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Debate and dialog reign at
the annual gathering of EMS
medical directors.
By Michael Gerber
Medical directors from some of the largest EMS
systems in the nation (and a few from overseas)
came together in Texas earlier this year for the 16th
annual Gathering of the Eagles conference. And
one thing was clearcoming to a consensus in
prehospital medicine is not easy.
In fact, one of the highlights of the conference was a debate between Ray Fowler, M.D.,
chief of EMS operations for the Dallas-area BioTel system, and Tucson Fire Department
Medical Director Terry Valenzuela, M.D., over whether the long backboard should be
routinely used for spinal immobilization. In between inside jokes and lighthearted personal
digs at each other, the two veteran EMS physicians cited dozens of studies in defense of their
arguments. Fowler argued in favor of reducing backboard use, while Valenzuela titled his
talk Keep the Backboard: Nothing Sensible Ever Goes Out of Fashion. In the end, it was
clear that even though two major national physician groups had recently published a position
paper questioning the routine use of backboards, medical directors and EMS agencies still
have to make a decision based on evidence that can be interpreted in many ways.
Brent Myers, M.D., who serves as both the department director and medical director
of Wake County (N.C.) EMS, said that conducting any kind of rigorous clinical trial of
backboarding would be nearly impossible because of the relatively small incidence of spinal
cord injuries. So the debate likely wont end anytime soon.
Tese are some of the dilemmas faced by prehospital providers and their medical directors
in an age of evidence-based medicine, a recurring theme during the conference. While EMS
Continued on page 7
Continued on page 10
In an efort to staunch the string
of deadly helicopter EMS crashes
that have killed dozens of patients
and providers over the past two
decades, the Federal Aviation
Administration (FAA) issued a f-
nal rule on Feb. 20 that introduces
wide-ranging new safety require-
ments for air medical operators.
Te new rules include abiding
by stricter fight rules and proce-
dures for dealing with situations
such as landing in remote areas
or fying in poor weather, equip-
ping helicopters with additional
safety devices and improving
pilot training. In an FAA news
release, Transportation Secretary
Anthony Foxx called it a land-
mark rule for helicopter safety.
More stringent air medical
safety rules were frst proposed in
2010, afer the National Transpor-
tation Safety Board (NTSB) held
a series of hearings to address the
high rate of crashes and suspected
over-use of helicopters in emer-
gency response. Yet the NTSBs
resulting recommendations for
improving air medical safety
appeared to languish for several
Te 159-page FAA fnal rule
incorporates many of the NTSB
recommendations. Among the
new rules, helicopter EMS opera-
tors must:
Equip helicopters with radio
altimeters, which measure
Quick Look
May 2014
Vol. 17 No. 5
SCA survival, not community paramedicine, dominate the agenda at the Eagles.........................1
40 years of celebrating EMS .................................................................................................................. 2
Medicaid expansion increases ED visits in Oregon ............................................................................ 3
Allina Health EMS Brian LaCroix on how to keep the fre burning ................................................... 4
How a rural EMS system is using data to rebuild after Mother Nature strikes ...............................6
White paper urges support of mobile integrated healthcare ......................................................... 10
Beyond the Lone Ranger: Great teams ............................................................................................. 12
Highlights from this issue
Up Front
Jacob Knight
Editor in Chief
Keith Grifths
Carole Anderson Lucia
Art Director
Morgan Haines
Editorial Board of Advisers
Bonnie Drinkwater, Esq.
Drinkwater Law Ofces
James N. EasthamJr., SC.D.
CEO, CentreLearn Solutions, LLC
Jay Fitch, Ph.D.
President, Fitch & Associates
Stewart Gary
Principal, Fire & EMS Services
Citygate Associates, LLC
Kevin Klein
Director, Colorado Division of Fire Safety
WilliamKoenig, M.D., FACEP
Medical Director, Los Angeles County EMS
Jon R. Krohmer, M.D., FACEP
U.S. Department of Homeland Security
Pete Lawrence
Battalion Chief
Oceanside, Calif., Fire Department
Todd J. LeDuc, MS, CFO, CEM
Deputy Fire Chief, Broward Sherifs Ofce
Department of Fire Rescue & EMS
Lewis Marshall, M.D., J.D.
Chairman of Emergency Medicine
Wyckof Heights Medical Center
Brooklyn, N.Y.
Patrick Smith
President, REMSA
Gary L. Wingrove
Mayo Clinic, North Central EMS Alliance
Best Practices In Emergency Services (ISSN 1540-9015)
is published monthly by
Te National Emergency Services Institute
679 Encinitas Blvd., Suite 211
Encinitas, CA 92024
Tel. 760-632-7375 Fax 866-448-1436
2014 by Te National Emergency Services Institute
All rights reserved
Subscription rates: USA: one year: $279;
two years: $450 (save $108);
outside the USA: Please add $10 per year.
Best Practices is a membership beneft of the
National EMS Management Association.
Research Monitor
Reimbursing ambulance providers to transport patients to desti-
nations other than emergency departments could save Medicare
an estimated $283 million to $560 million a year. If private insur-
ers also reimbursed for alternative destination transports, the
savings could be even larger, according to a study by researchers
from the University of California, Irvine, and colleagues.
Researchers analyzed a random sample of 5% of the roughly
7.1 million ambulance transports resulting from 911 calls by
Medicare benefciaries between 2005 and 2009. Between 12.9%
and 16.2% of Medicare-covered transports were either not emer-
gencies or were for conditions treatable in a primary care setting,
the study found. Of patients not admitted to the hospital, about
35% had low-acuity diagnoses that could have been treated at
less-costly places such as doctors ofcers or urgent care centers.
Te study was in the December 2013 issue of Health Afairs.
Only about 10% of out-of-hospital sudden cardiac arrest victims
survive, according to the American Heart Associations Heart
Disease and Stroke Statistics2014 Update. And at just 5%,
survival rates for children are even lower.
Using data derived from a Resuscitation Outcomes Consor-
tium multi-center clinical trial registry, the 2014 update found:
More than 1,000 people sufer out-of-hospital SCA
daily in the U.S., including about 26 children.
