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EMSA DISPATCH - September 2011

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Howard Backer, MD, MPH, FACEP - Director
September 2011

This Dispatch...

EMSA Welcomes Director, Dr. Howard Backer

Public-Private Partnership Sustains Mobile Field Hospitals

Dr. Daniel Margulies appointed to Commission

EMS for Children Program Proposes Updates

Comment on EMT and AEMT Regulations

Childcare Provider First Aid Training Updates

September is Preparedness Month

Does it really matter what kind of shape we're in?

Emergency Medical Services Authority Welcomes Director, Dr. Howard Backer

Howard Backer, MD, MPH, FACEPHoward Backer, MD, MPH, FACEP, was appointed to serve as Director of the California Emergency Medical Services Authority (EMSA) July 25th and has quickly taken up his duties leading the Authority. Diana Dooley, Secretary of the California Health and Human Services (CHHS) Agency, announced Dr. Backer's selection and held the swearing-in ceremony July 25th in Sacramento.

"I've had the opportunity to work closely with EMSA staff on disaster preparedness and public health issues over the past ten years, and I am well aware of their commitment to improving California's EMS system," said Dr. Backer. "As Director, I look forward to working with EMSA staff and with our public and private partners to support high quality and effective care to patients in the field and appropriate transport to definitive care."

As Director, Dr. Backer leads EMSA in establishing and enforcing standards for EMS personnel, coordinating with local EMS systems, overseeing the development of statewide specialty care systems, and preparing for and responding to disasters.

Dr. Backer most recently served as the Interim Director of the California Department of Public Health (CDPH). He worked at CDPH since 2000 in a variety of roles including as Chief of the Immunization Branch.

Prior to government service, Dr. Backer practiced emergency medicine full time for 25 years in rural, urban, and suburban settings. He received a Doctor of Medicine from the University of California at San Francisco, a Master of Public Health from the University of California at Berkeley, a Bachelor of Sciences from the University of Michigan and is board certified in Emergency Medicine, Preventive Medicine and Public Health. He continues to work clinical hours in Urgent Care at the UC Berkeley Student Health Center.

From 2008 to 2011, Backer served as Associate Secretary for Emergency Preparedness at CHHS where he worked closely with EMSA, CDPH, the Department of Social Services and other CHHS departments on plans to coordinate public health and medical disaster response as well as mass care and shelter issues. In that capacity, he served as a consultant to the Ukrainian Ministry of Emergencies and was part of a delegation to Chile following the devastating 2010 earthquake there. He will continue to coordinate the development of Emergency Function 8 (Public Health and Medical) for the California State Emergency Plan.

Dr. Backer has a lifelong interest in wilderness and travel medicine. He is a founding member of the Wilderness Medical Society and a Fellow of the Academy of Wilderness Medicine. He also serves as medical consultant for an international adventure travel company and is a national expert in field water disinfection and infectious diseases of travelers.

Dr. Backer lives in Piedmont, with his wife, who is a registered nurse, and one of three daughters. In his time off, he likes to spend time in the Sierra Nevada mountains or do international travel to remote areas.

Daniel R. Smiley, who has served as EMSA Acting Director since November 2010, will resume his duties as Chief Deputy Director of EMSA, a position he has held since 1989.

The Emergency Medical Services Authority ensures quality patient care by administering an effective, statewide system of coordinated emergency medical care, injury prevention, and disaster medical response. Under statute, the Director of the Emergency Medical Services Authority is required to be a physician with experience in emergency medicine.

EMSA's Unique Public-Private Partnership Sustains the State's Mobile Field Hospital Program

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The Governor's proposed 2011/2012 budget eliminated $1.7 million in funding that sustains the State's Mobile Field Hospitals (MFH) in response ready condition.

The cuts included vendor management of the supplies and bio-medical equipment as well as the rent for the three warehouses where the MFHs are strategically stored.

The MFH Program was established in 2006 with the majority of funds, $18.3 million, provided by the State General Fund. The three (3) hospitals, of 200-beds each, have been strategically located to allow for transportation, set-up and patient treatment processing within 72 hours or less anywhere in the State (ED, ICU and OR ready in about 48 hours) after the order to deploy.

