Mar 5, 2015

Read Justin Schorr’s post by following this link! Everybody loves a good internet debate, right?  This afternoon I engaged in one of those with my good friend and Chronicles of EMS star Justin Schorr about response times and their impact on EMS.  Sparking the debate was an article that Justin shared that discusses the impact of response time compliance on a large city in the United States covered by a fire based EMS system backed up by two private services. In his post, Justin disclosed that he is a firefighter/paramedic and a “card carrying member” of the IAFF.  Staying in the same mentality, I need to disclose that I worked for a private EMS service for 12 years that held a busy urban 9-1-1 contract.  I now work for a municipal ALS only third service that intercepts a number of BLS level fire departments.  Also, as some might have heard, I am associated with the EMS Compass performance measures initiative.  The views in this post are my own and in no way reflect those of anyone associated with the project. The debate that Justin and I had revolved around two topics: the importance of response times, and the importance and relevance of ALS first response.  I am going to break down those two topics separately. Do response times matter? In most EMS systems, response times are king especially when it comes to those serviced by the private sector.  “Just get there, and we have nothing to worry about.”  All that matters is an ambulance shows up, and is most cases stakeholders want somebody on that ambulance to have a paramedic patch on their sleeve.  What happens from there does not really matter unless somebody complains. It is funny that this topic comes up now, because currently sitting on the desktop of my computer is an almost completed blog post about anecdote vs evidence.  The concept that response times matter to patient outcomes is one of the most anecdotal statements that has ever been made.  There are three different arguments that I feel support this. First think about the path that the majority of our patients take when they arrive at an emergency room.  Think about...

Dec 21, 2014

Saturday’s cold-blooded murder of two New York City police officers has rocked the public safety world.  The best emotion that I can come up with for myself right now is I am angry.  Extremely angry.  If you connect with me on any form of social media you have probably already seen some of my thoughts about it either reposted in the words of some of those who I follow, or in my own original thoughts.  I feel like many, many people have failed the NYPD.  The media has failed them, the mayor of New York City has failed them, and society in general has failed them.  They have not gotten nearly the support that they deserve for the incredibly difficult job that they do, and that is what i want to write about today: support, but not for who you might expect from the tone of this first paragraph. It is currently 2:30 in the morning.  I am at work, and I have been combing my Twitter feed for the last thirty minutes or so since I got back to the station from my most recent call.  That is when I saw this tweet posted by the NYC EMS Website’s Twitter account: “. . . no one talks about it but all the EMS EMT’s & Paramedics who responded to the 2 NYPD Police Officers who were killed carry a heavy load.”  Far too often, the involvement of EMS is so quickly forgotten.  I know, because I have been there. I briefly mentioned in a blog this Summer a call that I did back in 2012 for an officer who was shot and killed and it was by far one of the most difficult runs that I have ever been part of, and it is amazing the difference that two and a half years can make.  Just because of the incidents in New York City and Ferguson, Missouri this Summer, the climate in this country when it comes to not only law enforcement but all branches of public safety is rapidly changing. A call like this one can completely change someone.  It can ruin a career, and it can ruin a life.  If ever...

Nov 25, 2014

Last week, Justin Schorr, The Happy Medic, stepped up on his virtual soapbox to let the EMS world know what he thought about Community Paramedicine. I was to surprised to find that Justin, a rather vocal advocate of reducing needless EMS volume, was against the measure saying that it was “too important to be trusted to the 911 crowd” saying that it needs to be a specialty and not a “spin off” of our current EMS system. From one end, I can see where Justin is coming from. As a paramedic in a busy urban 911 system, demand and the current work load for paramedics is high. When you are stretched thin, and your workforce is not deployed to reflect the needs of the community, then every warm body that you have becomes important and no matter what we do, response to emergency calls will always be the primary mission of a system like Justin’s.  To add to that Justin works in a fire-based system. Far too often in fire-based EMS, running the ambulance is seen as a subspecialty thereby turning Community Paramedicine into a subspecialty of a subspecialty. With the additional training that should come along with the title Community Paramedic, a person is effectively being asked to wear “three hats” instead of the two that they were hired to wear.  That might not exactly be true in Justin’s system but plenty of providers can attest to this. In all reality, what else do we have in our potential toolbox that will help us reduce those unnecessary EMS runs? As it stands now, Community Paramedicine is the best option. Justin is quick to point out that when he was in England, “paramedics with only 1 year experience were out on their own making recommendations, referrals, and taking people directly to what they needed, not just a 2 person cot van to an ER.” The difference there is training and education. They were prepared for such an event and although there have been limited studies done on the matter, the evidence exists that paramedics in the United States do not do a good job determining who should and should not go to an emergency...

