Robert Vroman, M.Ed., BS NREMT-P

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EMS1 Daily News

Clinical scenario: Chest pain while mowing the lawn

You respond to a 57-year-old male who felt a sudden onset of chest pressure. What is your differential diagnosis?

Quick Clip: Does epinephrine work?

What do you think? Sound off in the comment section below

Fire, EMS responders share lessons from Ferguson

Trying to protect civilians and ourselves is a difficult proposition, as those on the ground in Ferguson will attest

6 injured in Pa. ambulance crash

One person was listed in critical condition after the three-vehicle crash that included an ambulance and an SUV

Vegas Fire, AMR reach deal over patient transport policy

Fire Chief Willie McDonald said the department will respond to more serious emergency calls while AMR responds to less serious calls

How an EMT bike team beats N.J. traffic

They get around the gridlock by responding on bicycles, and recently became a regular part of Jersey City's emergency response

N.C. county to track ambulances with MCTs

The devices allow dispatchers to see where ambulances are in real time, and are expected to help reduce response times

Responders collect supplies for police, military in Ferguson

Suggested donations include bottled water, energy and sports drinks, packaged snacks, hand sanitizer and gift cards to nearby sandwich shops

American Ebola patients released from hospital

They were discharged after three weeks and doctors say their release poses no public health risk

Pa. township to house ambulances at local college

The township ended 60-year-old contracts with two local fire companies and switched to the University of Pennsylvania Health Systems for emergency medical services

EMS1 Topic Articles

Clinical scenario: Chest pain while mowing the lawn

You respond to a 57-year-old male who felt a sudden onset of chest pressure. What is your differential diagnosis?

Quick Clip: Does epinephrine work?

What do you think? Sound off in the comment section below

Fire, EMS responders share lessons from Ferguson

Trying to protect civilians and ourselves is a difficult proposition, as those on the ground in Ferguson will attest

6 injured in Pa. ambulance crash

One person was listed in critical condition after the three-vehicle crash that included an ambulance and an SUV

Vegas Fire, AMR reach deal over patient transport policy

Fire Chief Willie McDonald said the department will respond to more serious emergency calls while AMR responds to less serious calls

How an EMT bike team beats N.J. traffic

They get around the gridlock by responding on bicycles, and recently became a regular part of Jersey City's emergency response

N.C. county to track ambulances with MCTs

The devices allow dispatchers to see where ambulances are in real time, and are expected to help reduce response times

Responders collect supplies for police, military in Ferguson

Suggested donations include bottled water, energy and sports drinks, packaged snacks, hand sanitizer and gift cards to nearby sandwich shops

American Ebola patients released from hospital

They were discharged after three weeks and doctors say their release poses no public health risk

Pa. township to house ambulances at local college

The township ended 60-year-old contracts with two local fire companies and switched to the University of Pennsylvania Health Systems for emergency medical services

EMS1 Columnist Articles

Clinical scenario: Chest pain while mowing the lawn

While parked at post, you receive a call to a private residence on a hot and humid Saturday morning. You are responding for a 57-year-old male reporting chest pain while mowing the lawn. Dispatch advises that they have prompted the patient to take aspirin and that he has taken three chewable tablets.

In your system, BLS ambulances respond with paramedic quick-response vehicles. Your assigned QRV is clearing a cardiac arrest on the other side of town and states an approximate ETA of 20 minutes. Your mobile data terminal indicates that you are five minutes from the call.

When you arrive on scene you walk up to the front porch of the residence where a moderately overweight man introduces himself as Frank. Frank states that he was mowing the lawn when he experienced a sudden onset of chest pressure. He says that he became sweaty and felt dizzy at the same time.

Thinking that he was just dehydrated he sat on the porch and drank a few glasses of water. When his pain did not subside, he asked his wife to call 911.

Patient assessment

Frank has a history of high cholesterol and high blood pressure and states that his doctor has been advising him to lose weight. He has had episodes of chest pain in the past but not for a year or so.

This time the pain seems unusual. He has a prescription for nitroglycerine and has taken two tablets with no improvement in his symptoms.

Frank reports that his pain is a six out of 10, feels like a pressure and does not radiate. Frank’s blood pressure is 172/92 with a pulse of 94 and respirations of 20. His pulse-ox is 97 percent on room air.

You request an updated ETA for ALS and are advised 15 minutes.

While you wait for ALS think about the following questions:

  • What is your differential diagnosis"
  • What are some “must not miss” diagnoses for this patient"
  • What are your treatment priorities"
  • What additional questions would you ask this patient"

Quick Clip: Does epinephrine work?

