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EMSA DISPATCH - December 2011

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Director's Message:
Howard Backer, MD, MPH, FACEP
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While we have been focused on State legislative proposals, there are important issues being considered at the national level. The most important issue is a national home for EMS.

H.R. 3144: Field EMS Quality, Innovation, and Cost Effectiveness Improvements Act of 2011, introduced by Representatives Tim Walz (D-MN) and Sue Myrick (R-NC). This act implements a cohesive strategy to strengthen the development of our nation's Field Emergency Medical Services (EMS) at the federal, state and local levels. As currently written, this bill would make Department of Health and Human Services the primary federal agency for emergency medical services and trauma care. It would create an Office of EMS and Trauma within the lead agency and task the director of that office to develop and implement a cohesive national EMS strategy (including standardizing training, credentials, scope, and data).

The bill also establishes an “EMS Trust Fund” funded by voluntary tax overpayments which would finance $300 million in grants to states, local governments and providers through five specific programs over four years. While there are numerous of these “tax check-off” accounts throughout the country at the state level, including 15 separate programs in California, the only program at the federal level is the federal election fund which collects about $600 million each year.

HR 3144 is currently being considered in the House Committee on Energy and Commerce and in the Committee on Ways and Means. This is the second legislative season for this proposal and if it doesn’t move this year, it is expected to return in the 113th Congress.

Comment: National Highway Traffic Safety Administration (NHTSA) and its predecessor agency were created within the Department of Transportation as a means of reducing the number of injuries and deaths on America's highways. As a key component in this effort, NHTSA/DOT have supported comprehensive national Emergency Medical Services System development for more than 40 years. In 2005, Congress passed reauthorizing legislation for NHTSA and mandated the creation of the Federal Interagency Committee on Emergency Medical Services (FICEMS). While NHTSA had for many years collaborated with Federal and national partners on EMS activities, this act required that NHTSA provide administrative support for FICEMS in coordination with its Federal partners at the Department of Health and Human Services and the Department of Homeland Security.

We owe a great debt of gratitude to NHTSA and DOT for developing EMS and most recently for creating the EMS database (NEMSIS) and our educational standards. However, there is recognition that EMS may need a new home for its future development. Some partners prefer to align EMS with Department of Homeland Security, reflecting its reliance on public safety personnel. HR 3144 reflects the perspective that EMS should be housed within Health due to its increasing integration with the medical system. While the personnel may be public safety, the primary function of EMS is to initiate medical intervention in the field and assure an optimal integration into the health care system. Increasingly, field care is a critical component of an overall treatment plan that is part of a system of care. EMS is accountable to medical direction, expected to generate and initiate the medical record for that encounter, and is held to medical standards of care and quality improvement as part of the medical system. The primary reimbursement for this care comes from health care funding. These are some of the rational for the proposal to shift the EMS federal home to the DHHS. In any case, the concept of FICEMS, which assures interagency coordination of EMS, remains necessary for an optimal system.

H.R. 2853: Emergency Medic Transition (EMT) Act of 2011. Authored by California Representative Lois Capps, this bill provides grants to state emergency medical services offices or other state entities with jurisdiction over emergency medical personnel to provide for the expedited training and licensing, as emergency medical technicians (EMTs), of veterans who received training as EMTs while serving in the Armed Forces. This bill would direct an eligible entity to give priority to training individuals who will serve as EMTs in areas that provide a high volume of emergency medical services and trauma care. It is currently being considered in the House Subcommittee on Health.

S 1407: Air Ambulance Services. Introduced by Sens. Olympia Snowe (R-ME) and Maria Cantwell (D-WA), this bill would create a process to accredit air ambulances in a tiered accreditation system (Level I, II, and III). Medicare reimbursement rates would be tied to accreditation level. Medicaid reimbursement would be dependent on state submission of air transport plans and subsequent compliance with FICEMS guidelines. It is currently being considered in the House Committee on Finance.

