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.

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.

Better Lifting for Better Care

Anyone who has been to a national EMS conference in the last few years has probably seen Rick Binder in the exhibit hall. If that name is not familiar, you may be more likely to remember his life-size teddy bear wearing a vinyl vest surrounded with brightly colored handles. While we are friends now, I have absolutely no financial interest to disclaim. In fact, I had initially avoided both him and the product that his dad had developed whenever I saw the booth at trade shows. Personally, I just didn�t see the need for it since I was a master with a hospital sheet and had acquired a wide repertoire in the many ways to use it. But there are times that peer pressure can be a good thing. Other teammates from my service had visited with him at EMS Today and appeared to be impressed. Curiosity got the better of me and I wanted to learn what I might have overlooked, so I took Rick up on his free offer to field test the device. It was because of my own experience with the Binder Lift that I was finally sold.

I have learned that there are many lifting situations where this device will be an incredible asset to me as well as my patients. The slogan, �because people don�t come with handles� initially led me to think that the use of the Binder Lift was directed primarily at the bariatric patient who requires only a simple lift assist to return them to an upright condition where they can sign my refusal form. While it is certainly useful in such cases, it is definitely not limited only to that situation.

In my first example of these many unique cases, the patient was over six-foot-tall and had been discovered unconscious, but breathing, on his front porch by a third-party caller. I had been to that address before and knew he had a history of stroke that had previously left him unable to drive. We had three responders available and knew we needed to get him to the hospital quickly. After a rapid initial assessment, the patient was rolled to his side so we could apply the Binder Lift. Once secured, one person grabbed his feet while my partner and I were able to grab different handles to balance our height difference and eased his lanky frame down the steps to our stretcher. This movement was much easier on our backs and proved safer for the patient compared to our other options that day.

The simplicity with which we were able to transport this patient made me think back to a previous visit here. I only wish I had had this device when this same patient had been helping his elderly father get to the bathroom toilet. I can only imagine the mishap that led to his naked father falling on top of him – pinning him to the bath tub wall. Then, whether it was due to the fall or just the wait for us to arrive, his dad had defecated quite a lot. The waste had eventually made its way over both of the men. Finding a firm handhold on the slippery gentleman was a challenge made even more difficult by his son being entrapped beneath him. The vinyl construction of the Binder Lift would have made the extrication job much easier to accomplish and also simpler to clean up afterwards. It may have even prevented the need to change my uniform that evening.

In another memorable example, it was about 2AM when the tones dropped for a fall with injury. The husband of a 62-year-old female found his wife on the ground in front of their porch. She had stumbled and fallen forward about a two-foot drop. Unfortunately, she had braced herself for the landing with a stiff arm before reaching the ground. Her primary complaint was pain in the right shoulder which, although closed, did exhibit deformation (a probable dislocation. She denied any other pain along her spine, but as a precaution against a distracting injury, we placed her in a cervical collar per protocol.) Getting the patient to a seated position was accomplished only with significant coaxing and some obvious pain. There was no option of lifting her from beneath her arms and her loose pajamas gave little hope of bearing the weight of her hips to lift her. So after placing her right arm in a sling, we were able to place the Binder Lift around her torso and helped her move her legs into a crouched position without any further aggravation. The patient was then easily lifted upright and the stretcher maneuvered behind her allowing her to simply sit down. The Binder Lift was also helpful in orienting her on the cot. Finally, the slick vinyl material of the vest and straps was easily removed to leave her comfortably in a high Fowler’s position on the stretcher.

In short, the Binder Lift allows for better body mechanics when lifting that not only help to raise the patient safely but can be effective in extending the careers of medics that might otherwise be forced into premature retirement due to back injury. If you don�t try a Binder Lift for your patients, at least do it for yourself. I still carry an extra hospital sheet for many situations, but it always lays right on top of my Binder Lift.

Learn more at http://binderlift.com.

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

 

tl;dr but commenting anyway

I’ll try to be brief. As an EMS blogger, I have always believed in the potential that social media possesses to change the dynamics of how we interact and grow professionally. The promise of the democratization of information and the timely access to news and research on-demand should only be making us better at our prehospital jobs. It is my experience, though, that we have simply become more efficient at sharing opinions than we are at actually communicating useful information. Worse yet, many individuals continue to abuse social media resulting in a stifling of their own professional development. Dave Statter terms this phenomenon as “Social Media Assisted Career Suicide Syndrome” (with plenty of examples.) But probably most disturbing is that we, as healthcare professionals, are hardly any more progressive in our knowledge or use of social media than the general public.

As author Stephen Covey has aptly pointed out, “the biggest communication problem is we do not listen to understand. We listen to reply.� Like the responder who keys the microphone before thinking through the data that needs to be transmitted, many of us share a stream of thought from our beliefs in place of observing facts that may serve to lift the conversation. What becomes all too apparent in the rush to comment is the lack of depth in our training instead of the width of our understanding. It amazes me how many readers of an article will post comments based on the title of the piece without reading the text itself. The acronym “tl;dr” sums up the very problem at its heart because the person writing the comment is admitting the post was “too long; didn’t read.” 

