EMS "EVENT" reporting

 

Dr. Deming, a well-known quality expert described errors being primarily management issues. He stated that “the problems are with the system, and the system belongs to management.” Another way to look at this is that you get the results that your system is supposed to get. If you can’t identify the errors and the system related to the issue then you can’t improve. He famously used the plan, do, study, and act method of process improvement. Possibly the most important first step is to identify the problem, and one of the best ways to do that is to have some type of easy-to-use reporting system.

The need for a tool for reporting when safety events occur is key in the process of creating a culture of safety. The anonymous reporting of safety-related data can identify potential hazards and trends that can then be addressed appropriately at all levels. Today I will talk a little about a reporting tool that has been in use for EMS for a little more than a year and is showing some great data.

The EMS Voluntary Event Notification Tool (EVENT) http://event.clirems.org/ reporting system is a tool that is meant for EMS providers to use to gather information about hazardous events that can occur in EMS. The EVENT collects information about 4 different types of occurrences; these include patient safety events, near miss events, violence events, and line of duty deaths.  

EVENT is a program of the Center for Leadership, Innovation, and Research in EMS (CLIR) with sponsorship from a number of national and international EMS agencies like NAEMT and the National EMS Management Association. This was in response to the general focus on errors in medicine identified over a decade ago by the national Institute of Medicine (IOM), which pointed out the fact that 44,000 to 98,000 patients die a year in the healthcare system due to errors.

 

 

The idea of a reporting system is something that has come out other industries like the airline industry and in fire-fighting.   Here is the main fire fighting close call website http://www.firefighternearmiss.com/index.php/home . They have a very robust reporting system and you can search by type of run, fire, extrication, EMS, etc. and contributing factors like situational awareness, training, or human factor. A quick search of EMS related event using those contributing factors stated previously I found a run in Indiana involving a simple “medical alarm” run which ended with someone with a gun that ended up needing tazed. There is even a section where the responder can reflect on lessons learned, like having better awareness of “unknown scenes” and proper approach on scenes (knocking on door, announcing as Fire Department, Paramedics, EMTs, etc., and keeping body to side of door). I will reprint this particular report at the end of this article.

Some confusion exists in determining what the difference is between a “near miss” and a patient safety event. The simplest explanation is that if after an event you say “whew… that was close,” and no injury occurred to anyone, your partner stopped you before injecting a wrong medication, then it was a near-miss. If contact was made, a cot actually fell 2 clicks accidentally, or a patient was actually injected with a wrong medication (or dose) than it was a “hit,” a patient safety event has occurred. Line of duty deaths are self-explanatory.

The last section that EVENT reports are made on is an area of growing concern that I have already written about, violence against EMS. FAR too often we get injured by patients and shrug it off as “part of the job” or rationalize not reporting it since the patient was having a medical condition or was somehow impaired. Until we start reporting these seemingly mundane occurrences, even the minor ones it will continue to be a silent epidemic.

Out of the 4 different reports you can made, the violence one is the shortest form, and may only take 5 or less minutes to fill out. The other reports are more in depth and may take longer. Any individual practitioner or supervisor can fill out the reports.

One of the obvious things that seems to be missing from EVENT is a reporting system about provider injuries. This data is usually collected by state and national occupational health and safety agencies. Some good reports have been made using this data and general statistics from the past few years are available on these CDC webpages http://www.cdc.gov/niosh/topics/ems/ .

I would suggest that EMS organizations begin having their supervisors adding information gathered in their field personnel’s incident reports into this system. I would also suggest that organizations should actively promote the use of the near miss reporting system or other systems if they think they may have an event or wish to remain anonymous about an event. The most important thing is that the information is shared and lessons are learned.

EVENT sends out information about the different reporting systems every quarter. These reports can be great sources of information to managers and even trainers. Trends can be identified and potentially deficient systems and processes can be changed before an incident occurs at your organization. Trainers and educators can identify where education has lacked in particular areas. A great example of this is in the treatment of Ventricular Tachycardia w/pulses. After delivering a synchronized shock, the monitor defaults back to unsynchronized, and if not caught the provider can easily deliver an unsynchronized shock at the next treatment iteration. One drawback to this reporting is that sometimes brand names are redacted to help prevent potential sabotaging.

I hope this topic has been enlightening for you all. So remember that anonymous reporting like the EVENT reporting system for EMS is a key ingredient in creating a true culture of safety in any organization. Please consider spreading the word of EVENT reporting as the more awareness and reporting the better designed systems we can have that will ensure ourselves and our patients have better outcomes.      

The EMS Voluntary Event Notification Tool

http://event.clirems.org/            For reports on previous incidents select types of forms and you should find reports option on the left side.

Airline Near Misses video http://www.youtube.com/watch?v=JAhXc9JKT14

Near Miss Fire Fighting Example

Search Reports    http://www.firefighternearmiss.com/index.php/search-reports

Report Number: 12-0000016
 
Report Date: 01/27/2012 08:50
 

Synopsis

Patient wakes up with gun in hand.
 

