# Most Aggressive/Progressive EMS Systems



## foreverbound (Dec 8, 2012)

What are some of the most advanced, progressive, and overall best EMS systems in the nation?

We've all heard about KCM1, Boston, etc. What are some other ones? I know here in Texas that ATCEMS, Williamson County, and Wise County are considered pretty top notch. 

With these systems...anybody have idea on education requirements or length of training?

What are some of the progressive EMS treatments and technologies that are being used in these systems? I think we know RSI and field hypothermia are "normal" things found in advanced systems. What about field ultrasound and glidescope use? Any EMS systems use propofol for continued anesthesia post intubation? Examples of aggressive analgesia protocols (here, there is no limit on pain management provided patient is stable)? Field ventilators? Plavix and heparin protocols for STEMIs? 

I'm curious to find out what others are doing that is laying down the road to better and more advanced EMS care.

All thoughts/comments/opinions are welcome! This is a great forum.


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## rwik123 (Dec 8, 2012)

Was listening to a podcast where some medics in Arizona in rural areas are using ultrasound and I-STAT. I'll have to look it up when I'm not on my phone.


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## mycrofft (Dec 8, 2012)

The Rural versus Urban paradox rises from it's box:
Long response and transit times and scarce care make rural/frontier care more appropriate as an aggressive advanced care setting, but they lack resources (including human) and money.

Urban settings get "Mobile ICU" 's ( I kid you not; Creighton in Omaha almost got a BOAT), but short response and transit times make it less valuable there.


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## Amberlamps916 (Dec 8, 2012)

In terms of California, I would say most progressive would have to be Kern County. Least progressive would be a tie between LA/Orange County. That's just my humble opinion.


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## RocketMedic (Dec 8, 2012)

Addrobo87 said:


> In terms of California, I would say most progressive would have to be Kern County. Least progressive would be a tie between LA/Orange County. That's just my humble opinion.



Liberty out in Ridgecrest/Lake Isabella has some _insane_ transport times and there's a lot of people out in the middle of nowhere. Them and Hall are the only places in California I'd consider moving back for.


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## medicsb (Dec 8, 2012)

First, define "progressive".   Everyone throws the terms around, but no one seems to define what they mean.  

To me (note: this is a rather loose collection of characteristics that i'd use to define the term and is not definitive for myself), it would be any system engaged in research and is willing to change its practice based on data they have collected on themselves or data from other places that can be applied to their own system.  A progressive system would also use the best available evidence to guide their practice and would use more than hunches or anecdote (as in, not implement the use of any device, drug, or procedure without having some evidence of improved efficacy, safety, and/or M&M).  A progressive system knows where its been, where it is, and where it would like to go and is willing to do the work to get there.  A progressive system is flexible in terms of ability to respond to calls.  A progressive system makes good use of its resources.  A progressive system values its employees and their health... Anyhow, I could probably go on all day.

For me, no system meets all of the above.  Many systems may be progressive in some aspects, but regressive in others.  I tend to find it easier to identify the systems that are definitely not progressive.


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## triemal04 (Dec 8, 2012)

Fancy toys, medications and procedures don't make a progressive system.  It may make people puff out their chest's and boast, but it doesn't mean a damn thing.

The glidescope is a perfect example (and pet peeve of mine).  Using direct laryngoscopy and using the glidescope (or any other type of video device or adjunct) are two different things; knowing how to use one doesn't mean you know how to use the other.  And the glidescope, just like DL, has a learning curve to it, and after gaining proficiency requires regular use to stay proficient.  I wouldn't automatically call a service that puts a Glidescope (or any other device meant to make things easier/simpler "regressive," but unless people are actually taught how to use that device, tested on their training, and required to maintain it, then it's not a stretch.  What would be progressive would be a service that actually requires their paramedics to know how to intubate, sends them for more initial training as needed, and then through either field intubations, time in the OR with an anesthesiologist throughout the year, or a combo of both, has them intubate enough people each year to maintain their skills.  THAT'S progressive.