Nov 19, 2014

The EMS model debate of fire-based EMS vs. private EMS is more active than ever on Facebook thanks to recent articles shared by JEMS, EMS World and EMS1, and I have been a frustrated, screaming at my computer participant. Both sides make some irrational arguments but when one searches through the mess, they can find some well thought out compelling cases made for both sides of the debate. It is no secret that I am a big advocate for EMS based EMS, whether that is in a private model or more preferably in a municipal model. Like many others, I feel that when you serve two masters you cannot perform both jobs as effectively as a person could perform one of them. Furthermore, I think that in fire-based EMS systems dedicated, highly skilled practitioners are locked out of the system for one reason or another to the detriment of the general public. The anti-private arguments are the ones that I always find interesting. The first one of “they are only in it for the all mighty dollar” amuses me. Almost any department regardless of their delivery model relies on the dollars that the business generates. With the model of health care that we have in this country, everyone is in it for the all mighty dollar. The other argument always seems to revolve around private EMS not being able to differentiate their business. They send units on non-emergent calls while disregarding emergency calls. Or they strip coverage to get dialysis transfers done. As someone who has worked in the world of privates and spent a decent amount of time perusing request for proposals for EMS services, I cannot help but think that most of what people are complaining about is a direct result of low standards contracted providers. When I worked in Massachusetts we had four contracted communities that we provided emergency services to. Once you moved past the out clauses, insurance requirements, and legal mumbo jumbo, the core of the requirements for each of these contracts came down to “you will provide X ambulances at the paramedic level and respond to calls in Y minutes or less.” That was it. Monthly reports were generated...

Nov 3, 2014

I spent some time listening to Chris Cebollero and Kelly Grayson’s show about the presence of cameras being present in the back of an ambulance, and I cannot figure out what everyone is afraid of.  I know what most will say that their fears are, but is there any foundation for those fears?  First of all, let’s throw HIPAA right out the window, or as many on the internet call it, HIPPA.  People who complain about patient privacy issues with cameras and HIPAA laws are people who do not understand HIPAA. A little more than ten years ago, I had the dubious honor of being my union’s chief steward.  One of the major fights that were dropped on our plates was the arrival of the infamous “black box” driver tracking devices in our ambulances.  If your system does not have them, I will briefly explain their function. The boxes track the truck’s speed, breaking, use of lights of sirens, use of seatbelts, and use of a spotter while backing up.  All of their information is downloaded to a master computer and is fully accessible if needed for any sort of investigation.  In addition to its, tracking, the boxes used accelerometers and g-force detection devices to give Pavlovian real time feedback to drivers in the form of growls and beeps from an audible speaker to create a safer and smoother ride. The fear from street personnel was always that “Big Brother” was watching.  People were absolutely petrified that information would be randomly pulled, and people would be disciplined as a result of their driving techniques.  I had to be the mouthpiece for the employee body, and because of a number of factors, we did not get very far with our argument, and the company pushed forward and installed the boxes into the ambulances. In the two years that followed, the number of disciplinary hearings that I remember taking place as a result of the boxes were few and far between.  Most of them were ones where someone would try to tamper with or fool the box.  The most amusing of them was a crew that was being investigated for “repeatedly slamming the truck into ‘reverse’...

