Reflections on a New System

Posted by Patrick Lickiss on Jan 25, 2012 in Current Events, EMS 2.0, General | 0 comments

So I’ve been working in my new EMS system for a little while now and a few readers have asked if I have noticed any differences between Western Michigan and Alameda County. I’ll spare you the weather-related differences and focus on the actual EMS aspect.

DISPATCH
The three counties we serve have fully embraced the Medical Priority Dispatch System (MPDS). While cards are used to determine if a call is Alpha (stubbed toe) through Echo (cardiac arrest) in severity, each county medical director has assigned a response priority to the phone triage results. A Priority One call involves both the transport and first responder units traveling with lights and sirens. A Priority Two call involves just the first responders using lights and sirens and a Priority Three call involves just the transporting unit responding with no first responders.

The end result of this system is fewer units running code around the city. The risk, of course, is undertriage. I can say that, so far, I have only been upgraded en route a handful of times and have not yet gone to a Priority Three that needed more medical resources (just the occasional manpower call out for lifting). There is a QA/QI process at the dispatch level and though I was skeptical at first, the system seems to work. I’m even considering cross training in dispatch after I get my bearings (I know, I know!).

FIRST RESPONDERS
All of the fire departments we routinely run with are BLS, at the most. Many of the volunteer agencies require only Medical First Responder. Now this is not to say that there aren’t some paramedics who volunteer with these agencies, but they are generally limited to providing BLS care. There is a caveat, however. If I, as the transporting medic, know that a volunteer firefighter is an approved paramedic in the county, I can ask him/her to operate at the ALS level. Medical direction basically offers us a way to have additional ALS hands on scene and during transport as needed. Pretty cool if you ask me.

The Sheriff’s Department in our neighboring county also staffs first response paramedic units. Back when the Federal government was first handing out money to develop EMS systems, this county chose to funnel those funds to law enforcement rather than fire. Today, the ALS first responder program is limited to a few townships under a contract basis with the Sheriff’s office, but the idea is sound and generally works well. When thinking about redesigning a system from the ground up, looking to this type of first response may be helpful.

PROTOCOLS
Now down to the nitty gritty: the medicine.

The protocols here are largely the same though we have a few medications like fentanyl and magnesium sulfate that I didn’t carry in Alameda. Most treatments are performed based on standing orders, though there are a few which I take issue with. For instance, I have to call medical control to treat abdominal pain. I can give pain meds for traumatic injuries, but any non-traumatic pain requires a physician consult. Now, that being said, I haven’t been turned down yet, but it feels a bit old-school to have to ask. That being said, the new Michigan State protocols allow aggressive treatment of anaphylaxis with IM/IV epinephrine and encourage liberal use of CPAP. I feel as though I’ve been able to treat critical patients as I see fit without needing to interact with medical control too often. That seems like a good fit to me.

Perhaps the best part about our protocols is that they are interpreted as guidelines, not as a cookbook. Decisions made in the best interest of the patient are honored as such.  That is a similarity to Alameda County that I am thankful to see.

CALL VOLUME
In a word: busy. I would say that, on a given shift, I run the same number of 911 calls that I did in Alameda. We also run transfers on top of that. The upside is that our days go by quickly. The downside is that I’m exhausted at the end of a shift. I will say, I actually enjoy running transfers from time to time. It’s usually a slower pace, but we also run CCT calls (including written orders from the sending physician with whatever medications they need us to carry) so some of the transfers are pretty critical.

SO WHAT’S IT ALL MEAN
Professionally, I miss Alameda County like crazy. That being said, the system here feels very similar. The protocols are largely the same and the Medical Director seems to support the idea of paramedics as true medical providers. The receiving facilities here are great and welcome us as team members. Though I miss where I started, I’m excited about where I am and where I’m going. Thanks for indulging me in a self-centered post!

Have you moved to a vastly different EMS system than where you started?  Any reflections on that process?  What do you like better about your system now?  What about your old system?  Let me know in the comments!

