This article originally appeared in Ed Racht’s January newsletter, Friday Night [under the] Lights, and is republished here with permission.
By Ed Racht, MD
I’m betting that we would all agree that never in our careers has there been so much change and disruption (both good and not-so-good) in both the art and science of emergency medical services. There’s so much going on in clinical medicine, operational delivery, cultural expectations of EMS, healthcare system changes at the macro level, system design and the technology that supports us in what we do.
2017 was a challenging year for the EMS profession – we were faced with a lot and we learned a lot. 2018 will continue to change the way we deliver care in our communities.
Like I’ve always said, as the largest EMS system in the country, we have an obligation to understand those changes and take an active role in developing sound approaches that improve the care we deliver and the way we do it.
So, if you’ll permit me, I’d like to take a stab at what I think are going to be the hottest aspects of EMS we’ll face in 2018:
1. Preparation and responses for active shooter/hostile events
One of the toughest evolving issues in out-of-hospital medicine has become the increasing number of active shooter events. The Oct. 1 shooting in Las Vegas, the worst mass shooting event in U.S. history, was a powerful reminder of the intense challenges we face in these events.
Fortunately, as with everything we face in EMS, we continue to learn better ways to prepare ourselves, better methods to care for our patients and more effective approaches to minimizing the impact of these events on our communities, our profession and our colleagues.
2. The opioid crisis and the new fallout from evolving approaches
We’re all aware of the horrific numbers of patients that die as a result of opioid misuse (term specifically used). As the No. 1 public health crisis today, EMS is smack-dab in front of the challenge.
Many states have passed permissive OTC naloxone laws allowing laypersons to obtain and administer naloxone when indicated. As more data accumulates regarding the effectiveness of these approaches (I’ll write more about the phenomenal efforts of Chris Stawasz and his colleagues in New Hampshire in another FNuL), we continue to look for solutions to this really tough problem.
But there’s a new evolving challenge in this battle. As more strict regulation and cultural changes in practice force lower narcotic prescribing, the healthcare system is beginning to see new challenges in managing long-term pain patients and more short-term pain patients seek relief through the 911 and ED access points.
Finally, the growing presence of more powerful and potent street narcotics has created both a real and a perceived personal threat to healthcare providers and public safety.
3. Defining, adopting, promulgating and measuring what really makes a difference in cardiac arrest
We continue to learn so much about what really makes a difference in cardiac arrest. Subtle changes in our approaches to maximizing continuous perfusion can have a dramatic impact on survival.
In addition, there is an increasing interest in the application and role of ECMO in this patient population, including a movement to move acute ECMO intervention from the hospital to the field
4. Alternative transportation models
I love Uber and Lyft. I’ll probably never take a taxi again in my life – unless I can’t “Uber” somewhere (used as a verb). The transportation world has been changed forever.
The reality is that many patients are beginning to use alternative ride-share transportation to get them to the right place to manage their unplanned medical event.
There is some real potential value and some scary potential risk for patients who may choose ride-share as opposed to EMS.
It’s clear that organized EMS (that’s us) needs to be a major part of this cultural change to help communities and patients make the right decisions.
We learned a tremendous amount about the role of ride-share impact during the Oct. 1 shootings.
5. Data collection and analysis – big data and hometown data
Data is still king (or queen). Healthcare systems understand the huge value in analyzing large amounts of data to better understand utilization, decision making, impact of care and how/where to focus targeted efforts.
No one “knows” more about patient decision making in sudden, unplanned events than EMS.
I hope 2018 sees a concerted effort to capture and analyze that data to help us collectively focus on what really makes a difference.
That said, there is also real value in using readily available data to impact the care we provide to individual patients (I’ll write more about a paper just published by Lynn White, our colleague Rob Walker at Physio Control and their colleagues on subtle changes in physiology during advanced airway management). And our colleagues in New Hampshire have shown us how “heat mapping” Narcan administration locations can help law enforcement and public health target high risk areas.
We have the data that almost no other healthcare entity has access to. Let’s use it to make a difference.
6. Prehospital identification and management of presumed sepsis
Sepsis wasn’t even recognized as a time-dependent condition as recently as 7-10 years ago.
Today, it’s the number one cause of in-hospital mortality and a significant reason for re-admission, hospital length of stay and transfer into long term care. It is recognized as a high stake, true medical emergency.
Evolving approaches (both assessment tools and screening algorithms) help identify high risk patients who may now potentially receive antibiotics administered rapidly in the field.
Much to still be learned, but it’s clear that an EMS focus has the potential to decrease morbidity and mortality.
7. Public education and preparation
If you handed your neighbor a CAT tourniquet, would they know how to use it?
Unfortunately, I bet we all know the answer …
And, although (at this point) the potential to need a tourniquet is relatively low, our world is changing.
I mean, let’s be real. Who would ever need to really know how to use an AED?
8. Critically ill patients managed outside the walls of a hospital
Even with all the changes in healthcare reimbursement and patient “navigation” efforts, one underlying principle has become very clear.
Move as much clinical care away from a bricks and mortar hospital as you can. Care for patients in the home, in alternative outpatient settings, a mobile clinic – you name it. New models emerge almost daily.
It’s clear that EMS has an opportunity to be a part of this new shift outside the hospital walls – whether it’s Hospital @ Home, mobile integrated healthcare or telemedicine, the movement is becoming very clear.
EMS can be a major player in that cultural evolution …
9. Multi-drug resistant bacteria – emerging infectious diseases
We had our first request to transfer one of these patients this past fall – a septic patient (bacteria and fungus) who was resistant to every known antibiotic and anti-fungal agent. The implications are significant.
For the record, we used our Ebola planning and transport approach to manage the patient. While the disease is different, the approach is almost identical.
The fact that we saw one means we will see more. This population poses new challenges to our IFT and critical care transport approaches.
So that’s my list – I’d be really interested in hearing what you think is on our horizon. What did I miss?
About the author
Ed Racht is chief medical officer, American Medical Response.