NAEMSP Dialog: Fire First Response (Condensed Transcript)
In this session of the NAEMSP Dialog, we addressed the policy issues surrounding the
use of fire department first response. It is a common feature in many EMS system
designs. When does it, and doesn't it, make a clinical difference? How can this important
resource be utilized most effectively, efficiently and safely?
(Begin Condensed Transcript)
We have several members in our panel of invited participants for this topic.
Alan Craig, Rick Verbeek, MD and Brain Schwartz, MD are the authors of the paper
published in the January 2010 issue of Prehospital Emergency Care entitled "EvidenceBased Optimization of Urban Firefighter First Response to Emergency Medical Services
9-1-1 Incidents."
David Cone, MD was the lead author of two research papers published in Prehospital
Emergency Care on this topic - "Is there a role for first responders in EMS responses to
medical facilities?" and "Can emergency medical dispatch systems safely reduce firstresponder call volume?" Rounding out our panel is Angelo Salvucci, MD from the Santa
Barbera, CA EMS System.
The resource page for this topic is now available at
http://groups.google.com/group/naemsp-dialog/web/fire-first-response. It includes
links to download PDFs of the papers mentioned above. If you have not already read
them, I would encourage you to do in preparation for our discussion.
I will begin the conversation with some questions to our invited guests and they will
have an opportunity to reply. During this initial exchange, the list will not accept
questions from list members per our usual format. After the initial exchanges with the
invited participants, the conversation will be open for questions and comments from all
list members.
Please remember to include your name and affiliation at the end of your posts. You are
encouraged to leave off the quotes of earlier posts in reply unless needed to clarify your
own post. Thanks so much for you interest and participation.
--- Mic
Mic Gunderson
Moderator, NAEMSP Dialog;
President, IPS
Let's begin with a question to the authors of the paper published in the January 2010
issue of Prehospital Emergency Care entitled "Evidence-Based Optimization of Urban
Firefighter First Response to Emergency Medical Services 9-1-1 Incidents" - specifically:
Alan Craig, Rick Verbeek and Brian Schwartz.
Your research suggests a way to systematically reduce the number of cases in which fire
department first response is utilized. You assert that this has potential advantages in
safety by reducing risk to for firefighters and civilians from emergency vehicle crashes;
by making more efficient use of fire resources; and not depleting fire resources for fire
calls. The data you used for the study was from 2003-4. I'm curious if you have modified
policies for use of fire first response in Toronto based on this model? If so, when and to
what effect?
--- Mic
Mic Gunderson
Moderator, NAEMSP Dialog;
President, IPS
No - This methodology has not be adopted by our joint EMS-Fire Tiered Response
Committee so no changes has been made to how and where Fire responds. We are
currently proceeding with a multi-city Phase 2a/2b validation study for publication in
2010-2011 to formally assess whether this can be advanced as a clinical prediction tool
or not.
Alan Craig
Deputy Chief,
Toronto Emergency Medical Services
Thanks Alan.
I'm going to ask a related question of Dave Cone.
Dave, your study describes an implementation - in contrast to the Toronto study where
Alan just told us they have not yet implemented a policy change yet. The conclusion in
your abstract on reducing fire first responder call volume says, "This study suggests that
a formal EMD system can reduce first-responder call volume by roughly one-half." Did
you encounter any resistance from the fire service when you implemented this dispatch
policy change? They are making fewer runs as a result. In some communities, this might
be cause for significant political turmoil. What was your experience in New Haven?
--- Mic
Mic Gunderson
Moderator, NAEMSP Dialog;
President, IPS
The idea for the study actually came from the fire union, which had been pressuring the
city (for quite some time) to reduce the EMS call volume for the first-responder engine
companies. The prior policy was to send an engine, lights-and-sirens, to EVERY medical
call in the city, regardless of nature or severity. The FD leadership, once convinced of
the need to change this (liability issues, large numbers of calls with no interventions,
etc) came to us asking for help on how to change the dispatch protocols to safely reduce
the number of calls. We basically drew a line between the Alpha and Bravo calls: the
first responders do not go to most Alpha calls (with a few exceptions), but do go to most
Bravo and higher calls (with a few exceptions).
The union has been quite happy with the results, and since we were able to
demonstrate (both through the original research project, and through ongoing quality
improvement activities) that the new practice is safe (i.e. we don't have patients with
poor outcomes due to not getting a first-responder resource), the city is also satisfied,
and is saving some amount of money due to decreased fuel costs, wear-and-tear on the
apparatus, etc. We have also heard (anecdotally) that it is less frequent for a moredistant unit to have to cover a call in a part of the city where the first-due unit is out on
a medical run - we haven't quantified this, though it would probably be fairly easy to do
so.
It is worth noting that the FD in question does not bill for EMS, since they do not
transport - so there is not a negative impact on revenue due to the decrease in call
volume.
Dave
-David C. Cone, MD
EMS Section Chief
Yale Emergency Medicine
Editor-in-Chief
Academic Emergency Medicine
www.aemj.org
Now that we have framed some of the issues with our invited participants, the
conversation about fire department first response will now enter the open dialog phase.
Please let us know your opinions, ask questions, offer ideas. We want to tap into the
collective wisdom of the EMS community with this conversation.
Also, let us know if you have other papers or resources to suggest for our information
resource page on fire first response. Send them directly to me at mic@onlineips.com.
Do you have colleagues that would benefit from or have something to contribute to this
conversation? Please encourage them to join us here on the Dialog. Consider posting
something about this on other EMS listservs (with permission from the moderator of
those lists as appropriate, please).
Please remember to include your name and affiliation at the end of your posts. You are
encouraged to leave off the quotes of earlier posts unless needed to clarify your own
post.
Thanks,
--- Mic
Mic Gunderson
Moderator, NAEMSP Dialog;
President, IPS
I am delighted to announce a late addition to our group of invited participants - Gary
Ludwig, Deputy Chief of EMS for the Memphis Fire Department and Chair of the EMS
Section at the International Association of Fire Chiefs.
--- Mic
Mic Gunderson
Moderator, NAEMSP Dialog;
President, IPS
Dave,
Interesting scenario with the fire union seeking ways to reduce EMS call volume.
Let me bring Gary Ludwig into the conversation at this point. Gary, could you comment
on the reasons why a fire department may not want to decrease its EMS call volume even if they do not transport or bill for transports?
--- Mic
Mic Gunderson
Moderator, NAEMSP Dialog;
President, IPS
I'd also like to bring Dr. Salvucci into the conversation here as well. Angelo, please tell us
about use of dispatch triage practices to determine what 9-1-1 emergency EMS calls
that fire first responders do, and not, respond to - in Santa Barbara County and the
surrounding areas of California. Does the FD always respond with lights and sirens to an
EMS calls that comes in via 9-1-1?
--- Mic
Mic Gunderson
Moderator, NAEMSP Dialog;
President, IPS
Mic,
For Santa Barbara County there are 6 PSAPs, with about half of the calls answered by (or
transferred to) an EMD-capable center. The fire department is dispatched, usually lights
& sirens, to all non-EMD calls. For EMD calls there is about a 15% non lights & sirens
response, but fire is sent on all calls. I am also involved with Ventura County (on the
southeast border of Santa Barbara). There we have universal EMD and prioritize the
response, but again send fire first responders on all calls. I cannot speak for every corner
of California, but the general practice out here is to have fire first responders go on
most or all medical calls. Perhaps with the research Alan and Rick will be presenting in
Florida we can sit down take another look at that.
Angelo
Angelo Salvucci, MD
....and Mic, I can't help but wonder whether I may be complicating things....but might
some form of stratification be needed here in terms of assessing clinical outcomes for
patients in those communities that respond to 911 medical calls with fire rigs where all
the responding personnel are cross-trained as firefighter/paramedics versus those with
firefighter/EMTs versus those with just firefighters (and I certainly realize the sample
size for the first group may be small, but in my local community, all 55 sworn fire
personnel are cross-trained as paramedics).....a random thought from a Fire/Police
Commissioner but clearly, an (almost) outsider.
Jerod
Jerod M. Loeb, PhD
Executive Vice President
Division of Quality Measurement and Research
The Joint Commission
One Renaissance Boulevard
Oakbrook Terrace, Illinois 60181
(e) jl...@jointcommission.org
(v) 630-792-5920
(f) 630-792-4920
www.jointcommission.org
Mic - Sorry for the delay answering this - I had to fly to D.C. tonight and then went
straight into a business dinner that ran late into the evening.