Oct 16, 2014

One of the biggest sticking points that most EMS systems have when it comes to being overworked is figuring out what the definition of an emergency is. Right now, that definition is subjective, much like a pain scale. Just watch any social media outlet, and you will find some provider complaining about responding to some level of nonsense.  We forget that the patient or the bystander is the one who gauges how bad a situation is, not the person on the other end of the phone or the responding EMTs and paramedics. One of the best paramedics I ever worked with walked into every situation with the same calm demeanor because, as he would put it, “its not my emergency.” Currently, there are a number of EMS systems around the country that are plagued by lengthy response times. The public is outraged. Departments that hung their hat one the concept of “we can do it faster, so therefore, we can do it better” are scrambling to find answers. But really, the answer is right in front of them, and it starts with admitting that they were wrong. One of the most influential articles that I have read over the last five years was the one that I have quoted numerous times about response times and patient outcomes for MedStar Mobile Healthcare (formerly MedStar EMS) during the Dallas Super Bowl, which was accompanied by a snowstorm. They found that despite their longer response times, their mortality rates did not go up. Their patient outcomes largely were not affected. They proved the point that the paramedic caring for the patient was far more important than how fast they go there. Think about the anatomy of many of these runs that we go on. We response lights and sirens to the patient with flu-like symptoms because nothing is more important than getting an ambulance in front of their residence in less than 9 minutes. Not a paramedic at the patient’s side, but an ambulance, capable of transporting a patient to the hospital, parked in front of their house in a desired amount of time. We load this patient up into the ambulance and head off to the...

Sep 16, 2014

System design has always fascinated me. Throughout my career, it has become more and more obvious to me that design of an EMS system goes far beyond what trucks are on the road, and who is on each of them.  Each aspect of the system from top to bottom effects every other aspect of it.  Those who make the big bucks to make the decision need to find the best balance possible.  Need more medic trucks?  Push to run a “one and one” style system.  Short on units?  Investigate the possibility of first response, or downgrading calls to allow longer response times.  While some look at unit hour utilization and time on task as two of their biggest determinant for the effectiveness of their system it is starting to become apparent to me that much of the success of an EMS system starts at its base when that phone is answered and those first first units are dispatched. Both major systems that I have worked in have utilized Emergency Medical Dispatch (EMD) and Priority Medical Dispatch (PMD) to determine response.  Or at least they have claimed to.  I feel like at this point in my career, I have experienced both ends of the spectrum and I have seen both the good and the bad. Previously, the quality of phone triage was poor.  Even if the right questions were asked, much of the determinant of response rested in the hands of a dispatcher who would read the notes of the call, shoot from the hip, and make the decision based on what they felt was going on.  If the call was for a pediatric patient, for example, the response would almost always be with lights and sirens for no other reason than “because its a kid.”  Calls were rushed and pushed to the dispatcher’s screen in a minute or less in an effort to churn them out. The system I am currently working in has a perception that they take a bit more time when prioritizing calls.  They will sit on the waiting screen sometimes for as much as two or three minutes to allow the dispatchers to make the best decision possible in order...

Sep 10, 2014

For today’s post I was going to share my thoughts about the ongoing fight between American Medical Response and the Las Vegas Fire Department.  Some might say that with the Las Vegas City Council’s approval of the 5 year contract between the two, the “fight” was resolved.  Then, I read the editorial by Glenn Cook that I am going to share below.  There are certainly some alarming constraints that any ambulance provider opting into this deal will have to deal with, including what some may consider a gag order when it comes to speaking with the media. What could Las Vegas Fire and their chief William McDonald be so afraid of that would make them add this stipulation to the contract?  Ultimately, AMR did what they had to in order to keep their doors open for their 450 employees and their company.  I still feel that this move is more about generating income for the city and the fire department.  I have plenty more that I could say about this but I will defer today’s post to Glenn Cook and his editorial titled “City to AMR: Shut up and drive.” This is what defeat looks like.   This is what happens when a business, trampled by government yet still dependent on government approval to operate, dares to defend itself and alert the taxpaying public to obvious wrongs. This is what happens when city functionaries decide to expand their empire, regardless of cost, regardless of harm.   Wednesday’s Las Vegas City Council meeting was all about a proposed downtown soccer stadium. But amid the sports circus, the council presided over another significant action, one that officially killed the city’s dual-response medical transport system.   Private ambulance business American Medical Response fought the Fire Department, and the Fire Department won.   Earlier this year, Fire Chief Willie McDonald put his boot on the neck of AMR, which had been paying Las Vegas nearly $400,000 per year to handle most patient transports within city limits. He ordered his paramedic units to drive more patients to hospitals, so that the city could boost its bleeding general fund with transport fees. McDonald also cut off AMR from emergency communications and put...

