I posted a question on my Facebook page asking my followers what they felt the “most innovative change” was that they have seen during their career in EMS. To date, I have gotten 26 responses of varying degrees of seriousness but the most common one that I have seen is prehospital CPAP. In fact, one nurse even weighed in with that answer. I decided to do some research and see what else I could find out about the topic.
I remember being an EMT in New Jersey home for the summer back in 1999 and watching the LIFE paramedics pull out a large bag with their CPAP setup out of the trunk of their unit. It was admittedly an intimidating piece of machinery to me. CPAP in my home system in Massachusetts was as foreign as prehospital 12-Lead EKG’s were at that time. We did not get LP-12’s until 2002 or 2003.
When I did a Google search for prehospital CPAP, I found an article from EMS World written in 2005 by my good friend Bob Sullivan outlining its use, why it is effective, and why it is so important to start CPAP sooner rather than later. Some of his references in the article date back to as early as 2000. The proof has been in the pudding for years, CPAP works.
A simple "Set it and forget it" CPAP Device. Photo taken from www.grandcountyems.com
Why then did it take a special project waiver and two years of evaluations to get it approved for use by paramedics in Massachusetts? Randy Cushing, a paramedic with the Agawam Fire Department was one of the leaders in the push for prehospital CPAP and his efforts finally paid off in 2010 when the change went through in the state protocols giving paramedics standing orders for prehospital CPAP. Eleven years after I was seeing it used in New Jersey. Five years after the article, one of many, was posted about its effectiveness in prehospital care. This leads me to make the broad conclusion that in 2013, there are still probably some systems out there that don’t use it, or haven’t gotten full approval to use it yet.
This makes me think about studies such as the one that compared usage of IM Versed with IV Lorazepam for seizures. Rogue Medic does a great five part write up of this, the first part of which can be found here. The evidence is there, IM Versed works both for the patient, and is a safer route of administration for providers as well. For the time it takes to establish an IV, especially on a seizing patient, and the risks of needle sticks which might be less with safety needles but still exist, I’d gladly go for an IM to the thigh or some other easily accessible spot.
It makes me wonder though, with as long as it took systems to adopt things like CPAP or 12-Lead EKG’s, how far off are other innovative revolutionary patient care techniques for prehospital providers? Also, why does it take so long? Why has it become necessary for each system and each state to seek out their own proof when the work has already been done for them?
We work in a field, the medical field, that is constantly evolving and changing. We, as providers of care, need to do a better job of embracing those changes, and driving that evolution. We are not talking about sterile surgical techniques here. CPAP is non-invasive. And every medic in the field should be able to give an IM injection or use an auto injector. Proven simple treatments that have proven profoundly beneficial results. These should be the sort of treatments that we, as prehospital providers, hang our hats on.
The truth is, there has not been much innovation in EMS. Next year will be 40 years, so I’ve had the perspective, at least from east to west and north to south in the United States. We have introduced “new” things to EMS, but they are usually late in terms of having been used in the hospitals etc. for a while.
What we have NOT had is any innovation in the non-clinical EMS arena. We are still driving what are essentially 1974-design vehicles, using slightly (but not much) updated stretchers, carrying 100 lbs of monitor and kit, and wrecking our backs, knees, and shoulders doing so. Why? Because we like it that way. As a community, EMS folks are the most change-resistant body that can be imagined – if it is in the least bit inconvenient, or requires the least bit of effort, we don’t want any.
As far as clinical innovation, why does it take five years for simple and effective things to migrate to the pre-hospital arena? To be adopted in “state protocol”? A couple of reasons, but they are very intertwined. First, we lack education, therefore we lack the respect of the rest of the health professions. Until we become, like physicians, nurses, physical therapists, x-ray folks, etc. etc., degreed at a meaningful level (baccalaureate), we will not get things with which others with better credentials got earlier. Second, (and this can’t happen until the first happens), we have to become self-regulating – and particularly we have to get our clinical practice out from under the state-wide bureaucracies. State-wide protocols everywhere are the worst, most limiting factor impeding innovation in EMS.
The relatively innovative systems that I’ve seen enjoy aggressive, LOCAL medical direction. Unfortunately, these docs are often stymied by their state colleagues, who write protocol to the least common denominator – the worst paramedic in the state. Perhaps some day, like our colleagues in Australia and Canada, we will see clinical leadership from paramedics – and not have to be entwined in the politics of the state medical society or ACEP or NAEMSP chapter.
Third, we’re limited by the whole “pay for transport” thing. Since 1964, we get paid for a ride in a truck. This requires a statutory change – but not a complex one – IF the EMS community could get together and make it happen. Unfortunately, there are a few people who are making good money in the “you call, we haul, that’s all” environment, so we stay unengaged and divided – and un-innovative.
Nothing to large to overcome……
Skip,
You are a breath of fresh air as always. Though the optimistic/sarcastic last few words are a good indication that I believe we CAN change.
Last year I was lucky enough to attend the annual Congress of the American College of Healthcare Executives. At one of the keynotes (very big conference), the speaker talked about innovation. He said that innovation is something that you have to give time to and hardwire into your organization. Change is inevitable and to stay ahead of other organizations, other sectors in health care, or other industries all together we must constantly be innovating. Just my 2 cents (breakfast is ready).
Garrett (the naptown medic) Hedeen
You ask why does it take so long? Why does each State seek out their own proof?
Ego, Money, Position.
Ego- Our EMS World is full of “That’s not the way we do it back home.” If one curriculum is good in one state, we’re going to make ours even better in another state, i.e., state community paramedic program curriculum or the national curriculum. If one EMS organization is using one brand of CPAP, we’re going to find a better brand.
Money- Budget rules and sometimes the decision for buying one piece of equipment over another comes down to discounts, salesperson relationships, and the fact that some grant monies are earmarked for specific equipment or training.
Position- EMS still lives with a “club” type brand or image, i.e., “They dropped everything and did the best they could to help.” We haven’t done a very good job in EMS for positioning the work that is done and the data (proof) that’s been generated as having good credibility.
It’s the end of the day and I am probably oversimplifying.