HR 1117: Air Ambulance Patient Safety, Protection and Coordination Act. Introduced by Reps. Candice Miller (R-MI) and Jason Altmire (D-PA), this bill authorizes states to regulate medical aspects of intrastate air ambulance services (quality, availability, communication, accessibility, physical attributes of air ambulances). It would require an ambulance service provider licensed in more than one state to comply with the most stringent regulation, if different, and would require adjacent states to negotiate mutual aid agreements. It has been referred to the House Subcommittee on Health.

EMSA Employee of the Quarter: Sheila Martin, MRC Coordinator

By Brian Bolton

10Sheila Martin was recently selected by her peers as the first EMSA Employee of the Quarter. Sheila exemplifies the intent of this new program to recognize staff members who not only contribute to the important work that EMSA does, but also who make EMSA a wonderful place to work. She was selected due to her outstanding attitude, knowledge of her function and committment to our mission.

Sheila has been with the State of California for 26 years. She has worked in several departments; however, when she arrived at the EMS Authority fourteen years ago she fell in love with emergency response. Many of you remember her as the former EMS Commission meeting coordinator, but for the past six years she has been the constant force behind behind our disaster response personnel programs.

Sheila is currently the Medical Reserve Corps (MRC) Statewide Coordinator and works with the 41 Medical Reserve Corps Coordinators in the state to provide resources for the management of their team members through the use of the Disaster Healthcare Volunteers (DHV) System. She works with stakeholders to coordinate infrastructure for the intrastate use of MRC units during disasters, training opportunities and standardization of mission responses. She also works with the Office of Civilian Volunteers Medical Reserve Corps (OCVMRC) national office to encourage local MRC Units to address the core competencies and the objectives set by the Office of the Surgeon General for MRC activities with their local public health departments.

Sheila has also worked the last six years in the Disaster Healthcare Volunteers (DHV) Program. She is one of a team of staff who is actively involved in teaching the system to county Medical Health Operational Area Coordinators (MHOACs), their designees and to the MRC Coordinators throughout the state. She is involved in DHV recruitment activities throughout the state and is working with staff and stakeholders on establishing deployment procedures and recommending training for DHV volunteers. She also has experience in grant writing and reporting.

In January, 2001, Sheila helped to start up the Sacramento Regional Disaster Medical Assistance Team (DMAT) CA-11 and has functioned as the Administrative Officer for over 10 years. This position has given her experience in volunteer management. She has participated in deployments of CA-11 to Hurricane Ivan, Katrina, Rita, Ike and the Haiti earthquake. In her spare time, she enjoys golfing, volunteers with the Blue Star Moms, and spends time with her grandchildren.

Lessons from Enforcement:
Role of the Base Station

by Jerry A. Allison, MD, MS, NR-P

Remember Johnny and Roy from “Emergency”? If you are old enough or have seen enough of the re-runs, you might remember the most frequent line in any of the episodes was, “start an IV of D5W at TKO.” By the end of the first show, or at least the end of the season, any non-health professional knew that Johnny and Roy were going to start an IV of D5W at TKO. It hardly made any sense that Johnny and Roy still had to call in just to start an IV after the 2nd, or 3rd, or 4th season. Fast forward a few years, when I was a paramedic in the 80’s, we were able to start an IV without online medical direction, but we were still calling our base hospital for orders such as dextrose for our obviously hypoglycemic patients, nitroglycerine for chest pain, and other orders that seemed obvious to us.

7Over 20 years later and after multiple curriculum, statute, and regulation changes, paramedics today undergo more hours of training and are more knowledgeable than many of us were years ago. Most EMS systems in the State and throughout the country now function on standing orders. Paramedics do not regularly have to call the Base Station to “ask permission” except possibly for some high risk procedures and medications. For the most part, a paramedic can get by only contacting the base hospital to notify them of their impending arrival.

However, with responsibility comes accountability. As a medical advisor for the Authority I review many cases regarding paramedics whose treatment of their patients is in question. These situations include declaration of death, industrial accidents, inappropriate medication administration, failure to provide medication, and many other types of cases. Some of the patients died, some had long-term complications, and others had no adverse outcome. The paramedics involved faced disciplinary action from minor to severe including fines or revocation of their license. The common denominator in most of these cases was no Base Hospital contact--no call to a medical director to ask for advice, guidance, or help. There was no attempt to mitigate a bad situation or share the burden with the medical control physician. While this may not have been explicitly required by the protocol, had the base station been contacted, the actions of the paramedic in most of these cases would not have been in question and there would not have been any disciplinary action. It is important to remember that, in disciplinary cases, the outcome of the patient has no bearing on the question of whether the paramedic followed the protocol. The question that will be asked is “did the paramedic follow the rules,” or “was there gross negligence involved”?

