Administration and Leadership, Columns, Commentary

Learning from the Past to Make the Future of EMS Even Better

Issue 6 and Volume 43.

Seeing the future’s potential as we learn from the past

I recently had the honor of addressing the first graduating class from the San Diego Fire-Rescue Department’s (SDFD) paramedic program, for which I serve on the academic advisory committee.

The ceremony was held on the top deck of the historic USS Midway aircraft carrier, which is now docked in San Diego bay as a floating museum.

It was a fitting location for the historic paramedic graduation, and it made me think about all the reasons why the 16 graduates are now pioneers in the next generation of EMS.

The astronauts who flew on the initial Gemini missions, cramped in a single-seat capsule with no escape hatch, later watched in amazement as advances in technology allowed three astronauts to ride side-by-side to the moon and back, which led to the seven who got to enjoy the comfort and capabilities of the massive space shuttles. In the same way, today’s young EMS pioneers are entering a much improved clinical and technological world of medicine.

As I stood on the deck of the Midway, I noticed the H-34 Seabat helicopter that was designed in the 1950s. The Seabat helped turn the helicopter into an effective anti- submarine weapon.

This now antiquated, low-tech helicopter was also used to recover Mercury astronauts and transport them back to the safe confines of the aircraft carrier during NASA’s early years.

More significantly, because of their age, prior experience, maturity and entry into paramedicine at this point in the evolution of EMS, the new graduates have many more options available to them. Their depth of knowledge, hospital clinical time and internships affords them so much more opportunity than I had as a paramedic student.

As a young paramedic graduate 43 years ago, I was proud of everything I was taught, including all of my new equipment and capabilities. But, as I look back, I realize that I was one of the “shoestring” medical pioneers.

We didn’t have the benefits of solid radio or cellular coverage; 12-lead ECG capability; CPAP; intranasal naloxone; impedance threshold devices (ITDs); adult intraosseous drills and needles; pelvic splints (vs. tied bed sheets); mechanical CPR and extracorporeal membrane oxygenation (ECMO) capabilities within our systems.

For many years, I wasn’t allowed to start an IV, defibrillate, administer drugs or terminate resuscitations on scene prior to receiving a physician’s order. The delay in care and administration of drugs and shocks resulted in few successful resuscitations.

These young graduates have all of this available to them—and much more.

A.J. addresses the first graduates of the San Diego Fire-Rescue paramedic program. Photo courtesy Monica Munoz

Teach it Back

During the ceremony, I recalled a fabulous educational exercise I’d been a part of a few months earlier—with this same group of paramedic students.

Paramedic program clinical coordinator Carolyn Gates and program coordinator Ted Chialtas recently added a new session, and had invited me to take part.

In the exercise, each student had to select a JEMS article, read it, understand it and develop a 10-minute presentation where they delivered a concise analysis on the topic of the article, including how it had an impact on them as well as their colleagues throughout the world.

In addition to their classmates, the audience also included a panel of guests that included SDFD’s medical director, several associate medical advisors, senior staff and me.

Carolyn was inspired to create this exercise after she learned about an amazing educational experience called “teach it back” that her two daughters, Ashley and Jackie, had when they were in fifth grade. Their teacher would present a lesson and then assign a student to teach it back to the class. It required the students to pay close attention to the content, because they knew one of them would have to teach it back. They were then tasked with redoing the class in their own words and style.

Carolyn loved the exercise for its educational value, and its ability to develop each student’s self-confidence in presenting pivotal EMS information.

After each student presented on the significance of the article they selected, the panel had the opportunity to either comment or ask questions of the students.

The concept has been beneficial not only for learning retention, but it’s also been connected to a reduction in medical errors.1

The 16 graduates of the San Diego Fire-Rescue paramedic program, class of April 2018. Photo A.J. Heightman

The 16 graduates of the San Diego Fire-Rescue paramedic program, class of April 2018. Photo A.J. Heightman

A Beacon of Light

The teach it back session was an amazing exercise that made a powerful impression on me, not only because I could hear the enthusiasm in each student’s voice, but also because I realized that I was hearing from the next generation of EMS providers who can—and will—make an impact on what we do and how we do it.

It’s rare for students or providers to be asked or afforded the opportunity to look toward the future and see which capabilities can and must be advanced to save additional lives.

As each student delivered their presentation and discussed their article’s impact, I began to appreciate how today’s providers are subject to much more violence than I ever was.

The uptick in fentanyl abuse means providers are more susceptible to the harmful effects of the drug if it comes in contact with their skin or respiratory system. Chemically induced suicides, where deadly gasses have been released from a bucket on the floor of a car, can also kill providers if they don’t wear proper personal protective equipment (PPE) and respiratory apparatus.

This remarkable learning experience also made me realize that, in addition to these hazards, there’s a beacon of light that shines over the EMS horizon.

New technologies and techniques can save providers’ backs and musculoskeletal systems, their respiratory systems and their lives—as well as the lives of many patients who we previously thought wouldn’t survive.

