The International Association Emergency Medical Services Chiefs’ 2014 Summit is underway at the Capitol Hilton in Washington DC, October 11-14. Last year the summit was interrupted by the threat of Category 4 Hurricane Sandy hitting the capitol. This year the shutdown of the federalgGovernment overshadowed the conference; two speakers and one field trip were cancelled.
Changes to Come
On Friday, a pre-conference workshop focused on the future of EMS and how the many varied systems across the country should prepare for Accountable Care Organizations, Community Paramedics and ever-shrinking budget dollars. The clear theme of the speakers was that EMS as we know it today will likely change in the next few years. Government funding of patients receiving medical care, including ambulance transports, will change and currently there doesn’t appear to be funding earmarked to make these changes.
Initial plans pressure hospital systems to reduce costs, improve outcomes and ensure customer satisfaction. An important cog in the wheel is all of the thousands of systems that are the initial contact for millions of patient’s primary healthcare. When in doubt, they call 9-1-1. The Community Paramedic concept sounds interesting and the policymakers have designed systems to initiate the concept, but funding for the paramedic providers to train, compensate, respond and intervene so they (patients) are not unnecessarily transported is not clearly identified from federal funding and reimbursement sources. There are lots of discussions about future revenue streams or networking with hospitals, but currently EMS has not made its way into any budget.
Saturday morning, Dr. Jay Fitch provided a thought-provoking talk on leadership and the principals of building and maintaining trust within EMS organizations. Attendees were encouraged to think about successful businesses, such as FedEx, Google, Nordstrom and Southwest Airlines, all of which have the common theme of taking care of their employees and building a base of trust, top to bottom.
Improvements in D.C.
Following Dr. Fitch was David Miramontes, MD, assistant chief and medical director for fire and EMS services in Washington, D.C. Miramontes has been successful in instituting numerous clinical and logistical improvements over his 26 months tenure as medical director. Overcoming some long-standing traditions with prehospital crews and pushback from local hospitals, his changes have improved service and system efficiencies in D.C. One significant change came when he directed that controlled medications would be carried onboard every paramedic unit.
The D.C. area routinely has large-scale special events, many with more than 150,000 attendees: presidential Inaugurations, marches on the Washington mall, protests and many more. These gatherings can collapse the system, both prehospital and hospital, if the day-to-day methods are depended upon to absorb the added requests for service. D.C. has experience in pre-deploying medical teams, EMTs, paramedics, nurses and physicians to strategic sites at the special event footprint to address many of the requests for service that otherwise would have been transported to a surrounding hospitals.
Questioning Traditional Practice
On Sunday, Alan Craig, vice president of Clinical Strategies with AMR, provided an eye-opening review of the redesign of Toronto’s EMS system. Alan challenged the way we have resuscitated patients over the past 30 years, noting past paramedic treatment options such as MAST suit use, fluid resuscitation, administration of epinephrine and the use of more paramedics. He pointed out that the first two have already been proven to be wrong in most situations and the last two have yet to prove higher patient survival to discharge. Additionally, many of the other traditional practices, including the Golden Hour, are now being challenged with data. The question remains: What should paramedics continue to do when studies expose long-standing treatments may not improve survival.
Inside the Boston Marathon Response
Brendan Kearny of Boston EMS provided an insider's view of the 2013 Boston Marathon EMS response, where improvised explosive devices killed and injured dozens of runners and spectators. Boston EMS had prepositioned 90 medical personnel of various levels along the 26-mile course. Due to mild weather conditions on race day, most of the medical stand-by teams were not overwhelmed with runners so many were able to be utilized to treat victims of the bombing.
During the first few minutes after the explosions, radio traffic announced that two devices had exploded and there were lots of casualties. EMS and related personnel were crowded onto radio channels and demonstrated remarkable radio discipline (priority traffic only) and held their assigned locations, while continuing to treat runners.
With the race shut down, the planned flow of runners through finish line logistical processes was interrupted and the backed up runners requiring race-related treatment impacted the course medical units. Civilians assisted with patient care immediately following the explosions and during Boston EMS’s operations. Proper preplanning and staffing of large-scale special events were critical success factors in the management of this volatile incident.
Have We Heard This Before?
The overwhelming sentiment of the chiefs attending this year’s IAEMSC Summit: The community paramedic train has started down the tracks, and we (cities and districts) need to either get on board or at least understand what not opting-in might due to our 9-1-1 EMS system.
Factor in new healthcare plan requirements, new medical coverage for some people currently not insured, hospitals reaching out to medical personnel (fire agencies, ambulance companies, employers of healthcare workers and even capitated contracts) who are willing if not anxious to begin this new line of business, and no one truly knows what our prehospital system will look like in one to five years.
Many fire chiefs are not committing at this point, as key issues are still being developed and everyone is struggling with how to fund these additional services. Case studies presented clearly demonstrate that continuing to transport everyone to emergency departments is not an option. Many patients are readmitted within that “30-day” period for preventable reasons, and it is the preventable causes of readmits that seem to be the biggest bogie on the radar screen.
Clearly the homeless, chronic inebriate and psychiatric patients represent one of the larger challenges of how to best direct their care options and plans, without defaulting to the local ED. Unfortunately, prehospital stakeholders had very little involvement in the planning to date and there seems to be the assumption we will once again fund the training, equipment and personnel necessary to save the hospitals and insurance companies' money.
Sounds like prehospital 12-lead and STEMI protocols all over again.