Examining the 2020 Vision of EMS

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

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

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

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

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

 

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How "New" Will "Normal" Actually Be?

Be careful what you wish for. Just a few months ago, before the words “COVID-19” and “social-distancing” became a regular part of our conversations, I was speaking with the Operations Chief of an EMS service about the difficulty in hiring and retaining paramedics. He said it would take “a downturn in the economy before we could hire enough medics” since candidates typically gravitate toward stable jobs in public service when the market is in a recession. Well, its technically not a recession, but the current pandemic is clearly stressing the world economy and even altering patterns of use for many EMS agencies. In some areas of the country, call volume is now out-stripping capacity while others find themselves in a very different place with far fewer calls than normal. So, as we even consider whether we still need the paramedics we had planned, the immediate questions become “what is ‘normal’,” and “what could be so ‘new’ about it?”

The past can often be a good guide. My primary job in consulting is helping agencies with the optimization of their resources. Doing this successfully requires that I can discover patterns from history to guide forecasts of the immediate future. This is a difficult position when the world is no longer behaving according to the regular fluctuations of the past. Yet, as an undeterred student of history, I continue to search for models that can illuminate the path before us as I did regarding demand in my previous post. There is no shortage of significant anecdotes from history to review, but each has its limitations when applied to today.

My first study was the so-called “Spanish Flu” of 1918-19. It was the deadliest pandemic in history that infected nearly a third of the human population and killed well over 20 million (or by some estimates more than 50 million) victims, including some 675,000 Americans. This historic pandemic had a similar effect to today by shutting down world economies and hiding its population behind face masks. The scariest consideration of a modern parallel to this period would be the idea of an even more devastating second (or even third) wave of infections yet to come. This historic flu, however, was still not able to destroy the world order as some feared. In fact, it preceded one of the greatest economic expansions of industry leading to a period that would be known as the “Roaring Twenties.” The score of our current pandemic is merely a shadow of its predecessor with less than 5 million worldwide infections known and slightly more than 300 thousand total deaths around the globe. So, could we also expect a similar economic boom following our current crisis? That is highly doubtful as the economic conditions preceding this shutdown were entirely different than a century ago. And I’m also not sure we would necessarily want that same exuberance that stemmed from a generation that developed an attitude of “nihilistic hedonism” born from a season of austerity and fear caused by the disease. The age group primarily affected at that time developed a laissez-faire attitude toward life fueled by a rapid rise in prosperity induced by sweeping changes in technology, society, and economy. It was literally the beginning of the modern age – and then came the worst economic depression ever.

Fortunately, the current death toll is still far too low to engender a similar sociological backlash even in a time of modern polarized politics echoing the protests of the last century. With a presidential election less than six months away, many states have entered some form of “Phase 1” of a controlled economic reopening of society. There are probably as many anecdotes as opinions with states like Texas going big on economics over epidemiology compared to the more cautious moves of hard-hit states like New York and New Jersey only ‘cracking open’ slowly. While scientific advances are promising, we still do not have a vaccine, effective treatment, or even reliable tests. Yet we seem reliant on the promise of “contact-tracing” in an environment of community-spread rather than recognized efforts elsewhere at “contact-isolation.” So we can likely plan on seeing more cases of COVID-19 in the coming months and political reactions will likely vary with an increased influence of politics.

What is likely to be lasting from our current experience are new “telemedicine practices” being implemented by physicians and widely accepted by a public that fears even going to the hospital at the moment. If EMS will ever be able to justify the continuation of Community Paramedicine practices or possibly even extending them through their own Mobile-Integrated Healthcare outreach (or as a home-provider within the telemedicine practice of doctors) it will be right now. If the opportunity of the current crisis passes without making political gains to extend the reach of EMS, it will only be more difficult to accomplish in the future. We have also seen traditional conferences gone virtual to eliminate travel and large physical gatherings. Although the experience lacks some of the traditional perks, it has huge cost and time savings. Similarly, professional-referred journals are quickly giving way to a faster social exchange of information and ideas online that bypasses traditional peer-review being replaced by a new social review creating “healthcare influencers” online. To continue this trend, we must figure out how to “qualify” these social icons in the long-term and socially circumscribe their power.

There are also examples we could study of pre-hospital responses to HIV/AIDS, MERS, and SARS. Even though each occurrence caused a significant public panic and subsequent EMS response, their lasting influence quickly waned and the lessons they taught for preparedness were not applied nationally to help us respond to a pandemic. Consequently, the real strategic question we must consider in planning for the future is fortunately not how society will react or estimate how many cases of COVID-19 we will experience, but what effective change will be wrought related to how EMS functions or is financed going forward. As we contemplate moving out from the Department of Transportation  where we are paid only for moving patients, we could consider the terrorist attacks of September 11, 2001, as another example of a precedent model. However, that initiating event concluded within hours and its perpetrators targeted an ideology rather than a lack of immunology. Both passions and fears were inflamed worldwide by these coordinated attacks, but the only lasting results have been legislation expanding government surveillance in the Patriot Act (reauthorized yet again nearly two decades after the event), the creation of a new government bureaucracy over the traveling public in the Transportation Security Administration (which remains focused largely on airline travel which was the target of the terrorists at that time), and the longest on-going war of American history.

