Columns, Major Incidents, Mass Casualty Incidents

Don’t Forget the Small & Mighty

Thankfully, the capabilities and scope of practice for EMS have advanced exponentially over the years, resulting in improved patient care in the prehospital setting. As advancements in medical technology have been made, EMS agencies face the challenge of providing additional equipment and training to their providers in the face of shrinking financial resources and support.

I was appointed state medical director of the Division of EMS within the Ohio Department of Public Safety in July 2004. However, I became — and continue to serve as — the EMS medical director for Lake Hospital System in Lake County since 1995. Lake County is less than a 30-minute drive east of Cleveland, and the EMS system I oversee serves a mixed suburban and rural population.

I reside in Kirtland, a small city in Lake County filled with parks, homes and churches that lacks the fast food chains and neon lights of the big city and suburbia. I m one of the few state medical directors that practice emergency medicine at a community hospital not affiliated with an academic institution. In my role as a local EMS medical director, the Grand River Fire Department is my smallest municipal EMS agency, and their part-time EMS providers serve a population of 345 residents.

At the state level, I serve on a multitude of committees. The committees are tasked to create and implement such processes for EMS as adult and pediatric medical protocols, research, legislation, trauma protocols, and disaster planning. As I drive past the marble statehouse in our capitol city on my way home to a town where the only drive-through window is at one bank, I ponder the master plans at the state and national levels, and ask myself the litmus test question. Will this work in Grand River?

I m fortunate Ohio s EMS Board and my colleagues in the EMS office are not only cognizant, but sensitive to the needs of the rural and smaller EMS agencies. Analogous to the most of our nation, the majority of prehospital and emergency medical care in Ohio is provided by rural and smaller suburban EMS agencies and community hospitals. In addition, we all realize that a universal foundation of knowledge and training of all prehospital care providers is essential for the successful implementation of any response, especially during mass casualty events and disaster planning.

Yet, I m concerned about the trend of funding for EMS. Financial resources are declining, especially for the currently struggling small EMS agencies. I m equally alarmed by the strained budgets and reduced opportunities for training. A coordinated emergency response, particularly during a disaster, hinges on an adequate local initial response by local EMS agencies and local hospitals. In a mass casualty incident, academic centers alone cannot save the world and can potentially be overwhelmed by the increased patient volume.

When Mother Nature floods the streets, burns the bridges, blows away the street signs and disrupts the GPS tools, the local emergency responders will still know the path through their communities, the location of people with special needs, and resources within their vicinity that will suddenly seem foreign to mutual aid responders.

Having said that, how can we consider ourselves prepared when many agencies have completed personal protective equipment (PPE) training, but lack the resources to purchase the appropriate PPE gear? How can we consider ourselves prepared when our colleagues have no other option but to place essential equipment and opportunities for training on Santa s wish list year after year?

I m always energized and inspired after the bi-annual meetings with the other state medical directors. We share our successes, challenges, goals, solutions, cutting edges ideas, and dreams. The networking that occurs during our hours of conversation about issues and various projects is stimulating and constructive.

One of my favorite recollections during our conference about a year ago involved a verbal presentation by Dr. Bill Jermyn, the state medical director for Missouri. He shared an EMS mission where a simple enhancement of prehospital care by EMS providers would markedly enhance patient care delivery in his state as well as others. I hung on his every word as he spoke, and his proposal made perfect sense for both EMS and the patients. By the end of his presentation, everyone in the room seemed eager to get started on the mission immediately until someone asked Dr. Jermyn how he planned to implement the plan. He calmly responded, Unfortunately, funding remains elusive. Silence filled the room as we all shared his angst and pain. Since then, I joke with Bill about his prophetic statement every time we discuss a common sense avenue where EMS can benefit patients that is extinguished by lack of financial resources. We have to laugh to keep from crying.

Until the growing financial gap is addressed legislatively, what can EMS agencies and their medical directors do to try to bridge the gap until a reliable, continuous funding source is established? Hospitals are limited in their ability to purchase equipment for EMS agencies by federal Safe Harbor legislation, but other avenues can be explored at a local level. The development and maintenance of a good relationship with the community served is essential. A community will value and support an EMS agency that reaches out to them and can urge their legislators to do the same. Private-public and public-public partnerships can assist EMS agencies to acquire additional equipment and training.

Believe it or not, the Rock and Roll Hall of Fame and Museum was built with funds generated from private-public partnerships, and no taxpayer dollars were required. Industries housing substances that place their employees at additional risk may purchase the appropriate antidote kits for the EMS agencies that will be responding to them during an event if the kits, (i.e. a $700 cyanide antidote kit) are too costly for the municipal budget. The benefit to both parties is symbiotic. An EMS system in central Ohio spearheaded a campaign to educate their community about the risk of cardiac disease and the current medical interventions for acute myocardial ischemia. They were able to generate enough donations from community businesses and citizens to purchase 12-lead ECG monitors for their EMS system and a telemetry receiving station at their hospital.

On July 30, I took a break from work and drove to a nearby bed and breakfast in Amish country for a night s respite. I drove past the Newbury Volunteer Fire Department, and a sign posted outside of their station said Help Wanted. Calls YTD 280. Some may think that an agency with this call volume is small potatoes. I care to differ. These are people that work a full day at another job, yet immediately interrupt dinner with their families, peaceful sleep, and chores at home to respond to those in need once or twice a day including weekends and holidays. The calls YTD 280 translates into 280 volunteered instances of commitment and dedication.

I am proud of the level of training within my own local EMS system, but much work always remains. I am confident the deficiencies in our prehospital and hospital emergency care systems identified in the Institute of Medicine report will be addressed. As improved support for EMS is legislated, I remain concerned about the distribution of resources. Private-public partnerships are not a primary financial solution. They are pebbles in an ever-expanding crater that can only be filled by equitable, continuous funding streams. Too often, I see EMS projects and plans that either exclude or minimize the full inclusion of all potential responders. Tertiary care centers and metropolitan EMS systems alone cannot save the world.

A plan may look good on paper and be administratively pleasing, but doesn t meet the needs of the blue shirts on the front lines because it s not fiscally functional. Regardless of where you live, when disaster hits, you ll need these responders and they will need to be fully prepared and funded. Will your master plan work for Grand River Fire Department? How about the Newbury Volunteer Fire Department?

As I arrive back home and transition from my business suit and car to a pair of jeans and my John Deere, I contemplate the heart of the matter. Life is a person s most valuable asset. EMS responders are committed to reduce morbidity and save lives. Yet, the image of a billboard bearing a shameful message stays in my mind as I think of those left behind.