Known for its induced hypothermia protocols, Advanced Practice Paramedics and conspicuous vehicles, innovation is truly a hallmark of the Wake County Department of Emergency Medical Services, based in Raleigh, N.C.
The department, which is actually comprised of multiple provider agencies, is directed by J. Brent Myers, MD, who was selected by the National Association of EMTs as 2006 Medical Director of the Year. The largest agency within the system is the Wake County EMS (WCEMS) division, which is headed by Chief Skip Kirkwood, who also serves as the deputy director of the entire Wake County system. The system is comprised of five contracted, not-for-profit providers: Apex EMS, Carey EMS, Eastern Wake EMS, Garner EMS and Six Forks EMS. A sixth partner agency, Holly Springs Fire Department, provides a driver and ambulance for the county’s paramedics.
This system’s induced hypothermia by EMS protocol is yet another example of how well-informed EMS leaders are able to create change within hospitals to patients’ benefit.(Watch Myers’ recent Webcast on prehospital hypothermic resuscitation here).Wake’s protocols have now been implemented in some variation in many EMS throughout the country.
Advanced Practice Paramedics
WCEMS’ take on Advanced Practice Paramedics (APP) was featured several months ago in JEMS.com.Read it here.
In what must be among the most desired opportunities in EMS, specially trained paramedics provide both preventive primary health care and high-level ALS care, responding to scenes in HEMI-powered police Dodge Chargers. According to Kirkwood, the program is going well, if a bit differently than anticipated.
WCEMS proposed a two-year phase-in program, which was approved for a three-year phase-in. The county fully funded the first year, but the economic downturn has hurt the program’s funding and, at the present time, the county does not have funding for the second year. “So we have five [APPs] on the road during the day and two at night, instead of the 14 the plan originally called for,” said Kirkwood. This change has modified their activities, so they’re spending more time running DELTA- and ECHO-level emergency calls, and less time performing preventive health activities. Even with the unplanned changes, WCEMS officials hail the program as a success. According to Kirkwood, several frequent flyers don’t even dial 9-1-1 anymore, because the program has facilitated getting their primary care needs met.
But more importantly, Kirkwood says the program has saved lives. APPs making home visits have discovered unconscious patients on more than one occasion (for example, with blood sugar levels of less than 20 with nobody else at home) who may well have died had they not been discovered. The program has also saved emergency department (ED) hours by getting patients with mental health needs to a more appropriate destination than a hospital ED, and kept ambulance resources available.
Vehicle Conspicuity
WCEMS has been leading the way with emergency vehicle conspicuity and visibility in the U.S. for some time. When pictures of its European-looking, chevron-patterned vehicles were first published in 2007, they were an oddity. Now, many EMS systems have embraced conspicuity over aesthetics, and such reflective decal patterns are commonplace. And now, the U.S. Fire Administration (USFA) has informed WCEMS that its vehicle will be featured on the cover of the USFA’s soon-to-be-released vehicle conspicuity manual.
WCEMS has also aided in the validation of Emergency Medical Dispatch protocols and evidence-based treatment protocols. In 2007, they participated in a resuscitation trial evaluating a threshold impedance device. WCEMS seems to be well at home at the forefront of our discipline.
Chief Skip Kirkwood provided the following detailed service specs.
Wake County EMS at a Glance
Name of service:Wake County EMS System and Wake County EMS Division
EMS chief:The Wake County EMS System is headed by Brent Myers, MD, MPH, FACEP, who s responsible to the county manager and the board of county commissioners for the operation of the EMS system. WCEMS is headed by Chief Skip Kirkwood, who also serves as the deputy director of the county EMS system.
Medical director:Myers is also the medical director for the entire system. In addition to his emergency medicine training, he completed an EMS fellowship prior to entering full-time practice. He s a board-certified emergency physician and also holds a master’s degree in public health.
Assistant medical directors:Myers is assisted by a part-time assistant medical director, Paul Hinchey, MD, MBA, EMT-P. Dr. Hinchey spent a year as an EMS fellow before joining Wake emergency physicians and has been a paramedic and paramedic educator for many years. WCEMS’ current EMS fellow is Jose Cabanas, MD. Cabanas is a former paramedic with the Cuerpo de Emergencias M dicas del Estado Libre Asociado de Puerto Rico, the state EMS system in Puerto Rico.
EMS organizational structure:Each of the operating agencies, as well as the office of professional development and the office of medical affairs, reports to Myers but has its own internal structure.
Primary service Area:Wake County, North Carolina — one of the fastest growing counties in the U.S.
Population served:866,000
ALS ambulance staffing:Historically, the WCEMS has utilized a dual-paramedic staffing model, while the contract agencies have staffed one paramedic and one EMT or EMT-I. This past year, with the introduction of the APP program, WCEMS hired a class of “technician I” employees who are EMTs, EMT-Is or new paramedics.
