EMSA DISPATCH - January 2011
|Daniel R. Smiley - Acting Director||January 2011|
EMSA is sorting and packing in preparation for our big move out Hwy 50 to Rancho Cordova March 1st. The lease is up on our little brick building downtown so we're moving up to a more modern space that is compliant with the Americans with Disabilities Act, where parking is free and abundant, and where we can all be under one roof together.
According to the current project schedule the new building will be ready for occupancy beginning March 1 and we plan to waste no time. Our plan at the moment is to close the Department that week, so staff will try to address high priority issues as we are able.
Our new address will be 10901 Gold Center Drive, Suite 400, Rancho Cordova, CA 95670. Our main phone number will remain the same (916-322-4336), however, each employee now has a direct line as well so you don't need to go through the receptionist for each call.
National EMS Education Standards are Changing: What will the changes look like in California?
Just about a year from now, the first visible changes to the national EMS system resulting from an overhaul by the National Highway Transportation Safety Administration (NHTSA) will debut nationwide. If you've been following this process with half-an-ear over the past decade, it's time to bring it all together and break down what it means for California, for your organization, or just for yourself.
In 1998, the NHTSA and the National Association of State EMS Officials (NASEMSO) released a comprehensive five-part plan to move the national EMS system and the profession of EMS forward. The resulting plan, named the "Emergency Medical Services Education Agenda for the Future: A Systems Approach" and referred to as the "Education Agenda," reflects the belief that EMS education should seek to enhance EMS as an allied health profession by promoting standardization.
It focuses on the factors determined to be most crucial to enhancing the professional credibility of EMS practitioners - common understanding of the profession, standardized provider levels, minimum educational requirements, accreditation of training programs, and competency examinations. The component parts have been released in phases over the past decade, with the accreditation and testing components still in development.
"Everyone involved in developing the new national standards looked at this as an opportunity to make sure that the provider levels and the training match up with the knowledge and skills needed by EMS providers in today's environment," said Daniel R. Smiley, Acting Director of the California EMS Authority and a contributor to the Scope of Practice portion of the Education Agenda. "EMS has grown up as a profession over the past three decades and these changes recognize the need to rethink the scope of practice of the providers with an eye toward enhancement."
This will be the first change to the National Registry exams since California switched to NREMT as a statewide standard for certification and licensing in 2006. By almost all accounts this revision, while not an exact fit for all states, is long-awaited and very welcome move forward to professionalizing prehospital EMS.
What Does it Mean for California?
States have the freedom to adopt any parts of the Educational Agenda that work for them and to adapt the recommendations to meet their local needs. "It serves as a springboard for us to critically look at the scope of practice to make improvements and make sure that we're meeting the generally accepted standard for prehospital scope of practice," said Smiley.
Erika Reich is the EMS Education Director in Los Angeles County overseeing 40 EMS training programs and says she has been keeping them informed about the changes coming up. "They are aware that the curriculum is changing and we have provided them with the new content," Reich said. She is holding a mandatory meeting for providers next week and the new educational standards are high on the agenda.
One of the big challenges right now, according to Reich, is that adding content to the course requires more classroom time or another method for learning the added material. "We've also asked them (educators) to start looking at their hours. With the new content, they will have to increase the length of their programs in order to teach the material, but right now they're having trouble getting their administrators to approve more hours because the state regulations are based on the old standards." Reich said that for now, some programs are looking at incorporating more individual learning such as online training to increase the learning time without increasing the classroom hours.
EMSA is in the process of revising regulations to implement the educational standards. "We're working with many of our EMS stakeholders throughout the state to implement the new curriculum and revise our regulations," said Sean Trask, Chief of the EMS Personnel Division at EMSA. "We want to make sure that the training hours, curriculum, scope of practice and provider levels we incorporate or adapt actually meet the need of EMS providers in California."
Brass Tacks: Changes to Scope of Practice and Training Requirements
Emergency Medical Responder (EMR): EMSA is developing state standards for the approval of EMR as well as a defined scope of practice. The EMR will replace the First Responder and will function as a non-transporting emergency medical provider with a skill set similar to that of an EMT. The training hours needed to meet the educational objectives will be increased from 40 hours to 60 hours. The National Registry Exam for EMR will be available January 1, 2012.
