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

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EMS1 Daily News

NEMSMA, IAEMSC to merge in next year

The two leadership organizations provided an update on their plans to consolidate

EMS leaders talk industry changes at Pinnacle

From the diminishing role of ALS medics to Obamacare reimbursement changes, here’s a roundup of conference highlights

Clinical scenario: Near-amputation in a boating accident

You arrive to find a 23-year-old male whose right leg has been nearly amputated above the knee. What are your treatment priorities?

Family of pregnant woman who died in ambulance sues city

The family alleges she would still be alive today if the responding paramedics were properly trained and had proper medical equipment

Off-duty medic honored for cardiac arrest save using mobile app

He was working out when the app PulsePoint alerted him on his phone that someone in the parking oh his health club had suffered sudden cardiac arrest

Pa. man caught using emergency light to beat traffic

He claimed he was a former firefighter and EMT; officers found the light, a pellet gun, a fake U.S. Marshal badge and handcuffs in his truck

Court: Miami’s non-resident $100 ambulance fee legal

The Third District Court of Appeal overturned a trial judge’s ruling last year that the fee was an unconstitutional tax

Northern Calif. to gain new air ambulance base

REACH Air Medical Services plans to open in Rancho Cordova around October, and will feature a new Eurocopter EC135 helicopter

EMS call uncovers mobile home meth lab

Responders uncovered a "shake and bake" meth lab operation after searching the home of a man found lying on the floor

Is an Ohio island overusing air ambulance?

Patients are being flown off the island for intoxication, an anxiety attack, abdominal pain, fingers caught between two boats, allergic reaction and a thumb laceration

EMS1 Topic Articles

Charting the course of community paramedicine

Experts discuss the challenges, opportunities — and, perhaps, inevitability — of mobile integrated healthcare and community paramedicine programs

Why EMS needs higher education

An increasing number of accredited paramedic education programs can lead to better care, career growth, and more respect within the health care industry

NEMSMA, IAEMSC to merge in next year

The two leadership organizations provided an update on their plans to consolidate

EMS leaders talk industry changes at Pinnacle

From the diminishing role of ALS medics to Obamacare reimbursement changes, here’s a roundup of conference highlights

Clinical scenario: Near-amputation in a boating accident

You arrive to find a 23-year-old male whose right leg has been nearly amputated above the knee. What are your treatment priorities?

Family of pregnant woman who died in ambulance sues city

The family alleges she would still be alive today if the responding paramedics were properly trained and had proper medical equipment

Off-duty medic honored for cardiac arrest save using mobile app

He was working out when the app PulsePoint alerted him on his phone that someone in the parking oh his health club had suffered sudden cardiac arrest

Pa. man caught using emergency light to beat traffic

He claimed he was a former firefighter and EMT; officers found the light, a pellet gun, a fake U.S. Marshal badge and handcuffs in his truck

Court: Miami’s non-resident $100 ambulance fee legal

The Third District Court of Appeal overturned a trial judge’s ruling last year that the fee was an unconstitutional tax

Northern Calif. to gain new air ambulance base

REACH Air Medical Services plans to open in Rancho Cordova around October, and will feature a new Eurocopter EC135 helicopter

EMS1 Columnist Articles

Charting the course of community paramedicine

Despite the unexpected snow outside, more than 100 EMS providers and administrators gathered in a Washington, D.C., ballroom on March 25, 2013, to learn more about mobile integrated healthcare — and how to get paid for it.

As mobile integrated healthcare (MIH) and community paramedicine (CP) programs expand around the country, so do the ways in which agencies get reimbursed for these programs. The path forward is at the same time murky — as almost no two systems seem to have the same funding model — but also promising, since so many have figured out ways to get paid for providing these innovative programs.

“Every patient coming into [our MIH] programs is now attached to a funding source,” said Matt Zavadsky, public affairs director for MedStar Mobile Health in Fort Worth, Texas.

Zavadsky and Eric Beck, D.O., associate chief medical officer for American Medical Response (AMR) and Evolution Health, opened up the meeting with a brief overview of some of the changes occurring in EMS and healthcare across the country. Beck talked about more than a dozen MIH programs currently in place or in development, while Zavadsky presented the results of a survey in which more than 230 agencies said they currently have some type of MIH or CP program.

The highlights of the summit — which was sponsored by EMS World and its new sister publication, Integrated Healthcare Delivery, in partnership with Medtronic Philanthropy, the American Red Cross and the National Association of EMTs — came during the second session, when speakers from across the country talked about their experiences with starting and funding MIH programs.

Challenges abound, yet payoffs loom

Chris Cebollero struggled to convince his hospital system that EMS could provide the types of services he was suggesting. Convincing them was critical not only because successful MIH programs rely on partnerships with hospitals but also because in his case, the hospital is also his employer. Cebollero is the chief of EMS for Christian Hospital in St. Louis County, Mo.

“My hospital system was not listening to me when I told them how I could help them and how we could move forward,” he said. “I was talking to the president, I was talking to the vice presidents.” One of those vice presidents was his boss, but even “she wasn’t hearing it,” he explained.

But when he met with a member of the hospital system’s process improvement team, Cebollero said, he gained some insights into how to convince those executives. In that meeting, he learned that more than half of the hospital’s patients stay too long, and that one extra day in the hospital was costing $4.4 million each year — significantly more than the readmission penalties.

“I finally sat down with the process improvement guy, and he said, ‘You’re looking at it all wrong,’” Cebollero told the audience. “You need to affect the length of stay. And that’s going to get you to the high-risk readmission people.”

Cebollero’s story, like others told at the summit, demonstrated the importance of meeting with the right people at the right time and bringing the right information. Some hospital executives, for example, might be less than thrilled to hear that a CP program will keep patients out of the emergency department. After all, the ED has traditionally been how the hospital brings in patients … and dollars.

“Right now, today, in the fee-for-service world" They get really nervous,” said Brent Myers, M.D., director of Wake County (N.C.) EMS.

