EMS Flashmob

Eli Beer formed an all volunteer First Aid/EMS group when he was 17.  In the process of developing the program he volunteered on an ambulance and was always upset when they would get stuck in traffic.

Eli attributed his dying patients’ demise on the extended response time and wanted to do more for them in the time between when they needed help and when help arrived.

This video goes directly to the core of the Response Time argument and it is important to make a clear distinction between first response and ambulance response times.

We can all agree that getting someone in the door quickly can help guide the rest of the system’s response.  This can be a fire department engine, an EMT Police Officer or perhaps a third service handling first response.  What we don’t need is to send a reclined cot van on every call, nor does it need to get there in 4 minutes most of the time to make a difference.

In this TEDMED talk, Eli talks about how he came to found United Hatzalah and send motorcycles he calls “Ambucycles” to the scene of an emergency to help until an ambulance can arrive.  He touts a 3 minute response time to over 207,000 incidents last year and is using mobile technology to achieve it.

The phone app broadcasts the medical incident to the 5 closest volunteers in the same way CPR needed apps do so in the states.  When he mentioned it was kind of like an EMS flash mob he had my attention.  We’re locked into some old ideas and this one breaks the mold.

 

Why aren’t we as communities encouraging this kind of organization?  Sure there are volunteer First Aid Squads all over, but this is far far simpler than that.  And don’t wave the liability flag here, those folks would have to be trained to get access to the app and with the right kind of basic QA program built in you’re golden.

What do you think of the various things mentioned in this video?

  • Motorcycle first response
  • Volunteers
  • Phone App dispatching

 

Response Time or Patient Outcomes – How do you measure your EMS system?

I know it’s been quite around these parts lately but a recent article caught my attention this morning.

High Performance EMS posted “Does Response Time Matter?” and it got me thinking.

The author states an example of a patient being “treated” by fellow citizens at an airport and having to wait 20 minutes for an ambulance to arrive.  The author goes on to describe how we need to arrive quickly to save the public from themselves.  After 30 years of telling them to call 911 for anything and convincing them that “seconds count!” what did we expect?  While I agree that a delayed response to certain patient presentations could result in an adverse outcome, that points out a glaring omission from the story.  Missing from the story is the patient outcome.  The outcome will allow us to marry all the data from the response to determine the answer to the author’s question in the headline.

The short answer is no, response times don’t matter.  And no, I don’t have to pee.  I have data that does not have any correlation between quality of treatment, outcome and response time.  From my perch here at the data hub of a quite busy EMS system we have been trying to determine the quality of our EMS system and we rarely look at response times.

Don’t get me wrong, we look and our Department statistician collects, quantifies, qualifies and reports to regulators the 90th percentile of all code 2 and code 3 calls to meet their requirements.  We report it, they receive it.  The document says nothing about the quality of care or patient outcome.  The reason being that we can not guarantee a positive patient outcome, but can measure when we left and when we arrived.  Imagine if we had to treat 90% of symptomatic asthmatics with oxygen within 5 minutes of arrival and document an improvement in condition.  Can your system guarantee that?  Why aren’t EMS systems measured by the quality of their care instead of the quality of their response?

Apply this metric to any other industry and it fails.  Industry is measured by their quality and efficiency, not the speed in which they complete their tasks.  So long as we only look at one metric with any regularity we will continue to shuffle ambulances 2 blocks at 5 minute intervals to meet an average instead of realizing just leaving them still would bring the same outcome.

That’s where I come in.  My Medical Director and I, unhappy with the lack of actual patient care quality metrics, created our own in an effort to determine the quality of care being provided.  We learned very quickly that our ambulances do not respond in a vacuum.  Each patient receives a call taker, dispatcher, first response, ambulance response, assessment, treatment and some get transported.  Once at hospital they receive a whole new level of care and review until they are finally sent home.  It is hard to argue that the time it took to get an ambulance from point A to B has an impact on this outcome without any review of the call taker’s coding of the call, the dispatcher’s assignment of the ambulance all the way to the destination hospital capabilities and location.

We can all sit at the Pratt Street Ale House in Baltimore and discuss short times that had a bad outcome and long times that had a good outcome, but the worst part of all of this discussion is that so few systems measure anything more than response time.

