A Trip To The State House - Indiana SEA 224

Once again, I am putting a planned, very long blog entry on hold regarding beliefs. It is hard not to continue with my scheduled blog as the church choir is practicing "Thy Strong Word" in the background and it stirs my heart (I am writing this from the church library while my oldest son is in class). I am doing this entry instead because I have made a promise that as Chairman of the Indiana EMS Commission, I will use every possible method at my disposal to keep Indiana EMS informed of what is happening. When we are educated, we make better decisions and our patients and our profession are better served.

So here goes...

On October 23rd I was able to do something for the second time in my life that I honestly thought would never happen again. I had what I consider a great opportunity... a chance to speak before a group of Indiana legislators.

If you have never heard how I feel about Indiana as a State, let me enlighten you. I love Indiana. I love our state flag and I hold it with 99.9% of the regard that I have for our nation's flag. I love how our EMS is structured... in such a way that it allows the provider medical director and the local community to decide how to provide evidence-based medicine and not be tied to only what the lowest common denominator provider can provide (as what happens in some states using state or regional protocols). I love the majority of our laws as they actually make sense. I love how our current administration has made costs a focus and requires fiscal impact studies... it is good stuff.

I am also a firm believer in the concept of state sovereignty in regards to federal government. The will of the State comes first (that topic may be saved for another blog entry).

As many of you know, it was my ultimate career goal to be a member of the Indiana EMS Commission, let alone spend any time as Chairman of this group. Fire Chief John Buckman once told me several years ago after I was first placed on the Commission, "You have a designated amount of time to make a difference. Use it well." Those sage words ring in my ears every day.

As Chairman, I have one of the greatest Vice Chairs anyone could ask for, Deputy Chief Chuck Valentine of Decatur Township Fire Department. He is the very definition of a true paramedic with the patient's best interest at heart. Most of all I consider him a friend. It is very easy for us to come to consensus and find a path that works for the majority and makes sense. He believes in data and evidence-based medicine just as I do.



Indiana House Chamber

 With all of this said, I had the opportunity just over two years ago to testify before the Indiana Health-Finance Commission regarding my beliefs on paramedic licensure. I was awed that I got to stand on the floor of the Indiana House Chamber and deliver this testimony. It may not seem like much, but for me it was a very humbling and inspiring experience to speak to these Representatives and Senators and have them ask questions regarding my profession. I enjoyed the opportunity even though I think most people would call it stressful unless they did it every day. It gives you the chance to see how government works.

I never expected to get the opportunity again.

Well... during a whirlwind of working as a simple member of the committee drafting the report required by SEA 224 (the committee itself was not a whirlwind, but most of you know what I juggle every day)... I was made Chairman of the Commission by Governor Daniels and would actually get to be a signatory of the report alongside State Fire Marshal James Greeson.



Indiana Senate Chamber

 I then learned last week, that I would get to be the one to deliver the high points of the report verbally to the same Health-Finance Commission. This time it would be from the floor of the Indiana Senate Chamber. Again, I was awed. For a paramedic to get to speak in just one of these venues regarding EMS is a once in a life-time experience, but to get to speak in both... well, I still feel humbled. I also feel better educated as to how to help others understand the intricacies of what we do and the level at which we do it.

So what was this all about?

SEA 224 required that the Indiana EMS Commission to answer eight questions within a specified time frame. Those questions were:

1.      Policies and procedures for calling and responding to 911 calls for emergency medical services, including the determination of what type of health care emergency service provider should respond to the call

2.      Any requirements or guidelines for equipment that should be on an ambulance or other emergency services vehicle that is necessary to respond to the emergency medical needs of an individual.

3.      Ambulance response time for emergency calls.

4.      Ambulance transportation procedures.

5.      Procedures or policies for health facilities to obtain emergency and non emergency medical transportation for health facility residents.

6.      How ambulance coverage is affected by ambulances that are subject to geographic or jurisdictional limits within a county, city, town, or township.

7.      Procedures or a policy for determining to which hospital a patient is transported.

8.      A review of the state trauma care system.

Understand that these questions may seem a bit tough, but remember that they are not being asked from a perspective inside EMS. Think about them as being asked by any member of the public.

If you would like to read the detail of the report, I will place the link at the end of the blog.

I want to concentrate here on the evidence behind question number three, "Ambulance response time for emergency calls." This gets into issues of when does the clock start? What constitutes arrival on scene? Is the data collected manually or via computer time stamping? You get the point.