And while the world where hospitals get rich from emergency patients may be nearing an end (“This is the end of fee-for-service” was a refrain heard more than once during the half-day session), some hospital executives are not quite ready to take that leap. So EMS systems may need to think of other ways to pitch these programs — such as reminding the hospitals that the Centers for Medicare and Medicaid Services (CMS) ranks hospitals based on some of these factors on its Hospital Compare website.

“The incentive [for hospitals] at the moment may not be financial,” Myers added, “it may be to keep yourself off the bad list.”

But if convincing the hospitals has its challenges, the insurers and accountable care organizations (ACOs) have been, perhaps surprisingly, very interested in what MIH can deliver. Cebollero, for example, said that five different payers are interested in what his agency is doing, and they have several contracts pending.

What do payers want"

A few of MedStar’s partners spoke at the summit, giving the audience a chance to hear from the payers themselves. Dan Bruce, the administrator of Klarus Home Care in Fort Worth, Texas, explained why his agency chose to partner with an EMS MIH program at a time when similar home health organizations across the country see these programs as a threat.

“We instruct our patients to call us, but they don’t always do that,” Bruce said. “They just call 911, and there they are, back in the hospital.”

Instead of simply increasing staffing to the point where each Klarus customer had a nurse in the home 24 hours a day, Klarus contracted with MedStar to help assess and treat those patients at home and, when possible, avoid trips to the ED. “That’s probably going to sound like treason in your community,” Bruce said. “There is a lot of turf, a lot of territorialism there. You need to break through those walls.”

But the partnership made sense for both Klarus and MedStar—MedStar has the staffing and the resources, and Klarus wants to keep its patients out of the hospital. While readmission penalties for home health agencies are not a reality yet, they may be soon. And hospitals want to refer their patients to agencies that will keep them from bouncing back.

So now Klarus is paying MedStar to help keep those patients at home, which makes the patients, the hospitals and both agencies happier. MedStar will send its advanced practice paramedics on 911 calls from any Klarus patient, and they will contact the Klarus nurse and access the Klarus medical records to try to avoid transporting the patient to the hospital if possible. If the patient calls the nurse instead of 911, Klarus may contact MedStar and request a home visit in order to do an assessment or provide treatment.

Bruce also suggested that EMS agencies hoping to partner with home care companies may have to think of other ways to sell their services, such as reminding the home health executives that MIH programs can bring in business, not drive it away. After all, EMS providers often see patients, whether through traditional 911 services or MIH programs, who are in need of home health. That can turn into referrals for the company, especially if they choose to partner with EMS on these innovative types of projects.

Options encouraging yet overwhelming

The wide range of MIH programs on display at the summit can be both encouraging and overwhelming to the EMS community. Overwhelming because there are so many different models, potential partners, roadblocks and unsettled questions. Encouraging, though, because while at one time it was thought that EMS reimbursement couldn’t change until Medicare and Medicaid changed, the changing healthcare marketplace has created incentives for other payers to become the innovators.

“Trying to change Medicare is going to take some time,” Myers said, suggesting that in this case, the private sector may be the ones who force the federal government to change how it reimburses EMS. Referring to those private insurers, ACOs, hospitals and other private entities, he added, “Those folks can see the value of what you’re doing.”

While significant policy changes may take time, CMS and state and federal Medicaid administrators have shown interest in exploring ways that EMS can help provide better care at reduced costs. Several conference presenters were scheduled to meet with top officials from CMS and other agencies in the days following the conference.

One speaker, Brenda Staffan from Reno, presented an update on her program, which is currently being funded by a $9.8 million CMS Innovation Grant. Another presenter, from Fort Worth, spoke about a Medicaid waiver program that is allowing her publicly funded health system to partner with MedStar to help patients navigate the healthcare system.

Dawn Zieger, a project director for community health with the JPS Health Network in Fort Worth, spoke about why her system chose to partner with MedStar, giving the summit audience a chance to hear what potential collaborators are looking for. One thing they learned:

EMS systems and their partners might have to invest in a program first before they can lock in external funding sources.

“It really helped us to leverage that pilot program to get the funding moving forward,” Zieger said. After a pilot program appeared successful, however, JPS and MedStar worked together to receive what’s known as a Medicaid Section 1115 Waiver, which authorizes experimental or demonstration projects. The JPS–MedStar waiver is for a five-year program that will try to decrease costs by using MedStar’s MIH program to help JPS patients avoid hospitalizations and other expensive and avoidable services.

Under the program, JPS pays MedStar a monthly fee for each patient in the program, as well as an annual payment based on the outcomes and savings created by the program. At the summit, Zieger announced that JPS had just made its first annual “outcome” payment to MedStar — for $189,000.

Other issues addressed at the summit included education and accreditation for MIH providers and programs, as well as state regulation of these programs. The paths forward on accreditation and regulation both remain uncharted, but the clear message was that in the future, EMS in general — and CP and MIH programs in particular — will need to be evidence-based and will need to measure outcomes.

Changes that hospitals and doctors are seeing today, such as outcomes data being made public on government websites and reimbursement being impacted by patient satisfaction scores, will eventually come to EMS as well, several panelists said.

Ed Racht, M.D., chief medical officer for AMR, put the summit in perspective when he asked members of the audience to take a mental picture of the meeting. “One day everyone in this room is going to be sitting around telling a story,” he said. “You’ll be able to say, ‘I remember when the concept of mobile integrated healthcare [was new] and there were no guidelines, there was no course.’”

Racht compared today’s discussions of community paramedicine to those half a century ago, when EMS transitioned into a system of care with standards for education, equipment and treatment. In 10 years, he said, the people sitting around the tables will be looking at mobile integrated healthcare systems and say, “I was in one of those meetings, where we were trying to plot out what it was going to look like.”

Why EMS needs higher education

Field medicine is evolving faster today than ever before.

External factors such as changes in an aging population, health care reimbursement, evidence-based medicine and a move toward preventive care are affecting the population EMS providers serve. Proactive EMS systems are rising to the challenges, adapting in innovative ways to not just survive, but also thrive in the new environment.