EMS assesses 424,000 SCAs annually, or about 60% of
the total number of out-of-hospital SCAs.
25% of SCA victims treated by EMS have no symp-
toms before the onset of their arrest.
Among EMS-treated cases, 23% have an initial shock-
able rhythm of ventricular fbrillation or ventricular
Blacks and Hispanics have a higher age-adjusted risk
of SCA than whites. Tey also have a lower rate of
survival to 30 days post-hospital discharge.
Prior heart disease (heart attack or heart failure), or a
family history of cardiac arrest in a parent, sibling or
ofspring, is associated with an increased risk of SCA.
Survival to hospital discharge afer EMS-treated
non-traumatic SCA with any frst recorded rhythm is
Survival afer bystander-witnessed VF is 31.7%.
Among people who survive to hospital discharge,
fve-year survival is better among those who receive
angioplasty (78.7% vs. 54.4%) and among those who
receive therapeutic hypothermia (77.5% vs. 60%).
Survival rates are higher among those who receive
compression-only CPR (10.2%) vs. chest compressions
and rescue breathing (8.5%).
Each year, EMS responds to SCAs in 9,500 children
under the age of 18 and treats 7,700 of them.
Black athletes aged 17 to 24 are at higher risk of SCA
than whites, while male athletes are at higher risk
than females.
Survival to hospital discharge afer EMS-treated SCA
in children is 5.4%. About 7,000 children die annually
from SCA.
Of cardiovascular deaths that occurred in athletes
younger than 18, 29% occurred in blacks, 54% in
high school students, and 82% with physical exertion
during competition or training.
Te SCA update was published in the January issue of Cir-
culation. Te summary of the reports fndings was prepared by
the Sudden Cardiac Arrest Foundation.
Fewer children are dying in motor vehicle crashes, according to
the U.S. Centers for Disease Control and Preventions Fatality
Analysis Reporting System.
From 2002 through 2011, 9,182 children died in motor vehicle
crashes, including 650 in 2011. Te good news is that over that
same period, the annual death rate fell 43%, from 2.2 deaths per
100,000 children in 2002 to 1.2 per 100,000 in 2011.
One in three of the children who died in 2011 werent in
an age-appropriate restraint such as a car seat, booster seat or
seatbelt, according to the study, which appeared in the Feb. 4
Morbidity and Mortality Weekly Report.
Black children were at higher risk of death: 1.5 per 100,000,
compared to 1.0 for whites. Black children aged 12 and under
were also more likely than whites to be unrestrained at the time
of the fatal crash (45% compared to 26%). Hispanic children were
also more likely to be unrestrained than whites (46% vs. 26%).
Yet usage of car seats and seat belts is increasing, research-
ers found. From 20022003 to 20092010, the proportion of
unrestrained child deaths decreased by 27% for whites, 16% for
blacks and 14% for Hispanics.
In 2008, Oregon initiated a limited expansion of a Medicaid
program for uninsured, low-income adults, drawing names by
lottery. By analyzing ED usage of about 25,000 lottery participants
in the 18 months afer the lottery was established, researchers
found those with Medicaid coverage visited EDs more ofenby
0.41 visit annually per person, or 40% relative to an average 1.02
visits per person in the control group.
Researchers from the Massachusetts Institute of Technol-
ogy and colleagues found ED visits increased across a range of
conditions, including visits for conditions treatable in primary
care settings. Te study was in the Jan. 2 issue of Science.
By Keith Grifths
What were you doing in May of 1974? Some of our more senior readers might have
already entered the EMS profession, inspired by the popular TV show Emergency!,
which had debuted just a few years earlier. EMS was in its infancy then and just
starting to gain momentum, with a big push from that national spotlight.
Another push for EMS in 1974 came from the frst national EMS Week, which
President Gerald Ford had signed legislation for the year before. Te intent of the
week is to celebrate the men and women providing care on the front line, while at
the same time educating the public about what they (and the system) actually do.
EMS Week is May 1824 this year, representing its 40th anniversary. What
are you doing to educate and celebrate?
One common way to do both, and get some media attention in the bargain,
is to encourage your local, regional or state ofcials to issue a proclamation. Te
American College of Emergency Physicians, which creates an EMS Week Guide
each year, has created an updated sample, which weve reprinted below. Its interest-
ing to note how the references to injury prevention, public outreach and being a
member of the healthcare community and providers of care 24/7 are touchstones
of community paramedicine and mobile integrated healthcare.
To Designate the Week of May 18-24, 2014, as Emergency Medical Services Week
WHEREAS, emergency medical services (EMS) is a vital public service; and
WHEREAS, access to quality emergency care dramatically improves the survival
and recovery rate of those who experience sudden illness or injury; and
WHEREAS, EMS plays a critical role in public outreach and injury prevention, and
is evolving in its role as an important member of the healthcare community; and
WHEREAS, frst responders, emergency medical technicians and paramedics
stand ready to provide compassionate, lifesaving care to those in need 24 hours a
day, seven days a week; and
WHEREAS, emergency medical responders are supported by emergency medical
dispatchers, frefghters, law enforcement ofcers, educators, administrators, re-
searchers, emergency nurses, emergency physicians and others; and
WHEREAS, the members of EMS teams, both career and volunteer, engage in
thousands of hours of specialized training and continuing education to enhance
their lifesaving skills; and
WHEREAS, it is appropriate to recognize the value and the accomplishments
of EMS practitioners by des-
ignating Emergency Medical
Services Week; now
THEREFORE, I [name, title,
city, state], in recognition of
this event, do hereby proclaim
the week of May 1824, 2014,
CATED. FOR LIFE I encourage the community to observe the week with ap-
propriate programs, ceremonies and activities.
Running out of ideas for EMS Week?
Go to or
for more information.
2 Vi si t emer gencybest pr act i ces. com for qui ck access to al l web l i nks l i sted i n each i ssue. May 2014 3
President, Allina Health EMS
Allina Health EMS is part of a
large hospital system. What
benefits does that bring you?
