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Creating and Maintaining Drug Addictions in the EMS/ED Setting

Some background:

 

I have a very good friend who is a nurse who recenty admitted to me that the reason s/he "dropped off the face of the Earth," was s/he had an addiction problem.   This person is on the road to recovery and offerred to write about what occurred.  Interestingly, over the years, I have come across many healthcare workers in EMS with addictive problems.  Some with alcohol, some with other substances.  Regardless – please read and share comments.   This clearly is an important topic to discuss

 

 

Creating and Maintaining Drug Addictions in the EMS/ED Setting

Addiction and associated drug-seeking behaviors have reached, to use a cliché, epidemic proportions. The sad thing is that patient satisfaction surveys, patient “rights”, and lack of support from administrators when confronting behaviors has contributed to this problem far more than the addicts themselves. In days gone past, we had our heroin junkies, our pot smokers, and our valium-grandmas; these patients we could see coming from a mile away. Today’s addicts come from all walks/occupations, all age groups, and are less easily identified than in the past. They can be lawyers, hamburger-flippers, homemakers, mechanics, car salesmen; or in my case, an ER nurse.

 

No one was more surprised than I was the day I entered rehab for opioid dependence. An experienced ED nurse of 15 years,  with a great reputation as a leader, teacher, mentor; I was a junkie. Popping or snorting oxycodone or shooting up dilaudid was my daily routine, in between taking care of patients. But as with all addicts, I could rationalize, minimize, or bullshit my was out of any situation. Until I hit the bottom. I tell this not for sympathy, understanding, or shock value; but to underscore my understanding of these addicts which I always hated taking care of. After all, they were taking up my time, lying to me and expecting be to believe their pain scores, and generally being a waste of space.

 

Our role in the problem is creating the addict, maintaining the addict, then condemning the addict. First we create them. Unlike the days of gateway drugs leading to heroin, today we prescribe Percocet and oxycontin for pain. Legitimate drugs for legitimate reasons, we keep giving these meds and keep writing the refills… Then one day the patient tries to cut down or stop and get “dope-sick”, a horrible withdraw constellation of pain, anxiety, cramps, shakes, nausea, and feeling of impending doom. All these go away as soon as another “oxy 30” hits the GI tract.

 

When I was in rehab, I met many addicts, some as young as 19, who were addicted to narcotics secondary to a back injury, a surgery, or other legitimate illness/injury. It would be impossible for me to count the number of prescriptions for percocet, vicodin, oxycontin that I handed over for a sprained ankle, broken finger, or even a peritonsilar abscess. Imagine how many more are given upon discharge from an inpatient setting after injury or surgery. Oxycontin is so powerful and addictive that one 21 year old addict that I spoke with turned to heroin after his doctor cut him off from oxycontin, if given the choice between IV heroin or snorting an oxy 30 would take the oxy every time. Heroin was what he turned to when he couldn’t get his drug of choice. Imagine that; heroin is second best to a pill.

 

The second problem is maintaining the addict. We’ve all gotten calls for patients with intractable back pain who can’t drive to the hospital, after they’ve run out of their narcotics. So we roll our eyes, load them on the litter, and dump “another drug-seeker” into the ED. Then the ED doc, who knows that his paycheck is based, at least in part, on his “patient satisfaction scores, is torn between giving a shot of dilaudid and a script for “enough narcotics until you can see your doc”, and dealing with a negative patient survey than translates to less dollars in his/her paycheck. Add to this a crazy busy night in the ED, overloaded, and its often just easier to give them what they want and get them out of the ED “so we can take care of real patients”. 

 

If we call the patients on their drug-seeking behavior, then we’re called to the carpet from a director, a manager, or a charge nurse who quotes something from an ancient text; “Pain is subjective, it’s whatever the patient says it is..”. After all, the ED/EMS setting is a business, and “we have to keep the customers happy”. I’m guilty of this myself. Many times I’ve told a doc “Look, this morons is just drug-seeking, but causing all kinds of ruckus. He’s tying up two of my nurses, the tech, and three security guards, and I just got a call from the ‘patient advocate’. And there’s thirty patients in the waiting room to come back. Can you just write for whatever he wants so I can empty the bed and get back to the patients who are really sick? Please…”

 

Then we condemn them. I’m as guilty of this as anyone, perhaps more so. Addiction is a disease, right? What a load of crap! It’s just a lack of willpower or some loser who wants a free high. Or they come in to get into detox and rehab, perhaps legitimately wanting help or just making their parole office or family happy, and we let them sit for hours, in pain, while waiting for social services to find a bed for them at some rehab facility. To keep them comfortable, we “might” give them 1mg PO ativan and some zofran. Then we wonder, after sitting for eight hours in withdraw, the sign out AMA while yelling “you people don’t want to do anything for me”. I sat in the intake office at a detox for five hours while waiting for insurance to clear, in full blown withdraw, and believe me it was not fun. Only the thought of permanently losing my nursing license and fear of my wife kept me there.

 

Why don’t we treat the withdraw while waiting for placement? If someone is withdrawing from narcotics, who are we not giving them narcotics? Detox centers use a tapering program of Subutex to bring patients down over a period of three to five days. Patients are using upwards of 240mg of oxycontin a day or 4-10 bags of heroin, yet we thing nothing of giving them a little ativan and zofran, thinking that will keep them quiet until we can get them placed. Are we withholding the narcotics to punish them? Would we withhold D50 from a diabetic whose blood sugar was 20? Are we not withholding medical treatment?

 

So what is the answer? If I knew that, I’d be heading up the presidential council on drug addiction, rather than going to Cocaine, narcotics, and alcoholics anonymous. Perhaps, rather than condemning the addict, we need to look at our own behaviors and attitudes towards them. We created many of them, then we crush them and withhold care. Perhaps we need to worry less about patient satisfaction surveys driving our standards of practice, and more about the patient. While its true that “if we don’t give them what they want, they’ll just go somewhere else”, that can’t be our guiding principle. If a patient wanted another medication, say a cardiac med that they heard was good, would we give it to keep the patient satisfied?

 

Somehow, and I’m still trying to figure out how, I crossed the line from social drinker and occasional Percocet user for back pain to a full-time junkie, shooting up between patients in the bathroom. Yet still able to provide care for the most critically ill patient. Only through the grace of God did I not harm anyone other than myself. I’ve reached the bottom of a hell that I wouldn’t wish on anyone (other than a nursing administrator or two). But if there is a good side to this addiction of mine, I’m becoming a better person than I was before; less selfish, self-centered, grandiose and ill-tempered. And when the state decides it’s time for me to begin practicing as an ED nurse again, I’ll have a very different perspective for this unique group of patients who can be very challenging to care for. Perhaps God made me an addict to allow me to care for other addicts. Stranger things have happened.

