The Neon Red Elephant of EMS

I grew up riding fire-based ambulances: as a volunteer, a seasonal employee and within my municipal career. Done part-time work with a commercial ambulance. Teaching high school EMT in rural Virginia sensitized me to the needs of all-volunteer community life-saving squads.

My first Firegeezer.com column, Walking the Fire-Based Talk, discussed the 2007 release of “Prehospital 9-1-1 Emergency Medical Response: The Role of the United States Fire Service in Delivery and Coordination.” This was the white paper promoting the vital role of the fire service in delivery of emergency medical services. (17 page 162 KB HERE).

HOW THE NON FIRE SIDE THINKS

I spent the past eight years attending conferences, business meetings and hallway discussions held by non-fire ems organizations. American Ambulance Association, EMS educators, high performance systems status advocates and EMS physicians. Fire service was the neon red elephant in the room at every discussion of turf, power or politics.

Hanging out in Las Vegas with an ems expert who is grounded within commercial and third-service systems. Comparing ems conferences, he noted that the IAFF was one of the better organized venues. Provided a more diverse group of speakers: politicians, economists and highest level of regulators/ administrators. He reflected that firefighter labor was a well-resourced and politically-astute sleeping giant that could dominate ems.

Two years after that conversation the giant awakened, as one of five national fire service organizations sponsoring the fire-based ems white paper

WHY TALK ABOUT THIS NOW?

IAFF and IAFC reaffirmed their support for fire-based ems (JEMS item). On JEMSconnect a discussion question was posted that exceeded 147 posts at the time this item was published (HERE).

The first Public Utility Model of EMS delivery, Kansas City MAST, is scheduled to be taken over by the fire department in May 2010, ending three decades of service. (HERE)

This is particularly heartbreaking to the high performance advocates, since the fire department does not intend to maintain an ambulance response time of 8:59 minutes to priority one calls 90% of the time. Fire Chief Dyer points out that their implementation of fire company delivered compression-only resuscitation has almost doubled the number of patients showing a return of spontaneous circulation.

David Williams, a senior Fitch and Associates consultant, tells Best Practices in Emergency Services "MAST is a reaccredited ACE center that does Medical Priority Dispatch and advanced systems status management, none of which the fire department has any experience with." (HERE) Stephen Dean, PhD, provides a great PUM description (HERE).

ITS NOT ABOUT CLINICAL EXCELLENCE OR CAREGIVER DEDICATION

Delivering municipal services is a political and economic activity. The voters are not focused on the details of delivery of the service, until it becomes perceived as a problem. Voters failed to approve the renewal of funding for the King County/Seattle Medic One program in 1997 (HERE).

Philadelphia tolerates grossly overworked ambulances, 20 to 40 minute waits and occasional fatal outcomes. (HERE)

SOME SYSTEM DELIVERY PRACTICES MAY NOT BE IMPORTANT

Patient outcome studies are challenging ems system design assumptions, with the amazing results from uninterrupted compression-only CPR (HERE).

Last year the U.S. Metropolitan Municipalities EMS Medical Directors Consortium issued recommendations impacting six areas of clinical treatment. ST-Elevation Myocardial Infarction (STEMI), pulmonary edema, asthma, seizure, trauma and cardiac arrest. Their recommendations for cardiac arrest are surprising:

Response interval of less than 5 minutes for basic CPR and automatic external defibrillators (AEDs). No response interval was specified for ALS arrival.

In justifying its cardiac arrest recommendation, the group noted that much of the clinical research used to establish acceptable ALS response time intervals was conducted prior to the widespread dissemination of AEDs and at a time in which the compression component of CPR was not emphasized as it is now.

As a result, the consensus group proposed that EMS systems not focus response time measurement on ALS ambulances, but rather pay greater attention to first response/BLS response time to measure what it called the “most important predictive elements for optimal outcome: time elapsed until initiation of basic chest compressions and time elapsed until defibrillation attempts.”(PEC article HERE)

IT IS ALL ABOUT FIREFIGHTER JOBS

General President Harold A. Schaitberger, speaking at the June 2009 EMS Conference, noted that hundreds of IAFF members lost their jobs. By June 2010 it may be thousands.

If aggressive takeover of private and third service 9-1-1 ambulance service preserves jobs, then expect to see fire departments reaching out.

Mike "FossilMedic" Ward

This is reposted from Firegeezer.com, where you can read more articles about fire and ems topics. It is part of the http://fireemsblogs.com/ network.

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Comment by Ben Waller on January 3, 2010 at 1:11pm: Lesa, my point is that you assume that the changes will all be bad. Time will tell, but unifying the dispatch, providing consistent first response/CPR/AED combined system will likely improve outcomes, just as one example of how things could be improved.