If you consider response time your metric of success you have already failed.  You have failed the patient who improves when you arrive “late” and discounting that response as a failure, yet trading high 5s when a 2 minute response yields a call to the Medical Examiner’s Office.

We all know the stories of companies staffing ghost cars near the end of the month to bring down the monthly response metric to meet guidelines.  It happens.  But I also wonder if that flood of ambulances to help more people had any other impact.

The complication in tracking outcomes is the relationship your agency has with local hospitals.  We may never have a seamless transfer of data but what we can do is pull data from the PCR to determine if the patient received the indicated treatments for the recorded chief complaint and observed complications.  By reviewing your policies and protocols as well as your patient demographics you can quickly spot your core performance indicators and design tools to track them.

It may be nice to know that we make our 90th percentile in 8 of 10 districts on a regular basis, but what if those 2 districts happen to have the highest number of cardiac arrest survivals to discharge?  Are they still a failure?

Widen your view to include more than how quick you can put the ambulance in park.  This goes far beyond the lights and sirens System Status Management debate and speaks to the core of the reason we’re out there to begin with:

To make someone’s bad day better

Delays can hurt, but not unless you look deeper into your system to find out if that is the case…or not.

999

You got WHAT stuck in a bowling ball?

In my memoirs of EMS (Working title – My Life in CQI: Kill me now, just document it properly) some calls will stand above all others.  This, sadly, is not one of mine, but from a friend overseas.

No, not Mark.

I got an email about a curious rescue his agency was called to and was wondering what I would have done.

So, here is the scenario:

 

A 19 year old male has gotten his finger stuck in a bowling ball.  He somehow wedged it in there so far, it up against the webbing of his hand with very little wiggle room.  Rotating the ball is out of the question as he seems to have the finger next to it wedged in almost just as bad.

25 minutes into the call you’ve tried gel, ice, lubricants of questionable origin (who carries that stuff into a bowling alley?) and brute force.  Prayer is taking place and all options seem exhausted when the decision is made to simply move him, and the 16 pound bowling ball, to the hospital.  What will they do there?  Dunno.

 

What would you do?

“You should read this blog…” said the Medical School Professor

Our local teaching hospital / trauma center / STEMI center / stroke center is putting on a new lecture series which focuses on STEMI and ROSC patients.  It is very similar to the trauma seminar I’ve mentioned before and has a wealth of information.

It starts with our pre-hospital radio report and continues through the balance of care for the patients.

 

My favorite part was when the MD leading the presentation suggested everyone in the hall go to a blog for ECG knowledge.

Mine?  Of course not, not until the seminar on fart jokes and grammar mistakes.

No, he directed us all to “Tom Boot-hill-aye” and his excellent work at EMS 12 Lead .com.

I will admit I sat a little taller in my chair when someone I know was mentioned as an expert in his field…and uses a blog to disseminate it.

Sure Tom Buothillet speaks nationwide about the importance of pre-hospital 12 lead ECGs, among other things, but also uses social media and video to make his message more powerful.

Tom recently debuted the London Ambulance Service episode of CODE:STEMI where he travels the world talking about EMS systems and their reaction to sudden cardiac chest pain and arrest.

 

Good work Tom, keep it up!  I think you’ll get a few more hits from today’s session!

Our Caridac Arrest Survival Rate is 100%

You read that right.  San Francisco has a cardiac arrest survival rate of 100%.

Does that mean that everyone who suffered a sudden cardiac arrest survived?

Of course not.

But our survival rate is still 100%.

That’s because today my numbers for witnessed Asystole with ROSC and cooling measures look really good.  So, our rate is officially 100%.

Hogwash you say?  How is that any different than some communities who bend their inclusion criteria to give the impression that they have an amazing rate of survival when their overall numbers are a complete unknown.

I rub my temples when editing our CARES registry, not because the data fields seem unending, but because there is one that I’m not sure we should be editing until long after the event:

“Suspected Cardiac.”

This term sits in a line with others such as drowning, respiratory, trauma etc.  Since our cardiac arrest patients seldom tell us what led to their arrest, we have to make a HUGE assumption and hope the hospitals update the information accurately.  That is also assuming that the hospital was able to discover the cause of the arrest.

