Ten Years Later

Posted by Patrick Lickiss on Sep 11, 2011 in Current Events, General, Politics | 0 comments

It’s interesting and a little bizarre to be writing this post from an airport.  In the decade since September 11, 2001 much has changed in our national consciousness but nowhere is this more publically apparent than when going through airport security screening.  I remember how annoyed and flustered my fellow passengers used to get when they had to take off their shoes and only bring 3oz of liquids as a carry on.  Now, everyone has it down to a science.  The adjustment is pretty impressive when compared to ten years ago.

I wrote recently about celebrating my tenth year in EMS.  If you do the math, you’ll realize that I had been an EMT for just about a month on September 11, 2001.  I was in college at the time and I remember my roommate knocking on my door and waking me up to tell me that a plane had flown into the World Trade Center.  As we watched on the news, reports came in of a second plane impacting the Twin Towers and another striking the Pentagon.  We watched dumbstruck as the towers collapsed and mourned with the rest of the country the loss of the emergency workers and civilians who perished.  Though I can’t be sure, I don’t recall ever questioning my decision to start a career in EMS.  I never had the opportunity to help out at the World Trade Center site, though I know many who did and I am extremely grateful for all they sacrificed to be there.

I was watching The Daily Show the other night and Jon Stewart was interviewing Dr. Sanjay Gupta about his CNN special on the health effects of the dust inhaled by the emergency workers at Ground Zero.  Stewart made an especially thought-provoking point about the current debate surrounding coverage of medical expenses for Ground Zero responders.  For those who aren’t familiar with the back story, the government is providing medical care for rescuers with a variety of ailments which can be scientifically linked to the working conditions at the WTC site.  The government recently decided that although elements present in the dust at Ground Zero are linked to cancer, the combination of those elements hasn’t been definitively linked to cancer so while they will provide coverage for a variety of respiratory and musculoskeletal issues, they won’t cover cancer in previous healthy individuals who worked on the pile.  Apparently exposure to several cancer-causing elements at the same time doesn’t have a logical link to cancer.  Go figure.  Stewart said, and I’m paraphrasing, what’s the harm in accidentally treating a cancer in someone who volunteered to come back day after day to dig through smoldering rubble?  Would it really be so bad to comp these first responders some health care even if we can’t definitively link their cancer to the dust at Ground Zero?  I’d certainly be happy to have my tax dollars go towards that.  But no one asked me.

Stewart made another point which made me realize that I’m probably getting old.  He said that most of the members of his audience probably didn’t remember the attack or the aftermath around the county because they were too young.  I guess that’s probably true.  Those images, emotions and conversations are forever ingrained in my memory.  Don’t think for a second that this is a bad thing.  I remember the shock and the grief as we watched the events unfold, but I also remember the way the country united around this event and, for a while, actually stood together as a whole.  With the recent rash of partisan nonsense in Washington and around the country, my hope is that everyone takes a moment to reflect not only on the loss we suffered on September 11^th, but also how much stronger we became in the weeks and months afterwards.  Remember how proud you felt to be an American and how united we felt.  Remember the way it felt to see this picture in every magazine and newspaper and on every website imaginable.

My hope is that we won’t wait for another tragedy to put politics aside to work for a common good.

Where were you ten years ago today?  Do you have vivid memories of the events or just glimpses?  Let me know in the comments.

Is Santa Clara on the Right Path?

Posted by Patrick Lickiss on Jun 22, 2011 in Current Events, EMS 2.0, General, Politics | 2 comments

I had debated for a while whether to weigh in on the recent report by the Santa Clara County Grand Jury (PDF link) detailing what they see as failings of the fire-based EMS system. I struggled with this decision because the jurisdiction is local to me and I have a few friends who work for fire agencies in that area.  Ultimately, however, I think that I have a few thoughts that I can contribute to the dialogue without alienating myself.

FIRST THINGS FIRST
First, I’m going to defer on any statements regarding the usefulness of fire-based EMS.  Truth be told, I’ve never worked as a firefighter and haven’t been interested in joining the fire service in a long time.  Chris Kaiser over at Life Under The Lights, however, has worked in both first response and transport EMS.  He also has a very interesting post detailing his thoughts on fire-based EMS and I could not have stated the situation more clearly or objectively.  Please give it a read.