Demographics

Department type:  Combination, Mostly paid
 
Job or rank:  Lieutenant
 
Department shift:  24 hours on - 48 hours off
 
Age: 43 - 51
 
Years of fire service experience: 21 - 23
 
Region: FEMA Region V
 
Service Area: Suburban
 

Event Information

Event type:  Non-fire emergency event: auto extrication,technical rescue,emergency medical call,service calls,etc
 
Event date and time: 01/27/2012 05:21
 
Hours into the shift: 
 
Event participation: Involved in the event
 
Weather at time of event: Not reported
 
Do you think this will happen again? 
 
What were the contributing factors?

·     Situational Awareness

·     Other

What do you believe is the loss potential?

·     Other

·     Life threatening injury

Event Description

This morning the engine and paramedic crew responded to a medical alarm with no contact.   We were advised of key location information over the Mobile Data Computer and upon our arrival we checked for the key but did not find it.  I asked if the alarm company had any contact information for a key holder before we forced entry into the residence.   I was advised that they located a possible key holder at the residence. A police officer responded to see if they had a key for the residence. The police officer returned with a key for the home and entry was made. 

Upon entry into the home, the police officer and I announced our presence with no answer or indication anyone was present in the home.  A secured door was located on the first floor in the northeast corner of the home.  The lock was a simple push lock and it was unlocked using an ink pen.  The police officer opened the door and saw an elderly man come up from the bed with a gun and the police officer announced that there was a man with a gun.  The police officer attempted to talk to the subject.  I informed the police officer that I was notifying dispatch of the man with a gun and additional back-up personnel.  I then began to work on how to get the rest of the crew out of the living room and out of the house safely.  I advised the crew one at time to head across the living room back towards the front door and out of the building.  Additional police officers arrived on location and after a short time they advised that the scene was secure.  The patient had been tased once in the stomach. The “Taser” probes had been removed by police officers prior to our re-entry.  Paramedics treated the patient and transported him. 

 

Lessons Learned

It is important when responding to medical alarms to ensure we are requesting the assistance of law enforcement, especially if there is a need to force entry or even use a key provided.  You can startle a homeowner and they might have a gun and use it.  Worse yet, they might be unstable due to a medical condition.  Staying aware of your surroundings and keeping a way out to retreat in the event that the incident goes south is very important.

 

EVENT Violence against provider Examples from 2^nd Quarter 2013

#2

While caring for a mentally ill female who was under the influence of alcohol she struck the paramedic twice in the head.

#3

While working in the apparatus bay at the fire station, personnel noticed a male staggering across the outside ramp near the overhead doors. "Walk-in" calls are not uncommon at this fire station and the crewmembers immediately approached the man to assess his condition and render aid. All members noted that man exhibited signs and symptoms of alcohol intoxication. The crew walked with the individual to the staff door at the eastside of the station, where several crewmembers stayed with him while another went inside to retrieve medical equipment. In that employee absence, the individual threw a punch with his right fist, striking the other employee in the face. The employee did not fall or lose consciousness, but rather with crew assistance, restrained individual on the ground and called for law enforcement assistance over the radio. Crews reported the individual did not appear to be agitated by their presence or assistance and that the punch was not provoked or expected. Law enforcement responded to the scene with two officers, who placed the individual into custody, restrained with handcuffs. Examination of crewmember noted minor soft tissue injuries, did not request further medical evaluation and remained on duty.

 

#4

Called for chest pain, double critical care paramedic crew. Performed normal exam and 12-lead on patient in her home. Patient had no desire to go to the hospital and refused transport. While putting away the ECG cables the patient screamed and grabbed my partner and managed to scratch his face a couple times. He was defending himself from her unarmed strikes with our tablet computer. I dropped the ECG cables and pulled her off of him, and she then attempted to bite my arm. I was able to push her onto the bed and that time her boyfriend ran into the room and restrained the patient. For safety and since the patient had already signed all the forms and did not want to be transported we left the scene and reported the incident to management right away. They were not interested in the report since we were no longer on scene. No follow up was ever performed by the company and we were disciplined for the incident later because the patient called and complained about us.

#5

Pt was possibly high on unknown substance. Pt was swinging at firefighters and EMS went behind patient to take him to the ground. Pt was fighting for 10 minutes and IM versed was given.

 

#6

 Patient was intoxicated and grabbed at hair and struck victim; also verbally abusive.

 

#7

Crew called to psychiatric floor of a medical clinic for a "man down." 28 y/o patient was now calmly sitting in chair with parents & MD stating pt. was found collapsed on lobby floor earlier. During assessment & without warning, pt. punched attendant in head resulting in incapacitation & minor concussion. After 2nd outburst damaging property in exam room, pt. transported by a 2nd crew. Pt. also attempted to punch medic on transport crew.

