Christmas Responders

A special Christmas poem for first responders…

1 Comment

Filed under Emergency Communications, EMS Topics, Fire Rescue Topics, Opinion, Training & Development

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.

2 Comments

Filed under Administration & Leadership, EMS Health & Safety, Opinion, Technology & Communications, Training & Development, Vehicle Operation & Ambulances

"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

28 Comments

Filed under EMS Health & Safety, EMS Topics, In the Line of Duty, News, Opinion, Training & Development

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.

 

 

Leave a comment

Filed under Administration & Leadership, Conferences, EMS Health & Safety, EMS Topics, Fire Rescue Topics, Funding & Staffing, News, Opinion, Patient Management, Technology & Communications, Training & Development, Vehicle Operation & Ambulances

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.  

9 Comments

Filed under Administration & Leadership, Dispatch & Communications, EMS Dispatch, EMS Health & Safety, EMS Topics, Funding & Staffing, Line of Duty, News, Opinion, Patient Management, Technology & Communications, Training & Development, Vehicle Operation & Ambulances

What Starman is Saying About the Future of EMS

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

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

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

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

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

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

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

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

I used to think there was a simple formula, a best practice that universally applied, but then I took a look for the moon of our profession. Like Neil Armstrong said in July of 1969 when he stood on the surface of his dream and gazed back toward earth and said, “I didn’t feel like a giant. I felt very, very small.” Just a few years later, Alan Shepard had his turn on the lunar surface. His remark was, “when I first looked back at the Earth, standing on the Moon, I cried.” But probably the best statement came during an interview with Apollo 14 astronaut, Edgar Mitchel, when he said “from out there on the Moon, international politics look so petty. You want to grab a politician by the scruff of the neck and drag him a quarter of a million miles out and say, ‘Look at that, you son of a bitch.’”

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

1 Comment

Filed under Administration & Leadership, Command & Leadership, EMS Health & Safety, EMS Topics, News, Opinion, Technology & Communications, Training & Development

More Reasons to Support Dynamic Deployment

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

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

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

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

 

10 Comments

Filed under Administration & Leadership, Dispatch & Communications, EMS Dispatch, EMS Health & Safety, EMS Topics, Firefighter Safety & Health, News, Patient Management, Technology & Communications, Training & Development, Vehicle Operation & Ambulances

Dynamic Risk for Intelligent Fire Move-Ups

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

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

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

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

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

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

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

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

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

Leave a comment

Filed under Administration & Leadership, Command & Leadership, Dispatch & Communications, Fire Dispatch, Firefighting Operations, Funding & Staffing, Technology & Communications, Training & Development, Vehicle Operations & Apparatus

Innovation Review: StethoSafe

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

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

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

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

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

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

 

 

 

 

 

 

1 Comment

Filed under EMS Health & Safety, EMS Topics, News, Opinion, Technology & Communications, Training & Development, Vehicle Operation & Ambulances

Anatomy of an EMS Kit: The Importance of Case Design and Contents

Editor’s note: Beyond our skills and knowledge, some of the most important assets of the EMT are the collection of tools and supplies they carry. But how often do we really consider the container in which we carry these critical items? The following post is from an invited guest author on the subject of EMS bags. Sam Distefano works with Fieldtex Products, Inc., a supplier and manufacturer of quality custom EMS carrying cases, and a Medical Division that stocks them with life-saving supplies. He shares his insight on what to consider when evaluating and acquiring new bags for the working EMS professional.

 

The Anatomy of an EMS Kit: The Importance of Case Design and Contents

The well-trained medic or First Responder has so much more to offer than what is stocked in their kit, but a well-stocked and intuitively organized kit can make any responder more effective. There are innumerable ‘First Responder’, ‘Trauma’, and ‘Professional’ First Aid Kits on the market in all shapes and sizes, boasting selections of supplies and tools that vary from kit to kit. Whether built, bought, or borrowed, you become acclimated to your kit layout and it’s supplies, and can feel confidence in your ability to utilize the kit in an emergency situation. However, the vast and varying selection of cases raises several questions: what features should your carrying case have, and what supplies will be stocked inside?

Design Priorities

The most effective carrying cases for EMS have been designed with input from field providers in the very early stages of development, starting with the Prototype and Design phases. Oftentimes, the greatest innovation stems from these fundamental conversations. Without this input, the kits may be aesthetically well designed, but rendered useless if there is a negative impact on your effectiveness or efficiency due to any design flaw that was overlooked due to lack of field experience.

There are a few key features that should be consistent throughout all EMS Cases. We will discuss their Durability and Material Quality, Convenience of Transport, Ease of EMS recognition, and (most importantly) the Organization of your contents.

