What`s-Up Docs

Within the industry of healthcare, at least, deserving doctors can achieve the status and prestige they really should get from society at large. In the prehospital arena in particular, some have such lengthy records of accomplishment that they've attained almost a kind of celebrity status, drawing rapt crowds to conference presentations and commanding attention with each new article published or protocol changed.

     A handful of municipal EMS medical directors fit this mold. Guys like Paul Pepe in Dallas, Joseph Ornato in Richmond, Ed Racht in Austin and Michael Copass in Seattle are familiar names to EMSers who peruse medical journals and attend industry shows. But such rock-star docs aren't the only ones achieving significant things with their EMS systems. There are many smart, accomplished medical directors doing positive things to improve their services and benefit their constituencies. This article profiles three such docs.

Two Of Everything
     Imagine the headaches involved in removing EMS from your city fire department and merging it with a county third service. That's the challenge Neal Richmond faced when he came to Louisville, Kentucky.

     Formerly deputy medical director with FDNY, Richmond arrived in Louisville in November 2004. Three months later, Louisville Fire Department EMS merged with Jefferson County EMS to create Louisville Metro EMS (LMEMS). The new organization's CEO, as well as its medical director, Richmond had to manage the transition.

     "The mayor often talks about feeling like Noah, where he had two of everything," Richmond says. "There were different payrolls, different shifts, different staffing patterns, different protocols, different benefits. There were two different cultures-a fire culture and an EMS culture. And suddenly you're in a position of having to hang that all together."

     The immediate challenges were many: County providers were represented by the Teamsters, city ones by the IAFF. County providers worked 12-hour shifts, city providers 24. And when things went live that Valentine's Day, the new system had an estimated 60 vacant positions to fill. All of this and more had to be reconciled without missing a patient-care beat.

     "It sounds trivial, but a lot of the early challenges were basic administrative issues," Richmond says. "There were two different unions, and we had to go through a vote process and collective bargaining negotiations. We were more than 60 people down, so a big issue was keeping a reasonable number of units out there. Once we got through all that, probably our biggest issue was to erase the boundaries."

     Those would be physical boundaries that, although Louisville and Jefferson County governments had merged into a single entity in 2003, still separated city fire response areas from county EMS response areas.

     Says Richmond: "It was ridiculous to have a unit answer a 9-1-1 call from across the county when three blocks away there's an urban apparatus that can't be dispatched because they're on a different CAD system, different 9-1-1 system, the whole bit. The challenge has been melting away those boundaries and allowing us to run units across the county, east to west, north to south."

     Part of the solution was a new, integrated communications operation, MetroSafe, that brought police, fire and EMS dispatchers together in one interoperable entity. MetroSafe launched last September, and a new, state-of-the-art 9-1-1 comm center will open this June. Everyone, for the first time, will be on the same CAD, working as a single agency.

     Other boundaries separated regional fire department first-response agencies. Their previously fragmented and inconsistent response policies were streamlined into all-hours reliability.

     "There were services participating at certain times of the day, at certain days of the week, with different priority-level calls," Richmond explains. "We now have all 18 fire departments providing 24/7 response capability to certain priority-level calls at a minimum. Most have also agreed to cross jurisdictional boundaries. So for the first time, we have them thinking about mutual aid for emergency medical calls, not just for fire calls. That's going to have a tremendous impact."

     Other innovations have included paramedic fly cars for increased response efficiency, and creating an associate's degree program for medics at the city's Spalding University. Response times have been cut. Protocols have been rewritten to more clearly delineate the duties of LMEMS personnel in things like hazmat and technical-rescue incidents. Medical changes are likely to come next.

     "We have a whole list of things we want to get to," Richmond says. "Now that the system's running, we can start to really take apart the protocols and introduce some things. It'd be really neat to pioneer some new approaches and use this as a testing ground for new technologies and skill enhancements, education and training."

     With any large-scale EMS transition, there are bound to be bumps. But Richmond's boss is pleased with the first year's results. Says Louisville Metro mayor Jerry Abramson: "We have more EMS personnel than ever before. We have more ambulances than we had adding the old city and county departments together. We've added the fly cars, and this new paramedic program is just superb. We couldn't be happier."

A Statistical Bounty
     Serving as medical director for one major metropolitan area can be difficult. Try doing it for two.

     As medical director for Oklahoma's Emergency Medical Services Authority (EMSA) and its Medical Control Board, that's John Sacra's job. His agency serves 1.1 million people in central and northeast Oklahoma, including both Tulsa and Oklahoma City.

     "It makes things interesting," says Sacra, whose career in emergency medicine spans back more than 30 years. "I spend a lot of time in my car and videoconferencing, but it's rewarding. It gives us a great deal of economy of scale, as well as providing a lot of clinical data."

     Data is important, and EMSA has a unique opportunity to collect it. Two major metro areas with the same protocols, same provider training and same quality assurance processes can yield a statistical bounty that might not be possible in other systems.

     With a pre-EMS background in trauma systems, Sacra was well aware of the need for data and how useful it can be in evaluating what you do.

     "I saw, in organizing resources for optimal trauma care, how some of the things we intuitively thought would make a difference, when you started really looking at the evidence, just didn't," Sacra says. "MAST trousers are a good example. There were a lot of things that fell by the wayside when you started to look at the evidence. And that's what intrigued me about getting into EMS: We've really not tapped into the public-health potential that emergency medical services have for the communities and citizens they serve. You really have to get into looking at the data in order to show that."

