Columns, Commentary, Operations

EMS Agencies Must Learn to Adapt to New Challenges

Issue 3 and Volume 43.

 

My job as Editor-in-Chief requires a lot air travel, where I get to visit with the individuals that keep EMS rolling.

People are always proud to tell me what’s working for their agencies and systems. More importantly, they often open up to me about the problems and challenges they face. Some ask for solutions from those who have faced similar challenges.

I’m often able to help them, but sometimes I can’t. Regardless of the challenge, I have plenty of time in the air to think about and synthesize their issues.

As I fly, I often look out the airplane window at the mountains, rivers, snow and deserts below and wonder how the early settlers in these vastly different landscapes coped with the challenges ahead of them.

I wonder how the Conestoga wagons, with their limited water supply, wooden wheels and no air conditioning, traversed the territory and allowed them to survive and prosper in uncharted areas.

The fact is, they did. They learned to adapt, analyze their problems, and develop innovative solutions like water towers, telephone systems, tunnels, railroads and airplanes.

I consider it my job to synthesize what I observe and learn, and present information and concepts to you, along with the success stories, science and references to best describe it. What you, your colleagues and administrators do with it is beyond my control.

Here are just a few of the challenges I see on the horizon, as well as information that can assist you in addressing some common problems in EMS.

My goal is for these concepts and examples to challenge you to follow up, read the available science, pass the information along to those who can make changes—and convince others to follow suit.

New Threats & Disasters

An increasing number of terrorists in vehicles; individuals with automatic weapons in tall buildings, schools and other soft-target areas; deadly domestic violence and responder traps; massive wildfires, mudslides, hurricanes, floods and the threat of tsunamis and nuclear attacks, have changed the way we prepare for major incidents and protect our staff.

As society and situations change, we too must change. We have to be able to deploy our personnel faster, and give them the processes, tools and resources they need to counter each of these threats.

Body armor and ballistic helmets are no longer a luxury in many service areas—they’ve unfortunately become a necessity.

Keeping Up With the Science

Medicine is changing rapidly thanks to research, advances in technology and improved communications.

Research like we presented in the December issue and its accompanying 36-page supplement present documented and undeniable proof that we can do better in the area of resuscitation if we change our mindset and approach.

The Rialto (Calif.) and Lincoln (Neb.) fire departments, and EMS systems like Alameda County (Calif.), Minneapolis and King County (Wash.) are closely aligned and interlinked with their hospital clinicians for a holistic approach to cardiac arrest.

They exhibit what can be done if you rethink your approach to resuscitation, implement changes outside the norm and convince hospitals that there can be better outcomes if the care we start in the field is continued in the hospital.

These systems have shown that survival rates can improve by using defined bundles of care, which include things like technology and citizen alerting systems; mechanical compression devices; direct-to-cath lab care; extracorporeal membrane oxygenation (ECMO)-capable EDs and committing to continuing resuscitation attempts long after a 20-minute limit that many systems still adhere to.

Soldiers in Afghanistan are being saved by resuscitative endovascular balloon occlusion of the aorta (REBOA), a procedure that temporarily stems bleeding until they can be treated in an operating theater. Patients are being resuscitated after hours on mechanical compression devices and days of ECMO therapy.

We’ve proven that EMS can detect and report ST-elevation myocardial infarctions (STEMIs) and sepsis in the field, and reduce morbidity and mortality by implementing direct-to-cath lab and sepsis alert protocols in conjunction with accepting hospitals.

The problem is that many hospitals keep their heads buried in the sand. They either ignore the prehospital assessment, or hold critically ill or injured patients captive in their EDs without allowing them to benefit from essential procedures.

The real elephant in the room is that, despite proven research and practices, outdated thinking and stale protocols in hospitals aren’t offering the same aggressive care to patients once we deliver them through the doors of the ED, or they’re calling resuscitative efforts after the unsubstantiated 20-minute limit.

This is an area of liability and change that I promise JEMS and many other associations, researchers and lawyers will no longer allow to go unnoticed and unaddressed.

Rethinking Patient Care

Thermometers, capnography, impedance threshold devices and compression devices are becoming the norm for BLS and ALS units, allowing them to detect and care for septic patients, strokes and STEMIs.

Despite resistance from many in the medical community, I predict that improved, compact, accurate and affordable ultrasound units (and headsets like the BURL Sonic Device) will soon be guiding care in the detection and treatment of codes, strokes and trauma patients.

I also believe that a new study by Boston University researchers and published in Brain, a respected peer-reviewed journal, will soon change the way we assess and triage concussions and head injuries. Their ground-breaking research has found that it’s the impact to the head that causes chronic traumatic encephalopathy (CTE), the neurodegenerative disease that’s been linked to the type of head trauma that has been killing football players, combat veterans and, likely, many trauma patients.1

The researchers analyzed the brains of teenagers with head injuries and used mice to recreate head trauma, and revealed new facts about the origins of CTE and its relationship to traumatic brain injuries, concussions and subconcussive head injuries. They found that brain pathology was “unrelated to signs of concussion, including altered arousal and impaired balance.”1

Lee Goldstein, MD, an associate professor at Boston University’s School of Medicine and College of Engineering, and author of the watershed study, has stated that concussion is “really irrelevant for triggering CTE.” Rather, it’s “the hit [to the head] that counts.”1

We learned years ago that mechanism of injury was an important assessment tool for predicting the seriousness of multisystem trauma patients.