Aug 22, 2014

Every day, I try to put aside some time for combing the internet and reading a variety of industry related articles.  This week an older article from FireRescue1.com from July of 2012 that former Washington DC fire chief Dennis Rubin reposted called “5 reasons not to merge fire and police” caught my eye.  The article presents arguments against combining police and fire departments.  I read through the article and was able to draw a parallel between this topic and the argument against merging fire and EMS.  Keep in mind that this is in no way a reflection of every single fire-based system on the map.  Some do it very well but for each of those effective, progressive fire based EMS systems, I feel like I have found two who do it very poorly or worse, do not understand or care what they are getting into when they take over ambulance response.   I invite you to read the full article by clicking here  but here are some of the chief’s observations and my thoughts on them. “There are a multitude of examples where communities have fused the police and fire departments into one public safety agency.  The motivating logic seems to be that neither department is busy enough to command the tax share needed t operate separate agency. The initial belief is that merging two costly departments into one will create a more efficient department, thereby saving big public bucks.” EMS and fire are often combined for the exact same reason.  The fire departments are not busy enough so in theory, combining fire and EMS gives them the ability to handle an additional piece of the public safety workload.  The workload that EMS brings in, however, is often ignored or it is not realized to be as involved and time consuming as it is. However, the transition of police duties into the fire and rescue department comes at a steep price that you will not find on a budget line-item spreadsheet.  Intangibles such as organizational stress, personnel, resistance, and demoralization of the rank-and-file members of both departments are the major factors that will ensure this type of plan’s failure.” Take a close look at any fire and...

Aug 6, 2014

Recording Monday’s podcast was a lot of fun.  The topic of arming paramedics and EMTs usually results in a heated discussion and I got to sit back and listen to two people with a lot more knowledge on a topic debate the finer point of it for close to an hour.  The arguments shared by both Chris Montera and Sean Eddy were both constructive and well thought out.  I found myself agreeing with both of them on many points, and could each of their sides of the arguments and walked away better understanding why they stand where they do. The one thing that I did not do on the podcast though is share my personal opinion on the topic.  So, where do I stand, you ask? Let me start out by saying that this topic is nothing new to the internet.  People have been debating arming EMTs and paramedics for years.  With each and every story posted on Facebook that has anything to do with an EMT getting assaulted comes a barrage of comments both for and against arming EMTs and paramedics.  There have been times where I have added my two cents to the conversation, consistently on the “con” side of the issue.  The replies I have gotten have been amusing. I have been told that I am “infringing on (my) Second Amendment rights.”  I have been called a liberal who wants to empty out everyone’s gun cabinets.  Well, if you have met me, or read my political views, you would realize that I am far from what most would consider a liberal.  If you have any doubt about that, just ask Justin Schorr.  We have had some spirited political debates over the years. Also, if you follow me on Twitter, it is easy to see that I am also a fan of the Opie and Anthony Show on Sirius/XM radio.  I feel silly calling it that now after the firing of Anthony Cumia, which personally I feel was unjust.  Without getting into the particulars of my feelings on that topic, I bring it up to point out one particular argument brought up by some of Anthony’s fans.  Some think that Anthony should not...