Let's talk about the "eight minute rule." If you have been in EMS any length of time, you have probably heard that response times of less than eight minutes are best for the patient. This all stems from a 1979 JAMA article by Dr. Mickey Eisenberg (I will post the link to the abstract below).

EMS accepted this for many years, nearly without question. The problem is that science marched on. First response became more prevalent and gained more capabilities. Fire Departments jumped on being EMS responders. As fires decreased, an increase was recognized by fire departments in the need to be on EMS scenes. AEDs became very prevalent. Life saving care became prevalent before the arrival of a transporting ambulance.

This has called the eight minute response time into question. There are many entities looking at this today. I will put a handful of links at the bottom so you can do your own reading. The point is that it is time for enhanced local system development. We need to assure that:

1) First responders and ambulance providers are working together to collect and review local data.
2) National level evidence-based outcome data is being utilized to direct what is being done.
3) First responders and ambulance crews must train together and review calls together.
4) Implement care that evidence-based.
5) Ensure quality CPR.
6) Train bystanders in hands-only CPR and forget about issuing a CPR card.

These things have been shown to make a real difference in outcomes.

Dispatch prioritization of calls can also assure that shorter response time preference is given to calls of a more critical or time sensitive nature.

If we can get these things to happen, we find that the response time of the ambulance does not matter near as much. We still have to educate and understand public perception, but adherence to a mythical eight minute standard will cost communities millions in resources. The less the resources are used, skills degrade. We know this. I can post links on that too if anyone wants to do the reading. More runs per unit means better caregivers and better skills performance.

I just wanted to give everyone reading an idea of what goes on behind the scenes. Our legislators really do want to know what is going on and that the people they represent are being protected. They worry about what is right. They worry about cost I am sure also.

With these things being said I would be remiss if I did not mention the people who I shared this recent experience with, all of whom are committed individuals working toward the same ultimate goal... advancing EMS toward better patient outcomes: Mike Garvey (IDHS), Rick Archer (IDHS), Mara Snyder (IDHS Legal Counsel), John Zartman (EMS Commissioner), Tony Murray (Indiana Fire Alliance) and Art Logsdon (ISDH Trauma). All of these people have devoted themselves to the service of the State and EMS.

The authors of the report are on page two. The report was built through consensus. That to me is the best part.

Let me close with Rick Archer's drafted conclusion that was also agreed upon via consensus: Indiana's "Emergency Medical Service providers are a passionate, dedicated group of people who work tirelessly for long hours and at personal hardship to be there for their friends, family and fellow Hoosiers in their time of need. Hoosiers want and expect a timely, professional emergency medical response to arrive when they perceive a medical emergency is occurring. Public perception of “timely” response vs. what is really needed is a difficult dichotomy to address. Because of unmeasured and uncontrollable factors, a fast “response time”, despite public perception, can be irrelevant to the outcome of seriously ill or injured patients. What occurs before arrival of an ambulance is more predictive of successful patient outcomes. Better public education on signs and symptoms of true medical emergencies and when to call EMS is needed. Better utilization of the many resources in the community to collaborate with ambulance services to create a true “systems approach” to EMS is needed including better collaboration with law enforcement, public health, schools, business and industry, and neighborhood and civic organizations. AED availability in businesses, industrial complexes, schools, and other venues where large crowds gather should be an integral part of the EMS system. A dynamic “first response” capability, using the closest public safety unit, be it fire, law enforcement or EMS provider, to respond in those cases where quick intervention with a simple medical procedure could mean the difference in a positive patient outcome. Such an approach is more cost-effective and reduces the need to have expensive ambulances racing from long distances while nothing is being done to assist the patient."

Here are the links to the report and supportive info on response times (not all there is of course):

http://www.state.in.us/legislative/igareports/agency/reports/HOMESEC04.pdf SEA 224 Report.

http://www.co.portage.wi.us/EMS/Portage%20Co%20EMS%20Stategy%202012%20and%20beyond.pdf  Excellent Powerpoint on one communities view on response times.

http://jama.jamanetwork.com/article.aspx?articleid=364653 JAMA Abstract from original 1979 Mickey Eisenberg article – applies to ambulance response times in cardiac arrest before robust first response and AEDs.

http://www.usfa.fema.gov/pdf/efop/efo37506.pdf

The Washington, DC 2004 study – This was by FEMA. Found little impact of shorter response times with the exception of public perception.

