Will a federal agency lead EMS in the near future? Industry leaders await the answer, which will come from review of a report submitted by the Federal Interagency Committee on Emergency Medical Service (FICEMS). The National Security Staff Resilience Directorate had directed FICEMS to submit an options paper evaluating alternatives for establishing or designating the lead agency or office by May 15.
“Engaging people is always better than an arbitrary decision. I applaud the fact that they’ve encouraged people to submit comments,” says Jay Fitch, owner of Fitch & Associates and a JEMS Editorial Board member. “It does have an impact on the future of EMS in terms of its credibility and its ability to get things done within the federal government.”
FICEMS began seeking public comment during its Dec. 16 meeting. In March, it held a public hearing at the 2011 EMS Today Conference & Exposition. And in April, it held a stakeholder conference call, which was the last of the meetings seeking public comment. Both times, many of the attendees agreed a lead federal agency could unite the divided EMS industry and that it should be in the healthcare, not transportation, system.
National Association of Emergency Medical Technicians (NAEMT) President Connie A. Meyer says NAEMT did not take a position on which agency should be the lead, but does believe a lead federal agency for EMS is necessary. “We know that EMS needs a lead federal agency. We agree on that. But we’re still looking at all the pros and cons of all the different places it could be,” says Meyer, a registered nurse and paramedic who’s the EMS captain of Johnson County (Kansas) Med-Act.
“We know what we want, but we just don’t know where we want it to be yet. We want to look at all the options first. It’s much too important a decision to enter into it hastily,” she says.
FICEMS learned about how EMS leaders saw the federal government involved in the full continuum of EMS, including medical 9-1-1 and emergency medical dispatch, ground and air prehospital services, hospital-based emergency care and trauma care and medical-related disaster preparedness.
“We often demonstrate that we lack even that basic level of consensus,” said Skip Kirkwood, MS, JD, MET-P, EFO, CMO, in his March 21 JEMS.com article, “Federal EMS Agency Wish List.”
“Many people in EMS complain that we don’t get any respect and, more importantly, don’t get our share of the federal dollar when compared with our law enforcement and fire suppression colleagues. Why not? Well, our inability to agree on anything substantial contributes to that dilemma,” Kirkwood said in the article.
During the meetings, several representatives suggested FICEMS review past white papers and legislation on the subject. These included The Future of Emergency Care in the United States Health System, Field EMS Bill and Consolidated Federal Leadership for Emergency Medical Services: An Essential Step to Improve National Preparedness: A perspective from EMS on the front line.
Regardless of where the EMS industry is placed within the federal government, many industry leaders believe it’s an essential element of healthcare reform and a first step in including EMS in national preparedness. It’s now up to the National Security Staff Resilience Directorate to make its determination.
Tuscaloosa Takes a Direct Hit
In one of the hardest hit areas of Tuscaloosa (Ala.), comic book artist Chris Wozniak had only 24 minutes to prepare for the arrival of the Apr. 27 tornado. He donned a motorcycle helmet, leashed his two Jack Russell terriers to his leg, held a sofa cushion over his head and curled up in his bathtub.
When the tornado blew apart Wozniak’s home, he held onto bathroom fixtures to keep from being sucked out of the tub where he took refuge. His beloved dogs were pulled up into the air over his head like a kite on a string, but their leashes, collars and small bodies remained unbroken, and they survived.
In the Alberta City section of Tuscaloosa, firefighters Jeff Roberts, Terry Jordan, James (Buck) Bice and Miles Dutton were between assignments at Station 4. They were in the middle of their 24-hour shift and knew what to do. They secured their equipment and apparatus, donned their turnout gear and relocated to the shower area of a bathroom in the center of their station. The room was constructed with cinder blocks on all four sides, so they knew it was one of the most solidly constructed areas in the station.
