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EMSA DISPATCH - November 2010


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Daniel R. Smiley - Interim Director November 2010
Dear EMS professional,
Welcome to the November 2010 issue of the EMSA Dispatch. In the next issue scheduled for January 2011, we will examine the new National EMS Education Standards and what they mean for California. Released in 2009, the new curriculum will officially debut on National Registry Exams beginning in January 2012. There has been significant lack of clarity regarding how the changes will affect California's EMS providers, educators and administrators. In preparation for writing a through article, we would like to hear your questions regarding the new standards. Please send any comments, questions or observations regarding the national standards to I invite you to send your ideas for future articles as well. Thank you for reading and please forward this e-newsletter on to your colleagues using the link at the bottom of the page.

June Iljana
Deputy Director
EMS Policy, Legislation and External Affairs

EMSA Dispatch at a Glance...

Closing the Quality Loop: Observations from Enforcement
EMSA Director Moves to Prison Health Care Services
State Trauma System Summit December 2
EMSA Issues Scope of Practice Position Statements
EMSA Supports the World Series Games!
AHA 2010 CPR Plan: No More ABC's
Announcements - Calendar


By Daniel R. Smiley, Interim Director

We live in a pre-historic world of "patient man and radio man" or "senior paramedic and junior paramedic" or "paramedic and EMT" or "transport or non-transport" paramedic or even "driver and attendant." Each of these has a clear connotation of a team leader and some other less-responsible individual. There does need to be a team leader. There is authority for a team leader to have patient health care management (HSC 1798.6) and a defined hierarchy does exist, but when it comes to quality patient care, every EMT and paramedic at the scene is individually responsible and accountable.

But is also possible that not all team members are aware of all the history or physical details and may not be aware of why a certain decision was made. They have the right and responsibility to question decisions and the leader should be confident enough to explain their rationale. To make this a reality, strategies for communication and situational awareness between team members must be implemented to ensure quality patient care is delivered.

Everyone is Responsible for Patient Care

At the California EMS Authority, the Enforcement Unit receives approximately 400 complaints each year. Many of the complaints, which are patient care oriented, could have been easily corrected by the timely intervention of another paramedic or EMT at scene. Unfortunately, we have observed that the stated reason for not intervening is that they were not the person "in charge" for that response and they felt uncomfortable with assertively assisting other paramedics or EMTs on scene.

Yes, we understand that human errors do occur. But too often, many other paramedics or EMTs are on scene that do know the correct way to proceed but are often afraid or not encouraged to speak up. When a call goes bad, the EMS Authority looks at each certified or licensed person at the scene as each has an individual responsibility to ensure high quality patient care to their level of training. As EMTs and paramedics work in the pre-hospital EMS environment, there should be no excuses for complacency when caring for patients.

Situational Awareness and Crew Resource Management (CRM)

Strategies for fostering communication and situational awareness during emergency medical care should be implemented. The Advanced Cardiac Life Support course already uses the term that alludes to this as "constructive intervention." In air safety applications, crew resource management (CRM) is a procedure and training system in systems where human error can have devastating effects. Just as a co-pilot (first officer) of an airliner would not allow their captain to make a fatal error while transporting 200 passengers, the many paramedics and EMTs that are often on the scene must work together to ensure patient care and safety in the same way.

CRM aims to foster a climate or culture where the freedom to respectfully question authority is encouraged. However, the primary goal of CRM is not merely enhanced communication but rather enhanced situational awareness. These are often difficult skills to master, as they may require significant changes in personal habits, interpersonal dynamics, and organizational culture. It recognizes that a discrepancy between what is happening and what should be happening is often the first indicator that an error is occurring. It uses the five-step Assertive Statement method as one technique to diplomatically express a difference of opinion.

  • Opening or attention-getter: Address the individual. "Dan" or "Captain Smith" or whatever name or title will get the person's attention.
  • State your concern: Express your analysis of the situation in a direct manner while owning your emotions about it. "I'm very concerned about the respiratory status" or "I'm very uncomfortable with leaving the patient at the scene."
  • State the problem as you see it (real or perceived): "I am not seeing adequate ventilations being given" or "It seems that the patient can't make an informed decision due to his mental status."
  • State a solution: "Let's try to provide better basic airway management or an advanced airway" or "I think we should go ahead and transport the patient to the hospital now."
  • Obtain agreement (or buy-in): "What do you think?" or "Does that sound good to you, Captain?"

This can certainly be a delicate subject for many organizations, especially ones with traditional hierarchies. Appropriate communication techniques must be taught to supervisors and their subordinates so that supervisors understand that the questioning of authority need not be threatening and subordinates understand the correct way to question orders. Consideration should be given to its required use in the pre-hospital care setting by EMTs and paramedics to decrease the chance of human error.

The concept is not new to EMS. In fact, the IAFC has already published documents related to its application within the fire service and articles and books have been published that make the case for CRM as a foundational level of competency in EMS.

Next Steps

The EMS Authority will be asking all LEMSA Medical Directors, provider agencies, and training programs to discuss the concept of individual responsibility and accountability. Additionally, the training and use of tools and techniques, like Crew Resource Management, should be examined for their routine application in pre-hospital care to provide quality patient management.