Our parent organization, Allina Health,
is a collection of 12 hospitals, more than
100 clinics and a group of specialty op-
erations including pharmacies, homecare
and hospice agencies, durable medical
equipment providers and of course EMS.
So, yes, its a very large organization with
a large number of employees: 24,000.
Being part of this type of organiza-
tion brings us many benefts, but one of
the most important is our connection to
a lot of physicians. Tis connection allows
us to participate in a systemwide devel-
opment of emergency medicine that has
a signifcant impact on patients. For in-
stance, through this relationship we were
among the frst in the nation to develop
a systematic way of identifying STEMI
patients and bringing them straight to
the cath lab. We knew the cardiologists
and they knew us, so we were able to work
together to come up with an efective,
patient-centered program.
Another example is our stroke
program: We sat down with the neu-
rologists in the hospitals and asked what
mattered to them when it came to stroke
care. One illustration of what we found is
they wanted us to use at least an 18-gauge
needle to administer thrombolytics, so
now when we start IVs on these patients,
thats what we use.
Do you have your own culture
within Allina Health?
Allina Health EMS, like all EMS systems
across the globe, lives in the worlds of both
public safety and healthcare, yet the rest
of our parent organization is all about
healthcare. Our EMS folks interact with
frefghters and police ofcers as well as
hospital workers, but the hospital side of
our company doesnt do that, just by the
nature of the work they do. So, yes, were
very much a standalone culture.
What services does Allina
Health EMS offer?
My division is primarily a 911 ambulance
service75% of our work is related to
emergency response. Te other portion
of our work is related to interfacility work:
wheelchair, BLS, ALS and critical care. Im
particularly proud of our partnership with
Childrens Hospitals and Clinics of Min-
nesota, which allows us to ofer neonate
We also have our own dispatch center,
with 30 PSAP dispatchers. Im proud to
say we are well on our way to achieving
ACE accreditationour hope is that we
will have our accreditation wrapped up
by the third quarter of this year.
What sets Allina Health EMS
apart from other EMS organiza-
Culturally, we care a lot about people,
and I dont mean that in a corny way. It
is deeply rooted in all of us that the work
we do is vitally important. On a personal
level, I get up every morning and think
about our patients. I remember my own
experience as a patient and try to instill in
our employees a sense of deep importance
that we do good work.
Te other part of that is that we care
about each other. Our organizational
culture is that we have high expectations
but deep support.
Structurally, being part of a large,
healthy organization makes us fscally
strong and allows us to buy the equip-
ment we need and to hire good people.
And, most important, it gives us access to
and interest from a lot of physicians, and
we enjoy extraordinary medical support.
We are also unique in that we have
two half-time medical directors. Tey
each work half of their time with us in
EMS, and the other part of the time they
work clinically as ER physicians in dif-
ferent Allina ERs.
So, yes, we are part of a large orga-
nization, but that alone does not make
us good. What I always say is that when
a crew steps out of a rig and touches a
patient, thats what makes us good.
Is it true that you have a chap-
lain on staff?
It is. We decided to create this position
post 9/11 because we wanted to engage
our staf in terms of their own well-being.
Our chaplain has a phrase: high ex-
pectations and high support. We expect a
lot out of our people: to know the proto-
cols, to give great clinical care, to be nice
to someone who just threw up in their
shoe. We expect them to do good work,
but we have their back in turn. We support
each other.
His role is not to pontifcate or to
advocate for any religious position at all,
but simply to support the well-being of our
caregivers. He sees himself as a teacher
of self-care.
Physical and emotional wellness
is a benchmark of your compa-
ny. Why is it so important to you?
Yes, we want to take good care of our
employees, but at the other end of the
spectrum is the business case for well-
ness: Burnout, or employees who are not
in a good place emotionally or physically
hurt patient care, hurt job satisfaction and
hurt the bottom line. Its not just that we
have this Pollyanna view.
How do you benchmark well-
ness among your employees?
Tis is another advantage to being part
of a big healthcare organization: We have
epidemiologists and other social scien-
tists whose job it is to do a lot of research.
And part of that research is on employee
Among other clinical work they do,
this group of researchers studies the well-
being of Allina physicians, and recently
they started including paramedics in that
group. What they found is 25% of the
general population identify themselves as
being burned-out. Among family-practice
physicians, that number is about 50%.
Among our paramedics, just 17% identify
themselves as being burned-out. Whats
the secret sauce were feeding them? We
dont really know, but were learning.
Another measure is our annual
employee engagement survey. Tis is a
high priority for our leaders, and their
compensation is based partly on their
employees engagement. If their employ-
ees arent engaged, they need to fgure
out why, and how to help them become
Im very proud of the fact that 87%
of Allina Health EMS workers are fully
engaged. When I started here, that number
was at 34%. Every year weve made a little
headway, but it didnt happen overnight.
Two of your employees were
involved in a crash while on duty
this year. What were some of the les-
sons learned from this?
Our vehicle was transporting a patient
without lights and sirens in a heavy snow-
storm at 1 a.m. and was hit by another
car head-on on a rural highway. Te
patient was uninjured, but two of our staf
members were severely injured, and the
woman who struck us was killed.
It was a tragic situation, but Im just
really proud of this organization. People
from every corner of Allina Health were
there to support our injured colleagues, as
were our partners at the fre department
and in law enforcement.
Te extraordinarily happy note is that
both staf members have recovered and are
doing very well. Tey have a long road of
recovery, but both are highly functioning.
When all is said and done from an
investigation standpoint, I dont think
well learn a lot that we could have done
diferently from a safety point of view.
What we did learn has more to do with
the clich that when the chips are down,
your family will rally. Weve enjoyed an
ever-growing culture of caring within our
organization that was absolutely lit on
fre afer this incident. Te outpouring of
support has been phenomenal.
Your company has a reputation
for having employees who take
great pride in their work. How do you
help engender this?
Teres a concept of line of sight: Everyone
is invited and encouraged to think every
day about how they impact patient care.
Its easy for a medic to understand how
BP Interview
Continued on page 11
Walk into the training center at Allina Health EMS in Minne-
sota and you may be surprised to see an entire wall lined with
a series of paintings depicting the history of EMS. Even more
surprising is the fact that the pieces were painstakingly created
by the organizations president, Brian LaCroix.