Posted in ems-health-safety, ems-topics, patient-management

4 comments Posted by on October 3, 2011

A Tale of Two, Two Tiers

Disclaimer:  I appologize for the format of the text as this is one of my first blog entires with this interface, and for some reason it and Word didn't want to play nicely.  I tried to fix it up best I can.  Future posts will not have this problem.

It’s interesting that Dr. Barnett picked a topic in the previous blog that is so near and dear to my heart. Rather than post a comment, I decided to create a new entry, because it’s going to be lengthy in nature, and I would like to see separate comments and feedback.  Why, might you ask?  Well, I’m a true believer in EMS, and in the ability of providers to bring quality basic and advanced pre-hospital care to the public. 

Throughout the fifty states and assorted territories, each individual EMS system needs to adapt to specific needs of the community.  It is not a “one size fits all” system.  Some states have system wide mandates whereas others leave it to each individual organization or municipality to decide on how they are  going to operate their EMS system.  All must operate within their regulations, but some allow for more self rule than others. With this, I am going to go a little more into detail on the “chase” system in New Jersey and how we differ and compare to other systems that are run through the country.

I believe our system is “unique”, and, dare I say BETTER in some ways, while antiquated in others. To understand EMS in New Jersey, we need to look way back in the past to when the EMS system in New Jersey was conceived.  Since we are focusing on southern New Jersey (which for those not from this area, is COMPLETELY different from the north), I am going to use references and examples from this region to simplify things.  The Office of Emergency Services (OEMS) was created in 1967, and was charged with the task of creating standards as well as regulations regarding pre-hospital care.  At this time, calling pre-hospital care basic life support was a stretch at most.  Certifications evolved, and we went from the 5 points certification, to EMT.  Now, we must not forget that OEMS was not the only “organization” that had an interest in EMS in New Jersey at this time.  Back then, EMS was run completely by volunteers that would pick up the ambulance and race to the call from home when the air siren blasted, or the old Plextron would alert.  The New Jersey First Aid Council (NJFAC) , which even today exists as a private organization, was a place where volunteer ambulance squads could join to share ideas, support each other, and come together to lobby for a specific cause:  volunteer EMS in the state.  Back then, EMS was run 100% by volunteers. 

Things, however, began to change. Up to this point, there was NO ALS in the state.  I’m a little rusty on specific dates, but ALS didn’t evolve in NJ until the mid to late 1970’s; do we all remember “Emergency!”?  New Jersey’s Department of Health wrote regulations which allowed for advanced pre-hospital care, but it was set up with a rather unique frame work.  ALS could ONLY be provided through a hospital system, not by local EMS agencies.  Also, in order to provide ALS care to a specific area, a hospital system that was interested in providing these services had to submit a formal request to OEMS in order to be awarded a Certificate of Need (CN).  This CN would authorize a hospital system to provide ALS care within a specific geographical region, usually one or more counties. In the southern most counties, Camden, Burlington, Gloucester, Cumberland, Salem, Atlantic and Cape May, there were three main sources of ALS care, provided by three hospital systems: West Jersey, Underwood and Burlington Memorial. This CN system still exists to this day.  A CN may be taken away and re-awarded if it is proven by a challenging agency that their area is being underserved by the current provider. Regulations that governed ALS care were written so that a two tiered system was created, which would allow for local volunteer ambulances to transport the patient, while the ALS unit would intercept the ambulance if advanced care was needed.  There were wivers created which allowed for some systems, particularly up north, such a UMDNJ and Jersey City, as well as a few others, to provide ALS transport-capable ambulances.   But they were the exception.  

The MAIN reason a chase system was created was due to the local volunteer squads as well as the NJFAC.  They didn’t want “outside people” to come in, transport “their” patients to the hospital, and illegitimize their existences.  These volunteer organizations felt extremely threatened, and lobbied to the state so that they could maintain their local control, while allowing ALS intercept vehicles to come into the mix if needed.  Added to this was a lack of ALS providers, as well as long transport distances which didn’t allow for paramedics to accompany every patient to the hospital.

Fast forward to today.  We now have more ALS units (or less depending on where you live), more advanced scopes of practice, as well as more aggressive protocols.  Some areas fared better than others financially, and those that were able to keep their heads above water, expanded their services and took over those that weren’t able to compete.  In the beginning, ALS care was very profitable.  Even though the volunteer squads wouldn’t charge for services, the hospitals would.  All was well and dandy up to the point that Medicare started to reform its billing regulations.  

Now keep in mind, New Jersey is NOT the only state that runs a completely tiered ALS system.  WHAT!? Yes, it’s true.  Some might call shenanigans on this, but it’s true.  Our neighbor to the south, Delaware, has the EXACT same system that we do.  They run a regionally based ALS system, chase vehicles with two paramedics that would intercept a BLS ambulance to provide ALS care.  The main difference between the two states is that rather than being mandated to be hospital based such as we are, Delaware ALS is completely run by county governments.  Granted, Delaware only has three counties, but it’s still a regionally based, tiered ALS system with extremely high quality of care, and run with great efficiency.  Not to mention their volunteer and paid BLS agencies are all held to the same standard. (Can’t say the same about NJ!)  There’s a reason I bring Delaware into the mix.  You’ll see in a bit.

Medicare reformed its billing practices, and stated that only one agency is allowed to bill for services. Now, these ALS agencies have to contract with local squads, in order to bill for services through them.  For example, let’s say an ALS ride to the hospital would cost $1,000, but the BLS agency bills for services which costs $500.  The ALS agency has to submit their bill through the BLS agency, and spilt the difference in cost.  So now the ALS and BLS agency both get $500.  This is not very profitable if you have a low call volume.  If the BLS agency doesn’t bill for services, then the ALS agency can send the bill directly to the insurance company, and get the full amount without having to share anything.  Why do I bring this up?  Because with this system in place, hospitals were unable to support their ALS services, and many were gobbled up by larger systems.  My point is that hospitals aren’t able to maintain ALS coverage due to expanding populations without losing profitability, since they would have to staff more units, without being reimbursed their full amount to break even. 

New Jersey brags that the state is 100% ALS covered, but what they fail to tell you is that it’s not 100%, 100% of the time.  All too often, citizens go without ALS care, because there are no ALS units available. On a positive side, I feel that the tiered system is the way we should provide services in this state; however, I feel that ALS coverage needs to be expanded so that there are fewer gaps in coverage due to increased demand.  The consensus on response times is that you should have BLS level care within 8 minutes or less, 90% of the time, and ALS care within 12 minutes or less, 90% of the time.  While there are no regulations or laws that state this, it stands as a general consensus throughout the country.  Now, working as a paramedic in New Jersey, I can say that the agency I work for is able to meet the 12 minute mark, 90% of the time.  I can’t say the same, however, for  BLS.  There are countless times where I have sat on location, waiting for an ambulance for 20, 30, even 40 minutes at a time.  Unacceptable.  Many would argue that if paramedics were staffed in ambulances, we wouldn’t have this problem.  True, but if agencies were regulated and mandated to meet minimum response time criteria, we wouldn’t even have this discussion.  But that’s a different blog….

