Back in September of 2010 when this blog was still in its infant stages and living on Blogspot, I wrote a post about STAR CARE, which I described as the “magnetic north of your moral compass.”  In light of the recent events in Washington, DC (say it with me folks: WHICH ONE?!) I want to take a look at the decision made by Lieutenant Kellene Davis that led to her granted retirement and dodging of department discipline. For those of you who have spent the last couple of months living under a rock, or just recently have been introduced to the wonderful world of the internet, Lieutenant Davis was the officer in charge of Truck 15.  To summarize, and keep the story short, she failed to act when 77 year old Cecil Mills had collapsed across the street from her fire station.  He eventually died.  While we cannot be sure that a response by Truck 15 would have saved the man, what we can be sure of there was no action taken. Now, Dave Konig was quick to point out to me that STAR CARE is an EMS tool and not a fire department tool, but DCFEMS is an EMS provider, so STAR CARE can and should apply to them as well.  As the commanding officer on Truck 15 that day, the responsibility ultimately rests on her shoulders, or at least that is what DCFEMS wants us to believe, so looking at her actions seems to me like the appropriate thing to do.  Let’s take a look at this and see how Lieutenant Davis did. S: SAFETY This was an unknown medical, so looking at it from the most positive side of things, she did not send her crew into danger or allow them to cross a busy street. T: TEAM BASED By preventing her crew from acting, she did not allow them to serve the purpose that the crew was deployed to do which is protect the people and property of Washington, DC. A: ATTENTATIVE TO HUMAN NEEDS I doubt that Lieutenant Davis would want a medical emergency experienced by herself or a member of her family with the same disregard that she...

Through my career I have worked in a couple of different style of EMS systems.  I started out in a volunteer system that commonly saw anywhere between 2 and 4 people riding on an ambulance, cramming themselves in back with a medic and a patient for transport to the hospital.  Despite how big our ambulances were (and granted, they were smaller than many of the ones on the street today) things still felt cramped.  I must admit that from my BLS stand point things seemed to run smoothly.  It was all that I knew.  Everyone had their role.  Things seemed to go well, however, now, twenty years later I can certainly see where things could have been frustrating for an ALS provider. Fast forward a few years to my tenure in Springfield.  There was no predicting who I would be in an ambulance with, and more importantly, how much help I would get if I asked for it and it was actually granted to me.  Sometimes I worked with another medic, sometimes an intermediate, and sometimes an EMT.  I did not mind the work load that was generated by not working double medic because such a high volume of our runs were BLS runs anyway.  Admittedly though, there were certainly some frustrating times in the early years of my career as I felt like I could never get enough done.  I was and am my own worst critic.  When things don’t go how intend them to, I beat myself up.  That seemed even easier when I was the only medic there. On most cardiac arrests, we had a fire engine or ladder company with us ready to do compressions, but they were not always the easiest to give feedback to if compressions weren’t being done well enough, or there was something that needed to change.  Don’t get me wrong, many of them were fantastic but it was certainly a barrier we encountered.  Finally, the question of “how many EMTs do you need to run a code?” was a common question that was asked.  A lack of recognition for the evolution of medicine was something that constantly held us back.  My opinion was always that...

With the general public clamoring for help, the debate over Narcan and who should have it rages on.  Recently, I read a post by EMS and fire author and blogger Captain Michael Morse from Rescuing Providence.  Michael relates some of his own personal experiences as well as those as a paramedic firefighter with the Providence, Rhode Island Fire Department to shape his opinion that making Narcan available to the public will allow drug users to “push their high to the limit and then return from the brink of death trough the judicious use of the miracle drug that they can now get as easily as they can their drug of choice.” While I respect Captain Morse and his willingness to share his personal experiences with the community at large, I think he is missing the mark here. There comes a time in medicine when we have to weigh the risks of the care and medications that we provide against its benefits and that is exactly what we need to do with Narcan.  I am sure that somewhere in the United States the scenario that Captain Morse has shared with us could happen.  Heck, I’m sure it probably has already happened, but we just don’t know about it, but making this argument is as absurd as saying that someone who is allergic to shell-fish would want to try lobster just once, Epi Pen in hand, ready to bring them back from the “brink of death.”  While I am sure that it has happened, it is the exception to the rule. “What if the drug is given too fast and the patient vomits?” “What if the patient is actually speed balling and comes up violent?” There could be a million and one “what ifs” that we throw out there, much like we could for C-Spining patients, or putting a patient on CPAP.  The medical world is full of “what ifs” which is why every drug commercial on TV is followed by a long list of side effects that I am pretty sure include spontaneous combustion. Rogue Medic will tell you that the problem with an opiate overdose is not Narcan deficiency, and that effective ventilation can...

