I recently had the opportunity to attend the Michigan Community Paramedicine Summit in Mt. Pleasant.  As I’ve written previously, the idea of community paramedics has received increasing traction of late.  More and more states around the country are looking at adopting these types of programs as healthcare costs increase and funding and federal reimbursement falls.  There is no question that EMS can help to play a role in remedying this situation.

The Paramedic Summit was sponsored by the Michigan Association of Ambulance Services.  Presenting were Gary Wingrove, Chris Montera and Anne Robinson.  Attendees were provided background on various community paramedic programs around the country by Wingrove while Montera and Robinson presented the Eagle County, Colorado model and how their program was developed.

After attending the summit, I have a few thoughts.  First, I absolutely feel that EMS has a role in the future of preventative/primary care.  EMS practitioners are well positioned to have resources available 24 hours a day and have been raised around the idea of standing orders and autonomy.  Second, I support the idea of a college-based training program.  There is a healthy debate on the social media forums about whether EMS providers “need” a college degree.  This debate goes hand-in-hand with the notion that we need to move EMS towards an actual career rather than a job stop on the way to a fire or nursing career. Go get education, seriously.

While I like the idea of a standardized educational curriculum, I hesitate at the idea of tying such a curriculum to the term “community paramedic” in a mandatory sense. I maintain that there are many systems around the country in which paramedics are filling the needs of their population outside of standard transport to the emergency room.  To me, those programs accomplish the spirit of a “community paramedic”.  All that said, the IRCP is willing to provide its curriculum free-of-charge and from what they showed us, that curriculum does an excellent job of incorporating experience from public health, social services and EMS into one clearing house.

During the talk, I found myself thinking of ways to implement a version of this program in my own community.  Both Chris and Gary preached about finding a need.  I can think of a few needs my community has, but there have to be others I haven’t even imagined.  Perhaps the first step is reaching outside of my normal EMS-centered circle to find partners in the community.  At any rate, this is an exciting possibility that I look forward to exploring. In the spirit of informing myself and then my readers, over the next several weeks I will be reviewing some of the currently implemented community paramedic programs and brainstorming ways that these models can be incorporated in my largely urban system.

What are the needs in your community? Does your system address those needs? Do you provide any sort of preventative care when you run 911 calls?  What about connecting patients to services outside of medicine? Let me know in the comments.

You arrive on scene to find a sedan that has rolled down a small embankment from the roadway. The vehicle has come to rest on its roof in the middle of an unsuspecting homeowner’s living room. It’s a pretty spectacular scene. The fire department has started stabilizing the vehicle and is beginning to set up for extrication. You check in with the Battalion Chief who indicates that no one in the house was injured. The vehicle was occupied by a driver only and extrication may take up to 20 minutes. Ever the efficient paramedic, your partner already has the back of the ambulance prepped for a patient and you have handed c-spine supplies over to one of the fire crews. Now starts the waiting game.

Fifteen minutes later, the BC waves you over and you meet your backboarded patient, carried by the fire department, with the gurney and move quickly to the back of the ambulance. The patient is altered, smelling strongly of alcohol. He appears to be mostly stable but does have some chest wall tenderness and abdominal bruising. A police officer appears at the back door and asks if she can take a few pictures. You agree, but ask her to wait for questions until the patient is at the ED. The officer snaps her pictures and heads back to interview witnesses. You tell the patient that you need to cut off his clothes to better assess the extent of his injuries. The patient starts yelling loudly and attempts to remove himself from the backboard. You call for your partner and work to restrain the now combative patient. With the patient appropriately restrained, you transport to the hospital.

A week later, as you check out your ambulance for your shift, a coworker comes up and asks when he gets his ice cream. The look on your face must communicate your confusion. “You’re famous now,” he laughs. “Or maybe infamous. Don’t tell me you haven’t seen the You Tube video!” You pull out your phone and search for the name of the video: “Paramedic checks Facebook while patient suffers”.