Today, in many EMS systems, mechanical chest compression devices and ECMO keep cardiac arrest patients alive for hours, sometimes days. These new providers are entering a world with resuscitation capabilities that have never before been presented: The capability to place and maintain patients in a “suspended” state with continuous compressions, ITDs, targeted temperature management and ECMO. These advances allow specialty centers to intervene and correct problems hours and days after a major insult to the lungs, heart and/or brain.

A.J. takes part in the teach it back exercise with San Diego Fire-Rescue paramedic students. Photo courtesy Carolyn Gates

A.J. takes part in the teach it back exercise with San Diego Fire-Rescue paramedic students. Photo courtesy Carolyn Gates

The Challenge of Change

Along with these new skills, technologies and research come additional challenges that these new pioneers will face.

The first is tradition. More experienced providers haven’t always been exposed to the same articles and research, or had the firsthand experience of a prolonged resuscitation, a chemical suicide or violence. Because of this, they’ll often resist change and remain in their comfort zone.

There’s a touch of complacency that occurs when people get used to calling a cardiac arrest after 20 minutes, or taking patients to closer hospitals rather than resuscitation centers that might be blocks or miles away.

The second challenge is getting medical centers, the recipients of these patients, to realize that EMS now offers much more than it did previously. Many of these facilities now accept our judgment when calling trauma alerts.

However, now we’re calling in and asking them to trust our judgment with ST- elevation myocardial infarction (STEMI) alerts, cath lab activation, stroke alerts that need early staff intervention, and sepsis alerts to battle the insidious effects of infection.

Many physicians come from the “old school,” and don’t react well to prehospital personnel alerting them that actions are needed after we deliver our patients into their domain.

The young pioneers of EMS are tasked with being patient, and understanding that these hurdles must be overcome to have new techniques, protocols and equipment accepted by their colleagues and hospital counterparts.

To address this, the programs that SDFD and other educational centers have instituted teach students to be diplomatic, well-informed and strategic. New providers are now armed with articles, research and case studies to educate their colleagues about the tremendous capabilities that we currently have—and will have—in the future.

It’s a noble mission for all new graduates, both EMTs and paramedics, to embark on.

Program clinical coordinator Carolyn Gates, EMT-P, FP-C, addresses the graduates on the deck of the USS Midway. Photo A.J. Heightman

Program clinical coordinator Carolyn Gates, EMT-P, FP-C, addresses the graduates on the deck of the USS Midway. Photo A.J. Heightman

Looking Forward

Early astronauts were launched into space in what they understood to be a safe and technically advanced environment. They never knew what would come after their pioneering efforts.

The Apollo spacecraft that successfully landed astronauts on the moon and safely returned them to Earth did so with, by today’s standards, a primitive computer that had just 10 megabytes of memory.

Today’s EMS pioneers have much more than 10 megabytes of storage space on their phones. This gives them the ability to instantly to look up protocols, hazmat indices, drug interactions and checklists that allow them to deliver care faster and more effectively than in the past.

It’s an exciting and challenging time for new EMS providers who choose this path because of what it has the potential to do going forward—rather than what it’s been doing for decades.

It’s important that we support their efforts and respect their opinions. They represent the future of EMS.

Reference

1. Tamura-Lis W. Teach-back for quality education and patient safety. Urologic Nursing. 2013;33(6): 267–271, 298.

Skills & Experience: San Diego Fire-Rescue April 2018 Paramedic Class

Didactic/classroom education includes 579 hours of training:

>>83 drug, protocol, ECG and pathophysiology quizzes;

>>10 major exams;

>>Certifications in prehospital trauma life support (PHTLS), advanced cardiac life support (ACLS) and pediatric advanced life support (PALS);

>>3 written final exams; and

>>2 oral field readiness interviews.

Clinical education with live patients includes 160 hours of training:

>>1,618 IVs established successfully;

>>1,955 doses of medications administered; and

>>144 successful endotracheal intubations.

Field internships include 528 hours of training:

>>2,510 9-1-1 calls run on both San Diego Fire engines and AMR ambulances;

>>847 attempted IVs with 77.29% success;

>>1,038 ECGs interpreted; and

>>27 cardiac arrest cases managed.

About the students:

>>The most senior graduate in the class has served 9 years with SDFD. The least senior graduate has served 2 ½ years;

>>April 2018 class graduated 16 of 18 students (88.9% retention rate);

>>9 came to the program with a bachelor’s degree—one from Harvard University;

>>2 students graduated from the U.S. Naval Academy in Annapolis, Md.; both served in the U.S. military (Navy and Marine Corps), and a third is anticipating acceptance to an Air Force Reserves special operations unit.

>>1 was previously an analyst for the Department of Defense at the Pentagon;

>>4 are college athletes;

>>1 is a licensed private pilot and skydiving instructor who has completed more than 11,000 jumps; and

>>1 holds a purple belt in Brazilian Jujitsu.