"This provider level will be tailored to meet a couple of significant needs in California that have been growing for some time," said Smiley. "Rural communities and public safety agencies have been seeking a less time and cost-intensive option to provide immediate, life-saving care."
EMR will be exempt from the fingerprinting and background check requirement that took effect statewide last year for EMTs, so volunteers will not be on the hook for the additional cost. According to the Regional Council of Rural Counties, the background check requirement is a deterrent to volunteer recruitment that is hampering EMS service in rural communities.
Advanced Emergency Medical Technician (AEMT): EMSA is also revising regulations for training standards and scope of practice for AEMT, which was just created in regulation last year. One goal of this revision will be to adopt the new educational standrads for AEMT. The AEMT National Registry Exam will become available June 1, 2011.
AEMT replaces EMT-II and has more restricted capabilities. AEMTs scope of practice will not include needle chest decompression, non-interpretive and 3-lead cardiac monitoring, certain administration routes, orotracheal intubation, extubation among other procedures. Providers who are certified as EMT-IIs right now will be certified as AEMTs with expanded scope of practice in order to retain their current scope of practice, however no new EMT-II's will be certified. Training hours for an AEMT are expected to be EMT plus 150 hours.
Emergency Medical Technician (EMT): EMSA got a jump start on this process by doing away with EMT-B and revising the scope of practice for EMTs during a recent regulatory change for the EMT 2010 project, however the new educational standards for EMTs need to be incorporated in regulation and additional training hours will be required. We anticipate the training requirement fro EMT to increase to 160 hours. The National Registry Exam for EMT takes effect January 1, 2012, so educators should begin preparing to teach the new material now.
Paramedic (EMT-P): EMSA has already made the changes necessary to implement the new national education standards for paramedics in California. Last year, the national educational standards and instructional guidelines for paramedic were adopted in regulation in California and the scope of practice was aligned with the National Model Scope of Practice for paramedic with enhancements.
Public Health and Medical Emergency Operations Manual Draft Released for Public Comment
The Emergency Medical Services Authority (EMSA) and the California Department of Public Health (CDPH) have released the much-anticipated Draft Public Health and Medical Emergency Operations Manual (EOM) for a 45 day public comment period.
"This manual is the culmination of two years of work that began after EMSA published the California Disaster Medical Operations Manual (CDMOM) in December 2008 to define and standardize disaster medical response operational procedures and set performance guidelines to ensure that Californians are effectively served by the system's new capabilities," said Lisa Schoenthal, Chief of the EMSA Disaster Medical Services Division.
Following the publication of CDMOM, a broad spectrum of stakeholders consisting of EMSA, CDPH, environmental health and EMS system participants, were brought together to develop the California Disaster Health Operations Manual (CDHOM) to address public health operations during emergencies. The H1N1 influenza pandemic of Spring 2009 forced the workgroup to accelerate the introduction of an interim version of CDHOM in October 2009 to assist with the H1N1 response. The Interim CDHOM was widely disseminated and used extensively during H1N1 and thereafter.
The stakeholder workgroup subsequently recommended that key elements of CDMOM be integrated with Interim CDHOM to create a unified document called the California Public Health and Medical Emergency Operations Manual with an objective to provide standardized operational processes and performance guidelines to assist operational areas when assistance is needed during emergencies. This approach is consistent with and meets the requirements of the State's development of Emergency Functions (EFs) which mirror the federal Emergency Support Functions (ESFs), as well as the principles reflected in the Standardized Emergency Management System (SEMS) and State Emergency Plan.
The draft manual consists of a series of "cross-cutting" chapters that span common emergency management topics, including:
In addition to the cross-cutting chapters listed, a series of "function-specific" topics were created to address specific public health and medical topics, such as Hazardous Materials; Patient Transportation, Distribution and Management; Mass Fatality, etc.
The draft EOM will be posted on EMSA's website through February 4, 2011. EMSA anticipates the manual to be subject to review and approval by the EMS Commission in March 2011.
2010 EMS Awards Presented to the Brave and Dedicated
Photos by Art Hsieh, CEO and Education Director of the San Francisco Paramedic Association
Twenty-nine emergency medical services providers and associates 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. Daniel R. Smiley, Acting Director of the EMS Authority, and Colleen Stevens, Chair of the Commissionon EMS, presented the 2010 EMS Awards at a meeting of the Commission on EMS in San Francisco December 1. More than 100 people attended the ceremony, filling the meeting room at the Marines Memorial Hotel.