To prove that this is not simply an opinion letter, I’ll submit a Pew Research Center study from earlier this year that demonstrates how differently various age groups receive their news. Hardly anyone younger than a Baby Boomer will dirty their fingers by thumbing through an actual newspaper any longer as social media finally edges out this traditional printed news in popularity. Even digital newspaper websites are declining in readership while television manages to retain its lead as the most popular medium (also propped up in large part by older generations.)  It is apparent that, independent of its source, more Americans prefer watching stories to actually reading the news. In fact, the most interesting insight from the survey is that the top two platforms for news among the college-aged crowd is Facebook and Snapchat.

My greatest fear has now become the “democratization of information” because of how much of the internet is fake. Not just “fake news,” but fake businesses, fake metrics, and even fake people. Artist Donny Miller, known as much for his typographic-based prints as his politically astute comments, noted that �We don’t communicate anymore. We just talk.� He is also the one who popularized the quote: �In the age of information, ignorance is a choice.� However, the internet has become much less than we thought it could be. And even using it becomes more of a challenge to mine information than simply find information.

As a sign of the decline of printed news in the prehospital arena, PennWell Corporation discontinued printing the Journal of EMS earlier this year and has opted for a digital approach to disseminating news. Whether JEMS, or its competitors at EMS1 and EMSWorld, can navigate the new reality of news is still to be seen. But it is clear that “readers” are demanding more interactive content that includes engaging visual infographics and flashy videos. One of the bright spots on the web to me as a professional has been the appearance of FOAM (the Free, Open Access Medical educational resources.) But this collective has many challenges as well. Some of the ethical issues that need to be analyzed and resolved are outlined in this article which also posted this handy summary graphic.

 

A few years ago, someone posted a question to a Reddit forum pondering, “If someone arrived from 50 years in the past, what thing would you have the hardest time explaining?” George Takei shared the reply of a very astute observer of society who answered, “I possess a device, in my pocket, that is capable of accessing the entirety of information known to man. I use it to look at pictures of cats and get in arguments with strangers.”

Although I am not fan of New Year’s resolutions, my personal plan for this coming year is to continue to educate myself (going beyond the bare minimums of ConEd classes) by actually reading more research and commenting my opinions on the news less often. We will have to see what happens to this blog as well as my Facebook and Twitter pages as a result. Happy New Year. 

Christmas Responders

A special Christmas poem for first responders…

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.

"So God made an EMT"

Editors Note: To celebrate EMS Week last week, my good friend Eric Garton wrote a poem in the style of Paul Harvey and recorded his narration. It has touched many people so I asked him to share the words here along with a link to the YouTube version. Feel free to share them further, but please give the credit to Eric for his hard work and creativity.

 

“So God Made an EMT”

by Eric Garton   (c) 2018, All rights reserved.

 

And on the ninth day, God looked down on the world he worked hard to create and said,

�I have doctors and nurses in hospitals and clinics. Now I need a caregiver in the field.�

So God made an EMT.

 

God said, �It must be someone who gets up early in the morning, checks their truck off, scarfs

down breakfast, run a cardiac arrest, run two hospital transfers, skips lunch, finish paperwork,

run another transfer, command a horrible car wreck, restock, clean truck, run three sick calls

and hopes for at least four hours sleep before the end of their shift.�

So God made an EMT.

 

God said, �It must be someone who can work continuous CPR on an infant knowing they have

died, and while holding back tears console the family and tell responders on scene, �Good

teamwork everyone. Maybe next time.� �

So God made an EMT.

 

God said, �It must be someone who can manage a patient�s airway while upside down in a

wrecked vehicle. Someone who can calm a ten year old girl and her parents, while splinting her

fractured arm. It must be someone who can aggressively recognize and treat medical

emergencies, yet has the compassion to hold an elderly lady�s hand who fell at nursing home

telling her, �I am here for you. Everything will be OK.� �

So God made an EMT.

 

God said, �It must be someone who is selfless. Someone who will respond to an emergency

without a second thought. Someone who can handle the blood, the guts, the vomit, the broken

bones and give one hundred percent to all their patients. It must be someone who believes in

teamwork and respects all services involved. It must be someone who performs acts of

heroism, yet never calls themself a hero. It must be someone who praises victory, yet not

ashamed to admit defeat. It must be someone who can look the Grim Reaper right in the eye

and say, �Not this time.� �

So God made an EMT.

 

God said, �It must be someone who is loyal to their community. Someone who will put their life

on the line with the hope of saving a complete stranger. Someone who cares more about the

lives they save than the money they make in a year. Someone who will educate themselves,

and willing to share their knowledge with others. Someone who will remain professional and

caring, no matter how minor or major the emergency may be. Someone who can bring their

coworkers together as a family and see them as fellow brothers and sisters.�

 

�Someone who will reply with a smile on their face and a tear in their eye when their child says

they want to spend their life �doing what you do.� �

So God made an EMT.

 

From Eric: I want to thank all for the support and kindness from everyone who has listened and shared my poem. Many of you have requested a written version of it for yourselves or to share. I hope all of you enjoy reading this to others as much as I have enjoyed reading it to you. Thank you for all that you do.

Download a PDF version here: SoGodMadeanEMT