Bringing about system change

[Jambi]

This will deal with American EMS, but all opinions, thoughts, and suggestions are welcome.

My question is how do we go about changing our EMS systems for the better. By this, I'm speaking of better accountability, training, QA/QI, and consistency.

What sparked this delusion of grandeur was a post by SpecialK in the RSI thread in the ALS forum.

RSI is available to approximately 40-50 of our 300 Intensive Care Paramedics.

They are selected based upon competence at a three part selection process involving

(1) endorsement from their District Operations Manager stating they believe the Officer has ability to pass,
(2) an hour long online exam testing knowledge of the Clinical Practice Guidelines, pharmacology (all medicines within ALS scope), core anatomy and physiology and core pathophysiology, and
(3) a number of assessment stations around assessment, patient management, leadership, clinical decision making and airway/ventilation/failed intubation management; specifically
(a) Simulation – Each person will be a team leader for a scenario involving a critical patient. These scenarios are not particular to RSI, but test ALS skills, knowledge and decision making,
(b) Mini simulation – Each person will be given a scenario with a patient that is not obviously time critical. These will test assessment, differential diagnosis and decision making, and
(c) OSCEs – Each person will undergo about six short skill and/or knowledge assessments (referred to as OSCEs). These will last 5-10 minutes each and are not scenario based. Examples of these OSCEs could include demonstrating a failed intubation drill, cricothyroidotomy, or answering some questions relating to capnography.

If the Officer is successful at all components they are placed on the RSI course which is a learning package consisting of online workshops and some material on DVD plus practical. It has been designed by the Clinical Director who is an Anaesthetist/Intensivist supported by the National Medical Advisor who is an Emergency Physician.

Each RSI or potential RSI must be debriefed with the Clinical Director or Medical Advisor.

Indication for RSI is GCS < 10 with airway or ventilatory compromise and most patients will either have traumatic brain injury or be post-cardiac arrest but others can be stroke, poisoning, DKA (noting a significantly altered level of consciousness with somebody who has DKA is very unlikely), postictal or status epilepticus etc.

Medicine regimen is fentanyl and either midazolam or ketamine and suxamethonium. Post-intubation regimen is vecuronium, morphine and midazolam. There is talk of moving to rocuronium only in 2014.

There is a limit of two attempts and you must be able to visualise vocal cords within 15 seconds of beginning laryngoscopy and intubate within 30 seconds. A bougie is mandatory. Failed intubations are salvaged with an LMA.

To date we have performed over 500 RSI with (my understanding) no surgical airway and near 98% success rate.

RSI can be done properly and safely in Paramedic hands provided it is a small, highly trained and very select group who get adequate ongoing exposure.

These places that just tube people by shovelling midazolam into their drip until they are obtunded enough to accept a tube or just etomidate people into submission should be tried for crimes against humanity.

I know the barriers to excellence have been discussed numerous times here, and many have said that American EMS is hopeless because of many external factors with their genesis being paramedic education (vocational training really) that refuses to advance into the changing world and its needs, and other external factors that benefit from easy training (cost) and limited accountability (non-transport first response fire).

There are also other issues at play. It's hard to motivate someone to advance into the future when they're making $15/hr and having to work 70 hours a week just to pay bills.

I also understand there are some obvious stuff like, "get more involved, etc.," but this is also akin to what to study and being told, "the book."

And honestly, I don't know where to start, what strategies to use, or even how to advocate such things, but there is desire.

So shoot away and let's discuss strategy. I'd love to hear from some physicians on how this would affect them (QA/QI. etc., it all takes time after all)

 

[Bullets]

Bludgeon people with evidence. Its how we adopted a pretty progressive RLS response policy and our new SMR policy

Work locally, improve your system. This may not work in profit driven IFTs and private companies but in municipal 911 systems where the system is usually funded via tax money or (dare i say it) fire departments they may be more open to change. This is how i was able to get my service to amend our SMR policy. After presenting our leadership with multiple studies as well as the Yale-New Haven policy, the NAEMSP/ACS position paper, we have adopted the YNH policy. Our medical director liked it and sent it up the the BLS subcommittee for hopeful adoption statewide

 

[Clipper1]

There are also other issues at play. It's hard to motivate someone to advance into the future when they're making $15/hr and having to work 70 hours a week just to pay bills.

I doubt if it is fair to compare Australia to the US.

Why would the US Paramedic want to spend more time on education when most of them can do every skill the ICP can in Australia and with less than 1/4 the education and a lot less than 1/4 the training in clinical hours?

 

[Jambi]

I doubt if it is fair to compare Australia to the US.

Why would the US Paramedic want to spend more time on education when most of them can do every skill the ICP can in Australia and with less than 1/4 the education and a lot less than 1/4 the training in clinical hours?

Which is the heart of the matter I think. We shouldn't necessarily be doing all these things without more education, training, and follow up...it's just no one wants to foot the bill for it.