With the elimination of $1.7 million in funding, EMSA worked hard to identify solutions to sustain the MFH Program. We explored alternatives with public partners at the local, state, and federal level as well as with private entities to sustain this program.

EMSA is pleased to announce we have accomplished our mission to sustain the MFH Program through at least June 30, 2012. EMSA has executed a contract with our MFH vendor, BLU MED Response Systems, who will continue to maintain all three hospitals in response-ready condition at no cost to the State. In this agreement, BLU MED will have the ability to deploy two of the three MFHs outside of California and receive compensation for this from the requesting entity. California will have at least one MFH ready to deploy within the State at all times at no cost. EMSA considers this to be is a win-win creative solution for the people of California during the current fiscal crisis.

The Mobile Field Hospitals serve as full General Acute Care Hospitals. They can be transported by ground, sea or air. Each of the three Mobile Field Hospitals contains facilities and equipment to operate an emergency department including:

  • Intensive care unit
  • Flexible medical-surgical ward
  • Point of care lab testing
  • Cascade oxygen system with concentrators to re-supply the oxygen system
  • 130 ventilators
  • Operating rooms
  • Reverse Isolation
  • Digital X-ray

Personnel can be utilized from specialized California Medical Assistance Teams (CAL-MATs) and Hospital Administrative Support Units (HASUs).

EMSA acknowledges and thanks SCRIPPS Health for their assistance in evaluating alternatives for sustaining the MFH Program. SCRIPPS Health sponsors the premier specialized CAL-MAT and HASU and is recognized as a leader among health systems in disaster medical response.

EMSA also acknowledges and thanks our partners at the California Department of Public Health (CDPH) who are providing EMSA's rent for the hard leases for MFH warehouse space through an Inter-Agency Agreement. The warehouse funds which were originally appropriated for CDPH warehouse costs were reappropriated during the last fiscal year in order to fund hard lease costs for both CDPH and EMSA.

Disaster Medical Services Division Chief, Lisa Schoenthal, extends special thanks to Response Resources Unit Manager, Bill Hartley, and Health Program Specialist, Jim Hamilton, for their diligence throughout the mission of sustaining the MFH Program.

A warm thank you is also extended to each staff member of the Disaster Medical Services Division who helped fill in the gaps while resources were directed to this effort.

The MFHs have been deployed twice for exercises and have been placed on alert four times for potential deployments in California in response to wildfires and H1N1. They have not been deployed for a real world medical mission as California has not had a catastrophic disaster that exceeded hospital bed capacity in the past four years.

Dr. Daniel Margulies appointed to Commission on EMS

Dr. Daniel Margulies

Dr. Daniel Margulies, Commissioner

EMSA welcomes Daniel R. Margulies, MD, FACS to the California State Commission on EMS. Dr. Margulies was appointed by Speaker of the Assembly, John A. Perez on August 16, 2011 to represent the American College of Surgeons on the Commission.

Dr. Margulies is the Director of Trauma Services at Cedars-Sinai Medical Center, Director of the Surgical Critical Care Unit and Associate Director of the Division of General Surgery. He continues to be active with many surgical professional organizations both regionally and nationally. Currently, he is the Chairman of the Southern California Committee on Trauma of the American College of Surgeons; serving his second 4-year term as Commissioner on the Los Angeles County Emergency Services Commission; serves as recorder for the Southern California Chapter of the American College of Surgeons; is on the membership committee of the Southwestern Surgical Congress; is on the membership committee of the Western Surgical Association; and is a member of the Pacific Coast Surgical Society, the American Association for the Surgery of Trauma, the American College of Surgeons, and the Society of Critical Care Medicine.

Dr. Margulies fills the seat previously held by Dr. Robert Mackersie. We thank Dr. Mackersie for his five years of service to the Commission as well as his many years serving as an advisor to EMSA in many roles, including his current position as Chairman of the State Trauma Advisory Committee. Dr. Mackersie will continue his role as Chairman, where he has been instrumental in the development of the current State Trauma Plan and we look forward to his continued leadership in those efforts.