"I am proud to present awards for heroic lifesaving efforts that highlight the excellent training and commitment of our providers," said Smiley. "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 and photos of the entire ceremony are posted at
The EMS awards were created in 2007 to honor and recognize noteworthy or exceptional acts and service while working as EMS certified or licensed personnel, administrators, trainers, or volunteers within the EMS system.
The EMS Awards Committee reviews all applications submitted and determines which awards will be granted. This year, the committee consisted of:
Visit www.emsa.ca.gov/about/awards/default.asp for information about the EMS Awards. Robin Robinson is the EMS Awards Coordinator for EMSA and can assist you in submitting nominations for future awards. Please contact her at 916-431-3701.
Observations from EMS Enforcement
By Dr. Jerry Allison, Medical Consultant to EMSA Enforcement Unit
The Dangerous "Non-Transport"
Not all EMS responses result in a patient transport; nor should they. However, a large percentage of EMS system responses do end up as a non-transport for many reasons. Unfortunately, non-transports are one of the most problematic issues for patients, provider agencies, and the paramedics that respond. At the EMS Authority, we often receive complaints regarding patients that should have been transported but were not. Sometimes the outcome is lucky, and sometimes not so lucky. In some cases EMS is called back and the patient is then transported to the hospital. In a few cases the patient suffers prolonged morbidity or even death as a result of the non-transport.
When a bad patient outcome ensues many people are affected. Bad outcomes often lead to death or further injury, the loss of the paramedic's license and/or job, and financial losses for the employer. However, even if the patient is lucky and escapes a bad outcome, the paramedic's failure to transport appropriately may be considered negligent or a violation of local EMS protocols and may result in licensure action.
What are the factors or dangerous situations that lead to inappropriate non-transports? What actions can be avoided to prevent these unfortunate situations from occurring?
Avoid "tunnel vision" and "complacency"
The two reasons that we often see cited for a failure to transport when necessary are tunnel vision and complacency. Consider this hypothetical case:
It is 0200 hours on a rainy and cold night. EMS responds to a trailer park. There the paramedics find a 60 y/o female that is complaining of shortness of breath. When you arrive she says that she may be "hyperventilating." You do an ECG and agree with the patient that they may be hyperventilating. You convince the patient that the ambulance bill will be expensive and she signs the AMA refusal. Several hours later you are called back by family to find the patient in cardiac arrest. CPR is initiated, but the patient is pronounced dead at the hospital. Autopsy report confirms coronary artery blockage.
Some of the factors that lead to inappropriate patient refusals include "tunnel-vision" or "locking-in" on a diagnosis, or failure to assess at all. Locking into a diagnosis, such as hyperventilation, alcohol intoxication, or "psychiatric" behavior, and not excluding other treatable and life-threatening emergencies, can lead to non-transports. When a paramedic arrives on scene and does not assess or transport because the police or family tells them the patient is "fine" has also led to departing the scene without examining the patient or sometimes even completing a patient care form.
Complacency is a most troubling factor as well. We have observed situations in which providers talk the patient out of going to the hospital rather than talking them into going. This often occurs after 11pm, near shift change, or when patients are perceived to be of lower socio-economic status, or an "abuser" of the system.
How to Reduce Your Risk
Inappropriate patient non-transports can have devastating consequences for the patient, paramedic, and employer. These can be avoided by recognizing dangerous situations, knowing the consequences of such actions, and taking steps to avoid them.
Several steps that can be taken to prevent these dangerous situations from occurring include transporting whenever possible, keeping an open mind when initially assessing your patient, following the local EMS protocols, and using your base-station physician with on-line medical direction to share in the decision-making.
Knowing these are high-risk situations, the paramedic should transport following locally established policies and protocols. Your local EMS protocols and policies governing care in your area established by the medical director of the local EMS agency cover these situations. Learn and perform an appropriate assessment and avoid "locking-in" on a "diagnosis." And maybe most importantly, avoid complacency by understanding your role as a caregiver. Use your base station medical director to help make decisions on unusual or unanticipated situations. The best course of action to reduce your risk is to contact the base hospital, follow local EMS protocols, and transport if in doubt.