Second, I’ve heard and read a great deal of pretty alarmist statements regarding this grand jury report.  It’s been said that the grand jury is simply attacking public safety unions. It’s been said that the fire departments and their employees are intentionally endangering patients to prove a point.  Relax folks, the sky isn’t falling.  Statements like this make a conversation about the merits of this report impossible.  Have these grand jury members worked for the fire department or private EMS?  Probably not.  Does that disqualify them from looking objectively at the data?  Absolutely not.  Might it be a benefit?  Perhaps.

FOOD FOR THOUGHT
Now, to the point I think that needs to be made.  The EMS system isn’t perfect.  It never was and it never will be.  We will always be changing it and tweaking it to provide better patient care.  Because that’s what the EMS system is for right?  Right?  I think we can all agree that the current system is outdated.  It’s based on an old response plan steeped in tradition.  As the fire chief said at my friend’s academy graduation:  ”The fire service is 200 years of tradition unencumbered by progress”.  EMS is no better, just younger.

Why not take a fresh look?  Why not redesign a system which is more efficient, cheaper, faster and better for patients?  The chief interviewed for the San Jose Mercury News article stated that a private provider would have to hire more paramedics at an added cost to patients if they were to provide first response.  This is only a valid statement if we substitute three or four private paramedics for public paramedics.  There is no evidence to show that more paramedics equals better patient care.  The grand jury report suggests taking a long, hard look at the status quo.  Why couldn’t we provide better care with fewer paramedics?  Is there any evidence (actual published data) to show that we can’t?  We’re all in favor of evidence-based medicine in EMS, what about evidence-based response plans?

This brings me to my last point.  What is our goal?  Improved patient outcomes?  Survival to discharge in cardiac arrest patients?  Decreased morbidity and mortality from stroke, STEMI, trauma and sepsis?  Then why don’t we design a system with these outcomes in mind?  Sounds like EMS 2.0 to me!  Why do our first responder and transport system status plans simply put as many paramedics on scene in as short a time as possible?  Where is the evidence showing that this does anything to improve patient outcomes?

At the end of the day, I hope that the message of the grand jury report doesn’t get lost among the political posturing.  That message is simple:  why not focus on the patients?  Why not set the status quo aside and build a system that actually improves outcomes?  So you tell me; why not?

With reimbursement for treat-and-release and treat-and-refer looming at both the state and federal levels.  This might actually be a reality. I, for one, don’t want to be left behind.

Why EMS 2.0?

Posted by Patrick Lickiss on Sep 7, 2010 in Current Events, EMS 2.0, Politics | 2 comments

So if I were asked to pick one buzzword most often thrown around in the EMS blog community I would have to land on “EMS 2.0″.  But what is it?  And more importantly, what does it mean to me?

WHAT IS THIS EMS 2.0 THING ALL ABOUT?

Thankfully Justin Schorr, of Happy Medic and Chronicles of EMS fame, has taken a moment to post the EMS 2.0 manifesto over at Chronicles of EMS.  Now he doesn’t refer to it specifically as a manifesto, but that’s more or less what we’re talking about.  In my opinion, the idea behind the EMS 2.0 movement is basically the thought that if we are given more leeway in treatment (and at the same time have higher expectation of ourselves and our peers) that patients can only benefit in the long run.  What this means, unfortunately for some systems, is that management and medical directors are going to have to move outside of their comfort zone.  Some folks are unwilling to do this.  To that end, we, as a community need to push this type of agenda.  There’s a link on the site to a PDF of the EMS 2.0 manifesto.  Print it out, give it to your coworkers, students and management staff.  Get involved with protocol committees and research groups.  Learn all you can because when the time comes, we will need to stand together and show that we have the knowledge, skill and compassion to move away from a system which values us largely as glorified taxi drivers.  It’s up to you folks!

DON’T GET LEFT BEHIND

One important point Justin raises is that not everyone has a place in the new EMS.  You have to work for it.  Now this is probably not a popular opinion, but that doesn’t make it any less true.  It does however, jive pretty well with another post I read recently about psychomanipulation by bloggers of their audience.  The basic premise is that a lot of blogs (in general, but definitely in EMS) pander to their audiences and only say things which are already popular.  Doing so gets a lot of positive comments and makes the author feel good about how great they are, but does little to affect real change.  What we should expect from authors, coworkers, management, the public and EMS agencies is the opposite.  Honesty, and the tough conversations which result will do more to improve EMS as a service and a career than all the daisy and puppy dog posts in the world.