Still, one asks, why a tiered system?  Simple; all one has to do is compare the amount of sick people, critical skills that are needed, and the amount of providers there are to provide these advanced interventions.  Let me bring this more into perspective.  Only about 3 – 5% of 9-1-1 calls for medical emergencies are actually life threatening in nature. Wouldn’t it make sense to have a proportional amount of people that can treat life threatening situations to the demand that actually exists?  It doesn’t make sense to have a paramedic on every ambulance.  Here’s another example.  Let’s say that there are 1,000 highly invasive skills that are going to be performed within one year.  If we had more ALS providers, say 26,000(roughly the amount of EMT’s in NJ), the chance that a good majority would encounter one of those 1,000 skills is highly unlikely.  Now, let’s say we have 1,700 ALS providers (roughly the amount of paramedics in NJ).  The likelihood that they are going to encounter one of these skills increases dramatically.  Because we have a higher exposure to only extremely sick and critical patients, we are able to maintain our skills and a much higher clinical standard. 

As a paramedic in New Jersey, I do notr respond to every broken bone, stubbed toe, cough, cold and tooth ache. We also have lower staff injury rates due to the fact that we don’t typically operate stretchers or other carrying equipment, and we are able to keep highly experienced medics because they are able to work longer due to lack of injury.  I get sent to only life threatening emergencies when deemed appropriate.  Everything else warrants only a BLS response.  If BLS arrives on location and judges that we are required, they request our services, and we arrive on location typically within the 12 minute window. Here’s another interesting perspective.  Some people actually come to work in NJ as paramedics from other states with single level response systems, in order to maintain their ALS skills.  In their previous systems, they get sent to more basic, non life threatening calls, and have a lack of exposure to highly invasive procedures.  How comfortable would you feel if you or your family member was being treated by such a medic?  Would you want a medic that only does 1 or 2 intubations a year intubating you?  Or would you want someone that quite literally may do several a week?  It’s a no-brainer.  Because we have such a high exposure, we are able to perform much more aggressive and invasive procedures.  Remember I mentioned Delaware way back?  That’s because they have the same tiered system we do with similar competencies and skills.  And you know what, we have comparable success rates in high risk, low frequency procedures.  Both New Jersey and Delaware prove that a tiered system works where appropriately applicable.  Over-saturation of ALS providers is unnecessary; we must not have our skills be watered down.  We merely need to have enough ALS providers to provide complete coverage within twelve minutes, ninety percent of the time, to calls where we are specifically required.

As for the legislation that is working its way through the Senate at this time, it would allow for a much needed overhaul of the system.  Yes, there were provisions that were removed because of the lobbying from the NJFAC, but those things can be tackled at a later point in time.  Personally, I don’t care about the training fund.  Leave it for the volunteers.  I paid my way through paramedic school, as well as additional certifications and higher education and certainly don’t miss the training fund.  As for the two EMT standard, that’s ok as well.  It’s better than NO EMT at all which seems to be the status quo for volunteer squads.  As of right now, only BLS services that are licensed by OEMS are required to have two EMTs.  Those that are not licensed do not have to have ANY EMTs.  And no, as of today, there is no law or regulation that requires a BLS agency in the State of New Jersey to be licensed by OEMS.  They basically regulate themselves, and do as they please.  This piece of legislation would thankfully change that. In regards to EMT education, right now the Department of Health is revamping the way in which EMTs are trained in NJ, including the amount of classroom time and clinical hours required for testing.  I agree with many of the responses to the previous post, that education standards need to increase, as well as minimum number of exposure hours to field and clinical settings.  This too will get a future blog.

I found the comments regarding emergent mode of transport to a receiving hospital rather amusing.  Personally, I only transport to the hospital with lights and sirens about 5 – 10% of the time.  Unless the patient is next to death’s door, or needed to be in the hospital “yesterday”, they get no lights.  With that, I believe BLS transport should ONLY be no lights or sirens, unless the patient deteriorates, or there is an immediate threat to the crew due to a combative patient, for which you should have a police officer present anyway.   I once told an EMT that was transporting us to the hospital to use no lights and sirens.  Her response “We don’t do that.  It’s our policy, all patients get lights and sirens.”  And so I replied “Too bad, no lights.”  I’m not endangering my life for a stable patient, whom I can easily manage, by going lights and sirens for no reason at all.  My agency encourages this position as well. Ok, this was long enough.  I hope I was able to enlighten a few people about our lovely system (note the sarcasm), the pros, the cons, and the direction that our state is headed.

Comments and suggestions are encouraged. Future entries to come.

Armor Medic

Posted in 911, administration-leadership, command-leadership, ems-health-safety, ems-topics, patient-management, training-development

11 comments Posted by on April 27, 2011

New Jersey’s Two Tier ALS System. Time to Advance?

I had missed dinner and was heading in for my first of three night shifts. I made excellent time on the highway, and pulled into a local strip mall just several blocks from the hospital to grab a bite to eat before tackling my shift. Off along the curb a quarter mile back along the state highway was a local ambulance. The lights were flashing, the doors open, with a paramedic chase truck having clearly stopped the vehicle to assist with a patient in the rear. Where the ambulance was stopped is literally less than one mile to the Emergency Department entrance. Expecting the paramedic to have climbed aboard of the ambulance and to be off in moments, I entered the fast food establishment, grabbed my sandwich and soda and sat down to eat. Fifteen minutes later I exited and the ambulance was still sitting there. With New Jersey Highways being the way they are, the only way to assist would be to drive another half mile down the road, find a jug handle, wait for a light, drive in the opposite direction and find another jug handle to return. With only minutes to the start of my shift, I figured I would find out soon enough what was going on.

I arrived at the hospital, put my bags down, hung up my coat, and proceeded to receive sign-out from the dayshift doctor. After receiving report, I asked if the department had been alerted via HASTE for any inbound ambulances. I explained that there was a unit along the road a mile or two back with a MICU unit behind it for a least twenty minutes. At that moment, the squad rolled through the door. An approximately 60 year old was sitting upright on the stretcher, apparently quiet comfortable, wearing a 100% non-rebreather mask, smiling, and looking around. I asked if this was the same unit stopped on the state highway just up the road. The squad gave report of the various treatments and interventions initiated in field curbside along the highway.

Southern New Jersey has a very unique two tier EMS system which, after fifteen years, I am still getting use to it. It is predominantly a volunteer BLS system with ALS being provided by “chase-units”, consisting of Ford Explorers. The ALS units have no transport capability. Typically, the medics would climb aboard the BLS ambulance and provide higher level of care when needed or provide such on scene. Unfortunately, this system has lead to several issues, including the one addressed above.

