BCS Releases MARVLIS Version 4.5

Dale Loberger                                                FOR IMMEDIATE RELEASE: 9/13/22

BCS, Inc.

(803) 641-0960

dloberger@bcs-gis.com

BCS Releases MARVLIS Version 4.5

MARVLIS 4.5 Available Featuring Significant New Features and Updates

Aiken, SC: BCS today announced the release of MARVLIS version 4.5. This major release provides new and updated features focused on our rapidly changing world. Incident recommendation has been expanded in scope and complexity, adding tiered recommendations to get the right resources to the right place even when resource counts are running low. Incident recommendation now also supports response packages for those incidents where a single resource is insufficient. This release also contains tools to simplify MARVLIS database deployment and adds support for multiple MARVLIS systems running on a single database instance. Finally, this release contains improvements in the Dashboard report and help system, NETCall functionality, and the MARVLIS technology stack.

“The evolution of MARVLIS to version 4.5 is yet another example of our dedication to innovation in the Public Safety sector. This new release expands on MARVLIS’s position as the complete solution to control, route, and manage resources across the entire agency. Communication centers will save time and reduce manual steps with new features like tiered responses and response packages”, says Tony Bradshaw, President at BCS. “The latest version of MARVLIS NETCall is a game changer for the efficient management of non-emergency resources and provides technology to optimize trip assignments to maximize profitability.”

Features and benefits of MARVLIS 4.5 include:

• Added Incident Recommendation module support for tiered recommendations and response packages
• New Query Sets to create vehicle and incident queries for incident recommendations
• Dashboard pages now include context-specific help links
• MARVLIS Database now supports multiple MARVLIS systems running on a single database instance
• Updates to Playback, Post Coverage, and Incident Recommendation Reviewer Dashboard Reports
• Added support for password complexity 
• Updated technology stack includes:
  • MARVLIS Client updated to support ArcGIS^® Runtime 100.13
  • MARVLIS Dashboard updated to support jQuery^® 3.6.0 from 3.3.1
  • MARVLIS Dashboard updated to support the ArcGIS^® API for JavaScript^TM 4.23
• Added support for routing with live traffic in Canada using the TomTom^® Real Traffic Feed
• NETCall updates to support revenue information in processing and numerous user interface enhancements

MARVLIS 4.5 is now available and is included as part of annual maintenance for existing MARVLIS customers. If you’d like more information or think that MARVLIS might be the right solution for your organization, please email sales@bcs-gis.com or visit https://www.bcs-gis.com/marvlis.html.

About BCS, Inc.: Founded in 1998 in Aiken, SC, BCS develops solutions to help organizations leverage technology and strategies to improve operational performance and delivery of time-critical resources, services, and management of non-emergency transportation. Visit us at bcs-gis.com

About Esri: Esri, the global market leader in geographic information system (GIS) software, location intelligence, and mapping, helps customers unlock the full potential of data to improve operational and business results. Founded in 1969 in Redlands, California, USA, Esri software is deployed in more than 350,000 organizations globally and in over 200,000 institutions in the Americas, Asia and the Pacific, Europe, Africa, and the Middle East, including Fortune 500 companies, government agencies, nonprofits, and universities. Esri has regional offices, international distributors, and partners providing local support in over 100 countries on six continents. With its pioneering commitment to geospatial information technology, Esri engineers the most innovative solutions for digital transformation, the Internet of Things (IoT), and advanced analytics. Visit us at esri.com.

About TomTom: At TomTom we’re mapmakers, providing geolocation technology for drivers, carmakers, enterprises and developers.

Our highly accurate maps, navigation software, real-time traffic information and APIs enable smart mobility on a global scale, making the roads safer, the drive easier and the air cleaner.

Headquartered in Amsterdam with offices worldwide, TomTom’s technologies are trusted by hundreds of millions of drivers, businesses and governments every day. Visit us at tomtom.com

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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.  

Where Do We Go Next?