It would be refreshing to be able to determine the cause of cardiac arrest and only count the patients we were going to be able to help at all, but that should not be taken into account when reporting survivability.

Imagine it this way: Our major trauma survival rate is 99% because we don’t include patients who had a BP of less than 50/P in the field since our efforts are unlikely to impact them.

Insanity, right?  If trauma care and survivability from injuries is our population, why exclude those who are less likely to make it?

Because it makes us look bad.

We can argue the semantics of statistics, reporting and the like for decades, we have and we will, but make sure when someone reports 60% survivability from a condition that kills more than 90% of those who suffer it, ask what they mean by “survival” “cardiac arrest” and “witnessed.”

It’s all in who you place in the denominator that decides your final answer.

So when I neglect to tell you our survivability only includes tourists with witnessed arrest who received bystander CPR and an ALS intervention within 4 minutes, am I really telling you the chance of you surviving cardiac arrest in my community?

Nope, but it sure is fun to say.

What is our actual rate?

We don’t know, some of our 2012 patients are still in the hospital.  Some communities might count them as survivors and move on, but we’re looking for total survivability, not simply a target some time after admission.  It will also help us guide future interventions if we can wait to learn exactly what happened to cause the arrest in the first place.

Sub point being that putting all your efforts into community CPR may seem like a fantastic idea, but if none of your survivors received it, will it make a difference in your community?

None of your survivors received cooling measures…does it still have an impact in your community?

No one who had a transport time of less than 5 minutes survived…should we slow our response?

 

Asking questions like this comes from looking at the data with too fine a comb.

1/2 of 1% (.5%) of the patients seen by my system are in cardiac arrest.  Of that group upwards of 90% do not survive, many of them being beyond our help before we arrive.  So now look at the subset of the population we’re observing. 10% of .5% means .05%.

That’s 50 cents out of a $100 bill.

Are you willing to change your system, your community, your children’s graduation requirements… for .05% of your patients?

While I’m a big fan of community CPR, I’m also a big fan of community asthma programs, community hypertension screenings and community programs to reduce unnecessary 911 calls.

Those programs impact a far greater population and while there are not immediate results, like in ROSC, we are preventing far more cardiac arrests 30-50 years from now.

Which is better: Preventing an arrest, or classifying one so as to show success?

Hard to prove a negative.

 

EDIT – I was contacted by someone I respect very highly who informed me my stance has been misinterpreted (ie I didn’t get my thoughts out the way I thought I had.  Not the first time either, go figure).  I am not calling for the muddying of the waters when it comes to Cardiac Arrest Survival rates, simply that agencies know what they are reporting and, more importantly, WHY!  I’m aware I come off as a non-believer in this post, implying that all the new fangled stuff doesn’t work, I just want to make absolutely sure we don’t all focus on one outcome at the possible expense of others.  My views may be confrontative, ill-advised and downright wrong, I’ve never claimed to have the answers, but in my current position of gathering and interpreting data I see how easy it is to steer the results in my favor.  It’s tempting when someone survives cardiac arrest and goes home mere days later…yet doesn’t fit the Utstein numbers, so doesn’t “count.”  It’s also frustrating when we have an Utstein case arrest in the ambulance and not survive.  The one person we think we have the best shot with and there’s little we can do or learn from it.  Agencies like Medic One and Hilton Head Island, with impressive Ustein results should be admired. They’re using their data, learning from it and applying it.  Good for their patients (and good for them) but if you are not part of the CAREs registry make damn sure you know your metrics and are reporting apples to apples, otherwise you’re not only fooling yourselves, but doing your patients a disservice.

-HM

 

Code 3 for the Headache – Sudden

…and it’s contagious.

 

THE EMERGENCY

A headache!  Won’t someone think of the children?!

 

THE ACTION

I’m cooking tonight and the chicken enchilada casserole will be OK cold I guess.  The bells ring and we’re out the door code 3 for a headache, sudden, worsening.  It suddenly occurs to me that the sensation that develops behind my eyes between the kitchen and the engine is likely worse than what we’ll find on scene.

