By Julia Connors
Chapel Hill Herald (Durham, NC)
Copyright 2006 The Durham Herald Co.
CARRBORO — A siren wails from the radio. David Silfen reaches and turns up the volume. The radio crackles for a few seconds before the dispatcher announces a call: An elderly female cancer patient is having trouble breathing.
Silfen picks up the radio’s handset and tells the dispatcher he’ll take the call. Silfen, a paramedic with Orange County Emergency Medical Services, or EMS, flips on the siren of his SUV and jams on the accelerator.
As usual, he’s working alone.
Orange County EMS operates a unique initial response vehicle, or IRV, system that offers more independence to paramedics and has transformed their ability to handle emergencies in the field, explained Kent McKenzie, deputy emergency management director for Orange County EMS.
A traditional EMS system may send an ambulance with one emergency medical technician and one paramedic to each 911 call, said Jane Brice, medical director of Orange County EMS and chair of the UNC Hospitals Disaster Committee. The ambulance almost always transports the patient to the hospital, and the patient does not receive much other care in the field.
But ambulances are expensive to operate and maintain, and paramedics often become tied up taking patients to the hospital unnecessarily for minor injuries or illness, Brice said.
Orange County’s IRV system gives its paramedics a lot of autonomy and the unusual leverage not only to assess, but also treat, refer and even discharge patients as necessary, she said. “We have tremendous flexibility in responding to the community’s growth and the citizens’ needs for medical care,” Brice added.
“It multiplies our capacity to handle calls,” McKenzie added. “We make about double the number of patient contacts than others counties can with the same amount of money.”
Computer program
In the IRV system, a trained dispatcher determines the type and urgency of services a patient likely requires by plugging the caller’s answers to a list of questions into a computer program, Brice said. The dispatcher then sends an experienced paramedic to each call, and only sends an ambulance, staffed by two less-trained emergency medical technicians, when a patient may need transport to the hospital, said Kim Woodward, a paramedic and operations manager for Orange County EMS.
“The principle is that each citizen who calls for 911 should get the highest level of assessment possible,” Brice said. “Every call gets a paramedic. We send our best.”
Fifteen years ago, the system operated with a less standardized structure, McKenzie said. The county employed paramedics only during the day, and they rode on ambulances with partners. But on weekends, volunteer emergency medical technicians provided all emergency services. Concerns arose regarding inconsistencies in care, McKenzie said.
The area’s population growth also signaled a need to modify the system. “We were at this transition point,” Brice explained. “The community was just beginning to take off and grow. The resources required to respond to [the] community’s needs were going to change.”
So EMS brought together an advisory council of citizens, health care professionals and EMS staff to develop a strategic plan to better serve the community. McKenzie said the goals were threefold: to ensure patients are receiving appropriate assessment and care required in the field; to minimize the need to increase taxes to cover the climbing costs of care; and to recognize that not every call requires transport.
In 1996, EMS decided to implement the IRV system after several years of planning, design, testing and research, McKenzie said.
But with such high levels of responsibility and autonomy granted to paramedics comes more liability, he added. Many counties do not want to start an IRV system for this reason, he said.
Specialized training
Orange County has responded to the increased liability by offering specialized training and keeping a keen eye on the system through its Continuous Quality Improvement Program, said Brice, who writes the medical protocols the county’s paramedics follow and monitors the quality of their work.
“We’re trying to shape the way they think,” Brice said. “If you’re practicing alone, you’ve got to be good at what you’re doing.”
“The county does amazing training,” Silfen said. “UNC devotes so much time to us. It’s a pretty progressive system.”
Silfen’s high levels of training and experience have calmed his nerves and boosted his confidence over the years. “The adrenaline rush is not like it used to be,” he said, as he speeds solo to his call.
A yearlong study conducted by Orange County showed that out of 150 patients discharged by paramedics, only one was dissatisfied with the IRV service, McKenzie said. Another study showed that the IRV system exhibited better cardiac arrest outcomes and overall cost efficiency than the previous system, he added. The National Association of Counties and the N.C. Association of County Commissioners have presented Orange County EMS with outstanding program and achievement awards for its IRV system.
Although the system may be efficient, both McKenzie and Brice believe they lack appropriate resources. “We do not have adequate staff to meet all the call demands we’d like to,” McKenzie acknowledged.
But for now, “I’d say it’s humming along okay,” Brice said.