When I worked in another state I asked the paramedics on several occasions, “Why didn’t you start an IV?” Their answer was, “If we start an IV we have to make Base Hospital Contact (per their protocol) and I did not want to have to call.” I also spoke with some experienced California paramedics who teach others. I asked them what they teach paramedics regarding when it is appropriate to make Base Hospital Contact. The answers I received were similar. “I teach my students to call the Base Hospital whenever they have a question, an unusual case, are unable to follow protocol.” I also asked the paramedics if they see a reluctance to contact the Base Hospital. The answer is overwhelmingly “yes.”

So paramedics are taught to contact the Base Hospital, but they are reluctant to make contact with the Base Hospital physician, even when there is a potential for adverse outcome . This is not safe for the patient or the paramedic. In the hospital we frequently call our colleagues or other specialists when there is any question about the care that should be provided to our patients. The practice of medicine is complex. Standards and guidelines evolve on a regular basis, and patients are complicated with co-morbid conditions. The most complex decisions require a collaborative effort.

So when is the appropriate time to contact the Base Hospital physician? When there is a patient that has an unusual presentation; when the impression is not clear or there are several similar “alternative” or “differential” diagnoses; when you are unable to follow the protocol for any reason; when you follow the protocol and the treatment is not effective; when you feel the protocol is not applicable to this particular situation; and any other time you feel the need to consult your Base Hospital Physician.

One of the most successful strategies that you can follow for success in your EMS system is to know and follow your local EMS Agency protocols, including when to make Base Hospital contact. Whether it is required or not, you should have a low threshold for making contact with your Base Hospital Physician to obtain advice or guidance for the care of your patient. If you made contact, even if there is an adverse outcome, it will be much less likely to have an adverse effect on your career as a paramedic. By making contact with your Base Hospital you are showing a sincere interest in doing what is right for the patient and in providing a collaborative approach to patient care.

(read more)

2011 EMS Awards Wrap-up

by Adam Willoughby
Photos by Art Hsieh

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Thirty emergency medical services providers, associates and civilians were recognized by the Emergency Medical Services Authority (EMSA) for exceptional acts of bravery and service to their communities and the state over the past year. This is the first time the awards have included a luncheon presentation ceremony and nearly 200 people attended. The EMS awards honor noteworthy or exceptional acts and service while working as EMS certified or licensed personnel, administrators, trainers, or volunteers within the EMS system.

Dr. Howard Backer, Director of the EMS Authority, Colleen Stevens, Chair of the Commission on EMS, and Daniel Smiley, Chief Deputy Director of the EMS Authority presented the 2011 EMS Awards at an awards luncheon at the Marines’ Memorial Hotel in San Francisco on December 7.

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"It was an honor to have the opportunity to recognize so many selfless, professional EMS personnel. Their actions are truly extraordinary and I commend them all for their actions and dedication,” commented Dr. Backer. "It's equally important that we honor the individuals who have dedicated their entire careers to building and improving our EMS service in California. Their work has saved lives every day though the creation, development and oversight of a coordinated, efficient and effective statewide EMS system."

A complete list of award recipients is available at: www.emsa.ca.gov/about/awards/recipients_2011.asp and photos of the event and award recipients are available on our Facebook page at: www.facebook.com/CAEMSA

EMSA Dispatch Newsletter
December 2011

RECENT NEWS:

Pediatric Readiness Assessment

The California Emergency Medical Services for Children (EMSC) program has partnered with researchers at the Los Angeles Biomedical Research Institute and Harbor-UCLA Medical Center and the National EMSC Data Analysis Resource Center to conduct a statewide evaluation of pediatric readiness in emergency departments. This is the first statewide assessment of compliance with the 2009 Guidelines for the Care of Children in the Emergency Department. Hospitals can complete an on-line survey (www.pedsready.org/). All participating hospitals will receive a gap analysis to assist them in achieving and maintaining pediatric readiness. This project will begin in California, and then go nationwide.