I think it really has to have it's genesis with training programs transitioning into educational degree programs.

I know it's more complex than this, and the EMS ecosystem will respond in many different ways, but it's where it's got to start.

 

[Clipper1]

I looked at the price of some private Paramedic sshools lasting 6 - 8 months which cost $12 - $22k. That is 2 - 3x more than a 2 year degree in some states. Some EMT 110 hour programs are well over $3k especially if they are 3 - 6 weeks. So, I don't think it is the money but rather the length of time "to an EXCITING career" as the comercials and websites promise. The sirens blaring and flashing lights on those ads probably snag a lot of youngsters to sign for huge loans whereas a college could help them with grants. But, the degree approach would take at least 2 years rather than a few months.

 

[Hunter]

I had a conversation with someone about a topic somewhat similar to this and we can't to this conclusion; in EMS you have two kinds of people, not everyone falls into one of these two but this is the majority of them.

The young and excited guy who has a bunch of ideas to improve the system, they wanna make things better and truly live the career. These guys get shot down at every suggestion, eventually transition either into the casual worker or leave EMS all together because they want a profession and end up feeling like EMS will never be that.

The casual worker,skills vary within this group, passion does too but the bottom line for them is, they wanna do a job, go home, and don't really care about the system. Usually people who are near the end of their career who don't want to create waves or get on management's bad side. These are the people who could have the biggest effect since they have tenure, but they don't want to put their pensions/retirement at risk.

 

[EpiEMS]

So, I don't think it is the money but rather the length of time "to an EXCITING career" as the comercials and websites promise.

Quoted for truth: it's the "one semester wonder," or "zero to hero" in three months appeal that keeps EMS from being where it should be. Not that I'm actively helping, I suppose.

 

[Wes]

Let's also recognize that, whether or not college credits are awarded, EMS education is higher education. In my experience, EMS initial education is one of the few education programs where, someone somewhere will accept anyone who pays for the class. We need to have some standards for initial entry into education. I remember a classmate in my paramedic class who had never taken high school biology. When we were doing basic anatomy and physiology in the class, he had the "deer in the headlights" look the entire time. Within a week, he dropped out of paramedic school. That served no one other than the private ambulance service offering the paramedic class that cashed his check anyways.

As for "zero to hero" classes, I still think there is a limited place for them for people entering EMS who already have a solid educational foundation (IE, a bachelor's degree or higher) and just need their EMS education.

 

[Clipper1]

Let's also recognize that, whether or not college credits are awarded, EMS education is higher education.

EMS is considered a trade and is largely done in tech schools with hours of training as the standard rather than being measured in college credit hours. Tech schools do not have the expectation that you had a 4.0 high school record or that you took college prep courses. It is meant for easy entry to learn a trade.

 

[Wes]

Isn't that a huge chunk of the problem? <_<

 

[46Young]

This will deal with American EMS, but all opinions, thoughts, and suggestions are welcome.

My question is how do we go about changing our EMS systems for the better. By this, I'm speaking of better accountability, training, QA/QI, and consistency.

What sparked this delusion of grandeur was a post by SpecialK in the RSI thread in the ALS forum.


I know the barriers to excellence have been discussed numerous times here, and many have said that American EMS is hopeless because of many external factors with their genesis being paramedic education (vocational training really) that refuses to advance into the changing world and its needs, and other external factors that benefit from easy training (cost) and limited accountability (non-transport first response fire).

There are also other issues at play. It's hard to motivate someone to advance into the future when they're making $15/hr and having to work 70 hours a week just to pay bills.

I also understand there are some obvious stuff like, "get more involved, etc.," but this is also akin to what to study and being told, "the book."

And honestly, I don't know where to start, what strategies to use, or even how to advocate such things, but there is desire.

So shoot away and let's discuss strategy. I'd love to hear from some physicians on how this would affect them (QA/QI. etc., it all takes time after all)

I'm fortunate to have worked in different types of systems: Hospital based 911/IFT in NYC, Muncipal Third Service in South Carolina, and Fire Based dual role in Virginia.

In NY, the IFT side was well funded and fairly progressive. 911 was regressive - mother may I protocols, you have to call for permission to merge/jump protocols, OLMC options are limited to choices listed in the protocol, and equipment is incosistent between the agencies. For example, FDNY buses didn't have CPAP. I feel that significant change is unlikely due to the numerous 911 participating hospitals/companies (no uniform standard for providers) and FDNY, and politics.

The third service provider was somewhat progressive with equipment and protocols, but the working conditions were less than optimal.