Bandaged Teddy BearEMS for Children Guidance Documents Available for Public Comment

By Farid Nasr, MD, Specialty Care System Specialist

California's long-term Emergency Medical Services for Children (EMSC) program goal is to have 100% coverage of emergency medical services for children in California. In 1994 the Emergency Medical Services Authority (EMS Authority) released to the public the EMSC Model which includes nine sets of EMSC guidelines. Of the nine sets of guidelines, the EMS Authority is proposing to amend the "Guidelines for Pediatric Inter-facility Transport Programs" and the "Inter-facility Pediatric Trauma and Critical Care Consultation and/or Transfer Guidelines."

The "Guidelines for Pediatric Inter-facility Transport Programs" was developed to provide uniform guidelines within the state for pediatric inter-facility transport programs to assure quality of care, cost efficiency, coordination of transports, and adherence to state and federal regulations. These guidelines are intended to apply to both hospital-based and non-hospital based programs that regularly provide pediatric inter-facility transport services. Pre-hospital care providers are currently involved in the inter-facility transport of pediatric patients. If such transport services are rendered routinely, as part of a pre-hospital care provider's services plan or contract, it is recommended the provider follow these guidelines.

The "Inter-facility Pediatric Trauma and Critical Care Consultation and/or Transfer Guidelines" are intended to assist physicians and hospitals to identify the types of critically ill and injured children who might benefit from consultation with pediatric critical care specialists or trauma specialists and transfer to specialized pediatric critical care or trauma centers, when indicated. If an inter-facility transport is required, the referring physician, in consultation with the receiving physician, should determine the method of transport and appropriate personnel to accompany the child. The Model Pediatric Inter-facility Transfer Agreement was developed to assist pediatric critical care centers, pediatric trauma centers, and local EMS agencies to develop appropriate pediatric transfer agreements for their regions.

Please visit our public comment page to view the details of these proposals, now open for public comment until October 15, 2011.

EMT and AEMT Regulations are Out for Public Comment Through September 15th

(Correction: The e-mail newsletter included paramedic regulations, but they are not yet available for public comment.)

Regulations to add the United States Department of Transportation's National EMS Education Standards and Instruction Guidelines as the State of California curriculum for EMTs and Paramedics are out for public comment until September 15, 2011. The highlights are:
  • Chapter 2 will be amended to increase the required EMT course hours from 120 to 160 hours (144 hours of didactic training and 16 hours of clinical experience); adopt the EMT Instructional Guidelines as the EMT course content; amend the scope of practice to mirror the National EMS Scope of Practice Model; and minor clean-up to sections of the regulations to provide more clarity.
  • Chapter 3 will be changed to increase the required AEMT course hours from 88 to 160 hours (80 hours of didactic instruction, 40 hours of clinical experience, and 40 hours of field internship); amend the scope of practice to mirror the National EMS Scope of Practice Model; update sections pertaining to base hospital accreditation; and minor clean-up to sections of the regulations to provide more clarity.
  • Chapter 4 will update sections pertaining to base hospital accreditation, and include two new levels of specialized paramedic practitioners: the Critical Care Transport-Paramedic (CCT-P) and the Advanced Pre-hospital Paramedic (APP). The CCT-P and the APP will require each classification to obtain an additional 120 hours of expanded training (80 hours didactic, 40 hours clinical). The scope of practice will be amended to add a number of local optional scope of practice items to the basic scope.

Visit EMSA's public comment page to see the detailed proposals and input your comments.

kid handsChildcare Quality Improvement Updates for Providers

By Lucy Chaidez,

Child Care Training Program Analyst

The EMS Authority's child care training unit is working collaboratively with three sister departments, the California Department of Public Health (CDPH), the Department of Social Services (DSS), and the California Highway Patrol (CHP) on various projects to improve children's safety in California. The Authority is also working closely with the Department of Defense to develop more stringent standards for child care for California's military families.