Farewell to Ken Martzen

We said goodbye to Ken Martzen in November when he retired from state service. Ken has been with the EMS Authority for more than 10 years maintaining our mobile medical assets. He was instrumental in setting up three EMSA response stations and in developing the Disaster Medical Support Unit program. Ken has already begun his new role with the federal government as Western Region Mission Support Center Site Manager.

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Saving Lives One Pump At a Time

by Robin R. Robinson

The San Francisco City Attorney’s Office in partnership with the San Francisco Paramedic Association organized BOLT (Basic Ongoing Lifesaving Training) a program that offered free hands on training in CPR, AED and First Aid to the general public on October 18, 2011 at San Francisco City Hall. With the objective to improve survival rates and engage Good Samaritans, earlier this year City Attorney Dennis Herrera and San Francisco Fire Chief Joanne Hayes-White and Jane Smith, Executive Director of the San Francisco Paramedic Association announced the Local Lifesavers initiative which would notify trained CPR/AED bystanders via a smartphone app to assist victims of cardiac arrest.

Below: SFPA Executive Director Jane Smith demonstrates CPR. BOLT offers the general public free training in basic lifesaving skills.
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National Registry Transition Course

The Department of Transportation National Standard Curriculum has been replaced by the National Model Scope of Practice. New content was added to the curriculum for every level of EMS practice. In order to ensure that every provider has the appropriate knowledge of this new content, the National Registry of EMTs (NREMT) is requiring proof of successful completion of a State-approved transition/refresher course.

EMTs and paramedics are required to pass the National Registry exam to be licensed or certified in Califonria, either initially or after a lapse in licensure or certification, but they are not required to maintain national certification. Many choose to maintain national certification for a variety of reasons including ease of transferring between states and educational opportunities. If that is the case, be aware that you will have to take a transition course within the next four years to learn the new material.

The EMS Authority is currently working on course content guidelines for use by the local EMS agencies in approving transition courses. EMSA expects that the guidelines will be complete and disseminated this summer.

Individuals looking for approved transition courses in their area should contact their local EMS agency. The EMS Authority will not have any information regarding specific courses.

EMS Apps for Smart Phones

by Adam Willoughby

Use of cutting edge technology by medical providers is nothing new. The latest thing to come along for field EMS is smart phone applications, known as “apps," which act as a digital resource for EMS personnel while on the go. Such apps are experiencing wider use by educators, trainers and EMS personnel.

Mobile apps can be particularly useful for pill identification, drug interaction checks, overdose situations, and doing dosage charts, as well as providing direction during unfamiliar situations. Bruce Barton, EMS Adminsitrator for Riverside County, says, "There are apps for medical terminology, A&P, medications, differential diagnosis. Some EMS systems, like ours, even have the local protocol manual available via an app."

The sheer number of apps being marketed is tremendous and the buyer should be very aware that some apps are more accurate and useful than others. With so many options, it can be difficult to identify the more reliable options. For instance, an app of Orange County EMS protocols is being sold but, according to Sam Stratton, EMS Medical Director for Orange County, the developer didn't consult with the local EMS agency and the app has not been reviewed or approved by them.

“Mobile apps have great potential to enhance the quality of patient care when personnel find themselves in complex or unfamiliar situations,” said EMSA Chief Deputy Director, Dan Smiley. “They can be a good addition to the EMS toolkit, but they are no substitute for comprehensive training and continuing education.”

Despite the many benefits of these apps, their utility in field use remains unclear. Sometimes there is a perception that providers are just standing around, messing with their phone when they should be rendering care,” said Smiley. “However, with clear guidelines for appropriate use, apps can be a valuable tool for the EMS professional.”

Although EMSA does not recommend any particular app, to explore some of the different options available, you can start at http://www.ems1.com/ems-iphone-apps/ or www.skyscape.com/estore/store.aspx?category=51 or www.everydayemstips.com/7-ems-iphone-apps.

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