I hope you find this informative. Thank you for reading.

1/12th of My Life... (or WHY POPCORN ?)

At the moment, I have four draft blog posts in various stages of completion. I can tell you that the one about my beliefs is going to be a long one… hopefully laden with references and at the same time informative without being inflammatory (although I will warn you in advance that my favorite section of the hymnal is labeled “The Church Militant”).

With that said, back to the title… 1/12^th of my life.

It happens the last week of September every year (I remember doing this as a Cub Scout in the early 1970’s). Boy Scout Popcorn. It runs through what is usually the last weekend of October.

It started again for me in 2005 when Michael became a Cub Scout. We sold a bit the first year (I thought having over $100 in sales was pretty good actually). Then we went to over $300 the next year. Then over $1,000 the year after. 

During the 2011 sale, between Michael and Luke, our family sold $6,124 of BSA Popcorn. So, why the family focus on this aspect of Scouting? It is called the “Power of Popcorn” by many in Scouting. It’s a bit pricey (but so is any fundraiser you look at… it has to be to earn money to support the organization doing the fund raiser).

1)      70% goes back to Scouting. 30% pays for the product. The remaining 70% is split between the local Council and the unit selling the product. For us that means we have a Scouting support staff and center locally to help us accomplish what we do as a Scouting unit (whether that unit is Cub Scouts, Boy Scouts, Venturing, etc…). It also means that we as a unit get critical funding. In Cub Scout Pack 310 this goes to support the Program itself (a pinewood derby track can cost $1,500 or more) and a portion goes to each individual Scout’s account to pay for approved items such as uniforms, camping fees, gear, etc… (this helps make possible the ability to participate for low income families). In Troop 310, 90% of our split goes into the individual Boy Scouts account. Why so big a portion? Summer camp is around $200. A good pair of hiking boots is well over $100. If a Scout attends Jamboree he is looking at $1,200. A good backpack is $200. Again, this helps all be able to afford being involved to get the fullest experience out of Scouting. The Scout’s account can be used to help fund a portion of their Eagle Scout project as well.



Annette & Michael



2)      The Scholarship. Once a Scout has sold over $2,300 in a single year’s sale, they are a part of the Trail’s End Scholarship program. Every year they sell after that, 6% of their sales) regardless of amount) is donated by Trail’s End to a scholarship for that Scout for College expenses. It earns interest too.

3)      The sale teaches responsibility. To make sales they have to talk to people in several ways. They have to ask people to buy face-to-face (salesmanship, confidence and communications). They also have to ask parents to see if they will post a flyer at work and family to gather sales (networking, developing processes). They have to handle and count money (financial management and responsibility). They have to figure out how to make themselves presentable for the sale (grooming, uniforming, presentation, signage and sometimes a gimmick… like a garden cart loaded with popcorn wheeling don your street). It is a big learning experience.

4)      Incentives… yes, they earn prizes. But the prizes are big in correlation to a BIG workload. To get good prizes… they have to work HARD.

5)      With that said… its exercise. It is exercise for both the parents and the youth. You cannot sell a lot of popcorn without walking a good distance (Michael and I are over 10 miles of residential area this year), loading and unloading boxes and being outside.



Luke in 2010



6)      From my point of view… it allows me to teach as a parent. How do you politely knock on a door. Should you walk on a lawn? Do you bother people mowing their grass? Do you thank them for supporting Scouting when they say they have purchased already from another? Time spent in this endeavor is not wasted as a parent.

7)      It gives people a chance to ask about Scouting. What rank are you? What is that merit badge for? That is a neat Neckerchief. Some buyers even ask the Scout to say Scout Oath and Law (I love it when that happens).

8)      The Scout gets to hear the stories on the door step… I went to Philmont in 1964… I did an elevated trail construction for my Eagle project… I did not make my Eagle and here is why… those stories that customers tell on door steps is a wonderful thing for the Scout to hear.

9)      Where do you go to church? When that question comes up it gives the Scout the ability to relay their faith and discuss it.

10)   The Troop actually gets a performance bonus back also that pays for almost a full year of awards, rank and advancement related patches.

Those are just a few of the reasons we do this massive endeavor. I know that both of my boys have handled large sums of money now. That experience is invaluable.

It wears me out.

