Improving Operations in Crisis

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

Notes:

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

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

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

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

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

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

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In Support of Backboards

“Proper Placement of Backboard”

One of my first really successful posts years ago was “A Short Take on Long Boards” where I found myself piling on the negatives regarding our habitual dependence on the Long Spine Board. I do not feel as though I can take any credit, however, for agencies such as the Palm Beach Florida Fire Department or the New York City Regional Medical Advisory Committee who have since chosen to abandon the practice of its use.  Many others have made their displeasure of the practice clear in endless commentaries on the topic. And the photo above on the “Proper Placement of Backboard” garnered many “Likes” on social media. It is the traditional reliance on the backboard, in an attempt to totally immobilize patients, based predominately on the MOI that has lead some to parody the practice in a clever cartoon episode. As a matter of fact, the only evidence I could find to support the use of the spine board as an immobilization device for transport was this randomized clinical trial setting it up against a vacuum mattress splint in a false dichotomy that I could only hope is a mocking satire. In an even deeper insult to our immobilization practice, Dr. Bryan Bledsoe, emergency physician and EMS textbook author, has also gone on to suggest limiting use of the rigid cervical collar as well. Suddenly, the topic of immobilization seems to be much more fluid.

Still, I fear some may have gone too far in calling for the removal of the LBB from ambulances everywhere. In general, we are often all too willing to jump from one bandwagon to another in an “all or nothing” dance to be more “evidence-based” than the next medic. I have heard colleagues suggest that the KED is the rightful heir to the immobilization throne, but in my mind that is like replacing the standard stretcher with a stair chair. In some cases one may be more appropriate than another, but the recognition that a tool has limitations does not mean it should be replaced in every instance. We simply need to become more aware of when to use it, not just remove the tool from the toolbox altogether. I feel we have done the same thing with response times, if they don’t ALWAYS matter, then they NEVER matter (but that is a topic for another post.)

The backboard remains a flexible extrication tool that is widely available and already well understood by first responders. Furthermore, it can be adapted for other uses. Another topic that is hot in EMS right now is High Performance CPR. While the basics of CPR have been around for decades, we are learning better ways to apply it and even understanding more about the science behind the mechanics of how it works. We know, for instance, that the patient must be on a firm platform for effective compressions and the backboard fits that need very well.  More recent research also suggests that tilting the compression platform to a semi-fowlers’ position decreases ICP for better brain perfusion. Instead of introducing a new device, the backboard can be adapted to this use by raising the head about the height of your bag.

It is great when we can improve the efficacy of our work without adding anything to the expense of it! The most difficult change is in our attitude.

We Need Some New Stories

We always hear that EMS is still a relatively new discipline. And in the scheme of medicine, or even public safety, that is certainly true. But we shouldn’t let the fact of its youth keep us from acknowledging that it has already been around long enough to accumulate some of its very own antiquated dogma. If you have any doubt, consider the reaction to changes in protocol – even those with good evidence to support some new practice. Working cardiac arrests on scene, for instance, was not met, at least in my experience, with enthusiasm at the prospect of improving patient outcomes. What I heard were excuses for why something different wouldn’t work. I thought about that exchange this week as I was listening to a recent Medicast podcast on an entirely different topic. Near the end of that recording, Rob Lawrence remarked that we really need to do away with the old stories that start out with “back in my day…”

The stories of some grizzled professionals include not just memories of MAST pants or nitrous oxide, but the idea that tourniquets take limbs, not save lives. More recently stories have been spun about the movement away from the long-held reliance on the long spine board as an immobilization splint during transport or even the value of therapeutic hypothermia for cardiac arrests.

While there is no denying, or even stopping, a rapid state of change in EMS, we must be sure that it is not just change simply for the sake of change or even resistance for the same reason. Change must be meaningful change that is guided by reasoned thought and scientific evidence, not personal anecdote. And new practices should be carefully modified to address current issues or new understandings of the problem.

Another sacred, yet unjustified, belief among too many providers is that the dynamic deployment of resources (commonly referred to as “SSM”, or System Status Management) is an unmitigated failure of cost-consciousness that actually leads to increased expenses and provider dissatisfaction. The evidence, however, from many of the services who now employ some facet of dynamic deployment has proven that while it can be tricky to implement well; the savings in time, money, and lives are definitely real. And those savings need not come at the cost of provider safety or comfort either. Whether you have had bad experiences in the past, or just heard about it from others, it is time to set aside the old stories and take a new look at the current technology and practice in every aspect of EMS that leads to improved performance.

To advance our profession, we must completely ban the expression,  “but that’s how we’ve always done it” and look toward “how we can do it now!”

 

Index of Suspicion Includes Me

It doesn’t take long in an EMT career before the excitement of “rushing to an emergency” turns in to “just another transport call.”  The philosophy of “you call, we haul” in nearly every service can break the community servant’s spirit by turning a skilled paramedic into just an ambulance driver.  But our system “just is what it is,” right?

Well, far from being a service based strictly on tradition, EMS is constantly challenging previous assumptions and struggling to reinvent itself.  How we administer CPR has changed (again), we question the effectiveness of C-spine immobilization that we do standard on nearly every trauma patient, or argue the very validity of the “Golden Hour” around which many services have been designed.  Almost all assumptions are open to be questioned.  I say “almost” because I have found that there still are some boundaries to the willingness of many EMS practitioners to consider change.  Some limitations are easily admitted, like the aversion to legal liability that means we transport anyone who asks us to do so regardless of their suspected need or ability to pay, but there are also less easily acknowledged sacred beliefs.

One of those that comes quickly to my mind is response time.  To many, a quick response indicates excessively fast driving and is contraindicated by safety concerns.  Besides that, we can justify ourselves since very few of our daily calls actually “require” a code response.  While that point may be strictly valid medically, I would argue that our performance is often measured by the public in the agonizing minutes between the 9-1-1 call and the ambulance arriving at the curb.  A patient does not need to be in some form of arrest in order for them, or their family members, to be distressed.  Part of our job is being a calming and supportive influence.  At the same time, I admit that it does not justify putting the driving public or ourselves at risk with an ambulance speeding to every call. But is it really a given that one means the other?

System Status Management – oops, another term laden with strong negative feelings in the field – is actually all about improving performance (both time and economic efficiency) without sacrificing safety.  As advocates for patients, medics see themselves sometimes fighting the system in order to provide the best possible care.  Talk of economic efficiency is seen as just making their job harder.  But again is it really a given that one necessitates the other?

Imagine a system where patient needs are accurately forecast in advance. Where the posting of ambulances is not just another place to sit and wait, but in a practical sense it is the staging for a call that has yet to be received.  Response is thereby improved not by excessive haste, but by the strategic pre-positioning of resources.  The cost savings is not simply an amount  taken from others in a “zero-sum game”, but effectively rescues budgets for proactive wellness programs or, in the current economy, may mean simply saving jobs that allows us in turn to save lives.  This process really works and these systems do exist.  They are called “High Performance EMS” systems and many are profiled here each month while others receive recognition through accreditation agencies like CAAS.  What sets them apart is often observed in technology, but the reality is that it is a culture of seeking constant improvement by the entire staff that makes a difference.

While we consider improvements to the many technical aspects of our profession, let us not neglect the philosophical perspectives that motivate us as individuals.  We operate as a team, not just the pair on the truck, but the whole EMS system is one team with a singular goal.  A goal to do even better each day. So, as we continue to assess our profession should the index of suspicion not include our attitudes toward improving the overall system?