 

#8

During the course of treatment, patient became physically assaultive. Patient was advised to cease and desist assaultive actions; patient did not. The violent actions of the patient were noted to escalate, in which the provider felt that an imminent danger existed. The patient was physically restrained by provider in a manner that did not impede airway, breathing or circulation, until police presence was available. The patient was handcuffed by law enforcement, with hands in front of the patient, and patient’s handcuffed hands were restrained above and behind the patient's head. Once the ability of the patient to assault providers, the patient calmed and became compliant with legal orders.

Sterile Cockpit

Safety Sunday, Volume 1. Issue 6 (7/7/13)

Sterile Cockpit for EMS. Are you setting up for a safe ride?

The term “sterile cockpit” obviously originated in the airline industry, which has done a lot in recent decades to increase the safety of flying, and until just yesterday, has had quite a good streak going of non-fatal accidents on commercial airlines. The overall concept is about decreasing distractions, especially during key points during a flight. In 1981 the FAA made it a requirement for pilots to not engage in any “non-essential” activities or conversations during critical phases of flight, mainly below 10,000 feet.

Different aspects of healthcare have taken this approach and created some interesting safety mechanisms. One study in Oregon found that approximately 20% of adverse events were rooted in some type of distraction. These dangerous distractions occur at key phases in the care of patients, notably during patient handoff, medication administration, medication pickup, and surgery. Many hospitals have implemented initiatives like “distraction-free” zones and “sashes” to wear during interactions. These are often around medication dispensing and preparation areas or ORs. Sashes are sometimes worn by nurses during medication preparation or patient handoffs. This is to prevent the death-by-thousand-paper-cuts phenomenon. If 5 people come up to you and ask “do you have a sec?” while you are trying to get report about a new patient that you have, you will surely forget some, potentially vital, details.

Luckily for EMS we usually are dealing with one patient, but similar issues from hospitals can still occur. Though for EMS the sterile cockpit generally refers to our “cockpit,” the cab of the ambulance.  I’ve added a picture of an example of my ambulance with some examples of a non-sterile cockpit. The key is finding the distractors and setting up processes that keep those items from being distractors. Here are some of the common distractors and risk mitigation techniques:

·         Items in the dash.

o   I have seen jackets, stethoscopes, computers, glasses, clipboards, food, and many other items on the dash in an ambulance. These items all clog up important visual space, especially if the items are reflective vests or white paper during heavy sunlight. They can also be projectiles in sudden turns or accidents, possibly even rolling under driver.

o   Simply clear ALL items from the dash.  

·         Mobile data terminal/computer/GPS

o   After the driver has gotten a good idea of where they are going they should turn any screens around or close the screen, getting rid of a distractor. GPS’s, if used at all, should be out of direct eye-line.

·         Dispatch Radio.

o   When both EMS providers are up front, the driver should not be actively communicating on the radio. Place the radio away from the driver.

·         Music Radio.

o   Besides acting as a general distractor, some “heavier” music may add extra adrenaline to a situation that doesn’t need more speed.

·         Electronic PCR.

o   If you use an ePCR and your computer-aided-dispatching doesn’t automatically link to your ePCR the passenger is likely busy entering information and can’t assist in identifying potentially hazardous situations. Proper role by a passenger in emergency driving is a topic for another day.

·         Idle conversation. Common emergency communication.

o   When you are driving lights and sirens is not the time to have a discussion about what to have for lunch, current relationship statuses, or how stupid your boss was when he gave you a write-up for something everyone does. If your passenger doesn’t have anything to do they should be helping with identifying hazards.

o   I intentionally didn’t use the term “clearing intersections” because as a driver I don’t want to rely fully on a partner to clear a side, because he may be doing something else at another intersection and not hearing anything may make me think it is clear when it is not. Simply adding another set of eyes will add another layer of protection. Commonly agreed upon terms like “clear right,” “vehicle not stopping,” “driveway on right,” “driver/(vehicle descriptor) in left lane is on phone,” etc. will help with any confusion.     

·         Phone.

o   This should be obvious. Anyone that has worked EMS for any amount of time has seen the results of texting and other phone-call related distraction MVCs. Over 3,000 lives were lost in 2010 by texting alone. Leaving your phone out of reach will limit this distraction.

·         Clutter.

o   Your whole work area should be free of extra wires, unsecured drinks, loose items, radio straps, etc.

Hopefully with some of these you can help prepare yourself to provide the best care to your patients, while arriving safely to the scene. I’ve added some reference material and other information on the sterile-cockpit concept.

Wikipedia entry on sterile cockpit rule.

http://en.wikipedia.org/wiki/Sterile_Cockpit_Rule

 

Oregon patient safety commission discussion with links.

http://oregonpatientsafety.org/healthcare-professionals/articles/sterile-cockpit-for-healthcare/527

 

EMS World article on a sterile cockpit in EMS.

http://www.emsworld.com/article/10779814/are-you-driving-in-a-sterile-cockpit

 

Scholarly article talks about sterile cockpit later in the paper.

http://www.paems.org/pdfs/online-ce/EMS_provider_and_patient_safety_during_response_and_transport.pdf

 

Guns for medics?