It wears my wife out more…

She works with one of our boys while I work with the other on sales. Sometimes we trade off.

She serves as the “Popcorn Chair” for both the Pack and the Troop which is a huge job… ordering, sorting, distributing, setting up store front sales. All of this plus helping her own sons sell. She also helps the District with sorting the popcorn when it comes in from Trail’s end.

Needless to say, this is why 1/12^th of my life each year, centered around the wonderful Fall month of October, rotates around popcorn. For the part of our lives that is Scouting and a personal ministry through our units. When you buy popcorn from us, that’s the story.

At this time, Michael has walked over seven miles and has sold around $2,200 of his $3,150 goal. Luke is around $1,450 of that same amount.

We were the highest selling family in the Council last year. Michael still has the goal of someday being the highest selling scout… We have not figured out how to get there… yet. Last, year that hard working scout that sold the most had over $6,000 in sales.

So, I am finishing this blog from a McDonald’s on the west side of Evansville on a lunch break from driving Michael all over Vanderburgh County.

Now for the shameless plug… If you would like to help, send me an email to gleeturpenii@gmail.com or message me on Facebook. We deliver anywhere in about a four county area.

If you don’t buy from us… please take a moment and think about the 102 years of impact that Scouting has had and still has today and buy from the Scout that comes to your door to help keep this effort vibrant and strong.

If you are at a distance and would consider buying popcorn for shipment to you, here are links for Michael and Luke:

http://www.trails-end.com/estore/home_alt.jsp?_requestid=2780017#     Michael

http://www.trails-end.com/estore/home_alt.jsp?_requestid=2780444#     Luke

Luke is currently a bit behind due to two bouts of illness since the start of the sale.

Thank you all, as always for what you do in your many daily vocations. Praise always to our God and his Son Jesus Christ.

God is good, all the time. All the time, God is good!

Till I next get the chance to debrief of the 4F trail… be safe!

EMS is a Mixed Bag of Tricks

That's what EMS is: A mixed bag of tricks. Being an EMT or a paramedic is an extremely diverse job. I once heard it said (although non-scientific) that a paramedic must be able to process nearly 300 points of data during their first minute of patient contact.

I never thought about that much until I took part in an experiment with a certifying body. In a room full of doctorate level analysts, myself and four other designated SMEs (subject matter experts) were given a verbal patient scenario. We were asked to openly state at each step what we would do in that situation. It was amazing as to how each of us (different backgrounds and cities) answered relatively the same or readily agreed with a peer. We were of course told that we were picked because of our backgrounds of long term management of EMS and having worked as field paramedics. What struck me in this was that it took hours for us to walk through this process of a single patient contact so that the researchers could analyze how we used critical thinking to arrive at our conclusions... and just as I had been told many years ago, just how many data points and decisions occur in a matter of seconds.

That being said... We are products of how our axons, dendrites and synaptic clefts have developed. What we accept to be truth in training and experience subconsciously directs our critical thinking. This is the engine behind what we do. In a way, however, it is also our greatest flaw.

In taking my Six Sigma training, there was one quote that always stuck in my mind: "What you know is wrong." So many times this has been proven to be true when I look at data. That is a known fact... WRONG. I predict that... WRONG. This is the cause of... WRONG. And so it goes.

And our care and critical thinking is directed BY WHAT WE KNOW. That is why we have to look at data, studies and most of all "true outcomes" (in other words, it doesn't matter if you get a pulse back if the patient does not survive until discharge... Your definition of a save may not be exactly what the patient is looking for here).

My last post was a bunch of links to data, quasi-science and peer reviewed articles. Now, on the scale of validity, peer reviewed is always the best, but even those can suffer from flaws such as inadequate subjects in the test field. Manufacturer studies are always suspect as they may be tainted subconsciously to a desired outcome.

So how do we define "evidence-based." Sometimes that is just looking at real data. At other levels it must be peer-reviewed. It depends on how important it is to mortality and outcomes. In a nut shell, to be called evidence based, it has to address these points:

1) Is the data as clean as it can get?
2) Has bias been removed or at least accounted for?
3) Are the results convincing?
4) Can the data and results be replicated elsewhere?
5) What is the impact?
6) Is the resultant course of action more efficacious and safe than what we have today?

Now, let's look at some examples:

1) Did you know that the relationship between Epinephrine and cardiac outcome had never been studied until recent years? But we blindly want everyone to have Epi because it "saves lives."