I believe this new study will change the way we assess, treat and transport head- injured patients.

This information will likely lead to protocols being rewritten to move patients who sustain a significant impact to their head to a trauma or neurology center based on the impact—rather than relying on visible trauma or other signs of concussion.

A study has shown that concussion is ‘really irrelevant for triggering CTE.’ Rather, it’s ‘the hit [to the head] that counts.’

Death Traps Redesigned

It took stubborn military leaders and our government years to accept the fact that flat- bottomed Humvees were death traps when they encountered roadside bombs.

Countless soldiers lost their lives until we invested in mine-resistant armored vehicles (MRAVs): vehicles with V-shaped, deflective, heavily armored bottoms and ballistic underwear. These innovations have become the standard of protection for soldiers and vehicles.

It’s taken years, and the loss of countless emergency personnel, for our industry leaders to accept that reflective chevron striping was needed on the rear of all emergency vehicles and reflective vests needed to be worn by emergency personnel who park or operate on fast-moving highways.

In the 80s, we moved from unibody limousine and truck ambulances to “boxes” bolted on truck frames that frequently cracked open like eggs when hit from the side or rolled over.

Our industry is now on the right track to redesigning safer ambulances and safer seats that keep providers securely in place while able to reach equipment and patients.

Our crews are struggling with stress, finances, excessively demanding shifts & punishment for sleeping on duty & reporting medical errors.

Deadly Fatigue & Stress

On Jan. 22, 2018, an EMT in Miami County, Indiana, allegedly fell asleep at the wheel of an ambulance, ran a red light and crashed into a car. The ambulance rolled on its side and Mousa Chaban, a 32-year-old paramedic, was partially ejected and killed.2

Our crews are struggling with stress, finances, excessively demanding shifts, and punishment for sleeping on duty and reporting medical errors.

These are issues that have been largely ignored—until now. There’s now significant evidence, and well-documented cases proving that sleep deprivation, excessively long shifts and working back-to-back jobs and overtime, are resulting in our personnel dying needlessly or making deadly clinical mistakes.

The research done by JEMS editorial board member P. Daniel Pattterson, Ph.D., EMT-P, and his colleagues, reported on in the February cover story, has, along with many other studies and reports, now charted a roadmap that emergency service officials should—and will probably have to—pay attention to.3–8

Research and deadly incidents, like the one described previously, have awoken the sleeping giant of ignorance and placed responsibility—and liability—on managers and government officials to make changes.

The military noticed accidents on aircraft carriers and in cockpits, and solved many problems by adopting the proven process of crew resource management (CRM), which carried over to EMS, fire and law enforcement agencies. CRM was born out of tragedies at sea and in the air, and is now accepted and practiced by forward-thinking emergency service agencies.4

Perhaps the most impactful example of CRM was Captain Chesley “Sully” Sullenberger’s safe landing of a U.S. Airways plane in New York’s Hudson River on Jan. 15, 2009.

On takeoff from LaGuardia Airport, a flock of geese was sucked into the plane’s engines, shutting them down in an instant, and forcing Sullenberger to take quick action in just three minutes—actions that experts agree wouldn’t have occurred without CRM knowledge and training. 9

Many lives have been saved by CRM safety procedures, which involve use of checklists and empowering employees to take control of situations and report risks and near-misses without fear of reprimand.

The U.S. Navy is finally beginning to recognize the problems caused by excessive stress, long shifts, and limited, cyclical sleep and sleep deprivation.

After several preventable and fatal accidents that that killed sailors and crippled vessels loaded with accident avoidance technology, the Navy realized that sleep-deprived and overworked sailors were the root of the problem.10

The Navy has now implemented a Circadian Rhythm Watch Program on surface ships to address the problem.10 I believe this will be adopted by high-demand, high-stress emergency service agencies.

Circadian rhythm is a naturally occurring 24-hour rhythm that drives human processes—even at the cellular level. Sailors now work on a routine that allows them to work, eat and sleep at approximately the same time each day.

Nita Lewis Shattuck, PhD, a professor at the Naval Postgraduate School, has worked with the Navy and Marine Corps for more than 14 years, tracking physical, mental and behavioral changes of sailors who follow a circadian rhythm watch schedule and comparing these with sailors on the typical “five and dime” watch rotation (five hours on, ten hours off), in which their watch times are different every day.10

Shattuck says, “People see the 10 hours off [on a five and dime] and think it’s better, but the sleep pattern is not as good. The body likes to sleep at the same time every day, and the five and dime is a three-day rotating pattern of sleep.”10

Researchers Michael H. Bonnet and Donna L. Arand report, “There is strong evidence that sufficient shortening or disturbance of the sleep process compromises mood, performance and alertness, and can result in injury or death. In this light, the most common sense ‘do no wrong’ medical advice would be to avoid sleep deprivation.”10

The researchers have shown that the 3/9 (three hours on, nine hours off) schedule is better than a 5/10 (five hours on, ten hours off), with sailors now working 30% faster and 40-50% more accurately than those on the 5/10.10

Shattuck says, “Better sleep is linked to improved memory, creativity, productivity, concentration, happiness, optimism and frustration tolerance.”10 I believe the research done by the Navy and Patterson will force EMS agencies to soon have to rethink and reduce shift lengths, stop back-to-back deployments and work by mercenary providers.