To answer your question - a fire department's main role in any community is to serve
the community. I do not know if "a fire department may not want to decrease its EMS
call volume" in as much as fire departments want to deploy the right fire resource(s) for
the right need. Thus, if they deploy the right fire resource(s) for the right need, they are
serving their communities.
The fire service's role is to mitigate and manage risk. Risk can take the form of a fire, an
EMS call, a hazardous material event, etc. Unlike many EMS calls that can be somewhat
predictable based on numbers of people and their activities, other risks that the fire
service mitigate and manage are not predictable. Thus, proper static and geographic
deployment is necessary. With that static and geographic distribution is the availability
to respond to medical or traumatic emergencies. Therefore, as I read the study, the fire
department's run volume was decreased, but more focused on deploying the right fire
resource(s) for the right need. The trick to deploying the right fire resource(s) for the
right need is determining those needs and then deploying the right fire resource(s). I
believe that every need on a medical call should be examined to determine the right fire
department resource(s) and not only focus on clinical needs but other issues that impact
better outcomes for patients when designing a response matrix for first response.
Gary Ludwig
Deputy Fire Chief
Memphis Fire Department
(901) 320-5464
I very much agree with Gary's excellent reply - The only "opponents" of the plan within
our FD were those who felt that service to the citizen was the main objective: "If they
call 9-1-1, we should show up in our big white [sorry - East Coast thing] truck with the
lights flashing." I replied, "Even if it's not an emergency? And if that truck and its crew
could better be used elsewhere? Do we really want to continue the risk of L&S response
to cases that we KNOW are not emergent?"
We eventually won the support of the (few) skeptics, and we had to pay close attention
to our data to do so - it was imperative to show them that were were NOT denying
service to any citizens who actually needed it.
Dave
-David C. Cone, MD
EMS Section Chief
Yale Emergency Medicine
Editor-in-Chief
Academic Emergency Medicine
www.aemj.org
Gary and Dave both make important points. There may be non-clinical reasons for FFR
such a haz-mat control, extrication, fire suppression and safety such blocker vehicles on
busy roads and highways. Those need to be addressed in other parts of the dispatch
decision process and are in our system through MPDS etc. They are entirely separate
from our paper and can be triggered by the call screening process. Dave's point is key. In
fact, we know that most EMS calls are not emergent. Most of what we do in EMS is
what police call "barking dog calls"; important to the caller, important to our mission,
and important to public service, but they don't need SWAT. Our job is to figure out
when to send a maximal response, and when to just sent an ambulance crew. Most EMS
calls in our system are handled "cold" -- no lights or siren -- by a single EMS crew, and
with good reason. Clinical data provides excellent evidence to support decisions about
how EMS should response -- BLS or ALS, hot or cold -- and the same evidence helps send
FFRs selectively, balancing risk and benefit. Fire services have lots of experience in this
form of nuanced response
decision -- it's why you get a "full box" -- four engines, two trucks, a squad and two
battalion chiefs -- to a fire in a store, a single engine "hot" to extinguish a trash barrel,
and a single engine "cold" to check a CO detector sounding in an unoccupied building,
all for good reason and with good judgement. This process is simply a matter of applying
that decision-making to EMS responses using clinical evidence as a guide for the
discussion.
Alan Craig
Deputy Chief,
Toronto Emergency Medical Services
Alan, David and Rick - thank you for opening the door for me to explain that the fire
service does not just see first response as a "totally clinical" application with the goal
stopping a clock and say sticking a bandage on something to control the bleeding. The
fire apparatus carries not only the human resources but other resources that may be
needed for a scene. Auto accidents are a classic example. The patient's injuries may be
minor in nature and a first response clinical application is not a priority - but engine and
ladder companies serve as excellent blocking tools for protecting EMS personnel
working on the scene. In the last two years, here in Memphis, we have had three pieces
of fire apparatus struck while serving as blocking tools. One crew tells me they have no
doubt that they would have been dead if the engine had not been parked there. On
auto accidents there is also opportunity for precautionary hoselines to be laid while
extrication is occurring in the event there is fuel that could ignite; extrication tools in the
event a door is crimped; etc. - even though the patient may have minor injuries.
The other issue with first response that is not always clinical in nature are time-to-task
functions. Some EMS calls are labor intensive, even though the patient is of a minor
nature. This could include obese patients (who are never on the first floor ironically);
someone with a neck and back injury on a second floor where immobilization
equipment and a stretcher would have to be brought to a second floor. In order to do
this, a two-person ambulance crew would have to possibly leave the patient's side for a
significant amount of time to retrieve equipment and carry it to the second floor and
then try to carry that patient down from a second floor.
These all factors that should be considered in first response determinants.
Gary Ludwig
Deputy Fire Chief
Memphis Fire Department
(901) 320-5464
Remember - Everyone Goes Home at the End of the Shift!
Gary and I are in complete agreement on car crashes. Send appropriate responses from
EMS and Fire when need is established in the dispatch information. I think even
"ALPHA" sick person calls on an expressway should trigger a special supplementary
response by Fire to provide blocker/scene safety, perhaps not a widely held view. On
the latter issue of FFRs as additional manpower on the scene of routine non-emergent
EMS calls: It is for exactly this reason that our methodology proposes an entire class of
FFR responses to provide on- scene assistance to paramedics, in our example, 58,000+
calls in a 16-month sample. However, they are in MPDS categories unlikely to produce
the need for critical FFR interventions, so the FFR response would be "cold", that is, no
red lights or siren, arriving, as they would, a few minutes after EMS, well in time to
provide any needed on-scene assistance without the danger of additional "hot"
responses. I would feel terrible if I mandated a lights-and-siren FFR response to help lift
a patient with a minor illness or injury who we already know will await treatment for
many hours in the ED if that response became a enroute FFR crash. We often need extra
hands at the scene, and even if they are not part of the initial response, they can be
summoned to the scene, almost always on a non-emergent basis.
The transitional piece of this is introducing non-emergency response as a norm in FFR,
just as it is in EMS, and considering whether even this response is likely to be needed on
enough classes of calls to support a "engine-to-every-911-call" policy, or perhaps, as we
suggest, strategically selected MPDS determinants. Good data collection by everyone
supports making sophisticated decisions which will make sense to our providers.
Alan Craig
Deputy Chief,
Toronto Emergency Medical Services
Good day Gentlemen, I am not sure if I am allowed to comment but I thought I would
try to let you know what we are doing in British Columbia on this subject.
Very interesting discussion, but sense I do not know any of you and you do not know me
I feel I should give a quick background of myself. I have over thirty years fire service
(Deputy Chief and Chief for ten yrs.) experience in the metropolitan area of Vancouver,
British Columbia, I consulted for Vancouver International Airport when they went with
their own Aviation Fire Fighters rather than contact to Richmond City and for the last
two years I have been working for the Provincial Government as the Director, First
Responder Services.
As Gary was saying the role of fire is to mitigate and manage risk, and that is why in BC
motor vehicle accidents are not classed as a First Responder call they are classed as a
fire call. When British Columbia Ambulance Service dispatch receives a Motor Vehicle
Accident it is immediately passed on to Fire Dispatch for a combined event call BCAS for
Medical, and Fire to mitigate any danger that my exist from the MVI.
Now you can imagine that when sending two agencies to a MVI (when approximately
80% do not require transportation) you are wasting Ambulance resources that could be
unitized some where else for more critical medical calls. In BC we are doing a pilot
project in the City of Surrey where when we have no injuries the Fire Service cancels the
Ambulance through a combined events radio channel which in theory allows the
ambulance service to attend other calls
As for non-emergency response for First Responders it does not happen but when the
ambulance crews need help such as assistance with stretcher lifts, assistance with
getting a patient out of a cumbersome spot, etc. the Ambulance crews puts a call in to
the First Responder and we respond non-emergency.
Just thought I would try and let you gentlemen know what BC First Responders are
doing on this subject.
Randy C. Shaw
Director, First Responder Services
In response to Mic's question, clearly consistent adherence to the MPDS algorithm is
essential if consistent call classification is to be achieved. Followed carefully, MPDS will
place calls reported the same way in the same determinant very reliably, which then
allows depterminant-specific response plans to be developed.
At the time of the study, Toronto EMS was not yet an accredited NAEMD comm centre,
but still a very experienced MPDS site. Unfortunately, no MPDS compliance numbers are
available for the period, although we now are accredited.
