Early Christmas morning, Philadelphia trauma surgeonJohn Pryor,MD, 42, was killed in Iraq by mortar fire while serving his second tour as an Army combat surgeon. John lived a life of service to others. He started in EMS at age 17 and, unlike some who use EMS to bolster their medical school applications, John never forgot where he came from and never lost his love for prehospital care. As a prestigious surgeon, John continually gave back to EMS, lecturing to squads in New York (where he cut his teeth as a young EMT), serving on the editorial board of”žJEMS and serving as the trauma surgeon on the State EMS Medical Advisory Committee in Pennsylvania.”ž
John was never arrogant or condescending, and he never said “no” to any request that would help improve care for injured patients in the moment or in the future. He was a passionate teacher who freely shared his time and expertise with the Red Cross, EMS providers, nurses, medical students, residents, fellows and colleagues. John was also a wonderful friend and a loving husband, son, brother and father. He adored his wife and three young children. Those of us privileged to call him our friend delighted in his enthusiasm, humor and playful spirit.
As a surgeon and citizen, John believed he needed to use his talent and skills serving others. He volunteered for the U.S. Army Reserves in October 2004 and requested to serve on the front lines in Iraq, an unpopular decision among those close to him. He understood the dangers he faced but also understood that brave soldiers serving their country deserved a chance to survive and recover. For John, service as a combat surgeon was a duty he owed his country. Major John Pryor died after saving many lives.”ž
The loss is excruciating. Family, friends, colleagues and patients are crushed. For some, John_s death is almost unbearable. We believe the life and death of our beloved friend calls for each of us to examine how we live our lives. We salute John, we honor his integrity, we remember his contributions, and we seek to emulate his spirit. Our world is unquestionably a better place for his short time amongst us.
Æ’Edward T. Dickinson, MD, FACEP, & Mike McEvoy, PhD, NREMT-P, RN, CCRN”ž
Fallout from the deepening recession has created a myriad of new challenges for EMS agencies nationwide. Although most communities try to minimize the fiscal impact on public safety while tightening their belts, most EMS and fire departments are still taking a hit. For instance, Philadelphia, where the fire department provides the city_s 9-1-1 transports, has proposed closing seven fire companies. Firefighters in Vancouver, Wash., recently approved a pay freeze to help save the cash-strapped city more than $700,000. And the Collier County (Fla.) EMS Department has postponed replacing three ambulances and may reduce the number of units it fields.
“There are cuts occurring in public safety all across the country,” says Gary Ludwig, deputy fire chief for the Memphis Fire Department and chair of the International Association of Fire Chiefs_ EMS Section.”ž
Job losses often mean the loss of health insurance, and many uninsured people use emergency departments (EDs) as their source of primary care. “They can_t go to a doctor or a physician_s office, so 9-1-1 is their introduction to the health-care system,” says Ludwig.
Many uninsured patients don_t have the money to pay for ambulance transportation, adding additional economic burdens for EMS providers. “Collections are going to be a problem,” says American Ambulance Association President Jim Finger, chief executive administrator for Regional Ambulance Service in Rutland, Vt., “so we_re going to have to try harder to collect and make sure that those who can pay are paying.”ž
“The main thing we have to do is protect the Medicare income we have today and try to build on that,” Finger says. The AAA will introduce new legislation in Congress this year in hopes of keeping Medicare reimbursement steady and increasing future reimbursement.”ž
The need to replace ambulances and equipment has also become a challenge. “People have to ask how they can make their equipment last longer, and they need to take care of the equipment they have,” Finger says. In Memphis, the addition of two new ambulances will have to wait. “I_m going to maintain where I_m at, but I_m not going to be able to add,” says Ludwig.
Memphis has also seen house fires double as desperate homeownersÆ’many facing foreclosureÆ’set their properties on fire in hopes of collecting insurance money.”ž
“Once homes are vacant, there_s an opportunity for vagrants and kids to get in and do vandalism,” says Ludwig. “More homeless people squat in [abandoned homes] and use alternative heating sources, which also creates the opportunity for fire.”
Although the current environment poses numerous challenges, it also creates new opportunities. Budget shortfalls require public safety and EMS departments to look for alternative revenue opportunities like never before. “Everyone thinks cut, cut, cut,” Ludwig says, “but before you cut, you need to look for additional sources of revenue and [opportunities to] achieve efficiencies.””ž
To generate needed money, some public-sector services are adding interfacility transport to their menu, and firefighters are giving flu shots. Ludwig_s department has started charging $100 to attorneys who request patient medical records.
Technology is also opening new opportunities for efficiency. Communities are increasingly using software or the Internet to reduce ambulance diversion and long ED waits to minimize the number of ambulances needed. In Seattle/King County, Wash., emergency dispatchers and EMS providers can access a new Web-based software system, KCHealthTrac, to check ED capacity before deciding where to route ambulances. “It has definitely improved our efficiencies,” says Allison Schletzbaum, healthcare resource and information manager for King County Health Care Coalition.”ž
“With some creative thinking, patience and teamwork, we can weather this economic storm and come out stronger in the process,” says Finger. “America is a great country, and our businesses and citizens are always trying to make things better,” he says. “I think we will eventually come through this with things being just fine.””žÆ’Cynthia Kincaid
CDC Promotes”žUniform Triage
The Centers for Disease Control and Prevention (CDC) wants all EMS responders to use a new decision-making scheme for triaging injured patients in the field. This is the first step toward national evidence-based EMS clinical guidelines, an Institute of Medicine recommendation that federal agencies are working to make a reality.