The opening vignette, in my experience, is not at all unique. Prolonged transports from nursing homes only two or three miles down the road from one of the hospitals I work at for respiratory and cardiac arrests or from neighboring residential developments is not uncommon. There is a very strong motivation to provide advanced life support on-scene care despite the close proximity of a fully staffed Emergency Department. The concept of “scoop and run” by BLS units when close proximity to hospital care is at hand is often mistakenly misplaced for delayed scene times to await the arrival of ALS.

Another product of the two-tier system in New Jersey is a dangerous race of emergency vehicles and civilians in a long, “vehicular parade” to the hospital. The ambulance is followed by the paramedic chase unit, which is often followed or lead by a police car or two. Racing up the rear is usually family in their car despite being told not to try to follow the ambulance to the hospital. Other drivers, when hearing the sirens, usually only expect a single emergency vehicle. Two vehicles, especially if driving fairly tightly behind one another, can easily be unanticipated by motorists. With families trying to keep up with “the parade,” the potential for additional injuries is very real.

With state economics being what they are, funding to advance New Jersey volunteer crews to having ALS level of care is limited. The ideal would be to bring all squads up to the capacity of having a medic available for all runs if needed. Fewer rescue vehicles on the road would have the financial benefits of lower costs in equipment, fuel, and insurance for cash strapped municipalities. This system has been proven to work in New York State for decades. Nassau and Suffolk Counties in New York provide financing to train their volunteers to ALS level of care and limit the number of vehicles on the road for any individual call. Prolonged scene times are a rarity. Meanwhile, New Jersey has not managed to learn from it’s sister states how to manage within the constraints of finances to advance its volunteer EMS system and limit public risk.

I suspect the current system in New Jersey, with the paramedic chase units, represents a product of local politics, limited funding, billable ALS care by these chase units, combined with a hold over from when New Jersey was predominantly farmland with long distances between medical facilities. Southern New Jersey is increasingly not rural. As such, the current system is only adding to the financial costs to townships.

I invite others who read this blog to discuss their volunteer systems. Specifically, how do your systems manage to keep the public safe, provide ALS care, while dealing with the economic austerity affecting all municipalities today?

Comments from paramedics I work within this system are pending. At their request, I will post their thoughts regarding this blog’s subject matter anonymously and without editing.

ADDENDUM: All comments received have been posted provided objectionable language was not included. I have made every attempt to answer as many of the comments posted as I can.

Thank you to everyone who has contributed!

Posted in ems-health-safety, ems-topics, funding-staffing, in-the-line-of-duty, patient-management, rescues, training-development, training-fire-rescue-topics, vehicle-operation-ambulances

Tagged , , , ,

67 comments Posted by on April 26, 2011

EMS System in NJ

With permission – the following is an email from a paramedic with whom I have a great deal of respect for.   He and I have had conversations regarding the state of EMS in New Jersey.   Fear of reprisals from his employer is the reason his identity having been removed from this email.   This Paramedic has also discussed the number of other New Jersey paramedics with similar frustrations.  We have also discussed the issue of this individual coming on-board under an alias and using this blog as a conduit and public forum to help institute change to a very broken system.

This paramedic’s email follows:

Hey Jordan,

I thoroughly enjoyed reading your blog.  I can certainly understand your frustrations with the system since you are a direct recipient of the final product as the squads roll into the ED each and every day.  I myself am appalled by the way things are run, particularly in clinical oversight, education length and quality, as well as policies and procedures. Unfortuneatly, there is nothing, you, I, nor anyone at the Department of Health level can actually change, due to the restrictive legislature that gives us the authority to operate is antiquated and limiting in it’s wording, rather than being enabling and progressive.

What really blows my mind is that the system we currently operate in does not mandate any minimum standards for providers (mainly BLS, as ALS is in my opinion OVER regulated), does not require an ambulance to be licensed by the Department of Health nor meet any minimum standards, nor mandate minimum response times.  Better yet, EMS in New Jersey isn’t even considered an essential service like police, fire, and municipal services are.  It’s simply, sickening.

Like I told you, there is a bill that we are trying to pass which will overhaul the EMS system in NJ, and change A LOT of things.  This is in response from a outside consulting company that spent quite some time in the state, auditing the way our EMS system is running, and what we can do to improve it.  I have included a copy of the report as well as a copy of the bill, which is a response to the system report in this e-mail.  In a nutshell, the report stated that the NJ EMS system in a “state of near collapse.”

The main opponent to this overhaul bill is the New Jersey State First Aid Council, which we so affectionately call “The First Grade Council.”  I am thoroughly convinced that they are the sole reason EMS in NJ is so backwards and antiquated.  If they are allowed to maintain any type political or lobbying power, there is no way we can progress into the 20th century here, let alone the 21st century.  They oppose a two EMT minimum standard, increasing the amount of time an EMT class takes to complete (we’re trying to comply with the new National Scope of Practice with this bill), allowing the Dept. of Health full authority over the operation of an ambulance, as well as many other things.  Too many to list actually. However, if this passes, the Council will basically be rendered powerless, and we can finally move on, without them.

Here is a link to the TriData report that was done on the EMS system a few years back. Verrrry interesting.

http://www.state.nj.us/health/ems/documents/ems_study_report.pdf

Here is a link to the bill they want to pass.  They’re hoping to put it in front of the governor by the end of the month. But don’t hold your breath.

http://www.njleg.state.nj.us/2010/Bills/A2500/2095_I1.PDF

Here is a link to the website that all the stakeholders in the new bill setup in support of the bill.

On the “The Issue” page, there is a short commentated video that explains what the bill is going to accomplish.

http://www.supportnjems.com/

I hope this gives you some interesting reading.  Talk to you soon!

->Signature and Name withheld.

Posted in 911, ems-health-safety, ems-topics, healthcare reform, patient-management, training-fire-rescue-topics, Uncategorized

10 comments Posted by on January 10, 2011

Time for Intelligence in Implementing EMS

During the recent snowstorm, the governor of New Jersey declared a state of Emergency closing all roads to nonemergency vehicles.  As luck would have it, I was on shift at one of the hospitals where I work.  My colleague received a call from a local EMS squad.   A stabbing was inbound.   The EMT on the phone relayed no valuable details except she didn’t care how bad the wounds were. While she hadn’t even arrived at the scene yet, with the weather being bad as it was, she was coming to us  “no matter what”.   The hospital where I worked that day is a small community hospital without in house surgery, no trauma team, and a physician staff for the entire hospital that evening which probably consisted of two ER physicians, an anesthesiologist, and two hospitalists.   Several miles down the road is a larger hospital with significantly more resources.   While the above vignette alone can generate significant discussion, this is only one item in my ire over local prehospital care

The literature is full of studies how the Europeans will actually divert ambulances with acute MI patients from local hospitals to those with catheterization labs.  Two Emergency Physicians whom I enjoy listening to on their Emergency Medicine literature review CDs, Doctors Jerry Hoffman and Richard Buckata, not long ago discussed how patients having acute coronary events in the driveways of European hospitals would be told not to unload their patients, travel to the next facility with the appropriate interventional resources, and how much better the outcomes are for these patients.   This is certainly not the practice in the region where I work.