“They knew their station could be damaged or destroyed by a tornado, but because tornados can change course so rapidly at the last minute, we never relocate apparatus. So Engine 4’s crew took refuge in the safest possible area of the structure,” says Chief of Tuscaloosa EMS Travis Parker. As an added safety precaution, each firefighter covered himself with a mattress off a station bed, an action that helped add more distance and padding from the destruction and debris that was just moments away from them.
The EF-5 storm hit like an out-of-control freight train, traveling almost directly over the top of Station 4 and the neighborhood it served, producing 200-mph winds. The resultant damage was equivalent to the damage 50 bulldozers could do if they ran side-by-side through the area, Parker estimated. Station 4 was torn apart in an instant, and ALS Engine 4 was so severely damaged it was immediately inoperable.
Fortunately, Reserve Rescue 24 was out for maintenance at the time and wasn’t destroyed.
Luckily, the crew of Engine 4 survived without significant injuries. When their communications center did an immediate “all call” request after the storm passed, their company officer, Captain Jeff Roberts reported that they were alright. Even with their station destroyed, their apparatus inoperable, they were taking EMS equipment and search-and-rescue gear and heading into their district on foot to start search-and-rescue and EMS operations. Like true professionals, the crew of Engine 4 that had just survived a near-death experience immediately brushed themselves off, geared up and moved out to find, rescue and treat the residents they serve.
—A.J. Heightman, MPA, EMT-P
To read the rest of JEMS Editor-in-Chief A.J. Heightman’s report about the Tuscaloosa tornado, visit www.jems.com/tuscaloosa-copes-death-destruc
Less Use of Lights & Sirens
New York City Fire Department (FDNY) has expanded its modified response program—a scheme to reduce the number of runs made with lights and sirens—from Queens to Brooklyn and Staten Island. Since October, FDNY units in Queens have responded to non-fire and non-life threatening calls with a single unit traveling at reduced speeds, obeying traffic regulations and foregoing the exhilaration of lights and sirens.
John Freese, MD, FDNY’s medical director for training, says he doesn’t foresee any immediate changes in the department’s EMS response protocols. FDNY EMS has used the department’s “home grown” dispatch prioritization strategy since about 2002 to determine when lights and sirens are appropriate. Calls are categorized into eight segments, and the two lowest-level segments respond without lights and sirens.
FDNY Fire Commissioner Salvatore J. Cassano says there were 32% fewer fire-vehicle accidents during the test period in Queens.
Jeff Clawson, MD, former medical director of Salt Lake Fire Department (SLFD), says when SLFD started using the Medical Priority Dispatch System—his invention—vehicle accidents declined. In 1983, the department experienced a 78% reduction in accidents.
“Running hot [lights and sirens] doesn’t make a dime’s worth of difference when it comes to clinical outcomes,” says Clawson, also the co-founder of the National Academy of Emergency Dispatch.
We’re not talking about just vehicle damage and minor injuries when emergency response vehicles are involved in an accident. Although there don’t seem to be current studies on EMS vehicular deaths, a study of EMS line-of-duty deaths from 1992–1997 determined that at least 67 EMTs and paramedics died as the result of ground transportation accidents. That doesn’t take into account the number of patients killed or the civilians who died from those accidents.
When more EMS agencies re-assess the cost-benefit of lights and sirens, we’re likely to see even fewer ambulances and chase cars screaming through the streets.
It’s All in the Wrist
A study in Circulation (April 2011) includes research that links overweight children with larger wrist bone measurements and higher insulin resistance, which is a risk factor for developing future heart disease. The high insulin resistance occurs when the body makes insulin but can’t use it efficiently to break down blood sugar.
Senior author of the study, Raffaella Buzzetti, a professor in clinical sciences at Sapienza University of Rome, says, “One of the major priorities of clinical practice today is the identification of young people at increased risk for insulin resistance. This is a very, very strong link.”