Download this quick clip on iTunes, SoundCloud or via RSS feed

In this week’s Inside EMS podcast quick clip, hosts Chris Cebollero and Kelly Grayson discuss a study that looks at whether epinephrine really works.

“One milligram of 1:10,000 solution every three to five minutes may not necessarily be what they need,” Cebollero said.

Cebollero also mentions that after almost 50 years, we’re late in getting to such a study.

“And therein lies the problem,” Grayson said.

In the United States, getting permission for such a study has always been problematic, and continues to be problematic today, he said.

What are your thoughts on epinephrine" Sound off in the comment section below and stay tuned for the full Inside EMS podcast tomorrow.

Fire, EMS responders share lessons from Ferguson

To say the situation in Ferguson, Mo. is a mess is to put it mildly.

At last week's Fire-Rescue International conference, I spent time with two people who've been on the ground during the Ferguson protests and riots. Both, though in different capacities, were concerned with EMS units in the hot zone. During dinner one night, they relayed some unnerving stories.

It is understandable that mainstream media outlets overlook the risks this situation presents medics and firefighters on the ground. But it is probably one of the first things everyone reading this thought about.

The stories I heard over that dinner ranged from unprovoked one-on-one aggressive confrontations to objects being hurled seemingly at random targets.

If you've not yet seen it, watch this video featured in Tuesday's newsletter and our new Paramedic Cheif newsletter for industry leaders. In it, EMS Chief Chris Cebollero walks you through the initial EMS response and how they reacted to a very fluid situation.

Chief Cebollero talks about "feeling" the situation get more dangerous and instructing his crews to keep an eye out for those who may be reaching for weapons and repositioning his ambulances for a fast and safe getaway.

During his presentation at FRI, Chief Rob Wylie talked about keeping safe in tactical EMS situations. He likened it to geese; while the flock eats, there's always one with its head up looking out for danger.

One of the interesting observations from Chief Cebollero was that if anything positive has come of this situation was that it taught those paramedics how to manage an EMS scene in a dynamic crisis.

And that is a lesson we can all take from this incident and the observations of those on the ground.

As Chief Wylie pointed out in his session, when a violent situation catches us off guard, we have a one-in-three chance of making the right decision. And those odds are dramatically increased if we've thought through the scenarios and the best reactions well before it hits the fan.

Take the situation in Ferguson, overlay it on your jurisdiction and work through how you'd handle it.

How to define leadership in EMS

Last month I wrote about a smart and talented young EMS supervisor named Jason who has little interest in leadership. He sees little he wants to emulate in the bosses running his agency and the so-called leaders at the forefront of the industry. I concluded that we need to do a better job of guiding a new generation of young people into leadership. Getting clear about what leadership is — and is not —and reflecting on our own leadership may illuminate some needed changes.

The term leadership gets thrown around a lot these days. From NEMSMA to NAEMT, IAFC, NASEMSO and the AAA, there is much talk about the need for leadership development in EMS. But here is where the confusion starts: If you listen closely, there is wide variation in what’s being talked about.

8 questions to help define leadership

Some are talking about the knowledge and skills needed to manage an EMS operation such as budgeting, deployment strategies and human resource management. Some are talking about mastering a set of officer competencies. Others are talking about creating a ladder where field providers can move from the field to supervision to management and so on. But there is little clarity about what leadership is — and, consequently, little clarity about how to develop leadership in others.

To stir the pot around this topic, consider the following questions:

  • Does calling someone a leader make them a leader"
  • Can someone manage an EMS agency without providing leadership"
  • Does the title of director, administrator, manager, supervisor, executive or chief guarantee leadership"
  • Are most EMS agencies truly led or simply managed"
  • Is your state EMS director providing leadership of EMS in your state"
  • Are the people tasked with leading EMS in the federal government exercising leadership"
  • Is the head of your association actually leading the members somewhere"
  • Is that charismatic speaker at the national conference a model of leadership"

Many are called leaders, but there is often a wide gap between the title and the actual practice of leadership.

Leadership at its core

The need for leadership shows up when there is a need for a group of people to collectively move toward a goal or destination. The acute need for leadership is often most visible in crisis.

But the need for leadership shows up daily when something impacting a group needs group action to change, be different, be improved, be created or be stopped. Leadership then is a process of identifying a goal or destination coupled with a process of influencing others to action toward the achievement of the goal or destination. At its most basic level, leadership is about seeing ahead; it’s also about social influence.

Most of us would agree that EMS would benefit from having more people who actually see ahead, describe a compelling vision of the future and inspire others to put their best efforts toward achieving that vision.