To know where our increasingly limited emergency resources will be needed next, we need to understand where future requests for service will originate. If we knew exactly where the next call would come from, we could proactively dispatch a resource there even before it is requested (watch the movie “Minority Report” for an idea of how that might work.) Unfortunately, the nature of emergency response is not nearly that easy, but that is not to say it is impossible to recognize useful patterns across both time and space. While the 2002 Spielberg movie was set 50 years into the future, it correctly predicted the use of several new technologies that have become reality in less than twenty years. And although we don’t use “precogs” in forecasting demand, the ability of data to show future patterns that effectively influence deployment is also now well established within some agencies.

No one can tell you who will be that very next person to dial 9-1-1; however, it is imperative for the effectiveness of deployment that we concede that people and events often follow certain predictable patterns. Let me explain how this works in just a few steps. First, consideration of the repeatable nature of the temporal distribution of calls has been used for years in making shift schedules. The following chart represents the daily call volume from a specific study, but without a scale along the vertical axis, it could easily be representative of almost any agency regarding their relative hourly volumes.

The daily behavioral routine of individuals perpetuates the collective pattern for the larger community. These daily patterns not only replicate over the years, but across various types of political jurisdictions according to a 2019 Scandinavian study on the �Use of pre-hospital emergency medical services in urban and rural municipalities over a 10?year period: an observational study based on routinely collected dispatch data.� The following graphs from that study represent the relative call volumes of rural, small and large towns, as well as medium and large cities over a decade showing the reproducibility of call volume forecasts by hour of the day.

If we segregate the total call data by weekday, we can capture variations by the hour-of-the-day within each day-of-the-week. The chart of call volumes by day over a twenty-week timeframe, shown below, displays the commonly repeated variation throughout each week. It is the reproducibility of these volumes that allows us to schedule adequate crews to cover these anticipated call volumes.

The next step is to adequately distribute those available resources spatially to address the variation over the geographic area by time which requires an even deeper understanding of the call patterns. The fact that we, as social creatures, often live or work in communities that share similar and predictable risk factors allows us to generalize assumptions of individual activities over larger community groups. Corporations have used targeted demographic profiles to understand local populations for many years. Community profiling has even been recognized by the World Health Organization as an essential skill for all health professionals to help understand the specific and detailed needs of focused populations. (See �Community Profiling. A Valuable Tool for Health Professionals� published in Australia during 2014.) Beyond predictable human variables that focus primarily on medical emergencies are the physical characteristics of our built environment that determine the repeatability of traumatic accidents. A 2009 publication by the Association for the Advancement of Automotive Medicine looked specifically at �Identifying Critical Road Geometry Parameters Affecting Crash Rate and Crash Type� to aide road safety engineers with the challenge of addressing safety issues related to the shape of motorways. The existence of identifiable causes explains the ability to properly forecast the vicinity of calls in addition to their timing.

The following animation demonstrates several spatial demand forecasts in quick succession that are normally separated in the real world by hours. Your existing historical CAD records contain the necessary information to build such dynamic views in real-time.

The demonstrated reliability of demand forecasts, both spatially and temporally, is well known to MARVLIS users and proven to provide the critical information necessary to make decisions in prepositioning resources to reduce the time of emergency responses and limit the distances travelled in emergency mode to enhance the protection of crews and citizens. Furthermore, the Demand Monitor has the capability of grading demand hotspot calculations specific to your service by comparing actual call locations � as they are being recorded � with the forecast probability surface to highlight both the accuracy and precision of our demand forecasts over time that is specific to your agency data and query parameters. The following screenshot shows comparisons of various forecast models.

The percentage of calls that correspond with each shaded area over the selected timeframe quantifies the query accuracy while the hotspot size denotes the relative precision. Accuracy could be increased easily by enlarging the hotspots, but this would be at the cost of precision. A well-balanced query should result in a relatively small-sized hotspot that properly captures a significant portion of actual calls.

Still, knowing when and where to anticipate calls is not enough in itself to determine resource deployment. Some number of outlier calls will likely occur outside of the forecast hotspots, so it is critical to also develop a strategy for managing the risk of covering demand versus geography as weighted factors in any deployment decision. Where we need to be next is well beyond the simple strategies we typically employ now and must fully leverage the depth of our data for deeper understanding and action.

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. 

 

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.