“Guidelines for Field Triage of Injured Patients: Recommendation of the National Expert Panel on Field Triage” appeared in the CDC_sMorbidity and Mortality Weekly Report(MMWR) Jan. 22. The agency is also developing an implementation toolkit, which includes posters, pocket cards and guidance on dealing with related issues.
Richard Hunt, MD, FACEP, director of the CDC Injury Center_s Division of Injury Response, says 17 national organizations have endorsed the new field triage protocol developed by a CDC-convened, 37-member committee. The American College of Surgeons already incorporated the actual one-page decision scheme into PreHospital Trauma Life Support courses and its revised “green book” (Resources for Optimal Care of the Injured Patient 2006).”ž
“Those documents are great,” Hunt says, “but thisMMWRprovides background in depth on how it was developed, the rationale of its development and the interface between EMS, public health and trauma systems.” He encourages EMTs and paramedics to read theMMWRarticle (atwww.cdc.gov/mmwr under “Recommendations and Reports”) and take an online test for continuing education credits. “This is the first time CECBEMS [Continuing Education Coordinating Board for EMS] has accredited an”žMMWR article for EMTs and paramedics,” he notes.”ž
The CDC also convened a committee of physicians and paramedics to develop a proposed national mass-casualty triage guideline. That proposed guideline, “SALT” (for sort, assess, lifesaving interventions, and treatment and/or transport), appeared in the September 2008 issue of”žDisaster Medicine and Public Health Preparedness (www.dmphp.org/cgi/reprint/2/Supplement_1/S25.)”ž
“This is a proposed framework, not a protocol,” Hunt says. “We_ve learned from the international community that you need some consistency in how triage is done when multiple agencies respond, especially to terrorist bombings.”
One commonÆ’but complexÆ’medical-legal question that arises in EMS is whether there are circumstances when it_s legally and ethically permissible not to attempt resuscitation on a cardiac arrest patient. Certainly, the decision not to resuscitate has irrevocable consequences for the patient, and it should be made only when all legal and ethical considerations are strictly satisfied.
The first issue an EMS provider must consider is their state law. Some states_ “do not resuscitate” (DNR) laws stipulate that resuscitation can be withheld or discontinued only in very specific circumstances, for example, when the EMS provider confirms that a valid “DNR order”Æ’such as in the form of a bracelet, necklace, form or cardÆ’is present. Other state laws dictate that an online EMS physician can order a DNR in particular circumstances. In addition to consulting your state law, be aware that your state and/or local EMS oversight agency may have regulations, policies or protocols that address DNR issues.
There are also cases where, both legally and ethically (and subject to your state_s laws, regulations and protocols), resuscitation is not clinically indicated. Generally, these include such cases as decapitation, rigor mortis (except in cases of profound hypothermia), dependent lividity, decomposition, and obvious mortal wounds when survival is not possible.”ž
A third category of potential DNR patients may include the terminally ill, such as patients suffering from advanced, end-stage or untreatable cancer or other terminal diseases. In these cases, patients and/or their legal decision makers should avail themselves of the formal EMS DNR process in their state (which exists in most states) so that they can obtain the proper EMS DNR identification. However, in cases where no such DNR order exists, the EMS provider should provide full resuscitative measures, unless the patient is legally pronounced dead (by a person authorized to do so in that state) or unless a qualified EMS physician, who is permitted by state law to give such orders to EMS personnel, specifically gives a DNR order.”ž
In cases that do not meet these criteria, EMS providers should initiate full resuscitative interventions for cardiac arrest patients. A DNR decision is irrevocable and should be made only when all legal and ethical factors have been taken into account.
Pro Bono is written by attorneysDoug Wolfberg andSteve Wirth ofPage,Wolfberg & Wirth LLC, a national EMS-industry law firm. Visit the firm_s Web site atwww.pwwemslaw.com for more EMS law information.”ž
For more on EMS-related legal issues, visitwww.jems.com/PWW
Names in the News
JEMS Welcomes New Technical Editors“ž
In December 2008,Travis Kusman, MPH, NREMT-P, andFred W. Wurster III,NREMT-P, AAS, were named as the new technical editors for JEMS. Kusman is the manager for San Diego County Operations of AMR, and Wurster is a paramedic supervisor/fire sergeant with Malvern Fire Company in Pennsylvania. Previously, the role was served by Richard Vance for 15 years.
An AED First: San Diego is the first city in the U.S. to add an AED requirement to its building code. On Dec. 3, 2008, the San Diego City Council passed an ordinance requiring AEDs in all new buildings that are taller than three stories or have more than 10,000 square feet of floor space or that can hold more than 300 people or 200 students. Since 2001, San Diego Project Heart Beat has purchased and distributed more than 4,000 AEDs and saved 52 lives.
In Brief: State EMS office preparedness activities report atwww.nasemso.org/Projects/DomesticPreparedness
Washington Post_s Kaplan division buys National Paramedic Institute Inc.
Fire Service-Based EMS Advocates creates Web site athttp://fireserviceems.com
What Do YOU Think?”ž
Many communities have begun charging when an ambulance is requested, even if the patient isn_t transported to a hospital. Some ambulance services charge if EMTs or paramedics assess the patient but don_t transport. Some fire departments charge a fee for dispatching first respondersÆ’even if a witness to a fender-bender placed the 9-1-1 call. Does your agency do this? Do you think it should? Let us know atwww.jems.com/extras“ž