Growing up in a small town in suburban Connecticut, Melissa Costello and her teammates on the high school rowing team volunteered at their local fire station/ambulance base. “In Connecticut, and really throughout New England, there are large municipal fire departments in the cities, but virtually everything else is done by volunteers,” Costello says. “For us teen-agers, it was a good place to hang out with some structure away from our parents.”
Those experiences turned out to be a first step toward a career in medicine. She took an EMT course and joined her campus rescue squad, GERMS (Georgetown Emergency Medical Response). After moving to Alabama to attend medical school, she volunteered as an EMT-Intermediate for Mobile County EMS and worked for NorthStar Paramedic Service in Tuscaloosa. “I enjoyed actually doing some hands-on patient care in the midst of medical school, which is very book-intensive in the beginning,” says CosteIlo, who was her medical school’s campus class president. “I also enjoyed the people. EMTs and paramedics are really a fun group.”
As a resident at Johns Hopkins University School of Medicine, she taught courses for paramedics who worked for the U.S. Secret Service. In 2003, she joined the faculty at the University of South Alabama Health System. She also stayed active in EMS, continuing to teach EMS studies as an adjunct professor at the University of South Alabama Brookley and serving as medical director for Gulf Coast MedEvac.
Today, Costello is an emergency physician at Singing River Health System in Ocean Springs, Miss., and associate medical director for Acadian Ambulance’s Mississippi operations, as well as associate medical director for Baptist Hospital’s helicopter EMS service, Baptist LifeFlight, based in Pensacola, Fla. She is also the EMS committee chair for ACEP.
Costello spoke with Best Practices about the importance of safety in EMS and what the public and the rest of health care need to know about the profession.
What makes a great medical director?
Engagement. The primary thing is being engaged with the crews, being available to bounce off questions and information and being an advocate for your people in the field. They get a lot of grief from the hospital side, and they need to know you have their back.
Field background and coming up through an EMS system help a lot. Having worked as an EMT and on an ambulance has helped me, although I don’t think it’s absolutely critical.
What sorts of things does EMS get grief about?
On the hospital side, there are some misperceptions about what is possible in the field and a lack of understanding about the limitations of field medicine and the reality of trying to do good medicine in the out-of-hospital setting. When a crew picks up a patient who is two minutes from the hospital, there is always the debate about how much to treat on scene vs. getting the patient to the hospital.
Crews might arrive at the hospital, and hospital staff will say, ‘Why didn’t you start an IV?’ And the crews are thinking, ‘Well, we were only two minutes from the hospital so we decided to get the patient here.’
It’s very easy to have a very high success rate when you are in a hospital, on a stretcher, with good lighting, good backup and extra equipment. In the field, you may be in the dark, in the rain, in a ditch, in a car and by yourself. On the hospital side they lose sight of that.
What misperceptions does the general public have about EMS?
The public’s misperception of the EMS profession is that providers are ambulance drivers, as opposed to EMTs or paramedics.
The public is failing to understand that the people who arrive at your house or your accident scene are skilled and educated, and that they come with training and equipment and the capability to handle an emergency. It’s not just that they have the keys to the vehicle that has lights and sirens on it.
Has the EMS profession itself contributed to those misperceptions?
It has, but it’s probably a function of what EMS grew out of, which was a very fragmented system. There were fire departments that took on some EMS responsibilities. Then there was private and commercial EMS, as well as third-service EMS.
The benefit physicians and nurses have is there is a consistent environment, and the standards are essentially the same everywhere you go. Where we are in EMS is about 40 years behind nursing from an evolution standpoint.
Physicians have a national standard for education. You go to medical school for four years, graduate with an M.D. or D.O., take certain tests and then you’re eligible for a license. Nursing has also evolved into a place where the education for an R.N. is nationally recognized and unified. EMS is getting there, but we’re not there yet. When we do get there, it will bring EMS into the realm of profession rather than vocation.
You’ve been involved with responses to several major hurricanes along the Gulf Coast, including Katrina. What’s your assessment of the response to Hurricane Sandy?
