New Mexico, also called the Land of Enchantment, is known for its hot chilies, adobe buildings and pink sunsets. It has a long and fascinating multicultural history. It is the fifth-largest state by land area and consists of a small population of only about 2 million people. Outdoor activities stretch throughout its rugged country from the Rocky Mountains to the Chihuahua Desert.
Unfortunately, residents of this frontier paradise have a plethora of health-related problems. Statistically, its children and most adults have the highest rates of unintentional injury deaths in the country, due to causes such as drunken driving, accidental firearm discharge, fire and drowning.(1)
According to the Centers for Disease Control, the homicide rate in New Mexico has been the third highest in the U.S. for more than 10 years.(1) For the past 20 years, the overdose rate has been among the highest in the nation.(2) Compounding the problem, New Mexico is also considered to be one of the three most medically underserved states for adult men and women.(3)
Because of these factors, a group of emergency physicians at the University of New Mexico (UNM) Hospital in Albuquerque—the state’s only Level 1 Trauma Center—has developed a new collaborative approach to EMS medical direction. Keeping New Mexico’s epidemiology in mind, the approach is applicable to both rural and urban areas, and it may be a more effective service model than was used in the past. The EMS physicians involved in this new EMS Consortium are both medical directors and field responders—a model that is consistent with the new medical subspecialty of EMS approved by the American Council of Graduate Medical Education in 2011.
The UNM EMS Consortium brings EMS fellows and EMS medical directors, who had previously worked independently at multiple agencies, together into one collective group. Fellows are physicians who choose to spend an extra year in specialty training after completing a three- to four-year residency in emergency medicine.
Each agency keeps one physician assigned as a primary medical director, but the other physicians are contractually considered associate medical directors for all of the agencies within the Consortium.
“The Consortium is much like a group of obstetricians,” says Consortium Director Darren Braude, MD, EMT-P. “Each woman has her own obstetrician for routine appointments, but it is understood that any member of the group may deliver the baby if they are on call. None of us would be able to provide 24-7 availability to our agencies, but as a group we can. So now we can be a real part of the system, not just someone who attends meetings, writes protocols and signs forms.”
Medical direction in New Mexico requires an atypical approach to wisely manage scarce resources. Consortium doctors wear a number of hats, providing tactical physician support for SWAT field medicine, remote wilderness (or austere) medical response and medical direction for fire/rescue and EMS services around the state.
Braude believes the major benefit of operating in the field is the systems-level observations physicians make while listening to the radio, responding to calls and talking with providers. “We have amazing EMTs and medics in our system. If they need us for patient care on more than 1% of calls, then we have done something horribly wrong as educators and medical directors,” he explains. “But if you are trying to run an EMS system from an office, you never really appreciate the problems that are ripe for fixing.”
Some advanced procedures provided by the physicians include field ultrasound, rapid sequence intubation for advanced airway placement and whole blood administration. A cooperative agreement between the Consortium and the blood bank at UNM Hospital resulted in the Field Blood Extraordinary Use Protocol. A total of eight units of blood, two units of type O positive and six units of type O negative are available for a Consortium physician to pick up on a moment’s notice. The protocol is used several times a year, mostly for tactical call-outs in remote areas or mountain rescue cases.
The Shield is a prominent rock formation in the Sandia Mountains overlooking Albuquerque. The Sandia Mountains are known internationally for challenging mountaineering. An extremely difficult route up the Shield is called Rainbow Dancer, named after the arches along the face of the rock climb. However, it’s a rescuer’s nightmare because technical rescues are logistically difficult to coordinate.
On Sept. 23, 2011, a climber fell more than 60 feet during a technical rock climb. The 26-year-old female suffered a bilateral pneumothorax, open elbow fracture, and more than three hours of exposure before extrication was possible. Several agencies participated in her rescue, including Bernalillo County Fire Department, Albuquerque Medical Rescue Council, New Mexico State Police and the New Mexico National Guard, whose members used a Black Hawk helicopter for the actual extrication.
The second leg of the National Guard helicopter rescue consisted of picking up Consortium physician Andrew Harrell, MD, and an Albuquerque Mountain Rescue Council physician’s assistant for an advanced-care intercept. During flight, the patient’s pulse oxymetry had dropped to 70%, heart rate increased to 160 beats per minute and her shortness of breath was worsening. The providers initiated a blood transfusion for hypovolemic shock, started antibiotics due to soft tissue injuries and performed bilateral pleural decompression because of a worsening tension pneumothorax. On arrival at University of New Mexico Hospital Emergency Department (ED), her pulse oximetry was greater than 90% and heart rate had decreased to 110 beats per minute. The patient is reported to have made a full recovery.
Justin Spain, EMT-P, an Albuquerque Fire Department paramedic/firefighter and an avid mountaineer, was one of the providers who responded to the Rainbow Dancer Rescue. He is also a member of Albuquerque Mountain Rescue Council, the volunteer search and rescue organization that participated in the actual rescue. Spain helped stabilize, initiate IV fluids, package and perform a technical lowering to the helicopter hoist spot. He thinks the Consortium in New Mexico has improved the overall capability of first responders, and says he’s “glad to see the Consortium is growing and going in the direction it is.”
