To say that Robert Boyd Tober, MD, FACEP, has been involved in all aspects of medical direction for Collier County, Fla., would be an understatement. The 30-year veteran, who is medical director for Collier County EMS, has been a driving force in protocol development, in-service curriculum development, and the creation of innovative programs and technologies that have saved thousands of lives over the years. His most recent innovation, a tiered medical care program, has led to return of spontaneous circulation (ROSC) rates that are far above the national average.
History of Achievement
A brief run-down of Tober’s accomplishments includes the introduction of a new technology in 2004 to treat both congestive heart failure and acute ischemia in the prehospital environment. He replaced the standard 12-lead ECG with a device known as AUDICOR, which helps paramedics identify subtle heart sounds that in the proper clinical context are highly correlated with acute decompensated heart failure.
In 2005, Tober initiated use of the AutoPulse, which he says is 400 percent more effective than manual compressions and reaches coronary and cerebral blood flows of close to 100 percent of normal. He also implemented the use of the ResQPOD, an impedance threshold device that improves cardiac output during CPR by increasing cardiac preloading.
Tober was not satisfied to rest on his laurels when, in 2005, he adapted the renowned Pit Crew concept to cardiac arrest. He designed the innovative system, whereby each person on an EMS team in the field has a specific task when responding to a patient in cardiac arrest, similar to how a pit crew at a NASCAR event has a specific job, which overall saves time getting the race car back on the track. This organized and choreographed approach to cardiac arrest management allowed Collier County EMS, and all of Collier’s first responders, to gain a return of spontaneous circulation in an amazing 53 percent of V-fib/V-tach (VF/VT) cardiac arrests in 2008. The concept is so popular that he has taught the EMS Pit Crew concept to other districts, some as far away as upstate New York.
Medical Pit Stop
Tober has now taken the Pit Crew concept a step farther and developed the “tiered medical care” concept to paramedics in the field.
Concerned that large numbers of paramedics would have insufficient opportunity to use their advanced abilities, leading to a deterioration of vital skills and diagnostic capabilities, Tober instituted advanced paramedic practitioners who self-dispatch to serious calls. They are not confined to geographical zones. Thus, when a patient calls, they’re ensured to get an experienced paramedic trained specifically for their needs.
They equipped four out of nine of the county’s independent fire districts, studying their utilization over 27 months. “And much to my surprise, I had no idea how little medicine the fire department medics were actually using, and how infrequently they got to make independent medical decisions, prior to the arrival of the EMS paramedics who have a lot more experience and training,” Tober says.
So Tober decided to take a smaller group of transport medics who would respond to calls in their areas of expertise. For example, rather than dividing 600 intubations county-wide among 250 medics, the 120 transport medics are more likely to perform all field intubations.
The goal is to get a skilled BLS provider on scene in less than four minutes, with care focusing on the first 10–15 minutes. Next is the goal of having an ALS transport on the scene in less than eight minutes. They transport the medic and the patient, assessing the needs of the patient en route to the hospital.
“When a 9-1-1 call comes down, the call is graded according to its severity; the Alpha and Bravo are pretty minor calls; Charlie, Echo or Delta are pretty severe calls,” he says. “For the most part, the system works pretty well. The call may or may not generate a tiered response, meaning that if it’s a very minor call, maybe only EMS will go or maybe only Fire will go. We are still working on the perfect mix of who should go on what type of call.”
More experienced paramedics commonly referred to as Medcoms, can also arrive on the scene to provide support care in the worst cases. If a rare procedure, such as a cricothyrotomy, needs to be performed, the Medcoms assist with the procedure and assist the transport medic, who may have only performed the skill in a lab training setting.
“The Medcoms are a subset of about 15 highly experienced medics who have demonstrated a lot of good leadership and patient skills, along with clinical excellence. They travel in rapid response vehicles,” Tober says.
Based on Specialty
The entire tiered-medical care approach, founded on evidence-based medicine, has set the standard of care for other EMS systems. However, tiered medical care, while familiar in hospital settings, is still controversial in prehospital settings.
“Every RN in a hospital has the same RN degree, but their skills are vastly different depending on where they work,” Tober says. “You have nurses who work in the operating room, nurses who work in cardiac cath, nurses who work in the CCU, the surgical intensive care or the emergency department. They are all very different people with different subsets of skills, but they’re all nurses.”
Likewise, Tober tries to educate others that a paramedic is not a one-size-fits-all profession. “We all have the same degree, but we’re not the same people,” he says. “We all have a niche, and I have tried to simply place the tools in the hands of the people who use those tools the most often. From my standpoint, it’s common sense.”
More studies are supporting the concept that the addition of multiple paramedics on scene is counterproductive and contributes to a decrease in positive patient outcomes. Tober wants to have fewer paramedics on the scene, but he also wants the right paramedics on the scene, especially where cardiac arrest is concerned.
“If you look nationwide at cardiac arrest, it’s probably only 1 percent of the emergency medical calls. But it’s studied intensively as a benchmark of the system functionality because it’s so time-dependent,” says Tober. “If you don’t get to the cardiac arrest patients pretty darn quick, certainly within five to six minutes, they almost all die.”
Despite its controversy, the tiered-medical care concept seems to be working. The approach has contributed to Collier County maintaining a ROSC in 49 percent of VF/VT cardiac arrest cases, and 31 percent for all cardiac arrests in 2009. Discharge from the hospital in good neurologic shape has averaged, quarter to quarter, from 20–40 percent of all V-fib cardiac arrests. This is far above the national average of 6–10 percent.
Recognizing the Impact
Tober is justifiably proud of the impact some of his innovations and approaches have had on his community.
“I came from a very busy metropolitan emergency system in St. Louis and moved to this paradise called Naples, Florida, where they didn’t even have paramedics riding in ambulances,” he says. “I came to basically a frontier to do what I’ve been trained to do, and I built it from scratch. That’s really why I came down here.”
Tober has been recognized and supported by many organizations, including the Florida Association of Medical Directors, the American College of Emergency Physicians, the Academic Association of Emergency Physicians, the National Association of EMS Medical Directors, the Florida Department of Health and Collier County Medical Society, which represents more than 500 physicians in his community.
He also works closely with other outstanding organizations, such as the Sarver Heart Center at University of Arizona at Tucson, Richmond EMS and Wake County EMS, to provide quality, evidence-based patient care.
To launch the first ALS ambulance system in 1979, Collier County spent $1.5 million getting the program off the ground. Not surprisingly, Tober’s superiors wanted to see results—specifically in lives saved. He got his chance on the second day when a call came in for a 55-year-old cardiologist in cardiac arrest. The system, and the team that Tober helped put in place, saved the cardiologist’s life.
“That’s why I keep putting up with [some of the aggravations],” Tober says. “I’ve sort of affixed my little microscopic identity on a dot on the landscape. Given the limitations of human interaction, the system works very well, and it has been very, very successful.”