Transcript The Fire Service and the EMS Medical Director Current Concepts and Thoughts from the “Eagles”

The Fire Service
and the EMS Medical Director
Current Concepts and
Thoughts from the “Eagles”
Raymond L. Fowler, MD, FACEP
Professor of Emergency Medicine
Chief of EMS Operations
Co-Chief in the Section on
EMS, Disaster Medicine, and
Homeland Security
Section on Resuscitation Research
UT Southwestern Medical Center
Attending EM Faculty, Parkland Hospital
www.rayfowler.com
Objectives for this Talk
Assessing our Position
EMS Medical Directors – who we are!
Relationships with the Fire Service
Current Challenges
Cardiac Arrest and the quest
for excellence
Summary
The Eagles Coalition
represents the EMS care of
over a hundred million lives
The Eagles Coalition
• Best practices (always steal good
ideas from others)
• Innovation (e.g. Community Medics)
• Bonding to solve issues
• Consultants for each other
• Sharing educational materials
Medical Directors Joining
Forces to Address Problems
• San Antonio’s, San Diego’s, and
others attempts to decrease the
impact of substance abuse and
mental illness
• Began with a bond between the ED
and EMS Medical Directors to help
analyze the problems and
fund the efforts
My Background as an
EMS Medical Director
32 Years working with the Fire Service
18 Cities currently as Operations Chief
Some 2000 fire-based paramedic staff
My Work as an EMS MD
in the Fire Service
Through thick and thin
Lean times and fat times
Times of stress and Celebration
Watching the Fire Service grow up as
an EMS Powerhouse
The Dallas-Fort Worth Numbers
2000+ Fire and Municipal Medics with
Central On-line Medical Command in
Dallas
17 Cities
350,000 +/- Responses
150,000 + transports
120,000 + non-transports
3,000+ Cardiac arrests
And…we are AWASH in BLS calls!!!
Awhile back, at a Fire
Service Banquet, a very
nicely done video was
shown…
I couldn’t HELP but think…
It’s 80% of what we do in the
Fire Service
It’s MOST of the actual
revenue generated
We’re probably saving more
actual lives in EMS
I thought to myself:
“What is it about EMS that’s
not as notable or interesting
as Fire Suppression
to show in a video?”
“What message do we send
our EMS members?”
Are we
DABBLING
in EMS Medicine
in the
Fire Service…
…or are we
COMMITTED
to quality care?
So, who are we?
“Emergency medical services is a clinical
specialty that includes the care of
patients in all environments outside of
traditional medical care facilities,
including clinics, offices, and hospitals,
until arrival to a definitive medical care
facility. It includes evaluation and
treatment of acute injury and illness in all
age groups, planning and prevention,
monitoring, and team oversight.”
We are clinical
practitioners
of EMS Medicine…
…the newest
subspecialty in the
House of Medicine…
Identical in scope and
responsibility to…
…The ED
…The OR
…The ICU
IDENTICAL
My Job as a Medical Director
Policies, procedures, protocols
Handle problems
Interview new hires
Oversee education, especially CE and
remediation including Web-based
Set up and manage IT systems
Budgeting and finance
Manage infrastructure for EMS research
The Medical Director
What IS the EMSP’s “hammer”?
PATIENT WELFARE
Whining does NOT work!
The EMS Medical Director
IT’S THE PRACTICE
OF MEDICINE!!!
EMS Medical Director Duties
• Training
• Retraining (C.E.)
• CQI
• Retraining for Cause/Remediation
• Community Liaison
• Protocol Development
• ?Workplace Medicine?