Training EMS providers to perform tasks such as discharge follow up, high-frequency caller reduction, and harm-reduction efforts may result in far more effective care, at a lower cost than the traditional EMS model of being highly reactionary and high cost.

While such efforts are laudable, they fall short of what is needed to sustain long-term growth in the profession. Systems will need to depend upon not only a well-trained workforce, but a well-educated EMS professional to provide increasingly sophisticated medical services in this dynamic environment.

In this regard, EMS education is at a crossroads.

Will it take the more difficult path of growth and change, or will it take the easier path of "if it ain't broke, don't fix it"" This decision has significant consequences for the industry's future.

The tail wagging the dog

In 1996, the National Highway Traffic Safety Administration's EMS section released EMS Agenda for the Future, a consensus document that provided a glimpse of what EMS might look like in the future. The Agenda advocated for continued development of "out of facility" care by focusing on various attributes of an EMS system.

Of particular note was the state of EMS education. The Agenda noted that there were no fewer than 40 types of EMS certification across the country, and that education was being provided in a wide variety of environments and circumstances. Little information regarding public health, management and research principles was offered in initial education programs.

Moreover, the nature of education in EMS was unusual in that it drove the development of the industry, rather than the other way around. Typically, new procedures, techniques, and processes in an industry are developed through innovation and research. Educators review the developments and incorporate the new content into the primary education process.

In early stages of EMS education, the industry adopted education content embedded in documents such as the National Standard Curriculum. In essence, it was a case of the tail wagging the dog, creating circumstances that were awkward and limiting to the practice of a local or regional system.

As a result of the discussions related to the Agenda, subsequent efforts of various EMS associations culminated in the release of the 2000 EMS Education Agenda for the Future: A System's Approach. The document outlined a process where the domain of practice was described (National EMS Core Content) and divided among various levels of field providers (National EMS Scope of Practice).

A set of National EMS Education Standards was then developed to provide guidance to educators who could develop curricula that was more specific to the practice of their region.

The Education Agenda also details the need for a consistent recognition process (National EMS certification) that would promote license portability across states, and a method to ensure that EMS education programs had the infrastructure to reliably and consistently train new providers (EMS Education Program Accreditation).

The Education Agenda suggested a 10-year timeline to implement the process. With the intent of bringing a level of consistency and quality to EMS education programs and their students, where does the Education Agenda stand today"

Where we are now

Since the release of the Education Agenda, the National EMS Core Content, Scope of Practice, and Education Standards have been completed and released. Many, if not most states have adopted the standards as the basis of education for EMTs and paramedics.

Educational institutions have been transitioning from the old standards since 2010. In March, NHTSA requested input from the national EMS community as to whether to update the Education Standards.

The general consensus was to only slightly modify the standards; most stakeholders felt that ongoing significant developments in EMS practice precluded a major update at this time.

Efforts continue to achieve national EMS program accreditation. There is no current requirement that EMS programs be accredited by a peer-driven, nongovernmental agency similar to all other allied health professions. The most evident trend has been the increasing number of accredited paramedic education programs.

The Commission on Accreditation of Allied Health Education Programs currently recognizes 389 paramedic programs across the United State; another 285 paramedic programs are currently under review for becoming accredited. It is not clear how many paramedic programs exist nationally.

There appears to be a trend toward national EMS certification, at least for EMTs and paramedics. Forty-six states currently require that EMS providers gain initial certification by the National Registry of Emergency Medical Technicians (NREMT) as a condition of state licensure. This may include EMT, paramedic, or both certifications. However, far fewer states require their providers to maintain NREMT certification.

In 2013, the NREMT required that paramedic candidates graduate from CAAHEP-accredited programs. This has accelerated the number of paramedic education programs that are accredited or under a letter of review.

The value of a college degree

At this time, there is no effort to accredit programs that provide other levels of EMS education, such as EMT or advanced EMT. As many states require that paramedic students be certified as EMTs prior to, or during their program, the lack of consistent quality in EMT education programs may result in paramedic students who are underprepared to complete paramedic training.

The Education Agenda and its components do not address how formal higher education relates to EMS training, specifically when it comes to a college degree. While a few states such as Oregon and Texas have degree-based paramedic providers, the vast majority do not.

Most accredited paramedic programs award a significant number of college credit for successful completion; in many circumstances a paramedic student would need to only complete a few general education requirements to receive an associate's degree.

The completion of a degree is significant. Achieving college-level proficiency in English and math skills may improve EMS-related tasks such as patient care, report writing and problem analysis. Liberal studies in philosophy, language or social sciences may help expand the mind and lead to greater possibilities or alternative perspectives on an issue.

The lack of a degree requirement is not lost upon other health care providers. Physicians, most levels of nursing, and nearly all allied health providers require a degree to practice.

These vocations are considered professions; that is, their members possess qualifications gained through extensive learning, demonstrated through rigorous testing, and are self-powered to admit and discipline themselves.

Given that at the paramedic level at least, the level and intensity of education is deemed worthy of at least half to two-thirds of the credits needed to complete an associate's degree, points to a reasonable expectation of a degree requirement.

While a national EMS certification may permit EMS providers to work across state borders, a degree creates portability across the profession. Credits associated with a two-year degree are much simpler to transfer to a four year institution.

Degrees are often required to enter EMS-related fields such as biomedical technology support. Even within the industry, promotion to a supervisorial or administrative leadership position is increasingly at least partially based on the candidate's degree status.

The expense of education

Inevitably, critics point toward the perceived lack of value of a college education in EMS. Superficially, the facts would bear that out; few agencies tangibly recognize the college-degree paramedic through a higher starting salary/benefit level. Employers are also concerned that the additional education and training will result in a higher-cost employee.

Looking beyond the surface, such concerns may be of significant benefit to the industry overall. The provider's dedication to obtaining a degree, coupled with higher employment benefits, may raise the level of organizational loyalty.

