A Whirlwind of Innovation

At EMSToday 2014, I had a chance to sit and chat with Dr. Nadine Levick, the founder of the EMS Safety Foundation. She is an Emergency Physician in New York and a tireless promoter of many interesting innovations that directly affect our industry and work. We sat down in the booth she had set up on the expo floor. When I say she’s a tireless promoter, I mean it. Several times during our interview, Dr. Levick would jump up to chat with a passerby, excitedly proclaim how cool these various projects are and greet people whom she had taught and lectured before.

Dr. Levick is a constant multi-taker and her almost-manic energy and enthusiasm are clearly driving forces in promoting that in which she strongly believes. During our interview, she wore a Google Glass headset. Being someone who uses a lot of eye-contact when speaking with others, I found it a little bit distracting. Even so, she was engaged and really, really happy to tell me all about the EMS Safety Foundation, INDEMO and, iRescU. I wouldn’t have been surprised if she was also working up another innovative scheme via her headset while chatting with me.

Dr. Levick is the CEO and Chair of Objective Safety, an organization that, according to its website,

… has unique expertise on safety and hazard awareness in the Emergency Medical Services Transport Environment in addition to safety and injury prevention and control in the pediatric setting.

Dr. Levick tours and lectures on these issues, providing useful guidance to EMS agencies in increasing transportation and in-ambulance safety. The EMS Safety Foundation grew out of that. As well as being an emergency physician, Dr. Levick also has a Master’s in Public Health. She has participated in a lot of academic research, and “what was really, really quite very clear to me, and it’s clear to most people in academia, is lots of stuff we know, it’s not operationalized.” She saw a gap between the things she was learning as a researcher and what was being learned and applied at the operational level of EMS and public safety and there was, “…an increasing need for people in EMS to make operational decisions based on state-of-the art technical science.” She noted that many EMS agencies do not typically budget for the research and investigation needed to access that state-of-the art science. Through Objective Safety, she sought to bridge that gap.

As she traveled and spoke, more and more people came back to her asking for more information and starting discussions about safety innovation. Recognizing that EMS as an industry doesn’t have a lot of money to send its people everywhere to have meetings, summits and discussions, Dr. Levick first made all of her presentation material available to anyone via the Internet. She was quickly surprised at the thousands of downloads that her presentations were logging.

Interest increased and, knowing that there is limited budgets for travel in many EMS agencies, Dr. Levick started a quarterly web-seminar that very quickly turned into a monthly regular event. Everyone who came to her with questions and ideas were quickly drawn in by her enthusiasm and enlisted to help with finding solutions and innovative ideas. The EMS safety foundation grew almost organically as more and more people involved themselves in the process, drawn in by Dr. Levick’s positive charisma. “All sorts of people reached out to Objective Safety and asked me really good questions.  They self-selected. I had this whole cohort of really smart people every year to make this a real going sort of a community.  There they were screaming questions, and great questions! Each one of those people who approached me about Objective Safety was asked if they would be interested to be part of an innovation consortium, and that’s how it started.”

She didn’t just rely on people in the EMS industry. Her previous work and research into ambulance safety put her in close collaboration with automotive and ergonomic engineers. She included them in the collaboration to help find real, applicable and scalable ideas to apply to EMS Safety. Dr. Levick also looked outside the USA. She traveled to RETTMOBIL, a rescue and mobility exposition held in Europe every year and came back brimming with ideas on how to design ambulances in the USA so that they are safer for the patient and the provider. “There was a suggestion to bring a European truck over here. I said, ‘Well, yeah, I can, but it’s not sustainable because it’s going to be gone in four weeks. It’s not scalable ’cause no-one’s going to build it ’cause they’re going to say it’s European it’s not American. And it’s not translatable; different areas aren’t going to be able to adopt it.’ SO I said, ‘No, let’s think of another way.’ I thought what we really want to do is physically demonstrate an alternative way of laying out an ambulance that is driven by technical science: the science of automotive safety, occupant protection, and ergonomic factors, all tangible so you can touch it and feel it, but not branded so it was a European ambulance, not branded so it was so-and-so company built it. Have it a generic illustration, a 3-D illustration of how this can work. It’s one thing to look at a blueprint, it’s another thing to sit your butt in the seat and reach for stuff.