Agencies will have to allow staff to take breaks and naps while on duty and educate their staff about the deadly hazards of fatigue, exhaustion, stress and sleep deprivation.

‘Peak-Hour’ Fire Engines

Fixing EMS response time gaps has typically involved peak-time deployment of ambulances. Brian Fennessy, San Diego (Calif.) Fire-Rescue’s innovative chief, will soon try deploying peak-hour engines (PHEs) staffed by a crew of four paramedics—and not connected to a station—in an attempt to reduce emergency response times until additional fire stations can be built.

The engines will operate from 9 a.m. to 9 p.m. each day—the time when the city’s emergency calls are typically highest—in areas where response times have been difficult to meet, or where crews aren’t regularly available.11

This trial program will run until additional fire stations can be built in hard-to-serve areas, but results may show that fire departments can benefit by mimicking EMS’ flexible deployment models, which have been effective for decades.

City officials have agreed to Fennessy’s plan to add six PHEs to help achieve a goal to have EMS arrive on scene within 7.5 minutes at least 90% of the time.

The city is currently meeting that goal about 80% of the time; this program will determine if the additional deployment model can significantly boost that.11

To fully staff all six engines, the city plans to hire 48 additional firefighters at a cost of $6.3 million per year. No capital costs are anticipated because the city has several reserve engines it can use. 11

Conclusion

My wife calls me “the Fly” because I bounce from topic to topic, project to project and mission to mission like an insect on steroids.

I accept the nickname because time is never our friend, and these issues need to be addressed.

Trust the research from our industry, the military and other professions, and work to adopt principles and practices that can prevent needless medical errors, help us avoid financially devastating lawsuits, and, most importantly, save our patients and keep our crews safe.

References

1. Boren C. (Jan. 18, 2018.) A new study shows that hits to the head, not concussions, cause CTE. Washington Post. Retrieved Jan. 23, 2018, from www.washingtonpost.com/news/ early-lead/wp/2018/01/18/a-new-study-shows-that-hits-to-the-head-not-concussions-cause-cte/.

2. LODD: EMT driver falls asleep-technician ejected & killed in the line of duty. (Jan. 22, 2018.) Firefighterclosecalls.com. Retrieved Jan. 23, 2018, from www.firefighterclosecalls.com/lodd-emt- driver-falls-asleep-technician-ejected-killed-in-the-line-of-duty.

3. Patterson PD. Dead tired: Evidence-based recommendations for combatting fatigue in EMS. JEMS. 2018;43(2):26–35.

4. Saylors E. (Jan. 6, 2018.) Firefighters are not machines; they need sleep. Medium. Retrieved Jan. 23, 2018, from www.medium.com/@esaylors/ firefighters-are-not-machines-they-need-sleep-9fc33b8cfb3e.

5. Von Thaden TL. (April 1, 2017.) How sleep affects long-term health. Fire Engineering. Retrieved Jan. 23, 2018, from www.fireengineering.com/articles/print/volume-170/issue-4/features/how-sleep-affects-long-term-health.html.

6. Carvajal J. (October 2011.) Managing firefighter fatigue. NSCA TSAC Report. Retrieved Jan. 23, 2018, from www.nsca.com/education/articles/managing-firefighter-fatigue.

7. Do firefighter shift schedules affect sleep quality? (Aug. 17, 2017.) U.S. Fire Administration. Retrieved Jan. 23, 2018, from www.usfa.fema.gov/current_events/081717.html.

8. Elliot DL, Kuehl KS. (June 2017.) Effects of sleep deprivation on fire fighters and EMS responders. International Association of Fire Chiefs. Retrieved Jan. 23, 2018, from www,aams.org/toolbox/IAFC%20-%20Effects%20of%20Sleep% 20Deprivation%20Report.pdf.

9. Mulenberg J. (May 11, 2011.) Crew resource management improves decision making. ASK Magazine. Retrieved Jan. 23, 2018, from www.nasa.gov/pdf/546130main_42i_crew_resource_management.pdf.

10. LaCrosse L. (Oct. 20, 2017.) Circadian rhythm being implemented on navy surface ships. U.S. Navy. Retrieved Jan. 23, 2018, from www.public.navy.mil/surfor/Pages/Circadian-Rhythm- Being-Implemented-on-Navy-Surface-Ships.aspx.

11. Garrick D. (Dec. 30, 2017.) San Diego adding roving fire engines to shrink response times. Los Angeles Times. Retrieved Jan. 23, 2018, from www.latimes.com/local/lanow/la-me-ln-sd-fire-response-times-20171230-tory.html.