MAST or PASG



2) For years we added (what we are told) are precious minutes to trauma scenes by applying MAST (or Pneumatic Anti Shock Garment) to patients that were bleeding to death? Why? It worked to "save lives" in Vietnam so it had to work here. When someone finally decided to measure it, the results were not replicable. The time frames to surgery at MASH units was much shorter and transport was mostly by helicopter in Vietnam. Here, we saw it raised blood pressure and we gave it a big thumbs up. We at the same time prided ourselves on getting two 14 gauge IV lines and pouring liter after liter of fluid into trauma victims. There are plenty of buried bodies to prove that both concepts were wrong... which brings us to number three.



Vietnam Era Bell UH-1b Iroquois



3) "We need intravenous therapy at levels lower than paramedic." Why? "It saves lives." At the services I have worked for during the last decade or so, we have all practiced fluid restrictive resuscitation in trauma. We have known that fluid in trauma has been de-emphasized. Read the opening statement at this link: 

http://www.trauma.org/archive/archives/permhypo.html

What does that tell you. It is the current scientific model. Large volumes of fluid simply hinder the bodies ability to compensate for shock. On top of this, with the advent of many nasal administered meds, the RAMPART study showing that IM Versed is faster than IV Versed in seizures, sublingual Zofran... well, you can see that we just don't have an increasing need for IV access in the field.

4) Some of the caregivers finishing the new AEMT program in Indiana desire adult EZ IO. I agree. It makes sense for those rare times when a drug route is needed and cannot be gained with an IV. But has anyone thought what happens if you do an EZ IO on a conscious patient without Lidocaine prior to the fluid push? You might find your patient in pretty intense pain. PRIMUM NON NOCERE! That said, I would say they need Lidocaine for the IO... but not Lidocaine for anything else. Why?

5) Look at the numerous studies on Lidocaine vs. Amiodarone. Fairly inconclusive as to which is better. Some minor arguments exist that the Vasopressin/Amiodarone combination has some additional numbers attached to it.... but, in all of this has anyone looked at the proarrhythmia issue? What is proarrhythmia? It is what happens sometimes about 24-72 hours after you give Lidocaine. Some patients return to their ventricular arrhythmia and cannot be converted easily. This happens less with Amiodarone... far less. So I would argue that this fact alone makes Amiodarone the better antiarrhythmic medication.

6) For years we pushed D50. Then along came a shortage and many of us had to switch to bags of D10. What did we learn? No combative wake ups. Less chance of necrosis. Less incidence of phlebitis. Less incidence of headache upon waking. BUT WE HAD TO BE FORCED BY A PROBLEM TO LOOK AT A DIFFERENT MECHANISM AND CHANGE.

Those are just a few examples... there is getting ready to be a ton of data collection starting on cervical immobilization. Why? Read up on internal decapitation by cervical collar application. Not pretty. Neurologists are already calling for change.

I understand that there are a large number of people who want to keep doing what they are doing now. The problem is that there have been issues nationwide with these skills producing outcomes or increasing numbers of complications due to low initial training hours or infrequent skills use.

I am not opposed to seeing any caregiver get any skill AS LONG AS THEY CAN THROW THE EVIDENCE BASED DATA ON THE TABLE. I want to make one very clear statement:

NONE OF US GET TO DO WHAT WE WANT TO DO IN THE BACK OF AN AMBULANCE JUST BECAUSE WE WANT TO DO IT.

Be very careful when you say your only reason is: "It saves lives."

In many ways, Indiana is ahead of the game. I talk to many EMS operations in a lot of places. Many wish they had what we have on the Paramedic level... local control of the medicine. I personally see many states with drastically stale and outdated protocols because they are on a state or regional protocol that is a lowest common denominator so that all can comply. We do not want that to occur. At the same time, the EMS Commission's charge is to build functional EMS systems. We cannot do this if we ignore evidence-based medicine. We have to start making all providers meet a test of need for a waiver to the rules. And most of all, we need evidence.

This entry could go on for ever, but it does not need to do so.

This train is leaving the station and hopefully it will never return.

What did the Conductor say in The Polar Express?

"The thing about trains... it doesn't matter where they're goin'.... what matters is whether or not you decide to get on."

In this case, we know where the train is going... focusing on outcomes produces better outcomes.

We function by what we believe. Don't you want to make sure you are believing the right thing?

