Director's Blog

March 2011

Recent changes in state law will have a negative effect on the delivery of emergency services in Massachusetts. Until recently, Massachusetts required that two paramedics be staffed on advanced life support ambulances. For those not familiar there are primarily two levels of pre-hospital providers in Massachusetts; the EMT-Basic and the EMT-Paramedic. Paramedics are trained and authorized to provide a host of life-saving skills such as medication administration, cardiac monitoring, and intubation. These are skills not practiced by the EMT-Basic. Recent changes will now allow an advanced life support ambulance to function at that level with one paramedic and one basic.

There are several considerations and problems with this, and how it happened. Let�s start from the beginning. Normally, clinical changes like this undergo a long process that involves several committees at both the local and state level. These committees are made up of physicians, and other interested parties. Proposed changes are looked at from an evidence-based clinical point of view. After vetting and debate, a recommendation and possible change is made to the regulations. This proposed staffing change did not undergo this process. Instead, interested parties were able to get it tucked into a house bill pertaining to municipal relief. I submit that this was intentional and measured. Those who supported the change did not want open and informed discussion about the bill. The bill passed, and with it, the staffing change commenced without any discussion from medical professionals.

Clinically this is also a step backward. It�s simple, two-heads are better than one. We don�t expect physicians to make decisions in a vacuum without the benefit of consultation, so why do we place our paramedics in this position? Further by allowing this reduced staffing, we in most likelihood will increase the actual number of ALS ambulances. Data and research has shown time and time again, that fewer paramedic units mean better patient outcomes. (reference previous articles) The reason for this result, is that to be good at being a paramedic, you have to see a high-volume of sick patients. Decreasing the staffing requirements, thereby increasing the number of units, dilutes the skill pool. Constant exposure to a high-volume of acute patients is what makes a good paramedic.

Financially this is a costly change. Federal and State Medicare and Medicaid programs reimburse calls done by ALS units at a higher rate than those done by BLS units. The sponsors of this bill knew this. Decreasing staffing requirements and thereby increasing the number of ALS units responding to emergency calls, will have a dramatic effect on health care costs. Reimbursement rates will be higher. This will cost taxpayers and stakeholders more money for less care. It is also a financial step- backward for paramedics. For the level of care and amount of training paramedics undergo, they were already undercompensated. By reducing staffing requirements, paramedics have become in less demand, and as such, pay will fall.

For some situations, and in some parts of the state, reduced staffing may be appropriate. Before this state-wide change, we had an effective waiver process in place. This regulated and mandated process helped to provide checks and balances, as well the ability to change the staffing requirements in those circumstances where it was appropriate. This state-wide change was over- reaching, unnecessary, and in fact will have a negative impact on pre-hospital care.

When choosing an ambulance provider, ask how they staff. Be an informed consumer.

PrideSTAR EMS will not utilize the new staffing model for emergency calls. Despite the additional costs incurred we will continue to staff emergency paramedic units with two paramedics, and we will continue our support of regional paramedic models.

June 2010

Currently, the National Registry of Emergency Medical Technicians, and the Commonwealth of Massachusetts, recognize three levels of certification for EMT�s. Basic, Intermediate, and Paramedic. The Basic level incorporates the core life saving skills of bleeding control, basic airway management, splinting, shock management, and some advanced skills like Epi-Pen administration and AED use. The intermediate level adds IV therapy and more advanced airway management, and in some states, some basic pharmacology. The paramedic level adds advanced airway techniques, a comprehensive pharmacology component, and cardiac monitoring and intervention.

I believe we should advocate for an additional level of certification. You could call it paramedic advanced, or paramedic 2, or whatever acronym you cared for. The point would be to clearly delineate additional skills that are acquired through occupational training, experience, or both. As a paramedic goes through his or her career they accumulate a vast amount of relevant clinical knowledge. This often relates directly to the type of work they do. For example, the paramedic who spends a significant part of their career working in the critical care transport arena accumulates a very different skill and knowledge set than the paramedic who primarily works in an urban EMS arena. I would envision the paramedic 2 level to require a certain specialization. Almost akin to physicians and their specialty/board certifications. I would envision a significant experience requirement as well as a comprehensive written examination that goes above and beyond the current scope of practice.