EMS wasnt LaCroixs frst calling, you see. Having received a
degree in fne arts, he had worked as a commercial artist for
a billboard company and was freelancing in 1981 when he ex-
perienced a medical emergency and called 911. I was 22 years
old, had a pulse of greater than 220 and was having syncopal
episodes, LaCroix recalls. Te EMTs who came to take care of
me were probably more scared than I was because they had no
idea what was wrong, but they connected with me on a very per-
sonal, human level. Te impact they had on me was extremely
So powerful, in fact, that LaCroix became an EMT and started
working for the same system that took care of him when he had
his episode of PAT (paroxysmal atrial tachycardia). He went
on to become a paramedic, working the streets for several years
before joining Allina Health EMS as an operations manager in
the late 90s. He eventually got a business degree and worked
his way up to president, though he admits that wasnt always his
I didnt have designs to be an EMS chief or president of an EMS
organization, he says. I loved being a feld medic, but I was
intrigued by working with and for a few very good leaders and
eventually became interested in leadership.
Even as the head of a large EMS organizationAllina Health
EMS serves 1 million people in a state with a total population of
5 millionhes never lost sight of why he got into the business in
the frst place. We respond to nearly 90,000 calls each year; 260
times each day, someone, potentially having a similar experi-
ence as I had years ago, calls on my service and asks us to help,
he says. I fnd this to be a profound responsibility.
Now in his 17th year with Allina Health EMS, LaCroix spoke
with Best Practices about how he keeps the fre burning in him-
self and his 570 employees.
I get up every morning
and think about our
patients. I remember
my own experience
as a patient and try to
instill in our employees
a sense of deep
importance that we do
good work.
Brian LaCroix
4 Vi si t emer gencybest pr act i ces. com for qui ck access to al l web l i nks l i sted i n each i ssue. May 2014 5
In Focus
May 4, 2007, is a day that will live in
infamy for the residents of Greensburg,
Kan. At 9:45 p.m. that spring night, an
EF5 tornado, estimated to be nearly 1.7
miles wide, touched down, traveling for
nearly 22 miles. Afer a harrowing 65
minutes, the twister fnally dissipated,
leaving 95% of the rural town leveled and
11 people dead.
Soon afer, the people of Greensburg
and the surrounding Kiowa County em-
barked on the rebuilding process. But
with resources tight and a population
base that would dwindle by nearly 50%
in the following years, rebuilding would
prove tough. To compound the challenges,
the EMS director retired 1 years later.
Enter Chad Pore. Coming from a
larger metropolitan EMS system, Pore
was commissioned as director of Kiowa
County EMS in 2008 and tasked with
helping to rebuild the system. It was a
real challenge, he says. In the beginning,
our EMS system was still operating out
of ffh-wheel trailers and frst responder,
EMT-basic and continuing education
classes were being held in military tents.
Volunteerism was low and resources were
minimal. Tere was a lot of work that
needed to be done to get back on our feet.
Challenges aside, Pore had big plans
on how to rebuild, and he knew exactly
what he needed to get the job done.
He needed to analyze the data.
Te amount of data at an EMS
systems disposal is incredible, Pore
explains, but its up to the director to
be proactive in analyzing it. One of the
frst things we did when I arrived is pull
data on every aspect of our system, from
response times to medication usage to
equipmentwe looked at it all.
For any EMS director, and especially
one who manages a rural system, having
the facts in front of you can make the
decision-making process easier when
addressing system shortfalls. Te frst
things Pore looked into were response
times and the overall coverage of Kiowa
County. What he found was unnerving.
In 2009, our average en route time to
a call was 3 minutes, 48 seconds, and our
on-scene time was 45 minutes, 5 seconds.
We had to improve, he explains.
Afer noticing that 30% to 35% of his
calls were interfacility transfers, which
were currently being run with a big box
ambulance, Pore was able to make several
recommendations to city leaders. Tat
included the purchase of a new Sprinter
Type 2 ambulance.
Te Sprinter would provide the same
service while costing $40,000 less than a
box ambulance, double the mileage and
cut maintenance costs in half. In addition
to the new Sprinter, Pore proposed the
relocation of an existing unit to better
serve the rural community.
Te result? By 2013, Kiowa
County EMS en route time was
cut to 2 minutes, 54 seconds, and
the on-scene time was slashed to
15 minutes, 59 seconds.
What I found in the data I
pulled helped me make the deci-
sions that would beneft our community
and raise the bar on the level of service
we provide, Pore says. I never would
have known where we were falling short
if I hadnt pulled the data and analyzed
it on my own.
In addition to improving response
times and coverage area, Pore drilled
down deeper.He used the data to identify
obsolete medications and to determine
what type of equipment was (and wasnt)
being used on calls on a routine basis.
Having the dataset in front of me
when talking with my medical director
and city leaders was invaluable, Pore says.
Having rock-solid information allowed
me to speak confdently and accurately
about exactly what changes needed to be
made to our system.
Te result? Pore was able to dump
more than 20 medications that had not
been administered in more than fve years
and lighten frst responder bags by more
than 20 poundsall without sacrifcing
patient care or arriving unprepared.
Tis was accomplished by creating
three diferent bags: frst-in bag, airway
bag and the critical-patient bag. None of
the bags weighs more than 10 pounds and
all are still on the ambulance in case ad-
ditional supplies are needed.
Pore also decreased the number and
sizes of various bandages and fuid bags
(among other things) that were carried,
further lightening the weight of the packs
for his frst responders.
Tough Pore is currently pulling his
data through patient ePCR records and
at the state level, hes both excited and
optimistic about moving toward a more
robust, comprehensive national data set,
known as the National EMS Information
System (NEMSIS).
In an era of tight resources and high
expectations, EMS directors should take
the time to pull data on their systems from
every available angle and analyze it, he
suggests. Tat was the biggest beneft to
me and my organization: being able to say,
Hey, heres our dataheres whats going
on. Now lets work to make it better.