THE BOTTOM LINE

So basically the message is this:  If you aren’t happy in EMS as things stand right now; get involved.  If you like the idea of EMS 2.0 (realizing that is means something different for each system); do something about it.  If you sit back and wait for EMS to improve around you, you’re going to get left behind. My part, and something that I see other EMS authors trending towards, is to have high expectations of my readership.  The time has passed that paramedics are able to say “I don’t need to know that because I won’t use it”.  The very real possibility is that you will need to use that knowledge in the future.  Just because it wasn’t taught during medic school doesn’t mean it isn’t worthwhile.  I hope that this and other blogs are places you can come to expand your knowledge base and become a better practitioner.

So get out there, learn all you can and take action.  The future of EMS depends on all of us.

The Changing Landscape of EMS

Posted by Patrick Lickiss on Aug 10, 2010 in Current Events, EMS 2.0, Politics | 2 comments

We are truly working in EMS in an exciting time.  For one of the first time since the advent of prehospital medicine, our industry is poised to make huge leaps forward.  With the advent of new technology and the ability to share ideas between practitioners across the country and around the world, the EMS 2.0 movement has the potential to revolutionize the way we do our jobs.   As with all revolutions, however, this one will leave some of our coworkers behind.  The “old school” way of providing care is no longer considered best practices (if it ever was) and those providers who are unwilling or unable to keep up will find that they have a diminishing role in the field.  The role of EMTs and paramedics as providers of emergency care will still remain an important aspect of the job, but preventative, community based care will become a new emphasis.  One of the major sticking points of this revolution, however, will be finding a way to bill for these new services.

When looking realistically at scopes of practice for EMS practitioners in the US, it is unlikely that the current scopes will change drastically.  Areas that allow procedures like Rapid Sequence Induction and surgical airways will likely continue to do so, and regions which don’t (here’s looking at you, California) will likely not add these procedures.  While some medications may be added, they will only be approved for limited numbers of patients in limited agencies.  Take thrombolytics, for instance.  With the current model of EMS research, very few systems would be able to enroll a sufficient number of patient to prove whether paramedics could effectively evaluate and provide thrombolytics in the prehospital setting.  While small scale studies may convince the medical director of the county or agency performing the study, it is unlikely that medical directors around the country will take progressive steps based on those limited results.  These factors all combine to result in a largely static scope for the foreseeable future.

Given that scopes of practice will likely remain static, the only expanding arena of care for the prehospital provider is into preventative medicine.  Community-based public health programs could benefit directly from the incorporation of paramedics and the experience we bring to the table.  Experience with standing orders and working independently gives prehospital providers a leg up on current public health practitioners.  The ability to perform home visits for check-ups, basic diagnostics and vaccinations could prove invaluable for an ailing and broke healthcare system.  The idea of universal healthcare is one which sounds great in theory, but loses some of its luster when you realize that the current healthcare reform programs do not include provisions for public education campaigns.  Providing everyone with insurance sounds like a great plan, but politicians seem to forget that many currently uninsured patients have used emergency rooms as their only contact with a physician, sometimes for generations.  Theses patient have not had a general practitioner and have no experience  with receiving care in that setting.  Staffing paramedics in public health roles could help to bridge the gap between these patients and a standard general practitioner.  In this way, new, non-emergent  services are being provided in a familiar way, namely through the 911 system.

It has been said that one of the most difficult aspects of a community paramedic program is finding a way to make it a sustainable business model. While grants are available for trial programs, these generally do not last forever.  In the end, providers need to be able to bill and be reimbursed for services rendered, including preventative ones.  What Kaiser Permanente figured out years ago (and what seems to escape Washington) is that it is not only better for patients to practice preventative medicine, but in many cases it can be cheaper.  The unfortunate side of healthcare reform is that while insurance companies have large amounts of lobbying dollars at their disposal, EMS has basically none.  With the formation of organization like the International Association of EMS Chiefs, however, there is hope that EMS will not be left behind during the pending healthcare reforms.

What is certain, however, is that EMTs and paramedics need to make their voices heard to ensure that our role continues to expand and that funding sources become available to facilitate that expansion.  For the next few years, it will be up to all of us to expand our knowledge base and skill set so that when new opportunities present themselves we are able to seize them.  Keep reading the many great EMS blogs available and encourage your coworkers to do the same.  Subscribe to a few podcasts and keep current on news related to EMS.  When the time comes, write letters and make phone calls to your representatives and members of key committees in Congress.  As I’ve said before, the future of EMS is in the hands of the providers, make sure you are able to make it a profession you can be proud of.