We especially need leadership that is not self-serving and has more than a personal career at its center. We need leadership that serves the basic missions of the organizations and groups being led and leadership that is benevolent and fully engaging to followers.

The development of leadership requires learning, but it also requires modeling and mentoring — which means those of us who would develop leaders need to reflect on how we personally show up as leaders.

So I end this with some personal questions. If a young EMS millennial came to you wanting to learn more about leadership, could you adequately define leadership for him or her" Could you help them clearly distinguish leadership from management" Is your own practice of leadership a model worthy of followership" If you were to mentor someone in leadership, could you point to your own successes in influencing others toward a destination"

In answering these questions we will discover how we might better lead a new generation into a positive and compelling view of leadership.

Ebola: What does EMS need to know?

The largest outbreak of Ebola in history is occurring in Western Africa, with more than 1,700 infected and 1,000 deaths from the virus so far. The World Health Organization declared it a public health emergency, and Doctors Without Borders is calling it a disaster.

So how exactly did this outbreak happen" Should we in the U.S. be concerned" And what information does EMS need to know"

Although Ebola is a very concerning virus, the risk to the U.S. is still quite small. However, EMS providers should be educated about what to look for in an Ebola patient and have access to and training in use of isolation equipment.

Remember these eight points.

  • Early detection can be difficult due to the non-specific symptoms.
  • Patients with an unexplained fever and recent travel to a country known to have had Ebola — specifically Guinea, Liberia, Sierra Leone and Nigeria — or had direct contact with someone known to have Ebola, should be treated as infected until proven otherwise.
  • Exercise immediate contact isolation in patients with suspected Ebola to include gloves, goggles or face shield, full-body gown and respiratory mask.
  • Immediately notify the receiving hospital that EMS is transporting a suspected Ebola patient, since this patient will need to be isolated upon arrival.
  • Thoroughly decontaminate all equipment and surfaces potentially contaminated from treating a suspected Ebola patient.
  • Be extremely careful with blood exposure and limit the number of interventions such as starting IVs and using nebulizers unless clinically indicated.
  • Have a plan for contacting the local or state health department if a case is confirmed to be an Ebola patient.
  • Have a plan for workforce issues such as quarantine of EMS providers.

What is Ebola"

Ebola is the virus that causes Ebola Hemorrhagic Fever. The virus was discovered in 1976 when there were two simultaneous outbreaks in the Sudan and the Democratic Republic of Congo (called Zaire at the time). Some of the patients came from a village situated near the Ebola River, hence the name Ebola.

Outbreaks usually occur when a human comes into contact with body fluids from an infected animal such as a chimpanzee or gorilla, particularly when the animals are used as a source of meat. The African fruit bat is also thought to be a reservoir that can pass the virus through contact with its droppings.

Signs and symptoms

Once a human has contracted the Ebola virus there is an incubation period where the patient is not yet symptomatic. This period can last from two to 21 days.

It makes this infection particularly troubling, since someone could leave one of the countries with Ebola and not become ill until they have reached their destination weeks later. This is why people exposed to Ebola are quarantined for 21 days with daily fever checks to make sure they do not have an active infection.

Once a patient becomes symptomatic, he will display signs typical for any viral infection such as fever, nausea, joint pain and headaches. Other symptoms include conjunctival hemorrhages (burst blood vessels in the eyes), rash and sore throat, although these are less typical.

Once the patient develops a fever, he is considered infectious and has the potential to spread the virus to others through bodily fluids. Health care workers are particularly susceptible to the virus if strict contact isolation precautions are not taken.

Once symptomatic, patients can become deathly ill within days, with nausea and vomiting, bloody diarrhea as well as bleeding from other sites. Left untreated, this eventually leads to shock and death.

There is no vaccine for Ebola and with the exception of some experimental drugs, there is no approved therapy other than aggressive supportive care. Ebola is extremely lethal with a fatality rate of up to 90 percent. The current outbreak has a fatality rate of around 60 percent.

Why is this outbreak so bad"

There are a number of issues that have made this outbreak the perfect storm for an Ebola outbreak. Location and culture are two of the prominent issues.

This is the first time that Ebola has appeared in Western African countries. All of the previous outbreaks of Ebola have been in either Eastern or Central Africa.

Because of this, it is likely that the illnesses were not recognized quickly and strict isolation and quarantine practices were not instituted until the virus had already begun to spread. This is coupled with the fact that the countries of Western Africa are some of the poorest in the world with limited medical and public health infrastructure.