The video, shot on a cell phone, shows your accident scene with the fire department working to extricate your patient. Periodically, the camera pans back to a familiar looking paramedic leaning on the hood of an ambulance on his smartphone. The captions on the video indicate that you obviously don’t care about the injured patient if you’re taking time to text and check Facebook. The video then cuts to a view of the back of your ambulance as you and your partner work to restrain your combative patient. The caption tells a story, just not your version: “These paramedics were so mad about having to treat this patient that they started assaulting him as soon as the police left the area!”

Shocked, and feeling slightly ill, you head to your supervisor’s office for advice.

Has this ever happened to you? Ever wound up on the legitimate news? What about on YouTube? Do you look for cameras on scene? Do you let it affect your behavior on scene? Let me know in the comments.

Image via Flickr

At my real job the other day, I was offered a chance to participate in a state-wide summit on community paramedicine. Our state ambulance leadership is interested in understanding how other community paramedic programs are operating and whether this model is appropriate for Michigan.

This got us talking around the office about what, exactly, a community paramedicine program is.  Community paramedicine has been in the news lately as state after state (most recently Maine) looks at the usefulness of developing such a program.  Issues with funding and reimbursement as well as educational standards not withstanding, let’s look at what a community paramedic was intended to be.  According to communityparamedic.org:

The Community Healthcare and Emergency Cooperative (CHEC) formed in July 2007 to address critical health care shortages in rural and remote areas—specifically by developing a new community health provider model.

Now this is all well and good, but I work in a largely urban/suburban system.  What if I want a community paramedic program?  A search for the term “urban” on the CHEC site turns up:

Now the International Roundtable on Community Paramedicine site states:

While its focus is on rural and remote medicine, the lessons learned may prove beneficial to the better provision of urban health care.

And I couldn’t agree more.  The goal of a community paramedic program seems to be providing care to fill a gap in a particular community.  While many of the existing and proposed programs are focused on the rural environment, why can’t we do the same in urban systems?  In fact, what if we’re already doing this in an urban system?

When I worked in Alameda County, my manager Mike Taigman developed a program to send EMTs and paramedics into the homes of chronic adult asthma patients to work on educating them in “asthma-proofing” their homes.  The county offered a similar program for children, but nothing for adults.  Find a need and fill it.

Here in Grand Rapids, crews are able to take indigent and intoxicated patients to a sobering center staffed by nurses and EMTs to reduce load on the local emergency rooms.  The hospitals subsidize the cost of the program because it  provides a direct benefit to the community.  Find a need and fill it.

At the end of the day, the term “community paramedic” is more of a buzz word than anything else.  With state legislators becoming involved we are at an increased risk of building a “one size fits none” program by blindly patterning it off of existing programs.  Each community needs to define what they need from their EMS practitioners both for emergency and non-emergency care.  If we rush into implementing community paramedicine before we establish a usefulness and a need, then all we will do is prove that a system which worked in rural Minnesota doesn’t work in metro New York City.  We are so interested in changing what we do now that we haven’t looked carefully at what we ARE doing that takes us outside traditional 911 response.

What about your system?  Do you function outside of the traditional EMS realm already?  Are you considering a community paramedic program?  Who is guiding that process?  Let me know in the comments.

In news first broken by the First Responders Network, five of the agencies which represent EMS as a whole authored a letter, dated April 15th, to President Barack Obama, Vice President Joe Biden, Secretary of Health and Human Services Kathleen Sebelius and Secretary of Homeland Security Janet Napolitano detailing the predicament placed on EMS by recent drug shortages and requesting immediate action.  The letter from the Emergency Medical Services Labor Alliance, the International Association of Fire Chiefs, the International Association of EMS Chiefs, the National EMS Management Association and the National Association of EMS Physicians is available to read over at FRN.

It’s no secret that drug shortages have hit EMS hard.  The letter cites a report by the IMS Institute for Healthcare Informatics which indicates that 63% of drugs affected by the shortage are concentrated in five treatment categories, three of which affect day-to-day healthcare by EMS.  Compounding the problem is the fact that many of these drugs have only one manufacturer.  The letter calls upon the Federal government to take timely action and to treat the drug shortage as a public health and national security crisis.