Image via Flickr

Wishes for a New Year

Posted by Patrick Lickiss on Jan 1, 2012 in EMS 2.0, General | 0 comments

So here we are, another year is upon us.  For those of you following me on Facebook and Twitter, there have been a lot of recent changes in my life.  A cross-country move, a whole new EMS system, a son growing faster than I can imagine; the list goes on and on.  As you may have guessed, I’m sitting down and writing this post well before the new year begins.  I’ve been reflecting recently on what I’m hoping to accomplish in the new year.  Part of that process is to look back on what I’ve done in the past 12 months.  So far, in the EMS 2.0 world, one item stands out beyond all the others.

This year I was able to connect with a group of like-minded providers at the First Responders Network to develop an online magazine that I think has a great deal of potential.  I certainly harp on the need for evidence-based practice in EMS often enough but Interventions goes a step beyond that.  Our goal with the magazine is to engage the EMS community and get them talking to their own managers, medical directors, peers and public about the next steps in EMS.  It’s not enough to sit here and demand evidence-based standards, I want to mobilize an entire community.

So there it is, my EMS 2.0 resolution for 2012:  I pledge to do whatever I can to involve those in the EMS community not already engaging on Twitter and Facebook, those who don’t yet read blogs but are interested in shaping the future of EMS.  I encourage you to think of ways to do the same.  We over at FRN can’t do it alone.  What are your ideas for engaging the rest of the EMS community?  Let me know in the comments.

Image via Flickr

Fast Response Paramedic Program Accepting Applications

Posted by Patrick Lickiss on Oct 25, 2011 in Current Events, EMS 2.0, General | 1 comment

As regular readers of my blog have noticed, I am a huge advocate of actually teaching medicine to paramedics.  I see no reason why we can’t teach paramedics the necessary skills to take their place in the medical community rather than simply teaching them to pass a test.  For quite some time, there were few options for paramedic students seeking that opportunity.  That will hopefully change with the new Paramedic Academy offered by Fast Response in Berkeley, CA.

I had the opportunity recently to speak with a portion of the instructional staff from Fast Response and I was definitely impressed with what they have planned.  Their goal is to incorporate available technology like realistic simulation mannequins and tablet computers with the power of social media, podcasts and the EMS blogosphere and combine them with small-group, case-based scenarios to create a program which is unlike any other I have been a part of.  The goal is to build a quality paramedic program from the ground up and turn out fewer, better paramedics rather than cranking out as many successful National Registry candidates as possible.  I, for one, think this is a great idea.

Before going further I should note that I am in no way being compensated for this post.  I simply liked what these instructors had to say and wanted to pass the word.  My thought is that any EMTs who are progressive enough to be reading an EMS blog would be a great fit for this program.

For any EMTs out there in the San Francisco Bay Area looking for an exciting opportunity, head over the the website to take a look at the requirements.  This first academy starts in April of next year.  The application process for Fast Response is certainly more rigorous than most (including requiring documented EMT experience) but my hope is that it creates a more effective learning environment by attracting dedicated, motivated students.

If you do apply, drop me a line and let me know what your experience was.  I would love to get the inside scoop from a student in this first class.  Best of luck!

California Paramedic Regulations are Open for Public Comment

Posted by Patrick Lickiss on Sep 21, 2011 in Current Events, EMS 2.0, General, Treatment | 26 comments

Did you hear that?  That was the sound of my brain exploding.  Seriously.  If you’ve read this blog for any length of time, you’ll know that I’m a huge advocate for expanding the role, educational requirements and scope of practice of prehospital practitioners.  I may finally get my vindication.

The State of California is looking at revising their scope of practice to fall in line with the National Scope of Practice Model.  This can’t happen soon enough.  There are three main areas of focus:  additions to the paramedic scope, establishing a standard for Critical Care Transport Paramedics (CCT-P) and Advanced Prehospital Paramedics (APP) and revising minimum standards for controlled substances management.  Since narcotic control is a dissertation in itself, I’ll focus on the first two topics today.

BASIC PARAMEDIC SCOPE
Alameda County readers of this blog will note that many of the changes detailed below represent medications we already give and treatments we already perform.  It’s important to note that local medical directors ultimately control what happens in their system and that many counties have requested permission from the state to incorporate these treatments already.  Adding these to the state scope means that special permission won’t be necessary and that local medical directors can add these items to their protocols with ease.