There are cultural issues as well that are challenging. It is African tradition to directly handle the dead bodies of family members. At the time of death, the body is at its most infectious period and it is therefore easy to spread the virus to unsuspecting family members.

Likewise, since this virus has not been seen in this region of Africa, the population has been slow to accept that a virus is causing such illness in the communities, with some people blaming western non-governmental organizations such as Doctors Without Borders for bringing an illness into their communities.

In addition there is still a reliance on traditional faith healing by a village medicine man. This practice causes the virus to spread to those in the community.

What protections are in place in the U.S."

Customs and Border Protection agents are trained to passively screen all patients coming into the U.S. from foreign countries for signs of illness. In addition, 20 airports around the country are equipped with quarantine officers from the Centers for Disease Control and Prevention.

Should the officers encounter someone with symptoms or appearing ill, they will be referred to the quarantine officer for evaluation.

In addition, CDC has recently sent some 50 experts to Western Africa to combat the virus. CDC performs testing on suspected cases and offers expert advice to clinicians around the globe.

They work in direct contact with local and state health departments and issue case definitions and guidance on handling cases of Ebola.

FirstWatch founder honored for leadership mantra: 'What is the right thing to do'

By Jay Fitch

Like father, like son.

After Jack Stout accepted the Pinnacle Lifetime Achievement Award for his pioneering EMS management concepts, presenter Jay Fitch, co-founder of Fitch & Associates, wouldn’t let him leave.

“Jack I need you to stay right here for a minute because there’s more to the story,” Fitch said. “We have another award to present tonight and I need your help with it.”

In a surprise presentation, Fitch presented Jack’s son Todd Stout with the Pinnacle Leadership Award. Stout is the founder of FirstWatch, a company that helps public safety agencies turn raw data into useful information.

“He threw himself into his business with a passion,” Fitch said. “But with a passion tempered by kindness for others, respect for every individual he encountered, and by always asking the question, ‘what is the right thing to do"’"

A leader from an early age

Fitch met Stout through his father, and hired him at 16-years-old.

“I thought long and hard about this but can tell you now that hiring Todd as the system’s stock boy was one of the best leadership decisions I ever made,” Fitch said. “Todd took a lot of grief from the medics but he proved himself and went on to become an EMT and medic, taking care of people in the streets of Kansas City."

Stout went on to work with his father for a few years as a consultant before joining EMSA in Oklahoma City as the vice president and chief operating officer of the Western division. He then moved to California and served in business development with Lifefleet ambulance before joining TriTech as the director of VisiCad.

“Todd kicked it to another level about 15 years ago by developing First Watch,” Fitch said.

Stout and his colleagues have helped police, fire, EMS and public health agencies capture and interpret data used to positively improve health outcomes and our systems’ operational performance, he said

Stout's wife Amy, his daughter Samantha, and his son Ben were there to see him accept the award.

“When we honor Todd tonight, we honor the leaders of our profession,” Fitch said. “We honor the best qualities that each of us strive to exhibit, qualities that Todd exemplifies.

“We honor the innovators among us, who never stop asking the question ‘What if"’ We honor the mentors, who never fail to make the time to share what they’ve learned. And we honor those who lead with a caring, humble heart, and who gauge their decisions by asking, ‘What is the right thing to do"’"

Pinnacle: 6 critical EMS future improvements

EMS must adapt.

That much was clear after the Pinnacle EMS Leadership Forum held in Scottsdale in July. The annual meeting of senior chiefs and executives from every service model is designed to stir things up.

This year was no exception, with many presenting conflicting views on the future that came down to an overarching concept.

“If you always do what you've always done, you'll always be what you've always been,” said Jay Fitch, president of Fitch & Associates and the organizer of the conference.

EMS leaders agreed that there are significant challenges facing out-of-hospital providers, not the least of which is the inherent tension caused by such a diverse industry trying to find a unified voice.

At a time when the U.S. health care system is undergoing rapid changes, the need for the nation’s EMS services to find some common ground while still being flexible is more critical than ever. And as both public and private payers emphasize value, EMS needs to demonstrate to the rest of the health care community the critical role it can play in achieving the triple aim: a better patient experience, improved population health, and decreased costs.

Why EMS must start measuring industry progress

Evidence-based medicine, health care reform and coming changes to reimbursement models dominated the agenda, as conference-goers heard from agency leaders, insurance executives, medical directors and data experts.

In his closing keynote, Dr. Brent Myers, the director of Wake County (N.C.) EMS, challenged leaders to look critically at the evidence but to avoid paralysis.