Are you going to get on?

We Interupt Our Regularly Scheduled Program...

I lied. I will discuss my Faith in a blog in the near future.

This is an information laden post as it has been brought to my attention that there may be some who need to have examples of evidence-based medicine. So... here are some links to quasi-scientific and some peer reviewed evidence-based information. Some is data, some is true evidence.

In my next blog, I will give some actual story style examples, but this should keep you busy if you are a clinical animal such as I...

http://gatheringofeagles.us/

http://gatheringofeagles.us/EaglesPresentations.html

http://gatheringofeagles.us/2012/2012Presentations.htm Latest presentations...

http://gatheringofeagles.us/2012/Presentations/Slovis%20IV%20Epinephrine.pdf Epi

http://gatheringofeagles.us/2012/Presentations/McMullan_Eagles_RAMPART.pdf Versed IM

http://gatheringofeagles.us/2012/Presentations/Goodloe%20BLS%2012%20Lead%20ECGs.pdf BLS 12-Lead

http://gatheringofeagles.us/2012/Presentations/Colwell%20Use%20of%20Blood%20Products%20and%20Substitutes.pdf Blood products and substitutes

http://www.ncbi.nlm.nih.gov/pubmed/ Pub Med is storage of all peer reviewed studies

http://en.wikipedia.org/wiki/Permissive_hypotension Wiki on permissive hypotention

http://www.trauma.org/archive/archives/permhypo.html Read the opening statement

http://www.emsworld.com/article/10319458/collar-me-bad The tip of the iceberg on c-collars

https://roc.uwctc.org/tiki/tiki-index.php?page=roc-public-home Resuscitation Outcomes Consortium home page

http://informahealthcare.com/doi/abs/10.3109/10903127.2010.519822 Zofran

http://www.ncbi.nlm.nih.gov/pubmed/21091329 Zofran again... Angelo Salvucci is one top notch Doc.

http://www.ncbi.nlm.nih.gov/pubmed/9212810 Zofran

http://www.ismp.org/newsletters/acutecare/articles/20060810.asp Why we should not use Phenergan

http://www.youtube.com/watch?v=79lJuEM5FnQ 2006 video from FDA on Phenergan

Have a good day! More to follow soon!

The Idea... Part 4

Tooth of Time - Cimarron, NM
9,003 Feet Elevation

It has been a few days of extreme busy work and sheer exhaustion, not to mention an ill child and a mound of make up homework that would rival the Tooth of Time in height (not actually, but it seems that way)... So I apologize for not adding this part of "The Idea" in a timely manner. But we must press on so that I can explain my rationale for this online journal creation and venting of my mental diatribe. And for those of you that know me... it is a good thing for me to vent from time to time (how many times can you use the word "time" in one paragraph?).

Well... It seems I promised some EMS in this part as I recall. What a better way to deliver that than by pursing where we left off regarding the intense week of travel. As I alluded to, there was finally a day in the office where I managed to get a few pressing things done. Of course, not near as many things completed as to match the rate at which projects labeled themselves as "incoming!" in the same manner and warning of an artillery shell.

That particular Friday found me waking up at 3am to be on the road by 4am. Had a short meeting to attend in Brownsburg an hour before my first EMS Commission meeting as the Chairman. Looking back... I have been on the Commission since 2005. I was voted the Vice-Chairman in 2006 by my peers on the Commission.

This sudden elevation to the Chair came as an appointment rather than an election. I am not always sure as to how government works, but I would like to think that someone (or more than one) thinks that I can handle this and do well at leading the Commission. One of the changes that I have been wanting to see for awhile has been one of perspective. Indiana's EMS Commission is by nature a reactive entity. Part of that is by design as it is a decision based body which weighs facts and impacts of a variety of issues. These range from the certifications of providers and caregivers to actually approving new rules and regulations regarding how EMTs, Paramedics and ambulances perform.