Medications

• Amiodarone
• Dextrose 10%
• Diltiazem
• Fentanyl
• Ipratropium
• Lorazepam
• Magnesium Sulfate
• Ondansetron (Zofran)
• Potassium up to 40 meq

Procedures

• External pacing
• Perilaryngeal airways and pediatric endotracheal intubation
• CPAP/BiPAP
• Intraosseous Insertion
• Prehospital lab tests including capnography and carbon monoxide monitoring
• Naso and orogastric insertion and suctioning
• Intranasal medication administration

Not a bad list of additions if you ask me.  I’m glad to see a move towards fentanyl for pain management and I think that lorazepam is better suited for sedation than the midazolam most of us are using now.   Standardizing CPAP and IO usage is a great idea as well.  We’ve had excellent results here with both and I think those skills will serve other systems as well.

CCT-P/APP
Now this is what I’m really excited about.  Several counties in the Bay Area have implemented CCT-P programs but this opens that idea up to the rest of the state and expands to allow advanced ALS practitioners.  The state would standardize the training programs for both designations and allow local medical directors to authorize these levels of care without additional state approval.  Let’s start with the CCT-P scope:

• Set up, maintain and troubleshoot thoracic drainage system.
• Set up, maintenance and troubleshooting of a mechanical ventilator.
• Set up, maintenance and troubleshooting of fluid delivery pumps and devices.
• Administer medication infusions during interfacility transports including, Heparin, blood and blood products, Glycoprotein IIB/IIIA inhibitors, nitroglycerine, norepinephrine, TPN, and thrombolytics.

Not too shabby.  This allows systems to develop CCT-P level interfacility units with the ability to backup the 911 system, or to train a portion of their 911 responders to perform these transfers, depending on the volume of either type of call.  I’m actually an advocate for the second option.  By providing advanced training to interested 911 responders, you not only obtain the ability to utilize them for complex transfers (which likely have a higher reimbursement success rate than 911 calls) but you also win on the 911 side by having better trained providers caring for your emergent patients.  Everyone wins.

Now, on to the coup de gras…Advanced Prehospital Paramedics:

• Perform digital and nasotracheal intubation procedure.
• Surgical cricothyrotomy.
• Perform procedure for facilitated intubation using sedation and neuromuscular blockade.
• Set up, maintenance and troubleshooting of a mechanical ventilator.
• Administer medication including succinylcholine and etomidate.
• Administer OTC medications.
• Assess and refer patients, and assess and provide treatment without transport.

Now the likelihood is that I’ll be writing about this level of care for some time to come so let’s start with the big one:  ”Assess and refer patients, and assess and provide treatment without transport.”  Simply awesome.

One of the biggest roadblocks to APP programs is the inability to bill for services.  State and Federal insurance programs (and most privates) reimburse for transport only.  The addition of treat and release/treat and refer to the state scope is a huge step towards advocating for EMS reimbursement for those programs.  Making those programs sustainable means that they can be rolled out on a state-wide basis.  Now you see why I’m so excited about this and I hope you are too!

If you’re interested in reading the regulations in their entirety or making your voice hear during the public comment period, head over to the EMSA website. The period for public comment ends October 24th!

What are you looking forward to in the future of EMS?  Were any of those addressed in this scope update?  What are your next steps towards making your EMS dreams a reality?

Image via Flickr

Reflections on EMS Expo

Posted by Patrick Lickiss on Sep 14, 2011 in EMS 2.0, General | 0 comments

Sorry it’s taken me so long  to get around to writing this.  Life seems to move pretty quickly and suddenly it’s been a week going on two since I got back.  First of all, for anyone who has never taken the opportunity to attend a large-scale EMS event like EMS World Expo or EMS Today, I highly recommend it.  This was my first year and I can’t say enough about the experience.