Friday the Washington Post published an opinion article by Toby Halliday.  Mr. Halliday is apparently the son in law of David Rosenbaum, the New York Times reporter who many feel died because of the inactions of the Washington DC Department of Fire and EMS.  Rosenbaum’s death in 2006 prompted the formation of a committee in 2007 that shaped DC’s EMS system today.    Mr. Halliday was part of that committee. The restructuring that took place in 2007 has been a far cry from an effective solution of the problems that plague DCFEMS.  Some of them were not even addressed, for example, mismanaged ambulances that caught on fire, ran out of gas, or were out of service when they were needed.  While the 2007 study addressed some operational issues it completely ignored many cultural issues the likes of which resulted not only in the death of David Rosenbaum, but also Medric Cecil Mills Jr who died on a DC street while firefighters from Engine Company 26 refused to go across the street and see what was going on. It seems like the article posted by Mr. Halliday is one that is attempting to address and defend the findings and still unfollowed recommendations of the committee that was convened seven years ago in the face of criticism that DC should adopt an EMS system similar to that of Boston, which, arguably is the most effective metropolitan EMS service in the country.  While different systems might be more effective at different levels, I think Washington, DC is a strong testament to the needs of large municipalities when it comes to prehospital medicine.  In Friday’s article, Mr. Halliday shares the “key task force recommendations” from the 2007 committee. 1.  Elevate and strengthen the EMS Mission – While Halliday cite leadership failures and a lack of patient-care experts in leadership positions, if they are searching for an effective mission statement they should look no further than the EMS based EMS system in Boston.  Boston EMS’ mission statement reads as follows, “Boston EMS, the provider of emergency medical service for the City of Boston, is committed to compassionately delivering excellent pre-hospital care and to protecting the safety and health of the...

This post can also be found at TheEMSLeader.com With EMS Today right around the corner, I got thinking the other day about the past conferences that I have been to.  This year’s gathering in Washington, DC marks my ninth consecutive major conference that I have attended.  I’ve been to Baltimore three times, this will be my second appearance in DC, Las Vegas twice, New Orleans, and the first conference that I attended back in 2010 in Dallas. That year in Dallas, Had quite the opportunity drop in my lap.  One morning, I had the chance to sit down and interview a person who I very quickly came to admire because of his involvement in the National EMS Management Association, Skip Kirkwood, who at the time was the chief of Wake County EMS.  Even before I had a chance to meet Skip the words “Well, in Wake County. . . ” were a constantly used phrase in my vocabulary.  I admired the changes and strides that they had made in their quest to provide the best possible patient care for the residents of Wake County. More than that though, I admired Skip’s approaches to problem solving.  For years to follow, presentations that I have given have involved little pearls of wisdom that I have obtained at the hands (and fingers) of skip over the years from e-mails and posts that I have received from him, so while I had a long standing admiration for Skip, having the chance to sit down with him as a captive audience and pick his brain was quite the opportunity for me. One thing that stood out to me was how he approached change and progression in Wake County.  As I read about his service it was clear that things always seemed to progress quickly there.  Skip’s answer to me was that he always promotes an environment that is comfortable and welcoming to change.  He wanted his people to be ready to walk in one day and find a new piece of equipment, or a new policy change.  By doing this, when major changes were rolled out his staff was more welcoming and willing to adapt. I cannot tell you how...

