A GATHERING OF EAGLESDebate and dialog reign at the annual gathering of EMS medical directors.By Michael Gerber

Medical directors from some of the largest EMS systems in the nation (and a few from overseas) came together in Texas earlier this year for the 16th annual Gathering of the Eagles conference. And one thing was clear—coming to a consensus in prehospital medicine is not easy.

In fact, one of the highlights of the conference was a debate between Ray Fowler, M.D., chief of EMS operations for the Dallas-area BioTel system, and Tucson Fire Department Medical Director Terry Valenzuela, M.D., over whether the long backboard should be routinely used for spinal immobilization. In between inside jokes and lighthearted personal digs at each other, the two veteran EMS physicians cited dozens of studies in defense of their arguments. Fowler argued in favor of reducing backboard use, while Valenzuela titled his talk “Keep the Backboard: Nothing Sensible Ever Goes Out of Fashion.” In the end, it was clear that even though two major national physician groups had recently published a position paper questioning the routine use of backboards, medical directors and EMS agencies still have to make a decision based on evidence that can be interpreted in many ways.

Brent Myers, M.D., who serves as both the department director and medical director of Wake County (N.C.) EMS, said that conducting any kind of rigorous clinical trial of backboarding would be nearly impossible because of the relatively small incidence of spinal cord injuries. So the debate likely won’t end anytime soon.

These are some of the dilemmas faced by prehospital providers and their medical directors in an age of evidence-based medicine, a recurring theme during the conference. While EMS

Continued on page 7

Continued on page 10

FAA ISSUES FINAL RULE TO IMPROVE HEMS SAFETY

In an effort to staunch the string of deadly helicopter EMS crashes that have killed dozens of patients and providers over the past two decades, the Federal Aviation Administration (FAA) issued a fi-nal rule on Feb. 20 that introduces wide-ranging new safety require-ments for air medical operators. The new rules include abiding by stricter flight rules and proce-dures for dealing with situations such as landing in remote areas or flying in poor weather, equip-ping helicopters with additional safety devices and improving pilot training. In an FAA news release, Transportation Secretary Anthony Foxx called it a “land-mark rule for helicopter safety.”

More stringent air medical safety rules were first proposed in 2010, after the National Transpor-tation Safety Board (NTSB) held a series of hearings to address the high rate of crashes and suspected over-use of helicopters in emer-gency response. Yet the NTSB’s resulting recommendations for improving air medical safety appeared to languish for several years.

The 159-page FAA final rule incorporates many of the NTSB recommendations. Among the new rules, helicopter EMS opera-tors must:• Equip helicopters with radio

altimeters, which measure

Quick Look

Ideas Analysis

Insight

May 2014Vol. 17 No. 5

SCA survival, not community paramedicine, dominate the agenda at the Eagles.........................1

40 years of celebrating EMS .................................................................................................................. 2

Medicaid expansion increases ED visits in Oregon ............................................................................ 3

Allina Health EMS’ Brian LaCroix on how to keep the fire burning ................................................... 4

How a rural EMS system is using data to rebuild after Mother Nature strikes ...............................6

White paper urges support of mobile integrated healthcare ......................................................... 10

Beyond the Lone Ranger: Great teams ............................................................................................. 12

Highlights from this issue

Up Front

PublisherJacob Knight

Editor in ChiefKeith Griffiths

EditorCarole Anderson Lucia

Art DirectorMorgan Haines

Editorial Board of AdvisersBonnie Drinkwater, Esq.

Drinkwater Law Offices

James N. Eastham Jr., SC.D.CEO, CentreLearn Solutions, LLC

Jay Fitch, Ph.D. President, Fitch & Associates

Stewart GaryPrincipal, Fire & EMS Services

Citygate Associates, LLC

Kevin KleinDirector, Colorado Division of Fire Safety

William Koenig, M.D., FACEPMedical Director, Los Angeles County EMS

Jon R. Krohmer, M.D., FACEPU.S. Department of Homeland Security

Pete LawrenceBattalion Chief

Oceanside, Calif., Fire Department

Todd J. LeDuc, MS, CFO, CEMDeputy Fire Chief, Broward Sheriff ’s Office

Department of Fire Rescue & EMS

Lewis Marshall, M.D., J.D.Chairman of Emergency MedicineWyckoff Heights Medical Center

Brooklyn, N.Y.

Patrick SmithPresident, REMSA

Gary L. WingroveMayo Clinic, North Central EMS Alliance

Best Practices In Emergency Services (ISSN 1540-9015)is published monthly by

The National Emergency Services Institute 679 Encinitas Blvd., Suite 211

Encinitas, CA 92024 Tel. 760-632-7375 • Fax 866-448-1436

emergencybestpractices.com

© 2014 by The National Emergency Services Institute All rights reserved

Subscription rates: USA: one year: $279; two years: $450 (save $108);

outside the USA: Please add $10 per year.

Best Practices is a membership benefit of the National EMS Management Association.

Research Monitor

ALTERNATIVE DESTINATION TRANSPORTS COULD SAVE MEDICARE MILLIONS

Reimbursing ambulance providers to transport patients to desti-nations other than emergency departments could save Medicare an estimated $283 million to $560 million a year. If private insur-ers also reimbursed for alternative destination transports, the savings could be even larger, according to a study by researchers from the University of California, Irvine, and colleagues.

Researchers analyzed a random sample of 5% of the roughly 7.1 million ambulance transports resulting from 911 calls by Medicare beneficiaries between 2005 and 2009. Between 12.9% and 16.2% of Medicare-covered transports were either not emer-gencies or were for conditions treatable in a primary care setting, the study found. Of patients not admitted to the hospital, about 35% had low-acuity diagnoses that could have been treated at less-costly places such as doctor’s officers or urgent care centers.

The study was in the December 2013 issue of Health Affairs.

SCA SURVIVAL STUCK AT 10%Only about 10% of out-of-hospital sudden cardiac arrest victims survive, according to the American Heart Association’s Heart Disease and Stroke Statistics—2014 Update. And at just 5%, survival rates for children are even lower.