“We've got to do the best we can with what we have today,” Myers said of the current state of EMS research and practices. “I can't just wait on the perfect study, nor can I assume that what we did five years ago is right.”

Myers was one of many speakers to emphasize the need for EMS to adapt and be flexible, but change in EMS hasn’t always come easy; just ask Pinnacle Lifetime Achievement Award-winner Jack Stout.

Fitch presented the award to Stout, who received a rousing applause and standing ovation from the crowd. Stout, an economist, is considered a pioneer in EMS system-design and the father of high-performance EMS systems. (In a surprise, his son, Todd, president of the data-tracking company FirstWatch, received the annual Pinnacle Leadership Award at the same time.)

If EMS leaders refuse to adapt, many Pinnacle presenters warned, someone else will make changes for them.

In a talk on the importance of the patient experience, Allina Health EMS President Brian LaCroix told the audience that the patient’s opinion of how he was treated by EMS will soon impact EMS reimbursement. He advised EMS leaders and providers to measure and try to improve the patient experience, and for the industry as a whole to start defining the best way to measure it.

“We as a profession should start thinking about doing this ourselves, before [the Centers for Medicare and Medicaid Services],” LaCroix said.

It’s only a matter of time before the agency starts using patient experience as a factor in determining reimbursement, as it does now with hospitals, he said. But, it’s not only about the money; it’s also about the patient and the EMS provider.

“When there's a positive patient experience, there's a positive caregiver experience,” he said.

Similarly, in a meeting for users of FirstWatch, the company’s medical director spoke about efforts to define quality measures and benchmarks for EMS.

Dr. Alex Garza, who previously served in Washington as assistant secretary for health affairs at the U.S. Department of Homeland Security, suggested that CMS and other payers would eventually use clinical quality measures to determine reimbursement, and agencies should begin defining and measuring before someone else makes them.

“If we don't do it then the government is going to do it for us,” Garza warned.

Of course, defining those benchmarks won’t exactly be easy. Many agencies and jurisdictions still use response times or the number of ALS providers on-duty as measures of performance.

In a talk addressing some of the more controversial issues in EMS, Alan Craig proposed significant changes to how EMS leaders and providers think about the industry, especially ALS.

Is ALS a fading concept"

Craig, who retired as deputy chief of EMS in Toronto, currently serves as vice president for clinical strategies at American Medical Response. He brought four decades of EMS experience to his talk, entitled “Is the ALS paramedic a fading concept"”

“It's time for a major overhaul and to rethink what we're doing,” Craig said, recounting his role as one of the promoters of expanding ALS services.

“By extension, if ALS was good for certain things, it's good for everything,” said Craig, describing how he once felt about paramedics. “I'm here to recant. We were wrong. But I was in good company.”

Craig used data from an unnamed metropolitan ALS service to show that many skills are rarely used. For example, a paramedic performed a surgical airway only once in more than 70,000 patients.

Craig argued that providers could not be proficient in skills that were so rare, and that performing them without proficiency could put patients at risk.

“We should not do things that we're not good at,” he said.

EMS also needs to take a critical look at whether the skills that paramedics pride themselves on doing — such as intubation — are actually good for patients. He pointed out some of the other procedures, like MAST trousers, which were once thought to be lifesavers but eventually determined to be ineffectual at best, and possibly detrimental.

“I did a lot of those,” he said. “I wonder if I caused great harm in my enthusiasm to do good"”

The “new medic”

Craig proposed creating a new medic, who would be trained in skills that are known to be beneficial and that are required frequently enough for providers to develop proficiency. He also recommended that new paramedics spend a much longer time — perhaps several years — practicing with a more senior provider after receiving their credentials.

Another new medic was also discussed extensively at the conference: the community paramedic. Mobile integrated healthcare (MIH) was on everyone’s mind and several of Pinnacle’s sessions addressed issues related to the concept.

Several conference attendees spent an entire day at pre-conference MIH sessions, where they learned about innovative programs across the country. They also heard warnings from industry leaders that they should not jump into these programs without slowing down, doing some serious planning, and ensuring proper medical oversight.

How fire departments are rethinking medical response methods

EMS agencies face a crossroads. On the one hand they are being told to slow down and not rush into new programs, while at the same time they are being told they must evolve.

At a session on how the fire service needs to change, retired fire chief and current Pinellas County (Fla.) Director of Safety and Emergency Services Bruce Moeller suggested that fire departments that weren’t considering new ways of providing EMS care were committing suicide.

Scott Somers, a paramedic and firefighter in Phoenix and city council member in Mesa, Ariz., spoke about Mesa’s efforts to adapt to changes in community expectations and the health care environment.