Continuous Quality
Improvement Duties of the
EMS Medical Director
Continuous Quality
Improvement Duties
EMS Medical Director Duties
Leading Clinical Guidelines
Development
Canada, Alabama,
Alaska,
Arizona, California,
Writing
Protocols
Colorado, Connecticut, Delaware, District of
Columbia, Florida, Georgia, Hawaii, Idaho,
Illinois, Indiana,
Iowa,
Kansas,
Kentucky,
Canadian
Evidence
Based
Protocol
set:
http://www.acidremap.com/index.php
Louisiana, Maine, Maryland, Massachusetts,
http://emergency.medicine.dal.ca/ehsprot
Michigan, Minnesota, Mississippi, Missouri,
ocols/protocols/toc.cfm
Montana,www.emsprotocols.org
Nebraska, Nevada, New Hampshire,
New Jersey, New Mexico, New York, North
http://www.acidremap.com/index.php
Carolina, Ohio, Oklahoma, Oregon,
Pennsylvania, Rhode Island, South Carolina,
http://www.emsprotocols.org
Tennessee, Texas, Utah, Vermont, Virginia,
Washington, West Virginia, Wisconsin
© 2012 Ray Fowler, MD
EMS Medical Director Duties
to Educate Providers
• Examine the standards of care
• Examine the evidence for treatments
• Work with the agency to prepare
materials for the providers
• Work on dissemination
• Steal good ideas from others
If you’re not finding quality
www.rayfowler.com
education online, you’re just
not finding the right sources!
EMS Medical Director –
Community Leadership
Examine the evidence for
community public health
imperatives that must be
addressed
The Dallas AHA – Caruth
ACS Effort
• UTSW, AHA, and the
Communities Foundation
of Texas
• $3.5 million in funding
• The “SOAR Metric”
The Dallas AHA – Caruth
ACS Effort
• First database of its kind linking
EMS and hospital data
• Lowered STEMI deaths from
over 4% to 2.5% in a year!
• Lowered cath lab activation from
70 minutes to 48 minutes
• >4000 providers trained in
12-lead ECG Interpretation
This is the role of the EMS
Medical Director
• Working to bring consensus
within the community
• Helping apply community assets
for the greatest service to all
• Building on successes to be able
to continue building in the future
• Passing it on to the
next generation
Getting the EMS Medical
Director into the field
Personal vehicle?
Ride alongs?
Respond with SDO?
Response vehicle?
Observe 1 team at a time or more?
Getting the EMS Medical
Director into the field
Creates a better bond
between
the Medical Director
and the providers
BLS Looking like ALS!
AED
12 leads
King Airways
Nebulizers
Epi Pen
CPAP
“Glutose”
Bleeding control
Basic monitoring?
Great CPR
Splinting/Pelvic sling
?Intranasal Meds?
?Intraosseous?
?Basic IV’s?
CRITICAL Issues to Address
• Medications shortages and use of
expired medications
• The DEA
• Credentialing and re-credentialing
• Impact of ePCR and NEMSIS
• Networks (STEMI, Sepsis, RRC)
• MCI and Disaster Preparedness
• Risks of Nuclear Terrorism
The Relationship
The relationship between the Fire
Department and the EMS Medical
Director is a mutual investment of
confidence targeted toward the
betterment of the human condition
Threats to the Relationship
The Frequent Movement of
EMS Leadership through the
EMS Area in the Fire Service
Can this be stabilized?
Threats to the Relationship
• Skulking: “Trying to steal
EMS Medical Direction contracts
from another Entity”
• It’s not “business as usual”
• It’s unethical
• To go to the City Fathers, accuse the
department of poor care, and then ask that
the EMS Contract be awarded to the entity
responsible for making those statements
Skulking in EMS
• It is unethical
• Such statements are slanderous
• If they’re made in writing,
they are libelous
Budgetary Challenges
in EMS Practice in the
Fire Service
“You can’t add anything
unless you take
something off the truck”
The Impedance Threshold
Device Dilemma
Another CRITICAL Issue
to Address
Repairing relationships
Opportunities are Coming!
The Community Paramedic
• It is a way of the future
• It is part of the future of income
• It enhances community wellness
• Can the Fire Service do it?
NEVER look an
income source
in the mouth!
http://www.health.state.mn.us/divs/hpsc/hep/
transform/dec10documents/communityparam
edic.pdf
So, for you….