And while the residents of Kiowa
County will never forget the disaster that
hit their hometown in May 2007, they can
rest a bit easier knowing that if another
disaster does happen, Kiowa County EMS
is prepared to respond better now than
ever beforethanks to data, leadership
and confdent decision-making.
Greg Gayman
How a rural EMS system is using data to rebuild
Gathering of Eagles
only a small portion of the agenda, one
of the most popular topics was one that
has been debated since the earliest days
of prehospital emergency medicine: how
to improve cardiac arrest survival. Tese
presentations drew some of the most ques-
tions from the audience and provided
some of the more intriguing data.
Te presentations included one from
Joe Weber, M.D., a medical director for
the Chicago EMS system, who discussed a
major efort by the city to improve cardiac
arrest survival rates. You must measure
in order to improve, Weber said, an apt
introduction to the following presen-
tations. Even if the medical directors
didnt always agree on the conclusions
of each others presentations, nearly all
did agree that collecting data, analyzing
it and making improvements based on
that data are critical in any EMS system.
People do [try to improve on] what
you measure said Paul Hinchey,
M.D., medical director for Austin/Travis
County EMS in Texas. But only if you tell
them the results. Measure what matters,
and give feedback.
In Chicago, one of the changes they
are trying to implement and measure
involve simply training providers to stay
on scene longer in order to avoid inter-
ruptions in chest compressions and delays
in defbrillation.
Sabina Braithwaite, M.D., medical
director for the Wichita-Sedgwick County
(Kan.) EMS system, told the story of a
system that was a little further along
than Chicagos in its eforts to improve
cardiac arrest outcomes. Now that the
pit-crew approach and high-performance
CPR have become widespread across the
country, systems like Wichitas can share
some of the pitfalls of implementing these
methodsand ways they have tried to
correct those problems.
For example, in Wichita, they saw
immediate improvements to compression
fraction afer implementing the program,
but they didnt seem to last. We thought,
Tis is great! Braithwaite said. Ten we
started analyzing it and we started back-
As with any good quality improve-
ment process, the team in Wichita delved
into the data to try to fgure out why the
training hadnt made as much of a dif-
ference as theyd hoped to see. Teir frst
Are they doing airway management
thats interfering [with compressions]?
Braithwaite said. But afer further ex-
aminationusing information from the
CodeStat sofware and electronic patient
care reportsairway management didnt
seem to be the culprit.
So the agency focused on the little
things: pre-charging the defbrillator
during every cycle of compressions,
keeping a fnger on the femoral pulse
throughout the entire code, and more.
Afer follow-up training, Wichita found
its average length of pauses in compres-
sions felland survival rates are now
11.3% for all cardiac arrests and 38.6%
using the Utstein criteria (compared to
8% and 24.6% nationally).
Te presentations on cardiac arrest
resuscitation from the medical direc-
tors from Chicago and Wichita, as well
as several other areas, elicited the most
response from an audience clearly trying
to tackle similar issues in their own agen-
cies. In particular, the growing practice
to work cardiac arrest resuscitations on
scene and delay transport until a patient
regains a pulse has led to a new dilemma:
has made great strides in recent decades,
research in the feld is still very ofen dif-
fcult to conduct. But that isnt stopping
some agencies from trying, as was clear
at this years conference.
A few subjects dominated the agenda this
year, while some were notably absent or
rarely mentioned. For instance, although
they were discussed by a few speakers,
community paramedicine and mobile
integrated healthcare were not high-
lighted, and few lightning round questions
touched on the subjects.
I think that was a conscious de-
cision, says Marshal Isaacs, M.D.,
medical director for Dallas Fire-Rescue
and a professor of emergency medicine
at UT Southwestern Medical Center,
which sponsors the conference. Pri-
vately, medical directors from several of
the nations largest agencies questioned
whether the current focus on community
paramedicine programs is encouraging
agencies to rush to create new programs,
without frst determining what the needs
of their communities are and whether they
are capable of providing those services.
While the EMS topic du jour received
Te Gathering of the Eagles started in 1998 as a small group of medical direc-
tors who got together to share ideas with each other and some paramedics
and other EMS administrators. Tey realized that between them, they were
responsible for prehospital care for a large chunk of the nations population.
Over the years, the conference has grown, and while the core group of
Eagles remains small, more than 700 others attended this years conference,
which was held Feb. 28 and March 1 just outside of Dallas. Te conference
format is diferent than any other, with two days packed with 10- to 15-minute
presentations, one afer the next. Twice a day, the entire group of Eagles
gathered on the stage for lightning rounds, where audience members could
question any or all of the physicians in front of them.
Continued on page 8
Continued from front page
For more information on the efforts to
collect data at the local, state and national
level, visit
6 Vi si t emer gencybest pr act i ces. com for qui ck access to al l web l i nks l i sted i n each i ssue. May 2014 7
How long should paramedics attempt to
resuscitate out-of-hospital cardiac arrests
before giving up?
Heres the question we were getting
all the time [from medics over the radio],
said Wake Countys Myers. Teres no
ROSC. What do we do next?
In Wake County, they are trying to
answer that question by looking at data.
Tey have partnered with SAS, a statistical
sofware company headquartered in Wake
County, to help comb through years and
years of cardiac arrests. In addition to
presenting some fascinating new results,
Myers also highlighted the importance
of working with public health and other
partners that have resources that might
not be available internally in most agen-
cies. For Wake County, that happens to be
one of the worlds largest statistics com-
paniesin other jurisdictions, it could
be other organizations that are available
and willing to help.
Myers said they were surprised to
discover that about 10% of their patients
who survived cardiac arrest with good
neurological outcomes were resuscitat-
ed for nearly 40 minutes. So now their
paramedics are ofen working codes for
nearly an hour if they feel its clinically
appropriate, based on a number of factors,
including end-tidal CO2 levels and cardiac
If we have a PEA [with a rate] above
20 with an end-tidal [CO2] greater than 30
[mmHg], we are not terminating today,
Myers said.
