Improving EMS Deployment Performance

I work regularly with agencies that are looking to improve aspects of their operations. Some casual readers may be surprised to know that the focus of those discussions is not always about cutting response times. While response is a simple and common measure, it clearly does not evaluate EMS well and certainly fails to encapsulate many of its complex needs and values. Still, I feel the necessity to address the time objective briefly before going on to other important aspects.  

Advertisement

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.”

Improving Operations in Crisis

Our practice of EMS is facing significant challenges right now. Although many traditional aspects must still continue, we have a few more obstacles to overcome in a crisis. This “pilot podcast” highlights some practical modifications to consider for operational improvements, especially for MARVLIS users.

Notes:

Demand for EMS services is disproportionate across America and outside of normal patterns, but some changes to our practice are helpful across any service right now. If you haven’t begun seeing longer times yet, you can expect it to be coming as we face longer dispatch delays for extended EMD, longer on-scene times for re-triaging patients using a “1-in and 1-out” scouting method, longer decontamination times for ambulances possibly infected with COVID-19, and fewer professional human resources collectively making operational efficiency and crew management even more important than ever. At the same that time we are still dealing with our regular calls, mass quarantines and stay-at-home orders are likely to increase calls for domestic violence, drug abuse, acute mental illnesses, and even suicide as people socially distance.

1. Consider modifying queries in Demand Monitor to include longer general timeframes when forecasting dynamic demand:

• Extend the period of weeks, e.g. 56-60 days both Before and After the current date.
• Extend the period of minutes, e.g. 90-120 minutes both Before and After now.
• Enable hotspot accuracy reports to quantify the value of different queries.

2. Create new posting plans with Deployment Planner that balance the weight of geography and demand to limit post move recommendations.

3. Implement a Leapfrog in Deployment Monitor value to penalize moving stationary ambulances by preferring to move units already in transit.

4. Call BCS Support for any help you need to configuring MARVLIS to your operational challenges beyond simple mindless efficiency.

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.