EMSA Discontinues EMS License Plate Program
The Emergency Medical Services Authority (EMSA) announced last month that it will discontinue efforts to establish a specialty license plate dedicated to emergency medical services. In January 2008, the Department of Motor Vehicles authorized EMSA to collect orders for a license plate featuring the EMS Star of Life symbol to recognize healthcare professionals who work in the emergency setting and raise funds for EMS charitable purposes.
In 1992, the Legislature established criteria for specialty plates and set a base for participation. In order to create the license plate, at least 7,500 prepaid applications must be received within one year and that participation rate must be maintained annually. The EMS license plate orders did not reach the required minimum despite a one-time one-year extension.
"This is a disappointment for the many people who participated in developing the EMS license plate program," said Dan Smiley, Acting Director of EMSA.
At least ten percent of California's 77,000 emergency medical technicians and paramedics would have had to participate for the program to be successful. The license plate was available to anyone, so emergency physicians and nurses were also expected to purchase the EMS plate.
According to the Department of Motor Vehicles, only two plate programs - the California Memorial Plate and the Gold Star Family plate - have become a reality in the last ten years, and both had the 7,500 application threshold waived. There have been seven attempts to create a plate program since 2000. Only the Breast Cancer plate effort even reached 1,000 orders.
One factor that may have contributed to the low response is the cumbersome ordering process. A standard vehicle re-registration can easily be accomplished online in a few minutes, however ordering a specialty plate requires individuals to fill out a form, write a check, make a copy of their vehicle registration, and mail the package.
Another factor could be that much of the audience for this effort overlaps with the firefighter license plate. Roughly half of California's EMS personnel are eligible to purchase the state's firefighter license plate.
Aaron Hamilton, 30, of Santa Ana, has worked as chief technology officer at GPS Logic since January 2010 and as systems engineer, dispatcher, and emergency medical technician at Care Ambulance Service since 2000. Hamilton previously worked as reserve firefighter and driver-operator at the Orange County Fire Authority from 1998 to 2006.
David Rose, 46, of Livermore, worked as a fire captain and paramedic for the Santa Clara Fire Department since 2000 and as an emergency medical technician (EMT) instructor since 1993. Rose has worked as an EMT instructor for Mission College in Santa Clara, where he also serves as an EMT training program director. He previously served as a driver, engineer and paramedic for the Santa Clara Fire Department from 1998 to 2000 and as a firefighter and paramedic from 1991 to 1998. Rose worked as a firefighter and paramedic for the South San Francisco Fire Department from 1986 to 1991, as mobile intensive care paramedic for Santa Clara Valley Paramedical Services from 1985 to 1986.
Helen Najar, a real estate agent in Long Beach, is stepping down from the Commission after five years of dedicated service. We wish Helen well in her future activities and will miss her charm and unwavering support of EMS practitioners, as well as her committment to representing the public perspective on the EMS system.
Daniel Smiley, who is once again serving as EMSA's Acting Director, was recognized recently for his leadership in developing and implementing guidelines for tactical medicine training programs in California. Dan received a plaque from Dr. Lawrence Haskell, founder and CEO of the International School of Tactical Medicine, Inc. honoring his committment to establishing the tactical medicine standards for California. Dan wrote the standards with Ken Whitman, who recently retired from the Commission on Peace Officer Standards and Training, and they were released as POST regulations in March 2010. Dan also reviews applications from training schools in California that wish to provide tactical medicine training to ensure they meet the state guidelines.
"Decisions first responder crews make in the field with severely neurologically-traumatized patients who obviously do not have short or long-term viability of survival, can have successful outcomes as potential donors - and up to eight lives can be saved by one donor," said says Katherine Doolittle, Manager of Public Education for Golden State Donor Services. That is why the organization has partnered with Folsom Fire Chief Dan Haverty, a transplant recipient, along with a committee of fire captains, paramedic and EMT trainers and hospital staff to develop "Keep Hope Alive," a free online video training session.
Learn how first responders actions can help those waiting for a life saving organ transplant at www.donateLIFEcalifornia.org/firstresponders. The online video training is FREE, does not change protocol, and provides one hour of continuing education upon completion. The website is also set up to easily accommodate classroom teaching.