Using data derived from a Resuscitation Outcomes Consor-tium multi-center clinical trial registry, the 2014 update found:

• More than 1,000 people suffer out-of-hospital SCA daily in the U.S., including about 26 children.

• EMS assesses 424,000 SCAs annually, or about 60% of the total number of out-of-hospital SCAs.

• 25% of SCA victims treated by EMS have no symp-toms before the onset of their arrest.

• Among EMS-treated cases, 23% have an initial shock-able rhythm of ventricular fibrillation or ventricular tachycardia.

• Blacks and Hispanics have a higher age-adjusted risk of SCA than whites. They also have a lower rate of survival to 30 days post-hospital discharge.

• Prior heart disease (heart attack or heart failure), or a family history of cardiac arrest in a parent, sibling or offspring, is associated with an increased risk of SCA.

• Survival to hospital discharge after EMS-treated non-traumatic SCA with any first recorded rhythm is 10.4%.

• Survival after bystander-witnessed VF is 31.7%.• Among people who survive to hospital discharge,

five-year survival is better among those who receive angioplasty (78.7% vs. 54.4%) and among those who receive therapeutic hypothermia (77.5% vs. 60%).

• Survival rates are higher among those who receive compression-only CPR (10.2%) vs. chest compressions and rescue breathing (8.5%).

• Each year, EMS responds to SCAs in 9,500 children under the age of 18 and treats 7,700 of them.

• Black athletes aged 17 to 24 are at higher risk of SCA than whites, while male athletes are at higher risk than females.

• Survival to hospital discharge after EMS-treated SCA in children is 5.4%. About 7,000 children die annually from SCA.

• Of cardiovascular deaths that occurred in athletes younger than 18, 29% occurred in blacks, 54% in high school students, and 82% with physical exertion during competition or training.

The SCA update was published in the January issue of Cir-culation. The summary of the report’s findings was prepared by the Sudden Cardiac Arrest Foundation.

FEWER CHILDREN DYING IN CAR CRASHESFewer children are dying in motor vehicle crashes, according to the U.S. Centers for Disease Control and Prevention’s Fatality Analysis Reporting System.

From 2002 through 2011, 9,182 children died in motor vehicle crashes, including 650 in 2011. The good news is that over that same period, the annual death rate fell 43%, from 2.2 deaths per 100,000 children in 2002 to 1.2 per 100,000 in 2011.

One in three of the children who died in 2011 weren’t in an age-appropriate restraint such as a car seat, booster seat or seatbelt, according to the study, which appeared in the Feb. 4 Morbidity and Mortality Weekly Report.

Black children were at higher risk of death: 1.5 per 100,000, compared to 1.0 for whites. Black children aged 12 and under were also more likely than whites to be unrestrained at the time of the fatal crash (45% compared to 26%). Hispanic children were also more likely to be unrestrained than whites (46% vs. 26%).

Yet usage of car seats and seat belts is increasing, research-ers found. From 2002–2003 to 2009–2010, the proportion of unrestrained child deaths decreased by 27% for whites, 16% for blacks and 14% for Hispanics.

MEDICAID EXPANSION INCREASES ED VISITS IN OREGON

In 2008, Oregon initiated a limited expansion of a Medicaid program for uninsured, low-income adults, drawing names by lottery. By analyzing ED usage of about 25,000 lottery participants in the 18 months after the lottery was established, researchers found those with Medicaid coverage visited EDs more often—by 0.41 visit annually per person, or 40% relative to an average 1.02 visits per person in the control group.

Researchers from the Massachusetts Institute of Technol-ogy and colleagues found ED visits increased across a range of conditions, including visits for conditions treatable in primary care settings. The study was in the Jan. 2 issue of Science.

40 YEARS OF CELEBRATING EMSBy Keith Griffiths

What were you doing in May of 1974? Some of our more senior readers might have already entered the EMS profession, inspired by the popular TV show Emergency!, which had debuted just a few years earlier. EMS was in its infancy then and just starting to gain momentum, with a big push from that national spotlight.

Another push for EMS in 1974 came from the first national EMS Week, which President Gerald Ford had signed legislation for the year before. The intent of the week is to celebrate the men and women providing care on the front line, while at the same time educating the public about what they (and the system) actually do.

EMS Week is May 18–24 this year, representing its 40th anniversary. What are you doing to educate and celebrate?

One common way to do both, and get some media attention in the bargain, is to encourage your local, regional or state officials to issue a proclamation. The American College of Emergency Physicians, which creates an EMS Week Guide each year, has created an updated sample, which we’ve reprinted below. It’s interest-ing to note how the references to injury prevention, public outreach and being a member of the healthcare community and providers of care 24/7 are touchstones of community paramedicine and mobile integrated healthcare.

To Designate the Week of May 18-24, 2014, as Emergency Medical Services WeekWHEREAS, emergency medical services (EMS) is a vital public service; andWHEREAS, access to quality emergency care dramatically improves the survival and recovery rate of those who experience sudden illness or injury; andWHEREAS, EMS plays a critical role in public outreach and injury prevention, and is evolving in its role as an important member of the healthcare community; andWHEREAS, first responders, emergency medical technicians and paramedics stand ready to provide compassionate, lifesaving care to those in need 24 hours a day, seven days a week; andWHEREAS, emergency medical responders are supported by emergency medical dispatchers, firefighters, law enforcement officers, educators, administrators, re-searchers, emergency nurses, emergency physicians and others; andWHEREAS, the members of EMS teams, both career and volunteer, engage in thousands of hours of specialized training and continuing education to enhance their lifesaving skills; andWHEREAS, it is appropriate to recognize the value and the accomplishments of EMS practitioners by des-ignating Emergency Medical Services Week; nowTHEREFORE, I [name, title, city, state], in recognition of this event, do hereby proclaim the week of May 18–24, 2014, as EMERGENCY MEDICAL SERVICES WEEK. With the theme “EMS: DEDI-CATED. FOR LIFE” I encourage the community to observe the week with ap-propriate programs, ceremonies and activities.

Running out of ideas for EMS Week? Go to acep.org/emsweek or emsideas.com

for more information.