When I took the EMT course (back in 1983), there was a section of the course, near the beginning where EMTs would learn the number of people on the Commission and what the Commission was responsible for doing in regards to Indiana. Even when I became a paramedic in 1987, the Commission was still prominent and was understood to be the lead role in the continuing formation of Indiana EMS and at the same time, the watchdog over proper prehospital practice. They don't include this in curricula anymore. Now it is hard to find an Indiana EMT or paramedic who even know the Commission itself exists at all. Many times, the first time anyone has even heard of the Commission is after they have been reported for some alleged wrong-doing. Certified (and now some licensed) individuals usually have contact with an EMS Commission staff employee (or Indiana Department of Homeland Security - EMS Division) when they have a question, recertify (relicense) or need clarification on regulation. The IDHS EMS staff does the massive daily work and handles the majority of what makes EMS function on the government side of medical response. With that said, it is no wonder that there is a bit of a disconnect between the line EMS caregiver and the Commission from the bottom up perspective.

I assure you, that is not the case from the top down view. For the last several years, the Commission has dealt with some pretty big issues in the state that affect Hoosiers dramatically. The act of adopting a Trauma rule is one of those issues. It took a great deal of time, a great number of meetings, much gnashing of teeth and sack cloth renting to publish a trauma rule in the state. Many issues and opinions were in play. Many providers reported on the issue of impact regarding transporting patients out of their communities and what that would do for coverage. Whether or not paramedics (and EMTs) could handle patients for the sometimes long transport times to a designated trauma center was brought up. Many arguments even took place. But today, through hard work and consensus, a trauma rule exists. Indiana's propensity for using time as a measurement of distance even showed up and was debated as we discussed the trauma rule.

The Commission has debated adopting the new national certification levels and the attached scope of practice for each. This one is still heated even after the adoption of each level. Herein lies another reason for this blog... communication of my reasoning on certain issues.

Meetings are limited in time and scope. I would love to be able to hear every question and deliver an answer to each person attending a Commission meeting. That would be fair. We would also never finish the business at hand. Always remember this... any person can write a letter addressed to the Commission and send it to IDHS. All of the Commissioners will see it and then will be aware of your desires. Also understand that it isn't always about desires. Let me state some facts:

1) I do not hate or dislike EMT-Basic Advanced level personnel.
2) I do not hate or dislike EMT Intermediate personnel.
3) I do not hate or dislike those desiring to be the new AEMT level.
4) I am not out to get you... I really don't have the time for that...

With that said, let me explore some reasons for my actions on these topics over the last few years.

1) I have instructed no less than five EMT-Basic Advanced classes. I have worked with many great EMT-BA certified individuals. I believe that the ones I have known were all about patient care. I will tell you that I always had some qualms about the curricula. I never liked the fact that it did not teach all ECG rhythms. That just is not safe... allowing someone to use an ECG monitor but then tell them you are only going to instruct them in how to interpret 90% of the rhythms? Does that sound safe to anyone? If you are working on a truck with a medic, its all good... but what about the unit that has the EMT-BA as its highest level of provider. I worry about that person being stuck in a position of possibly not knowing a rhythm because it was outside of scope.

2) The EMT Intermediate was designed primarily for the rural setting where some paramedic skills and medications were just not frequently utilized. It was a shorter, less costly way of doing advanced life support. Here are some issues. During the time frame of the I-99 curricula (as it is referred to nationally) it was found that field intubation has a high incidence of mortality (I will not go into the reasons yet... that is a blog entry of its own). Drug errors by I-99 personnel were more frequent (this was noticed nationally (not referring to Indiana specifically). It is just the truth that there was too much skill/knowledge needed for too short of a class.

3) The new AEMT (Advanced EMT) was designed to rectify the training level and scope of the "middle ground" certification. It gives some advanced skills but limits the scope to essentials that can occur with a short time frame of training while steering clear of skills that require frequency of use to assure proficiency. This is about as close as we get to an evidence-based middle ground certification.

4) I have heard many say that they have to do the middle ground due to cost. I can tell you that the main difference in cost between and Intermediate EMT ambulance and a Paramedic ambulance was not in the equipment, drugs, vehicle or insurance... it is in payroll. So essentially what you get with the Intermediate is a lower paid, 85% paramedic. I do not think this is fair to the Intermediate. I know of some communities that send their paramedic units out on long distance transfers, leaving the Intermediate units to run the 911 calls.