The Authority was asked to serve on a task force convened by CDPH to set standards for safe sleeping for infants. The group's work will help the state's child care providers improve the safety of babies while they sleep. Safe Sleep Project coordinator Rachel Zerbo, MPH, says, "EMSA's participation in the Safe Sleep Policy Workgroup goes a long way to ensure that the most current SIDS and infant suffocation prevention strategies are incorporated in child care policy and regulation statewide."

The Authority is also working with DSS' Community Care Licensing (CCL) Division to clarify training standards that are required for the state's 60,000 child care providers. The Authority's child care unit recently wrote an article for CCL's "Child Care Update," a publication that is distributed quarterly to the state's child care providers and the parents of children who are in state-licensed child care. The "Update" keeps providers current on laws, regulations, and guidelines for improving children's care in the child care setting. The Authority regularly contributes articles to the "Child Care Update," and the most recent article outlined the Authority's requirements for child care provider training in first aid, CPR, and preventive health and safety practices.

The Authority is partnering with the CHP to develop new first aid exams for school bus drivers. The exams are given to drivers as part of their licensing requirements. The Authority sets the standards for school bus driver first aid and CPR training in California. Almost a million of the state's children ride school buses each school day, and this program helps to train their drivers to respond to medical emergencies on school buses.

The Authority is also working with the California Military Child Care Liaison, Mary Beth Phillips, Ph.D. She requested the EMS Authority Child Care Unit's assistance with child care quality improvement issues for her work with the Military Child Care Liaison Initiative, which is funded by the Department of Defense. The initiative is working in twelve states, including California, and serves National Guard, Reserve, and Active Duty military families. Ms. Phillips says that the work of the initiative is "to promote and support quality child care policies, best practices, and provider training to ensure children are cared for in safe, healthy, and nurturing environments that support each child's development and learning."

About the collaboration with the EMS Authority, Ms. Phillips goes on to say, "The Department of Defense-funded Military Child Care Initiative seeks to expand the availability of quality community-based child care to support California's military families. Provider training is an integral component for ensuring quality, and I am excited to have the opportunity to collaborate with the Emergency Medical Services Authority to advance the quality of California's child care health and safety training standards."

Questions about the EMS Authority's childcare program may be forwarded to Lucy Chaidez at lucy.chaidez@emsa.ca.gov.

National Preparedness Month
EmergncyPrepPrwpnt1

National Preparedness Month (NPM) is an annual campaign to encourage Americans to take steps to prepare for emergencies in their homes, schools, organizations, businesses, and communities. NPM is led by the Federal Emergency Management Agency (FEMA) and is sponsored by the Ready Campaign in partnership with the Citizen Corps. Every September, NPM works with Coalition members to increase emergency preparedness awareness and activities across the nation. This September marks the eighth annual NPM. This year's campaign will focus on remembering disasters from our past, whether it be the tenth anniversary of the September 11th attacks or the disasters in Alabama and Missouri earlier this year, or Hurricane Irene last week, and asking our communities to work together to make our country more resilient.

* You provide vital services to your community.

* You provide essential support to your family.

* While you are busy saving lives and responding to emergencies, is your family safe?

Visit www.ready.gov/responder to download a free toolkit specifically designed for first responders. The toolkit provides resources on how to develop an organizational preparedness plan. The Quadrennial Homeland Security Review Report in 2010 stated, "All of the most advanced, high-tech tolls in the world will not transform our security unless we change our way of thinking, the way we approach individual, family and community preparedness, the way we organize, train, and equip our professional capabilities and the way all of the elements interact. The preparation of individuals, families, and businesses for unexpected disasters is a civic virtue, and cannot be accomplished without ensuring the safety of responders and their families who serve those communities. By ensuring that their families are safe and protected, responders can turn their full attention to the life-saving missions of the rest of the community."