Te research presented by the Wake
County medical director struck a chord
with members of the audience, many of
whom seemed surprised at the results,
which led to as many new questions as it
did answers. Certainly other agencies will
now be examining data and their proto-
cols to see if perhaps there is a better way
to predict survivability and know which
patients should be resuscitated and for
how long.
Tats the goal of the Gathering of
the Eagles, say its organizers and veterans
of the conference: To surprise people, to
inspire further debate and more research,
and to change how prehospital emergency
medicine is provided.
Tat was the point made by Ed Racht,
M.D., a long-time Eagle and national
medical director for AMR, when he chose
to abandon his slides and change topics
at the last minute. Instead of discussing
the latest research or a medical topic, he
told the audience that the methods used
to introduce new theories and new ways
of practice are as important as the science
Tis is all well and good, the science
is fabulous, he said, but if you dont so-
cialize it right, youre dead in the water. If
we dont do that, its not going to change
the practice of medicine in our commu-
Cardiac arrest wasnt the only topic being
discussed, and medical directors from
around the country said that the growing
use of ketamine in the prehospital setting
was one of the big take-away messages
from the weekend.
A majority of the big-city medical
directors said their systems use ketamine,
and while many reserve its use for seda-
tion of patients with excited delirium,
others are beginning to explore it as
another option for pain management.
Te pharmacology is diferent than any
other drug we give, said Melissa Costello,
M.D., chair of the EMS Committee for the
American College of Emergency Physi-
Perhaps more fascinating than the
rise of ketamine is the decline of mor-
phine. During one of the lightning rounds,
an audience member asked the medical
directors gathered in front of him to talk
about their preference for pain manage-
ment. Only a handful still use morphine
as their go-to narcotic, while the rest all
strongly prefer fentanyl.
Continued from page 7
Gathering of Eagles
Morphine is not an EMS drug, end
of story, said Peter Antevy, M.D., a pe-
diatrician and medical director for several
agencies in Broward County, Fla. Surpris-
ingly, no one disagreed, demonstrating
just how much prehospital pain manage-
ment has shifed in the past decade.
In addition to its use in pain manage-
ment, ketamine is growing to be more
popular among medical directors for
managing agitated patients who could be
a danger to themselves, the public and
medical providers. In between jokes about
legalized marijuana in his home state,
Denver Paramedic Division and Denver
Fire Department medical director Chris
Colwell, M.D., gave a fascinating talk on
the increased use of synthetic cannabis
products, such as black mamba.
A trial of ketamine for these patients
resulted in emergency department intuba-
tion rates lower than those associated with
prehospital Versed, Colwell said.
While mobile integrated healthcare did
not dominate the agenda like it does at
many EMS conferences and meetings, a
few presentations gave updates on some
innovative programs aimed at reducing
the number of unnecessary emergency
calls and transports. Jef Beeson, D.O.,
medical director at Fort Worth, Texas-
based MedStar Mobile Healthcare, shared
audio recordings of actual low-acuity 911
calls that were referred to his agencys
triage nurse. Even a skeptical patient
eventually sounded satisfed once she
realized that the nurse was going to help
her fnd an appropriate place to receive
care and, most important, transportation
to get there.
Patient satisfaction is high, said
Beeson, who is leaving MedStar to join
Acadian Ambulance Service. Nearly
43% of patients referred to the nurse
triage lines had alternate dispositions,
meaning they were not transported by an
ambulance to the ED.
But Beeson ended the presentation
with a key point. A vision without re-
sources is a delusion, he said. Te message
was clear, especially to the hundreds of
agencies across the country getting ready
to dip their toes into the pool of mobile
integrated healthcare: Dont do it unless
you have resources and a well-developed
During a lunch with the Eagles,
Austins Hinchey also expressed concern
that too many people view community
paramedics as a panacea for all of EMSs
problems. Community paramedicine
is not the answer if you dont need it,
he said. Not only do the programs need
to be specifcally tailored to the needs of
the community, he added, but they would
create an even higher demand for good
EMS providers. Finding good medics is
going to be even harder, Hinchey said.
But Fort Worths Beeson delivered a
second presentation that showed another
aspect of the MedStar mobile integrated
healthcare system, one that appears to be
succeeding and paying for itself. In the
agencys Hospice Revocation Prevention
program, MedStar partners with hospice
to try to prevent ED transports for hospice
patients. So far, the hospice agency (which
pays for the service) has been pleased with
the results, Beeson said, adding that of
the 10 911 calls for patients enrolled in
the program, there have only been fve
transports: three for reasons unrelated
to their hospice status, and two direct-
admits to hospice beds, which did not
result in revocation of their hospice status.
A few other presentations touched on
alternative destination programs, triage
of mental health patients and recidivism,
but even Wake Countys Myers questioned
whether these presentations would make a
signifcant impact. Myers, who presented
on a new protocol that his agency is about
to implement to try to reduce transports
from psychiatric facilities to the ED,
thought the main take-away from the
conference would be the push for coor-
dinated, on-scene and longer treatment
for cardiac arrests.
Te diversity of thought among the
Eagles was refected in the audience as
well, with other attendees listing the dis-
cussions of response to active shooters and
explosions, or the talks about evidence-
based guidelines as the highlights of the
As Racht said, though, the point of
the conference is not to come to an agree-
mentnot on what the most innovative
presentation is, whether community para-
medics are the future of EMS, or even
which pain medication to use.
Arguing and disagreements are
public here, he said. Its an environment
where you can say, Youre smoking crack.
We share our successes, and we share our
failures. Eagles is a place where we get
Michael Gerber, MPH, is a writer and
paramedic in the Washington, D.C., area.
The message was
clear, especially to the
hundreds of agencies
across the country
getting ready to dip
their toes into the pool
of mobile integrated
healthcare: Dont do
it unless you have
resources and a well-
developed plan.