Having something available doesn't make you progressive.  Knowing what to do with what you have, when to use it, how to do so successfully and appropriately and being correct in your decisions leading up to it's use and after...that makes you progressive.


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## NomadicMedic (Dec 8, 2012)

If your intubation example is a true measure of how progressive a department is, then Sussex County meets that criteria. I tend to agree with the other post that said "a department needs to know where it's been, where it is now and where it's going… And them make efforts to get there".

I would say in some cases my department, Sussex County EMS, is very progressive. In others… stagnant.

The measure of a progressive department is very subjective. To define progressive you need to come up with your own list of benchmarks and then find the departments that meet or exceed those. What I find progressive may be old hat to somebody else.


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## triemal04 (Dec 8, 2012)

n7lxi said:


> If your intubation example is a true measure of how progressive a department is, then Sussex County meets that criteria. I tend to agree with the other post that said "a department needs to know where it's been, where it is now and where it's going… And them make efforts to get there".
> 
> I would say in some cases my department, Sussex County EMS, is very progressive. In others… stagnant.
> 
> The measure of a progressive department is very subjective. To define progressive you need to come up with your own list of benchmarks and then find the departments that meet or exceed those. What I find progressive may be old hat to somebody else.


I think it's almost entirely subjective, and like being "the best," a particular place might be thought of as progressive in one area, but not in another.  I'll gaurentee that Sussex isn't the only service like that.  

My example was not (to me at least) a true measure of what makes a progressive service.  Clinical skills and procedures are only one part; people seem to get caught up on what people CAN do whenever this topic comes up and ignore that there are multiple areas that should be considered, as well as ignore the fact that simply being able to do something isn't always good.

medicsb said it; a place that actually looks at what they do, studies the results, compares them to other results, and then based off of that makes an informed decision about what they should be doing instead of jumping on the latest fad...and is willing to make those changes as needed...that would be a good start.


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## NomadicMedic (Dec 8, 2012)

I think getting caught up in the "I can do these clinical skills" shuffle is really a bad idea when judging a service, although that seems to be the benchmark that most judge by. What I was referring to in my last post was the fact that we practice RSI, have an extensive and sometimes exhaustive QI process, send our medics to the OR frequently to practice intubation and we intubate enough people that our skills stay sharp. That's the mark of a service that both practices progressive skills and assures success from the medics by providing additional training and QI.

But let's look at another example. My service doesn't allow providers to work more than 18 hours in a patient contact role. Many services still allow medics to work 24s or 48's. We believe that patient care suffers the longer the medic works without rest. Because of this, we pay more overtime when somebody calls out sick. Is this progressive? Compared to the services that I've worked at in the past, yes.

Case reviews. Every month at our continuing education sessions two medics from each shift are required to present case reviews. They don't have to be calls that went bad, they just have to have a teaching point. Progressive? Sure. In most cases the only time a paramedic presents a case review is when he's getting his *** nailed to the wall for something that he did wrong or there was a bad outcome. 

So, I guess the benchmarks that I would use to judge a progressive service may differ from yours. I don't care about medications… Or clinical skills. I care about the service's view and growth in providing positive patient care experiences and continuing education and growth for the staff.


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## triemal04 (Dec 8, 2012)

That's exactly my point.  There is much more that goes into making a system "progressive" than what you can do, administer or carry.

Simply looking at what procedures are done, which meds are given and what equipment is used as the sole criteria for making a decision is flat out wrong.  If it's taken into consideration as part of the overall outlook that's one thing, but even then more needs to be looked at beyond "I can do this so we're awesome" before it should hold any weight.  



> Having something available doesn't make you progressive. Knowing what to do with what you have, when to use it, how to do so successfully and appropriately and being correct in your decisions leading up to it's use and after...that makes you progressive.


If you don't factor in the above and much more then there is no point in even thinking about clinical skills.  And regardless, like I said in my first post, fancy toys, medications and procedures don't make a progressive system.  If you can't look beyond that at the system as a whole, then it's pointless.


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## Clare (Dec 8, 2012)

I am not sure what you mean by "progressive" or "aggressive" but I think the way things are done here is very good and is sensible, but then again I do not have a lot of experience to compare it to.