2 Vis i t emergencybestpract ices.com for quick access to a l l web l inks l isted in each issue. May 2014 3

Q&AWITH BRIAN LACROIXPresident, Allina Health EMS

Q Allina Health EMS is part of a large hospital system. What

benefits does that bring you? Our parent organization, Allina Health, is a collection of 12 hospitals, more than 100 clinics and a group of specialty op-erations including pharmacies, homecare and hospice agencies, durable medical equipment providers and of course EMS. So, yes, it’s a very large organization with a large number of employees: 24,000.

Being part of this type of organiza-tion brings us many benefits, but one of the most important is our connection to a lot of physicians. This connection allows us to participate in a systemwide devel-opment of emergency medicine that has a significant impact on patients. For in-stance, through this relationship we were among the first in the nation to develop a systematic way of identifying STEMI patients and bringing them straight to

the cath lab. We knew the cardiologists and they knew us, so we were able to work together to come up with an effective, patient-centered program.

Another example is our stroke program: We sat down with the neu-rologists in the hospitals and asked what mattered to them when it came to stroke care. One illustration of what we found is they wanted us to use at least an 18-gauge needle to administer thrombolytics, so now when we start IVs on these patients, that’s what we use.

Q Do you have your own culture within Allina Health?

Allina Health EMS, like all EMS systems across the globe, lives in the worlds of both public safety and healthcare, yet the rest of our parent organization is all about healthcare. Our EMS folks interact with firefighters and police officers as well as hospital workers, but the hospital side of

our company doesn’t do that, just by the nature of the work they do. So, yes, we’re very much a standalone culture.

Q What services does Allina Health EMS offer?

My division is primarily a 911 ambulance service—75% of our work is related to emergency response. The other portion of our work is related to interfacility work: wheelchair, BLS, ALS and critical care. I’m particularly proud of our partnership with Children’s Hospitals and Clinics of Min-nesota, which allows us to offer neonate transport.

We also have our own dispatch center, with 30 PSAP dispatchers. I’m proud to say we are well on our way to achieving ACE accreditation—our hope is that we will have our accreditation wrapped up by the third quarter of this year.

Q What sets Allina Health EMS apart from other EMS organiza-

tions? Culturally, we care a lot about people, and I don’t mean that in a corny way. It is deeply rooted in all of us that the work we do is vitally important. On a personal level, I get up every morning and think about our patients. I remember my own experience as a patient and try to instill in our employees a sense of deep importance that we do good work.

The other part of that is that we care about each other. Our organizational culture is that we have high expectations but deep support.

Structurally, being part of a large, healthy organization makes us fiscally strong and allows us to buy the equip-ment we need and to hire good people. And, most important, it gives us access to and interest from a lot of physicians, and we enjoy extraordinary medical support.

We are also unique in that we have two half-time medical directors. They each work half of their time with us in EMS, and the other part of the time they work clinically as ER physicians in dif-ferent Allina ERs.

So, yes, we are part of a large orga-nization, but that alone does not make us good. What I always say is that when a crew steps out of a rig and touches a patient, that’s what makes us good.

Q Is it true that you have a chap-lain on staff?

It is. We decided to create this position post 9/11 because we wanted to engage our staff in terms of their own well-being.

Our chaplain has a phrase: high ex-pectations and high support. We expect a lot out of our people: to know the proto-cols, to give great clinical care, to be nice to someone who just threw up in their shoe. We expect them to do good work, but we have their back in turn. We support each other.

His role is not to pontificate or to advocate for any religious position at all, but simply to support the well-being of our caregivers. He sees himself as a teacher of self-care.

Q Physical and emotional wellness is a benchmark of your compa-

ny. Why is it so important to you?Yes, we want to take good care of our employees, but at the other end of the spectrum is the business case for well-ness: Burnout, or employees who are not in a good place emotionally or physically hurt patient care, hurt job satisfaction and hurt the bottom line. It’s not just that we have this Pollyanna view.

Q How do you benchmark well-ness among your employees?

This is another advantage to being part of a big healthcare organization: We have epidemiologists and other social scien-tists whose job it is to do a lot of research. And part of that research is on employee wellness.

Among other clinical work they do, this group of researchers studies the well-being of Allina physicians, and recently they started including paramedics in that group. What they found is 25% of the general population identify themselves as being burned-out. Among family-practice physicians, that number is about 50%. Among our paramedics, just 17% identify themselves as being burned-out. What’s the secret sauce we’re feeding them? We don’t really know, but we’re learning.

Another measure is our annual employee engagement survey. This is a

high priority for our leaders, and their compensation is based partly on their employees’ engagement. If their employ-ees aren’t engaged, they need to figure out why, and how to help them become re-engaged.

I’m very proud of the fact that 87% of Allina Health EMS workers are fully engaged. When I started here, that number was at 34%. Every year we’ve made a little headway, but it didn’t happen overnight.

Q Two of your employees were involved in a crash while on duty

this year. What were some of the les-sons learned from this?Our vehicle was transporting a patient without lights and sirens in a heavy snow-storm at 1 a.m. and was hit by another car head-on on a rural highway. The patient was uninjured, but two of our staff members were severely injured, and the woman who struck us was killed.

It was a tragic situation, but I’m just really proud of this organization. People from every corner of Allina Health were there to support our injured colleagues, as were our partners at the fire department and in law enforcement.

The extraordinarily happy note is that both staff members have recovered and are doing very well. They have a long road of recovery, but both are highly functioning.

When all is said and done from an investigation standpoint, I don’t think we’ll learn a lot that we could have done differently from a safety point of view. What we did learn has more to do with the cliché that when the chips are down, your family will rally. We’ve enjoyed an ever-growing culture of caring within our organization that was absolutely lit on fire after this incident. The outpouring of support has been phenomenal.