WHO’S AT FAULT?!?
Obviously this is a difficult time for EMS.  Our drug formularies are admittedly limited meaning that we have little flexibility when drugs are in short supply.  Take midazolam for example.  From my understanding there is only one generic supplier of injectable midazolam.  That supplier decided to stop making the drug.  Now the cynic in me questions if that has something to do with profitability.  It’s no secret that there is far more money brand name drug production than in generics.  So as a for-profit business, why would a drug company make a product that isn’t profitable?

What about the government?  Drug companies cite federal regulations as the cause of drug shortages.  The government has an obvious role to play since the FDA approves drugs being tested and produced. Maybe they should force companies to make the drugs we need.

I think the true blame lies closer to home, however.  The real culprit was conspicuously left out of the letter to the President.  There is plenty of blame to go around but the lion’s share rests on the shoulders of EMS.

WHAT?

Yup, it’s our fault.  For too long we have focused too narrowly on the medications within our scope of practice.  One of the hallmarks of a good EMT or paramedic has always been flexibility in difficult circumstances by that is rarely applied to pharmocology.  I was extremely impressed when my system put lorazepam in the local scope to combat the midazolam shortage.  But why stop there?  Can’t get morphine?  Carry ketamine.  No epinephrine or amiodarone?  Study the effect on cardiac arrest outcomes without it!  The fact that all of these organizations signed this letter means that labor, management and medical direction are all on board to do something about the shortage.  So DO something.

We need to stop feeling sorry for ourselves and asking the federal government to help us out and start by helping ourselves.  Now I realize that this situation is not without risk.  With drug supplies in flux, we need to go back to the basics to make sure that we don’t make medication errors.  That means studying up on indications, contraindications and mechanism of action.  It also means going through the “six rights” of medication administration every time.  It also means calling and asking for input if you aren’t sure.  What it does though is allow us to expand our practice safely and still provide a high level of care to our patients despite shortages that show no sign of letting up.  It lets us do that without waiting for someone else to bail us out.  The flip side is that it places more responsibility on you as a provider.  Will you rise to that occasion?

What about your system?  Have you changed protocols or practices in response to the drug shortages? Is your system using one of the “compound pharmacies” talked about in the letter?  Let me know in the comments.

I wrote the other day about the recently released JAMA article detailing the improved survival of major trauma patients transported by air ambulance versus ground ambulance.  As I stated in that post, I have some concerns about several limitations of the study that I thought warranted their own post.

The authors did a good job of controlling a variety of variables usually associated with these types of studies.  They were able to show that there was a number of patients that needed to be transported to save the life of one patient.  When looking at level I trauma centers that number was 65 and for level II trauma centers, that number was 69.  Using that figure, they calculated that $325,000 would have to be spent on air transport to save one life.  They admit, though, that

…this figure does not account for the number needed to treat to prevent disability or other health-related quality-of-life outcomes. [1]

As experienced medical providers realize, merely surviving a traumatic incident is just the beginning.  Cardiac arrest research has changed focus from ROSC to neurologically intact discharge.  Why would the study authors not take a similar step and determine the number of patients needed to treat to maintain functionality for one patient?

Additionally, and through no fault of their own, the authors were unable to use “total prehospital time” to determine if EMS time had any effect on patient survivability.  Evidently the time data is flawed in the National Trauma Database during the time period studied.  Though the concept of the “Golden Hour” has been shown to be faulty, it is reasonable to assume that trauma patients still benefit from timely care.  As such, prehospital times are a vital part of patient outcomes and are clearly missing from this study.

Finally, the study authors were not able to analyze distance transported and crew configuration of transport aircraft.  These data were not available in the Trauma Database but just as time may be a factor, distance is also important to include before inferring causation.

