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

 

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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. 

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Christmas Responders

A special Christmas poem for first responders…

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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.

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"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

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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.

 

 

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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.  

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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.

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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.

 

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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.

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