Where is the logic of a pediatrician sharing in clear language her high clinical suspicion for acute appendicitis in a child with an EMS team and then those same EMTs making the decision to bring that child to a hospital without pediatrics or pediatric surgery?  This defies any logic.  What is accomplished?  Delay in definitive care, added unnecessary expensive, additional transport time, and psychological trauma to the child and her family.

At another hospital where I also work, local EMS squads historically will ignore bypass requests.  Responses by EMTs to questions regarding their rational for ignoring critical care divert and bypass requests as the nurses share with me that they have run out of pumps and cardiac monitors, “The patient insists on coming here”.  Other responses I have received from these same EMTS and medics as they bypassed two and three hospitals (incidentally, all within the same hospital system with the same physician groups) on their 25 mile trek to this particular hospital are “ divert is a courtesy request only,” and, this is my personal favorite,  “ we don’t want to be accused of kidnapping patients”.   Kidnapping patients? ! I understand completely that while on divert a hospital cannot expect all EMS inflow to stop and critical care patients will still arrive. Bypassing multiple hospitals that aren’t overwhelmed due to a family request is endangering ALL patients in that ER – including the one being “Kidnapped!” When someone is calling 911, they are calling for a rescue service and not a taxi ride.  Of course, I should share that this problem has been partially “solved.”  Many hospital administrators regionally are refusing to allow the ED Attending physicians to warn EMS squads of strained resources by forbidding bypass requests.

I have been in the streets myself for many years working for EMS systems.  I helped pay my way through school working in Brooklyn and Queens. I am very proud of my background with New York City EMS.  I am currently actively involved in EMS education.  Hence, I don’t believe anyone can say I do not know what I am talking about in regards to “being in the field.”    Under most circumstances, when I worked in New York, you were taken to the closest hospital.  No “special trips” taking a rescue unit out of it’s assigned region because the family likes the décor at a different hospital better.  It was simple.  Burns?  Burn unit.   Trauma?   The nearest trauma hospital. If the local hospital in our “PAR” was over whelmed, we tried to “share the burden” with the next closest facility

Going back to that snowstorm shift and the trauma patient, the blade missed the femoral artery on CT angiography.   The child who had been taken past a facility with pediatrics by local EMS had no difficulties in being transferred to another pediatric surgical hospital by ground three hours later after I had back all the studies to make a convincing argument to the surgeon at this other hospital to accept transfer. CT confirmed acute appendicitis.  As far as the local roads were concerned that night, while I am sure some portions of New Jersey were hit hard, I enjoyed listening to Jimmy Buffett on the radio as I took my time driving the some odd twenty-five miles home in my car without any difficulties.

Posted in 911, command-leadership, ems-health-safety, ems-topics, patient-management, special-operations, training-fire-rescue-topics

4 comments Posted by on January 1, 2011

Christmas Eve in the ER

As my thirteen year old daughter would put it,  “it bites” being stuck working on Christmas Eve in the Emergency Department.  Considering how busy we normally are on a typical work day, the fact that I am able to sit here with the nurses at the computer typing this entry I find thoroughly amazing.   Since 2:00 pm today, my staff and I have been keeping a tally of what pathology has shown up so far.  The tally is as follows:

1 ) Varicose vein that bleed and stopped bleeding  before arrival.   Bandaid applied

2 )Elderly lady.  Syncope in the closet.   Etiology unclear.  Admitted

3 ) The diabetic husband of the elderly lady who fell into the closet (see #2 above)  felt his blood sugar was low while trying to pick his wife up out of the closet.  Sandwhich provided.  Discharged

4 ) A nonbleeding, nonthrombosed hemorrhoid.  Tucks Medicated pads suggested. Discharged

5 ) A chronic alcoholic who was brought in because feeling short of breath for days.  Medics described new onset afib.  Turned out to be an MI who had already “Qed” out inferiorly.  Transfered to facilitiy with cath lab.

6 ) Cardiac Arrest in a cardiac transplant patient.  (Horrible!   Trying to be nice, we shut off all the Christmas music until family left)

7 ) toothache

8 ) Back sprain after a motor vehicle accident

9 ) A scrotal bleed (Don’t ask.  Really.   Just don’t)

10) Intoxicated alcoholic

11) A panic attack

12) A violent patient with dementia arguing with my 5 foot ED colleague.   Demented patient won!  (Staff taking bets at nursing station whether five foot tall doctor would win.  Not so much. )

13) An ankle sprain.

14) Another toothache.

15) Another minor MVA

16) “I’m out of town and I am out of my oxycodone, percocet 15, ambien, and lorazepam”    Discharged unhappy

17) Packing removed from a recent I&D of an abscess

18) STD check (really? On Christmas Eve?   Yep .  You have one! Discharged.  Really.  Pun intended. )

19 -22) Assorted lacerations.

23) Knee sprain from three days at work. ( Just ask for the work note!  You told us you were do in and we saw you walk into the ER without a problem. )

24) Shingles out of meds.

25) Another alcoholic psych patient.  Every racial slur .  Where is my five foot physician colleague?  This has his name all over it.

26) MVA  – refusing evaluation.  Brought in by BLS

27)  Chronic back pain – seen recently.   PMD won’t treat pain.  “Nobody understands me”

28)  Another drunk. “I want to go to Kosovo so I can fight for my country….I want to be a hero…..I don’t know where Kosovo is….do you know?”   Patient can barely stand up straight let alone be trusted with a rifle.

Thus, in an Emergency Department which has a volume usual of 120 patients or more a day, since 2:00 pm today, that is our total census.  Of this census, 5 via ambulance  total.

I dare say that after the salt ladened ham, seven fishes, alcohol, and over eating, none of us will be able to make a similar entry tomorrow.

Merry Christmas to everyone from my staff and colleagues at the Emergency Department!

ADDENDUM:   The above represented the time window from 2pm to approximately 8pm.    The ER exploded at about 9pm.  There were probably more police with people in custody in the ED that night than were manning the local stations.  The psych unit exploded.

As I head in to work now, I expect no different.  The doctor’s offices have been closed, those that should have been in yesterday probably have delayed to the point that they can’t hold out much longer, and, of course, the usual weekend crowd.