Crew configuration is extremely different from one system to the next.  This paper cites a study that was unable to link presence of a physician on scene to survival or quality-of-life.  However, this study also states that many of the previous air ambulance studies are flawed so inclusion of crew configuration in a study this large may have produced interesting results.

That last limitation gave me the most pause, however.  The study regarding presence of a physician evidently included a measurement for quality-of-life for air ambulance patients.  The authors of the JAMA study knew that not including quality-of-life was a limitation but did not correct for it even though they cited a study which had calculated it previously. That’s a pretty big miss in my mind.

Though there are limitations, the important thing to take home is that this IS a well-designed study.  No research will ever be flawless and it appears that these authors went to great lengths to get useful, unbiased results.  Readers should be cautioned, however, against merely reading the abstract of this article and accepting it as gospel.  Many EMS and outside news outlets are citing this study as definitive proof of the usefulness of air ambulances.  While this study starts to paint the picture, further research needs to be performed by any such statements can be made.

So what do you think, am I totally off base?  Are the study authors right?  Wrong?  Let me know in the comments.

CITED ARTICLE

[1] Galvagno Jr, SM et. Al. Association Between Helicopter vs Ground Emergency Medical Services and Survival for Adults With Major Trauma. JAMA. 2012;307(15):1602-10.

There are many arguments over methods of patient care in the medical community but few cause people to take sides as easily as helicopter EMS (HEMS).  In a study published in today’s Journal of the American Medical Association, authors looked at over 220,000 trauma cases to determine if HEMS is linked to improved survivability.  For a quick review of the study, check out the article here.  The conclusion from the abstract is as follows:

Among patients with major trauma admitted to level I or level II trauma centers, transport by helicopter compared with ground services was associated with improved survival to hospital discharge after controlling for multiple known confounders. [1]

Well that wraps it up right?  HEMS benefits major trauma patients.  Well that’s not all.  What the conclusion from the abstract does not state is the percent improvement as well as some specifics about the study.

First of all, let me say that this is a well-designed study overall.  The patient population is large and the authors go to great statistical lengths to control for as many variables as possible.  In fact, this is being touted as one of the more unbiased analyses of HEMS utilization and outcomes.  That said; let’s get to the big question:  How much better off is your patient going by helicopter?

The study authors found that the absolute risk reduction for patients transported to level I and level II trauma centers with major trauma by helicopter versus by ground was 1.5% and 1.4% respectively.  Not particularly ground-breaking if you ask me.  The authors additionally calculated that for level I trauma centers, 65 patients would have to be transported by helicopter to save one life.  For level II trauma centers, the number needed to treat was 69 to save one life.

The study authors additionally utilized a figure of $5000 as the cost for an average HEMS transport.  This means that to save one life by transporting to a level I trauma center by helicopter, the cost is approximately $325,000.  Now if this is myself or my wife, that’s money well spent and pretty much everyone would answer the same for themselves.  But that isn’t how we decide if medical care is appropriate, we decide based on the greater good.  Is $325,000 too much?  Is there a difference if that is billed to insurance companies or patients?  If 65 patients need to be transported to save one life that means that 64 patients are being charged an average of $5000 each for an unnecessary flight.  Is this a different conversation if the helicopter in question is run by a government agency and the cost is charged to the taxpayers?  That’s not up to me to decide though I certainly have opinions.

Additionally, I think that this study had some significant limitations, but I’ll save that for a post later this week.

So what do you think?  While there is an improvement in survivability, it would be crazy to say that HEMS is not associated with risks to the public, the flight crews and the patients.  Is a 1.5% improvement in survival worth the risk?  What about the cost?  Let me know in the comments.

CITED ARTICLES

[1] Galvagno Jr, SM et. Al. Association Between Helicopter vs Ground Emergency Medical Services and Survival for Adults With Major Trauma. JAMA. 2012;307(15):1602-10.