Mesa, whose fire department recently changed its name to the Mesa Fire and Medical Department, just received a $12.5 million grant from the federal Center for Medicare and Medicaid Innovation for its Community Care Response (CCR) units.

Somers described the program, which places three different types of the CCR units in the field: one with an experienced paramedic and an EMT, one with a paramedic and a nurse practitioner, and one with a paramedic and a behavioral health specialist.

The goal is to provide the most appropriate service to the patient as quickly as possible and avoid unnecessary transports to the hospital.

“This is a potentially sustainable service,” Somers said. “It decreases fire apparatus response and is a potential revenue source.”

In the same session, Fitch and Associates Partner Guillermo Fuentes showed how some departments are struggling with shrinking budgets and limited resources, and how the fire service can adapt.

Some of those changes might be sending only first responders, and not transport units, to the lowest acuity calls and only calling in the transport unit when necessary. At the same time, he suggested that sending first responders to every call was also a waste of resources, and that priority dispatching could limit the need for first responders.

“Sending fire [department first responders] to 7 percent of the calls would lead to the same [patient] outcomes,” Fuentes said.

He also said that with the way the industry and health care financing was moving, EMS agencies and fire departments needed to rethink their business models.

“Transport companies are not making much money,” he said, arguing that revenue is decreasing as expenditures are rising for agencies that do emergency 911 transports. “Fire departments and EMS are fighting for the wrong prize. There's just no money being made in transports.”

The future of EMS funding

The future of EMS funding was the topic of a panel discussion featuring two insurance executives and hosted by Sharon Henry, president of Evolution Health.

Edward Kim, who heads Cigna’s Arizona health plans, spoke about the “potential of [the EMS] industry in playing a key role in reducing costs either before the hospital admission or after discharge.”

“That is something I would definitely like to partner with you on,” he said.

At a panel of representatives of federal agencies, the audience wanted to know when CMS — the largest health insurer in the country — would change its reimbursement model to pay for services provided by EMS other than strictly ambulance transport to a hospital. While CMS was not represented on the panel, Gregg Margolis, representing a different U.S. Health and Human Services agency, addressed the issue.

“I will say that I have some concerns that EMS [is] trying to solve a problem with an old model … [by] doubling down on a fee-for-service model,” said Margolis, a paramedic who serves as director of the Division of Health Systems and Health Care Policy for HHS’s Assistant Secretary for Preparedness and Response.

Instead of thinking about a short-term fee-for-service approach to reimbursement for non-transport and MIH programs, Margolis suggested EMS agencies start preparing for a world that isn’t based on fee-for-service, and think about “aligning incentives and value-based purchasing.”

Improving cardiac arrest survival rates

Although the evolving healthcare system, finances, and other big-picture issues dominated the conference, one speaker addressed a clinical topic that has remained a priority of EMS care for decades: cardiac arrest.

Dr. Bentley Bobrow, M.D., the medical director for the Arizona Bureau of EMS and Trauma Systems, discussed Arizona’s statewide efforts to improve survival from cardiac arrest. The presentation touched on all aspects of the chain of survival, from public and dispatch-assisted CPR and AED use to high-performance CPR and post-resuscitation care.

“If someone's in ... a shockable rhythm when EMS arrives, we should save them,” Bobrow said.

Bobrow’s talk was a good reminder to everyone at Pinnacle that with all the changes coming to health care and all the uncertainties ahead, agencies that focus on evidence-based medicine, training, and quality improvement can make a difference in people’s lives right now and into the future.

What county officials could learn from an EMS ride along

Now, this is a switch: Rather than the EMS agency not wanting to enhance their level of service, community leaders are balking at getting that help. Where is this coming from"

There is a tremendous gap that currently exists in social and chronic health services. While most patients of some means are able to maintain their conditions once they leave a physician office or hospital, there are substantial populations that cannot do so for one reason or another.

EMS sees them as repeat callers — the CHF patient who goes back to the hospital two weeks after discharge; diabetics who become hypoglycemic monthly; addicts who relapse with their alcohol or drug dependencies. We provide care, and take them to an emergency department, where they are seen for a few hours, possibly admitted for a few days, and then discharged back into the same cycle.

Many of us have been party to this frustrating health care merry-go-round for a long time. It’s a relief to see that efforts are underway to get off the carousel, by providing after-care checks, performing preventive activities, and transporting patients to facilities other than expensive and ineffective emergency departments for that specific complaint.