Additional educational requirements, and demonstration of mastery in certain areas, would I believe, allow paramedics to expand their role in healthcare. I�d like to see more paramedics involved in care in Emergency Rooms, and I�d like to see them providing direct healthcare in people�s homes. Often times a paramedic transports a patient, often repetitively, to an Emergency Room, for care that could have not required a trip to the hospital. Expanding the paramedics role in this area would increase the level of healthcare for patients, especially those in marginal populations, and dramatically decrease costs. It may also increase job satisfaction for providers, and lead to more people making the choice to make a career of paramedicine.

Be safe out there!

July 2009

Recently I attended a conference in Biloxi, Mississippi for the AMR Disaster Network. PrideSTAR EMS is a sub-contractor for AMR's contract with FEMA, and provides ambulances and paratransit services to national disasters. Part of the program was reviewing previous deployments to the Gulf Coast hurricanes.

We started with Hurricane Dean in 2007. This was the first major deployment after AMR was awarded the contract. The disaster network mobilized approximately 300 ground ambulances, 25 air ambulances, and 3,500 para-transit seats. Ambulances came from 30 states. At that time, this was the largest deployment of EMS in the history of the world.

In 2008, the system was tested again. Hurricane Gustav required a massive deployment for a period of 25 days. Once again, the network responded with 533 ground ambulances, 25 air ambulances, and over 3,000 paratransit seats. The network had topped its own record from only a year ago. Unbelievably, just a few days would pass before the system would be called upon again. Hurricane Ike arrived on the heels of Gustav. Ike required a response of 600 ground ambulances, spread over three states, 27 air ambulances, and over 3,900 paratransit seats. Ambulances came from over 40 states. This set a new record for the largest ever EMS response in the history of the world. For four days these two events overlapped. Hurricane Hannah further complicated matters by threatening the atlantic coast simultaneously. Ambulances from the possibly effected states of Hannah were released, and replaced by others.

What's even more amazing is the success of all of these mobilizations. USDHHS Lt. Commander Bruce Dell characterized AMR's performance as follows: "Deploying roughly 600 ambulances across three Gulf States is grossly equivalent to a U.S. Army Armored Division deployed across an area more than twice the size of Iraq�" In all these deployments, the disaster network successfully completed their missions, with high scores for communication, professionalism, and cost control.

Private EMS should be very proud of their accomplishments in regards to these deployments. No other group of medical professionals would be able to muster these massive resources on such short notice. I strongly believe that these deployments help to demonstrate the importance of private EMS, and the extraordinary capacity that such a system provides. Well done everyone. Furthermore PrideSTAR EMS is ready and willing to once again commit resources to this effort. We thank our employees for their willingness to facilitate such massive deployments.

Stay safe!

March 2009

Welcome to a new feature here at The Director's Blog! After reading another issue of JEMS : Journal of Emergency Medical Service, I felt compelled to at least attempt to publish some relevant and hopefully intelligent literature regarding EMS. Now don't get me wrong, JEMS can be great fun, but its target audience doesn't seem to be me, or my peers. I'm not sure who writes their articles, or how they recruit them, but let's just say the most recent article on keeping air bubbles out of your drip-set drove me to the edge.

I'm starting with some thoughts on what makes an ideal EMS system. I will offer a disclaimer, I am not an expert. I have however, worked in a number of varying EMS systems, and as such, can offer lots of first-hand observations. I will try to offer evidence where I can, but unfortunately good data is just starting to come to market.