And that’s exactly what she did. Using money earned from her speaking fees from Objective Safety, Dr. Levick had a trailer built which has the exact interior dimensions of a typical van ambulance. True to form, she enlisted the help and advice of other experts: Chris Fitzgerald, an ergonomics specialist, and Ronald Rolfsen, an advisor to the Oslo University Hospital’s ambulance service, on more than just where to put the oxygen and the patient. In the design, everything can be moved, adjusted, finessed and reconfigured, in real time. Someone can get in the design module trailer, sit in the chair on the side of the stretcher, and adjust the chair position almost infinitely until it’s in the perfect spot.

Aircraft mounting track in the INDEMO trailer allows a full range of customization. (photo by maddogmedic)

Aircraft mounting track in the INDEMO trailer allows a full range of customization. (photo by maddogmedic)

Likewise for the stretcher, the monitor bracket, the bag storage and more. Furthermore, the walls are completely transparent, making the trailer accessible to all participants while the live design process is going on. What Dr. Levick and her team have created is a tool by which any ambulance service, fire department, transport agency or, even, tiny volunteer department can specifically and personally design their own ambulance to meet their own specific needs and maximize the safety of innovations such as, forward facing crew seats, seat positioning that allow the usage of seatbelts during patient care, ergonomic protection from back injuries and more. “Yeah, you can do it on a computer, but you can’t sit on a computer.

(photo by maddogmedic)

Layout of the INDEMO trailer.

This you can sit in. This is real world. This is ‘rubber-meets-the-road.’ If you want to lay out your ambulance, you can actually do it on this, move everything around just like Lego blocks bu in the real world and have a good sense of how your operational environment’s going to work.”

Photo by maddogmedic

The INDEMO trailer has see-through walls to enable group participation in the live-design process.

 

INDEMO, stands for Innovative Design Module. The intention is to get a prototype up and working and then, with the help of crowdsourced funding, create a tool that can be deployed to help agencies design their ambulances to be safer and easier to use. She started a campaign on the medical-oriented crowd-funding page called Medstartr to fund the further development of INDEMO. Check it out and pledge to help.

When I asked Dr. Levick about how she thinks ambulance manufacturers would react to this she replied, in her usually enthusiastic manner. “They’re not experts on ergonomics and occupant protection… They want the end user, the purchaser to make a request…. We’ve tried to fill that void…with technically sound information on what is going to give you the best outcomes. So the manufacturers are delighted about this because all of a sudden it’s like, ‘Oh, great! We don’t have to be guided by all sorts of stuff that may or may not be sound.’ It’s actually worked out very well.”

While working with fleet management system designers and simultaneously trying to teach herself how to use a smartphone, Dr. Levick came up with another innovative idea that can certainly save a lot of lives. As an emergency physician, she sees, along with the rest of us, that cardiac arrest survival rates are pretty abysmal. Even in systems that have instituted “resuscitation academies’ Such as Howard County, Maryland, or where “Pit Crew EMS” systems are deployed with aggressive training, the biggest gap in the chain of survival is bystander CPR.

Simply put: not enough of the general public know CPR, where to find the nearest AED or even what an AED is. Dr. Levick saw that companies can use cloud-based databases to keep track of all the minute detail and locations of thousands of ambulances. Why can’t we do that with AEDs? Furthermore, can that information be gathered by and used by the public?

