightening beyond imagination. Nearby, was another very popular choice for a pre-conference class in the Active Shooter Simulation. It was unfortunate, but just the evening before this shooter simulation class was a vivid reminder of its importance to us in the form of a gunman who killed 3 and wounded 14 more in¬†Hesston, Kansas. Violence leading to an MCI can clearly happen anywhere and we must all know how to respond. Thanks to this timely offering, many more EMS providers are now better prepared.

Moving quickly from the lab to change my clothes, I headed for the formal EMS10 awards ceremony. This invitation-only event hosted by Physio-Control was an opportunity to rub elbows will the people marking their mark to improve the level of care in EMS today. You can always read about the 2015 EMS10 recipients and their innovations, but by being here I was able to run into them several times throughout the conference and even had the chance to speak with some of them to learn their detailed stories.

The next day (which officially began the conference) started early with sessions beginning promptly at 8AM. I was given reasons to consider “Point of Care Testing” by Kevin Collopy who helped me¬†better understand what we can, and cannot, do today based on federal CLIA regulations and why to consider accreditation. Next was¬†Jonathan Washko discussing the success of community paramedicine at North Shore LIJ EMS. The best part of being at a conference with such notables is hearing comments that challenge your work. Jonathan asked “if you can’t manage yourself, or control your own emotions, how can you manage others” and reminded us that it is “the strongest leaders who ask for help.” Then from my virtual visit to NYC, it was on to a global view of self-regulation in paramedicine with Michael Nolan, Gary Wingrove, Becky Donelon, and Peter O’Meara. A couple of great lines prompted a shift in professional thinking, like when being told that “as paramedics it is time to ‘move out of mom and dad’s basement'” and as we argue over the universal meaning of “paramedic” (or “ambulance driver”),¬†“the patient, the media, and your mother should all know what to call you!” Over in the room where¬†Ray Barishansky spoke on “proactive professionalism,” it was crowed as he said¬†“we as a profession have let ourselves down with our behaviors, low pay, and attitudes.” Ray¬†also reminded us that it is “professional EMS providers who own their mistakes, are respectful, and are always advocates for the patient” and asked us to give further thought to the idea that¬†“93% of how you’re judged is based on non-verbal data.”

Plenty of more data was presented at the¬†Prehospital Care Research Forum session hosted by David Page where I am proud to say North Carolina was nicely¬†represented. We also learned interesting tidbits in these lightning talks such as “volunteer EMS services are¬†27% more likely not to transport (also to accept refusals, or do ‘treat and release’) than paid services” and that the gender differences in the use of restraint (chemical or physical) is not about the sex of the patient, but more likely to happen with male providers even though female providers are the ones statistically more likely to be assaulted. Matt Zavadsky along with Rob Lawrence (filling in for Nick Nudell) also presented plenty of facts in their session on the Data Dichotomy of the current EMS payer landscape. All of these sessions were going on as the¬†JEMS Games preliminary competitions were being held to see who could brag about being the best of the best in EMS. If you want to see how challenging these “games” can be, here is a quick view of the obstacles that participants face to prove they can handle the job.

It was the mid afternoon that the official opening of the conference was held with all of the pomp and circumstance (including fifes, drums, and bagpipes) that you expect at any public safety conference. There was a somber recognition of our brothers and sisters in EMS who have answered their last call due to LODD along with multiple awards and a stirring multi-media presentation by alpinist Brian O’Malley. The prestigious James O. Page award went to NEMSMA for this ground-breaking whitepaper aimed at preventing EMS provider suicide. There was also a brief¬†visit from Maurice Davis to promote¬†his tribute designed to raise awareness and remove the stigmatism that keeps EMS providers, the military, and many others silent and leading all to often to “The Wrong Goodbye“. The video depicting the impact of suicide¬†is something we should all be sharing with our friends.

It is after the keynote presentation that the exhibit hall opens for a brief reception. If you didn’t get to see it, follow along with a bodycam highlight video of¬†the exhibit hall from my friend Jeffery Armstrong. I must also recognize the generosity of Limmer Creative who donated several of their LCReady classes for me to give away during the conference for people who were able to find me and even opportunities for followers who retweeted my post about the contest. Being social is beneficial!

As my friend Bob Holloway put it, “Day 2 was packed with sessions on EMS innovation, MIH (Mobile Integrated Healthcare), and creating value.” And what better way to kick that off than with a cup of coffee and a lightning round called “Ask the Eagles”? If you aren’t similar with the Gathering of Eagles, it is also known less colloquially as the EMS State of the Sciences Conference. This year’s conference was held the previous week¬†in Dallas and consequently the session at EMS Today (always a favorite of mine) is packed with the latest EMS Pearls that will hopefully one day make it into your local protocols. This is where you can hear progressive medical directors from around the country like Bryan Bledsoe busting dogma with comments like¬†“less spinal movement with self extrication compared to backboard extrication.” Unfortunately, I missed it this year to interview Ferno in a video on their innovative iNTraxx system to promote safety, flexible modular design, and increased efficiency. Watch for the interview made in conjunction with my friends from EMTLife later this week.