Lets start with the antithesis of a good functioning EMS system. I think I worked in this system. I won't name names, but this city is awfully close to where Mickey Mouse lives� It was 2am, and myself, then an EMT, and my Paramedic Partner were dispatched to a chest pain call at a nearby apartment complex. We worked for a private ambulance company contracted by the city. We responded and arrived 3-4 minutes later. As the first to arrive we grabbed our gear, and headed into the apartment. Seconds later, 2 fire engines arrived. One from the city, and one from the county. You see, in this particular town, there were both city and county fire stations that served this address. A turf war was underway, which meant that if the address fell in both engine companies first due, they both responded. Each fire engine was staffed with at least 1 paramedic, and 2 EMT's. Just behind the 2 fire engines, pulled up a county fire rescue/ambulance staffed with 2 paramedics. Lets review. Currently we have 1 patient, being attended to by 5 paramedics, and 5 EMT's. What ensues is nothing short of chaos. The protocols dictated that the fire services paramedics would be in charge of patient care, until they turned it over to the transporting agencies paramedic (my partner). The fire services paramedics conducted a patient interview, performed a 12-lead EKG, established an IV, and administered first line medications to the patient. This all occurred on scene, with a scene time of well over 20 minutes. After this was completed, care was turned over to my partner. We disconnected the patient from the fire departments monitor, and attached ours. The patient was then extricated to our ambulance, while my partner continued care to the hospital. At the hospital, the spiral continued. Even though our patient had symptoms, a medical history supportive of, and an EKG suggestive of a heart attack, we waited in the hallway for almost an hour, before our patient was given a room and triaged. We lovingly referred to this as "holding the wall". This was the reason the city had contracted with our private ambulance company. The hospitals were infamous for delaying receiving patient care, and the city and county fire departments postulated they couldn't tie up their resources at the hospital "holding the wall". Obviously this system is broken. The most egregious of the problems with this system is skill dilution. This system has a 5:1 paramedic to patient ratio. Therefore, even if the paramedics rotate skills, each paramedic only gets to perform skills 20% of the time. Dilute that 20% by the relatively infrequent critical patients, and you have serious skill degradation. It's a simple matter of risk management. Any good risk management professional will tell you that the thing that keeps them up at night is low frequency/high risk procedures. These events, carry the highest risk of failure, along with the highest risk of serious harm. Paramedics are highly-trained medical care providers, often trained in advanced pharmacology, and advanced medical procedures including: intubation, defibrillation, surgical airway placement, chest decompression, and many others. While these skills have the ability to help a great many patients if done correctly. Done incorrectly, the iatrogenesis can seriously harm a great many patients. Many of these patients may have been better off receiving no advanced level care at all. A recent white paper by Patricia Gabow, MD, seems to support this:

The maintenance of paramedic skills is extremely important. This may be why cities with more paramedics actually have worse patient outcomes (Boston 10 paramedics per 100,000, cardiac arrest survival 40%: Omaha 44 paramedics per 100,000, cardiac arrest survival 3%)� Even though the relationship of the number of paramedics to patient outcomes seems counterintuitive, it suggests that simply adding ambulances may be counterproductive.

Matt Zavadsky, MHA, the director of tri-state ambulance, also articulates this well:

Paramedicine is a technical skill that requires practice to perfect. Consider this - many great paramedics get promoted in our agencies. Along with the promotion usually come fewer patient encounters. At some point, that great paramedic becomes a great supervisor, operations manager or deputy chief and a mediocre paramedic. Eventually, that great chief or director is a dangerous paramedic, unless they continue to actively engage in patient care. This is nothing personal against the paramedic, just reality. Now, consider the tale of two EMS systems with similar demographics and patient care volume, but much different approaches to the medicine in emergency MEDICAL services. System A (say perhaps in a large urban area in the southeast) has an unlimited number of paramedics. In fact, the stated goal of the department is to have all their personnel certified as paramedics. Consequently, when they respond two units to every EMS call, all seven personnel on scene are paramedics. That patient:paramedic ratio is 1:7. This means that once out of every 7 patients, one of those medics will do a complete patient assessment, start an IV, intubate, or interpret a 12L ECG.
System B (say perhaps in a large urban area in the northwest) decides to limit the number of paramedics so that only 2 arrive on-scene for medical calls resulting in a 1:2 patient:paramedic ratio. This means that once in every 2 patients one of those medics will do a complete patient assessment, start an IV, etc. Which system as the better skilled paramedics? More importantly, which system generates better procedural success rates and patient outcomes?
Now, I know what some of you are saying already... "But, we train on mannequins to maintain our skill levels!" I've been in EMS for nearly 30 years and have been blessed to work with some of the best paramedics in the world throughout many outstanding EMS systems. Not once has a paramedic ever said "ya know, I had a mannequin do the most confounding thing to me last year", or "That Fred the Head had one of the most anterior airways I've ever tried to intubate". No matter how advanced a plastic dummy is; it is not the same as a real patient. Simply ask any anesthesiologist, or cardiac surgeon, or emergency physician and they will tell you that you have to acquire skills treating REAL people.
Another common misconception relating to this concept was recently articulated by a hospital administrator. He said as long as they meet the minimum standards, a paramedic is a paramedic'. I wonder if that's the criteria he uses to choose a staff neurosurgeon for his hospital? Decades ago, most state governments put into place Certificate of Need laws for hospitals and specialty care centers. Why did they do that? They knew that in order to assure high quality patient care systems, they needed to control the proliferation of high risk, low volume care centers. That is why to this day, there are REGIONAL trauma centers, REGIONAL stroke centers, REGIONAL burn centers and the like. This regional concept concentrates the experts in medical procedures into catchment areas designed to assure a high utilization for trauma centers for example. Why is there not a trauma center on every street corner? Because it's better for the patient to be cared for by a few well practiced trauma teams then by numerous rarely utilized teams. Think about it in a personal way - would you want your loved one who needs cardiac bypass treated by the surgeon who does 100 real cases and simulated 100 cases a year, or the one who does 1,000 real cases a year? The same principle is true in EMS. But don't let the theory alone convince you!
A study published in the May 2006 Academic Emergency Medicine Journal demonstrated that patient survival from sudden cardiac arrest was directly impacted by the patient care experience level of the field paramedics. Sayre, Hallstrom, Rhea, found that patients treated by paramedics with a cardiac arrest patient experience level of 4.68 cases per year had a 27% survival rate; while patients treated by paramedics with an average of 1.63 cases per year only had a 4% survival rate. [i] >>Fewer medics = better patient outcomes
Another study presented at EMS Today in March 2007 by Dunn, Dunn and Krowka at Denver General compared two cities served by the same EMS system with identical demographics, response times and run volumes. The only difference between the two cities was that one had an ALS 1st Response tier and the other had a BLS 1st Response tier. The results were compelling. 100% of the patients in the BLS 1st Response city were successfully intubated, while only 78% were successfully intubated in the ALS 1st Response city. ALS 1st Responders were unable to intubate 53% of the patients attempted. 38% of the BLS 1st Response patients had a ROSC, but only 13% of the ALS 1st Response patients had a ROSC.>Fewer medics = better patient outcomes
The now infamous research by Wang and Yealy published in Annals of Emergency Medicine [ii] found a 25% rate of unrecognized misplacement of endotracheal tubes. They indicate that the low frequency of intubation practice is the primary determiner of proficiency. >>Fewer medics = better patient outcomes