Vehicle types:The system standard ambulance is a Type III ambulance on a Ford E-450 chassis. This year, WCEMS will take delivery of five medium-duty ambulances (Freightliner M2). Several of the contract agencies operate one or more medium-duty trucks. WCEMS district chiefs operate GMC Suburbans, with a test implementation of a four-door pickup with a utility body this year. APPs and senior staff operate Dodge Charger patrol vehicles. Other senior staff members operate a variety of mid-size SUVs.
Number of BLS transport vehicles:None.
Number of ALS transport vehicles:There are 55 licensed ambulances within the system. At peak hours, 35 units are on duty. This number falls to 28 after midnight.
Station type:A variety of deployment locations are utilized. The system deployment model is described as “station-based dynamic deployment.” An estimated 50% of units operate from single-purpose EMS stations. Several operate from county-owned or privately owned fire stations, and two fire departments operate from county-owned facilities. Several City of Raleigh, Town of Wake Forest, and other fire stations serve as dynamic posting locations, particularly for the peak-load (12-hour per day) units.
Number of EMS supervisors:At any one time, five EMS system supervisors are on duty. Three are division district chiefs, one is employed by Cary Area EMS and one is employed by Eastern Wake EMS. All supervisors have systemwide authority (operationally, they work as a single agency). Ten district chiefs are employed by the WCEMS; Cary and Eastern Wake each employ three supervisors.
Number of ALS non-transport:APPs comprise the only non-supervisory, non-transport ALS resource. Five APP units are on duty during daylight hours and two overnight. Special APP roles include supplementary response to critical calls, handling of high risk refusals, intervention with frequent system users, performance of well-person checks, and provision of mental health crisis intervention services (facilitating direct access to the county’s crisis assessment unit instead of sending patients to the ED).
Number of EMT certified personnel:There are about 225 paramedics and 225 EMTs in the system. The department also accredits fire service EMTs and medical responders (1500) and all 9-1-1 tel-communicators through the EMD oversight process.
Number of EMS annual calls:The system handled 72,000 calls last year, with 42,000 of those handled by the WCEMS and 30,000 shared by the contract agencies.
Average response time:The system performance goal is 11 minutes, 59 seconds at the 90th percentile. Performance is measured monthly, and it hovers at 88 92% percent each month. First response performance is just over eight minutes at the 90 percentile countywide (all are defibrillator-capable).
Co-responders:All fire departments in Wake County provide medical first response service either at the medical responder (first responder) or EMT-basic levels. There are no “first response paramedics.”
Starting salary EMT:$25,500 42,500
Starting salary: paramedic:$34,400 54,400, depending on years of paramedic experience in an EMS system of comparable demand. A 5% premium is paid to up to 52 authorized field training officers.
Protocol highlights:WCEMS prides itself on having state-of-the-art, evidence-based EMS protocols. Paramedics are expected to function independently, with minimal on-line medical supervision. Although the system has a consistent 99% intubation success ratio, use of the King airway use is on the rise by paramedics who understand that cardiac arrest survival is heavily dependent on zero-interruption chest compressions. WCEMS protocols are available online atwww.wakegov.com/ems.
Current or past research activities:Peer-reviewed papers have validated selected aspects of the medical priority dispatch system, and Myers was a principal author of this past April’s seminal paper on evidence-based EMS practice (Myers JB, Slovis CM, Eckstein M, et al:”Evidence-based performance measures for emergency medical services systems: a model for expanded EMS benchmarking.”Prehospital Emergency Care. 12[2]:141 151, 2008).
Current Challenges:Like everybody else, WCEMS struggles to maintain quality and quantity of service in the tight economy. They’ve also been challenged by the Ford 6.0 liter engine. Recruitment and retention were problems for a while but seem to be less so now.
Use of helicopters in the system?:Rarely. WakeMed AirMobile 1 is based in central Wake County, but an excellent transportation network makes its in-county use infrequent. Other helicopters operated by Duke University and the University of North Carolina are nearby if needed.
Currently recruiting?:Yes, although they have suspended hiring pending the finalization of the county budget in mid-May. However, at the time this article was written, it did not appear that either WCEMS or the contract EMS agencies would have to reduce workforce size due to budgetary issues.
Recruit Requirements:Applicants must have a North Carolina EMT, EMT-I or EMT-P license, or be eligible for one prior to hiring. National Registry certification is accepted for obtaining a North Carolina credential. The hiring process involves a comprehensive assessment center, background investigation and pre-employment drug screening. WCEMS also expects to introduce a physical abilities test when hiring resumes in a few months.
Contact for employment or other information:Positions are posted and applications accepted online atwww.wakegov.com/jobpostings/code.
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