A word of caution - EMS systems which do not interview the caller (ie just get a dispatch
address and complaint created informally by a PSAP) may lack the data required to tailor
anything in their system, including FFR. There is a broad scientific literature arguing in
favor of strict algorithmic EMS call triage, and instituting such a system, even at the
Primary PSAP, is an essential step to evidence-based decision-making.
Alan
Alan Craig
Deputy Chief,
Toronto EMS
I have enjoyed the discussion as well. Some of it centered on first (fire) response to
motor vehicle collisions, so a couple of comments:
1. Like Mr Shaw (below), we found that a significant number of reported motor
vehicle crashes in Boston did not result in a transport. After reviewing the situation, we
found that many of the incidents without a transport were initially reported as
"unknown injury". This was also found to be the case in a study by Key and Pepe in 2003
(I'll send to Mic). Based on that, we stopped dispatching an ambulance to a motor
vehicle crash with unknown injury a few years ago unless there are other factors
involved (high speed or rollover, on a limited access roadway, or involving a high
occupancy vehicle like a bus). We will wait until the police or fire department arrive to
determine if there are injuries and a need for EMS. We have found that when there are
injuries, they tend to be relatively minor and the 5-6 minute delay in dispatching an
ambulance does not appear to negatively impact the patient. If we are responding to a
motor vehicle crash with reported injury and the first arriving police or fire unit
determine there are no injuries, that is entered into the common CAD system and we
are cancelled-- I was surprised to hear that is not how it's done in other communities
(re: the "pilot project" to our friends to the North)
2. It sounds like there is an acknowledgement that first response to motor vehicle
crashes and, in fact, most medical calls, does not improve patient outcome, but they
respond for other reasons: to open doors, deal with fuel leaks, assist with patient
movement. It has also been argued that having the fire apparatus respond can assist by
"blocking" at the scene, especially on a high-speed roadway. Chief Ludgwig points out
that there have been 3 cases in his service in the past 2 years in which this prevented
rescuers from being injured. I'm curious how often in those same 3 years fire apparatus
was either involved in a crash while responding, contributed to a crash (wake effect), or
was not available for a simultaneously occurring incident-- that's the risk/benefit
question we all struggle with. When your house is on fire, you don't want to find out
the closest fire apparatus was tied up taking care of someone with an ankle injury.
Brendan Kearney, MPA, EMT-P
Superintendent Field Support
Boston (MA) EMS
There's a difference between "taking care of someone with an ankle injury" and
blocking a scene so EMS providers can take care of someone with an ankle injury safely,
and I think that was Chief Ludwig's point. The latter is a perfectly appropriate use of a
fire apparatus. We have to take steps to ensure our own safety on the roadway. Our
safety comes first, then the patient's, then the general public. Motor vehicle accidents in
busy roadways occur more frequently than structure fires and busy roadways pose a
danger to the people involved, just like structure fires. Your argument seems to suggest
that the fire department should limit itself to.... structure fires! Those days are long
gone.
That doesn't mean anyone should be driving like an idiot or running red lights on the
way to an emergency call. I honestly think that's the bigger issue. It's possible to drive
"lights and sirens" safely. If drivers aren't driving defensively and carefully then the
driver, the officer, and the department are negligent and we shouldn't accept that. It
will be a sad day that we stop blocking traffic (which we know poses a significant safety
threat to responders on the side of the road) because the more likely scenario is that we
hurt someone en route.
Tom
-Tom Bouthillet
Lieutenant / Paramedic
Town of Hilton Head Island
Fire & Rescue Division
843-247-3453 (cell)
Tom: Of course I'm not suggesting the fire department only respond to structure fires.
There is certainly a need for a well coordinated response, including first responders, to a
subset of truly time sensitive emergencies- airway obstruction, uncontrollable
hemorrhage, cardiac arrest to name a few. There is also a need for first responders at
other incidents, such as forced entry, bariatric patients, and other hazards- including
blocking at crash scenes when other resources aren't available. It's the premise that we
should send first responders to all calls (including ankle injuries) that I don't agree with,
and that also seemed to be the findings of the journal article.
Boston EMS takes responder safety very seriously- some of our ambulances are pictured
here: http://www.usfa.dhs.gov/downloads/pdf/publications/fa_323.pdf . My point
was we should not underestimate how dangerous it is (both to rescuers and the public)
every time we go on a response (25% of firefighter fatalities are caused by motor vehicle
crashes).
More on blocking: http://www.usfa.dhs.gov/downloads/pdf/publications/fa-272.pdf
Respectfully,
Brendan Kearney, MPA, EMT-P
Superintendent, Field Support
Boston EMS
Brendan - in response to your question on the numbers of accidents in the last three
years where fire apparatus was responding to an accident and had an accident - I do not
readily have data available that correlates that information. Anecdotally, I can tell you
that we have had no serious accidents or injuries with fire apparatus responding to
medical calls in the almost five years I have been in Memphis. It seems the main cause
of our accidents is mirrors on apparatus (including ambulances) bumping mirrors on
other vehicles (which we are looking into including measuring how wide apparatus is in
comparison to normal lane widths and maybe adjusting specifications). We believe our
defensive driving programs, Opticomm system, and driving simulators all play into this.
As you make reference to, I am sure no one wants their "closest fire apparatus tied up
on an ankle injury" when their house in on fire. That's the perspective of the person
whose house is on fire. The person who has a fractured ankle and is laying there waiting
for someone to show up probably would have a different perspective. I am also sure
the ambulance crew and the person with the ankle injury would certainly appreciate the
extra manpower if the patient were down in a ditch and had to be carried up steep
terrain or over uneven ground.
As I said, for the fire service, every EMS call is not limited to its ability to deliver clinical
care - our scope is clinical, plus more!
Gary Ludwig
Deputy Fire Chief
Memphis Fire Department
65 S. Front Street
Memphis, TN 38103
Office: 901-527-1400
Fax: 901-320-5631
To add some realism to our ongoing discussion I just noticed on a local news website
that their was a collision between a car and a fire engine in a suburb just north of
Toronto today. Early word is that the Fire Engine was responding to a call which almost
certainly means lights and sirens. No information regarding the nature of the call. One
civilian killed, another critically injured and apparently some
minor FF injuries as well. An unusual event but still occuring often enough to warrant
the google group going on right now.
We obviously want to sent FFR to calls where lives can be saved but on the other hand
no one wants what happened here today. This brings up the whole tolerability of risk
issue which is one of the inputs of the model we put forward. This was actually Alan's
idea (he is much more brainy that I am) and I think it is one of the most creative parts of
our paper since it quantifies the issue and can be applied to local data to derive a "best
choice" cut-off point for MPDS determinants that a system may choose to respond in
"hot" mode.
The idea behind tolerability of risk is to decide how averse you are to taking a life (like
what happened above) versus how keen you are to save a life (e.g. when an FFR delivers
the first and only shock and the patient survives to discharge neurologically intact. If
you are equally averse as you are keen the slope of the tolerability of risk line is one.
(This is what we chose for illustrative purposes.) If you are twice as averse as you are
keen the slope of line would be two. This results in fewer MPDS determinants to which a
"hot" response would be assigned. There is no right answer, only local expert opinion. It
may differ between communities. Note that this is not the same as saying I am willing to
take 10 lives provided I save 10 lives on the other side so you can't determine the slope
the line by "keeping score".
It is this line of thinking that makes me feel we need to find a balance between "hot"
responses to every call versus a "hot response" to calls where FFR have a high chance of
intervening in a potentially life saving way blended with a "cold" response to calls where
the chance is not all that high but isn't zero.
On a slightly different note, I do find Randy's pilot intriguing. I must say I haven't
thought of having FFR "call off" EMS to vehicle crashes where FFR identify no injuries.
Our current policy is that once EMS is dispatched they should proceed to at least "lay
eyes" on the patient before they cancel. This is probably what most of us do but clearly
Randy's idea may be a worthy part of the mix. Randy, I hope you are planning to publish
your experience with this. There will be learning in it for all so please share.
Rick Verbeek
Medical Director, Sunnybrook Osler Centre for Prehospital Care
Toronto
In June of 2009 we implemented the same basic concept in the Tulsa EMS System.
Under the direction of our Medical Director Dr. Jeff Goodloe, we reviewed each call type
using a group of parameters. The result was a decrease in the EMS responses by Tulsa
Fire apparatus and reduction of Alpha and Bravo level responses. Overall, the impact
has been a decrease in about 5,000 responses or roughly 1%. I am of the opinion that in
order to implement this type of change in fire service response you must focus on the
"why". A reduction of activity by a profession that thrives on response and service must
be communicated effectively to avoid the appearance of elimination. Safety of
responding personnel and the deployment of resources was the always the primary
focus, a cost savings naturally followed.