The gain in employee longevity may in turn reduce the incidence of mistakes associated with inexperience. Collectively, the body of knowledge gained by the profession through its long-term members may expand far greater than what currently occurs.

Stabilizing the workforce is but one benefit. Recognition and respect among other health professions is gained through the professional recognition of degree awards.

EMS providers work hand in hand with other medical providers, each with their specialized training, education and skill set. There is enough technical, operational and clinical expertise associated with the out-of-facility provider that other health care providers can recognize as a separate and integral medical profession.

This recognition of the individual as a valued member of the health care continuum may translate more importantly at a higher-level service reimbursement.

Government health insurers such as the Centers for Medicare and Medicaid have not been kind to EMS. The fact is, most financial reimbursement is centered on transportation services, not medical care.

It's reasonable to expect this, if the profession itself does not value the investment of education for the benefit of the patient. Current demonstration projects in community paramedicine may change the reimbursement formula — if the industry is prepared to follow through with a greater depth of educational preparation.

The EMS industry faces a decision point in regards to the preparation of its providers. As the education model continues to formalize and create consistency in quality, EMS professionals will need to self-advocate both within and outside of its boundaries.

This move toward a profession will benefit its members, their patients and ultimately society as a whole. Higher education serves as the foundation needed to build upon the profession.

Clinical scenario: Near-amputation in a boating accident

While volunteering as an EMT with the local sheriff’s department marine patrol, you are dispatched to a report of a boat accident. The deputy you are assigned to patrol with helps you load your gear into the launch and you begin the five-minute ride to the reported location.

You are currently patrolling a large inland lake over a holiday weekend. The lake is a popular destination for water sports, and this weekend has been particularly busy.

As you approach, the driver of the boat waves to you. You see that there are three people in the back of the boat crowded around a fourth person who has obviously been injured. Once the two boats are tied together, you step aboard and survey the scene.

Patient assessment

Your patient is a 23-year-old male who is conscious and oriented but in obvious distress. The driver of the boat reports that the patient was water skiing when he fell. The driver circled back to where he thought the patient was but overshot the location and struck the patient.

As you visually assess the patient you see that his right leg has suffered significant trauma and has been nearly amputated above the knee. The patient currently has uncontrolled bleeding from his leg despite direct pressure being applied by bystanders.

Your ALS ambulance is en route with a 15 minute ETA. There is a community hospital 25 minutes from the scene and a trauma center approximately 90 minutes from the scene.

Think about the following questions:

  • What are your treatment priorities"
  • What additional equipment do you need to package the patient"
  • Which hospital should the patient be transported to"

Post your answers below in the comments.

A weekly agency-wide email sends the right message

By Jay Fitch, Ph.D.

I was listening to the radio the other day when Sting's 1983 song "Every Breath you Take" came on. I'd always thought of it as a tale of a loser stalker, but this time the lyrics resonated with me in a different way.

If you remove the bit of romance introduced in the refrain, it demonstrates a basic principle of good communication — but one that's easy to forget: When you’re a leader, everyone is bit of a stalker.

“Every move you make … Every vow you break … Every smile you fake … Every claim you stake … I’ll be watching you.”

It's not easy being a leader, knowing your every move is being scrutinized for hidden meaning. You can say all the right things and still blow it, because you're being watched.

Your stance, your eye contact, your folded arms, how you're sitting in the chair, and where the conversation is taking place (your office, your employee's office, across a desk or side by side) can transmit something entirely different than what you intended.

The good news is that if your leadership comes from a place that is genuine and personal, people will give you the benefit of the doubt when you occasionally send the wrong message.

Avoid under communicating

Leaders often fail in their communication because they fall into a habit of under communicating — that is, not realizing the need to actively communicate formally and informally, more so than they ever realized.

Just because you sent out one email, doesn't mean everyone in your organization "gets it." And if you don't address an issue, the troops will make up for it by filling in the gaps, often at conflict with the message you really meant to send.

Being a good communicator is an essential part of leadership — and it doesn't mean giving good speeches. You know you're doing well when everyone on your team understands your agency's vision, values, and what is expected of them.

This is easier said than done. I know some EMS agency CEOs and fire chiefs who send out a message every week to everyone in the organization, come rain or shine. For some reason it's usually on a Friday.

The best ones are not long tomes about policy. They're short, simple reminders of mission and values, in the form of stories about the people who work there.

If you decide try this, know you're committed to whatever frequency you promise. Miss one and, well, that sends a message too.

Jack Stout: Lessons on managing EMS like a utility company

“Our moral obligation to pursue clinical and service improvement is widely accepted. But our related obligation to pursue economic efficiency is poorly understood. Many believe these are separate issues. They are not. Economic efficiency is nothing more than the ability to convert dollars into service. If we could do better with the dollars we have available, but we don’t, the responsibility must be ours. In EMS, that responsibility is enormous — it is impossible to waste dollars without also wasting lives.” — Jack L. Stout

It was in a college classroom in 1990, during an EMS Management 101 class, that I first heard about the concepts of system status management, high-performance EMS, the public utility model — and the name Jack Stout.

We were learning about EMS system design as part of an undergraduate degree in EMS Administration. Our instructor Willie Krasner used Jack's theories as the cornerstone of the course, touting them as the science behind the best systems in the U.S. at the time.

Even today, 24 years later, most EMS management programs teach some form of Jack's concepts (whether they give him credit or not) and many communities still use elements of Jack's original performance-based contracts for their own — typos and all.

So why did Jack's theories resonant on such a fundamental level that they permeated our secondary education system and are at the heart and soul of today's most respected and successful EMS systems"

It comes down to a fundamental EMS leadership competency that my colleague John Becknell so well identifies in his teachings — managing scarcity.

Creating an EMS toolbox

Jack taught us how to manage scarcity, and do it very well indeed. Jack identified that given the economic variables associated with EMS reimbursement, infrastructure management and desired service outcomes, EMS was just like a public utility company, and could therefore operate much the same as one, reaping the benefits of economies of scale and quality reliability through market regulation and performance guarantees.

