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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

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67 comments Posted by on April 26, 2011

Hiding In The Nursing Lounge

Recently my feathers became ruffled when my nursing staff shared with me that two EMT students decided to sleep in the nursing lounge rather than to introduce themselves and “dive right in.”   Despite my nurses trying to “protect” these kids, I insisted on getting details and calling the EMT instructor to make sure hell was raised in class.  I requested that these students return to perform their observation time all over again.

The two nurses who shared with me the events of that day are angels.   Both were feeling incredibly guilty over “ratting out” these two kids.  They saw my anger upon my hearing about the total disregard for learning that was displayed.  “They aren’t learning to be fry cooks – they will be responsible for peoples lives!”  I explained to my nurses that the observation time provided to these students to see what the Emergency Department staff actually does is crucial.   The students need to be aware of what information we need, how we need patient histories presented, and how EMTs and Paramedics are our “eyes and ears” in the field.  The rotation is more than just about “watching,” it is about honing skills and gathering a feeling of what processes proceed upon their bringing the patients through our sliding glass doors.

Many EMTs that I have seen over the recent years lack effective communication skills.  The ability to communicate pertinent information in a concise and efficient manner is paramount.  In no other hospital environment does rapid transmission of data in an effective matter hold such a high priority.  Did the child have access to medications before he arrested?  Was the accident victim’s car displaying a spidered windshield?  How long ago was it that the stroke victim was last seen acting normally by his family?  There have been several occasions where I personally feel like pulling my hair out  trying to tease this data out of the rescue personnel bringing in patients.

I believe the solution to the effective data transmission problem is two pronged.  First, the minimal observation time in the Emergency Department needs to be extended to more than the minimum of ten hours with emphasis on patient presentations.  A rolling four-week rotation might make more logical sense, with students actively following a physician, physician-assistant, and nurse.  Secondly, minimal standards in language skills and public speaking should also be a requirement.  Testing should be mandatory to assure these skills are present prior to be entered into an EMT program. Failure to meet these standards represents a disservice to the EMT student and to the public for which they are training to serve.

ADDENDUM:

I have created a lot of conversation/controversy  with this piece as can be viewed in the comments.  There seems to be some general themes which I would like to share based on the responses.

First off, I wish to apologies to anyone who I offended with this blog post.  The intent was never to be insulting, but rather to start a conversation regarding the issue of  effective patient care reporting and student education.  I strongly feel that effective public speaking and communicating patient reports in an efficient manner is a paramount skill needed in the Emergency Medicine/EMS arena.   As such, all comments which were submitted, both positive and negative,  have been posted as of my logging in today on 1-19-11 at 1900 EST

For clarification to those who don’t follow my blog and expressed concern that I have no in-field experience, I was a New York City EMS provider.  I was initially stationed out of Bedford-Stuyvesant, (Woodhall Hospital) and subsequently out of Queens General Hospital  (worked a tactical unit) .   I have worked in the field in EMS for years (both public and private sector),  volunteer my time as a proctor for EMS examinations, actively teach EMT programs, and was a volunteer firefighter.  I have worked both the suburban and urban arenas.  I started this blog as an effort to promote positive change and as well as  advancement of Emergency Medical Services.

Of further note, a substantial number of the  nursing staff with whom I work are EMTs, flight nurses, and paramedics themselves.  We all put in a great deal of effort whenever an EMT student rotates through our ER to teach.   I have the students follow me on a rotating basis listening to heart sounds, breath sounds, and perform examinations.   We actively discuss and teach pathology .  The nurses help the students splint, take vitals, and assist in care.  We take our roles with these students very seriously.  We aren’t mandated to do this.   We do this because of  genuine concern for the education of these students and our patients.  In this context, I believe it becomes obvious why I was so angry regarding these two individuals who were found sleeping in the lounge.

To address some key points which were made:

1)  There are communication issues on both the hospital and prehospital side of EMS care.  As was noted in one of the responses listed below, most ED personnel are overworked and there are incidences where EMS personnel are ignored.   I agree that ignoring our infield colleagues is absolutely wrong.   A vicious circle, however, ensues.   ED staff who are met with ineffectively communicated reports  tune out the prehospital provider.  This, in-turn, leads to the prehospital care provider feeling unappreciated.   A negative feedback loop is created.

Since this blog is intended to discuss issues in prehospital/EMS care and look for solutions, my suggestion is that if you are dealing with a hospital environment where you or your staff are being ignored, discuss this with the ED nurse manager or ED director.   Find out how to correct this problem!  Offer ride-alongs.   Offer teaching in turn.  Meanwhile, the initial premise which I was trying to convey, being that of  assuring exposure to effective patient reporting to the EMT student, might be augmented by extended ED rotations and education in honing communication skills.

2)  The issue of pay and salary was raised by several individuals.  I agree that in many areas EMS isn’t even considered an essential service.  This is absolutely wrong and does need to be changed.  I have addressed this concern in a prior blog.  However, pay and the responsibility inherent to accepting a job where people’s lives are involved are two separate issues.   There are towns where police are paid horribly and their lives are constantly at risk.  Should they, therefore not protect the public?  Since the blog addressed two of my students who were caught sleeping in the nurses lounge, should police cadets who know they will be serving in poorly paid dangerous cities not bother to learn?  Obviously not.

3) Someone raised the issue of difficult staffing in volunteer squads.  This is a tough topic.   I would argue that maintaining a standard would be of greater value than pure staffing.

4) Another individual raised the issue of how, as a medical student, he routinely has to present cases as part of his training.   He referenced how little didactic coverage is included in the current EMT course work.  He makes a valid point! I would argue that this should be addressed in EMT core curriculum

5) For clarification, my statement regarding the need for effective communication skills does not imply being a native English speaker.  Being able to relay a concise detailed report with pertinent information is my concern.

I truly like the response from paramedic George

“It’s a skill that communication should be simultaneously efficient and effective. There are only benefits in seeking better cooperation between ER nurses and EMS. And between SNF nurses and EMS. Between any and all healthcare providers transferring care or working as a team. It’s everyone’s duty to keep improving their skills, for supervisors to support and encourage development of providers’ skills, including communication skills. Don’t wait until there’s a problem involving a patient outcome to recognize this. Thank you all.”.

Posted in ems-health-safety, ems-topics, training-development, training-fire-rescue-topics, Uncategorized

52 comments Posted by on January 19, 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

Advancement of EMS Oversight For BLS Arena

Beginning January, 2011, a Medical Director is required for all ambulance services in the Commonwealth of Pennsylvania. Additionally, the ability to contact Medical Command is required of all ambulance services as well. This seems as if we are heading in the right direction regarding oversight. Up until now, AEDs were optional for BLS ambulance services. The mandate that they are onboard has prompted the need for having a Medical Director. Hopefully, this will generate some quality control. Hopefully, this will not be a localized step forward in one individual state.

Posted in ems-health-safety, ems-topics, fire-rescue-topics, training-development, training-fire-rescue-topics

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No comments 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