Posted in ems-topics, patient-management, Uncategorized

No comments Posted by on December 24, 2010

The Free Taxi Ride

Years ago I was working with New York City as an EMT out of Queens General Hospital.  I remember being in shock after picking up an otherwise non-ill appearing man who gave a complaint that I currently cannot recall.  We took him in a city ambulance to the local hospital.  The part that shocked me was that he never entered the hospital.  He thanked us and proceeded to go across the street to do his shopping. He never was sick and never intended to enter the ED doors.   We served as free transportation for him.   He expressed no qualms regarding his actions.  The only conclusion I can draw today was that, in his eyes, it cost him nothing.   He was able to get away with it.   He had a complete disconnect not only from the ethical issues of what he did, but the costs being eaten by the city government for the taxi ride.

The same issues apply daily in the care I provide in the Emergency Department.   There are multiples of patients who use the ED as primary care who are donning the latest Iphones, wearing expensive leather jackets, downed in expensive Aeropostel and Uggs clothing.  They are at a lost when I ask them who provides their primary care.  “I just go to the hospital!” Attempts to explain to these people the importance of routine primary care by an appropriately trained individual falls on deaf ears.  They will openly admit that the use of clinics and primary care facilities will cost them money.  They have nothing in the game.  Hence, using one of the most expensive forms of medical care, which often isn’t the best care, continues to be used and abused.

I recently questioned an administrator regarding the potential logic of opening up various clinics.   Perhaps a pediatric clinic on Tuesdays staffed with board certified pediatricians, Wednesday an adult primary care clinic staffed by Internists, and so on.  It seemed like a perfect solution to me to guarantee good follow up with individuals most appropriately trained to assure convalescence and preventive care.  “We looked into this, and financially it isn’t viable.”  In other words, my translation of this statement is that the hospitals can collect more state money for emergent care for non emergent patients than they would receive if they set up and established local clinic care.  Follow the dollar signs.   The current government bureaucracy continues to do a disservice to the very individuals they are supposed to protect.

Emergency care being a safety net and providing primary care is something that will never end.  However, I wonder how much general abuse would stop if the general public had to send in their taxes monthly rather than not realize that they are disappearing from their paychecks until April 15th.  In other words, each month a payment would have to be sent in no differently than a payment to a cell phone carrier.  The statement of “let the government do it” would be reconnected to the concept that the government is us.  Abuse local services? – Your taxes go up.   Your monthly payment to the local government-taxing agent goes up.   Don’t pay?  Sorry – your garbage will no longer be collected.  Don’t pay?  Sorry, your mail service stops.

Will this ever happen.  Of course not.  Still, free taxi rides are destroying the system.

Posted in 911, ems-health-safety, ems-topics, healthcare reform, patient-management

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10 comments Posted by on December 22, 2010

The Perception of Care Versus Quality of Care

Recently, I received a letter “Thanking me” for servicing my car at a local dealership. Scripted words stated how they were looking forward to my having a “fantastic” ownership experience indicates that I will be receiving a survey in the mail. It is obvious that the dealership, based on guidance from the outside survey firm, hopes that these key phrases will become embedded in my mind as I fill out their forthcoming mailing. I believe that I am like most people and throw most of these surveys away. The real motivators for my paying attention to these flyers and letters is either boredom, frustration or, rarely, anger. The later usually generates from me a letter and a phone call.

The reason for bringing up this topic of surveying and scripting has to do with how their use has permeated hospital care. The staffs in most ERs are now taught to use scripting during all patient encounters to help boost scores on subsequent third party surveys. The phrases sound artificial and forced to my ear. I was raised by my parents with the adage that “actions speak louder than words”. Hence, with the amount of effort my colleagues, staff and I display in our patient care, have to state these phrases (referred to in the lexicon of these companies as “key drivers”) seems very disingenuous. I use them as has been requested of me. However, this is not my prime concern with the current means of surveying acute hospital care. Being polite and courteous is something that everyone should expect. I try to be such in all my endeavors, including my work as an Emergency Medicine physician. In this regard, I absolutely agree with these surveys. There are a variety of issues which I see developing from the over reliance and misapplication of the survey data

Roses and gift baskets often stream past me in the ER to the nursing station in the ICU. In a recent case, a 45-year-old father of three that we sedated and intubated on arrival in fulminant cardiac failure remembers nothing of his ordeal in the Emergency Department. Near death, my colleagues and I performed as we were trained and delivered excellent care. This patient woke up in the intensive care unit. No survey for the care we provided in the ER will be generated for this individual. Any collected data will reflect strictly the care provided in the Intensive Care Unit. Interestingly, this is precisely the type of patient that is central in the curriculum in Emergency Medicine residencies. In other words, the Emergency Department is ignored in surveys for providing the type of care the physician staff is most qualified to provide.

Recently, a physician assistant confided in me that her department head at another emergency department chastised her. She explained how she was trying to explain to a young, otherwise healthy patient with a viral illness that antibiotics are thoroughly ineffective for her and can actually be harmful. Apparently, a negative survey or phone call was the product of her trying to practice good medicine. She was told that in the future she was to provide these medications whether indicated or not because that is what the “customer wants”. The “hospital is running a business”. Her experience is not a unique vignette. This type of patient represents the focus of many of these surveys. Urgent and nonemergent patients, often with an expectation of rapid “one stop McDonald’s shopping” for care and an expectation of an immediate “cure”, often receive these surveys in the mail. Combine the acquiescing to patient demands for unnecessary tests and medications despite it being poor medicine, with the push to rapidly see and discharge low acuity patients, inappropriate and substandard care is often being provided. Unnecessary and repeat studies involving ionizing radiation, especially to children, often occur.

Television shows have given the public the belief that Emergency Departments have specialists just waiting to come out of the back room to solve any problem at a moment’s notice. Not only is that not true, but also patients have no idea what Emergency Physicians are trained to do or their fund of knowledge. It is not a uncommon experience for a patient with a chronic, nonacute illness to show up in my emergency department which has confounded their specialist. Obviously, my two weeks of residency training, for instance, in dermatology, is not going to swiftly provide an answer for such a patient. After potentially multiple hours waiting to be seen, these patients are often unhappy being informed that I will not be able to answer their concerns.

To push up satisfaction scores, narcotics are being administered and prescribed with increasing frequency regardless of the true nature of the injury or complaint. I have witnessed my colleagues prescribe Percocet and other narcotics often without checking to see how many times in the last six months an individual showed up with the very same toothache. Addiction is a large enough issue already. As mentioned before, the push to move patients through rapidly and to drive up survey scores is only adding to this problem.

Another failure of the current hospital survey system has to do with morbidity and mortality reports published in various magazines and newspapers. To the layperson, one surgeon may inappropriately be seen as a “butcher” or a hospital may seem “like a death trap”. Not taken into account is how many of the more aggressive, higher quality surgeons will take on more difficult case with, as a result, higher morbidity and mortality scores. Usually, these highly skilled individuals are located at teaching and university hospital settings. Often, they do not have a choice to accept these transfers from community hospitals. These surgeons and institutions end up being penalized in the public’s eye in published websites and print media. Their community based potentially less skilled counterparts appear better in the public eye in these publications.