Safety Sunday, Volume 1. Issue 5 (6/16/13)

 From my cold, dead hands! Guns in EMS…

Over the last year or two the topic of first response EMS carrying firearms has been brought up more times than stories about what the Kardashians did while on vacation (if you don’t get that, you are lucky!). One of this month’s major articles in JEMS was about a rural-Ohio company’s allowance of its EMS personnel carry handguns, as long as they were legal to carry in the state and took additional training. JEMS ArticleThe blogosphere and EMS chat rooms have been blasted with opinions, so I figure why not resurrect my safety Sunday series with an extra kick to the proverbial dead horse.

Let me start by saying that I am a proud multi-gun owner with a concealed carry permit in Indiana (though all you need to do is breath in this state to get it).  I also am a proponent of increased background checks. Anyway I thought I would anger a few people on both sides of the political aisle to get some increased viewership. If my company would allow carry I would be hesitant to carry myself, though if provided with extensive training I would have to consider it more. The problem though is I want a different kind of training than most people envision.

The first training I would want is to take a general EMS Safety Course (like the one the NAEMT has). After that 9 hour day, I would want to have a two-day course in verbal judo (the art of using verbal strip phrases, among other things, to calm angry people).  After these two days of learning about using more effective communication I would want to learn more about the thing that is most likely going to kill me in EMS (finally some hands-on work), driving.

Driving?? I know, I know, you want to shoot things or learn how to kick someone or put them in a sleeper-hold, but if my agency is serious about mitigating the safety of its personnel, then this makes the most sense. We do an actual multi-day course where we learn how to drive with grace, trying not to “spill the hot coffee” (thanks Guy Haskell), we learn about appropriate use of going code 3, we spend hours on a course with different road conditions. We then spend a couple of hours with our maintenance chief going over appropriate assessing vehicles every morning to identify potential maintenance issues, checking fluid levels, air pressure, belts being worn, etc. We learn the in’s-and-outs of appropriate emergency and non-emergency driving with trained instructors sitting next them for longer than 10 minutes. Ok, after that we are ready for some action finally, we are ready to get safe with… lifting and moving.

We spend usually an hour during orientation teaching people how to properly lift and move patients. Though a lifetime of poor moves in awkward positions lead to career-ending back injuries, missed days of work, missed play time with loved ones, and often disability or a pension is out of the question. There are some great courses out there, like Bryan Fass’s course (fitresponder.com) speaking about proper fitness and lifting and moving, NAEMT’s new ACE fitness recommendations talk about being in the right shape to properly move patients. There are hundreds of different products out there to aid in moving patients. One of the most important tools in my opinion is electric cots and automated loaders of cots. There are also many lateral transfer aids, sheet “chairs” with straps to help move a patient, slip sheets, bariatric cots, etc (I’m keen on just a trash bag between beds). Ok let’s get more physical, proper self-defense training.

Normal self-defense training doesn’t really provide EMS with the appropriate training to deal with the situations that they will encounter, we will need something more specialized. Previously I have mentioned defense training for EMS (dt4EMS.com) as a viable training option to prepare your people for surviving violent encounters. This class, along with a visit from someone to speak about increasing your situational awareness (Rich Gasaway for example at SAMatters.com) can help get you prepared for safety.  Finally we have reached the cool stuff, firearms training!

Firearm training should include range time (who pays for bullets?) with qualifying (I don’t want to be shot by my partner), time with qualified instructors (LEOs preferably), and training on how to secure their weapons upon entering secured facilities. Of course your company already has a policy on dealing with weapons found on patients, right?  There should be scenario training with video review. A few years back one of the JEMS games final involved a gunman grabbing an EMT from behind, this scenario should be included. You may also want a lawyer to come by (at $250/hour of course) to talk about appropriate level of response and the use of deadly force. Obviously there will be training on how and where to conceal the weapons, and recertification/requalification every year. There are many great tactical EMS (TEMS) courses as well that will go beyond these courses, especially important if the provider wishes to have a more active role in their area swat teams.

So by now you may get my point. I am not against providers not carrying weapons, though if you or your service is doing this for “provider safety” then you will need to do some heavy internal review of what REALLY matters when it comes to the safety of your providers. There have been instances where providers have been severely assaulted, shot and in some very rare occasions actually murdered, though EMS providers die and get injured in a multitude of other fashions. So if your agency is thinking about allowing your employees to carry a concealed weapon I would suggest you take care of all those other safety trainings first. Prioritize... then possibly, if you think the benefits outweigh the risks, liabilities, and costs, I say GO FOR IT!  

 

Disclosures... I have not received any remuneration for the different links provided, though I am a NAEMT Safety Course instructor

No Units Available!! Future of EMS Rant

Safety Sunday, Volume 1. Issue 4 (3/31/13)

No Units Available! Short staffed, Over worked, and Underpaid; is EMS really different from anyone else today?