By now, the New York Times article from last week has made its rounds in the EMS online community.  If you have not read it, I will give you the short version.  Based on the response to the Boston Marathon as well as some other high priority incidents, Federal Emergency Management Agency released new guidelines this past September in regards to the response of first responders to active shooter incidents.  The new recommendations revolve around what FEMA’s fire administrator Ernest Mitchell Jr refers to as “risk a little to save a little, risk a lot to save a lot.”  According to FEMA, risking a lot means sending EMS responders into the “warm zone” of an incident to treat and extricate patients. Most of the article revolves around one particular paragraph of the seventeen page document: b. While the community-accepted practice has been staging assets at a safe distance (usually out of line-of-sight) until a perimeter is established and all threats are neutralized, considerations should be made for more aggressive EMS operations in areas of higher but mitigated risk to ensure casualties can be rapidly retrieved, triaged, treated and evacuated. Rapid triage and treatment are critical to survival. Rush in, keep your heads down, and get out safe.  They have not completely ignored our safety, however, adding a few lines later: d. If exposed to gunfire, explosions or threats, withdraw to a safe area. e. Consider/Investigate the use of apparatus’ solid parts such as motor, pump, water tank and wheels as cover in the hot zone. Understand the difference between cover (protection from direct fire) and concealment (protection from observation). f. Remove victims from the danger zone in a manner consistent with predetermined agency training and standards of practice. LE officers may bypass casualties in order to eliminate the threat. Recommendation “f” leaves me with some hope that there eventually will be more mandated training and education for EMS providers, but the document seems to largely ignore any mandation of this.  There are, however, recommendations made in regards to what FEMA feels should be addressed when planning, and developing standard operating procedures.  For example, much of the treatment modalities recommended revolve around tactical emergency casualty...

In the wake of the controversy with the Mayor of Toronto, Canada allegedly using crack-cocaine, I revisited a post from a few months back regarding the struggles of Toronto EMS, and the attempted takeover by the Toronto Fire Department, and it got me thinking about priorities.  When it comes to delivering high quality pre-hospital care, we really need to take a closer look at what drives us to choose the systems and models for our community. EMS is a diverse field, much more so than our brothers and sisters in the other branches of public safety.  Largely, it is an a la carte industry.  Choices about response structure, desired time, equipment, and protocols based on what decision makers feel is best for their community.  Fire based.  Third service.  Private.  With first response.  Without.  Two trucks.  Twenty trucks.  One paramedic and one EMT versus two paramedics.  There are countless choices and configurations one could come up with, and countless community models to serve.  All in all though, it all comes down to Frank Stroud’s old saying of “ambulance services can be fast, cheap, or efficient.  Choose two out of the three.” Once a decision is made about a system’s design, the community has to stick with it, at least for a little while, to see what is good and what is bad about it, and then decide what changes need to be made.  Far too often changes are made based on snap judgments driven by one or two particular calls that usually require a high amount of attention.  Instead, when making a change to their system design, especially when looking at who provides the care, the first question that should be asked should be “how will this improve patient care?” I used to work a part time job in a small town outside of Springfield, Massachusetts for what was then the only third service municipal agency in the area.  It was really a terrific system with experienced providers who did a great job.  It had its share of short comings, but no system is the perfect system.  When time came for the reevaluation of the town’s delivery method, there was a strong push to shift...

Recently I read a story from Alameda County, California describing the issues that they are having there particularly with responses to stabbings and shootings.  According to the article, the dispatch center in ALCO has abandoned their previous “send anyone to anything as soon as it comes in” system for a more nationally accepted system utilizing Priority Medical Dispatch. Priority Medical Dispatch, or PMD, is supposed to prioritize calls and tailor responses to those calls by classifying them utilizing a limited amount of medical information.  Calls are classified from the lower “ALPHA” level response to the most serious calls classified as “ECHO” level calls.  ECHO runs are mostly reserved for cardiac and respiratory arrests.  The purpose of the system is to get the most serious calls taken care of first.  It is a means of phone triaging.  Using a series of questions, call takers do their own little “choose your own adventure” flow chart and end up with a call’s classification. The claim made by paramedics and EMTs in ALCO states that on occasions since the change over from AMR to Paramedics Plus, runs that turned out to be fatal or serious shootings and stabbings were classified at the less serious “BRAVO” level.  Field providers are now demanding that prioritization changes be made to give these calls a quicker response.  I, for one, cannot help but feel like they are barking up the wrong tree. I feel like I have seen both the “very good” and the “just okay” of Emergency Medical Dispatch and PMD throughout my career.  I have seen it work well, and I have seen it misused.  Any system that gets used is going to be less than perfect, and utilizing Priority Medical Dispatch is no exception to that rule.  I believe it was Justin Schorr who once described Priority Medical Dispatch’s greatest flaw as the “least informed person (the caller) is talking to the least trained person (the dispatcher)” any anytime we discuss dispatch, or the prioritization of any calls, that needs to be kept in mind. The real issue in Alameda County, as is in most systems that have I seen struggle with the problems they are having, is a...