One of the most popular
topics was one that has
been debated since
the earliest days of
prehospital emergency
medicine: how to
improve cardiac arrest
Membership pays. Members of the National EMS Management Association
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Need help? For membership questions or assistance accessing the website
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BP Interview
HEMS safety, continued from front page LaCroix, continued from page 5
height above the ground, used to
help during hovering, landings and
fying in bad weather; and helicop-
ter terrain awareness and warning
systems, used to help maintain
awareness of terrain and obstacles
Require that pilots are tested to
handle fat-light, whiteout and
brownout conditions
Equip helicopters with a fight data
monitoring system within four years
Establish operations control centers
if they operate 10 or more air
Institute pre-fight risk-analysis
Ensure that pilots in command hold
an instrument rating, or the ability
to fy using instruments rather than
Ensure that pilots identify and
document the highest obstacle along
the planned route before departure
Comply with visual fight rules
(VFR) weather minimums, instru-
ment fight rules (IFR) operations at
airports/heliports without weather
reporting, procedures for VFR ap-
proaches and VFR fight planning
Conduct safety briefngs or training
for medical personnel
According to the FAA, 2008 was the
deadliest year for helicopter accidents,
with 21 deaths occurring in fve crashes.
Te FAA estimates the new requirements
will cost the air medical industry an esti-
mated $224 million over 10 years.
Read the FAAs news release at Scroll down to
view a link to the complete rule.
A group of EMS physicians from AMR,
MedStar Mobile Health Services, Wake
County EMS and colleagues recently
published a white paper urging support
for mobile integrated healthcare practice
(MIHP). Te white paper reports that
when associated with EMS, these types of
programs are ofen referred to as com-
munity paramedicine. But that term is
too confning, according to the authors,
because it focuses on defning new roles
for paramedics and EMTs instead of con-
sidering the full range of potential mobile
integrated healthcare assets.
Even so, EMS systems and person-
nel are uniquely positioned to support
MIHP, according to the authors.
Te white paper, Mobile Integrated
Healthcare Practice: A Healthcare De-
livery Strategy to Improve Access, Out-
comes, and Value, was supported by a
grant from the Medtronic Foundation
to the AMR Foundation for Research
and Education. Read it at
Imagine a local park on a beautiful May
day. Joggers make their way along run-
ning trails and families spread picnic
blankets beneath the kite-dotted sky.
Someone strums a guitar.
Tis peaceful scene is interrupted by
the wail of sirens as several emergency
vehicles enter the parking lot. But this
is no ordinary response: As the frst re-
sponders step out of their vehicles, a disco
beat emanates from a boom box, and the
bystanders quickly recognize the tune:
Stayin Alive. Before the Bee Gees get
to the part about the New York Times
efect on man, responders have set up a
mannequin on the grass and begun doing
CPR. More mannequins are deployed as
the crowd grows, and the responders
invite onlookers to take a turn doing chest
Whats going on here? Its part of
the AMR World CPR Challenge. Spon-
sored by American Medical Response,
this years event will take place May 21
across the United States and overseas,
in locations ranging from public parks
to schools, beaches, shopping malls and
more. Last year, more than 54,000 people
were trained in compression-only CPR;
this years goal is to teach tens of thou-
sands more people how to save a life and
make their community safer.
For more information on how you
can get involved, visit
Lauren Chavis, an EMT and senior at
Johns Hopkins University, volunteers 24
hours a week as EMS operations director
for her campus EMS service, Hopkins
Emergency Response Organization.
Although shes thinking of going to law
school, Chavis says working in EMS has
given her experience in leadership and
handling difcult situations she couldnt
fnd anywhere else.
In EMS, you can do good while at
college, not in an abstract way, but in a
very real way, where youre helping real
people in real time, she says.
Chavis is one of hundreds of U.S.
and Canadian college students who
participated in 2013s Collegiate EMS
Week, which is modeled afer the national
version of EMS Week but is held during
the second week of November to accom-
modate college schedules. (In May, many
students are either taking fnal exams or
on summer break.)
Sponsored by the National Colle-
giate EMS Foundation and the Ameri-
can College of Emergency Physicians,
Collegiate EMS Week is endorsed by
Congress. It is a weeklong recognition
of campus-based EMSa time for those
organizations to publicize their services
and educate their communities. Te week
kicks of with National Collegiate CPR
Day, which focuses on training fellow stu-
dents and faculty in CPR. Other activities
can include open houses, blood drives co-
ordinated with local Red Cross chapters,
local or campus media ride-alongs, joint
training with other local EMS or fre agen-
cies, and dorm safety events.
At Johns Hopkins, volunteers for the
BLS ambulance service taught hands-only
CPR to more than 50 people in the quad
and created a hands-only CPR video that
was shown on monitors in university
buildings. Set to heart-thumping music
and depicting the sudden collapse of a
young male student, the video has re-
ceived more than 700 views on YouTube.
Quick Look
In Houston, volunteers for Rice
University EMS ofered free blood
pressure checks, taught hands-only
CPR in the quad and held a special
AED and CPR training session for
employees in a campus building
where a woman had recently died
from sudden cardiac arrest.
Celebrating Collegiate EMS
Week lets the members of the orga-
nization know how much they do
and how appreciated they are, says
Rices Patrick McCarthy, an EMT
majoring in biochemistry and cell
biology and captain of a team of 70
campus EMTs who answered about
750 calls for service last year. It also
raises general awareness among the
student body, the faculty and the
community about our capabilities,
how much time we put in and how
dedicated the personnel in the orga-
nization are.
Te National Collegiate EMS
Foundation was founded at George-
town University in 1993, when the
Internet made it easier for campus
rescue squads from around the
country to connect with one another
about ideas and challenges. Since
then, the organization has grown
to include nearly 250 campus EMS
groups in 41 U.S. states and four
Canadian provinces, collectively
handling more than 90,000 responses
annually. Teir annual conference
draws nearly 1,000 students for
lectures, skills labs and roundtable
Check out the Hopkins Emer-
gency Response Organization video
he or she afects patient care, but it isnt
so easy for a janitor or a mechanic. But
if you ask Arthur, one of our janitors, he
can tell you exactly how important his job
is and how he impacts our patients. Te
neat thing about Arthur: Our EMTs and
medics see him talking about it, and it
only reinforces their line of sight. It seeps
into peoples pores around here.
Im really proud of the fact that 15%
of our workforce has worked here 20 years
or more. Sure, theyll tell you there are
days when its tough to come to work, but
this is as good a place to do that hard work
as anywhere.