Q Your company has a reputation for having employees who take

great pride in their work. How do you help engender this? There’s a concept of line of sight: Everyone is invited and encouraged to think every day about how they impact patient care. It’s easy for a medic to understand how

BP Interview

Continued on page 11

Walk into the training center at Allina Health EMS in Minne-sota and you may be surprised to see an entire wall lined with a series of paintings depicting the history of EMS. Even more surprising is the fact that the pieces were painstakingly created by the organization’s president, Brian LaCroix.EMS wasn’t LaCroix’s first calling, you see. Having received a degree in fine arts, he had worked as a commercial artist for a billboard company and was freelancing in 1981 when he ex-perienced a medical emergency and called 911. “I was 22 years old, had a pulse of greater than 220 and was having syncopal episodes,” LaCroix recalls. “The EMTs who came to take care of me were probably more scared than I was because they had no idea what was wrong, but they connected with me on a very per-sonal, human level. The impact they had on me was extremely powerful.”So powerful, in fact, that LaCroix became an EMT and started working for the same system that took care of him when he had his episode of PAT (paroxysmal atrial tachycardia). He went on to become a paramedic, working the streets for several years

before joining Allina Health EMS as an operations manager in the late ’90s. He eventually got a business degree and worked his way up to president, though he admits that wasn’t always his aspiration.“I didn’t have designs to be an EMS chief or president of an EMS organization,” he says. “I loved being a field medic, but I was intrigued by working with and for a few very good leaders and eventually became interested in leadership.”Even as the head of a large EMS organization—Allina Health EMS serves 1 million people in a state with a total population of 5 million—he’s never lost sight of why he got into the business in the first place. “We respond to nearly 90,000 calls each year; 260 times each day, someone, potentially having a similar experi-ence as I had years ago, calls on my service and asks us to help,” he says. “I find this to be a profound responsibility.”Now in his 17th year with Allina Health EMS, LaCroix spoke with Best Practices about how he keeps the fire burning in him-self and his 570 employees.

“I get up every morning and think about our patients. I remember my own experience as a patient and try to instill in our employees a sense of deep importance that we do good work.”

— Brian LaCroix

4 Vis i t emergencybestpract ices.com for quick access to a l l web l inks l isted in each issue. May 2014 5

In Focus

May 4, 2007, is a day that will live in infamy for the residents of Greensburg, Kan. At 9:45 p.m. that spring night, an EF5 tornado, estimated to be nearly 1.7 miles wide, touched down, traveling for nearly 22 miles. After a harrowing 65 minutes, the twister finally dissipated, leaving 95% of the rural town leveled and 11 people dead.

Soon after, the people of Greensburg and the surrounding Kiowa County em-barked on the rebuilding process. But with resources tight and a population base that would dwindle by nearly 50% in the following years, rebuilding would prove tough. To compound the challenges, the EMS director retired 1½ years later.

Enter Chad Pore. Coming from a larger metropolitan EMS system, Pore was commissioned as director of Kiowa County EMS in 2008 and tasked with helping to rebuild the system. “It was a real challenge,” he says. “In the beginning, our EMS system was still operating out of fifth-wheel trailers and first responder, EMT-basic and continuing education classes were being held in military tents. Volunteerism was low and resources were

minimal. There was a lot of work that needed to be done to get back on our feet.”

Challenges aside, Pore had big plans on how to rebuild, and he knew exactly what he needed to get the job done.

He needed to analyze the data. “The amount of data at an EMS

system’s disposal is incredible,” Pore explains, “but it’s up to the director to be proactive in analyzing it. One of the first things we did when I arrived is pull data on every aspect of our system, from

response times to medication usage to equipment—we looked at it all.”

For any EMS director, and especially one who manages a rural system, having the facts in front of you can make the decision-making process easier when addressing system shortfalls. The first things Pore looked into were response times and the overall coverage of Kiowa County. What he found was unnerving.

“In 2009, our average en route time to a call was 3 minutes, 48 seconds, and our on-scene time was 45 minutes, 5 seconds. We had to improve,” he explains.

After noticing that 30% to 35% of his calls were interfacility transfers, which were currently being run with a big box ambulance, Pore was able to make several recommendations to city leaders. That included the purchase of a new Sprinter Type 2 ambulance.

The Sprinter would provide the same service while costing $40,000 less than a box ambulance, double the mileage and cut maintenance costs in half. In addition to the new Sprinter, Pore proposed the relocation of an existing unit to better serve the rural community.

The result? By 2013, Kiowa County EMS’ en route time was cut to 2 minutes, 54 seconds, and the on-scene time was slashed to 15 minutes, 59 seconds.

“What I found in the data I pulled helped me make the deci-

sions that would benefit our community and raise the bar on the level of service we provide,” Pore says. “I never would have known where we were falling short if I hadn’t pulled the data and analyzed it on my own.”

In addition to improving response times and coverage area, Pore drilled down deeper. He used the data to identify obsolete medications and to determine what type of equipment was (and wasn’t) being used on calls on a routine basis.

“Having the dataset in front of me when talking with my medical director and city leaders was invaluable,” Pore says. “Having rock-solid information allowed me to speak confidently and accurately about exactly what changes needed to be made to our system.”

The result? Pore was able to dump more than 20 medications that had not been administered in more than five years and lighten first responder bags by more than 20 pounds—all without sacrificing patient care or arriving unprepared.

This was accomplished by creating three different bags: first-in bag, airway bag and the critical-patient bag. None of the bags weighs more than 10 pounds and all are still on the ambulance in case ad-ditional supplies are needed.

Pore also decreased the number and sizes of various bandages and fluid bags (among other things) that were carried, further lightening the weight of the packs for his first responders.

Though Pore is currently pulling his data through patient ePCR records and at the state level, he’s both excited and optimistic about moving toward a more robust, comprehensive national data set, known as the National EMS Information System (NEMSIS).

“In an era of tight resources and high expectations, EMS directors should take the time to pull data on their systems from every available angle and analyze it,” he suggests. “That was the biggest benefit to me and my organization: being able to say, ‘Hey, here’s our data—here’s what’s going on.’ Now let’s work to make it better.”

And while the residents of Kiowa County will never forget the disaster that hit their hometown in May 2007, they can rest a bit easier knowing that if another disaster does happen, Kiowa County EMS is prepared to respond better now than ever before—thanks to data, leadership and confident decision-making.