Physicians who complete their residency in emergency medicine are eligible to apply for a one-year fellowship in EMS at UNM. The fellows, numbering one to two yearly, are fundamental to the program. Responsibilities include over-the-phone or radio consultations, field response, on-site continuing education, paramedic and EMT training, quality assurance and engaging in prehospital research.
Harrell completed the EMS fellowship at UNM and is currently medical director for the Albuquerque Fire Department (AFD). Harrell believes EMS fellows are the backbone of the Consortium and gain invaluable hands-on experience during the one-year program. “We are closing the loop. Instead of a medic calling and asking me, ‘Can I do this?’ I can be operational and on scene with them,” Harrell says. “Then I offer feedback, gather and disseminate patient follow-up and take my observations back to the office to make the system better.”
Some of the difficult situations Consortium doctors have encountered are termination of a traumatic arrest of a law enforcement officer in the field, reduction of a shoulder dislocation at 10,000 feet in the Sandia Mountains and coordination of a complicated refusal of care. Ultimately, the end-of-life wishes of a hospice patient were respected after 9-1-1 was activated. One of the most stressful cases involved a toddler.
Pediatric Airway Obstruction
A two-tiered response is standard in Albuquerque, a city with a population of 552,804.4 AFD delivers first response and Albuquerque Ambulance Service (AAS) provides a transporting paramedic unit to more than 100,000 EMS calls per year.(5)
On July 14, 2012, Braude was just clearing from a rollover when the public-safety answering point (PSAP) dispatched units to a 14-month-old who was choking and not breathing. The PSAP coded the call 9E1, cardiac or respiratory arrest, with life status questionable. A rescue, engine and ambulance arrived to the home in Northwest Albuquerque within a matter of minutes.
AFD paramedics Reed Page, EMT-P, and Melvin Martinez, NREMT-P, removed a foreign object with direct laryngoscopy and Magill forceps. When Braude arrived, the boy was sitting up in a paramedic’s arms, alert and grabbing at the non-rebreather mask on his face. The providers all thought the problem was solved, but Braude still accompanied AAS and AFD crews to the closest community ED. While in the ED, the patient deteriorated two or three more times again (it turned out there was a secondary obstruction), but the providers were able to establish a marginal airway with basic maneuvers.
Braude and the attending physician, Cathy Drake, MD, agreed that sedating or paralyzing the child might be disastrous and the patient needed to be in the operating room (OR) with a pediatric ear, nose and throat (ENT) doctor, but no such resources were at this facility. Braude was able to rapidly arrange for a direct admission to the OR at UNM Hospital with no further questions asked. The patient was transported by the AAS critical care transport (CCT) team, with critical care paramedics Mike Nuanez, CCEMT-P, and David Chapek, CCEMT-P, as well as Braude, attending to the patient after spending less than 15 minutes in the ED.
The team remained calm as the patient obstructed several more times during the CCT transfer. At one point he became apneic and bradycardic so they attempted direct laryngoscopy again, but the patient vomited, obstructing the view. The patient relaxed and oxygen saturation quickly improved with optimal bag-valve mask ventilation. They bagged the patient all the way into the OR and handed the patient off to the awaiting pediatric ENT surgeon and anesthesiologist with an oxygen saturation of 100%. A foreign object was removed from his vocal cords and the patient was discharged, neurologically intact, several days later.
Medical director of AAS, Philip Froman, MD, has firsthand knowledge of the improvement the Consortium has brought to EMS medical direction. In addition to AAS, Froman directs several other EMS and fire/rescue services around New Mexico including Sandoval County Fire Department. “Our EMS system has evolved dramatically over the last 20 years that I have been providing medical direction,” says Froman. “The advent and expansion of the EMS Consortium was the appropriate next step in providing excellent and advanced care to the population of Bernalillo County.”
Consortium physicians plan on taking 12-hour shifts on a rotational basis to improve coverage beginning in July. This schedule change will allow the group of doctors to be consistently available on the radio, rather than being on-call or monitoring intermittent radio traffic. jems
1. Web-based injury statistics query and reporting system (WISQARS). (2013). In Centers for Disease Control and Prevention. Retrieved March 17, 2013, from www.cdc.gov/ncipc/wisqars.
2. Whorton, B. Sales of prescription opioids and drug overdose deaths in New Mexico. New Mexico Epidemiology. 2012;2012(7):1–4.
3. Making the grade on women’s health: A national and state-by-state report card. (2010). In National Women’s Law Center. Retrieved Jan. 28, 2013, from http://hrc.nwlc.org/status-indicators/people-medically-underserved-areas.
4. Table 3. Annual estimates of the resident population for incorporated places in New Mexico: April 1, 2010 to July 1, 2011. (2011). In U.S. Census Bureau. Retrieved March 18, 2013, from www.census.gov/popest/data/cities/totals/2011/SUB-EST2011-3.html.
5. Albuquerque ambulance service: About us. (2013). In Presbyterian Healthcare Services. Retrieved March 18, 2013, from www.phs.org/PHS/programs/Ambulance/AboutUs/index.htm.