Durability and Material Quality: The use of durable textiles for an EMS carrying case should be obvious – you and your kit must be prepared to face some of the harshest elements in the field while safely transporting your supplies to any scene. The use of Cordura (nylon), or other comparable tough woven materials, is the foundation throughout the EMS carrying case industry, and undoubtedly remains the optimal choice for durability. This material is abrasion resistant even after numerous washes (which will be necessary) and continuous uses, providing you with mil-spec durability you can rely on. Other common material alternatives that are frequently used include vinyl and tarpaulin, synthetic non-woven textiles. While not as durable as a woven nylon, these are primarily useful in instances when water and fluid resistance are vital to the design. For example, a case including any sterile items or products that could be water damaged must be kept dry at all costs. Ultimately, there are pros and cons to any textile choices, but Cordura seems to be the most universally utilized – and with good reason.

Closures and other hardware are also a core element of a durable carrying case. YKK zippers are the most durable and reliable choice for zippers. This coil style zipper with plastic teeth prevents rust and corrosion even after extensive use, and every coil size (especially the #10 Heavy Duty) provides a secure and fail-proof closure. While there are other options for zipper brands, YKK is the leading brand in terms of long-lasting performance (there’s a reason you see it on most clothing and bag zippers). Alternatively, opting for durable plastic side-release buckles or high-performance hook-and-loop closures (Velcro being the most widely utilized brand) also provide adequately secure closure, and is simply a matter of personal preference. Some responders will argue these closures grant quicker accessibility than a zipper.

Still, a collection of durable materials and hardware are only the beginning. They must be put together with quality stitching. If you have the opportunity to build your own cases, seek a company with experience in manufacturing for the First Responder community. If you do not have someone that will ensure industrial-strength construction, the most durable fabric won’t matter much when you have missed or broken stitches. Look specifically for “mil-spec” and “industrial sewn” cases which will help reduce the likelihood of failure in the field and will extend the useful life of whatever case you choose. Looking for carrying cases made domestically will also ensure a quality-controlled and durability tested bag that supports American workers.

Convenience of Transport: Getting from your truck to the patient while having everything you need in one trip starts the scene off right. A system that offers more than one transport option (i.e. backpack straps, an adjustable shoulder strap, or handles) assures that your movement won’t be inhibited in any setting whether running through an open space or moving through a crowd. It also allows additional items to be carried separately as needed. Transport options also provide a critical backup in the event that one of the carrying methods may fail on the scene.

Due to the comparative size of some people to the bag they carry, struggling to a patient without being beaten up by your bag can be a genuine challenge. Designing cases with different transport methods also allows you to carry it in a way that won’t inhibit your effective movement or lead to discomfort. Ideally, you should not have to provide different bags based on staff height, strength, or other human variables. While shoulder straps and handles are more common transportation methods for EMS cases, backpack straps allow you to travel without the case bumping against your legs, to distribute the weight evenly across your back, and to keep both of your hands free from the first moment on the scene.

Ease of EMS Recognition: Use of bright colors, reflective straps/stripes or the universal Star of Life logo make it easy for people to quickly recognize you as EMS. Working with a custom case designer and manufacturer that additionally offers ”private label” and ”branding services” also allows you to brand your cases with your county logo, unit icon, or any other recognizable symbol to bystanders on the scene. This is especially important in the event of a motor vehicle accident in a busy intersection or a medical call on a crowded plaza. High visibility not only identifies you and lets people know you’re there to provide professional medical services, but also protects you both indoors and outdoors at any time of day or in situations of low visibility and high risk. Choosing a case that will allow you to easily access and integrate your identification can help expedite access to the scene and effectively reduce response time.

Organization: Last, but certainly not least, is organization of the contents. This is potentially the single most influential aspect of any EMS case in the moment. You never want your supplies to just knock around in the large open space of a duffle bag where they could be damaged. Further, having to dig through dozens of bandages, gauzes, and tapes to find the supply you’re actually looking for leads to delayed action and increased frustration. Buying bags with interior and exterior pockets, or sections, allows the user to organize the case in a way that will increase their efficiency and categorize their supplies in a way that is intuitive. Some bags on the market contain individual “modules” that can be removed. Each component should logically contain products to treat a specific kind of injury or support a unique procedure. Modularization, say for burns or advanced airways, allows these supplies to be quickly accessed and the bags to be easily customized for new situations you may face.

A word of caution on compartmentalization – there is a fine line between organization actually helping and it possibly hindering access. Sectioning products down too much can lead to further stress or added confusion in an emergency situation. Focus on making the case intuitive, not sectioning off products for the sake of sectioning off products. A general rule is that if you have multiple sections containing the same items, you probably have too many compartments. Larger sections should hold bulkier supplies, or supplies that require multiple pieces. While bandages may not be your “go to” on every call, you should always stock several of them in different sizes and compositions – because when you need them, you need them quickly. Storing them in a large compartment near the bag opening ensures easy access on any scene.