I’m a touch late to the party on this one, but here it is anyway. Just some quick background: Over at The EMS Patient Perspective a post was put up asking the question: Now That Doctors Specialize in EMS, Shouldn’t We?  This title refers, of course, to the recognition of EMS as a subspecialty by the American Board of Medical Specialties.  The venerable Skip Kirkwood weighed in on the topic and prompted the Rogue Medic to chime in.  Take a moment to check out those posts and come on back.

Now the comment of Skip’s that was quoted in the Rogue Medic post is as follows:

Before we can get to specialize and sub-specialize, we have to have a PROFESSION to begin with.

So what is a profession? One definition is “a calling requiring specialized knowledge and often long and intensive academic preparation.” That, we are emphatically NOT…We have high-school or at best trade school education. We have no distinct body of knowledge. We resist education and entry standards. We are, as a nationwide body (in the U.S.), someplace between a hobby and a trade or vocation. Profession? I wish, but I don’t think so.

Bold statement right?  But is he really that far off base? How many EMS practitioners are multitaskers? How many aspire to be multitaskers?  How many are looking beyond EMS to the next big thing? A good number right?

For that matter, how rigorous are our education standards?  How many people ACTUALLY fail an EMT or paramedic program.  Honestly, we created a system where you basically write your check and get your license.

What about the opposite approach: How many EMS practitioners are content to work in the prehospital arena for the rest of their careers and not include rescue, fire suppression, law enforcement, haz mat, etc. in their job description.  Now think about how you responded to that.  Did you think “I’d never want to be only an EMT/paramedic!”? That’s the problem.  We’ve never thought of EMS as a place we’d want to spend our whole careers.  Like Skip says, we’ve never seen it as a profession ourselves.  Why should we expect other to see us that way.  As said in the original post, we’re the one’s running calls every day, why is it that the physicians overseeing us are specializing in something we don’t take enough pride in to make it a profession?

So this is your call to arms:  EMS Week is fast approaching.  Just to remind you, EMS Week is sponsored by the American College of Emergency Physicians.  Are we sensing a theme here? We don’t care enough about our jobs to host our own appreciation week.  The theme this year is “EMS: More than a job. A calling”.  I propose something a bit different.  Figure out one thing you can do to make EMS more than a job.  Figure out one thing you can do to make EMS a profession.  Take a continuing education class you aren’t required to. Read an article from an actual peer reviewed journal.  Hold your coworkers to higher standards.  Make you sure actually look and act professional when you come into work.  Be proud of your chosen profession.  Seek out those who are doing good things in EMS and get involved.  But don’t continue to treat your career like your hobby.

What do you plan to do to help make EMS a profession?  Let me know in the comments.

The medical community has a love-hate relationship with the Broselow tape.  If you ask five providers, regardless of level of training, how accurate the device is, you are bound to get six answers.  The most recent report of the accuracy (or not) of the Broselow tape in estimating the weight of pediatric patients was e-published this month in the journal Prehospital Emergency Care.  Check out the abstract below:

Prehosp Emerg Care. 2012 Mar 23. [Epub ahead of print]

Accuracy of Paramedic Broselow Tape Use in the Prehospital Setting.

Heyming T, Bosson N, Kurobe A, Kaji AH, Gausche-Hill M.

Source

From the Department of Emergency Medicine, Harbor-UCLA Medical Center (TH, NB, AHK, MG-H) , Torrance , California ; St. Joseph’s Medical Center (TH) , Orange , California ; Los Angeles Biomedical Research Institute at Harbor-UCLA (TH, NB, AK, AHK) , Torrance , California ; Department of Medicine, David Geffen School of Medicine at UCLA (NB, AHK) , Los Angeles , California ; and University of California Irvine (AK) , Irvine , California .

Background: The Broselow tape is widely used to rapidly estimate weight and facilitate proper medication dosing in pediatric patients.

Objective: We aimed to determine the accuracy of prehospital use of the Broselow tape.