The dual role job is interesting - at first, the protocols were dated, providers had inconsistent proficiency, accountability, and motivation to improve vs doing the bare minimum to stay out oof trouble. The decision makers seemed to be old school and set in their ways. What I've seen over the past five years is a fair amount of new ff/medics coming in with degrees and single role EMS experience, and more forward thinking officers and chiefs with ALS experience being promoted into positions of influence. I've seen our protocols become more liberal and are now fluid guidelines. There is much improved accountability with QA/QI, recert, and initial EMS internships. We've let go of a few new hires that failed internship, and aalso failed incumbents that couldn't pass internship following an ALS upgrade course. New equipment/procedures include the Lucas, EZ-IO, field cric and quick trache, King Vision ETI equipment,IN meds, qua titative ETCO2, and many other things.

The interesting thing is that none of these employers have required degrees for hiring, only foe promotion (the dual role fire job).

I see the only way for significant change to occur is for younger, forward thinking individuals tto promote into positions of influence. Otherwise, politics and close-minded decision makers will keep things status quo.

 

[46Young]

I had a conversation with someone about a topic somewhat similar to this and we can't to this conclusion; in EMS you have two kinds of people, not everyone falls into one of these two but this is the majority of them.

The young and excited guy who has a bunch of ideas to improve the system, they wanna make things better and truly live the career. These guys get shot down at every suggestion, eventually transition either into the casual worker or leave EMS all together because they want a profession and end up feeling like EMS will never be that.

The casual worker,skills vary within this group, passion does too but the bottom line for them is, they wanna do a job, go home, and don't really care about the system. Usually people who are near the end of their career who don't want to create waves or get on management's bad side. These are the people who could have the biggest effect since they have tenure, but they don't want to put their pensions/retirement at risk.

I find your viewpoint interesting. I've transitioned from the first example to the second example, and now back to the first. This is due to working for a dated, restrictive system (NYC), being overworked and worn out (third service), and starting out in a dual role fire job with poor provider morale and also a restrictive system (but much better tha FDNY, even then), that has changed for the better (see my above post).

 

[46Young]

I looked at the price of some private Paramedic sshools lasting 6 - 8 months which cost $12 - $22k. That is 2 - 3x more than a 2 year degree in some states. Some EMT 110 hour programs are well over $3k especially if they are 3 - 6 weeks. So, I don't think it is the money but rather the length of time "to an EXCITING career" as the comercials and websites promise. The sirens blaring and flashing lights on those ads probably snag a lot of youngsters to sign for huge loans whereas a college could help them with grants. But, the degree approach would take at least 2 years rather than a few months.

Damn, that's rough! In 2002, my EMT original cost $500. In 2004-2005, medic original cost $6, 000. That was in NYC, where the prices should be inflated.

 

[46Young]

Let's also recognize that, whether or not college credits are awarded, EMS education is higher education. In my experience, EMS initial education is one of the few education programs where, someone somewhere will accept anyone who pays for the class. We need to have some standards for initial entry into education. I remember a classmate in my paramedic class who had never taken high school biology. When we were doing basic anatomy and physiology in the class, he had the "deer in the headlights" look the entire time. Within a week, he dropped out of paramedic school. That served no one other than the private ambulance service offering the paramedic class that cashed his check anyways.

As for "zero to hero" classes, I still think there is a limited place for them for people entering EMS who already have a solid educational foundation (IE, a bachelor's degree or higher) and just need their EMS education.

EMS isn't the only field that employs vocational education, but offers degrees. You can get an AAS in automotive, but not need it to get hired, and it's the same for a number of IT jobs.

For EMS many of these vocational schools are privately run, and profit is the motivation, so filling the empty seats is the priority. If the student is ill suited for EMS, they'll just fail out but still have to pay the school up to that point.

 

[46Young]

Isn't that a huge chunk of the problem? <_<

Yes, and the other side of the problem is that employers don't want to pay more for degreed providers, and students don't want to spend more more money and time for a degree when a cert alone is just as good. Field experience and a valid cert is still king in this field where hiring is concerned.

 

[Jambi]

Yes, and the other side of the problem is that employers don't want to pay more for degreed providers, and students don't want to spend more more money and time for a degree when a cert alone is just as good. Field experience and a valid cert is still king in this field where hiring is concerned.

Yes, but I believe it was the same way with nursing too, but nursing decided to up the anty, and now as least an AA/AS is required typically, and the BSN is much more standard.

I think moving to a degreed profession is the next step, but it's going to have to come at a national level. The NREMT is slowly making steps with it requiring accreditation for students to be eligible to sit for the NREMT exams. Granted, all states don't require NREMT for initial and/or continued licensure or certification, but I don't see any other way to go about halting the inertia of the "old guard."

I think it will happen, and 46Young summarized why I think it will come to pass.

I see the only way for significant change to occur is for younger, forward thinking individuals tto promote into positions of influence. Otherwise, politics and close-minded decision makers will keep things status quo.

I believe that as providers and as a vocation trying to become a profession, we must be the first to take the steps. To use pay as a point: Paramedics will not be paid more in the hope his or her training, education, proficiency, and capacity will improve, but rather those variables must change first. Those of us that wish to be professionals must be first willing to take up the mantle. It cannot be granted. It must be earned, and we must take the first steps.