Paramedics are now required to have a Degree and Intensive Care Paramedics need a Post Graduate Diploma.  Every two years something clinically new is introduced, whether its changing which level a medicine or procedure is at or introducing a new medicine or piece of equipment such as ceftriaxone, giving Paramedics midazolam for seizures, or introducing the combi carrier to replace the old metal scoops.  I have a feeling from 2013 that we will be getting automatic ventilators and thrombolysis.  

There is lots of freedom around how to treat people and as long as what you do is sensible and within your delegated scope of practice then you are pretty much free to do it.  Clinical judgement is very important and given lots of attention, guidelines are just that, a guideline, and a favourite saying of one of my mentors is "patients do not read textbooks" so you really have to have your thinking cap on and use your tools wisely.

We can leave people at home, refer them elsewhere, send a single responder and lots of things.  We are told basically to see a patient, determine what they need and how best to get it and refer them there, if necessary by taking them there.  Only about 70% of patients are transported to hospital.  Looking to the future there is now a big change to how 111 calls are dealt with where the less urgent/minor stuff isn't sent an ambulance but put through to the phone nurses or sent a single response in a car.  

The Clinical Development Team, Medical Director and Medical Advisors work really hard on ensuring that the care provided to patients is very high quality.  Since a couple of years ago everybody must now do 40 hours of CCE per year and there have been lots of different modules on things like airway, patient handover, shock, referral decision making, communication, history taking, all sorts of things.

I think things are really good, but I don't know, maybe somewhere else is better.


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## rescue1 (Dec 8, 2012)

Clare said:


> There is lots of freedom around how to treat people and as long as what you do is sensible and within your delegated scope of practice then you are pretty much free to do it.  Clinical judgement is very important and given lots of attention, guidelines are just that, a guideline, and a favourite saying of one of my mentors is "patients do not read textbooks" so you really have to have your thinking cap on and use your tools wisely.



Just out of curiosity, what is the malpractice/liability like in Australia? Since in the states EMS operates under fairly rigid protocols, there is a decent amount of protection for EMS if they follow them, even if following them led to the injury to the patient. If an ambulance officer in Oz makes a clinical desicion that has a less then steller outcome, could they be legally liable for it?


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## Clare (Dec 8, 2012)

rescue1 said:


> Just out of curiosity, what is the malpractice/liability like in Australia? Since in the states EMS operates under fairly rigid protocols, there is a decent amount of protection for EMS if they follow them, even if following them led to the injury to the patient. If an ambulance officer in Oz makes a clinical desicion that has a less then steller outcome, could they be legally liable for it?



Not being in Australia I would not know but I imagine it is similar to here in NZ.

In New Zealand if you do something and it causes harm to the patient then it goes to the Accident Compensation Corporation (Government accident insurance) and they will pay out for a "medical misadventure" and you get whatever you need free of charge, like treatment or rehab or physio or modifications to your car or house or job or whatever.

The patient can complain to the Health and Disability Commissioner and if you are found to be in breach of the Code of Rights that patients have (in this case, the reasonable care and skill or reasonable standard of care or such similar name) then you can be referred for like civil liability in court but such is so extremely rare its not funny and it has never happened to a Paramedic.  

You cannot be privately sued in New Zealand for medical misadventure type stuff because we have ACC and we gave up the right to sue for medical costs etc when we got ACC.  I don't really know about being privately sued but for other things like everyday stuff it is next to impossible so I imagine that it would just never get off of the ground because of the ACC system.  

The Ambulance Service can be found vicariously liable for your stuff up if they  did not reasonable steps to ensure it didn't happen but again its so unlikely to happen, I am more likely to get beamed up by aliens or something.

In short you are simply never going to be sued because its just so hard and the system has other ways of finding a resolution.

Last year the ambulance service treated and/or transported nearly 400,000 patients; for every 1,000 people they received less than 2 complaints.


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## rescue1 (Dec 8, 2012)

Clare said:


> Not being in Australia I would not know but I imagine it is similar to here in NZ.