An entire industry has been erected to measure the public’s perception of services offered by various forms of business. Unfortunately, the survey industry’s product doesn’t translate well for specific niches in healthcare. Emergency services selects for a unique “customer” base. This customer base is comprised of the truly ill and the desperate, those who have no where else to turn for care, as well as those with poor coping skills and a naiveté regarding emergency care realities and, on occasion, those with secondary gain interests. What is being measured is the perception of quality in care and not quality of care. The survey industry has duped the hospital administrators who are trying to promote their “businesses”. Kind, considerate, thoughtful care, with a focus on the patient is absolutely paramount. Inappropriate prescribing of antibiotics and addictive narcotics, exposure to potentially harmful unnecessary studies, especially in developing children, as well as further straining an already economically burdened health care system are just some of the products of blinding following these surveys. The survey industry has duped hospital administration into believing that the same system used to evaluate customer service at my auto dealership translates to all niches of hospital care. Obviously, it doesn’t. Blind focusing on these surveys without true reflection on their source and meaning will lead to many patients becoming victims.

Posted in ems-topics, healthcare reform, patient-management

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2 comments Posted by on October 29, 2010

Emergency Department Overcrowding

I found the following on a general search for a project I’m working on. Interesting points. The google search simply led to a download with no listed author. If you know who wrote this, please let me know!

Emergency Department Overcrowding: Right diagnosis, wrong etiology, no treatment

There’s been a lot of hoopla about the phenomenon of emergency department overcrowding in recent years. This has been an issue worthy of Time magazine, CNN, and Nightline. Do we know the solutions? Are we on message? Or have we done ourselves harm?

Emergency departments are overcrowded because of the large number of patients seen in the ED who could better be seen elsewhere.

Wrong! Count the times you left work thinking “Gee, if only those acne cases hadn’t come in, it would have been an easy day.” Sore throats are not what grind our system to a halt. Admissions are. Admissions fill our examining rooms, and fill our hallways. Treatment of heart attacks is not delayed because of sore throats. Treatment of sore throats is delayed because of patients with heart attacks, who may “enjoy” a substantial portion of their hospitalization in our hallways. Any delay in the treatment of the next heart attack entering the emergency department is due almost solely to the previous heart attacks, pneumonias, and traumas already admitted, but still remaining in the emergency department and consuming staff time, space, and resources.

The narcotizing notion that overcrowding is caused by sore throats and the flu suggests that the problem is temporary, and that the problem is not a hospital problem. The popular issue of the “unnecessary” ED visit has so overtaken the ED as a topic of discussion that one forgets that we actually see sick patients. It is an issue seized by the legislature and all the insurers of the land, both of whom know that one guy from Kansas who was on his tractor when an airplane crashed into him represents the only appropriate visit to the nation’s emergency departments in 1999.

Thank God for the TV show, “ER.” At least they get it right – the patients are sick, and the personal lives of the staff are a mess. The next ED physician who walks to the podium to talk about overcrowding caused by the healthy happy masses looking for a good time in the emergency department should get a nice little curare dart in the deltoid. We see sick patients and make people’s lives better, and we’ve made a big damn mess of letting people know that.

When the emergency department is truly overloaded and cannot provide care to further patients, the hospital can divert ambulances to other area hospitals.

Wrong! If our emergency department is full, so are the other area emergency departments. In some areas, there IS no other emergency department for miles. In some regions, entire hospital systems run at over 100% occupancy for months on end. If you’re full and they’re empty down the street, they must have a pretty scary ED.

When the emergency department is truly overloaded and cannot provide care to further patients, the hospital can transfer patients to other area hospitals.

Wrong! As noted above, entire regions can be overloaded with patients. The act of attempting to transfer a patient, should the patient agree to transfer, can literally consume hours of staff time in phone calls and paper work needed to arrange for the transfer of a patient to another facility. A nice swig of Ipecac is more palatable. An ED full of admitted patients is already out of control, pushing staff beyond their capacity to provide adequate care. In such circumstances, one can ill afford the time required to arrange for transfer.

When the emergency department is truly overloaded with admitted patients, the hospital should call in additional staff to provide care for these patients.

Wrong! A substantial number of emergency departments cannot fill positions needed for routine staffing of the emergency department, much less call in additional staff. In most places, additional staff simply does not exist. This sort of policy is another one of the “we tried we failed” policies which allows someone to show they really care. Of course, the proper staff to call in for admitted patients would be in-patient nurses and in-patient physicians, not additional ED staff. If you enjoy funny and contorted expressions on people’s faces, and want to test your job security at the same time, suggest that at your next medical board meeting.

When the emergency department is overcrowded with admitted patients, elective admissions should be canceled, and elective surgery should be rescheduled.

Wrong! First, the era of “elective admission” is no more. Patients get admitted to the hospital because they are acutely ill. Minor surgery has moved to the ambulatory setting. Also, the patient with the “elective” cholecystectomy has committed to detailed arrangements with work and family prior to undergoing the procedure. The “elective” surgery or procedure, such as cardiac catheterization, not performed today becomes the “emergency” procedure of tomorrow. In some regions where hospital occupancy runs chronically at 100%, following this rule would simply eliminate all elective procedures on a permanent basis. Since most patients admitted to a hospital are medical patients, this also allows the department of medicine to shut down the department of surgery. Thus, the best way to implement this policy is simply to declare that all surgery is emergent. In fact, admit them to a hallway bed in the emergency department.

Admitted patients held in the emergency department cannot be moved to the inpatient service until a bed is available.

Wrong! There’s far more square footage and hallway space on the in-patient units than in the ED. Don’t like the hallways? – Use conference rooms, waiting rooms, sunrooms. Put the patients on the wards where the appropriate nurses and physicians providing in-patient care exist. Spread out the overcrowding problem. Let multiple units absorb a small part of the larger crisis. If the patient is to be stuck in a hallway for lack of beds, why should they care which hallway they’re stuck in? Who doesn’t believe that beds would be found quicker for these patients if they were moved onto the units? Every objection to placing patients in hallways on floors pending a bed also applies, in spades, to the ED.

Can’t do it? There is no JCAHO policy that gives the ED hallway special status. We’re not Stonehenge. Bring in you local structural engineer to demonstrate the surprisingly observable fact that the ED is not built out of rubber bands that can infinitely stretch to provide never-ending space. They might also be able to point out the similar amenities available in any hallway, regardless of location.