Jack also showed us that EMS service demand was predictable, and therefore resources could be matched to this demand in order to provide more reliable services at a lower cost.

What set Jack apart from others was that he didn't just sit back and rest on his academic laurels. He implemented his ideas and theories in the real world, in places like Oklahoma City, Tulsa, Kansas City, and Pinellas County, with measurable outcomes that have impacted millions of lives.

Identified as high-performance EMS systems, they were able to deliver quality care that was highly reliable and economically efficient, to the great benefit of the communities that adopted his concepts.

Unfortunately, much of Jack's work has been demonized over the years as nothing more than better, faster, cheaper at the expense of the people in the field. This is so far from the truth.

What Jack did was create a set of tools that converted a limited set of resources (dollars) into the highest level of service and quality possible. Just as any tool can be used for something good (like using a hammer to build a house) or something bad (like using a hammer to bludgeon someone), it's the tool's end user who makes all the difference in terms of outcomes.

Many well-respected communities and EMS agencies with the courage and stamina to change have used Jack's theories and concepts with unparalleled results. Countless lives have been positively impacted while multiple millions of taxpayer dollars were saved.

Ahead of his time

As irony would have it for the naysayers, much of what Jack dedicated his life's work to in the 1980s and 1990s is what all of health care is aggressively seeking today: finding a way to simultaneously balance economic efficiency, quality patient care and employee well-being.

Why" Because health care is starting to experience the early forms of scarcity, driven by health care reimbursement reform and consumerism, due to our nation's unsustainable and highly ineffective systems of care delivery.

Jack's ultimate achievement and gift to society was recognizing that many of the pioneering concepts used by manufacturing for process improvement — like Deming's Total Quality Management, Six-Sigma, and Lean Manufacturing — could be translated for use in a service industry like EMS to improve outcomes.

This is also what we see happening at the root of health care reform, which promises eventual sustainability and improved reliability and quality.

The triple aim of health care reform, as defined by the Institute of Healthcare Improvement, is not far removed from Jack's original vision of balancing patient care, employee well being and economic efficiency.

Jack's lifetime of accomplishments shows us that even with limited resources, we can achieve amazing results that can reliably and effectively improve service outcomes — and most importantly, enhance the lives of the patients we serve.

The do’s and don’ts of social media in emergency services

By Dr. Shana Nicholson and Joseph Heaton

Social media has become a staple in today’s society. It is hard to find someone who does not participate in at least one service, whether it is Facebook, Twitter, Instagram, etc. Using social media for personal reasons is socially acceptable, however, when social media and emergency services mix, an explosive concoction begins to form. A simple Google search uncovers multiple examples of emergency responders being suspended, fired, and sued for their participation—as first responders—in postings on social media.

What to Consider Before You Post

First, you have to understand how you are going to be perceived: Are you posting on your personal account or on an (un)official department page"

Posting in an Official Capacity

When posting in an official capacity, always make sure your content is respectful (and grammatically correct!). Great examples include training announcements and pictures, awards to local first responders, promotional events for local departments, general public-relation announcements, and emergency alerts. Be sure that the information posted on official accounts is respectful and reflects positively on the department.

Read full story: The Do’s and Don’ts of Social Media in Emergency Services

What EMS agencies can learn from Cleveland sports teams

While I’m proud to call Arizona my home since 2000, I grew up in Cleveland — a city that constantly seems to be the punchline of every national joke.

I still remember watching “Major League” in theaters 25 years ago, and cheering as pictures of city landmarks and decaying buildings flashed on the screen. The movie mocking continues to this day, like with Kevin Costner’s recent film “Draft Day” about a failing Browns football team.

Clevelanders are especially hard on themselves when it comes to sports. I still haven’t forgiven Jose Mesa for costing Cleveland the World Series in 1997, and I have trouble saying LeBum’s name.

My wife, 9-year-old daughter and 6-year-old son may think it’s time to get over it, but I love defending my home town.

I love playing basketball with my kindergartener. If he decides to pretend he’s LeBum James and the Heat, I’ll start playing tighter defense and won’t let him get a shot off towards the hoop — and he knows it.

Create your own story

But here’s the rub. As Cleveland fans, we need to accept at least a portion of the responsibility for this perception. If we didn’t repeatedly self-describe our sports failures as “The Shot,” “The Fumble,” and “The Drive” then outsiders wouldn’t either.

Yes, we’d still have lost, but it likely wouldn’t define Cleveland as it does today.

I’ll root for Cleveland sports teams until the day I die. But EMS agencies don’t inspire the same public loyalty.

As leaders, we need to recognize how a seemingly benign negative perception can take root — growing both in-house and in the eyes of the community when repeated.

So instead, alter it. Create the narrative that you want people to define your agency by.

For instance, if an ambulance company is perceived over a period of time as having rude or poorly trained EMTs or paramedics, it’s extremely hard to change that perception even after you fix the problem. The trick is to address it quickly, before it defines you.

Share some human interest stories that show how caring your co-workers are, and how they go above and beyond for the community and their patients. Create buzz around an upcoming training session or highlight employees who receive certifications that give your agency an advantage over your competition.

As the public relation officer or spokesperson for your agency, it’s your job to not only talk, but listen to what’s being said about the company. Get a pulse on what people think by reading the comments on news websites, on social media, and in blog posts. And tune in to what you might overhear at events or parties.

By quickly promoting the positive reality, you don’t give the negative perception a chance to take hold.

Unfortunately, it’s too late for Cleveland professional sports.

Prove it: Does a delay between AED shock and compressions reduce survival rates?

Case review

Rescue 18 and Engine 12 respond to an office building where bystanders are reported to be doing CPR. Engine 12 arrives first, verifies no pulse and takes over CPR. An AED applied by the firefighters recommends a shock. After the shock, the firefighters resume CPR.