     In the quest to make better use of the information available to it, EMSA began utilizing electronic patient-care reports and automatically reviewing all its runs. This provides a wealth of information that, in turn, feeds system improvements.

     One example: a movement early in Sacra's tenure to put paramedics in all the region's fire stations to improve cardiac arrest survival rates.

     "We studied our chain of survival and realized that our weak link wasn't advanced life support, it was time to first shock and bystander CPR," Sacra says. "If we'd just had a knee-jerk reaction and put more paramedics into the system, we'd have missed an opportunity to truly improve. And where we have improved our system now is getting more citizens trained in CPR and encouraging our medics to get to the scene faster with their defibrillators."

     Back then, bystander CPR occurred in about 33% of witnessed arrests. Now the rate is around 50%.

     Another initiative involved reorganizing the cities' trauma systems based on the types and rates of patients being seen. "We couldn't have done it," Sacra says, "if we didn't have the data."

     Data is central to many of EMSA's efforts, and it's not just to benefit EMS. The knowledge it yields, Sacra says, can prompt public-health measures that can improve a community's overall health and safety.

     "Most people think that what EMS deals with are unpredictable events, but they're not," he says. "It's very predictable as to the numbers and types of patients we deal with on a daily basis. So then it becomes a matter of designing the system to manage that predictable load."

     By doing that, it follows that you can better distribute the load, better calculate and spread out costs, and perhaps even prevent problems on the front end.

     "For instance, we now know where our most dangerous intersections are in both cities," Sacra notes. "Now we can convince our elected officials that we need to stop red-light runners and speeding at these intersections, and we'll make our community a much safer place to live.

     "It really shows the power of emergency medical services. When you start to collect this data and use it to drive the design of your system, it's just incredible what you can do for your community."

     In October, Sacra will receive the American College of Emergency Physicians' Award for Outstanding Contribution in EMS.

Acquiring The Tools
     The development of Tucson's pioneering EMS telemedicine program has, rightly, garnered a lot of media coverage. ER-Link will allow the streaming transmission of video, still images, physiologic data, ultrasound scans and more from Tucson Fire Department ambulances to the city's Level 1 trauma center, University Medical Center. The system is the first of its kind in the U.S. It will go live this summer.

     ER-Link was the brainchild of Tucson's transportation officials, but determining how to use it optimally fell to Dr. Terence Valenzuela.

     "My role was mainly to figure out how we'd implement it," says Valenzuela, the TFD's medical director since 1985. "How do we actually fit it into taking care of people so it doesn't make things more complicated? So that it augments what we do without us spending more time on scene and having to do a bunch of things that distract us from taking care of the patients? One of the things medical directors ought to do is make sure that whatever is proposed that paramedics do is actually feasible within their circumstances."

     The plan is to phase the system in slowly. Initially, it will be used only for trauma cases-that's a controlled environment in which having earlier information can allow docs to wield hospital resources more appropriately.

     "Every trauma center has a graded response: The sickest patients get everybody there when they arrive-lab people, x-ray people-and that's very expensive," Valenzuela says. "If we can match the resources we have more exactly to what the patient's condition is, it will allow us to provide the same care a lot more efficiently."

     As it increasingly is in so many systems, data is also central to progress in Tucson. Prehospital providers there, for instance, have been doing 12-lead electrocardiography since 1987. And department leaders are currently "rebuilding from the ground up" on a quality-assurance system that will allow them to better monitor the impact of any changes they make.

     "There's a mountain of data in most urban EMS systems; it's a matter of accessing it and being able to use it," Valenzuela says. "We set up to collect fairly complete data on cardiac arrests in the late 1980s, and we've used that as our main outcome indicator, because everything has to work to save somebody in cardiac arrest-the dispatch system, the whole thing. It's one medical problem where survival depends on what happens before they get to the hospital. So by building our data analysis and problem tracking around that, then we're able to branch out into looking at other problems.

     "There are so many interesting problems in EMS. The challenge is acquiring the tools to address them intelligently. I took a year's sabbatical to get a master's in public health, primarily to learn about study design and statistics. I was dissatisfied with my competency at doing studies and analyzing other people's studies. I think that's helped a lot."

     Tucson providers were also ahead of the curve on the importance of chest compressions in CPR. As of around 2½ years ago, their protocols began calling for uninterrupted compressions before defibrillation; changes to the AHA's CPR guidelines released last year, of course, placed a greater emphasis on those chest compressions.

     The department aims to collect three years' worth of data before formally determining if more people are being saved by this method, but similar projects elsewhere have them optimistic.

     "One of the reasons we decided to do it was it looked like there was very little downside," Valenzuela says. "It seemed unlikely we could harm anybody by doing it. It seems to go a little more smoothly than it did before. Whether we're actually saving more people, we'll know pretty soon."

     As exciting as the coming years look for EMS, Valenzuela's biggest concerns for his service run toward the mundane-things like modernizing training and keeping rising call volumes from overwhelming his system.

     "One thing we're looking at," he says, "is whether we can create an intermediate tier of response, geared toward minor problems, that doesn't necessarily result in only two choices (refusal or transport). We're looking at ways we can treat and release more people, and for ways that people who call 9-1-1 and don't really have a medical problem-because it's the only way they know to get help-can be hooked into community resources and get their problems addressed.

     "Fortunately, in Arizona they've set up the regulatory framework to allow a lot more treat-and-release. The hard part is figuring out how to do it safely."