— Greg Gayman

FACING THE FACTSHow a rural EMS system is using data to rebuild

Gathering of Eagles

only a small portion of the agenda, one of the most popular topics was one that has been debated since the earliest days of prehospital emergency medicine: how to improve cardiac arrest survival. These presentations drew some of the most ques-tions from the audience and provided some of the more intriguing data.

The presentations included one from Joe Weber, M.D., a medical director for the Chicago EMS system, who discussed a major effort by the city to improve cardiac arrest survival rates. “You must measure in order to improve,” Weber said, an apt introduction to the following presen-tations. Even if the medical directors didn’t always agree on the conclusions of each other’s presentations, nearly all did agree that collecting data, analyzing it and making improvements based on that data are critical in any EMS system.

“People do [try to improve on] what you measure …” said Paul Hinchey, M.D., medical director for Austin/Travis County EMS in Texas. “But only if you tell them the results. Measure what matters, and give feedback.”

In Chicago, one of the changes they are trying to implement and measure involve simply training providers to stay on scene longer in order to avoid inter-ruptions in chest compressions and delays in defibrillation.

Sabina Braithwaite, M.D., medical director for the Wichita-Sedgwick County (Kan.) EMS system, told the story of a system that was a little further along than Chicago’s in its efforts to improve cardiac arrest outcomes. Now that the pit-crew approach and high-performance CPR have become widespread across the country, systems like Wichita’s can share some of the pitfalls of implementing these methods—and ways they have tried to correct those problems.

For example, in Wichita, they saw immediate improvements to compression fraction after implementing the program, but they didn’t seem to last. “We thought, This is great!” Braithwaite said. “Then we started analyzing it and we started back-sliding.”

As with any good quality improve-ment process, the team in Wichita delved into the data to try to figure out why the training hadn’t made as much of a dif-ference as they’d hoped to see. Their first suspicion?

“Are they doing airway management that’s interfering [with compressions]?” Braithwaite said. But after further ex-amination—using information from the CodeStat software and electronic patient care reports—airway management didn’t seem to be the culprit.

So the agency focused on the little things: pre-charging the defibrillator during every cycle of compressions, keeping a finger on the femoral pulse throughout the entire code, and more. After follow-up training, Wichita found its average length of pauses in compres-sions fell—and survival rates are now 11.3% for all cardiac arrests and 38.6% using the Utstein criteria (compared to 8% and 24.6% nationally).

The presentations on cardiac arrest resuscitation from the medical direc-tors from Chicago and Wichita, as well as several other areas, elicited the most response from an audience clearly trying to tackle similar issues in their own agen-cies. In particular, the growing practice to work cardiac arrest resuscitations on scene and delay transport until a patient regains a pulse has led to a new dilemma:

has made great strides in recent decades, research in the field is still very often dif-ficult to conduct. But that isn’t stopping some agencies from trying, as was clear at this year’s conference.

SCA SURVIVAL DOMINATES THE DISCUSSIONA few subjects dominated the agenda this year, while some were notably absent or rarely mentioned. For instance, although they were discussed by a few speakers, community paramedicine and mobile integrated healthcare were not high-lighted, and few lightning round questions touched on the subjects.

“I think that was a conscious de-cision,” says Marshal Isaacs, M.D., medical director for Dallas Fire-Rescue and a professor of emergency medicine at UT Southwestern Medical Center, which sponsors the conference. Pri-vately, medical directors from several of the nation’s largest agencies questioned whether the current focus on community paramedicine programs is encouraging agencies to rush to create new programs, without first determining what the needs of their communities are and whether they are capable of providing those services.

While the EMS topic du jour received

DOCS TALKThe Gathering of the Eagles started in 1998 as a small group of medical direc-tors who got together to share ideas with each other and some paramedics and other EMS administrators. They realized that between them, they were responsible for prehospital care for a large chunk of the nation’s population.

Over the years, the conference has grown, and while the core group of “Eagles” remains small, more than 700 others attended this year’s conference, which was held Feb. 28 and March 1 just outside of Dallas. The conference format is different than any other, with two days packed with 10- to 15-minute presentations, one after the next. Twice a day, the entire group of Eagles gathered on the stage for “lightning rounds,” where audience members could question any or all of the physicians in front of them.

Continued on page 8

Continued from front page

For more information on the efforts to collect data at the local, state and national level, visit ems.gov/NEMSIS.htm.

6 Vis i t emergencybestpract ices.com for quick access to a l l web l inks l isted in each issue. May 2014 7

How long should paramedics attempt to resuscitate out-of-hospital cardiac arrests before giving up?

“Here’s the question we were getting all the time [from medics over the radio],” said Wake County’s Myers. “There’s no ROSC. What do we do next?”

In Wake County, they are trying to answer that question by looking at data. They have partnered with SAS, a statistical software company headquartered in Wake County, to help comb through years and years of cardiac arrests. In addition to

presenting some fascinating new results, Myers also highlighted the importance of working with public health and other partners that have resources that might not be available internally in most agen-cies. For Wake County, that happens to be one of the world’s largest statistics com-panies—in other jurisdictions, it could be other organizations that are available and willing to help.

Myers said they were surprised to discover that about 10% of their patients who survived cardiac arrest with good neurological outcomes were resuscitat-ed for nearly 40 minutes. So now their paramedics are often working codes for nearly an hour if they feel it’s clinically appropriate, based on a number of factors, including end-tidal CO2 levels and cardiac rhythm.

“If we have a PEA [with a rate] above 20 with an end-tidal [CO2] greater than 30 [mmHg], we are not terminating today,” Myers said.

The research presented by the Wake County medical director struck a chord with members of the audience, many of whom seemed surprised at the results, which led to as many new questions as it did answers. Certainly other agencies will now be examining data and their proto-cols to see if perhaps there is a better way

to predict survivability and know which patients should be resuscitated and for how long.

That’s the goal of the Gathering of the Eagles, say its organizers and veterans of the conference: To surprise people, to inspire further debate and more research, and to change how prehospital emergency medicine is provided.

That was the point made by Ed Racht, M.D., a long-time Eagle and national medical director for AMR, when he chose to abandon his slides and change topics at the last minute. Instead of discussing the latest research or a medical topic, he told the audience that the methods used to introduce new theories and new ways of practice are as important as the science itself.