Well, that's embarrassing. This is why I'm switching out of night shift.



Clare said:


> In New Zealand if you do something and it causes harm to the patient then it goes to the Accident Compensation Corporation (Government accident insurance) and they will pay out for a "medical misadventure" and you get whatever you need free of charge, like treatment or rehab or physio or modifications to your car or house or job or whatever.
> 
> The patient can complain to the Health and Disability Commissioner and if you are found to be in breach of the Code of Rights that patients have (in this case, the reasonable care and skill or reasonable standard of care or such similar name) then you can be referred for like civil liability in court but such is so extremely rare its not funny and it has never happened to a Paramedic.
> 
> ...



That's good to hear. I'm jealous of NZ (and Australia's, maybe) protocols when it comes to provider freedom and clinical discretion.


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## Clare (Dec 8, 2012)

rescue1 said:


> Well, that's embarrassing. This is why I'm switching out of night shift.



Don't worry about it mate 



rescue1 said:


> I'm jealous of NZ (and Australia's, maybe) protocols when it comes to provider freedom and clinical discretion.



I don't have anything to hand to compare it to but I think what we do here makes sense.  Written guidance cannot possibly cover every situation and those treating the patient I think are best positioned to know what their individual patient needs so why shouldn't they be able to give it or whatever?


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## rescue1 (Dec 8, 2012)

Clare said:


> I don't have anything to hand to compare it to but I think what we do here makes sense.  Written guidance cannot possibly cover every situation and those treating the patient I think are best positioned to know what their individual patient needs so why shouldn't they be able to give it or whatever?



Well, in America it's because 150 hours of education isn't enough to give someone the discretion to make independent patient care decisions, to be honest. It's a shame, but that's how it is now.


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## triemal04 (Dec 8, 2012)

I'm curious, you said something about the degree requirements in another thread that I wasn't clear on.

When you say that Paramedics in New Zealand need a degree, is that a degree in anything and then they take the paramedic course, or specifically a degree tailored to paramedics?  Or is it a moot point since the paramedic classes are long enough to confer a degree at completion?


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## Clare (Dec 8, 2012)

triemal04 said:


> I'm curious, you said something about the degree requirements in another thread that I wasn't clear on.
> 
> When you say that Paramedics in New Zealand need a degree, is that a degree in anything and then they take the paramedic course, or specifically a degree tailored to paramedics?  Or is it a moot point since the paramedic classes are long enough to confer a degree at completion?



You need a Bachelor of Health Science (Paramedic) and Intensive Care Paramedic needs that, plus a Graduate Certificate in Health Science which is another year ontop of the Degree covering advanced stuff like RSI, ventilators, thrombolysis, advanced resucitation physiology, urgent community care etc.  Intensive Care Paramedic is the top level (I think you call it Paramedic in US).


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## Fish (Dec 9, 2012)

Addrobo87 said:


> In terms of California, I would say most progressive would have to be Kern County. Least progressive would be a tie between LA/Orange County. That's just my humble opinion.



Yes........ Add San Diego into that least mix


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## jgmedic (Dec 10, 2012)

Addrobo87 said:


> In terms of California, I would say most progressive would have to be Kern County. Least progressive would be a tie between LA/Orange County. That's just my humble opinion.



In 2009 KC's protocols still had stacked shocks and 4 lead ECG only. You could either follow that or ACLS. They had little to no micromanaging and I loved it, but progressive, I don't know


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## Jambi (Dec 12, 2012)

Clare said:


> There is lots of freedom around how to treat people and as long as what you do is sensible and within your delegated scope of practice then you are pretty much free to do it.  Clinical judgement is very important and given lots of attention, guidelines are just that, a guideline, and a favourite saying of one of my mentors is "patients do not read textbooks" so you really have to have your thinking cap on and use your tools wisely.
> 
> We can leave people at home, refer them elsewhere, send a single responder and lots of things.  We are told basically to see a patient, determine what they need and how best to get it and refer them there, if necessary by taking them there.  Only about 70% of patients are transported to hospital.  Looking to the future there is now a big change to how 111 calls are dealt with where the less urgent/minor stuff isn't sent an ambulance but put through to the phone nurses or sent a single response in a car.