 

 

Today is Easter and the middle of Passover, for those that celebrate I hope you have a wonderful day. This topic may be a little more nebulous than previous topics as it pertains to safety issues, though I think it all centers around the issue of provider fatigue. This may end up being more of a rant than a traditional blog entry, though I am relatively new to the blogosphere I find good amounts are ranty (if that’s a word) anyway.  I’m sure to anger a few on some of the following opinions, though am always up to a good debate that may change my mind as more information is posed.  I will likely only peel a couple of layers off of this very large onion.

DISCLAIMER: Unless otherwise specified I am not speaking of any specific agency or agencies (that I may or may not have worked for at some time), any likeness should be ignored, taken with a grain of salt, or used to influence policy change for the better. YOU ARE ENTERING... THE RANT ZONE!!

Last week at a bi-monthly Indiana State EMS commission meeting one of the commissioners started up a conversation about the dwindling numbers of EMTs after one of the officials from the state EMS office reported the numbers of certification renewals. My first instinct was “there he goes again,” but the more I listened to him, the more I realized that if we continue to ignore this problem, it’s only going to get worse.  Until I started attending state commission meetings, national conferences, reading posts from other providers, was a member of my state rural health association, I didn’t realize how increasingly rare having a paramedic was. I was mostly used to working in an urban environment where I was surrounded by about 200 paramedics in my county.

At commission meetings over the last couple of years I have also noticed an increase of waiver requests for providers wanting to not be required to have a second EMS professional. In the United States it is somewhat difficult to even start to define how many EMS personnel there even are. If you ask each of the roughly 15,276-21,283 ambulance services (American Ambulance Association {AAA}/National EMS Assessment) you will likely get a gross over count of the many thousands of providers that work at 2 or 3 different EMS agencies. If you get numbers from state EMS offices you get many miscounts with many “certification-only” providers, those pre-med/nursing/other allied health people that take the class for its great practical knowledge though don’t actually work anywhere. Until last year ALS providers in Indiana where automatically certified with their EMT-Basic and their other certification, leading to many “double-counts” of providers. The AAA puts the total number of providers at 840,669, the national EMS Assessment (2011) put this at 826,111.  

At the local level I know of a private service that had (and may still have) orientation every 3 weeks. Another larger municipal organization has had 4 hiring groups in a little over 2 years. The first organization orientation lasts about 2 days of talk, 5 days of FTO, the other is at the other end of the spectrum, about 5-6 weeks of “off-truck” orientation, 5-6 weeks of FTO.  In a time when millions are unemployed or underemployed this level of turnover is outright crazy. The turnover of EMS agencies was noted at around 10.2 % in one study that looked at this, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2883888/pdf/nihms201933.pdf , though the actual cost of turnover was extremely varied. Just for some comparison, a couple of weeks ago I attended my local hospital board meeting where they announced that they had a turnover of 1.45%, where the industry was slightly over 2%. An EMS agency that reports to that same board had a turnover around 17% (~40 separations in a year/230 avg # of employees during that time). That same agency paid out MORE in overtime costs in 2012 (w/~230 employees) than the local Fire department (with about 1,200 employees) did the year before (when numbers were available).  That same department hasn’t had a hiring group in about 4 years, though had just received a $4 to 5 million SAFER grant to have a recruit class around 30.

So I digress about some of my local occurrences, but I truly believe that they are a microcosm for the situation at hand. The fire and EMS agencies are both under public safety in this area, they are collocated at many locations and (without exception) the ambulances are generally about 20% busier. The fire department has a negotiated 3^rd year private (lowest rank) rate of over $60,000. The EMS agency lowest rank EMT would have to work 48 years to reach that level. As many know the main duty of almost all fire department nowadays (thanks to some great fire prevention initiatives) is EMS. At EMS Today a few weeks ago I heard a speaker say that they looked at Raleigh, NC fire department and found that the percentage of dispatches that wet stuff on red stuff” was 0.3%  Nurses in the area start around the 12 year paramedic mark.

I hope this doesn’t seem that I am bashing other professions, but I point at them for many of their successes that could help us moving forward.  So what is being done in other areas that help get our profession out of the funk. Well let’s look at some EMS agencies that are doing things well. King County, pays their employees well, gives them a lot of responsibility, and invests much into their training (thousands of hours of training after hire). Agencies that are getting people from the municipal agency discussed above aren’t necessarily paying more. They often have nicer, newer equipment, better schedules (24 hour usually, a whole other topic, and flexible scheduling) and more autonomy.

Many providers in my area are looking at going part-time for the sole purpose of having a flexible schedule, to deal with child care, pursuing higher education, or pursuing other hobbies/interests. I have changed my schedule about 5 times in as many years purely due to different interests. My first 2 years I was finishing my undergraduate degree which included mostly classes during the day, so I was on night shift. I had one year off of school where I moved to a tactical shift (11-2300 2 week rotating). The next year I started graduate school, which met on Saturdays and nights, so I moved to days. Without having many people trading I would not have been able to do this. Then a new shift opened up, Monday through Friday 0600-1500. PERFECT! Then 24 hour shifts became an option, though during football season I need Friday’s off to officiate varsity high school football, so I pick up a Wednesday/Saturday spot. PERFECT! Then I start to do some college football, so now Saturdays aren’t good. I then found a Wednesday/Sunday truck on the far end of the county. Finally, now I am working the same Wednesday/Sunday schedule about 5 miles from home. My point is that by pure luck, and willingness of others to trade, I have been able to remain a full-time EMS employee. Many haven’t been nearly as lucky as I have been and have had to quit, leave full-time, leave the company, or sadly leave the profession.