Please notice, that neither I, nor either of these authors have commented on who, meaning fire based, vs. hospital based, vs private, provides these services. Frankly, I think it doesn't matter. I've worked with lots of EMS professionals whom I admire. Some worked for the fire service, some for hospital based services, and some for private EMS. What I do think matters is the design of the system. I would advocate systems that provide short response times of AED equipped first responders, ample BLS transport capability, and a limited number of highly trained, highly utilized, paramedics. Furthermore, decision making on clinical issues, and oversight, needs to be the responsibility of an emergency physician. Finally, a good EMS system needs mechanisms to measure clinical outcomes, and address shortfalls and trends.

Another aspect that bears review, especially in today's economy, is the financial viability of systems that have a high paramedic to patient ratio. Systems that respond multiple units to the scene of an emergency, as well as staff as many units as possible with paramedics, have much higher costs associated with providing care. All these personnel and resources are expensive, and all are vying for a small amount of reimbursement dollars. So not only do these systems provide poor care, they cost more to do it!

I think it's important to talk about these issues as much as possible, in hopes to educate decision makers. Often the politicians who make system design decisions are unaware of the research, and since the data is counter-intuitive, they make the wrong decisions. Matt Zavadsky, MHA says:

What many politicians do not realize is that by diluting the patient:paramedic experience level, they risk lowering the clinical capabilities of all the paramedics in the community. It is for this reason that politicians are ill prepared to make EMS system design decisions. Those decisions should rest with physicians who are experienced in emergency medical care and who supervise the clinical activities of paramedics.

Now for some good news. Those of us living here in the Merrimack Valley have some of the highest-functioning EMS systems in the nation. The reason for this?; good system design. Let's take Lowell. A system I have had the pleasure of working in for a long time. If that same patient I started the story with had lived in Lowell, the response to his complaint would have been very different. A first responder, most likely the Lowell Fire Department would have responded. These firefighters are trained in first response care, and are equipped and trained with AED's. Since the fire department has stations throughout the city, they provide the short response times that are critical to patients survival in sudden cardiac arrest. Simultaneously a BLS ambulance from Trinity EMS would be dispatched, along with paramedics from our regional paramedic service, Saints Paramedics. The paramedic ratio on this call would be 2:1. Also, since these paramedics serve a large population, they have performed those high risk/low frequency skills far more often than most other paramedics. Finally, they have strong physician oversight, which also allows them the ability to perform even more advanced life-saving procedures than other paramedics. In my opinion this model is the best at providing a high level of patient care, in our setting. Still, others disagree, and move to change the model. It is for that reason, that I think it is important to talk about these issues as often as we can.

Well, thanks for reading. Please share any comments or questions you might have. You can email me directly at Check back in a few months for some more soap boxing, maybe we'll feature an article on tearing tape..