If items are placed on top other small equipment, the compartments may be too deep or too few. Another way to store items that need to be accessed quickly could be by attaching them to internal lanyards. One very new idea comes from Stethosafe, a new manufacturer that offers a rigid plastic cover with small lanyard to protect the bell of your stethoscope while also keeping it handy for immediate access.

Another great aspect of teaming up with a contract manufacturer and designing your teams carrying cases from scratch is that you can control the amount and size of compartments based on the inventory that your team regularly stocks. Carrying cases with interior movable/removable dividers (usually fixed with heavy-duty Velcro) also helps with organization and modification of supply compartments as needs change. Your supply stock could be changing as often as the seasons based on accident frequency and type, and your bag should be able to accommodate that. Generally speaking, designing from scratch is more expensive than off the shelf due to prototyping, sampling, and production costs. There could also be production lead times, making it a longer process even after the design is approved. However, designing from scratch is the way to go if you want a bag that is true to the contents your team carries and organization methods.

If you are limited to buying “off the shelf”, seek cases that can accommodate your recurring inventory and have adequate sections. Features like elastic bands to hold smaller items in place can also be an effectual interior design if it is practical and intuitive for the user.

Thoughts on Contents

The old adage that “BLS comes before ALS” points out the nature of the type of incidents that most First Responders face. Basic Life Support Kits are stocked with supplies to treat victims on the scene who have sustained life-threatening injuries. In other instances, these cases can be called upon to treat patients while in transit to the hospital. How your kit will be used will determine what supplies are required. Our stocked BLS Kits are designed to manage traumatic injuries (lacerations, burns, other severe wounds), choking, drowning, and other bodily insults that can be treated non-invasively. BLS training is the most common among EMS and Fire personnel, but is also common in lifeguards, police officers, and even teachers.  Advanced Life Support requires further training and certification as Paramedics who may utilize different medical equipment and procedures. These kits are designed to treat underlying medical conditions more invasively. In the case of cardiac arrest, an IV Kit with syringes, and a sharps shuttle allow medications to be administered safely and disposable supplies to be controlled.

It is likely that your organization has a checklist of required items to be stocked – some lists are even dictated by the state or other accreditation agency. While there is no “universal regulation” of what goes in a particular kit, at a minimum, you should stock sufficient supplies to provide life support in the event of an anticipated type of trauma given your location, training and certification level. The amount of supplies is also determined by the number of calls you expect and the length of time away from your base without being resupplied. That being said, there are some things that can be commonly found in these standardized kits:

Wound Dressings: Burn Dressings, Combine Pads, Gauze Pads and Rolls in Various Sizes (2” and 4” rolls are most common), Trauma Dressings, and (a lot of) Bandages of various sizes.

Wound Treatment/Cleaning: Irrigation Solution (normal saline), Hydrogen Peroxide, Alcohol (usually beneficial in a wipe/prep-pad), Antibiotic Ointment, Povidone Iodine solution/wipes, Instant Ice Packs, Pain Management Medication (Ibuprofen, Acetaminophen, Naproxen, and in the event of serious injury, Morphine, etc.). Be aware that while some of these items may be useful, there application may have legal implications. As always, please consult with your local protocols about administration restrictions. “Good Samaritans” who supply themselves and act according to general knowledge in good faith for the best interest of the patient may be held to different standards than certified individuals.

Tape: Transparent, Paper, or Cloth tape

Splints/Collars: Stock Various Size Splints and Cervical Collars (at least 1 child size and 1 adult size)

Personal Protection: Safety Glasses, N95 Face Masks, several pairs of medical gloves, emesis or Biohazard Waste Bags

Tools and Equipment: Utility Shears, BP Cuff, Stethoscope, Flashlight, Nasal Cannulas, Non-rebreather masks, pulse oximeters, Tactical Tourniquet, Thermometer

Drugs: Oral glucose (for diabetics), naloxone (for opioid overdoses), epinephrine auto-injectors (for anaphylactic reactions), or activated charcoal (for accidental poisonings) may also be added based on need and training.

At some point, it’s more likely than not that you will be on the scene of an accident and think “I could really use an (insert medical product here) right now!” Your personal experiences responding to calls in your region will aid in determining recurrent emergencies, therefore helping you stock enough of a frequently used product so you won’t run out prior to resupply. The ability to enhance a common kit with additional supplies gives you the opportunity to further improve your ability to provide emergency First Aid in a crisis situation.

While case design and contents are simply tools, there is no substitution for a well-trained medic. A First Responder or EMT Carrying Case should be designed to help provide the most efficient and effective care, and all play an important role in the layout and organization of supplies on hand.

To learn more about Custom Design and Manufacturing Capabilities, visit FieldtexCases.com.

To learn more about how we can help you Restock and Refill your EMS Kit, visit e-firstaidsupplies.com.

2 Comments

Filed under Administration & Leadership, EMS Topics, Technology & Communications, Training & Development, Vehicle Operation & Ambulances