If your hospital has a full-fledged OB department, take your administrators on a tour of the OB ward, that “other” area of the hospital with the magic rubber-band hallways. Ever hear of an OB department that refuses a woman at the door in labor because of lack of space? Ever hear of an OB department calling the ED to let them know that the OB ward is taking a “time out”, and for the ED to play obstetrician for a while? Ever hear the OB chief suggest that you keep the woman in the ED and let her deliver in the hallway? (I have no doubt that someone reading this probably has had this experience, but I think the exception proves the rule.)

Of course, one could always find more available beds if only change-of-shift came more often.

Admitted patients should receive the same standard of care, regardless of their location in the hospital.

Wrong! How many times have you held your fifth or sixth ICU patient in the ED (without additional staff, of course) when the ICU won’t take a patient because it would mess up their “staffing ratios”? Where is the in-patient physician specialist? I mean, sure, we’re good. But who wants to pretend that we are the equal of the specialist in providing specialty care to in-patients (assuming, of course, that we had the time to stop and do so)? Where is the in-patient nurse specialist? Where is the warm food and the discharge planner?

The worst perversion of this requirement is forcing the already overtaxed ED nurse to complete a 10-page comprehensive admission form on all patients admitted but held in the ED. This has four measurable effects. First, the ED nurse is pulled away from providing real care to emergent patients, and is instead completing mind-numbing admission forms. Second, the in-patient unit, which now will not have to complete the form, is rewarded for whatever delays they have contributed to the obstruction to moving the patient to the in-patient unit. Third, the primary nursing provider on the in-patient unit never has to really get to know the patient, since the ED already does all the paperwork. Fourth, the patient doesn’t benefit from this – not even a tiny bit.

Currently, the only way to truly implement this policy during ED overcrowding is to move all of the in-patients out of their rooms into the hallways and have their treatment rendered by someone other than their personal physician. Now you have a uniform standard of care.

The hospital should have a policy to facilitate early discharge in circumstances where the emergency department is holding admitted patients.

Wrong! Well, they may have a policy. But a well-run hospital is going to have early discharges anyway. Of course, “early” can be interpreted as “shortly after the afternoon change of shift”. What incentive is there for the in-patient staff and admitting physician to disrupt THEIR day when the emergency department can so easily bunk patients in the emergency department? Why spread the “mess” to other areas, when it’s so nicely contained in the emergency department? All the more patients to fill out those patient satisfaction surveys!

Sudden and unusual ED overcrowding gets everybody’s attention. But when it’s a day-to-day phenomenon, “disaster fatigue” sets in, and it becomes simply business as usual. Others don’t care, not because they’re uncaring, but because, as long as patients can be held in the ED, it’s just not their problem. This reflects institutional culture, not individual preference. I don’t involve myself in the problems of the operating room, or whether or not warm food is delivered to the OB suite. Why? Because it’s not my problem. Why does OB take any woman who presents in labor? Because they believe that this is their patient, and it is their problem. Unless admitted patients are delivered to the floors, bed or no, the problem will remain ours.

Of course, this doesn’t preclude meetings to discuss the problem, get the data, look into different options, and have further meetings. That’s why the “C” in CQI stands for “continuous” and not “completed.”

We should quit discussing solutions that don’t work, because they impede the implementation of solutions that CAN work.

Well, of course! The solution to ED overcrowding is to get rid of the crowd. Admit them and put them on an in-patient unit. Get JCAHO to mandate it. Clearly, nothing else has, will, or can work.

Posted in ems-topics, patient-management

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1 comment Posted by on October 23, 2010

EMS After 911: The State of Prehospital Care

Recently, I was offered an opportunity by the Burlington County Health department to serve on the New Jersey Medical Reserve Corps. The New Jersey Medical Reserve Corps is an outgrowth of the national mandate for disaster preparedness from the September 11th terrorism attacks.  This offer and the ninth anniversary of the terrorist attacks caused me to reflect on the realities of the preparedness of our current medical system in the event of another disaster.

The laundry list of the number of hospitals that have closed in the recent past in the Philadelphia region, where I practice, is outrageous.   Neumann, Parkview, City Line, Northeastern and The Medical College of Philadelphia are just a few names which come to mind.  A large result of these closures is a result of the red ink of insolvency.  I’m absolutely sure these hospital closures are not a unique event to my local area of practice as an Emergency Medicine physician.   Combine the number of hospital closures, the overcrowding of Emergency Departments and the treatment of the concept of “divert status” as taboo by hospital administration, the question arises, what would happen if another plane was hijacked and flown into a city center?

My grim view of our post 911 state of affairs for emergency medical services is further compounded by my perceived changes in pre-hospital training.  In the 1980s, in New York State, I was an Emergency Medical Technician. New York required my sitting for a recertification exam every two (2) years.  As an Emergency Medicine Physician, I am required to take a recertification exam to maintain my board certification status on a regular basis (Every ten years a proctored written examination, eight out of ten years online examinations based on materials from mandated articles, amongst other requirements). This same level of certification which assures a minimal standard of knowledge appears not to be required by the rescue personnel that we depend on.  Random continuing education credits, without assurance to their content, have replaced the reinforcement and assessment of basic skills and knowledge in many jurisdictions.  It seems as if the retention of personnel has become more important than the quality of the volunteer system.

While appropriate triage and scene command is a central subject discussed and taught in EMT programs, I see and hear of numerous hospital systems where the local EMS personal lack an understanding or a willingness to practice this act.  If local squads have no understanding that bringing ten to twelve auto accident victims into a single coverage community hospital concurrently at three in the morning, without sharing the burden with other nearby local hospitals, effectively shuts down that Emergency Department, what will occur with a major disaster?  Perhaps the overall problem is a refusal of a central government agency to take ownership of the volunteer EMS system.

My experience has lead me to believe that most metropolitan systems have mechanisms in place to contend with the volume resulting from a mass casualty incident. The only volunteer system I have personally witnessed years ago that centrally managed triage well was Nassau County, New York.  Back in the 1980s, I was a volunteer fire fighter and EMT with the Garden City Park Fire Department.  Routinely, our ambulances would call into Nassau County Medical Center with our patient reports, were given medical command, and were diverted and directed to a destination hospital based on a variety of factors.  In essence, “NCMC” not only oversaw the medical care provided, but also served as a “traffic control center”.  At least this region had, and hopefully still has, the mechanisms in place to handle the volume associated with a large calamity.

It seems as if the overall system for Emergency Medical Care is in need of reinvention.  A centrally controlled scene command, an assurance of minimal skill and proficiency for EMTs and first responders, and an ability of hospitals to have a built in cushion to absorb patients, are all core components of an effective disaster preparedness system.  This reinvention must be realized on a state or regional level.  Failure to address these issues could prove disastrous in the future if such circumstances ever reoccurred

Posted in 911, command-leadership, ems-topics, fire-rescue-topics, major-incidents, news, patient-management, rescues, training-fire-rescue-topics

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No comments Posted by on October 23, 2010