Methods: We prospectively enrolled a consecutive sample of pediatric patients transported to the emergency department (ED) at Harbor-UCLA Medical Center from February 2008 to January 2009. Eligible subjects arrived via ambulance and were less than 145 cm tall, the upper limit of height for Broselow measurements. Subjects were excluded if they had a medical condition preventing proper measurement (e.g., contractures). Per Los Angeles County protocol, paramedics obtained a Broselow weight on all pediatric patients. The paramedic Broselow weight was compared with the ED Broselow weight and the ED scale weight, which was obtained unless mobilization was contraindicated. Accuracy was determined by assessing Bland-Altman plots and the Pearson correlation coefficient. As part of a sensitivity analysis, multiple imputation was used to account for missing data.

Results: There were 572 subjects enrolled. The median age was 24 months (interquartile range [IQR] 10 to 49 months); 316 (55%) of the subjects were male. The weighted Cohen’s kappa assessing agreement between the paramedic and ED Broselow colors was 0.74 (95% confidence interval [CI] 0.68 to 0.79). The median difference between the paramedic Broselow weight and the scale weight was -0.10 kg (IQR -1.7 to 0.7). The accuracy of the paramedic Broselow weight when compared with the ED scale weight and the ED Broselow weight as defined by Pearson’s correlation coefficient was 0.92 (95% CI 0.90 to 0.93) and 0.97 (95% CI 0.97 to 0.98), respectively. Multiple imputation for missing data did not alter the results.

Conclusion: Paramedic Broselow weight correlates well with scale weight and ED Broselow weight. Paramedics can use the Broselow tape to accurately determine weight for pediatric patients in the prehospital setting.

This appears to be a fairly well designed study.  Comparing paramedic Broselow weights to those obtained both from the hospital scale and the hospital Broselow allows both the technique used by the prehospital providers as well as the accuracy of the tape itself to be analyzed.

Do you routinely use the Broselow in your practice?  Do you have a different technique for estimating the weight of pediatric patients? Any tips or tricks?  Let me know in the comments.

Image via Flickr

Like it or not, we have a stressful job. Some days are worse than others, some calls trigger us in different ways, depending on our perspective. I, for instance, approach pediatric calls very differently since becoming a father.

Think back to when you were in EMT or paramedic school. Chances are are someone spoke to you about the stresses associated with the job we’ve chosen. Chances are you, like me, figured that you could handle it and it wouldn’t affect you. Let me just say that I was wrong and you probably were too. Most of us will experience a period of increased stress at work. It’s a given. The trick is learning how to recognize it and deal with it constructively.

I was contacted the other day by David Whitley a paramedic and the EMS Coordinator for the York Region Critical Incident Stress Management Team in Ontario. David has created a series of videos posted to YouTube with the goal of providing resources for EMS providers to recognize stress before it becomes overwhelming. David hopes to use the power of social media to spread his message and advocate for better education and support for EMS providers. David’s YouTube channel can be found here.

David has three videos up so far with more to come. Take a few moments and watch them here then head over and follow his channel on YouTube. If you find anything in these videos helpful, share them with your friends and coworkers. If you’ve been feeling stressed and overwhelmed at work or at home, don’t hesitate to ask for help, there are a huge number of resources available. If you feel comfortable sharing any of your experiences with the others in the EMS community, I would invite you to do so in the comments.  Thanks.

Image via Flickr

In an unsurprising move, the Los Angeles mayor, Antonio Villaraigosa, announced that he was ordering six more ambulances as one of several steps meant to improve the level of service provided by the Los Angeles Fire Department.  As you may remember, LAFD ran into a few hiccups recently regarding exaggerating response time performance.  This is certainly a good move to make politically but will it ultimately matter?

The response time issue resulted from statisticians using a six minute response time requirement rather than the five minute response time actually required for first response units.  This had nothing to do with transport response or performance.

There is little, if any, evidence supporting the notion that response time affects patient outcomes.  There is also little evidence supporting the idea that more paramedics equate to better patient care.  Finally, the issue at hand has nothing to do with transport unit availability.  Sounds like three strikes against Villaraigosa.  What do you think?  Let me know in the comments.