A Question…
Does Saving More Lives
Where We Can
REALLY Matter?
I think that we would all
agree that it does…
Forging a Path to Address
a Public Health Imperative
The Visions of the Moment
Statement of the Problem
History of CPR
The ROC Trial
Thoughts for the future
Cardiac arrest is
a rapid and virtually
inexorable movement
toward death
The Specter of
Sudden Death in America
500,000 people every year!
Since the 1960’s an
emergency response system
- Paramedicine –
has emerged to try to
manage this challenge
Atmospheric O2 = ~ 150
Alveolar O2 = ~ 100
Arterial O2 = ~ 80 – 100
Tissue O2 = ~ 40
Tissue Damage at ~ ≤ 10
A “pool” of oxygen in the
tissues, about a quart!
20 cc O2 /100 cc Blood
In Addition to the Tissues!!!!
One quart of oxygen
5000 cc / 100 cc = 50 factor
on our hemoglobin
in the normal resting state
20 cc x 50 = A Quart!
Fick Equation
Gives “consumed oxygen”
VO2 = 1.38
(Hb)(CO)(SaO2- SvO2)/10
(normally 240-290 cc/min)
Fick Equation
Our bodies consume a
“cup” of oxygen each minute
So, with a well-oxygenated
patient at the time of arrest,
there are a total of
two quarts of oxygen
in the body!!!
How to address this?
Cardiopulmonary
Resuscitation
First described in 1960 by
Safar, Jude, Kouwenhoven,
and Knickerbocker
San Diego, 2010
…bringing us to…
Key studies
2006
2009
Survival
100 120
Compression Rate
Survival drops quickly
with compression rates
over 120 beats/minute
Aunt Minnie who
needs to do CPR on
Uncle Herman has
never heard the song
“Staying Alive!!”
Take Home Message:
COMPRESSION RATE
REALLY MATTERS!!
“ROW ROW ROW
YOUR BOAT”
Take Home Message:
Fick equation!
We have 6 – 8 minutes of
oxygen in our bodies
De-emphasize ventilation
Take Home Message
For the Public:
Get on the chest
Stay on the chest
Keep pumping
Find an AED!
Take Home Message
For EMS Providers:
Therapeutic Hypothermia
WORKS!!!
The Next Ten Thousand
“It’s my dream we would give
a $100 bonus to the
first person on the chest
in a cardiac arrest.”
A.J
Heightman
WriteTaxpayers
Ten
Million
Makes
a
Billion
100,000 people
10,000 people
Your x $100,000
x $100
10,000%
Congressman
$10,000,000
$1,000,000,000
Return on Investment
TODAY!!
Patients
Imagine the impact on this
nation if we could save
10,000 more lives yearly
Some thoughts…
…in closing
Our Partnerships in
improving the public
health can save lives,
reduce suffering, and
support public funding
The Fire Service is the
largest EMS provider in
this nation
The Fire Service should be
the BEST EMS provider
in this nation
The Fire Service must
MARRY EMS as a
permanent partner
in service to our citizens
Married Couples
GENERALLY
Change Their Names
• Fire Rescue?
• Emergency Services?
• Emergency Rescue and
Medical Services (ERAMS)?
EMS REQUIRES
committed oversight
by experienced leaders
If you are going to be in the
business of EMS, you
MUST commit the
resources for credentialing,
training, CE, CQI, and
protocol development
You must choose an EMS
Medical Director with
reasonable expertise in
these matters who will
reasonably commit time in
each of these areas
The development of EMS
as a subspecialty will bring
a huge flock of new EMS
physician talent, especially
as EMS providers continue
on to medical school and
emergency medicine
Vision for the Future:
That all that CAN be prepared, would be
That all of us who might give care sing as
a well-rehearsed choir from
the same sheets of music
That research will light our paths
as we maintain our commitment to the
betterment of the human condition…