Rescue 18 arrives and transfers the patient to a manual defibrillator, while medic Williams verifies the presence of ventricular fibrillation and begins charging the device. When he does, the firefighters stop CPR as one of them yells, "Clear!"

Williams asks the crew to resume chest compressions while the machine is charging; however, the firefighters seem reluctant to do so. After a short period of no compressions, Williams delivers the shock and the firefighters resume CPR.

Over the next 15 minutes, they establish an IV and administer epinephrine, amiodarone, and two additional countershocks. Each time Williams charged the defibrillator, the firefighters clear the patient’s chest.

At the 20-minute mark, the patient is asystolic. Since the arrest occurred in a public place, the local protocol does not allow the medics to terminate resuscitation efforts on scene. After the 10 minute ride to the hospital, the emergency department physician terminates the resuscitation effort.

Study review

In 2011, researchers from the Resuscitation Outcomes Consortium found the odds of survival significantly decreased when out-of-hospital rescuers stopped CPR for more than 20 seconds before delivering a shock. [1] However, the authors of that study identified a number of limitations that affected the final interpretation of the data, not the least of which was the small sample size of patients (n = 815).

In 2007, the ROC began enrolling patients for a randomized controlled trial called ROC PRIMED, which sought to examine what effects several different resuscitation strategies had on survival. [2] The authors of the current study used the more robust patient database from the ROC PRIMED study to examine the effects that peri-shock pauses in chest compressions has on outcome. [3]

From that database, the current researchers selected all adult patients who suffered an out-of-hospital cardiac arrest and presented in a shockable rhythm to the first arriving EMS crews. All patients received at least one shock from either a manual or automated defibrillator.

The research team excluded patients who either received their first shock from non-EMS personnel using a public access defibrillator or arrested in the presence of EMS crews.

Including these patients in the analysis could make the intervention appear more effective than it really is since survival in both of these patient groups is generally higher than when EMS arrives to find patients in cardiac arrest or when EMS delivers the first shock. The researchers also excluded the patients if the CPR process data was incomplete.

All of the participating EMS agencies used monitor/defibrillators equipped with impedance sensors. These devices recorded changes in electrical resistance across the chest that occurs when rescuers perform various interventions, such as chest compression or artificial ventilation.

As resistance changed, reviewers could determine the exact moment when rescuers delivered each chest compression. This allowed exact measurements of the time when no one was performing compressions before and after a shock, or the hands-off period.

The interval between the moment the rescue team stops compressions and delivers the shock is the pre-shock pause. The interval between delivery of the shock and the moment when the rescue team resumes chest compressions is the post-shock pause. Adding these intervals together gives the peri-shock pause. [4]

The primary outcome measure for this study was survival to hospital discharge. A secondary outcome measure was the neurological status of the patient. Researchers considered survival to be neurologically intact if upon discharge from the hospital the patient scored less than or equal to three on a Modified Rankin Score.

About 3,500 patients in the ROC PRIMED study presented to EMS in a shockable rhythm, or about 10 percent of all the patients in the ROC PRIMED study database. After excluding patients who did not meet the inclusion criteria or had missing data, the final patient population for this study was 2,006.

A comparison between the group with complete CPR process records and the excluded group found no significant differences with respect to gender, witnessed vs. unwitnessed arrest status, the presence of bystander CPR, or the location of the arrest. This suggests that excluding those patients likely had little effect on the outcome.

An unadjusted data analysis showed that the highest survival to hospital discharge rates occurred in patients with a pre-shock pause of 10.1 to 15.0 seconds. Survival was highest in patients with a post shock pause of 5 seconds or less.

Overall, survival was highest when the peri-shock pause was less than 20 seconds. However, unadjusted data includes the simultaneous effects of many variables, some of which could blur the true effect of the pauses.

Using a mathematical technique known as multivariate logistic regression analysis, the researchers isolated the effects that each of these variables had on the outcome.

After adjusting for the Utstein predictors of survival, chest compression fraction, compression rate and ROC site, the researchers found both the odds of survival and being neurologically intact were about 50 percent higher if rescuers keep the pre-shock interval to less than 10 seconds when compared to a pre-shock pause of greater than 20 seconds. These adjusted results represent the true effects of the intervention.

If rescuers kept the peri-shock interval under 20 seconds, both the odds of survival and the odds of being neurologically intact at survival almost doubled compared with peri-shock intervals over 40 seconds.

The researchers could not find any survival benefits associated with the post shock pause.

What this means for you

Animal studies published over a decade ago demonstrate that prolonged or frequent interruptions in chest compression caused by AED analysis or rescue breathing resulted in worsened myocardial perfusion and neurological impairment. [5, 6, 7]

Another study conducted in the out-of-hospital environment found an association between frequent interruptions in chest compression and a decreased probability of successful conversion from ventricular fibrillation to a perfusing rhythm. [8] Shortening the pre-shock pause by even a few seconds can improve the probability of a successful conversion following delivery of a shock. [9, 8]

EMS providers can have a positive influence on survival from out-of-hospital cardiac arrest by adopting any strategy that reduces the pre-shock and subsequent peri-shock pauses in chest compressions. This includes coordinating (with practice) the actions of the team so that the defibrillator operator can deliver the shock immediately after the chest compressor (and other team members) "clears" the patient’s chest.

To accomplish this, the defibrillator must be ready to deliver the shock even before the chest compressor has finished pushing on the patient’s chest. Rescuers who perform compressions while the AED is charging can reduce the pre-shock pause to less than three seconds. [10] Rescuers who charge a manual defibrillator during chest compressions can achieve similar results. [11]


Although the current findings support earlier work, EMS agencies must recognize what the research does not say. Although the data was collected as part of a randomized controlled trial for other interventions, this analysis was observational only.

Thus, it is only possible to state there is an association between the variables. Associations do not imply causation; one cannot state the reductions in the pre- and peri-shock intervals caused the increase in survival.

The researchers also report that many of the participating ROC sites did not collect data on chest compression depth. Thus, more than half of the compression depth data in the study group was missing. It is therefore not possible to know whether there was a difference in chest compression depth between patients who received the shortest or the longest hands-off intervals.