NatlPrepMonth11

Does it matter what kind of shape we're in?

by Brian Brereton

You are about ¾ of the way through your shift and already have run 5 busy calls. You park the rig at a 24-hour convenience store and grab a cup of coffee and a quick snack. You grab a power bar while your partner, Joe, opts for the 2-for-1 special on day old donuts. It's 3am when you settle into your seats and take a much deserved bite into your snack. The 911 call comes in for an unresponsive adult male. You and Joe take a last gulp of coffee and roll to the scene.

Your partner has about 20 years experience in the field and knows more than almost anybody about pre-hospital care. Unfortunately, the stresses of the job as well as some stress at home, let alone the odd hours and predominance of fast-food restaurants have not been kind to Joe. He is about 50 pounds overweight and looks significantly older than his 45 years. You also noticed that on many long nights Joe seems to be sluggish and struggles to catch his breath if you have to do much lifting or walking.

Joe mumbles something about the jelly stain on his white shirt as you pull up on scene to a two-story house and are greeted by a frantic lady screaming to help her husband. You grab the bag and the O2 as Joe gets the board and AED device, and head into the house. The wife tells you that he is upstairs in the master bathroom, on the toilet and won't respond to her. She thinks that he is not breathing.

You bound up the stairs with Joe following behind. You notice that Joe is going a bit slowly and taking a labored breath on every step. By the time he hits the bathroom with you and the patient, he is sweating profusely. The patient is slumped over with his head down and appears to be cyanotic. He also appears to be about 350 pounds and looks even larger in the tight confines of the bathroom. Your first instinct is to move him off of the toilet to a flat surface where you can start getting vitals and most likely start CPR and defibrillation. Unfortunately, Joe is bent over with his hands on his knees trying to catch his breath. What do you do first? When do you call for back-up? What if the patient was your husband or your father? Who is liable, if anyone, if the patient dies before reaching a hospital?

This scenario should never be played out, but that's what an Ambulance Company, the local EMS agency and two paramedics had to explain to a jury recently in a wrongful death suit. One of the defendants' opening comments was "Nobody wants to see a morbidly obese medic struggling just to walk up a flight of stairs, however...." (Names and situations changed)

Working on an ambulance is a demanding job. The average stay of most EMTs and Paramedics working in the US is about 10 years, with those leaving the 'field' due to injuries, promotions or 'burn-out.' Last year, the Cambridge Health Alliance and researchers from Harvard and Boston Universities found that 77% of fire and emergency medical technician trainees in Massachusetts were either overweight or obese.

For the past 30 years or so fitness 'training' or fitness 'tests' for the EMS industry has been a controversial subject. Almost everyone can agree that there are more positive and cost-saving benefits of being healthy and fit in almost every profession; and the benefits are even more profound in the public safety sector including fire, police and EMS personnel. According to Anne Wolf, an instructor at the University of Virginia School of Medicine, many years of published research say that "the heavier people are, the more lost productivity at work. From an employer's perspective, these studies provide evidence that workplace wellness programs that include weight loss and weight management would be benficial for obese employees with or at risk for diabetes," she added. "Employers who spend money in a lifestyle intervention will find their investment returned to them in the form of increased productivity and reduced absenteeism.

"The problem in EMS currently is that there are no national standards and no acceptable mandates applied across the board for wellness. Some EMS providers follow the fire-service models for passing certain skills to join, and others for maintaining fit standards while on the job. Some private ambulance companies have certain criteria for employment (such as lifting a stretcher with 150 pounds on it up a flight of stairs and back down to be lifted into the back of an ambulance). Of course, even these attempts are not really tested in real-life scenarios, and many individuals may train to pass the intial test, but get injured shortly after being hired in a real-life situation.

Wellness is also not just about preserving the lower back in a lift. It also involves factors such as sleep, hydration, nutrition and stress-management, to name a few. For now, the old addage "Doctor, heal thyself" can be applied as "EMTs, heal thyself." No one cares more about you than you.

For more information on Fitness in EMS, you can download an EMS 'Educast' (a podcast by and for EMS Educators) and request #50, entitled "Get Up & Move" at www.emseducast.com/archives/314; or visit Bryan Fass at www.thefitresponder.com

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