THE PEOPLE
During the past year and a half I’ve had the opportunity to collaborate with some amazing folks in the EMS community.  We’ve developed projects, shared best practices and traded stories about what we enjoy the most about our respective systems.  The interesting part is that I’ve done all of this collaboration largely through social media.  What EMS Expo represented for me was an opportunity to meet these people face to face and to continue to forge collaborative relationships to help advanced EMS as a true medical practice.

For me, the week kicked off on Tuesday night, about an hour after my plane touched down at the airport.  Charlotte and the team at Zoll hosted an EMS Blogger Bash at the Hard Rock Cafe on the Las Vegas Strip.  What I had assumed would be a small meet up of 25 of 30 people grabbing drinks was actually an impressive event with about 100 attendees.  It was nice to see that this many people “got it” and that a company like Zoll was on the same page as the rest of us.

As the week wore on, I had the opportunity to meet EMS practitioners from systems around the country and the world.  I met everyone from volunteer First Responders to system Medical Directors and everyone in between.  Each of these people was drawn to Las Vegas by something they felt was important.  For some it was likely a great reason to party.  For others, however, it was the same as my reason for coming: the opportunity to meet with like-minded professionals with a vision for where the future of EMS will take us.

THE CLASSES
There were an amazing array of presentations available to choose from.  The Expo is separated into “tracks” like “BLS”, “ALS”, “Operations/Management”, etc.  Given my penchant for turning EMS into a clinical practice, I tended to choose clinical topics, though there were often several courses offered at the same time which caught my attention.  I particularly enjoyed Paul Pepe’s presentation on the dangers of pre-operative fluid resuscitation in trauma patients and Sean Smith’s advanced toxicology lecture.  I hope to post more on these and the other courses I took at a later date.

On the final day, I had the opportunity to sit in on Justin Schorr’s lecture:  ”How a Blog Saved my Life”.  I’ve had the opportunity to work with Justin on a variety of projects recently and I had a vague notion of why he got into blogging.  This presentation, however, was a real eye-opener.  Afterwards, I began reflecting on what brought to the EMS blogging world and that reflection has allowed me to refocus my efforts and re-evaluate where I want to go with this project.  In fact, I encourage all of my readers to think about what got you into EMS and why you are still here.  You may find that your answer to those questions can provide clarity about your future in this business.

THE SOCIAL MEDIA
On top of being my first trip to Las Vegas and my first EMS Expo, this trip provided me with a variety of other firsts.  For instance, working with other bloggers from FRNtv, we launched Interventions a quarterly online magazine meant to inspire change from within the EMS community.  I also had the opportunity to record several videos for EMSworld.com which will be released at a later date.  And finally, after years (literally) of listening to EMS Garage, I was invited on as a guest.  Once that episode is published I’ll be sure to let you know.  The same day, Scott Keir graciously asked me to guest on the First Few Moments podcast which should also be posted soon.

My time in Las Vegas and the personal and professional connections I already had in placed merely solidified for me the power of social media.  I hope that you will consider a trip out to either EMS World Expo or EMS Today.  Both are amazing opportunities for fun, education and networking.  I can’t believe I waited this long to attend.

Image via Flickr

FRNtv Launches EMS 2.0 Magazine

Posted by Patrick Lickiss on Sep 2, 2011 in Current Events, EMS 2.0, General | 1 comment

Ladies and gentlemen, EMS 2.0 now has its own magazine:  Interventions.  Published by the bloggers at FRNtv, Interventions can be thought of as a series of white papers for the next steps in EMS.  This first issue is geared towards field personnel who may not be on board with social media and blogs and the power those media can have.  Future publications will be aimed at other audiences but will also perform a double duty.  If, for instance, an issue is geared towards medical directors, it will also give field practitioners the tools they need to speak with their own medical director about the future of EMS.

I am extremely excited about this project.  This group has been a huge inspiration to work with.  Now on to why this publication is so cool.  It’s web-based, but prints out beautifully.  That means you can help us spread the word around your station!  The magazine works on your computer or your smartphone.  Far from being a simple PDF file, every issue will include a variety of media, including audio and video.

So without any further ado:  I present to you, the first issue of Interventions!  We are very excited about this project and can’t wait to hear your feedback.  Enjoy!