5) If you... as a provider, or as a certified individual want to do all of the skills, we have a license (almost said certification) for that. It is called Paramedic. There is very little evidence-based proof regarding the impact of prehospital EMS. We now know quality CPR is the trick behind save rates. We know that Lidocaine is proarrythmic. The efficacy of c-spine immobilization is in question by neurologists. We know that IM Versed is faster than IV Versed in seizure patients (the RAMPART trial proved that... and we thought IV was always faster!). The list goes on. The middle ground desires IV therapy while we continue to learn that the effect of IV therapy on outcomes is limited. More nasal medication administration is coming. IV starts are sometimes sacrificed to get a patient to therapy 2-3 minutes faster. All of this information is out there. Here is where I will get on a soap box. Periodicals like JEMS are good. Scientific medicine periodicals are better. Read Annals of Emergency Medicine or Prehospital and Disaster Medicine. These are studies and are peer reviewed. If you want to attend a conference about the breaking knowledge of medicine, pick something like the "Eagles" Conference (The EMS State of the Sciences Conference) or the annual meeting of the National Association of EMS Physicians. These are where you can learn what is really going on.

6) Look at data. Every last one of us thinks we know the facts in EMS. Data tells us that we are usually wrong. A saying in my Six Sigma training rings like a bell: "What you think you know is wrong." Data helps us discern the truth from myth. Do you have any performance data to look at where you work. This will always be a work in progress, whether you are new at data acquisition or savvy at it. Data tells us that we need to look at an airway tool kit rather than Intubation as the Cadillac of airways.

In all honesty, My personal thinking tells me we need three levels of certification/licensure: Emergency Medical Responder (the First responder), EMT and Paramedic. We simply need to establish a specified standard of care and get everyone there, so that all patients get the most evidence-based care (not always provided by a paramedic. The fact that I think that way does not mean I am acting to try to not have the AEMT. The AEMT is here and will be here to provide care.

The thing we have to be careful about is adapting that certification level because we want to or because we "have that skill now."

We need to make these decisions based on data and proven outcome related facts. We do know one thing. The shorter the training is coupled with infrequency of skill does not deliver good outcomes. If a middle ground certification is to get a more advanced skill then the length and content of training must be equal to that required of the higher level on that subject. Training 90% of ECG rhythms is not safe or fair to the caregiver. Teaching skills without the commensurate A&P educational requirement is not a safe practice. This is why when I hear of "adding" to the middle ground certifications I tend to get vocal.

We need more CPAP, less Lasix. More vascular access, less fluid. More accurate assessment, less immobilization. More reading, less conjecture. If EMS is ever going to be taken seriously, we need to get our behavior under control. We all know of that "one time" when "this" helped "that patient." Is it repeatable? Does it stand up to scientific scrutiny and does it produce an improved outcome?

I heard of a paramedic student recently not wanting to ride with a preceptor because he was being grilled about the services protocols rather than what was taught in class. Get over it. If you are going to ride on any agencies ambulance and deliver care in their name, then you had best have an operational knowledge of their protocol set. Internship is a liability laden privilege. Be glad you get to be there, wherever you may ride. Remember... you are a student. No one has to be a preceptor.

Please think about these things. As I discuss, learn and vote, I am doing so for the patient and to also assure that you have a continuing pathway to success. It is not to harm you in any way.

I was once asked why I did not support a paramedic in a vote regarding their certification. The person asking me thought I should have supported the paramedic because I held the seat representing paramedics. I explained that I could not because of the evidence presented. Sometimes that is just how it is. Without evidence, it is difficult to support. Primum non nocere... First, do no harm. I also support assuring that providers of all types receive appropriate reimbursement. When we make a change that affects reimbursement, we limit what can be provided to patients. That is a simple fact.

Now to change gears... ever notice how many times we are told to be "Strong and Courageous" in the Bible? There are a lot of passages saying just that... look at the book of Joshua alone.

I returned that Friday evening to load five pallets of popcorn into my garage... rather tall pallets at that... my life, each October is popcorn. Our two boys in Scouting sold somewhere in the range of $6,100 worth of the stuff last year. So it begins again.

I learned tonight that a friend of mine's father has Stage 3 cancer in several locations including the lymph nodes. Prayers for my friend, his father and his family would be appreciated.

So, that said, be strong and courageous whatever your vocation of the moment... Faith, Family, Forest or in the Field (of EMS). So this is my idea. A running commentary on these things. It will be my thoughts and I as always take ownership of what I say or write.

Hebrews 4:12
Hebrews 11:1

Next time, I think I am going to tackle a small bit of Scouting stuff and explore why I am a Missouri-Synod Lutheran. Buckle your seat belts and stay tuned.

Spell check does not seem to be working tonight on Blogspot, so I apologize for any errors. Goodnight all...