Such a thing is possible with healthcare education. In this case it's an undergrad degree and seems like it is to EMS what the BSN is to nurses here in the states.  Now, here the average paramedic is likely between 1100-1200 hours of total time. This includes classroom, clinical, and field time.  Requirements for classroom time are generally less than 500 hours, which can be accomplished in 62 classroom days...not enough time to develop the foundation upon which to base clinical judgement.

I believe this breeds a disdain, or objectification at least, of the value and need for formal education as it pertains paramedics and EMS.  Thus there is much pressure against it, and meaningful CE in many places.  I could get into how this is a repeating cycle in this country and self-fulfilling, but I'm just preaching to the choir here.

Anyways, this is the basic reason, IMO, why the concept of progressive systems even becomes an issue.


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## Jambi (Dec 12, 2012)

jgmedic said:


> In 2009 KC's protocols still had stacked shocks and 4 lead ECG only. You could either follow that or ACLS. They had little to no micromanaging and I loved it, but progressive, I don't know



Since you're from riverside county, I'll throw out there that taking away pediatric intubation for the <8 patient group was and is progressive because it was based on data of success rates of paramedics in this county.  I don't blame Ochoa because what choice did he have with a dismal %50 success rate?


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## Joe (Dec 12, 2012)

We need to take away alot of things from la county 911 medics... some of the things i saw down there.

Now im up in kern and its mind blowing! Really made me want to be a medic again. Needle t's, crics, and spinal clearance for medics in the field. Just being an emt up here allows you the king airway.


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## Tigger (Dec 12, 2012)

Clare said:


> You need a Bachelor of Health Science (Paramedic) and Intensive Care Paramedic needs that, plus a Graduate Certificate in Health Science which is another year ontop of the Degree covering advanced stuff like RSI, ventilators, thrombolysis, advanced resucitation physiology, urgent community care etc.  Intensive Care Paramedic is the top level (I think you call it Paramedic in US).



To add, New Zealand Bachelor degrees are 3 years instead of the US 4 (on average), and have minimal general education requirements.


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## Clare (Dec 12, 2012)

Tigger said:


> To add, New Zealand Bachelor degrees are 3 years instead of the US 4 (on average), and have minimal general education requirements.



Yes, a Degree here is three years.  The University of Auckland is the only uni that has "general education" and I know some of my mates who might be doing a Nursing degree or trying to get into Medicine or whatever and have to take a couple of classes in e.g. poetry or business or something, WTF, I don't get that, that is what high school English is for.


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## Jambi (Dec 12, 2012)

Since I don't want to attribute too little or too many hours to the widely varied paramedic training in this country, and since is was also pointed out to me that some states have much lower requirements than the 1100 hour mark I quoted, I want to post what's required for California.

The minimum number of hours required for training is 1,090:
    Didactic and skills                           450 hours
    Hospital and clinical training                       160 hours
    Field internship                               480 hours
(which must include a minimum of 40 advanced life support (ALS) patient contacts)    

And as a contrast, here are the state's requirements barbers and hairdressers, etc.


1. How many hours are needed to qualify to take the State Board examinations?
Cosmetologist = 1600 hours, Barber = 1500 hours, Esthetician = 600 hours, Electrologist = 600 hours, Manicurist = 400 hours.


This is why many areas are not considered progressive.  As I see it, instead of increasing requirements for initial education and increasing CE and skill maintenance requirements because of political pushback, counties and medical directors simply tighten and limit scope and responsibility.


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## drjekyl75 (Dec 19, 2012)

I'm beginning my paramedic course in Michigan after the New Year and found this as the minimums: The curriculum includes 1,210 hours of training (600 classroom, 610 clinical & intership) including IV therapy, cardiac rhythm interpretation, defibrillation, drug administration, cardioversion, cardiac pacing, endotracheal intubation and advanced airway measures. Not sure where Michigan fits in with the rest.


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