EMSA Director Moves to Prison Health Care Services

Dr. Steve TharrattR. Steven Tharratt, M.D., MPVM has accepted a position as the Statewide Medical Executive for California Prison Health Care Services, effective Oct. 25, 2010. Dr. Tharratt served as the Director for California Emergency Medical Services Authority since 2008 and was Chief Medical Consultant to EMSA.

At EMSA, Dr. Tharratt was responsible for the strategic vision and leadership of emergency medical services and out of hospital care for California. He focused on protecting EMS funding, supporting EMSA's responsibility to lead the state's medical response to disasters, and improving communication with EMS stakeholders statewide. During his tenure, Dr. Tharratt led EMSA in responding to the H1N1 Influenza epidemic, implementing legislation to standardize certification and create a statewide database for the state's 18,000 emergency medical technicians, and averting closure of the California Poison Control System by securing federal funding through the Healthy Families Program.

He is formerly medical science advisor to the California Governor's Office of Emergency
Services, chief medical consultant to the Emergency Medical Services Authority, and vice chairman of the Commission on Emergency Medical Services. He previously served for 13 years as Medical Director for Sacramento County Emergency Medical Services and all Sacramento City and County fire agencies.

The Receiver is charged with bringing the level of health care to a constitutional standard for 165,000 inmates in 33 California prisons. As the Statewide Medical Executive, Dr. Tharratt will coordinate all medical services within the California Department of Corrections and Rehabilitation. "Dr. Tharratt was chosen for his outstanding leadership ability, depth of experience, and ability to effectively implement statewide programs and initiatives," said Federal Prison Receiver J. Clark Kelso in announcing the appointment. "Dr. Tharratt is a well-respected health care leader in California and the University of California, and I am confident we will benefit from his considerable skills and talents," Kelso said.
"Dr. Tharratt set many things in motion that will have a positive and lasting impact to improve EMS in California for decades to come," said Daniel R. Smiley, EMSA Chief Deputy Director, who will lead EMSA until a director is appointed by Governor-elect Brown. Statute requires that the EMSA Director be a physician with substantial experience in emergency medicine. Mr. Smiley has been Chief Deputy Director at EMSA since 1989 and has served in the Interim Director position for varying periods from 1989-1993, 1997, and 2007-2008. He has been involved in emergency medical services since 1974.

State Trauma System Summit

The California EMS Authority will be hosting its third annual State Trauma System Summit in San Francisco on December 2, 2010 at the Marines Memorial Club and Hotel in San Francisco. The Summit is a free event funded in part by a Federal Grant along with Stanford Hospitals and Clinics, Regional of Hospital of San Jose, Santa Clara Regional Medical Center, and the Trauma Managers Association of California. To register, contact Johnathan Jones at

The Summit will focus on key aspects of the State Trauma Plan currently under development. Education sessions include:

  • State and Regional Trauma System Updates
  • Regional Trauma Coordination Committees & Local EMS Agency: Going in the Same Direction
  • CDC Field Triage Presentation: Does One Size Fit All?
  • Significance of Over & Under Triage
  • Re-triage & Interfacility Transfer: How it Works
  • Relevance of Quality Improvement Taxonomy
  • Key Concepts from the Draft State Trauma Plan with panel and audience participation
  • Next steps for the California State Trauma System

Trauma SurgeryPre-State Trauma Summit activity includes The Rural Trauma Team Development Instructor Course (RTTDC) sponsored by the EMS Authority and the Trauma Managers Association of California. The RTTDC course is designed by the American College of Surgeons for surgeons, emergency physicians, family practice physicians, nurse practitioners, physician assistants, and registered nurses who are experienced trauma care providers/educators in a developed trauma system from a Level I or II Trauma Center. The objective of this class is to prepare experienced trauma providers within a given catchment area to assist rural hospitals within the same catchment area a path to communicate and improve trauma care. There is a $25 fee for this event. To register for the Rural Trauma Team Development Instructor Course contact Hendy Hums at

EMSA Issues Scope of Practice Position Statements

One of the more complicated issues we face in our decentralized EMS system is sorting out who can do what. Not only are there hundreds of different procedures in the EMS world, but the rules are constantly changing based on new methods, equipment, information or drugs. That is why continuing education is so critical to EMS professionals. Even with constant education, it can be difficult to pinpoint the scope of practice for different care providers in different local EMS agency jurisdictions.

To reduce that uncertainty, EMSA has identified the 65 procedures we most commonly receive questions about and written up a detailed position statement that includes which levels of providers can perform each procedure. All of the Scope of Practice Position Statements have been posted on the EMSA website and the procedures have been separated into five categories: Airway and Breathing, Cardiac and Medical, Trauma, Patient Asseessment, and Pharmacological Intervention.