“This is all well and good, the science is fabulous,” he said, “but if you don’t so-cialize it right, you’re dead in the water. If we don’t do that, it’s not going to change the practice of medicine in our commu-nities.”

MEDS A HOT TOPICCardiac arrest wasn’t the only topic being discussed, and medical directors from around the country said that the growing use of ketamine in the prehospital setting was one of the big take-away messages from the weekend.

A majority of the big-city medical directors said their systems use ketamine, and while many reserve its use for seda-tion of patients with excited delirium, others are beginning to explore it as another option for pain management. “The pharmacology is different than any other drug we give,” said Melissa Costello, M.D., chair of the EMS Committee for the American College of Emergency Physi-cians.

Perhaps more fascinating than the rise of ketamine is the decline of mor-phine. During one of the lightning rounds, an audience member asked the medical directors gathered in front of him to talk about their preference for pain manage-ment. Only a handful still use morphine as their go-to narcotic, while the rest all strongly prefer fentanyl.

Continued from page 7

Gathering of Eagles

“Morphine is not an EMS drug, end of story,” said Peter Antevy, M.D., a pe-diatrician and medical director for several agencies in Broward County, Fla. Surpris-ingly, no one disagreed, demonstrating just how much prehospital pain manage-ment has shifted in the past decade.

In addition to its use in pain manage-ment, ketamine is growing to be more popular among medical directors for managing agitated patients who could be a danger to themselves, the public and medical providers. In between jokes about legalized marijuana in his home state, Denver Paramedic Division and Denver Fire Department medical director Chris Colwell, M.D., gave a fascinating talk on the increased use of synthetic cannabis products, such as “black mamba.”

A trial of ketamine for these patients resulted in emergency department intuba-tion rates lower than those associated with prehospital Versed, Colwell said.

MOBILE INTEGRATED HEALTHCARE TAKES A BACK SEATWhile mobile integrated healthcare did not dominate the agenda like it does at many EMS conferences and meetings, a few presentations gave updates on some innovative programs aimed at reducing the number of unnecessary emergency calls and transports. Jeff Beeson, D.O., medical director at Fort Worth, Texas-based MedStar Mobile Healthcare, shared audio recordings of actual low-acuity 911 calls that were referred to his agency’s triage nurse. Even a skeptical patient eventually sounded satisfied once she realized that the nurse was going to help her find an appropriate place to receive care and, most important, transportation to get there.

“Patient satisfaction is high,” said Beeson, who is leaving MedStar to join Acadian Ambulance Service. Nearly 43% of patients referred to the nurse triage lines had “alternate dispositions,” meaning they were not transported by an ambulance to the ED.

But Beeson ended the presentation with a key point. “A vision without re-sources is a delusion,” he said. The message

was clear, especially to the hundreds of agencies across the country getting ready to dip their toes into the pool of mobile integrated healthcare: Don’t do it unless you have resources and a well-developed plan.

During a lunch with the Eagles, Austin’s Hinchey also expressed concern that too many people view community paramedics as a panacea for all of EMS’s problems. “Community paramedicine is not the answer if you don’t need it,” he said. Not only do the programs need to be specifically tailored to the needs of the community, he added, but they would

create an even higher demand for good EMS providers. “Finding good medics is going to be even harder,” Hinchey said.

But Fort Worth’s Beeson delivered a second presentation that showed another aspect of the MedStar mobile integrated healthcare system, one that appears to be succeeding and paying for itself. In the agency’s Hospice Revocation Prevention program, MedStar partners with hospice to try to prevent ED transports for hospice patients. So far, the hospice agency (which pays for the service) has been pleased with the results, Beeson said, adding that of the 10 911 calls for patients enrolled in the program, there have only been five transports: three for reasons unrelated to their hospice status, and two direct-admits to hospice beds, which did not result in revocation of their hospice status.

A few other presentations touched on

alternative destination programs, triage of mental health patients and recidivism, but even Wake County’s Myers questioned whether these presentations would make a significant impact. Myers, who presented on a new protocol that his agency is about to implement to try to reduce transports from psychiatric facilities to the ED, thought the main take-away from the conference would be the push for “coor-dinated, on-scene and longer” treatment for cardiac arrests.

The diversity of thought among the Eagles was reflected in the audience as well, with other attendees listing the dis-cussions of response to active shooters and explosions, or the talks about evidence-based guidelines as the highlights of the weekend.

As Racht said, though, the point of the conference is not to come to an agree-ment—not on what the most innovative presentation is, whether community para-medics are the future of EMS, or even which pain medication to use.

“Arguing and disagreements are public here,” he said. “It’s an environment where you can say, ‘You’re smoking crack.’ We share our successes, and we share our failures. Eagles is a place where we get ‘what-ifs.’”

Michael Gerber, MPH, is a writer and paramedic in the Washington, D.C., area.

The message was clear, especially to the hundreds of agencies across the country getting ready to dip their toes into the pool of mobile integrated healthcare: Don’t do it unless you have resources and a well-developed plan.

One of the most popular topics was one that has been debated since the earliest days of prehospital emergency medicine: how to improve cardiac arrest survival.

INFORMATION FOR SUBSCRIBERS• Membership pays. Members of the National EMS Management Association

receive Best Practices as a membership benefit. Visit nemsma.org for information.

• Want to view past issues? All content is archived online at emergencybestpractices.com. Access is available to subscribers and NEMSMA members with a special login.

• Need help? For membership questions or assistance accessing the website and archives, contact Melissa Dalton at mdalton@redflashgroup.com or call 760-632-8280, ext. 230.

• Smaller really is better. For your convenience, BP uses a service called “tinyURL,” which creates short aliases for long or complicated website addresses. They take you to the same place—but with less typing! (And, as always, all links in all articles are active on our website; simply click on one and you’ll be taken directly to the website in question.)