See What Others Can't

Ever since I was a kid, I wanted a superpower of some kind. Little did I know that one day my wish would actually come true. 

For anyone who is a serious user of Geographic Information Systems (GIS), it is not news that this week is the 2019 Esri User Conference. If you are not one of those people, the “UC” is an annual gathering of around 20,000 people who share an interest in applying geospatial technology to solve real-world problems from optimizing business to saving the environment. I was particularly inspired by the theme this year, “See What Others Can’t.”

At its core, GIS is a spatial database for the analysis and visualization of information. When it is used in EMS, it can take a deep dive through your call history and come up with an estimation of the likelihood of the location of calls for service within the next hour. Because it can be an automated process, this forecast can be repeated every few minutes to give you a constantly updated view of the near future regarding where you are most likely to be needed. Some users of MARVLIS Demand Monitor compare it to a weather map that shows the changing conditions in your service area. But knowing where you need to be is only a part of the problem of optimizing the delivery of emergency medical services.

To really be efficient, you also need to know where you are and where you can be within your response time allocation. To answer this question, you need a model of the street network and an understanding of both the daily patterns of travel as well as the unique driving conditions right now. Many counties across the US have dedicated GIS staff to maintain these navigation and addressing models, but commercial vendors can also provide a good base layer of data. TheAddresser is another product from BCS and it can be used to measure or even improve the quality of your geographic data to improve its ability to turn an address into a proper coordinate where a crew can physically respond. The digital road network that is used to calculate a route can be improved by modeling how fast vehicles in your fleet have traveled along each road segment in the past, divided by direction, and lumped into various traffic time periods. The MARVLIS Impedance Monitor automates the mining of your Automated Vehicle Location (AVL) history to generate these unique travel times to understand exactly what area can be covered even as an ambulance is moving. For the immediate hazards along the way, MARVLIS can leverage the events logged by Waze users in real-time to enhance your own road network data through MARVLIS Central. Together, this gives you the best understanding of the reach your crews have at any given moment.

The real trick is in how you choose to post ambulances to meet your specific objectives. If a fast, safe response is most valued, ambulances can be directed to uncovered hot spots which will minimize the distance they must travel to the next call. If cutting response times across the board, or minimizing post moves is preferred, a weighting can be applied in the MARVLIS Deployment Planner to optimize the geographic coverage area. Regardless of how the criteria are balanced, an hourly, prioritized posting plan can be generated based on your service objectives. That plan can then be automated through the live connection in MARVLIS Deployment Monitor that can not only see where ambulances are located by their status, but also directly viewing where calls are currently active from the Computer Aided Dispatch (CAD) software. It can then even make specific recommendations on reassigning units to automatically optimize your coverage criteria.

Together, these intrinsically GIS-based tools can provide an unparalleled insight into the operational world of EMS with timely automated recommendations on how to improve service according to your community’s values. The suite of MARVLIS applications give any EMS manager a view to “see what others can’t.”  To see clarity in the everyday chaos of EMS operations, GIS can give you genuine superpowers. 

-Dale Loberger

 

Body Cameras in EMS

EMS professionals are known for having opinions, but one topic that is sure to bring out their thoughts is the idea of bringing cameras into their world. Whether expressed as a fear of HIPAA violations or a worry of punitive measures against their own actions, the idea of being recorded can cause many to bristle. But our world is changing, and we are being recorded more often than we might appreciate. Sometimes it is the media reporting news, other times it may be the public trying make the news. Still other recordings happen with our own equipment. From the telemetric monitoring of our driving to the recording of audio being synchronized with the acquisition of vital statistics by the monitor at the cardiac arrests we work, we are already being watched. So, what is fundamentally different about video capture?

The concern over HIPAA does not pertain to the collection of data itself, but ultimately how it is used; or even more importantly, how it might inadvertently be made available to those not responsible for the direct care of a patient. On the other count, how managers choose to use any potential recordings will determine whether it becomes a tool for professional development or a weapon directed against paramedics. And we constantly see footage of events being captured by dash cams and body cams including the actions earlier this year when an EMT attacked a restrained patient in the back of her rig. This broadcast event became a reminder for all leaders to discuss not only how we respond to provocations but to consider the value of body-worn cameras to capture the EMS point-of-view during patient encounters. An article by EMS1 editor Greg Friese asked some interesting questions that are still largely unanswered by the community.