Michael Baker, NREMT-P,
Acting Chief, Tulsa FD EMS
Would like to add a bit to Alan's response.
Mic : This is a great question since it gets to right down to the essence of evidence
based change and decision rule methodolgy. The short answer is no. The line of
research that we have embarked up is very similar to clinical decision rule research
where there is a fairly well established series of steps that have to be taken before one
is ready to declare a new rule (or model in this case) is ready for prime time. The
general steps are Phase 0 – Demonstrate a need, Phase 1 – Derivation, Phase 2 –
Validation, Phase 3 – Implementation (which I think would be better labelled as
Knowledge Translation).
Our recent publication is best described as a derivation project where we have come up
with a model that we believe will provide similar findings when applied either internally
to a new data set from a different time period or externally when applied to a data set
from an EMS service that has data that can be analyzed in a similar fashion.
Most clincial decision rule projects that I have been involved in take 2-3 years for each
of the phases to be completed (Ottawa Ankle and Knee Rules, Canadian C-spine rule,
Head Injury CT rule, Termination of Resuscitation Rule) since each phase must be done
prospectively and requires patient by patient recruitment. Fortunately validation can be
done fairly quickly with the " Toronto FFR rule" (oh I like that name!) since the validation
can be done on retrospective data.
We are now in the process of undertaking a validation exercise so stay tuned for next
year in Florida!
Cheers, Rick
Rick Verbeek
Medical Director, Sunnybrook Osler Centre for Prehospital Care
Toronto
The Toronto studies were done with a BLS fire first response system. For Alan, Rick and
Brian, what parts of this might be different if you had ALS fire response?
--- Mic
Mic Gunderson
Moderator, NAEMSP Dialog;
President IPS
For this reply, I assume that ALS FFR are non-transporting and acting in a tiered
response setting with a third service EMS service. Our model reflects the opportunity to
intervene according to the procedures or level of care that were input parameters (we
called these FFR trigger interventions). If local medical control determines that the
trigger interventions for ALS FFRs would be the same then the output of the model we
described should be similar as well (i.e. to which MPDS determinants to send ALS FFR).
If local medical control comes up with a broader range of trigger interventions then the
model will likely provide an output with a longer list of MPDS determinants which of
course will mean a higher volume of calls. The model should still work to provide a
consistent reproducible working list though.
I think this is one of the major stregths of our model. It allows complete customization
based on local opinion. Not just in the trigger interventions but any of the input
parameters and the other underlying assupmtions we described. It is probably
worthwhile to point out here that the assumptions we used are not necessarily what we
recommend for our own setting. The data and assumptions we used was simply to
illustrate how the model actually works. Once we validate the model and it comes time
to consider implementation we will have to go through a detailed discussion with all our
partners as to what the inputs should be. Even then our implementation will be
carefully monitored.
There is still lots of interesting work to be done on this.
Rick Verbeek
Medical Director, Sunnybrook Osler Centre for Prehospital Care
University of Toronto
The studies in Toronto (by Alan, Rick and Brian), as well as the studies in New Haven (by
Dave), used the output of a 9-1-1 dispatch telephone triage protocol to determine the
type and severity of the situation in the field. This guided the decisions in both
communities on what fire response resources to send (or potentially send) and in what
response mode. I'd like to ask the authors of the studies in Toronto and New Haven to
comment on the impact of dispatch protocol compliance on the accuracy of their
telephonic case type and severity assessments and what level of dispatch protocol
compliance was in place during their respective
study periods. Was any attempt made to stratify results to include just those cases
where there was 100% protocol compliance?
--- Mic
Mic Gunderson
Moderator, NAEMSP Dialog;
President, IPS
We, unfortunately, have absolutely no idea of the level of compliance with the MPDS
protocols here in New Haven...
Dave
-David C. Cone, MD
EMS Section Chief
Yale Emergency Medicine
Editor-in-Chief
Academic Emergency Medicine
www.aemj.org
I joined the NAEMSP Dialog only recently so I apologize if this has already been
discussed: Can anyone explain the rationale for placing paramedics on fire department
first response engines in an urban setting? This is a common strategy in my neck of the
woods. The rationale is basically that these paramedics will get to the scene faster and
save lives! In reality, in an urban setting, the fire engine gets to the scene at most 5-6
minutes prior to the paramedic transport ambulance. I'm unaware of any prehospital
intervention that makes a difference on patient outcome when it's given a few minutes
sooner and that can only be performed by a paramedic. Some time-sensitive
intervention that come to mind include defibrillation, IM epi for anaphylaxis and
Hemilich for choking victims but these can all be performed by EMTs in Idaho. The
downside to this strategy is an over-abundance of paramedics whose experience with
critical patients and procedures (intubation) is diluted. In other words, too many
paramedics in a system creates skills maintenance problems. In addition, we've had
conflicts at scenes related to the transfer of care and what should be done for the
patient when 2 paramedics from 2 different EMS agencies butt heads. Am I missing
something? Does anyone have any data that shows too many paramedics is a problem?
I am aware of the study from Texas and the cardiac arrest abstract from SAEM several
years ago but that's it.
David T. Kim, M.D., FACEP
Idaho Emergency Physicians, P.A.
Life Flight Network
Boise, ID
Dr. Kim - unfortunately Idaho is not representative of many other states where an EMT's
scope of practice is broader. Firefighter/paramedics on engines are valuable in many
urban settings and I suppose (to use your examples) if you are the person who needs
defibrillation, who is in anaphylactic shock, or is choking, the 5 - 6 minutes prior to
paramedic transport (assuming there it is a paramedic transport because many systems
do not have this model) would matter.
I continue to hear the same arguments that too many paramedics in a system results in
maintenance skill degradation. I suppose the same argument can be said for too many
doctors at a hospital but I never hear that debate. The only data I have seen that
validates too many paramedics is a skewed article written by Robert Davis with USA
Today several years ago that measured cardiac arrest outcomes from different systems
that measured cardiac arrest outcomes themselves in different methods instead of an
objective approach with the Utstein model.
I have never seen any data or information that gives a definitive number of paramedics
that should be in a system from those that contend too many paramedics results in skill
degradation. Is there a formula; one paramedic per x amount of calls?: one paramedic
per x amount of cardiac arrests?: one paramedic per x amount of intubations? If anyone
knows that number I would be curious to hear it.
I contend, regardless of the number of paramedics in a system, the true mark of
excellent clinical care by firefighter/paramedics on engines is that the system has an
excellent QI program for identifying areas for clinical and system improvements and an
aggressive continual education program that works in conjunction with the QI program
to raise those standards in the system.
As I write, my QI staff is working with Mic Gunderson to apply a Six Sigma approach to
our system. All with the goal of making sure we continue to deliver excellent clinical
care not only from our transport vehicles but the first responder engines with
paramedics onboard.
Gary Ludwig
Deputy Fire Chief
Memphis Fire Department
(901) 320-5464
>>> I suppose the same argument can be said for too many doctors at a hospital but I
never hear that debate <<<
I think it's pretty well established in the hospital setting as well that increased
experience leads to more proficient practitioners, reduced errors, and better patient
outcomes. Hospitals have to see X number of patients in order to become a designated
Level I Trauma Center, surgeons who do at least X number of catheterizations a year
have much better patient outcomes and reduced infections, etc. Hospitals have to go
through a demonstration of need process before they're allowed to start providing a
new service. In EMS there often is no such requirement. We often hear about the
"paramedic shortage" across the country and the problem may not be a shortage of
paramedics, it may be how we're using them. Instead of using paramedics in a
coordinated, regional deployment to supplement the first arriving BLS units, many
systems have opted to put paramedics on engine companies or every ambulance,
leading to a shortage.
There are specialized teams within the fire service to deal with hazmat and heavy
rescue, we have specialized teams within the police to deal with hostage negotiations,
high risk warrant apprehension, etc. If 80-90% of EMS calls do not require ALS, why
don't we follow that same model? As for the systems that say 50 or 60% of their
patients require ALS, I suppose you could start an IV on anyone complaining of just
about anything and say it was an ALS call, but did the patient really need the IV in the
field as opposed to 20 minutes later in the hospital? It makes little sense from a
budgetary, proficiency, or patient outcome aspect to saturate a service area with
paramedics when only a small portion of the patients we see truly require those skills.