We treat our people like numbers, creating a perpetual rotating door amongst employers. System-status-management is a great administration tool to cover an area. Unless you do all the other things to make the employee happy, this doesn’t usually work well for the employee. Sitting at a gas station for 12 hours sitting in your ambulance in 95 degree weather does not lead to happy employees (or is it good for the environment or keeping drugs potent).

Paying above minimum-wage. This is the obvious problem, though it is a much tougher solution. Many places offer sign-on bonuses and longevity increases (like large increases at 3, 7, 10 years employment) that help, though our base pay is usually lacking in the beginning. Obviously, services can’t give out what they don’t have. So…

Changing how EMS gets money. Many private ambulance service leaders I know keep getting anxiety attacks because of increasing costs and declining reimbursements. They are getting hit on benefits, workers compensation, and increasing competition in the area (revolving door between EMS services). The big thing that they always get ulcers and increase their ACE inhibitors about is one thing, insurance transport reimbursement. Take a good look around and ask if you think medical reimbursements are going to stay at the same levels (or very slight increases).  The answer…

We MUST get away from relying 100% on insurance reimbursements.  When a community pays $140 million in property taxes for fire suppression and $0 for EMS, should they be surprised when they may have to wait 20-30 minutes for an ambulance at times. It’s amazing when emergency departments are bursting at the seams and you bring them your 4^th non-urgent patient of the day for the waiting room. This is especially true when you drove past 2 Urgent Visit centers, 5 doctor’s offices, a psychiatric clinic, a substance abuse facility and 15 minute clinics to get to the hospital. So who can help…

The rise of use of the public-health spoke of EMS is very promising. The use of “community paramedics,” and phone triage in the diversion of non-urgent patients, treatment/assessment of non-urgent patients is very exciting. The proactive (WHAT?? We can be proactive??) use of sending people out to talk with “EMS loyalty plan” patients, those who have chronic conditions which hospitals are beginning to experience declining reimbursements for readmissions), or being there at the end with hospice patients/families to help provide reassurance to help prevent unnecessary trips back to the ED (when they wanted to die at home). The problem with these are currently…

WHO is going to pay for it (aka How can we afford to do this?)? Well this is the tricky one. You need to bring data, have meetings with those outside of emergency medicine, and bring data. You need to identify the needs, formulate a plan, and provide solutions. We are one of few mobile medical professions that can, within minutes (and without authorization from 3 levels of insurance, 4 phone calls, and two forms signed by a doctor) get to a patient. Insurance agencies and hospitals are looking more and more to partnering with other health organizations to better “manage” patient’s health. The nurse practitioners, physician’s assistants, and home health agencies are all having similar discussions. If we don’t reach out to the other potential payers we will lose a lot of that pie.

So who is going to lead us? Well… we may need people actually trained in administration, trained in process improvement techniques, trained in finance and budgeting, trained in safety and risk management, and trained in leadership and management techniques. Too much of the time organizations are led by well-meaning, nice guys who don’t get in too much of a fuss with important people who control the purse strings. The fire service and other organizations have used unions very well in this area. Administration and labor all want similar end goals, a well taken care of workforce who are happy, well-trained, and carry out their duties effectively. When more funds are needed for equipment, personnel, or raises, the unions can help advocate where administration can’t. Labor groups for EMS are lacking at many local levels, though organizations at the federal and state levels, like the National Association of EMT’s are getting more and more political traction. Almost all other areas of business are ran by people with advanced degrees like MBAs or MHAs. Most small businesses have chief executives that at least got a bachelors. Too many times I hear EMS leaders answer the question of “What college did you get your training in?” with “College? I didn’t go to college, but I did stay at a Holiday Inn!”

Wow, that went a lot longer than I thought it would. Anyway I hope it was informative. Here are some of the possible solutions again.

-More pay.

-More training (community paramedic) for expanded scope

-Less reliance on transport revenue

-Well trained (with formal education) leaders

-More involvement in the “politics” of EMS, from the federal level of getting grants, getting a “seat at the table,” or simply clearly articulating the importance of our service to local officials

  

Violence against EMS

Safety Sunday, Volume 1. Issue 3 (3/24/13)

Violence against EMS: A freighting trend

I was going to address this very important and very complicated topic at some time, though some recent events have made me interested in addressing this topic sooner. Early last Thursday, during the last few hours of my last shift on my truck (before I moved to a truck closer to home) my partner and I responded on the old standby “sick person.” What started as a seemingly unresponsive 25 year old laying in his own vomit ended as an all-out throw down with 5 people holding him down and us calling for police. Though nobody was struck, the attempted restraining of a limb led my partner to strain his shoulder, thus ending our last shift together 4 hours early. The shift before my partner and me were struck by feet and hands and advised to “die” by our confused diabetic patient.