Comment by Lesa G on January 3, 2010 at 5:12am: Ben, the system has NOT yet changed. May 1, 2010 is the merge date. MAST is still operated by a Board of Directors who wisely had the sense to vote NO on disbanding early (before KC has their budget set by Feb 15th, a ploy attempted by the political powers that be) and allowing Smokey Dyer to become CEO. We currently still have Darryl Coontz as our Interim Director and others are sharing the responsibilities of the currently vacated position of COO. (His departure had nothing to do with the merger.) We have a fine team of Managers, an efficient and effective HR Management Company, and the same field crews as before. We shall wait and see how the budget works out in February as to how efficient this system will operate, won't we?

Comment by Ben Waller on January 2, 2010 at 11:09pm: asys,

Sorry - I misunderstood the specifics. However, if you have a ring magnet protocol, you can stop the ICD shocks without antiarrythmics, and then treat the v-fib/v-tach as if the patient did not have the ICD.

I agree that politics shouldn't take precedence over good patient care, but there's no evidence one way or the other in the KC Fire/MAST issue. If they get a good unified dispatch protocol out of the deal - one that includes organized engine co. first response - it might actually improve outcomes.

All system design is local, and decisions that negatively affect patient care are not the exclusive province of some of the less-than-stellar fire departments. For every Seattle, there is a Detroit. For every Wake County or Boston, there is an Atlanta and a Cleveland.

I like ALS engine companies and ALS rescue companies. I've worked both in my career, as well as ALS ambulances, ALS fly cars, and ALS supervisor vehicles. All have their place, depending upon what level and type of care the local government funds, and the system managers decide upon, and both of those are...political decisions at heart.

Lesa obviously doesn't like the local politics, and she has a lot invested in fighting the system change. However, the system changed. There's been no evidence that anything in that system has changed one way or the other, except for the savings due to fewer administrators and the corresponding drop in administrative costs. There are allegations that "everything will get more expensive", but providing more ALS providers do that as well.

This is one of those situations whose results will be determined only over time.

Comment by Ben Waller on January 1, 2010 at 10:12pm: asys,

My point is that if KCFD isn't doing first response on Delta-priority calls, they should be.
There has been nothing published indicating that there will be any expansion or cut in the number of either firefighters/fire companies or ambulances/paramedics/EMTs in KC.

There is also no indication that KCFD is planning PECs, as far as I've heard.

So...I'm not really sure what your point is there.

As far as antiarrythmics for malfunctioning ICDs, ring magnets are a far better option. They are a state standard here, and every ALS unit at my current and previous employer (opposite ends of the state) carry them. I've used ring magnets a couple of times and had one of those 45 minute transports from the boonies with a patient getting bunches of inappropriate shocks before our state EMS system approved the ring magnets. We couldn't stop the narrow complex tach with antiarrythmics or with sedation and cardioversion, so we got orders for additional benzos and had the ring magnet waiting at the ED doors.

However, in the big picture, those are outliers. Very important to the outlier, but we shouldn't be designing the system based on outliers.

I'm in favor of PECs (in the places that have them) doing real EMS - including sedation, ring magnets, CPAP...everything to manage one or two patients, other than transport. That includes taking care of comfort for outlier patients.

At the end of the day, aren't we supposed to be practicing evidence-based medicine?
You know, the kind that's based on statistical studies and outcomes?

And...it's barbaric to not control pain when reasonable means to control that pain are available.
If ALS isn't on scene yet, then the ALS pain control means is not available, ergo, no barbarity exists.

The bottom line here is that Lesa assumes that everything will get worse in KC because the FD took over the system management. That isn't a safe assumption - it's way to early to tell what will happen. By her own admission, she has a heavy emotional involvement in the change, has fought it extensively. That tends to indicate a less-than-completely objective look at both the situation and the crystal ball for the future.

The bottom line is that Utstein survival criteria is of major importance. It takes timely and effective first response, CPR, and defib to improve those factors. It is a rare EMS system indeed that has good Utstein survival without a well-organized, well-trained engine company first response system.

I'll close with a question. Was the previous lack of consistent engine company first response due to the lack of a combined FD/EMS dispatch system, a lack of an engine company first response protocol, a combination, or something completely different?

Comment by Lesa G on December 30, 2009 at 2:01am: asysin2leads...I think I love you! Ok, not really, but you have expressed the TRUE importance of EMS quality and response times! Thank you. I want to share a poem I wrote the week before Christmas that pretty well touches on what is happening here in Kansas City...

twas the night before christmas and all through the town,
the murders were up, instead of going down.
The guys were going down the chimneys with ease,
The soot inside, boy, made them sneeze!

The weapons were nestled all snug in their waists,
while cars ran away in a quick police chase.
My man in his doo rag and I in my cap,
had just settled down, when we heard him get capped!

When out on the lawn there arose such a clatter,
the screams and the tears, they just didn't matter.
The cops did we call , but alas there were few,
For city council made deals, as they always do.

The moon on the breast of the man on the lawn,
showed glimmers of red, where he had fall'n
When what do my wondering eyes do appear?
A big white box with medical gear.

With an efficient driver, so learned and fast,
I knew in a minute, IT MUST BE MAST!
To the man on the lawn, they arrived so swift,
I knew in a minute they just started their shift.