There is a definite need for well trained, experienced first responders on truly time
sensitive emergencies (arterial bleeding, airway compromise, cardiac arrest), but I don't
think there is any evidence that they need to be at the ALS level. We should focus much
more on providing good BLS care and supplementing that with ALS for the subset that
need it.
As for red lights / siren responses-we in public safety have created a monster. For years
we have told people to call 9-1-1 and we will be there within 4 minutes. The public (and
many elected officials) now have an unrealistic expectation. The fact that a patient
probably doesn't need an ambulance in the first place is irrelevant. The fact that once
they get to the hospital they'll be placed in the waiting room and sit around for two
hours before being seen by a doctor is also irrelevant. It's very difficult to tell people
that they may actually have to wait, and by the way-we may not even turn on our lights
to get to you. Changing the public's expectation about what is "reasonable" when they
call 9-1-1 won't be easy (or quick).
Brendan Kearney, MPA, EMT-P
Supt Field Support
Boston EMS
Hi everyone, I haven't been as vocal as others, but appreciate the dialogue. The
opportunity to engage in such a wide ranging, opinionated yet professional discussion
has been both refreshing and stimulating.
This is both a scientific and emotionally charged discussion. Our paper should be
considered to be a jumping off point of a scientific journey. We have developed a
model which needs to be validated on other datasets before being validated
prospectively and used. However it is more than that: as we have seen, policies and
procedures are informed by many factors other than science: cost, safety, risk analysis
(the precautionary principle), ethics and political considerations. Note: "because we've
always done it this way" is not on the list.
Rick has referred you to a previous paper on the ability of a dispatch protocol to predict
the "outcome" of paramedic assessment on scene. To what extent that uncertainty
should drive a lights and sirens/ALS response 100% of the time depends on the other
issues noted above, which our model incorporates. To me this is one of the most
important aspects of the paper. While science must drive policy decisions, in addition to
the pure science, the forward thinking EMS system will address these issues as well, by
consulting with the public, the payer, ethicists, occupational health and safety experts,
risk managers and other stakeholders.
Brian Schwartz, MD, CCFP(EM), FCFP
Executive Lead, Sunnybrook Osler Centre for Prehospital Care
Sunnybrook Health Sciences Centre
10 Carlson Court, Suite 640
Toronto, ON, Canada M9W 7K6
Associate Professor, Department of Family and Community Medicine
University of Toronto
p-416-667-2202, fax 416-915-0225, cell 647-282-5045
bschwartz@socpc.ca
Papers by Feldman et al and Wang et al pertaining to the Fire First Response Topic are
now available for download. Click on http://groups.google.com/group/naemspdialog/web/fire-first-response
The application of using discretion with lights and sirens is not only applicable to EMS but fire calls also. When I was with the St. Louis Fire Department, we had three
accidents with engines on the same day while they were responding lights and sirens.
The Fire Chief said we got to do something different. The end result was an "On The
Quiet" policy. Basically, 19 different categories of fire calls were dispatched with no
lights and no sirens. This included sprinkler alarms with no report of fire or smoke; pull
station alarms with no report of smoke or fire; dumpsters not close to a building; weed
fires not threatening a structure; smoke detectors with no report or smoke or fire; etc.
However, while the companies were enroute, if a phone call came in advising
differently, the response was upgraded to lights and sirens.
There were some positives and negatives to this - in the first year, vehicle accidents
were reduced by 62% and injuries from vehicle accidents was reduced 81%. These
were no small numbers. On the downside; there were some incidents of a serious
nature. One that comes to mind is a sprinkler alarm that came in on a lumber
warehouse and we received no phone calls. When the first fire company arrived on the
scene, they reported heavy smoke and fire and requested a first and second alarm. It
eventually turned into a five-alarm fire. That policy was begun in the early 90s and the
policy lasted until recently when it was changed to the first company urgent and the
other companies are sent non-urgent.
Gary Ludwig
Deputy Fire Chief
Memphis Fire Department
65 S. Front Street
Memphis, TN 38103
Office: 901-527-1400
Fax: 901-320-5631
Those are quite some awesome safety stats Gary quoted. Just reviewed the many
postings on this subject. Seems to me there is a fair consensus that it is desirable (and
already in practice in several systems) to be discerning about which medical calls FFR
should respond to, there is reasonable agreement as to which medical calls fire to
should respond to even where is is not expected they will provide direct hands-on
medical care, and that it is appropriate to respond to several categories of medical calls
in a "cold" mode. What I am not sure about from the current group of participants is
whether we are all preaching to each other as the converted or whether the above
practices are fairly widespread but not really talked about. It's surprising how little
literature has been published in this area.
I certainly think there is lots of room to be more rigorous (scientifically speaking) to
describe these kinds of practices and to continue to find ways to be more consistent and
accurate choosing medical calls to which FFRs should be sent . As has been pointed out
by several contributors, this all hinges on consistent and reliable call handling in the
dispatch centre. This certainly is a crucial aspect to any validation studies of the model
we have written about.
I am optimistic that the time will come where "lights and sirens" response will be
reserved for medical calls with a predictable probability of being emergent. While I
agree that it is possible to drive safely under "lights and sirens" as has been previously
mentioned, I still am prone to believe that the probability of a crash increases any time
lights and sirens are used due to an alteration in how the public drives when they see a
big red, white, or yellow truck bearing down on them in the rear view mirror.
Rick Verbeek
Medical Director, Sunnybrook Osler Centre for Prehospital Care
Toronto
Last shift I backed up an ambulance on a medical call. It was a very sick patient with liver
failure. He had a distended abdomen and they needed help getting him in a stair chair.
On the way in we noticed that the kitchen was unsanitary. There was garbage piled up
on the sink and hundreds of fruit flies everywhere. With the patient's permission, we
stayed after and gathered up all the garbage, killed as many fruit flies as possible, wiped
down the sink, swept the floor, ran the dishwasher, and left a fruit fly trap on the sink.
The guy lives by himself and there's no telling how long he'll be in the hospital. He'll
come home to a clean, safe house without rotting food lying around and no fruit fly
infestation. Was that medically necessary? I suppose not. But that's the superior level of
service we provide to our community and that's one of the many reasons the public
loves the fire service. Sometimes I feel like our cousins in third-service EMS are missing
the point with the fixation on clinical outcomes. It's important but it's not everything.
Tom
-Tom Bouthillet
Lieutenant / Paramedic
Town of Hilton Head Island
Fire & Rescue Division
843-247-3453 (cell)
I just wanted to say that there are many stories out there I have heard, but this one just
makes my day! This will make it on Chronicles of EMS one day!
Thank you for sharing...
Sincerely,
Thaddeus Setla NREMT-P - Creative Director
Chronicles of EMS
@Setla
Facebook.com/Setla
510.859.FILM
I recall the story of Chief Brunacini's guys in Phoenix taking care of a person who had
chest pain while pouring a concrete patio. While the ambulance crew took the patient
the hospital, the engine company personnel finished spreading the concrete before it
hardened-awesome customer service. I don't think your "cousins in third service are
missing the point with the fixation on clinical outcomes". We could certainly talk about
our file of life program, car seat check, domestic violence unit, EMT curriculum in public
high schools, peer support team, community outreach, honor guard, bike team, harbor
unit, community aed, BP screenings, the number of times we help uninjured elderly
residents off the floor and all the other non-clinical things we do, but that wasn't what
was asked *. The question had to do with the clinical benefit of first responders. To
play devil's advocate: other than sudden cardiac arrest, airway obstruction, respiratory
arrest, or uncontrollable hemorrhage, when does a rapid first response (of a fire truck or
an ambulance) make a clinical difference in patient outcome?
* original question: "Fire department first response is a common feature in many EMS
system designs. When does it, and doesn't it, make a clinical difference? How can this
important resource be utilized most effectively, efficiently and safely?"
Brendan Kearney
Supt. Field Support
Boston EMS
The Phoenix Fire Dept is well known for its "we're here to help, whatever the issue"
approach to community service - they take care of your problem, whether it is firerelated or not. They don't have a monopoly on this, though - several of us from my
department spent a lovely afternoon in an ice/sleet storm clearing away an ice dam that
was causing flooding of a woman's basement, clearing the water out of the basement,
and getting enough dry firewood into her house to keep her going for the rest of the
night. Anybody who has been in the fire service long enough has similar stories - it's
what we do.
The real issue here, in my opinion is not *whether* fire first responders should go on
EMS calls, but instead:
1) which calls they should go to, and
2) whether they should go "hot" or "cold" to which types of calls.
