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.