Since chest compression depth is known to influence survival [12], it is possible the current results reflect the compression depth effects rather than the effects of the hands-off interval.

Similarly, the researchers excluded 11 percent of the eligible patients because of missing shock pause data. The analysts could not find any significant differences between those with complete data and those with missing data suggesting the exclusion likely did not influence the outcome.

However, without the data, one can never be sure.

This is the largest study to examine the relationship between peri-shock pauses and survival following out of hospital cardiac arrest presenting in a shockable rhythm. The researchers replicated the findings from their previous work, and their results further support the American Heart Association recommendation to minimize interruptions in chest compressions, especially in the peri-shock interval. [13]


1. Cheskes, S., Schmicker, R. H., Christenson, J., Salcido, D. D., Rea, T., Powell, J., Edelson, D. P., Sell, R., May, S., Menegazzi, J. J., Van Ottingham, L., Olsufka, M., Pennington, S., Simonini, J., Berg, R. A., Stiell, I., Idris, A., Bigham, B., & Morrison, L. (2011). Peri-shock pause: An independent predictor of survival from out-of-hospital shockable cardiac arrest. Circulation, 124(1), 58-66. doi:10.1161/CIRCULATIONAHA.110.010736

2. Stiell, I. G., Nichol, G., Leroux, B. G., Rea, T. D., Ornato, J. P., Powell, J., Christenson, J., Callaway, C. W., Kudenchuk, P. J., Aufderheide, T. P., Idris, A. H., Daya, M. R., Wang, H. E., Morrison, L. J., Davis, D., Andrusiek, D., Stephens, S., Cheskes, S., Schmicker, R, H., Fowler, R., Vaillancourt, C., Hostler, D., Zive, D., Pirrallo, R. G., Vilke, G. M., Sopko, G., & Weisfeldt, M. (2011). Early versus later rhythm analysis in patients with out-of-hospital cardiac arrest. New England Journal of Medicine, 365(9), 787-797. doi:10.1056/NEJMoa1010076

3. Cheskes, S., Schmicker, R. H., Verbeek, P. R., Salcido, D. D., Brown, S. P., Brooks, S., Menegazzi, J. J., Vaillancourt, C., Powell, J., May, S., Berg, R. A., Sell, R., Idris, A., Kampp, M., Schmidt, T., & Christenson, J. (2014). The impact of peri-shock pause on survival from out-of-hospital shockable cardiac arrest during the Resuscitation Outcomes Consortium PRIMED trial. Resuscitation, 85(3), 336-342. doi:10.1016/j.resuscitation.2013.10.014

4. Kramer-Johansen, J., Edelson, D. P., Losert, H., Kohler, K., & Abella, B. S. (2007). Uniformed reporting of measured quality of cardiopulmonary resuscitation (CPR). Resuscitation, 74(3), 406–417. doi:10.1016/j.resuscitation.2007.01.024

5. Berg, R. A., Sanders, A. B., Kern, K. B., Hilwig, R. W., Heidenreich, J. W., Porter, M. E., & Ewy, G. A. (2001). Adverse hemodynamic effects of interrupting chest compressions for rescue breathing during cardiopulmonary resuscitation for ventricular fibrillation cardiac arrest. Circulation, 104(20), 2465–2470. doi:10.1161/hc4501.098926

6. Kern, K. B., Hilwig, R. W., Berg, R. A., Sanders, A. B., & Ewy, G, A. (2002). Importance of continuous chest compressions during cardiopulmonary resuscitation: Improved outcome during a simulated single lay-rescuer scenario. Circulation, 105(5), 645– 649. doi:10.1161/​hc0502.102963

7. Yu, T., Weil, M. H., Tang, W., Sun, S., Klouche, K., Povoas, H., & Bisera, J. (2002). Adverse outcomes of interrupted precordial compression during automated defibrillation. Circulation, 106(3), 368–372. doi:10.1161/01.CIR.0000021429.22005.2E

8. Eftestol, T., Sunde, K., & Steen, P. A. (2002). Effects of interrupting precordial compressions on the calculated probability of defibrillation success during out-of-hospital cardiac arrest. Circulation, 105(19), 2270–2273. doi:10.1161/01.CIR.0000016362.42586.FE

9. Eftestol, T., Sunde, K., Aase, S. O., Husoy, J. H., & Steen, P. A. (2000). Predicting outcome of defibrillation by spectral characterization and nonparametric classification of ventricular fibrillation in patients with out-of-hospital cardiac arrest. Circulation, 102(13), 1523–1529. doi: 10.1161/​01.CIR.102.13.1523

10. Edelson, D. P., Robertson-Dick, B. J., Yuen, T. C., Eilevstjonn, J., Walsh, D., Baries, C. J., Vanden Hoek, T. L., & Abella, B. S. (2010). Safety and efficacy of defibrillator charging during ongoing chest compressions: A multi-center study. Resuscitation, 81(11), 1521–1526. doi:10.1016/j.resuscitation.2010.07.014

11. Thim, T., Grove, E. L., & Lofgren, B. (2012). Charging the defibrillator before rhythm check reduces hands-off time during CPR: A randomised simulation study [Letter]. Resuscitation, 83(11), e210–e211. doi:10.1016/j.resuscitation.2012.07.034

12. Vadeboncoeur, T., Stolz, U., Panchal, A., Silver, A., Venuti, M., Tobin, J., Smith, G., Nunez, M., Karamooz, M., Spaite, D., & Bobrow, B. (2014). Chest compression depth and survival in out-of-hospital cardiac arrest. Resuscitation, 85(2), 182-188. doi:10.1016/j.resuscitation.2013.10.002

13. Berg, R. A., Hemphill, R., Abella, B. A., Aufderheide, T. P., Cave, D. M., Hazinski, M. F., Lerner, E. B., Rea, T. D., Sayre, M. R., & Swor, R. A. (2010). Part 5: Adult basic life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 122(suppl 3), S685-S705. doi:10.1161/CIRCULATIONAHA.110.970939

3 tips to starting an EMS grant application

Beginning to grant write for your agency can seem like a daunting task.