The MPDS protocols are helpful here, as are other dispatch systems, but they all leave
the ultimate decision on both of these questions up to the local system. This is basically
appropriate, since resources vary so much from system to system, but it leaves a bit of a
quandry particularly for those 'grey zone' calls. For example, one of our towns bumps
up the "fall outdoors" call to "hot" from Nov 15 to Mar 15, on the theory that they don't
want a pt lying in a snowdrift waiting for the ambulance, which may be coming from an
adjacent town. No other town in our area does this - I'm willing to bet (but haven't
asked) that this town had such a problem call, and this is the local solution that they
have applied. One town sends the FD to every call on the burns/scald/explosions card,
regardless of how minor it seems, on the theory that there must have been heat/fire
involved, which may be an FD matter - no other town here does that. We have reached
agreement among our 12 towns on about 95% of the MPDS call determinants, but there
are few stragglers like this that defy unanimous consensus. These are the ones that
prompt good discussion at our regional meetings - and while I am all for research, some
of these won't be settled by research data.
Dave
-David C. Cone, MD
EMS Section Chief
Yale Emergency Medicine
Editor-in-Chief
Academic Emergency Medicine
www.aemj.org
Hi All,
I have enjoyed this discussion thus far and appreciate the opportunity to post. I would
like to comment that while call prioritization systems may present opportunities to
reduce lights and siren use, it often seems much more difficult to change the vehicles or
staffing levels used in response. I blame this issue on what I'll call the "worst case
scenario" imperative where the majority of resources deployed in a fire or EMS system
tend to have much greater capability than most calls require. The fire example would be
the engine company, while the EMS example would be the dual paramedic ALS
ambulance. Clearly many systems chose to deploy resources at this level because it
allows for efficient management, interchangeablity of resources, and also adeqautely
addresses the worst case scenario those units could be called to (i.e structure fire,
cardiac arrest, major truama, etc.). While these units are very capable, they are also
quite expensive to deploy. I would contrast this somewhat to the law enforcement
model where the basic unit of production is the officer in the patrol car. In this model
the single officer or unit is expected to handle the majority of calls, while more serious
calls simply add more, or more specialized, units as needed. Therfore my question is:
Would a reduced response approach involving less capable resources (i.e. BLS
ambulances, 2 person fire response, non-transporting ALS units, etc.) be more useful to
EMS response systems? Why? or Why not?
Cheers!
Sean Caffrey
System Development Coordinator
Emergency Medical and Trauma Systems Section
Colorado Department of Public Health & Environment
A quick reply to Sean. This is the backside of the argument to rebutt limiting the
number of paramedics (in whatever deployment scheme you choose) and to which calls
should be designated as requiring FFR. It creates a cat-chasing-their-own-tail situation.
Basically the more paramedics the less chance they have to maintian their skills. The
more FFR calls the greater the chance of collisions. This has led to a desire to limit each
of these in some informed way. But as soon as you do that you risk a chance of missing
that one call where someone came to harm because of a limted response. This will lead
to a desire to increase each of these in some informed way. There is no scientific
solution to this dilemma. Good science can definitely contribute to defining the "risks"
associated with an overly vigorous stance in either direction but ultimately the final
solution will be "policy driven".
Rick Verbeek
Medical Director, Sunnbrook Osler Centre for Prehospital Care
University of Toronto
Good day all,
I do not have any research to confirm this, but I do have 20 years of experience on
ambulances. I think that RLS response to any but the most critical few calls is
unnecessary. There is also no reason for routine dispatch of FFR to the majority of calls
upon which they are sent. The last area I worked sent the FFR on every ambulance call.
This was simply a means of increasing their run numbers and getting out in the public
eye. There's nothing wrong with good PR mind you, but sending a fully loaded fire truck
careening down the street with RLS blazing for someone that twisted their ankle is a bit
much. I do think that there are times when FFR is maybe not necessary, but is useful, ie
interstate MVA scene for crew safety. This does not mean that the FFR has to be with
RLS though. Overall I believe that we should use the information gathered in these
studies to reduce not only the number of responses we generate for each call, but the
type of response as well.
Be safe,
Dewayne Cecil
On the one hand, we talk about studies that show it's not important when the ALS
ambulance arrives on the scene as long as firefighters (or police) arrive within 4-6
minutes with a defibrillator. That makes the fire service an indispensible partner in
many (if not most) EMS systems. Then we hear the claim that it's self-serving (politically
motivated) for the fire service to respond to non-life-threatening calls, even though
there are lots of things the fire service can do to help serve a citizen in distress, whether
the emergency is life-threatening or not (secure the house, feed the pets, help carry the
patient down the stairs, and so on). If I had a nickle for every time I've heard it said that
the only reason the fire department responds to medical calls is to justify budget and
staffing I'd have enough money for lunch. I've been a paramedic for 15 years, and I love
having extra hands on a medical call. It's extremely convenient for lots of reasons that
I'm sure everyone monitoring this listserv is familiar with if they are honest with
themselves. So as long as we're calling a spade a spade, it would be disingenuous to
suggest that politics plays no role in the desire of third-service EMS to keep the fire
service limited to the rare life-threatening emergency, lest this monster slip its leash and
try to take over the entire EMS system.
-Tom Bouthillet
Lieutenant / Paramedic
Town of Hilton Head Island
Fire & Rescue Division
843-247-3453 (cell)
It is equally disingenuous to suggest that politics plays no role in the desire of the fire
service to respond to as many EMS calls as possible because the monster has, in fact,
expressly stated that its' goal is to take over EMS in its' entirety and in many cities has
done just that, regardless of the quality of the service provided by the agency that was
put out of business.
Peter T. Pons, MD
Denver, Colorado
4. Alan
The Fire-vs-EMS discussion misses the point, or perhaps is simply another discussion
entirely. The issue revolves around three questions alone:
1 - In general, is there value to some form of FFR program, ALS or BLS? Answer: yes, of
course, and it is widely recognized.
2 - Should FFRs respond to every EMS incident? Answer: No, there is no practical reason
for this. It makes more sense to pick a subset where one can define a common sense
good reason for all the extra hands and equipment.
3 - Should all FFR responses be "hot" -- that is, using red lights and siren? Answer: No.
Most of what we do in EMS is not a medical emergency. Only a select subset of
responses warrant lights-and-siren. If FFRs are sent outside that small subset
(immediately life- threatening calls), the response should be non-emergency. (BTW, if
the test is "If we go, we go 'hot' ", then be extremely selective in what gets FFR
response.)
Alan
Alan Craig
Deputy Chief,
Toronto EMS
Thanks for clarifying that chief. I was just about to type the basic same thing. I did not
mean to incite the FD vs EMS debate. I was simply trying to state that all of us use RLS
way too much. The emergency response mode should be reserved for a small portion of
calls, both FFR and EMS.
There is one question that I have often wondered about since the inception of EMD and
prioritized dispatch. That is has anyone ever gone back and compared the initial nature
of a call to the end result or diagnosis for the patient? Confirming the validity of the
caller information. In my experience there is a vast difference between the nature of the
call when dispatched to what the actual emergency is upon arrival.
Dewayne Cecil
Paramedic
Dewayne,
Do you think that safe RLS driving could be a skill that would be lost if not performed
with frequency (just like assessments, IV's, and intubation)? Your comment brought this
to mind.
Also, I am interested to know of any research comparing the telephone triage and the
initial EMS assessment. As far as I know, the only comparative criteria is if response
mode vs transport mode. This brings me to my "Priority 3 Sick" dilemma.
Usually, these calls end up just as dispatched, though (anecdotally) many turn out to be
immediate life threats (e.g. v-tach) which the caller and calltaker assume to be far less
notorious. I am not sure if the frequency of this has been identified through meaningful
research.
Mike Schadone, NR/CCEMT-P
American Medical Response of CT, Inc.
Actually quite the opposite. It is my belief that if we reverse our current usage of RLS,
more "cold" responses and fewer "hot" responses, that when we do use RLS our
personnel would be more inclined to exercise more caution. I think now, as a whole,
people in emergency response type work get a bit blase about the use of RLS and
therefore are less cautious over time. Another factor is the reality of how much time is
truly saved by using RLS. If you are talking about a system with an average response
time of 6 minutes, then you are looking at a time difference of approximately 10 or 15
seconds being added to the response time. There have been numerous studies showing
the minimal difference in response times using RLS versus not using them. The reality is
that this will probably never happen due to public perception and political pressure.
Even the over use of FFR does not bother me so much if we just did it without all of the
bells and whistles.