It’s unfortunate that the county officials don’t get that. The comment made by one commissioner that some people "might quit calling because they might have heard of someone who called 911 and ended up in a nursing home,” harkens back to days of ambulance drivers, hearses and horse-drawn buggies. Even in Ohio, times have progressed and patients do have autonomous rights.

Maybe the department could invite the commissioners to ride along with a unit, so they could get a first-hand look at the issues that face today’s EMS providers.

Why highway safety programs are SO hot for EMS funding

The National Highway Traffic Safety Administration (NHTSA) has made a concerted effort to focus on the funding of EMS agencies, particularly when it comes to data-driven initiatives focused on motor vehicle and public safety.

In an effort to increase national safety and accident prevention techniques, the federal agency is encouraging EMS funding in priority areas such as occupant protection, injury prevention, safety initiatives, and public education at the state level through State Highway Safety Offices.

This isn’t purely charitable – the NHTSA has made it clear that EMS agencies have the ability to contribute valuable data to reduce deaths and injuries on the roadways, plan efficient responses, and focus training and education to master skills that will best meet the needs of the public.

The transition to Mobile Data Terminals (MDTs) and other evidence-based technology is being used to achieve the best outcome for injured motorists and to make continuous improvements in emergency medical care.

According to the NHTSA, “perhaps one of the most important uses of EMS data is to prevent injuries from happening in the first place, by analyzing how, where, and when certain injuries occur and developing countermeasures to prevent the crash.”

Programs that have been funded

EMS agencies and offices all around the country are acquiring funding to contribute to this NHSTA initiative.

Minnesota’s EMS office obtained NHTSA funding to analyze and improve data quality that will help provide a roadmap for improvements in the state ambulance reporting system and ultimately lead to a reduction in fatalities.

Alabama acknowledged a critical issue in response times to crash scenes and a resulting major increase in traffic deaths. With NHTSA funding, they created a Strategic Highway Safety Plan that identified and organized performance data, made improvements to communication systems and volunteer training, and provided air coverage for rural areas.

Most of these initiatives were done on a large-scale state level; however an abundance of funding is available for local projects. For instance, the push for data has lead to an increase in funding for equipment such as MDTs and PCR software.

MDTs in particular have been placed on high priority due to their ability to provide information that can assess response times and outcomes. This information can help allocate resources to the time and place of highest demand.

The technological advances in PCR software can create a cohesive data system for an entire state that allows for EMS data to inform others about the effectiveness, quality, and impact of pre-hospital care.

NHTSA is willing and has previously funded this equipment and projects that have stemmed from this equipment through State Highway Safety Offices and the Highway Safety Improvement Program (HSIP).

Initiatives to focus on

Additional projects that EMS agencies can acquire funding for include priority areas such as occupant protection and injury prevention.

Collaboration with the American Academy of Pediatrics has produced a push for child passenger safety in the form of Car Seat Fitting Stations. EMS agencies nationwide are heavily involved in becoming Child Safety Seat Technicians, producing permanent Car Seat Fitting Stations and community outreach events.

Prevention of injury on the roadways has been a major concern for NHTSA since its inception. Certain state offices may deem driver training simulators and other apparatus eligible under this funding a priority as well.

For more information or funding opportunities check out the Highway Safety and EMS Connection website or your state Office of Highway Safety.

Why you should quit your crappy EMS job

“The only thing standing between you and your goal is the bullshit story you keep telling yourself as to why you can’t achieve it.”

— Jordan Belfort, 'The Wolf of Wallstreet'

In the summer of 1997 I moved to the San Francisco bay area to be closer to my fiancé. The four hour commute between my apartment and the love of my life had become too problematic, so I took a job with a small mom and pop ambulance service in a semi-rural area south of San Jose.

It was hands-down the worst EMS job I ever had. On my first day, I was given an oversized, unwashed shirt from a former employee and placed on a medic unit with no orientation and minimal introductions.

The ambulances were in terrible condition, and the stations were worse. The local emergency room was shocked when I arrived with basic patient care accomplished and delivered a professional hand-off report. When our unit was cancelled enroute to a call, the owner of the company frequently came up on the radio and demanded that we continue to the scene to collect billing information from the caller.

A few short months later, I washed and ironed that same oversized uniform shirt and politely turned it back in. Everything in my experience told me to move on. That was my fourth EMS employer and I’m now on my seventh. It took seven tries to finally find the EMS job of my dreams.

Unhappy" Do something about it

Today, I earn excellent pay and have outstanding benefits. I work for an employer who is well-respected in the industry and the expectations of my job performance are high. I work along-side experienced and motivated professionals who constantly challenge me.