She’s in her mid 50s and is quick to mention her disability status (we noted the handicap placard in the BMW in the driveway) and her husband confirms it.  The disability status that is, not the headache.

Not one to take a patient at their word we do a full work up including 12 lead ECG which aquires a normal tracing just as the ambulance I downgraded arrives.

The patient’s headache seems to have subsided.  The pain that was an 11 is now a “tolerable” 7 although we all know that means nothing without knowing her 10/10, which she refuses to share…none of my business and all.

Turns out she had a bad tooth and got some medicine for it.  I know what you’re thinking, but no, she actually filed the prescription.

It was when the pain remained 30 minutes later that 911 was called.  And the call made it through the call center because of the words “dizzy” and “can’t think straight.”

 

Thanks MPDS, you win again.

 

Back at the house the casserole was cold and I lost the dinner shake, meaning I had to cover the cost of everyone’s meal.  That was a sudden headache.  I did not call 911.

 

 

I’ve seen it all, we’re done here

I thought I had seen it all until today.

Every manner of injury, illness, presentation and patient seen, noted and documented.

Oh universe, I love it when you mess with my mind.

 

THE EMERGENCY

A bicyclist has been hit by a car

 

THE ACTION

Well, not exactly “hit” and not exactly “by a car” but at least there’s a bicycle involved.  Units are approaching from all directions downtown and traffic is thick as it is almost 330 on a Friday afternoon.  The bicycle messenger rider is standing, rather clamly, on the sidewalk near a stretch of street with cars inching forward, but none of them stopped.  At least not stopped as much as you’d expect for someone who just hit a bicyclist.

As we approach he’s holding his right arm with what appears to be a napkin, likely from the Chinese take out place behind him.

The assessment begins and we’re hard pressed to find any injuries consistant with a vehicle versus pedestrian.  We are allowed to get so deep into the assessment before discovering what happened because, as always, our question of “what happened?” is met with a 25 minute slide presentation about how he was following all laws, riding this direction from this place as he always does, blah, blah blah.  I used my patented “skip to the part where it’s an emergency” more than once and finally he explained the napkin on the arm.

He got bit.

By a dog.

While on his bike.

I did a quick double take.  On the bike, even crouched over his shoulder is a good 5 feet off the ground.  How did a dog-

And that’s when the delivery truck in the far left lane, the one right in front of us hit a pothole, tilted and gently scraped a no parking sign.  Judging by the sign and the scratches on the truck, not to mention the truck not stopping, happens all the time.

The dog was in a car.

It was hard not to stifle the giggles and my partner is a pro at getting the giggles out, so my next question was tough.

“Did you get a look at the dog?”

He suddenly had somewhere to be and rode away before we got his signature on the form, but I imagined him on his hipster bike, riding along in traffic and some dog out for a joyride just sniffing the air decided to see what the City tasted like.

 

That was a first.  And it reminded me that as soon as you think you’ve seen it all-BAM-sumpin’ new.

 

Sideways

I am a big skeptic of putting the 2 people with the least ability to assess a situation in charge of the system’s response to a reported emergency, but until we change things they can only code what they are told, right?  And the caller is never, ever, EVER, wrong.  Especially when describing technical rescue.

 

THE EMERGENCY

A caller is reporting he has fallen over 50 feet and is unable to walk.

 

THE ACTION

I had to read it twice too.  First party caller has fallen 50 feet, unable to walk.  Should be unable to do most things after that fall, especially when he would have hit the ground at a decent pace, then suddenly stopped.  Stranger things have happened, right?

The dispatch rounds out, after us in the engine, the truck, medic, Battalion Chief and Captain, with the Rescue Squad.  Further questioning suggests the patient is trapped.  Never before have I wanted the TV version of EMS to be true so they could patch me directly through to the caller and figure this all out.

 

Arriving on scene my firefighter and driver are grabbing some hand tools and a long spine board when we all look around the address for a second, an old habit of sizing up burining buildings.  None of the surrounding structures, trees, even light poles are more than 20 feet off the ground.

Something doesn’t smell right.

The balance of the assignment arrives as we head inside, ready to treat trauma.

We found drama.