8 Vis i t emergencybestpract ices.com for quick access to a l l web l inks l isted in each issue. May 2014 9

BP InterviewHEMS safety, continued from front page LaCroix, continued from page 5

height above the ground, used to help during hovering, landings and flying in bad weather; and helicop-ter terrain awareness and warning systems, used to help maintain awareness of terrain and obstacles

• Require that pilots are tested to handle flat-light, whiteout and brownout conditions

• Equip helicopters with a flight data monitoring system within four years

• Establish operations control centers if they operate 10 or more air ambulances

• Institute pre-flight risk-analysis programs

• Ensure that pilots in command hold an instrument rating, or the ability to fly using instruments rather than sight

• Ensure that pilots identify and document the highest obstacle along the planned route before departure

• Comply with visual flight rules (VFR) weather minimums, instru-ment flight rules (IFR) operations at airports/heliports without weather reporting, procedures for VFR ap-proaches and VFR flight planning

• Conduct safety briefings or training for medical personnel

According to the FAA, 2008 was the deadliest year for helicopter accidents, with 21 deaths occurring in five crashes. The FAA estimates the new requirements will cost the air medical industry an esti-mated $224 million over 10 years.

Read the FAA’s news release at tinyurl.com/kztwude. Scroll down to view a link to the complete rule.

WHITE PAPER CALLS FOR EXPANDED EMS ROLE

A group of EMS physicians from AMR, MedStar Mobile Health Services, Wake County EMS and colleagues recently published a white paper urging support for mobile integrated healthcare practice (MIHP). The white paper reports that when associated with EMS, these types of programs are often referred to as “com-

munity paramedicine.” But that term is too confining, according to the authors, because it focuses on defining new roles for paramedics and EMTs instead of con-sidering the full range of potential mobile integrated healthcare assets.

Even so, EMS systems and person-nel are “uniquely positioned to support MIHP,” according to the authors.

The white paper, “Mobile Integrated Healthcare Practice: A Healthcare De-livery Strategy to Improve Access, Out-comes, and Value,” was supported by a grant from the Medtronic Foundation to the AMR Foundation for Research and Education. Read it at tinyurl.com/m78bz5l.

JOIN THE CPR CHALLENGE

Imagine a local park on a beautiful May day. Joggers make their way along run-ning trails and families spread picnic blankets beneath the kite-dotted sky. Someone strums a guitar.

This peaceful scene is interrupted by the wail of sirens as several emergency vehicles enter the parking lot. But this is no ordinary response: As the first re-sponders step out of their vehicles, a disco beat emanates from a boom box, and the bystanders quickly recognize the tune: “Stayin’ Alive.” Before the Bee Gees get to the part about the New York Times’ effect on man, responders have set up a mannequin on the grass and begun doing CPR. More mannequins are deployed as the crowd grows, and the responders invite onlookers to take a turn doing chest compressions.

What’s going on here? It’s part of the AMR World CPR Challenge. Spon-sored by American Medical Response, this year’s event will take place May 21 across the United States and overseas, in locations ranging from public parks to schools, beaches, shopping malls and more. Last year, more than 54,000 people were trained in compression-only CPR; this year’s goal is to teach tens of thou-sands more people how to save a life and make their community safer.

For more information on how you

can get involved, visit facebook.com/AMRCPRCommunity.

EMS WEEK GOES TO COLLEGE

Lauren Chavis, an EMT and senior at Johns Hopkins University, volunteers 24 hours a week as EMS operations director for her campus EMS service, Hopkins Emergency Response Organization. Although she’s thinking of going to law school, Chavis says working in EMS has given her experience in leadership and handling difficult situations she couldn’t find anywhere else.

“In EMS, you can do good while at college, not in an abstract way, but in a very real way, where you’re helping real people in real time,” she says.

Chavis is one of hundreds of U.S. and Canadian college students who participated in 2013’s Collegiate EMS Week, which is modeled after the national version of EMS Week but is held during the second week of November to accom-modate college schedules. (In May, many students are either taking final exams or on summer break.)

Sponsored by the National Colle-giate EMS Foundation and the Ameri-can College of Emergency Physicians, Collegiate EMS Week is endorsed by Congress. It is a weeklong recognition of campus-based EMS—a time for those organizations to publicize their services and educate their communities. The week kicks off with National Collegiate CPR Day, which focuses on training fellow stu-dents and faculty in CPR. Other activities can include open houses, blood drives co-ordinated with local Red Cross chapters, local or campus media ride-alongs, joint training with other local EMS or fire agen-cies, and dorm safety events.

At Johns Hopkins, volunteers for the BLS ambulance service taught hands-only CPR to more than 50 people in the quad and created a hands-only CPR video that was shown on monitors in university buildings. Set to heart-thumping music and depicting the sudden collapse of a young male student, the video has re-ceived more than 700 views on YouTube.

Quick Look

In Houston, volunteers for Rice University EMS offered free blood pressure checks, taught hands-only CPR in the quad and held a special AED and CPR training session for employees in a campus building where a woman had recently died from sudden cardiac arrest.

“Celebrating Collegiate EMS Week lets the members of the orga-nization know how much they do and how appreciated they are,” says Rice’s Patrick McCarthy, an EMT majoring in biochemistry and cell biology and captain of a team of 70 campus EMTs who answered about 750 calls for service last year. “It also raises general awareness among the student body, the faculty and the community about our capabilities, how much time we put in and how dedicated the personnel in the orga-nization are.”

The National Collegiate EMS Foundation was founded at George-town University in 1993, when the Internet made it easier for campus rescue squads from around the country to connect with one another about ideas and challenges. Since then, the organization has grown to include nearly 250 campus EMS groups in 41 U.S. states and four Canadian provinces, collectively handling more than 90,000 responses annually. Their annual conference draws nearly 1,000 students for lectures, skills labs and roundtable discussions.

Check out the Hopkins Emer-gency Response Organization video at tinyurl.com/kcdemmr.

he or she affects patient care, but it isn’t so easy for a janitor or a mechanic. But if you ask Arthur, one of our janitors, he can tell you exactly how important his job is and how he impacts our patients. The neat thing about Arthur: Our EMTs and medics see him talking about it, and it only reinforces their line of sight. It seeps into people’s pores around here.