Today, the enemy has no flag and the world (or even our industry) also has no unified leader to coalesce a response tactic. Even in the field, the providers of EMS services cannot agree on whether we represent public safety (which justifies an essential funding stream for the public good) or that we provide bona fide healthcare services as a part of an integrated service stream offering appropriate care anywhere from the home to a hospital (that is worth reimbursement independent of driving someone to the hospital.) What history teaches us are several lessons. First, government responds to situations that expand its own interests and that are simultaneously supported by the affections and desires of the public. Even during this EMS Week, it is doctors and nurses who are seen on the front lines of the pandemic war even though the tip of the spear is made up of Emergency Medical Services professionals who go into the homes of the sick and reach through the wrecked vehicles of the injured to risk themselves in the preservation of others. We will continue to be the ‘invisible third service’ as long as we struggle with our identity and lack the statement of a value proposition for a suitable underlying financial mechanism. Second, government consistently responds along an evolutionary path to the last threat rather than a forward-thinking approach. Until we can justify the payment for necessary treatment on scene in addition to any transport to definitive alternative destinations, we will not see revolutionary change. Even wars can be waged indefinitely as long as no one notices they continue. 

We may see some fluctuation in demand for a while, but in the long-run we will return to a familiar normal fare of heart attacks, strokes, and falls once again. It may not be the exact same place we left months ago, but it will not be an entirely new place either. The struggles we fought before will continue to be our struggles again. Hiring and retaining paramedics will again become a topic of discussion as we continue to fight for budgets to maintain our response metrics. That is unless we can learn from one other historical example that comes from back in 1843.  That is the year that Charles Dickens published his famous work known as, A Christmas Carol, where the the Ghost of Christmas Yet to Come prophesies, “If these shadows remain unaltered by the Future, the child will die.”

How is COVID-19 Affecting MARVLIS Users?

The current situation around the new coronavirus is developing rapidly. As we begin to map more cases in new areas along with tracking the shortages of PPE supplies we are also hearing the CDC update guidance for healthcare providers with constantly changing advice. Even the stock market is falling as investors try to make sense of the extent of the impact of cancelled public gatherings and increased social distancing.

While there are significant new challenges around exacerbated staffing shortages created by potential quarantines of first responders, it is still, at least to some degree, business as usual for EMS. Panic over the declared pandemic is not eliminating the “normal” calls to which we must respond. Medical emergencies including cardiac arrests, cerebrovascular events like strokes, diabetic emergencies, and acute respiratory attacks (including COPD, bronchitis, emphysema, and asthma) in addition to common influenza and pneumonia occurrences in this season are all still happening just as before. Similarly, traumatic events are also continuing to happen as a result of motor vehicle collisions or by trip hazards in the homes of the elderly. It is these “routine” calls that are the very reason the most high-performing EMS agencies across Amercia began using MARVLIS in the first place. Now, the added pressures of concern over COVID-19 are requiring additional precautions that can delay care and increase the costs of delivering service to our communities, it may even cause an increase in call volume soon.

The need for efficiency in operations is never greater than during a time of emergency or crisis.

 

While the vast majority of EMS calls have not changed significantly in response the crisis so far, it is likely to have an impact as the pandemic grows in extent across time and jurisdictional borders. As that happens, the query used in MARVLIS Demand Monitor can be modified to highlight past respiratory emergencies to help prioritize nursing homes or the residences of the most vulnerable elderly populations. On the other hand, if the concern is that this population cannot be so easily identified, MARVLIS Deployment Planner can be used to create a geographically balanced plan that position ambulances throughout the service area based on the best ability to respond anywhere given any potential service level. MARVLIS Deployment Monitor has settings to provide automated recommendations for unit movements to match the plan according rules you can control to either minimize the time to reach that optimal configuration or limit the number post moves that crews experience. The most recent releases of MARVLIS include a “hotspot accuracy report” that allows MARVLIS Demand Monitor to grade the ability of competing queries in making the most appropriate forecasts and MARVLIS PSAP Monitor can allow neighboring mutual aid resources to be seen live on a map.

As the current crisis evolves, it is good to know that experienced advisers are available at Bradshaw Consulting Services to help MARVLIS users modify their application configuration to assist agencies in meeting their changing business objectives. As resources become more constrained, the flexibility of MARVLIS becomes more apparent.

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.

 

 

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.  

Dynamic Risk for Intelligent Fire Move-Ups

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

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

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

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

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

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

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

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

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

What 'Level Zero' Really Means in EMS

“Rampart, Medic 13 with an�incoming patient report.”

“Go ahead, 13.”

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

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

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

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

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

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

The Fallacy of the "First Due" Area

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

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

 

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

 

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

      

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

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

Impact of Increasing Call Volume on Effective Service Areas

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

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

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.

 

 

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!)

Other 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.

Is 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.

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 automating 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.