A few days after the storm, leaders of national EMS organizations had a conference call with EMS in New Jersey and New York to try to figure out what their needs were then and what could be done better next time. I can tell you that living and working on the Gulf Coast through Katrina, Ivan, Rita, Charlie, Francis, Jean and Wilma meant you had to get your act together from the standpoint of hurricane preparedness. Compared to a lot of places, the Gulf Coast is far along with preparedness.
Preparedness has to be a line item on the budget. In a hospital system, you have to put money in the capital budget if you’re going to move your generator, heating and air-conditioning systems out of the basement and onto the roof where they will be protected from flooding, and to build redundancy in your electrical supply.
EMS agencies need to build redundancy in the fuel supply chain; make sure they have good, up-to-date contact information for their personnel; and have the ability to get them to and from work in the setting of a disaster. It’s things we on the Gulf Coast do well, because we didn’t do it well in the past and we learned our lesson. Unfortunately, folks in New York and New Jersey are having to learn a lot of the lessons we learned.
You’re involved with ACEP’s “Creating a Culture of Safety in EMS” project. Why has safety in EMS emerged as such an important issue?
The system of EMS we have has developed natively; it’s not a system we designed, built and rolled out nationwide. As that has occurred, we’ve drawn people into EMS who are Type A personalities—people who want to run lights and sirens. As with fire and law enforcement, there was an expectation of a certain degree of manual difficulty to the job and a certain tolerance for injury and unsafe environments. If you got injured on the job, the attitude has been, It’s EMS, it’s going to happen.
Now we realize that a lot of these things don’t have to happen. Some of it is in how we engineer vehicles and equipment; some of it is in education. The push for safety in hospitals is also raising the profile of the importance of safety in EMS. Eventually, we are going to be held to the same standards as in the hospitals, but in the field, we have to work twice as hard to be as good.
In the hospital, there are redundancies in place to ensure safety. For example, in the hospital, let’s say you need a dopamine drip. The physician types the order into the computer, including the dose and the route to administer. The patient’s weight and allergy list is already in the computer. The drip will come from the pharmacy at the proper concentration along with administration instructions. The drug is mixed by techs who deal with drugs all day, supervised by a pharmacist. If a dosage is above or below a certain threshold, the computer will alert you that the amount seems off. A drug order goes through multiple people and multiple computer systems before it gets to that patient, all of which are designed to prevent errors.
In EMS, a paramedic in the back of an ambulance takes the patient’s blood pressure and says, This patient needs dopamine. They estimate a person’s weight. They may or may not have allergy lists. They pull out a bag from their box, mix the medicine themselves, hang up the drip, and in a lot of systems, count drops per minute to estimate rate. It’s a totally different environment. All that math is being done in their head, and their partner may be a basic EMT.
The other piece of the Culture of Safety project is provider safety. In the ER, we know verbal and physical assaults happen frequently. A report published in November 2011 from the Emergency Nurses Association found that 57 percent of ER nurses reported a physical or verbal assault in the prior seven days. The statistics are shocking inside hospitals, yet EMS is out there with these patients by themselves. Sometimes they have law enforcement and firefighters with them, but it’s almost an expectation that patients are going to do stuff to you.
Another aspect of provider safety is vehicle safety. Do we ever need to run lights and sirens? We don’t know for sure, although the data is pointing to no. Even in trauma, the risk to the community and the providers vs. the benefit to the patient by saving a statistical average of 45 seconds isn’t supported by the data. There is always an anecdote where seconds mattered. But if in that 45 seconds someone is hit in an intersection, or we lose a provider in a crash, nobody has benefited.
Have you personally ever experienced violence or the threat of violence while working in EMS?
Yes. The only weapon we were allowed was a flashlight, and it has sat beside me on a lot of calls. I’ve had law enforcement ride with me on some calls, although the only physical assault happened in the ER.
In EMS, because our colleagues and our peers are law enforcement and fire, we are desensitized to the fact that being verbally or physically assaulted on the job is an abnormal work environment. But in EMS it happens so often, we don’t even think to report it. But that needs to change. No one should have to put up with that while on the job.
What needs to happen for EMS to live up to its potential as a community asset?
Really helping the community understand that there is an untapped resource out there. The second part of it is making sure that communities hold their providers to a high standard. Communities need to be clear about their expectations for EMS. They need to define what treatments they want available in their community. And there needs to be a collaborative relationship between EMS and community representatives.