The position statements include:

  • Name of procedure, drug or equipment to be used
  • Description of procedure, drug or equipment to be used
  • Classification - BLS, Limited ALS or ALS
  • Use and Level - Specifically names which levels of EMS providers are authorized for use
  • Authority - Reference to where authority is granted under Title 22
  • Training - Regulations and recommendations in training of skill
  • Equipment - Required and recommended equipment needed
  • Medical Direction
  • Considerations and Recommendations - Important information to consider

We created an easy-to-follow dashboard-style indicator at the top of each position statement so you can readily see what level providers may perform the procedure under the current EMSA regulations for First Aid, Emergency Medical Responder (EMR)(formerly First Responder), Emergency Medical Technician (EMT), Advanced EMT (formerly EMT-II) and Paramedic.


First Aid





Red - Not approved for use at specified level

Yellow - Not specified in Basic Scope of Practice but may be approved as a Local Optional Skill

Green - Approved for use as part of Basic Scope of Practice

EMSA Supports the World Series Games

and Victory Parade!

EMSA's California Medical Assistance Teams (CAL-MATs) enjoyed three successful missions in San Francisco in support of the World Series. EMSA deployed a 12 member CAL-MAT, a two member Mission Support Team (MST), and one Disaster Medical Support Unit (DMSU) to the World Series Games on October 29th and 30th and to the Victory Parade on November 3rd, 2010. The teams at the parade, in partnership with the American Red Cross, provided medical care and treatment to 56 patients who had medical and health issues that included heat exhaustion, dehydration, and injuries sustained from assaults. 22 of those patients were transported to local hospitals, thus the treatment provided prevented 34 patients from needing ER visits or ambulance transports. For the World Series Games, the teams were on stand-by outside of AT&T Park ready to respond to any need for medical surge treatment.

Dr. John Brown, Medical Director of the San Francisco Emergency Medical Services Agency, stated "It was great that medical providers from different jurisdictions could come together on such short notice to provide excellent patient care. Of the 1.4 million people in attendance at the Victory Parade and Civic Center Celebration, the CAL-MATs were the cornerstone of the Emergency Medical Services provided."

Lisa Schoenthal, Chief of EMSA's Disaster Medical Services Division, stated "We were very pleased the San Francisco Emergency Medical Services Agency requested our services through the Standardized Emergency Management System (SEMS) and remain ready to serve our communities through the CAL-MATs and other resources in EMSA's Mobile Medical Assets Program." Cal Mat

EMS Personnel Division Staffs Up
The EMS Authority is pleased to announce the appointment of two new managers in the EMS Personnel Division, Cheryl Lepley and June Leicht.
Cheryl Lepley

Cheryl is the new manager of the Personnel Standards Unit. The Personnel Standards Unit is responsible for maintaining and updating multiple chapters of regulations as well as approving pediatric first aid, CPR, and preventive health and safety training programs. The Personnel Standards Unit also approves emergency medical responder and EMT training programs for statewide public safety agencies. Cheryl has a staff of four full-time employees. Cheryl comes to the EMS Authority from the Human Resources Division of the Department of Transportation. Cheryl can be reached by e-mail at

June Leicht

June is the new manager of the Paramedic Licensure Unit. June has a staff of six full-time employees and two retired annuitants. June comes to the EMS Authority from the Department of Consumer Affairs where she worked in the Bureau of Security and Investigative Services Licensing Bureau. June can be reached by e-mail at

AHA 2010 CPR Plan: No More ABC's

When you get your CPR update, don't be surprised to find that the ABCs aren't what they used to be. The long-lived acronym for Airway - Breathing- Compressions used in teaching CPR for generations has been scrambled in the new American Heart Association Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC).

Now it's all about the C-A-B (compressions-airway-breathing) method wherein look, listen and feel, head tilt-chin lift, and the breath of life are all on the back burner. Now anyone who is unresponsive and not breathing normally gets hit immediately with compressions - harder and faster than before. The AHA guidelines call for 100 compressions per minute at least 2 inches deep for adults and children and 1.5 inches deep for an infant. According to the AHA press release, "Research shows that rescuers who started CPR with opening the airway took 30 critical seconds longer to begin chest compressions."

For laypersons learning CPR, the AHA has taken it down to the very basics. It turns out that people can be a bit squeamish about giving rescue breaths to others so they often just stand by and do nothing. Compressions are much better than nothing, so the AHA is recommending that laypersons be taught to just push, push, push - called Hands-Only CPR.

If, like me, you are wondering "How will I know if the person isn't breathing normally if I don't look, listen and feel before starting compressions?" I will pass on the answer I received... If you start compressions on someone and they yell at you, you should stop.

But for now, the LEMSA medical director and local protocols should continue to be followed until the new standards are implemented fully at the local level.


EMS for Children Conference November 16

The 13th Annual EMS for Children Conference will be held at the Doubletree Hotel in Sacramento November 16, 2010. The agenda and registration form are posted at

EMS Commission Meets December 1

The Commission on Emergency Medical Services will meet December 1, 2010 at 10 a.m. at the Marines' Memorial Club and Hotel in San Francisco. The agenda and hotel information are available on the EMSA website at

New Paramedic E-mail Box

The EMS Authority has a new Paramedic Email Box for any paramedic related questions, whether you are checking on the status of a paramedic application, you have a question about paramedic practices, training, reciprocity, or any other paramedic related topic feel free to use the new email box. The address is

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