Months earlier a news story was done about an elderly woman who struck a coworker of mine with her cane. Just an hour ago I heard that one of new partners had a 14” dagger pulled out of cane on him. The patient had reportedly been in a secured psychiatric facility with the cane multiple times. About 14 years ago at my service a paramedic was shot in the abdomen in the emergency department. These few examples are just examples from one service, and just the ones I can think of or have heard of.      

Nationally the risk of non-fatal assaults leading to lost work time is 60 per 10,000 workers. This compares to the national average of just 1.8. We are more than 30 times the national average to have these non-fatal assaults. In a 5 year look at statistics it was found that there were 10 violence related fatalities, about 3 times higher than the average worker. In an NAEMT survey they found that 52% of respondents had been victims of assaults.  (most items are from Skip Kirkwood’s August 2012 EMS World article Violence against EMS Providers)

So, we have established that you are more likely than not to be assaulted in this career. Next we have to decide what to do about it. Some have advocated for use of firearms. I think there are plenty of other things to do than add guns to the situation.  Guns may help in certain situations, but most likely the employer is missing an opportunity to have more “bang for their buck” somewhere else.  In another study it was found that 54% of providers did not provide any training on how to deal with violent patients.  

There have been some good resources released in writing about the assessment of body language in determining if a threat may be imminent. Some highlights of those include (from DT4EMS instructor Jerry MacCauley):       Other DT4EMS videos, very good and free, can be found here.

Eyes

Pupils dilate and contract depending on the emotional state of the person. True, there are physiological reasons also, such as drugs/alcohol, bright lights, etc., but they are often a good indicator. The pupils can grow up to 4 times their normal size when a person is excited. They tend to constrict when someone is angry.  More often than not, we use our eyes to gather information. People will look at a target before attacking it, just as we look at an object before picking it up. The advantage to us, if we catch it in time, is the time delay between the look and the movement. Any warning we get helps!   Occasionally, a person will use eye contact as a way to establish dominance or intimidate others. There will be a break in eye contact just before the aggression is unleashed.

Head

When you look at a persons head, pay attention to the position it is held in. Is it back? This is usually a sign of aggression, such as winding up to thrust it forward. If it is straight, that could indicate assertiveness and forward may be a sign of submission or indecision.

Face

Muscles in the face can indicate tension. Clenched teeth, narrowing of the eyes and ears back can all indicate anxiety or aggression. Check for changes in skin color because this can tip you off to anger, fear or rage. Skin generally appears pale with rage or fear and reddens with anger. Also, aggressors tend to distort their faces slightly on the left side near the mouth. Check for tight or tense lips as an aggression clue.

Arms

 Arms that are crossed high on the chest, sometimes with closed fists. Can indicate aggression, while arms that are held lower in front of the body is usually a non aggressive stance.

Hands

Opening and closing of the hands is an indication of anxiety. Ask yourself why he might be nervous. Perhaps one hand open and one hand closed could indicate a hidden weapon. Hands held close to the body may be hiding the telltale print of a concealed firearm or just a form of defensiveness. Watch how a police officer stands when he is in a crowd.

Legs and Stance

Rocking from toes to heels could be seen as aggressive, as in bobbing up and down on the balls of the feet. A martial arts or a boxer’s stance is also an obvious indication of an aggressive individual. A trained fighter will shift 90% of their weight to the back leg prior to attacking.

This is an important factor in DT4EMS’s approach to mitigating violence on EMS workers. Here are all of their 6 steps. Linked below will be the whole article.

At the crux of the DT4EMS approach is a series of six steps:

1) Don't be on an unsafe scene--This is not always possible. Obviously, providers are often assaulted on scenes they thought were safe. But we should strive to stay away from areas known to be trouble-prone. This will be the subject of our next article, appearing in July.

2) Awareness--Providers must be aware of their surroundings to prevent assaults. Be mindful of who is around and pay attention to the little things: What is being said? What are people's moods? Where are the exits, should the scene become unsafe?

3) Maintain a safe distance--If a scene starts going south, a provider should keep his/her hands up and open (a posture of nonaggression) and back away to about 6--8 feet, if possible (see Figure 1). This body language makes it clear the provider is not the attacker and not looking for a fight. Verbal skills are important at this stage, when words can still defuse a potentially violent situation.

4) Double tap parry--The DTP is the primary physical skill taught to defend against the majority of frontal attacks. It has three overlapping parts: the parry, momentary elbow control, and distraction. The DTP can be used in a variety of situations toward the ultimate end of escape.

5) Basic ground defense--If the DTP failed, contact (punch, grab, push, etc.) was made and the provider was knocked to the ground, the provider would tuck their chin, bring their knees up and yell on their way down. BGD tactics can keep an attacker from mounting (straddling) the fallen provider.

6) Escape the mount--If a provider is knocked down and mounted by an attacker (Figure 4), this teaches them how to escape and use BGD to create space.