Over lunch on Friday, I heard Dr. Keith Lurie, CTO of ZOLL Medical, discuss the changing perceptions of resuscitation through “active compression decompression” during CPR and his ResQPOD impedance threshold device that together can increase one-year survival after cardiac arrest by 49%. There was also discussion of heads-up CPR which can significantly decrease ICP during CPR ad many other tips to help us improve CPR survival rates. This discussion was followed up by another visit to the cadaver lab for some hands-on with real human patients. Practice such as this really makes the charts and figures come alive! But what had to be my favorite session of the whole conference had to be the experience of behavioral medicine with David Glendenning and Benjamin Currie. Far from a traditional PowerPoint presentation, we were invited to take a very different look at patients with behavioral issues by experimenting as a group with schizophrenia and delving into the taboo topic of viewing ourselves as potential patients. David suggested that “dealing with PTSD is NOT a rite of passage in EMS and we need to acknowledge it is a real physical condition and begin to talk openly about it.” The session closed with a thought-provoking¬†David Foster Wallace video¬†from a commencement speech explaining how¬†“sometimes the hardest things to see are all around us.” I hope you will take about 9 minutes and watch it. I would also like to recognize the fine efforts of The Code Green Campaign in this same area (as JEMS/Penwell also did.)

Another awesome session well worth mentioning was early on Saturday morning, it was called “Creating a Social EMS Culture” with Carissa O’Brien and Steve Wirth. While there were several good quotes, it is most important to note that “your EMS agency has a legal interest in your use of social media just as¬†you have a professional one.” There are several legal considerations that include the US¬†Constitution, National Labor Relations, defamation laws, HIPAA, harassment laws, and more; but the end game is not “big brother” watching your networking. It must be understood that your agency has a responsibility in¬†“building a culture that breeds responsible digital citizens.” Just as we develop our clinical skills,¬†“we need to train EMS¬†providers in social media just as we would with any other skill.” This discussion is one that can continue even after the conference by participating with the #socialEMS hashtag in your favorite forum.

For those who attended, you can access the conference proceedings with the username and password you received at registration. I also hope you will add your favorite memories below to give others a more accurate record of the whole conference.

I could go on about meeting the paramedics from Nightwatch, my childhood hero Johnny Gage (Randolph Mantooth), being able to sit in Squad 51, or see the original Heartmobile that played a significant role in the development of EMS in America, but I really think it would be best if you just went ahead and registered for your own journey and plan to attend the conference next year.

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What You Need to Know for EMS Today

I know that some of you will be in Baltimore this week for EMS Today, while still others cannot join us. Regardless of which category you may fall into, I have some advice to help you make the most of this week.

First, if you are travelling, hopefully all your arrangements are complete. But even so,¬†you still have an opportunity to save money during this trip. There are many transportation,¬†parking, eating, drinking and shopping opportunities in the Baltimore area that are offering discounts to conference attendees. All you need to do is “Show Your Badge” for discounts at these participating merchants. To help you keep track of all the sessions (and any last minute changes) or just find your way through the exhibit hall, you should¬†download the EMS Today app for your smart phone or mobile device. It is free for your Android phone from Google Play¬†or for your Apple device from iTunes.

Whether you are physically at the conference or not, networking is what any¬†conference experience is all about. And you can do it while you are here, at home, or even between calls. The key is to¬†“be social”¬†during the conference whether you are physically there in person or¬†you can join¬†us only in the virtual sense. Many attendees, including myself, will be active on social networks allowing you to connect with your peers and gain some insight of what is happening through the eyes and ears of others. If you are on Twitter use the #EMSToday2016 hashtag and follow the official¬†@EMSTODAY¬†account or join me,¬†@hp_ems, for the latest updates, comments, and feedback on what is going on at, or even beyond, the sessions. Check out the latest posts on Facebook at the official EMS Today Conference & Expo page or join the conversations on various topics throughout the year¬†at¬†the¬†High Performance EMS¬†page. You can also learn from¬†my own perspectives and the opinions of attendees that I talk with by reading my posts as this years official blogger of EMS Today 2016 at HighPerformanceEMS.com.

20160222_085251Being social can also win you prizes. There will be giveaways for visiting exhibitors in the Expo Hall, but also opportunities to find me at sessions where you can¬†tell me about your favorite¬†experience this week for an opportunity to win a prize from Limmer Creative who¬†can not only help you pass the test, but retain the knowledge you need to succeed at the job. Just look for me, Dale Loberger, or find me by my backpack pictured here, and tell me what you love about this conference. I’ll make it easier to know where I will be by posting the sessions I will attend to my Twitter account at @hp_ems. If you won’t be at the conference, you can still have an opportunity to win by simply retweeting my contest post starting on Wednesday. Reposts of the full tweet will be counted through noon on Saturday in the drawing. Watch my account for more details!

DaleLoberger

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