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Evolving EMS: Preventative Care a Focus in the Field

Sept. 07--The tones go off in the station and a paramedic, EMT and chaplain jump into the ambulance, slamming the doors as the driver starts the truck and flips on the lights and sirens.

Pulling carefully out into traffic on South Hanover Street in Carlisle, the ambulance and its passengers start the emergency trip to the scene of a call, navigating traffic as efficiently as possible.

As they arrive at the scene, everyone grabs gloves and gear and hits the pavement to seek out the patient.

This patient eventually decides she doesn't want to go to the hospital, but the paramedic on the call hooks the patient up to 12-lead electrocardiogram that transmits her heart's electrical activity readings straight to a doctor at one of the local hospitals.

Even with the doctor's suggestion that she go, the patient still refuses, and the crew packs up their gear to drive back to Cumberland Goodwill Emergency Medical Services headquarters.

Even as recently as 10 years ago, that scene in July would have played out much differently.

But now, with so many advances in technology, better and more comprehensive data can be collected by emergency medical technicians before they transport a patient to the hospital.

That change is one of many ambulance companies, such as Cumberland Goodwill EMS in Carlisle, West Shore EMS and Shippensburg Area EMS face.

Standards of care

The entire medical field is under a transformation, with the focus shifting toward preventative care and reducing repeat visits from patients. Emergency medicine isn't immune to that change, said Nathan Harig, the assistant chief at Cumberland Goodwill EMS.

Community paramedicine programs, where a paramedic performs a follow-up with patients after surgical procedures, are popping up all over the county.

Cumberland Goodwill runs a program with Carlisle Regional Medical Center. West Shore EMS has one with Holy Spirit Health System. PinnacleHealth System recently started a similar program.

Having a paramedic assigned to a non-emergency role to make a couple of house calls and check on patients is a way to reduce medical mistakes and possibly reduce readmissions. Harig said that's just one of the ways the field is shifting.

"One of the big changes is just how we manage resources," he said. "We're not just looking at that 911 call. Resource management has to include the community paramedic, the outcomes, transferring them to a facility, we have to keep all of this in mind versus just 911 calls."

Even with the switch in focus, Robert Pine, the chief of Cumberland Goodwill EMS, said the field isn't necessarily moving completely away from public safety.

"EMS is striving to become more efficient, more cost effective and as a result of that, (just transporting patients) isn't always in the best interest of the patient," he said. "The divergence from public safety is a tough one in EMS, because we still are public safety in certain realms. Because we still are involved in prevention and we still are responding to the auto accidents and doing the public safety measures. But we are still health care, so it's a constant struggle for EMS in identifying itself."

Equipment

With the change in scope of services, there is also a change in what EMS personnel must carry.

Harig said because of the nation's increasing obesity rate, there has been a need for bariatric trucks that carry larger stretchers and equipment to help get someone who is obese out of their home and into the ambulance without an EMT getting injured.

The bariatric truck can help no matter what, but it can be dispatched more quickly if the dispatcher knows ahead of time that there is a need for the equipment, Harig said. So, when a 911 call comes in, that caller can tell them that the patient is more than 300 or 400 pounds, which will immediately let the EMTs know that they will need the bariatric equipment. West Shore EMS and Shippensburg EMS also have bariatric equipment.

Cumberland Goodwill will also take calls ahead of time from people who are obese and may need extra assistance getting out of the house. They will go to that person's house and develop a plan that includes the easiest way to get the patient out of the house in the event of an emergency. Harig said that may not be something that the Carlisle community knows, but it's an important addition to their services and equipment.

"If you live in the first-due area and you are (partially or completely immobile) because of obesity, please let us know and we will come up with a pre-plan so we can figure out how to get you out of your house if you suffer a medical emergency," he said. "If we need (the fire department) we want to make sure when we get there that they know what to do and we know what to do, instead of standing there for two hours to get someone out of their house."

Another upcoming addition is a change to the stretcher itself.

As of right now, if an ambulance were in a crash and flipped over, the stretcher wouldn't stay locked in place.

EMS companies are starting to update the locking systems in their trucks because of upcoming protocol. Paul Christophel, the executive director of West Shore EMS, said it's just a recommendation right now, but it will likely become a requirement to have every truck contain the new locking system.

Other changes will address passenger safety and lighting.

Because the equipment for this change is so expensive, the new system will drive up the price of the already expensive ambulance. Harig said the current version of a factory-direct ambulance costs about $110,000, but that is expected to increase $20,000 to $30,000 with the new changes. Supplies would be an additional cost.

"Restrained seating is going to be a big one," Christophel said. "They're (also) going to have to install a system to keep that litter (or stretcher) in place if the vehicle were to go on its side or roll over. Right now, it doesn't do that. They're big on making the sterile cockpit where there's no distraction for the driver, too."

Education

Training is always required in order to make any change to how emergency medical personnel are expected to perform their jobs. So, every time a new program is added, CPR is changed or technology is updated, crews have to go through a training program, which can take up a lot of time and cost a lot of money. Christophel said the training required for a candidate to even become certified has gotten a lot more difficult as the standards of care have gotten higher.

There are now more medications about which paramedics need to know, and there is new protocol they have to follow, so it can get complicated and hard to recruit new people for the job. While the education has gotten more involved, it has also gotten less hands-on and moved more to online. A paramedic has to do 36 hours of continuing education each year, but that can all be done online instead of having to sit in a classroom.

Christophel said because that scares him a little bit, they do some continuing education of their own where the skills each person should know are verified during hands-on training.

"The practical training requirements aren't as robust as they used to be," Christophel said. "Paramedic (certification) is about two years, they don't graduate with an associate's unless they take extra classes. So the push right now is to get the paramedics to be at the associate's level. Everybody should be more toward the four-year level of education -- that's where I see it going."

Sharon Boyles, an EMT for Shippensburg Area EMS, said she started working in the field in 1978, and since then the entire industry has seen a complete makeover. Now with so much new technology and all of the changing protocols, she said the training courses are hard to keep up with.

If the changes continue, it's going to force out the volunteer EMTs because the cost of classes and the time commitment aren't worth the return.

"(Technology) is going to force the providers to become more educated, and because of that, I think there's going to be less volunteers because it's going to be more of a drain on their time," she said. "Which means it's going to be more costly to the public, but that's what I see coming. I just think that our whole medical system is becoming more complex."

Public perception and involvement

Christophel said one of the most important, yet often lacking, areas of the overall emergency care field is the public's perception.

Because emergency medical services are in higher demand as the population ages, the calls are getting more complex. Christophel said as the average person lives longer, the average age of those patients increases and they have more conditions to make the calls more difficult.

He said as that happens and more education is needed for paramedics to be able to continue to care for those patients, the public needs to continue to support their local companies. He said people think an ambulance is paid for by their taxes or their insurance, but it's a lot more complex than that.

"I always call us the secret service of public service because people don't really think about us," Christophel said. "Police and fire get a lot of media attention, but EMS doesn't really get a lot of attention because we're only taking care of one person at a time, normally. No one really thinks about it until you or a loved one (needs) it, and that's probably partly our fault because we have to tell people more and be out there in the public."

A lot of residents don't understand how the ambulance companies get their funding, but then want to know how come their bills are so high, he said. Christophel said he encourages everyone to become a member of their local company, because that gives the company money to continue running their business and gives residents a less costly bill.

Copyright 2014 - The Sentinel, Carlisle, Pa.

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