There are great EMS employers out there, but finding them can take time and getting hired can be a competitive process.

When I tell people how happy I am in my EMS job, I frequently hear the comment that I’m lucky.

I’m not lucky.

It was hard work getting to this place and I was willing to do something that very few folks in EMS seem to be willing to do: quit my job and go get another one when I wasn’t satisfied. I was willing to combine dissatisfaction with action. In EMS we often have plenty of dissatisfaction that results in very little action.

Show me a crappy EMS employer and I’ll show you a bunch of unhappy employees who refuse to leave for one reason or another. Perhaps they feel that they are hopelessly tied to that particular region of the country. (They’re not.) Maybe they feel like things are going to get better if they just wait long enough. (They won’t.) They’ve also convinced themselves that things are no better anywhere else in EMS. (They are.)

But at the heart of the matter, after all of our explanations and rationalizations, the reason we stay with crappy EMS employers is something called loss aversion.

An experiment in loss aversion

Loss aversion is a pretty well-known psychological concept. Economists call it “the endowment effect”. The basic premise is that we place a much higher value on the things which we already possess than on things that we would like to possess. Loosing something that we already have has a much more profound psychological effect on us than gaining something new.

Take this basic economic experiment as an example. Students in a college class were randomly divided into three groups: sellers, buyers and choosers.

Students in the seller group were given coffee mugs decorated with their college logo and allowed to set a price for which they would be willing to sell their mug. The buyers were given the option to buy one of the mugs with their own money. The choosers were able to either get a mug or a sum of money that they felt would be equivalent compensation for not getting a mug.

The results demonstrate human loss aversion perfectly. Byers were willing to a buy a mug for an average of $2.87. The choosers were willing to take $3.12 instead of a mug. The sellers were willing to sell the mugs for an average of $7.12. The surprising result is the difference between the choosers and the sellers. Both groups are making the same choice, have a mug or have a sum of money. The only difference between the two groups is that one group already has a mug in their possession.

Simply having the mug in their hand and knowing it belonged to them made the sellers value the mugs twice as high as the choosers. We are hard-wired to avoid loss much more strongly than we are designed to seek opportunity and gain. This is the way our brain works and it’s the reason why you won’t leave your current crappy EMS job.

Embrace the unknown

I bring this up for two reasons. The first one is that there are a bunch of EMS employees who are highly dissatisfied with their EMS work environment but they are held back from finding their happiness by the power of loss aversion.

It’s tough to admit it to ourselves. It’s hard to say, “Look, I know this employer treats me horribly, pays me too little and works me too hard, but I’m scraping by and I’m afraid of moving on much more than I’m afraid of my tiny apartment and my overdue VISA bill.”

The unknown can be scary. It’s not just that way for you. It’s that way for everyone.

The second reason that I bring it up is because loss aversion isn’t good for EMS either. Those groups of loyal EMS employees who stick around regardless of how bad working conditions become keep crappy EMS employers in business. Awful companies depend on loyal employees. This is why they foster fears of retribution if employees seek other jobs and fail. They need you to stay.

If the EMS workforce demanded fair pay and good working conditions and voted with their feet when better opportunities presented themselves, all EMS employers would be forced to compete for employees. As it stands, all the bad companies need to do is hang out a shingle and then convince people that they are the only opportunity in town. Loss aversion does all the rest.

What’s your EMS dream job"

Regardless of your current level of job satisfaction, when was the last time you looked at any other opportunities in our industry" Let’s do a little experiment. Look under 'Jobs’ on, and click on at least three; some should be jobs that you are qualified for and others ones that are out of range for your current level of training and experience.

For each job that you read, ask yourself, “What if…"” What if you decided you wanted to be a paramedic in Ohio or a medical device sales representative in California" What are the job requirements for the positions that sound appealing to you" What kind of a degree would you need to join the EMS faculty at the University of Hawaii" Could you start working on that right now"

Pay particular attention to the jobs that list their location as “nationwide.” That means that you could do that job from anywhere. You could probably do that job from where you are sitting right now. I’m not saying that you need to apply for a new job right now (though perhaps you should.) Just overcoming your personal loss aversion enough to explore what opportunities are out there can be a refreshing exercise. We should all do this more frequently.

When you’re done looking at the EMS1 jobs page, I’d like you to ask yourself, “To what degree is loss aversion keeping me from fulfilling my goals in emergency services"” Then ask, “How long am I going to let it hold me back"”

Goals stated publicly are much more likely to be acted upon. Before you leave, write a comment and tell us what your EMS future holds.


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