Urban Community Paramedicine @ CoEMS

Posted by Patrick Lickiss on Jul 21, 2010 in Current Events, EMS 2.0, Politics, Treatment | 0 comments

In episode 8 and episode 9 of Chronicles of EMS – A Seat at the Table, our intrepid hosts sit down with two amazing members of the EMS community, Mike Taigman and Bill Sugiyama to discuss the development of a community paramedicine program in an urban environment.  Much has been written in the EMS world about community paramedicine, but the roll out of this new mechanism of patient care has been generally been focused on under-served rural populations.  As an urban paramedic, I can tell you that there are plenty of medically under-served urban populations who could use some help as well.

Taigman speaks about an asthma management program, staffed by EMTs and paramedics and developed in partnership with local hospital, public health and community leaders.  Could such a program be the first step in treating and referring or treating and releasing urban patients at home?  Very possibly.  Taigman does mention that the training involved in such a program is akin to a PA or NP program.  Any thoughts on how to manage this aspect? Would you get a Bachelor’s or Masters degree to advance your career in EMS?  Would you be willing to move off the ambulance and work in a community clinic?

The issue of reimbursement is an important one.  How is it that a doctor having a conversation with a patient about smoking cessation is any more important than a paramedic having that same conversation?  Perhaps lobbying to be able to bill for such services as part of healthcare reform would be a place to start…anyone listening on Capitol Hill?

I’d love to hear your thoughts and I’m sure the CoEMS crew would love to hear them as well, so be sure to register over at the forum and get directly involved in EMS 2.0!

More Medical Care Isn't Always Better

Posted by Patrick Lickiss on Jun 7, 2010 in Current Events, Politics | 4 comments

First off, I’d like to apologize for my longer than expected absence.  I was taking a family vacation and just couldn’t bring myself to sit down in front of a computer when I could be sitting on a beach instead.  I have an article slated to post on Friday, but in the mean time I’d like to share a link to a story listed on a local new site.

I have long stated that technology and the Internet has made our jobs easier and more difficult at the same time.  I can assume that many in the EMS community have heard a medical complaint at least once that started with: “Well WebMD said that I should call 911…”  These calls can generate a large amount of frustration for responders and can tax an EMS system already running thin.

Internet-fueled medical calls notwithstanding, technology has also vastly improved the care we provide to our patients.  New assessment tools and standardized documentation procedures have increased our ability to perform differential diagnoses in the field and have improved our ability to transport patients to the proper facility.

The article mentions a variety of assessments and treatments (including CT scans, cardiac stents and antibiotics to name a few) which are performed on or given to American patients which are likely unnecessary.  Out of fear of legal ramifications or being accused of “rationing” healthcare, physicians and politicians are making a potentially fatal mistake: they are allowing patients to dictate their own care.

Note: I’m going to step up on my soapbox now, so let me reiterate that these are my own opinions and do not represent the opinions, legal or otherwise of any other entity.

So what, you may ask, is the problem with allowing patients to dictate their own care?  Shouldn’t people be allowed to get the care they need and deserve?  My answer is absolutely yes, people should be allowed to get the care they need.  Physicians spend years going to school to finish their MD and spend further time working on a specialty.  The average American coming to their primary practitioner’s office asking for a test or prescription is likely drawing from educational background as broad as a recent television commercial or maybe a national news magazine.  People place doctors on pedestals and then don’t trust these same providers to make treatment decisions.  It’s high time that Americans (all of us, including those of us in EMS) start letting our medical professionals make the treatment decisions.

The article talks about steps being taken to educate physicians about overused tests and treatments.  Programs such as these should help because they serve to protect physicians by establishing a “standard of care” that doesn’t include rampant overutilization of potentially harmful tests and procedures.

The article also mentions an important program incorporating patients and physicians in “shared decision making”.  I think we can all agree that the best way to work towards decreasing overutilization of medicine is to educate the patient population.

Given the massive amount of money spent every year on healthcare, it seems reasonable that one of the only ways to curb healthcare costs is to put treatment decisions back in the hands of the practitioners.  While this shouldn’t be done at the cost of patients, the average patient (even the average paramedic) is simply not educated enough (and is easily swayed by advertising in the media) to make those kind of decisions.  If we are going to cut back on unnecessary and potentially dangerous medical care, we need to educate ourselves and our patients before we will have success.

So now I put it to you: in the spirit of EMS 2.0 and community paramedicine, how can we help to educate our patients on a daily basis to help reduce overutilization of all medical services (not just EMS!)?  We are on the front lines of medicine and have an excellent opportunity to contribute to the solution to a dangerous and expensive problem. I look forward to hearing your ideas!  Stay safe out there.