I’m really proud of the fact that 15% of our workforce has worked here 20 years or more. Sure, they’ll tell you there are days when it’s tough to come to work, but this is as good a place to do that hard work as anywhere.

Q In your opinion, what are the greatest challenges facing EMS

provider agencies today?The first one is increased violence against providers. Across the board, we’re living in a culture of increased violence, and by the very nature of the work we do, EMS providers are in the midst of that on a regular basis. We’re seeing this even in rural areas, where there is an increased use of opioids, particularly heroin.

The second challenge is being able to attract and keep job candidates. We

need to work hard to provide continuing education that is relevant and meaningful so people stay on the job and stay engaged and motivated. We also need to be able to pay them a good living wage.

Finances for EMS is always on this list. It’s very challenging to run an EMS organization and provide good wages when nothing gets cheaper.

Lastly, we need to figure out how we can speak with one voice as a profession and not get fractured by our tax status (firefighter, municipal, private, etc.). We are often our own worst enemy in this regard. There’s an ever-shrinking platform of resources, and we need to figure out how to work as one or we’ll all pay the price.

Q What are some first good steps for an EMS leader wanting to

improve his or her organization?First of all, look outside our profession. If you have come up through the ranks of EMS and only know EMS practices and processes, it can be a big eye opener to look at processes and systems through a different lens. Look at leaders in the hospitality industry for how they deliver customer service. Take a look at FedEx for how they run their delivery service. When it comes to employee engagement and job satisfaction, what’s the best place and what are they doing? Take your myopic blinders off and try to find an industry that’s not involved in healthcare.

Most importantly, stay close to pa-tients. If you really want to know how to be a good EMS operation, ask your pa-tients what matters to them. It’s an obvious but often overlooked way of delivering top-notch patient care.

— Carole Anderson Lucia

“Yes, we want to take good care of our employees, but at the other end of the spectrum is the business case for wellness: Burnout, or employees who are not in a good place emotionally or physically hurt patient care, hurt job satisfaction and hurt the bottom line.”

— Brian LaCroix

10 Vis i t emergencybestpract ices.com for quick access to a l l web l inks l isted in each issue. May 2014 11

BEYOND THE LONE RANGER: GREAT TEAMSBy John Becknell

Most of us agree that the Lone Ranger, I-can-do-it-all-myself cowboy paramedic has no place in the team environment of the emergency scene. But we may be less likely to let go of the Lone Ranger mystique when it comes to leadership.

We love the myth of the lone leader. We illustrate our or-ganizational structures with charts topped by a single leader and we admire pictures of Presidents Roosevelt, Truman and Johnson sitting alone in their war rooms with pained expressions of heavy responsibility. We’re often told, It’s lonely at the top, and The buck stops here. And indeed, the lone leader often carries the brunt of criticism when things go wrong (whether or not that criticism is deserved). When things go right, it is also the solo leader who often gets praised. Michelangelo painted the Sistine Chapel, Henry Ford created the assembly line, Ronald Reagan ended the Cold War and Bill Gates built Microsoft. And so on.

Yet when taking a closer look at big accomplishments, we don’t find lone leaders—we find great groups and teams. Mi-chelangelo’s ceiling was not a solo act but actually the work of 14 artists and a crew of more than 200. The Manhattan Project, the polio vaccine, the first manned flight to the moon, the Disney studio, Xerox’s Palo Alto Research Center and the Human Genome Project were all the accomplishments of great teams.

“We have to recognize a new paradigm,” writes leadership scholar Warren Bennis, “not great leaders alone, but great leaders who exist in a fertile relationship with great groups.” When senior executives of international corporations were recently asked by The Economist who will be most influential in the coming years, a majority answered “teams of leaders.” We live in a time when change, information and technology are all speeding faster than one person alone can keep up with. “One is too small a number to produce greatness,” Bennis adds.

But great groups and teams don’t just happen. In my work, I’ve noticed that great groups and teams emerge from a very specific set of leader beliefs, attitudes and actions.

First, great teams emerge when leaders bridle their ego and let go of the need to be the lone answer person and decider. They admit they don’t have the answers and actively recruit others’ input about vision, direction and next steps. These leaders don’t worry about someone taking their job, actively recruiting people better than themselves. They’re not afraid that smart, successful hard-chargers will eclipse them; instead, they go looking for the best talent internally and from other organizations.

Second, great teams emerge when leaders call them to a big, hairy, audacious vision and mission. I’m not talking about a flowery mission statement, but about something that gets the juices flowing. No matter how the vision ranks in the scope of the world, the team believes it is doing something vitally impor-tant and worthy of all its effort and energy. When creating the Macintosh computer, Steve Jobs inspired his team by promising they were creating something “insanely great.” Leaders galvanize the group by infusing deep meaning in the work.

Third, team-building leaders trust the team and allow great latitude in how the work gets done. They give the members what they need and then let them loose. In so doing, they inspire great trust and loyalty and make room for the tinkering trial-and-error processes that often accompany great accomplishments. In these groups, failures are expected and viewed as necessary lessons.

Watching these groups work can be fascinating. I recently watched a team at a large EMS company wrestle with balancing the management workload with continued growth. What stood out was the level of productive disagreement and candor that accompanied the group. Arguments were filled with passion, and people wanted to stay late and get things done.

Even though the members of this group were clearly working harder than anyone else in the company, I doubt they regret the sacrifice. Doing something in collaboration with others is a heady experience that releases creativity and talent in a way that working alone does not.

John Becknell, Ph.D., is the founding publisher of Best Practices. He is a consultant, co-director of the EMS Leadership Academy and a partner at SafeTech Solutions, LLP (safetechsolutions.us).

Ruminations

July 21–25, Westin Kierland Resort, Scottsdale, ArizonaBest Practices is a proud supporter of the Pinnacle EMS Leadership Forum, a unique meeting experience for leaders and managers from every type and size of service. Connect with experts at the leading edge

of EMS to understand new leadership ideas and advanced operational practices. To sign up for updates and for more information, go to pinnacle-ems.com.

12 Vis i t emergencybestpract ices.com for quick access to a l l web l inks l isted in each issue.