Small Population, Big Plans

Frisbie Memorial Hospital EMS/ambulance service was established on April 1, 1980, and was the first hospital-based service in New England. Since then, it has developed into one of the most progressive EMS services in the northeast. Frisbie EMS has been designing and implementing new programs and protocols throughout its history, with some of the most recent being rapid sequence intubation in the field, sepsis alert, STEMI bypass and c-spine rule-out.

Located in Rochester, NH (population 33,000), the service responds to 5,000 calls a year, which include all 9-1-1 calls in the city of Rochester, as well as mutual-aid backup and paramedic intercepts to surrounding communities covering 650 square miles.

FMH EMS consists of a staff of 30 paramedics, which operates two dual-paramedic ambulances 16 hours a day and one dual-paramedic ambulance on the eight-hour overnight shift. There is also a single-paramedic intercept unit 24/7. When not on calls, the EMS staff is an integral part of the Frisbie Memorial Hospital Emergency Department. Each paramedic, under the direction of the emergency room doctor, is teamed with a nurse to help cover a portion of the emergency department, triage, cardiac, trauma and medical areas, and assist in delivering patient care. Departmental expectations and responsibilities go a long way in helping maintain each paramedic's critical thinking and practice skills.

In 2000, we identified a rise in closed head injuries, which increased airway safety risks. To maintain patient safety and quality of care, we implemented an RSI program. The paramedics and EMS medical director worked to develop a program based on Los Angeles' RSI program. Once complete, it was trialed for six months in the ED, where medics did intubations using the drugs they'd use in the field. The medics became adept at the procedure. We then moved the protocol to the prehospital arena in the spring of 2001 and trialed it there for another six months. During that period, the paramedics had a 95% success rate at first-time ET intubations and a 100% success rate when using the backup King airway when the ET attempt failed. Since its inception, the RSI program has expanded to include any patient who cannot maintain his/her airway due to trauma or illness, with the same percentages of success. We attribute this success to continued education and training in RSI and working closely with the ED staff.

In June 2006 FMH EMS medical director Robert Anthony, MD, discussed our program at the International Conference on Emergency Medicine in Halifax, Nova Scotia, in a presentation entitled "Prehospital Rapid Sequence Intubation in a Rural Setting: Just as Good?" Frisbie has since received inquiries about the program from numerous other EMS systems. In spring 2009, the New Hampshire Bureau of EMS adopted this RSI program as state protocol.

ST-elevation MIs (STEMIs) have long been a problem for EMS and small community hospitals. It was no different at Frisbie. Time translates into loss of cardiac muscle. Since FMH does not have an interventional cath lab, patients arriving at its ER lost precious time waiting for a cardiology consult to determine if we should send them on to the nearest hospital that did. Our medical, cardiology and paramedic staff saw this as a major obstacle to meeting the AHA standard of 90 minutes from door to balloon. Working with the cardiology group from Portsmouth Regional Hospital to reduce recognition and reperfusion time, we designed a STEMI diversion program. When paramedics recognize a STEMI in the field, they now call medical control at FMH to declare a STEMI divert. With this notification and a 12-lead faxed to the ED, PRH is then notified of the STEMI diversion to their facility. Paramedics transport the patient directly to the PRH cath lab, located 25 miles south of Frisbie.

While they're en route, a fibrinolytic questionnaire is completed. If all questions are answered correctly, the patient is given a heparin bolus. Since the onset of this program, the paramedic staff has had a 95% rate of correctly identifying STEMIs in the field and initiating diversion. They are transporting patients from scenes to PRH, which can be a 45-minute transport, to cath lab and reperfusion in less than 90 minutes.

Sepsis is another area in which Frisbie EMS has been proactive. According to the CDC, sepsis is the 10th-leading cause of death in the U.S. Research has shown that early identification and treatment of sepsis greatly reduces mortality. To identify sepsis as early as possible, Frisbie EMS carries point-of-care finger-stick lactate meters. These meters, along with a good clinical assessment, can detect the beginnings of a shock state in the septic patient. We can then start treatment in the prehospital setting.

Under new ACLS guidelines, Frisbie EMS is starting a trial on prehospital hypothermic treatment for post-arrest patients. We're doing this in conjunction with the hospital ICU, and hope to have the complete protocol in place by the end of 2009.

Frisbie EMS prides itself on the quality of its prehospital care and strong customer service. Its staff uses PL Custom Medallion ambulances and ZOLL E-series monitors equipped with 12-lead, telemetry and capnography, along with CPAP for respiratory patients. Monthly trainings with the Laerdal SimMan and M&M rounds make for interesting and lively continuing education. Having strong administrative and medical staff input makes Frisbie a unique and educational work environment.

For more information, contact John Levitow, jlevitow@fmhospital.com, or visit www.frisbiehospital.com.

Mike Kennard has been in EMS for 31 years, and currently works as a paramedic at Frisbie Memorial Hospital in Rochester, NH. He is also a program coordinator for the New Hampshire Bureau of EMS.

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