The service where I work in North Carolina recently began using a popular fleet management application utilizing GPS to track basic telematics during vehicle operations. Not long after the pilot project began gathering data, an unfortunate incident happened that automatically required law enforcement to investigate. During the probe, the medic operating the ambulance was cleared of any potential violations specifically because of the details that were recorded around the time of the incident. Similarly, a progressive EMS operation in the state of Texas began piloting a program with Axon (a bodycam provider formerly known as Taser.) In this case, the recording was made with a bodycam in the patient compartment of the ambulance during a transport. The male paramedic was later accused by a female patient of inappropriate touching. The video was produced from the Axon system resulting in the charges being dropped and a career likely being saved. While these are only two anecdotes, they show the very positive side of EMS actions being recorded. Another interesting study in progress is by a major EMS provider in Minnesota that has seen a lot of negative press for being pressured by law enforcement to administer sedatives to suspects. The intent here is to document the decisions of their paramedics through the use of body worn cameras. It is significant to note from experience at Axon that more LEO have been saved by being able to reproduce and evaluate actions than have been punished through administration review of bodycam video.

Another way to use video recordings captured during calls for service is as a record of assessments or treatments. Through voice recognition, or artificial intelligence, actions of the crew can be automatically transcribed for the PCR documentation. This could be a significant value as studies have shown up to a 40% increase in the accuracy of reports when the option to review recordings of what had happened are utilized. Depending on how quickly supervisors access the recordings, they can also be used for near real-time review and critique of procedures in the field to eliminate unnecessary skills training or professional assessments. There are many other potential uses that are far less invasive into our daily work. Many agencies routinely videotape training simulations for review with the objective to improve patient care. Some are even looking to turn that idea around by placing the camera on the patient and recording how the clinician interacts with the patient from the perspective of the patient.

A rural Tennessee EMS agency partnered with another body camera manufacturer, Wolfcom, back in 2016 to request donations through their bodycameradonations.com website saying that �it would help our crew members to validate situations we encounter and record and preserve critical video evidence.” The fact is that many times EMS is the first on the scene and often sees important evidence that may be trampled or moved while helping patients and victims. Body cameras can capture that critical video evidence from the moment we arrive on the scene. The county went on to argue that with body cameras, there is video proof of a patient refusing treatment adding that �in cases where patients refuse service and later on develop medical problems or die from their injuries, with body cameras we would have video evidence of them refusing the treatment.�

Consent is a potential legal issue with recording a patient/care-giver interaction, but again my home state of North Carolina is somewhat unique in that only one party in a conversation needs to acknowledge consent for the interaction to be recorded. Consent in other states could be handled differently. For instance, recordings could be limited to the interior of the patient compartment where notification could be posted of the recording in progress.

Preventing the violation of patient privacy is the objective of HIPAA. The federal act itself does not attempt to preclude the collection of patient data although the penalties of any breach of that trust can be severe enough for agencies to self-limit the recording of any non-essential patient data. Walking into a hospital with a camera recording everything observable to the staff could also provide significant challenges in how that video is accessed and may be a legitimate concern to the hospital administration charged with protecting the privacy of its patients in the ED.

It is important to recognize that the recordings made through the Axon system are backed up to the cloud where they can be automatically linked with other cameras that recorded at the same time nearby the scene to add additional perspectives. The web interface that is used in this application is called evidence.com and has been designed specifically to maintain the chain of custody for critical evidence by documenting the details of any access to recorded information. This security is very different than the application of a personal GoPro camera that is used frequently by firefighters, but where the Chief has no recognizable control over the viewing of the video that is captured or how it might be distributed.

How video recordings are ultimately used in EMS will be determined by our reaction to it. That is not to say we will control it, but we will influence how it is applied. If it becomes a tool for us to learn and improve our practice in relation to patients, it will be because we have embraced it. If it becomes something that is used against us as professionals, it will be a result of our attempts to circumscribe the terms under which it is utilized.

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.