EMS education needed: Overcoming the speed bumps of 2017
EMS sleep practices, the opioid epidemic, community paramedicine and patient transport mark some of the biggest issues to watch in 2018
As 2017 draws to a close and 2018 approaches, I think it’s appropriate to look back on the EMS events of the last year, and try to draw some lessons that will help us prepare for what is to come.
And the lesson I think we can all draw is, “Thank goodness it’s almost over.”
2017 turned out to be like that fantasy date with a supermodel: she looked great from afar, but over dinner you discovered she’s a narcissistic sociopath with a heroin habit and bad credit. You keep hoping that it’ll get better, that something about her personality will match her looks, but when she meets your parents, both hate her, and she’s mean to your dog.
And she just won’t shut up about Crossfit.
So now we’re all ready to break up with 2017, and praying that 2018 will be like Mary Ann from “Gilligan’s Island” – pretty, wholesome, well-adjusted ... you know, normal.
Safe sleep for EMS providers
2017 started off with promise, when Austin-Travis County EMS announced the implementation of Safe Sleep Rooms to combat crew fatigue. The rooms have blackout shades, fans and beds, and alarm tones are disabled to allow tired crews to get some much-needed sleep.
Mental health and psychological well-being of EMS crews have been concerns for several years now, and 2017 saw an increasing focus on the effects of crew fatigue and excessively long shifts on our physical well-being.
With research that shows drivers awake for 18 hours are comparably impaired to someone with a BAC of 0.05, and drivers awake for 24 hours are functionally equivalent to a BAC over 0.10 (well over the legal limit for driving while intoxicated), EMS policy makers are starting to take notice.
Numerous fatigue-related ambulance crashes highlighted the problem. Look for that trend to continue in 2018, with more agencies adopting fatigue-mitigation policies and curtailing shifts of 24 hours or more.
Regardless of where you stand on the political spectrum or your views about firearms, these incidents demonstrate to all of us that there are no truly safe spaces, and that evil can touch us anywhere.
All of us in public safety – fire, police and EMS – must adapt our thinking regarding responding to these events, and one big step is in crowd-sourcing patient care. When seconds count, we can no longer afford to be minutes away.
Look for 2018 to include even greater focus on integrating Rescue Task Forces into active shooter response, and more agencies will offer RTF training and ballistic vests to their crews.
Look also for a serious push to teach bleeding control techniques like tourniquet application to laypersons. Campaigns like Stop The Bleed that started in 2016 will continue to expand in 2018, and eventually will become as commonplace as layperson CPR training.
EMS and the opioid epidemic
2017 saw the opioid addiction crisis continue unchecked, and saw rampant hysteria in response to it. We had city councilmen in Ohio proposing a “three strikes and you’re out” policy for opiate overdoses, we had a fire chief and medical director actively postulating that EMS administration of narcotic pain relief may cause addiction, and we had a slew of ignorant journalists breathlessly reporting occupational exposures to fentanyl and carfentanil at overdose scenes.
Notably absent from these reports is anything remotely resembling an opiate toxidrome, or any drug-test confirmation of an exposure. Every major toxicology authority in the United States has stated that such a thing is extremely unlikely, yet still we saw it shared in EMS and law enforcement social media posts that someone’s brother-in-law’s cousin dates the nurse that cared for the cop two towns over who sneezed at a sketchy drug house and fell out from all the carfentanil wafting in the air.
Look for such hysteria to continue in 2018. Thankfully, Congress intervened back in January and amended ambiguities in the Controlled Substances Act that threatened the ability of EMS providers to provide narcotic pain relief in the field, but we’re still figuring out what is the “new normal” of our opiate crisis.
2018 will see more states promote layperson use of naloxone (probably a good thing), EMS regulatory agencies will explore alternative methods of pain relief like NSAIDs and nitrous oxide (definitely a good thing), and regressive EMS agencies will use the epidemic as an excuse to limit their crew’s ability to provide narcotic pain relief in the field (a very bad thing).
Maybe sanity will break out in 2018, but I don’t hold out much hope. As that noted philosopher Agent K said in “Men in Black,” “A person is smart. People are dumb, panicky dangerous animals and you know it.”
Community paramedics make strides in MIH
2017 saw both advances in diagnostic technology with point-of-care ultrasound (POCUS) and lab testing, and promising growth for mobile integrated health/community paramedicine with the decision by Anthem Blue Cross to reimburse treatment without transport. Anthem’s decision to reimburse under the Healthcare Common Procedure Coding System code A0998 code may be the first trickle in a reimbursement sea change as other insurers and CMS follow suit.
Widespread reimbursement under this code has the potential to replace the patchwork of varied funding models that has limited the growth of MIH-CP thus far.
More and more agencies are adopting POCUS, and with increasing utilization, prices of the units are falling steeply. With the recent FDA approval of an ultrasound iPhone peripheral that retails for only $2000, POCUS has officially moved from the realm of “nice toy, but cost-prohibitive” to “affordable and important piece of diagnostic equipment.”
Look for 2018 to see explosive growth in POCUS and MIH-CP, yet don’t hold out much hope for increased educational requirements for advanced EMTs and paramedics. These diagnostic tools and the primary care and gatekeeping we provide in MIH-CP require additional education, yet we still look to fill those gaps via a patchwork of continuing education.
There is a ceiling to how much initial education we can provide the paramedics of the future without requiring a degree, and we’re bumping against it now. Unfortunately, EMS has an institutional love of cool toys and procedures, but a loathing of more education to utilize them appropriately. Don’t look for that to change in 2018.
Outside the box patient transport
2017 saw several large EMS agencies form partnerships with on-demand transportation services like Uber and Lyft to transport low-acuity patients, including to some non-hospital destinations. With system demand and call volume steadily increasing, while the dismantling of Affordable Care Act and falling tax revenues threaten ambulance reimbursement, agencies are starting to think outside the box when it comes to triage and transporting patients. Look for this trend to continue in 2018.
Lastly, 2017 saw a continuation of the drug shortages we’ve seen for the past decade. Naloxone demand far exceeded supply, and manufacturers of numerous drugs experienced production shortfalls. The latest is a nationwide shortage of, of all things, normal saline. The problem isn’t in distilling the fluids, it’s that many of the IV bags were manufactured in Puerto Rico, which is still recovering from the devastation of Hurricane Maria. Expect more of the same in 2018.
Well, that’s the year that was 2017, and a look ahead to 2018. I wish you all Happy Holidays, and a 2018 that is more Mary Ann than Ginger!