Which project do I start" How do I get it funded" What do I even write"

With a million different complex questions crossing your mind, it's easy to abandon the application before it's even started. Starting a project and getting it funded is not easy, which is why for any project to be successful you need to be passionate.

Here are three keys boosting your chances for success.

1. Target ideas fueled by passion

As a field paramedic, my report with patients provides great insight into the needs of the community. It gives me access to our target population to truly figure out what can have the most impact on those we service.

I've found that I have a renewed passion for health care when creating a project that will improve the community, my agency and positively impact my coworkers.

For instance, community paramedicine is a topic that energized my academic pursuits and breathed new life into my career. So when I was given the opportunity to write a grant proposal to fund a pilot program through NHTSA's Innovation in EMS cooperative agreement program, I was overjoyed to begin work.

Yet, I was quickly overwhelmed by deadlines and the enormity of the application. Whenever I overcame one obstacle five more arose and I began to think I might not have it submitted in time.

However, I burned the midnight oil night after night because I knew what this funding meant: an opportunity to have federal funding for a community paramedic pilot program for my county. It meant a community program proven to better the health care system overall by reducing the burden on individual providers and the EMS system, and decreasing government spending on health care.

If you find your passion project it will be much easier to get funded.

2. Put it on paper

Being prepared to present your project to administrative personnel is key.

I find that writing a brief, but detailed project description focusing on how the project will enhance the community and improve both the agency and my coworkers directly is the best approach.

Give possible funding options including private foundations that have a history of funding similar projects, state grant programs, and federal grant programs. Consider whether your project may need continued funding like pilot programs or community events. Not all projects have to be complicated or span multiple years.

Funding assistance also can be used to buy equipment or apparatuses that can alleviate health care shortages and accessibility issues. Equipment needs can have a significant impact the community and your agency.

Putting a rough plan on paper is incredibly important to gain buy-in from administrative personnel that have the ability to submit grants on behalf of the agency. Developing support from your command staff is also an essential asset to work your project up the chain of command.

3. Follow application guidelines

Once approval has been gained for your project, the real work begins. Remember to re-read the application, keying in on what the grant maker is asking from you.

If you do not follow the guidelines for the application, it will be rejected and you may not have the opportunity to resubmit. I cannot emphasize this enough.

Additionally, if any questions arise, grant makers are typically very approachable. Contacting your grant maker is a great way to clarify information and get a better handle on an application.

Only on rare occasions do I find myself not contacting the grant maker, never be afraid to ask for help.

Inside EMS Podcast: Can you become paramedic in 2 weeks?

Download this week's episode on iTunes, SoundCloud or via RSS feed

In this week's Inside EMS podcast, hosts Chris Cebollero and Kelly Grayson discuss situational awareness in light of recent events that continue to put paramedics and EMTs in danger.

"It has been dangerous for us out there for quite some time and we always need to keep up our situational awareness and keep our heads on a swivel," Kelly said.

Chris and Kelly also debate nursing versus paramedicine in their clinical issue. The discussion comes from a recent announcement by Creighton (Neb.) University offering a paramedic bridge program that's awarding certain allied health care professionals to achieve their paramedic certification in two weeks.

They also interview Dan Limmer, author, national speaker and president of Limmer Creative, about the future of EMS education. Dan also gives an overview of his new educational apps.

Dan is offering a 20 percent discount to Inside EMS podcast listeners by using the promotional code "Ambodriver." You can purchase and download via iTunes, Google Play or on the web.

Here are links to some of the articles and other items mentioned on the show:

Mo. man drives son to hospital after confusion over 911 call

Better mobile phone tech could solve rural EMS dispatch issues

15 killed in 53 Chicago shootings over holiday weekend

Without federal action, states move on long-term care

Medic chased by knife-wielding man he revived

Escaping Violent Encounters: Where you stand could save your life

Limmer Creative’s new trauma app helps paramedic students study for the NRP

Innovation Zone: EMS exam preparation


EMS1 Tips

Active shooter response: Are you physically ready?

Normally, I am strong believer that paramedics are at their best when they saunter into a scene, slowly walking and looking for clues and risks. But an active shooter incident is going to require repetitive bursts of significant physical activity.

Energy-saving tips for your station

Earth Day 2012 takes place this Sunday, with events planned held worldwide to increase awareness and appreciation of the Earth's natural environment. So, it's a good time to see what you can do at your agency to save both resources and money.

How this video can "Keep Yourself Safe"

Consider using this PPE safety video in your EMT Basic or Refresher Class.

CPR class instruction: 5 ways to make it great

My most recent healthcare provider recertification was memorable for all of the things the instructors did well.

Patient assessments: How to avoid free-for-alls

Substantial cajoling and adult guidance from mom in a Santa hat was required to initiate an orderly process of taking turns, appreciating a gift after it was opened, and taking occasional pauses for a meal or to welcome additional relatives.

Patient assessment: A non-linear process

On a skill sheet, patient assessment is presented as a linear process: First size up the scene, then complete the primary assessment followed by the secondary assessment.

Blood pressure reading tips and tricks for EMS

One of the things I'm most often asked by students and rookie EMTs is, "Kelly, how am I supposed to hear a blood pressure in the back of the rig?"

How to use Slideshare for EMS

Slideshare is an online community and tool for sharing presentations.

How to get optimal battery life from your devices

The batteries in your wireless cell phone, tablet or laptop are probably not the same old Duracells you used in your childhood walky-talkies.

U-turn for the OB patient

If you have an OB patient about to deliver, do a U-Turn and put the patient backwards on the gurney. By placing their head at the "foot" of the gurney, this allows you to work out of the captain's chair and gives you more room. The hardest part of doing this is getting your partner to place the patient in this position. Old habits are hard to break and it may feel odd, but once in the truck ...

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