Medic called on the radio, just need to know,
Man shot in the gut in the fresh fallen snow,
BP is not good, respers are weak,
Loading him now, will be there shortly, with whom do I speak?

The doctor said his name, which never is clear,
It did not matter for this life is dear.

Though things will be changing, come around May,
let's hope there'll still be money, for the city to pay.
The people who drive and ride in the box,
still will be swift and smart as a fox.

They may not have badges and training and such,
but some say they don't need them, they just need the touch.
Time will not matter, advance does not pay,
Load them up quickly and get on your way.

He is chubby and plump, a jolly old chief, I cringed when I saw him, in utter disbelief.
A wink of his eye to Louie he made, the deal was all done, boy what a trade!

He spoke many words, no sense did they make, the council all nodded,said he was great.
Laying pen on the paper they wrote it is done, MAST is all gone now we are one.

When taxes go up and time limits go away, remember the man, in the snow as he lay.
Will there be money to pay for the gal, the guy, the equipment, the box, will you be asking why?

We will hear them exclaim as they drive into to sight, lets load him and go, it is football tonight!

Comment by Ben Waller on December 27, 2009 at 10:44pm: Lesa, if KCFD has more units and an overall lower call volume, it would make sense to have them dispatched first on Delta priority calls. If they are not dispatched first, then that's a dispatch error that's easily corrected by a policy change.

Seattle FD has Utstein save rates in the high 40%, approaching 50% on a regular basis. I don't know a lot of FD EMS systems that track this, but a lot of non-FD EMS systems don't track it yet, either, based on the tradition that all CPRs are reported and the save rate for those is very low because most of them don't fit the Utstein template. That isn't a function of the system model, it's a function of how data is tracked and reported.

Comment by Ben Waller on December 27, 2009 at 10:41pm: asys, the evidence says ACLS response time doesn't matter statistically to outcomes. I'm not sure of the mentality of someone who would disregard the scientific evidence.

Unsecured airway - basic EMTs and even MFRs are allowed to insert King LTs, LMAs, or Combitubes in most states. That can be done without ALS on scene. ET intubation isn't necessary to secure the vast majority of airways.

Being shocked by an implanted defibrillator - rare call, and usually that is because the patient is in a rapid, wide-complex arrythmia. If the patient is recieving shocks, the ICD is doing the defibs before anyone arrives on scene and either the patient will be fine before EMS arrives or the patient's prognosis is grim no matter what we do.

Antiarrythmics - greatly overused in the prehospital setting, not generally indicated for PVCs any more, stable wide-complex arrythmias are very rare and don't necessarily require immediate treatment, because they're, well, stable.

Immense pain from an injury - it would be nice to take the pain away a few minutes sooner, but once again, the evidence shows that it doesn't matter in terms of outcomes.

Not being able to breathe from a pneumothorax - in a viable patient, that is also very rare.

If you're right, you're providing an excellent argument for ALS engine companies, since they have much better response times than ambulances virtually everywhere they are used. I'm surprised to hear you arguing in favor of a fire-based EMS strength, but good for you.

Comment by Lesa G on December 27, 2009 at 10:18pm: Ben,
KCFD is neither the primary nor generally the first responders in KC. Yes, the help tremendously and are often on scene before MAST but they run fewer than 30k calls of all sorts per year with over 900 firefighters, etc while MAST runs over 75k per year with fewer than 300 employees. I have been on many calls where we were first in and started ALS well before fire arrived. The month of November MAST had resuscitation rate of 40% of ROSC for patients in V-Fib. How many other fire based ems services have this high of a rate? I would be interested in seeing the numbers.

Comment by Ben Waller on November 22, 2009 at 4:30pm: Mike,

The stories linked to your post seem to espouse two mutually exclusive points.

1) PUMs (MAST example) are supposedly the "best" EMS model. That includes the SSI criteria that improves ALS response times. However, the story goes on to say that ALS meant something very different when PUMs were invented, due to the lack of widespread AED use and ALS skills being performed by personnel certified to less than the paramedic level as we have now. One of your other links goes on to state that the old "8 minute" response time (redefined to 8:59 by the AAA and PUM advocates years ago) is now under question, as there has been no scientific evidence that t matters. Then - ZING - Philadelphia FD is being taken to task for its problems with ALS response times.

In regard to ALS response times, I ask "Which is it?" It doesn't make sense to complain about a Fire/EMS system's ALS response times on the one hand, then state that there is no scientific data showing that it matters in the same discussion.

2) K.C. Fire is being taken to task due to their lack of specification of ALS response times. However, in the key areas - CPR and 1st Defibrillation, K.C. Fire is already the primary - and generally the first - provider for those interventions. If K.C. Fire is already providing the two measures that are generally accepted to be the response times that matter, then ALS response times are less important. Why question K.C. Fire's lack of ALS response time specification when those response times may not matter to outcomes, even for cardiac arrest patients?

This is one of those issues where two mutually-exclusive arguements are both being used to complain about FDs who are involved in - or who want more involvment in - EMS.

Sorry, folks, when it comes to mutually-exclusive issues, you can't have it both ways.