This past week, Washington DC finally took a step in the right direction by hiring what they call “civilian paramedics.”  While I am not a huge fan of the term they use for their new employees, I cannot help but stand up and applaud their move to hire staff that can be 100% dedicated to addressing the department’s shortages. I have seen a lot of numbers of the past week: 38 paramedics on a shift with only 14 in ambulances.  80% of the department’s 160,000 calls medical in nature.  Trucks out of service.  Running out of gas.  Catching on fire.  Lately, it has been one horror story after another for DCFEMS.  While hiring paramedics seems like a logical move, one city councilman went as far to call it a “step in the backwards” for the department.  City Councilman Phil Mendelson was part of the Rosenbaum Commission which, in response to the assault and death of New York Times reporter David Rosenbaum.  That commission was a driving force in the cross-training of EMS personnel, and the overall integration of the fire and EMS systems in the nation’s capital. The circumstances surrounding Rosenbaum’s death seem more to me to be driven by complacency and burnout than the failure of the EMS system.  The EMTs involved failed to recognize a serious medical emergency and wrote the patient off as being drunk.  Because of this, he did not get the care that he needed.  The only place where the system failed was by not having the EMTs that initially responded to the call properly prepared for what they encountered. Now, almost six years after that committee’s recommendation, it is easy to see that the changes that were aimed at improving the system have failed.  The biggest sign of this is not the response times.  It’s not the number of trucks out of service.  It is the number of overworked and underappreciated paramedics who carried 80% of the department’s volume who have left the department because they have seen the writing on the wall.  The time for change clearly is now. Many have called for the firing of Chief Kenneth Ellerbe.  Some would even argue that due to his...

The other day, I had a chance to read an article about Toronto EMS, and their relationship with the fire department, or more specifically, the fire department’s union.  In a recent study done by a third party, it was recommended that paramedic unit hours be increased, and that a fire station on the city’s west side be closed down.  Ever since then, it seems like in Toronto, the fight has been on, and boy is it an ugly one.  With headlines like the one on a 2010 article reading “We’re in a War with the Fire Department” do nothing but draw unnecessary lines in the sand. Dispatch protocols were reviewed, and fire first response was removed from 50 of those protocols, but added to 22 others.  In the year since the revamping, they have been added back onto less than ten of those they were removed from.  It is the position of the Toronto Paramedic Association that what the citizens of Toronto need is exactly what last year’s study calls for: more paramedics.  Ed Kennedy, president of the Toronto Professional Fire Fighters’ Association disagrees.  He feels that care being provided to the citizens of Toronto suffers without the fire department’s first response, and even says that Toronto should scrap their third service paramedic system in favor of a fire-based EMS service. My question to Mr. Kennedy is a simple one: where is the evidence?  What does he have to hang his hat on that says not only that fire fighters should be added back as first responders but should, in fact, take over the ambulance service?    The study, which provides evidence to the contrary, recommends against consolidation and advocates for the addition of 25 ambulances per day, a jaw dropping number regardless of the current size of the service.  It is time to cut through the B.S. and let the evidence speak for itself. Toronto EMS, however, is not without their problems.  Their response goal of under 9 minutes 90% of the time is not even close to being achieved, and currently sits at an abysmal 65%.  Does that mean that the system needs first response, or does that say that the need for...