In the study, the wrist circumferences of 477 overweight and obese kids and teens (average age 10) were measured with a tape measure; 51 also had nuclear magnetic resonance imaging. This allowed researchers to measure the wrist bone alone. All the children also had blood tests to measure insulin levels.1
The research showed a much stronger relationship between wrist bone circumference and the level of insulin in the blood than the relationship between body mass index (BMI) and insulin levels. BMI is a number based on weight and height that’s used to estimate whether a person is of normal weight, underweight or overweight. BMI has also be used as an indicator of diabetes and heart risk.2
“While excess body fat is linked to heart disease risk, this is the first evidence that suggests a larger wrist circumference flags it too,” says Suzanne Steinbaum, director of women and heart disease at Lenox Hill Hospital in New York City. Steinbaum says it makes sense because it’s known that an increased amount of insulin in the system acts as a growth factor on bones. Steinbaum says, “We talk about the concept of being big-boned, but does that imply anything? What this is saying is that there might be some correlation between wrist circumference and insulin resistance.”
JEMS Editor-in-Chief A.J. Heightman says, “The relevance of this research to EMS is to further educate and alert prehospital personnel that obesity is an epidemic in our society, one that’s impacting our patients, family members and fellow EMS providers—and now perhaps starting at an extremely early age and progressing to conditions that will affect individuals later in life.”
Heightman adds, “Obesity needs our attention and is obviously one of the new symptoms and potentially causative factors that should be noted during our assessment and reporting of patient vital signs. The recording of a patient’s age and estimated weight is now more important than ever and should be transmitted to the emergency department as a standard part of every radio report.” JEMS
1. Brophy M. Apr. 11, 2011. Kids’ Wrist Size Tied to Heart Health in USA TODAY. http://yourlife.usatoday.com/health/medical/heartdisease/story/2011/04/Kids-wrist-size-tied-to-heart-health-/46025824/1
2. Capizzi M, Leto G, Petrone A, et al. Wrist circumference is a clinical marker of insulin resistance in overweight and obese children and adolescents. Circulation. 2011;123(16):1757–1762.
Over the past few years, EMS providers have heard a lot of talk about the Health Insurance Portability and Accountability Act (HIPAA) and patient privacy. You probably received your mandatory HIPAA privacy training from your EMS agency at some point. Despite all of the talk and training about patient privacy, we still hear frequent reports of both inadvertent and intentional breaches of confidential health information that should be protected under the law. Facebook and other social media websites seem to be where many of these breaches are occurring these days.
Facebook and social media aside, however, there are still many types of “everyday” inappropriate disclosures of patient information in EMS that simply shouldn’t happen. One of the most frequent types of violations is the purposeful or even neglectful sharing of patient information with co-workers and others not involved in a call. Simply put, although HIPAA permits formal review processes, such as quality assurance/quality improvement (QA/QI) and similar activities, it doesn’t permit informal, casual sharing of patient information with others not involved in treatment, payment or “healthcare operations” activities and who have a legitimate, job-related need for the patient information. It certainly doesn’t permit the informal, station house “chit chat” about specific patients that seems to occur all too often.
If you’re discussing a specific call in the context of a QA/QI meeting, and only the minimum necessary amount of patient information is being used, there are no HIPAA violations. But when you return from a call and tell a co-worker, “Man, that was a gnarly trauma call we just had. It was that guy who lives in that big house on Main Street, Mr. Smith. Man, what a mess,” then you’ve crossed an ethical—and legal—line.
Similarly, EMS providers should properly transfer and store their patient care reports in designated places after completion. They shouldn’t be left lying around in the open where others can see them. And if they are left in the open, other personnel in the organization who don’t have a legitimate, job-related need to see that information should, quite frankly, leave it alone and resist the temptation to sneak a peek when they have nothing to do with their jobs.
Everyone in EMS needs to be attentive to privacy and confidentiality issues at all times. Not only is it the law, but it’s also an ethical obligation of the highest order: We depend on the trust and confidence of the public we serve, and the surest way to lose that trust is to betray the confidence of our patients.
