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

Safety Sunday Series

Coming up later today I will be unveiling a series of weekly EMS-related safety messages. They are designed to provide some knowledge about areas of EMS that have been identified as having high risk for the EMS provider. I will also likely delve into patient safety issues at some time, but will focus early editions on keeping us safe. Just like anyone I occasionally get busy and may not be able to get a long article in, but will try to link to some story, or provide some information every Sunday.

I will try to embed or link to other articles, videos, news stories, pictures, etc. within this blog. As with any blog (or internet posting) feedback and discussion is welcome. Many safety issues that I will bring up have been discussed multiple times in multiple areas, though EMS providers still die every month, helicopters still fall out of the sky every year, and every other day a jumbo-jet full of people die in the US due to errors made my EMT's, paramedics, doctors, nurses, pharmacists, etc.

Some people who personally know me, or know of the service I work for, know that less than a month ago two paramedics (Tim is about to be awarded his Paramedic), were killed in the line of duty. My coworkers and friends Timothy McCormick and Cody Medley were driving an ambulance that was struck by a buzzed driver who ran a red light in downtown Indianapolis early one Saturday morning on February 16, 2013. They both died within about 24 hours of the accident. I had planned on starting this series before that time, though the events of that weekend only further brought home the need for these messages.

I was planning on doing these because as a full-time paramedic and part-time trainer I see unsafe behavior almost every day that I work. I have screwed up plenty of times and realize that I still have many unsafe behaviors, and out of pure luck I haven’t wrecked my ambulance, severely injured myself, or have killed a patient (not even sure on the last one). Please, if you have ANY feedback, stories, thoughts, rebuttals, evidence against, etc., share them here. You may also leave thoughts for future issues.

Some areas that I think may help me talk about safety include my formal education while obtaining by Bachelors in Health Management and Masters in Health Administration. During these programs I have included classes in lean process improvement, root cause analysis, healthcare failure modes effect analysis, healthcare risk management, health law, ethics, and organizational behavior. I have also served on a safety committee within an ambulance service that I was a graduate administrative intern and I currently am on a national health and safety committee through the National Association of EMTs. So between my clinical experience and other background I feel that I should be able to help facilitate knowledge spreading about safety issues in EMS.   Enjoy!  

 

Garrett Hedeen, “The Naptown Medic”