A middle aged man is sitting on a chair still on the cell phone with the call taker, no apparent injuries.  He is inside a single story building and the folks standing around him seem confused as to why so many firemen have arrived.  The rest of the units are cancelled as we begin to learn the tale of the “long fall.”

This gentleman tripped on the sidewalk and would like to know who he can complain to after we take him to the hospital.

“Why would you goto the hospital?” I asked, already knowing it was a mistake.

“For my injuries, of course.  I must be hurt if the ambulance took me in.  I’m on disability already and can’t be expected to get around on my own all the time.” Was his response as his cell phone rang.

The caller on the other end wants to speak to “whoever is in charge over there” and I LOVE these calls so as the EMT confirmed the appearance of non-injury I spoke to the patient’s wife who also heard what our call taker heard.

“He says he fell 50 feet!  He needs to be taken to a hospital or something, he could die!”

“Sir?” I was embarased it took me this long to put 2 and 2 together, “Where did you trip on the sidewalk?”

“50 feet up the block!  I couldn’t walk!  Go look at that crack!”

He kept giving the distance TO the fall, not OF the fall, hence all the confusion. GIGO.

After refusing to listen to our reassurances that an ambulance ride was not only unnecessary but would end up costing HIM money, he was taken to the local ED “to get checked out.”

While loading up the gear the engine boss decided to go have a look at the crack in the sidewalk that could end up being a killer.  About 25 feet up the sidewalk we saw a slightly raised seam that someone could indeed trip over.

So we taped it off.

Tragedy averted.

 

Of Blankets and Discipline

A very eye catching story has been circulating for a few days involving everyone’s favorite EMS system to hate, Detroit and a Paramedic who claims to have been reprimanded for giving a blanket to a person who was cold after a fire.

I was waiting to comment until the Detroit EMS Administration commented.  Let’s just say I’m glad I wasn’t holding my breath.

As a Quality Manager I see this differently than most line medics might.  On the surface a medic was doing the right thing giving a blanket to a cold person.  It’s what we do most: Make bad days better.  We all know most of the attaboy letters don’t involve medicine but instead note demeanor and comfort measures.

Seems like a non starter.

However, it seems there were some policies in place, whether you agree with them or not, regarding dispensing agency property.

Take a deep breath…I’m getting to my point.

Most Vice Principles have a list of trouble makers who are just under the disciplinary surface and are watching them like a hawk waiting for a reason, any reason, to bust them on a black and white policy violation.

I don’t know enough of the facts to pass a decision regarding the blanket, but I can tell you that if this was brought to my desk I’d ask how we solved all the other problems to be able to spend time on this.  If there had been a decision to reprimand based on the Rules and Regulations, in my experience, there is more going on than meets the eye.

I wander the halls looking for my borderline crews to screw up on something so I can have a chat with them, sure, but more often I’m wandering looking for any chance to talk with them about how things are going.

This could have been a policy enforcement or the straw that broke the camel’s back.

Let’s just hope the camel doesn’t need a blanket.

You Make the Call – Handcuffed

Man it sure has been awhile since we fired up the ol’ You Make the Call Machine here at HMHQ, but I thought it’s finally time to get back on the posting circuit.

 

For you new people, I post a situation, you answer it based on your local policies.

 

Dispatched in the first response vehicle of choice for your agency, the local PD has detained a man who assaulted another person.  The other person is receiving care from your partner and is stable, bleeding controlled and has agreed to transport.  PD presents you to the window of the patrol car where you can see a superficial laceration to the forearm just distal to the left elbow.  There was a small drip of blood that appears to be dry, no other injuries are obvious through the window.

After repeated pleas the officer agrees to open the door and remove the patient but warns that he became violent when they took him into custody.  He stands and allows a brief primary and secondary exam and you note no other deformity or injury.  He is refusing vital signs, treatment and transport in colorful language, but denies alcohol or drug use.  When asked if he understands the risks of refusing assessment and treatment he replies in the affirmative and states his reason for assaulting the man and the police is his business, not yours.

 

Is he able to refuse service?  If so, who signs the form when PD tells you there’s no chance of him removing the cuffs to allow for a signature?

 

You Make the Call.