EMS 3.0

“Your scientists were so preoccupied with whether or not they could, they didn’t stop to think if they should.” – Jurassic Park

This month the NAEMT released a series of infographics on what is being called EMS 3.0. One of the things the infographic spotlighted was community paramedicine, an idea I used to support strongly. I used to think community paramedicine was the future of EMS now I think it is simply bad brand extension, like Crystal Pepsi was.

Cheetos_Lip_Balm
An example of poor brand extension

When talking about EMS 3.0 the NAEMT states that EMS must expand our services to include the following: post discharge follow up, preventative care, nurse advice, chronic disease management and support. Make no mistake about it; these are all very real healthcare gaps that currently exist in communities. The issue is who should try to fix these gaps. I don’t know who should fix this or how they will go about it, what I do know is it is the wrong thing for a national EMS advocacy group to endorse at this time.

EMS needs to provide quality EMS 1.0 before adding other roles to it. We have major cities that have issues providing even the most fundamental 911 EMS services and we want to go right past that and do something else. It would be easy to sell community paramedicine to idealistic paramedics by using hyperbole and using emotion, I should know as I was one of them. . Endorsing mastery of the fundamental principles is not a sexy position, it will not generate buzz on social media, it won’t even make an exciting presentation at a state level EMS conference and it sure won’t sell advertising space but it is what we owe our patients and what they deserve.

We need to define ourselves before we add more to our plate. Are we members of public safety? Are we health care professionals? Should we simply be a bunch of protocol following ambulance drivers? Who should be in charge of us? The NHTSA? Doctors? Perhaps it is time we govern ourselves? What exactly is it we do? Do we take patients to the hospital, do we keep patients out of the hospital, do we make sure patients are healthy and compliant with their medications? Are we adrenaline junkies who fight death or are we the equivalent of home health and do things like fall prevention? Are we specialists who focus on emergency medicine or are we generalists with a holistic approach to health care? Are we all of those things or maybe none of them?

How many EMS services you would say are truly excellent and provide high quality patient care? I’m not talking about a service where there are some excellent providers, but ALL of the providers are excellent. A service where every patient is guaranteed to get excellent patient care regardless of what provider shows up at their house that day.

I used to think my service was excellent. Then I tested that hypothesis [read about it here] and found out we are in fact not excellent. I used to think my service was ready to take the next step and embrace community paramedicine. My goals have changed, I no longer want to be the most cutting edge service I want to be the service that every single provider is great at the meat and potatoes of EMS. I want to feel confident that any member of my service can show up and treat my family and I feel good about it and I can back that opinion with facts.

ems30_circle2016-page-001
Click picture for larger version (opens in new tab).

For the sake of argument let’s say you believe there are services that qualify as excellent, what metrics are you using for that? Can you back it up with facts? Some services boast about cardiac arrest rates and while those numbers are important they need to be viewed with the understanding that cardiac arrests are a very small percent of overall call volumes.

A large majority of EMS providers that think the best treatment is a diesel bolus, that we do not diagnose and that we must follow protocols even when it means performing unethical acts. Many of the treatments we do in EMS have no basis in science and little to no evidence that they work or change outcomes, and some might be outright harmful.

There are a lot of good ideas in the NAEMT’s EMS 3.0 ideology, but community paramedicine is not one of them. As much as I want to be progressive and embrace the notion of EMS 3.0, we need to make sure that EMS 1.0 is an excellent product we can deliver before we can take that next step forward.

Read more about EMS 3.0 and the NAEMT stance on community paramedicine here:

http://media.cygnus.com/files/base/EMSR/document/2016/04/ems30_circle2016.pdf.

http://media.cygnus.com/files/base/EMSR/document/2016/04/ems30_vertical2016.pdf

https://www.naemt.org/docs/default-source/community-paramedicine/naemt-mih-cp-report.pdf?sfvrsn=4

 

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Your service might suck, and that’s okay. Also, It is your fault.

The Best of the Best, of the Best with Honors.

My EMS service is high-speed, staffed with top notch providers who are chock full of knowledge, our progressive protocols are on the cutting edge. The providers at my service subscribe to the idea of being clinicians as opposed to technicians, many employees express an interest in getting a critical care certification, and we function with a high degree of autonomy.  Many times at shift change there are discussions about the latest podcast or things only an ECG nerd could appreciate, we are a service that is well above average, we are the EMS elite.

The service I work for is a smaller rural service with a call volume of less than 3,000 a year. This allows me to read every single report in our QA process. I do find a few things here and there to improve upon but I would say 80% of the issues are documentation errors.

I should have warned you from the start. If you follow my advice you may end up leaving a few bruised egos. If you have a decent non-punitive, just-culture based quality improvement program the amount of bruised egos should be minimal but there will be a few.

Until recently most of our training was based around on high acuity-low frequency events like RSI and ventilator transports. There was a recent training on vaso-active medications including things such as how to whip up an epi drip, giving push dose pressors, and why dopamine is old and busted. This was some upper level paramedic stuff, and why should it not be? We had paramedics that were highly functioning (so I thought) and this stuff was the icing on the cake.

Just don’t ask us to perform the most basic ACLS calls because we cannot. This is my fault.*

Hubris
I decided to institute ACLS competencies. I figured we would breeze through them. That was not the case; in fact it was far from it.

Paramedics chose a number and drew a scenario. The scenarios were fairly straight forward, a pediatric sudden cardiac arrest, an adult sudden cardiac arrest, chest pain with a STEMI that deteriorates in to an arrest, a symptomatic beta blocker overdose and symptomatic atrial fibrillation.

Some of the things I witnessed during the competencies were:

IN narcan given for a known beta blocker OD
IM glucagon given for a known beta blocker OD
CPR on an adult patient with a pulse
People not defibrillating a sudden cardiac arrest w/ bystander CPR
Nitroglycerin given to a profoundly bradycardic patient
Improper pacing –  this probably needs a separate post
Not using a Broselow on a pediatric arrest
Giving 1.3mg of epinephrine to a 2 year old, Yes 1.3mg of epi
No CPR on an apneic  2 year old with a weak carotid pulse of 22/min

When our agency was put to the test we were all blown away by the results. I would love to blame the providers for this shortcoming, or really anyone else I can lay the blame on but the cold hard truth is it is my fault.

Reading reports everything seemed like it was going well. We had some good patient outcomes but there is now a seed of doubt planted in my mind, are the good outcomes happening in spite of our not so good care? Are the providers in my service suffering from the Dunning-Kruger effect? Am I, as the CQI officer, suffering from an outcome bias? If I don’t see the bad outcomes then surely we are doing everything right, right? Wrong.

If your QA looks good ask yourself if either of the following conditions could occur.

  1. Providers are unaware that they are committing mistakes so they aren’t documenting these mistakes.
  2. The opportunity for these mistakes to happen simply has not presented itself yet.

Lessons Learned

The providers did not know what they did not know…and I did not know what they did not know because until we did these competencies I never went probing for the weaknesses in our system. I assumed everyone had the basics of ACLS down. I was wrong, which is actually great because it is now something we have fixed before it reached the patients.

Go probing for weaknesses in your system, assume nothing, take nothing for granted and make sure you have a good cake before you put that icing on it.

 

*If you haven’t read Extreme Ownership, well you should.