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Well I hope that helped, there is also a term that you may hear frequently when looking at some of these issues. Situational awareness is the philosophy of being aware of your environment to notice potential future problems and address them. A couple of years ago I went to a conference and heard Rich Gasaway, PhD talk about the issue in depth. I have since followed him on twitter and constantly utilize him as a resource. Here is his website, with upcoming trainings, books, and other tips and tricks. http://www.richgasaway.com/

 

Stay Safe!

Garrett Hedeen

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EMS World Violence against EMS providers

http://www.emsworld.com/article/10741287/violence-against-ems-providers-what-can-we-do-about-it

EMS World Real-world skills part 1

http://www.emsworld.com/article/10320329/real-world-skills-for-scene-safety-part-1?utm_source=related_content_box&utm_medium=related_content&utm_campaign=10741287

Part 2

http://www.emsworld.com/article/10320296/real-world-skills-for-scene-safety-part-2?utm_source=related_content_box&utm_medium=related_content&utm_campaign=10741287

EMS World Body Language part 1

http://www.emsworld.com/article/10783231/body-language-for-ems-part-1-deception-detection-techniques

Part 2

http://www.emsworld.com/article/10816986/body-language-for-ems-part-2-assessment?utm_source=related_content_box&utm_medium=related_content&utm_campaign=10783231

JEMS Paramedics and FF rarely face gun violence

http://www.jems.com/article/news/paramedics-firefighters-rarely-have-face

Chicago story about EMS being assaulted

http://abclocal.go.com/wls/story?section=news/local&id=8927455

Violence on fire fighters USFA Executive Research paper

http://www.usfa.fema.gov/pdf/efop/efo39115.pdf

DT4EMS Videos

http://dt4ems.com/?page_id=232

EMS Fitness Guidelines

Safety Sunday, Volume 1. Issue 2 (3/17/13)

Review of NAEMT's new EMS Fitness Guidelines

Hopefully you enjoyed the first week's safety Sunday message. This week will not be as statistic intensive, and will be mostly looking at an outside source. Next week I will present on the topic of violence on EMS providers. Here is the announcement this week from March 15, formally announcing the guidelines to the public.

Two weeks ago Don Lundy, current president of the National Association of EMTs (the nation's largest group of EMTs, click here to join) and American Council on Exercise Scientist Sabrena Merrill presented the final product of the EMS fitness guidelines at EMS World Conference in Washington DC. I was able to catch the tail end of this presentation and was able to preview this document over the last couple of months while the NAEMT health and safety committee did some final edits.

Here is an excerpt from the ACE guidelines about some of the background information about the need to examine EMS fitness issues.

As reported on NAEMT’s website, obesity and lack of physical fitness among the general population impact the ability of the EMS systems to effectively serve the needs of patients. That is, obese patients directly contribute to increasing levels of lifting-related injuries among EMS practitioners. In addition, the increased incidence of obesity and lack of physical fitness within EMS agencies also contribute to injuries and increases in chronic diseases. Specifically, NAEMT (2012) reports that:  

• EMS practitioners are seven times more likely than the average worker to miss work as a result of injury
• Half of all EMS workers suffer back pain annually   

• One out of four EMS practitioners will suffer a career-ending injury within the first four years of service  

• Back injury is the most frequently cited reason for leaving EMS  

• Back injuries are often the result of cumulative wear and tear

Other research on EMS practitioners and work-related injuries confirms the cause for concern about the occupational risks associated with performing the work. Data from the Bureau of Labor Statistics Census for the period 2003 to 2007 revealed that the majority of nonfatal injuries (84%) involved sprains and strains, mostly in the hands and fingers, and 42% affected the lower trunk. Approximately half of these incidents involved interaction with, or movement of, another person, often as a result of lifting or moving the patient (Reichard, Marsh, & Moore, 2011).

The National Institute for Occupational Safety and Health (NIOSH) also reported that among EMS worker injuries and illnesses, sprains and strains were the most common diagnosis. Most injuries affected the trunk, hand, and leg. For the years 2008 and 2009, the majority of sprain and strain injuries involved the EMS worker’s trunk. More than one-third of all sprain and strain injuries were related to interactions with a patient (NIOSH, 2009; NIOSH, 2008). These injury rates are alarming and reflect the need for EMS practitioners to meet and maintain the physical fitness requirements for the job.

    The most alarming statistic is the one that I and other EMS advocates use in explaining the risks associated with EMS jobs is the fact that 1 in 4 EMS practitioners will suffer a career-ending injury within the first 4 years of service. This fact points out the alarming rate of injuries EMS suffer.

The document does two very practical things, it provides a detailed Physical-ability assessment that helps identify postural deviations and/or physical deficiencies. Through the EMS specific assessment it helps identify what areas need improvement and have specified workouts and stretches to best improve those deficits.

Anyway, without further ado, please look through this great document which spent many months and brought together EMS and exercise professionals and researchers from around the country.

EMS Fitness Guidelines