Just my thoughts,
Dewayne Cecil
Paramedic
Dewayne,
I appreciate the response. I, on the other hand, would like to ensure that we have
telephone triage handled before we start to seriously limit RLS response. It may be an
unpopular position, but I feel that we are both over-reactionary and locked to tradition
when it comes to change. This is one opportunity to do it right, and arguably, we are.
Telephone triage is not done accurately where I work (both as a CCT & intercept
paramedic and volunteer FF first responder). We have recently had to change our FD
policies to respond FFR to every call in our district. Unfortunate as it is, this is the reality
in many parts of the country (that do not study efficacy of procedure).
Mike Schadone, NR/CCEMTP
American Medical Response of CT, Inc.
Sent on the Sprint® Now Network from my BlackBerry®
As we wrap up our discussion on the topic of fire department first response, I'd like to
make a final call to the list members for questions or comments before I ask our invited
participants to summarize with their closing thoughts.
--- Mic
Mic Gunderson
Moderator, NAEMSP Dialog;
President, IPS
Final posting.
I've quite enjoyed the insightful and collegial discussion on this topic. Actually we've
engaged in quite a range of topics starting with the medical indications for FFR, quickly
evolving into non- medical implications for same. Next we slid into a discussion of the
relative merits of an all-ALS vs combined EMT/ALS response from a medical need versus
skill maintence and even managed to drag EDs docs and other subspecialists into the
debate.
Three overarching area of consensus come to mind. The first is the need to ensure
there is a consistent application of dispatch protocols, second, development of policies
must be data driven, and last, there are likely multiple "correct" solutions based on local
community need that can be best developed when the other two areas are done well.
It is pleasing to see the number of "testable" ideas put forward and the degree of
enthusiasm to continue to work in this area. Seems to me we are just getting started.
Thanks to Mic and NAEMSP for hosting us.
Rick Verbeek
Medial Director, Sunnybrook Osler Centre for Prehospital Care
University of Toronto
While I am in the corner of those who contend we do not need to send a first responder
with lights and sirens on every medical call; I am also cautious that many times what the
caller describes as problem through an objective EMD system, is not the same scenario
when emergency personnel arrive on the scene. Many times, dispatchers are talking to
a third party and they do not know exactly what is going on - just someone ran into the
room and told them to call 911. This is especially true at businesses or other public
settings.
Additionally, the EMD approach does not always paint a true picture. The system we
use in Memphis required the dispatcher to ask, "is the person sweaty?" Unfortunately,
virtually everyone in Memphis is sweaty during the summer time.
Prudence is good - but pragmatic competence is also warranted.
Gary Ludwig
Deputy Fire Chief
Memphis Fire Department
(901) 320-5464
Dewayne: Here is a reference you might want to look at.
Feldman MJ, Verbeek PR, Lyons DG, Chad SJ, Craig AM, Schwartz B. Comparison of the
Medical Priority Dispatch System to a Prehospital Patient Acuity Scale. Acad Emerg Med
2006;13:954-60.
It was our first pass look at comparing the MPDS response acuity assigned by
dispatchers vs the acuity of the patient assigned by medics using the 5 point CTAS
(Canadian Triage Acuity Score) where CTAS 1 would be Cardiac Arrest and CTAS 5 would
be a stubbed toe. The general findings were that MPDS had a sensitivity and specficity
of 65-70% in assigning the correct "actuity" compared to CTAS assigment as the gold
standard. Conclusion is MPDS is overall better than chance but not great and so far all
that can be said is that as a whole dispatchers undertriage and overtriage a fair bit using
modern dispatch tools. Surprise! What we need to do now is to further refine this by
looking at individual MPDS determinants since we suspect there will be some
determinants that will have much better performance characteristics than above. These
particular ones may guide us as to when an ALS response is truly needed.
I will send the pdf of this article to Mic for posting.
Rick Verbeek
Medical Director, Sunnybrook Osler Centre for Prehospital Care
University of Toronto
Hi,
There's actually quite an extensive literature on exacting this point. Try searching
PubMed on MPDS and Medical Priority Dispatch System. Also look at the references in
our paper on FFR optimization (PEC 2010:1) MPDS tends to be very cautious and
overtriage, not undertriage. A number of studies show it is very good at being sure calls
classified as minor actually are minor, so not sending FFRs to minor calls is unlikely to
produce negative results.
MPDS tends to be very generous in up-triaging things where insufficient information is
available to be sure.
As Dave Cone points out, nothing works which isn't followed. If your system is producing
unexpected triag errors, the first place to look is as the call interview process and weed
out free-lancing. Warts and all, MPDS has been shown to be better than paramedic
intuition hands down (two studies in print on this).
A weakness of our paper (Feldman, et al) was that it looked at the card level only. In
other words, it assessed whether the card, as a protocol itself, was predictive. This is a
bit too blunt. Better work still to come.
Alan
Alan Craig
Deputy Chief,
Toronto EMS
Rick;
This may be a bit off topic but relates to this study. In Saskatoon we are using CTAS for
hospital destination. For this reason, we use the ctas after treatment and before
transport. As a result, I don't get any useful information on the acuity of the patients we
are seeing as they ctas changes with treatment.
In this study are you using ctas on arrival, after treatment, or on arrival at hosp? All of
these can be different. I know we could collect all of them for even more useful data
but our current system does not allow this.
Thank you for any guidance you can provide. I have met Alan a number of times and
think that your group does amazing work.
Tim
Tim Hillier, ACP
Director of Professional Development
M.D. Ambulance
Saskatoon, SK
Canada
the best estimate of "outcome" for 911 calls is CTAS (Canadian Triage Acuity Scale) score
on paramedic arrival.
Brian Schwartz, MD, CCFP(EM), FCFP
Executive Lead, Sunnybrook Osler Centre for Prehospital Care
Sunnybrook Health Sciences Centre
10 Carlson Court, Suite 640
Toronto, ON, Canada M9W 7K6
Associate Professor, Department of Family and Community Medicine
University of Toronto
p-416-667-2202, fax 416-915-0225, cell 647-282-5045
bschwartz@socpc.ca
Mic,
This has been a great discussion. I’ve taken home a few points and have two
questions/suggestions.
In Dave's study, where the consensus opinion (with only a “few skeptics”) is that the
number of engine company EMS responses is excessive, up to 50% of the calls may be
safely eliminated. However, as he writes in the excellent discussion and limitations
sections (which everyone should read), this magnitude of reduction may not be
reproducible, since an unquantified amount of that reduction was from
simply not sending a collocated BLS unit at the same time as the ALS unit. The lack of
EMD data also keeps this from being generally applicable to other systems.
Alan, Rick, and Brian’s work has moved (and will move) this along further. Their
discussion and limitations sections should also be required reading. The tolerability of
risk (to the patient, responder, and public) concept is important and must be part of any
EMS system dispatch structure. Though they will differ on what actions they take, if
any, the data from this study and the validation step that Rick promised will be useful
for every community. All of this starts with a solid, well-structured caller interrogation
and prioritized disaptch program. Without that one cannot reasonably or safely make
resource/response decisions – or QI the results.
Gary and others have pointed out the non-clinical role of FFR. Would it be possible to
quantify that? Car crashes would be easy but many others more challenging. Perhaps
someone could develop a list of non-clinical functions and look to see
when they play a role – and then see if that can be predicted by information available to
the dispatcher.
One of the interesting offshoot discussions was whether there was a relationship
between amount of recent experience and proficiency. This is an ongoing topic of
research for many physician specialties and hospitals/specialty care centers. Might this
be a topic for another discussion group?
Thanks,
Angelo Salvucci
Medical Director
Santa Barbara County, CA
In fact, this very issue was just e-published in Annals of Emergency Medicine. It shows
the very same results as for physicians, we do well what we do often.
Wang et al: Out-of-Hospital Endotracheal Intubation Experience and Patient Outcomes.
Presented at the National Association of EMS Physicians annual meeting,
January 2009, Jacksonville, FL.
Study objective
Previous studies suggest improved patient outcomes for providers who perform high
volumes of complex medical procedures. Out-of-hospital tracheal intubation is a difficult
procedure. We seek to determine the association between rescuer procedural
experience and patient survival after out-of-hospital tracheal intubation.