Pro Bono is written by attorneys Doug Wolfberg and Steve Wirth of Page, Wolfberg & Wirth LLC, a national EMS-industry law firm. Visit the firm’s website at www.pwwemslaw.com for more EMS law information.
Troy FD Battles System Abuse
Frustrated by reports of people calling an ambulance for minor or non-existent issues, lawmakers in Rensselaer County (N.Y.) are launching an investigation they hope will lead to a reduction of on EMS system abuse. “We’ve got some pretty solid information, but we’ve got to put it into specifics in terms of actual instances of misuse and address what it’s coming from,” says Rich Crist, a spokesman for the Rensselaer County Legislature, which adopted a resolution to start the research.
One goal is to cut increasing Medicaid costs associated with “chronic callers,” Crist says. “There’s one guy who gets intoxicated and he wants something to eat,” Crist says. “He knows if he says he’s experiencing chest pains, he’ll be admitted overnight.”
Those situations, Crist says, tie up EMS crews, hospitals, and they cost the Medicaid system.
“If we’re called, we go, but we have had instances where we’ve been called every day, in some instances for a couple months, for people who want a ride to the hospital,” Tom Garrett, chief of the Troy Fire Department told the Troy Record.
The legislature is aiming to get the review started this summer, Crist says. He admitted, however, that there are many unanswered questions, starting with how much the abuse costs the Medicaid or EMS systems. Likewise, lawmakers haven’t discussed what happens if they uncover Medicaid abuse, how long the research will take or how to implement solutions.
“That’s one of the big problems,” Crist says. “How do we incorporate this research and get some of these folks to a point where we can affect some positive change? We want to do something that discourages people from abusing a legitimate publicly-funded response system.”
Mecklenburg Reduces Unnecessary EMS Calls
The Mecklenburg (N.C.) EMS Agency has teamed up with two Charlotte healthcare companies to launch OMEGA, a program that gives 9-1-1 callers with minor illnesses a shot at speaking to a nurse and avoiding a trip to the hospital.
“We have a mantra, the right care at the right place and at the right time,” says Barry Bagwell, deputy director of Mecklenburg EMS, also known as Medic. “The goal is to give our patients an alternative if their condition does not dictate that they need a paramedic or an EMT to respond and transport them to an emergency room.” After researching the Medic’s calls for four years, officials identified 44 health scenarios that would qualify for the OMEGA program. Callers meeting those parameters are offered the option of talking to a registered nurse provided by either the Carolinas HealthCare System or Presbyterian Healthcare. The nurse can then suggest alternative care. Bagwell says OMEGA-qualified calls represent 1% of Medic’s 105,000 annual responses.
“All of the illnesses or injuries are absolutely treatable at home or [with] a ride to the hospital in their own personal vehicle that day or even the next,” says Don Robinson, Mecklenburg’s quality improvement/training coordinator.
Bagwell says the program wasn’t created to eliminate repeat callers or to save money, but rather to provide better service.
“It’s all about providing the right care,” Bagwell says. “If it works out that now an ambulance is available for the person with a STEMI, or a stroke or a trauma to get help faster, that’s an upside.”
Names In the News
JEMS Technical Editor Travis Kusman, MPH, NREMT-P, recently assumed the role of division general manager for Rural/Metro’s EMS operations in Santa Clara County (Calif.).
JEMS Technical Editor Fred W. Wurster III, AAS, NREMT-P, recently accepted the role of director of training for Good Fellowship EMS Training Institute. He oversees all the education programs, including ALS, BLS, community education
and member training.
In Brief: For more on the Federal EMS Agency discussion, visit www.jems.com/federal-ems-agency
145 providers attended this year’s EMS on the Hill Day: www.jems.com/2011-ems-on-the-hill-day
CDC study finds costs of U.S. crash-related deaths is $41 billion: http://1.usa.gov/jyWKv1
For the lastest news in the EMS industry, visit www.JEMS.com/news
This article originally appeared in June 2011 JEMS as “Lead Federal EMS Agency: Is it coming soon?”