In your opinion, what are the
greatest challenges facing EMS
provider agencies today?
Te frst one is increased violence against
providers. Across the board, were living
in a culture of increased violence, and by
the very nature of the work we do, EMS
providers are in the midst of that on a
regular basis. Were seeing this even in
rural areas, where there is an increased
use of opioids, particularly heroin.
Te second challenge is being able
to attract and keep job candidates. We
need to work hard to provide continuing
education that is relevant and meaningful
so people stay on the job and stay engaged
and motivated. We also need to be able to
pay them a good living wage.
Finances for EMS is always on this
list. Its very challenging to run an EMS
organization and provide good wages
when nothing gets cheaper.
Lastly, we need to fgure out how we
can speak with one voice as a profession
and not get fractured by our tax status
(frefghter, municipal, private, etc.). We
are ofen our own worst enemy in this
regard. Teres an ever-shrinking platform
of resources, and we need to fgure out
how to work as one or well all pay the
What are some first good steps
for an EMS leader wanting to
improve his or her organization?
First of all, look outside our profession. If
you have come up through the ranks of
EMS and only know EMS practices and
processes, it can be a big eye opener to
look at processes and systems through
a diferent lens. Look at leaders in the
hospitality industry for how they deliver
customer service. Take a look at FedEx for
how they run their delivery service. When
it comes to employee engagement and job
satisfaction, whats the best place and what
are they doing? Take your myopic blinders
of and try to fnd an industry thats not
involved in healthcare.
Most importantly, stay close to pa-
tients. If you really want to know how to
be a good EMS operation, ask your pa-
tients what matters to them. Its an obvious
but ofen overlooked way of delivering
top-notch patient care.
Carole Anderson Lucia
Yes, we want to
take good care of
our employees, but
at the other end of
the spectrum is the
business case for
wellness: Burnout, or
employees who are
not in a good place
emotionally or physically
hurt patient care, hurt
job satisfaction and
hurt the bottom line.
Brian LaCroix
10 Vi si t emer gencybest pr act i ces. com for qui ck access to al l web l i nks l i sted i n each i ssue. May 2014 11
By John Becknell
Most of us agree that the Lone Ranger, I-can-do-it-all-myself
cowboy paramedic has no place in the team environment of the
emergency scene. But we may be less likely to let go of the Lone
Ranger mystique when it comes to leadership.
We love the myth of the lone leader. We illustrate our or-
ganizational structures with charts topped by a single leader
and we admire pictures of Presidents Roosevelt, Truman and
Johnson sitting alone in their war rooms with pained expressions
of heavy responsibility. Were ofen told, Its lonely at the top, and
Te buck stops here. And indeed, the lone leader ofen carries the
brunt of criticism when things go wrong (whether or not that
criticism is deserved). When things go right, it is also the solo
leader who ofen gets praised. Michelangelo painted the Sistine
Chapel, Henry Ford created the assembly line, Ronald Reagan
ended the Cold War and Bill Gates built Microsof. And so on.
Yet when taking a closer look at big accomplishments, we
dont fnd lone leaderswe fnd great groups and teams. Mi-
chelangelos ceiling was not a solo act but actually the work of
14 artists and a crew of more than 200. Te Manhattan Project,
the polio vaccine, the frst manned fight to the moon, the Disney
studio, Xeroxs Palo Alto Research Center and the Human
Genome Project were all the accomplishments of great teams.
We have to recognize a new paradigm, writes leadership
scholar Warren Bennis, not great leaders alone, but great leaders
who exist in a fertile relationship with great groups. When senior
executives of international corporations were recently asked by
Te Economist who will be most infuential in the coming years,
a majority answered teams of leaders. We live in a time when
change, information and technology are all speeding faster than
one person alone can keep up with. One is too small a number
to produce greatness, Bennis adds.
But great groups and teams dont just happen. In my work,
Ive noticed that great groups and teams emerge from a very
specifc set of leader beliefs, attitudes and actions.
First, great teams emerge when leaders bridle their ego and
let go of the need to be the lone answer person and decider. Tey
admit they dont have the answers and actively recruit others
input about vision, direction and next steps. Tese leaders dont
worry about someone taking their job, actively recruiting people
better than themselves. Teyre not afraid that smart, successful
hard-chargers will eclipse them; instead, they go looking for the
best talent internally and from other organizations.
Second, great teams emerge when leaders call them to a
big, hairy, audacious vision and mission. Im not talking about
a fowery mission statement, but about something that gets the
juices fowing. No matter how the vision ranks in the scope of
the world, the team believes it is doing something vitally impor-
tant and worthy of all its efort and energy. When creating the
Macintosh computer, Steve Jobs inspired his team by promising
they were creating something insanely great. Leaders galvanize
the group by infusing deep meaning in the work.
Tird, team-building leaders trust the team and allow great
latitude in how the work gets done. Tey give the members what
they need and then let them loose. In so doing, they inspire great
trust and loyalty and make room for the tinkering trial-and-error
processes that ofen accompany great accomplishments. In these
groups, failures are expected and viewed as necessary lessons.
Watching these groups work can be fascinating. I recently
watched a team at a large EMS company wrestle with balancing
the management workload with continued growth. What stood
out was the level of productive disagreement and candor that
accompanied the group. Arguments were flled with passion,
and people wanted to stay late and get things done.
Even though the members of this group were clearly working
harder than anyone else in the company, I doubt they regret the
sacrifce. Doing something in collaboration with others is a
heady experience that releases creativity and talent in a way that
working alone does not.
John Becknell, Ph.D., is the founding publisher of Best Practices.
He is a consultant, co-director of the EMS Leadership Academy
and a partner at SafeTech Solutions, LLP (
July 2125, Westin Kierland Resort, Scottsdale, Arizona
Best Practices is a proud supporter of the Pinnacle EMS Leadership Forum, a unique meeting experience
for leaders and managers from every type and size of service. Connect with experts at the leading edge
of EMS to understand new leadership ideas and advanced operational practices.
To sign up for updates and for more information, go to
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