Methods
We analyzed probabilistically linked Pennsylvania statewide emergency medicine
services, hospital discharge, and death data of patients receiving out-of-hospital
tracheal intubation. We defined tracheal intubation experience as cumulative tracheal
intubation during 2000 to 2005; low=1 to 10 tracheal intubations, medium=11 to 25
tracheal intubations, high=26 to 50 tracheal intubations, and very high=greater than 50
tracheal intubations. We identified survival on hospital discharge of patients intubated
during 2003 to 2005. Using generalized estimating equations, we evaluated the
association between patient survival and out-of-hospital rescuer cumulative tracheal
intubation experience, adjusted for clinical covariates.
Results
During 2003 to 2005, 4,846 rescuers performed tracheal intubation. These individuals
performed tracheal intubation on 33,117 patients during 2003 to 2005 and 62,586
patients during 2000 to 2005. Among 21,753 cardiac arrests, adjusted odds of survival
was higher for patients intubated by rescuers with very high tracheal intubation
experience; adjusted odds ratio (OR) versus low tracheal intubation experience: very
high 1.48 (95% confidence interval [CI] 1.15 to 1.89), high 1.13 (95% CI 0.98 to 1.31), and
medium 1.02 (95% CI 0.91 to 1.15). Among 8,162 medical nonarrests, adjusted odds of
survival were higher for patients intubated by rescuers with high and very high tracheal
intubation experience; adjusted OR versus low tracheal intubation experience: very high
1.55 (95% CI 1.08 to 2.22), high 1.29 (95% CI 1.04 to 1.59), and medium 1.16 (95% CI
0.97 to 1.38). Among 3,202 trauma nonarrests, survival was not associated with rescuer
tracheal intubation experience; adjusted OR versus low tracheal intubation experience:
very high 1.84 (95% CI 0.89 to 3.81), high 1.25 (95% CI 0.85 to 1.85), and medium 0.92
(95% CI 0.67 to 1.26).
Conclusion
Rescuer procedural experience is associated with improved patient survival after out-ofhospital tracheal intubation of cardiac arrest and medical nonarrest patients. Rescuer
procedural experience is not associated with patient survival after out-of-hospital
tracheal intubation of trauma nonarrest patients.
Peter Pons, MD
Denver, CO
Here is my final response to this thread.
The fire service provides tremendous value and assets when responding as a first
responder to medical emergencies. Each day, throughout the United States and
Canada, the fire service responds on thousands of medical emergencies where the
single goal is to provide quick and outstanding clinical delivery to those in times of
distress. I would agree that it is not necessary to send first responders on all medical
calls since not all medical calls are true life-threatening emergencies. Therefore, the
challenge is fitting the right resource(s) with the right event. Unfortunately, in many
cases, what the dispatcher is able to extrapolate from the caller through an objective
criteria-based dispatching process is not the same when emergency personnel arrive on
the scene.
I feel the medical community and others need to realize and understand that first
responder companies are not limited to their clinical functionality. The first responder
company carries manpower assets and tools that prove invaluable on many scenes.
Even the fire apparatus itself is a tool on auto accidents scenes to protect emergency
personnel as a blocking tool - even though the patient(s) injuries may be minor in
nature.
Traditionally, in a hospital environment, if a critical patient presents itself, it is easy to
pull other human resources or equipment rapidly into the event. Unfortunately, this is
not true for EMS calls when additional resources may be a significant distance away.
Soon, study results will be released by the National Institute for Standards & Technology
that shows the time-to-tasks for various EMS calls under different scenarios, using
different staffing patterns of the EMS transport vehicle and the first responder
company. This study will show significant statistical difference between various
functions, depending upon the number of emergency personnel on the scene. As the
largest provider of emergency medical service delivery in the United States, the fire
service will continue to serve our communities and excel at our profession of being an
emergency care provider to those in time of need.
Thank you for the opportunity to be a participant in this discussion.
Gary Ludwig
Deputy Fire Chief
Memphis Fire Department
65 S. Front Street
Memphis, TN 38103
Office: 901-527-1400
Fax: 901-320-5631
20. mschad...@gmail.com
Rick, This is exactly what I was speaking to. I wonder if more subjective criteria would
help, but that would be problematic in itself. Thanks, Mike Schadone, NR/CCEMTP
American Medical Response of CT, Inc. Sent on the Sprint® Now Network from my
BlackBerry® -
Final Summary Comment from Alan Craig
Certainly an interesting discussion. I'm intrigued that no one has made a truly
impassioned plea for 100% FFR response, that is, FFRs to every EMS call. Yet, 100%
response is reasonably common, even in some large EMS systems. This is contradiction
warrants active discussion. So if there is a "consensus" or growing sense that 100%
response might not be the obvious best answer, then the professional debate should
logically migrate to deciding when to send FFRs, precisely the issue we addressed in our
paper. I think we should not understate the importance of this apparent migration in
the debate, and it's a credit to those who contributed to this fairly subtle discussion. The
question to then ask is: In your local community, what are the next steps?
While we propose no one "correct' solution, we believe our model provides a flexible
framework which can marry local preferences and intentions with local clinical evidence.
There are a constellation of locally "right" solutions. Since the risk of first response is
linear (ie, if you cut response in half, you cut risk in half), yet we showed that clinical
benefit is non-linear, optimization is possible. Although we used a single measure of
clinical benefit, we propose than any measure (other than the mere presence of FFRs)
would also be non-linear. As he always does, Dr. Salvucci's has very concisely framed the
keys issues in his comments. I do reinforce his reference to the principle of tolerance for
risk as outlined in our paper. It is an important and governing principle in public policy
and often poorly understood or
entirely ignored.
Finally, the discussion touched briefly on a very important issue which occupies much of
my professional time, the issue of the clinical competence of ALS providers and the
relationship between that competence and initial+ongoing experience. Although this is
beyond the scope this discussion, I would predict that the science available today (and
there is a lot of it), and that which will inform the discussion as it emerges, is unlikely to
support the argument that there is no such thing as too many ALS paramedics in a
system. Our optimism in creating all-ALS EMS systems and FFR ALS programs may or
may not ultimately prove to have been as predictable and safe as we proposed 25 years
ago. It's pretty clear in medicine that specialization and intense daily experience are
components of safe practice -- it's why we have ICUs and intensivists -- and that
inexperience is acutely dangerous. It's unlikely we are somehow exempt from this.
Finally, there is a growing realization that, if experience is important, then the issue isn't
"skill-decay", it's "never-had-the- skill-in-the-first-place". CME might fix the former; it
can't fix the latter.
Obviously, there will be a lot more to these debates over time.
My thanks to all the participants in this dialogue.
Alan
Alan Craig,
Deputy Chief,
Toronto EMS
Hi All,
This conversation leads me to believe the deck may be stacked against efforts to more
selectively utilize EMS resources regardless of the underlying data, primarily because
there is always a worst-case or alternative scenario that needs to be accounted for.
Consider the following points, many of which have been made in some way already:
1. Patients may require ALS care so the majority of providers in an ambulance system
need to be paramedics.
2. Ambulances may be busy so we need more of them, and they should all be ALS
capable.
3. A patient could be in cardiac arrest so we need to respond within tight time
parameters
4. Ambulance resources may be insufficient to respond within tight time parameters,
so we need to use fire resources to support them.
5. Patients may require ALS care, so firefighters need to be paramedics too
6. The dispatch information could be inadequate, so we should “up-triage” the
response when we’re not sure.
7. There could be a need for a fire response while the truck is out, so the fire
personnel and equipment we use needs to be capable of also responding to any hazard.
8. The extra personnel and equipment may be useful even if the call is minor
9. There is safety in numbers
10. Etc.
None of these arguments support decreased or selective resource use. I don’t mean to
come across a pessimistic, but I would suggest that despite compelling, or perhaps even
overwhelming data to the contrary, there will always be an imperative to increase
resource deployment for other reasons.
Cheers!
Sean M. Caffrey, CMO, MBA, NREMTP
System Development Coordinator
EMTS Section
Colorado Department
of Public Health & Environment
4300 Cherry Creek Drive South
Denver, Colorado 80246-1530
Office (303) 692-2916
Cell (720) 383-0250
Fax (303) 691-7720
A sincere thank you to all of you that have participated in this Dialog session on Fire
Department First Response. A special thanks to our invited participants: Alan Craig, Rick
Verbeek, Brian Schwartz, Dave Cone, Angelo Salvucci and Gary Ludwig.
The discussion threads on this topic are now closed. I'll be catching up with getting
summaries of the discussion threads written up for the resource page for this Dialog
topic and the prior one on response intervals. I'll then be announcing the next topic and
introducing the invited participants.
Thanks,
--- Mic
Mic Gunderson
Moderator, NAEMSP Dialog;
President, IPS
(End Condensed Transcript)