Thus was born the idea of iRescU. Once again, Dr. Levick used her charm and enthusiasm to enlist a team of experts to design a cloud-based database and mobile phone application to locate, propagate and publish AED location data, provide it to any smartphone-using bystander of a cardiac arrest, feed information to responding EMS providers and provide guidance in the usage of the AED and delivery of CPR. This was all conceived and designed using existing, ubiquitous technology. It’s one of those “Why didn’t I think of that?” concepts. Enough people were impressed that iRescU was chosen as a finalist in the American Heart Association’s 2014 Open Innovation Challenge with Medstartr.

This is one of those innovations that pushes beyond the small world of EMS and into that wide border between EMS and the public. There are other applications out there that try to help with early CPR in the chain of survival. One app alerts nearby CPR trained members of the public if there is an arrest in their area. AED location doesn’t seem to be included in some of these apps and early defibrillation is one of the links in the chain of survival. iRescU hopes to build a database that bridges limited government databases of AED locations by having iRescU app users geotag and update other AED locations and sharing them with all iRescU users. Crowd-sourcing. Now what iRescU really needs is crowd-FUNDING. That’s where Medstartr steps in.

Both of these projects are very dear to me as a paramedic. I am all for innovations and designs that keep me from getting hurt and put out of a job such as the INDEMO project. As a paramedic, it goes without saying that I want to save lives. More accurately, I want lives to be saved and I’m in a much better position to do so if CPR and defibrillation are available and deployed as early as possible in a cardiac arrest. I encourage everyone to learn more about these projects through the copious links I’ve sprinkled throughout this entry.

I walked away from my interview with Dr. Nadine Levick feeling a little dizzy and a little overwhelmed by all the things she’s doing. Dr. Levick see’s opportunity for change and improvement everywhere. She’s not driven to make money or become famous. She sees a need and pushes for a solution. She encourages those around her and is a tireless cheerleader for the causes before her.

–maddog

-Edited for format & style on 2/16/14
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The Hook

I’ve met a lot of people who impress me in the work they do. They all are dedicated, motivated, and committed to the work of improving what we do and how we go about it. Without fail, each and every one of those people have had some sort of "hook." The "hook" is the thing that separates the person from the job. The "hook," in true Jedi fashion, pulls them away from what they are doing and gives them the ability to see all of what they do in the context of who they are.

Our "hooks" teach us to be mindful of the things around us. It’s like pulling your head out of the sand. That’s the purpose of a "hook." It is something outside of what we normally do but we take lessons from it into every part of our lives. I’ve met amazing men and women who’s "hooks" were as varied as practicing martial arts, painting other people, taking amazing photographs, kite surfing, teaching children how to fish, and making clothes. They are all exceptional people. Perhaps they are so because of their "hooks," or, perhaps they have these "hooks" because they are exceptional.  I don’t know.

I don’t try to be exceptional, but I do have a "hook." I play this:

Yeah. That’s a bad photo of a lovely bit of mahogany, tortoiseshell (artificial), ebony, steel and nylon that keeps me busy when my brain is full. It gives me the pause I need to see what’s in front of me and rounds me out when the skeptic scientist of my brain gets too sharp.

We all find our own way. This one is mine.

–maddog

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Hot topics from EMS today that are still sizzling.

Maddog was a busy boy at EMSToday this year. I had a chance to talk to a lot of people about a lot of topics and will be putting up final copy after editing, final questions and formatting are completed.

I got to sit down and interview Niel Noble, the Lead Paramedic of Team Australia EMS about his work with Paramedics Australasia, the Paramedics Australasia International Conference (PAIC) coming up this September and a few other topics. In reviewing the recording of our interview, I’m reminded that this guy is a rockstar! Hit those links up there and learn a bit about how our brothers and sisters in Australia, New Zealand and the Pacific are pushing to make EMS better in their corner of the world. I’ll be publishing the best bits of my interview with Niel along with some of my own impressions.

I also visited with Dr. Nadine Levick of the EMS Safety Foundation about her work in developing an ergonomic, safety-oriented ambulance design tool called INDEMO and a program, called iRescU, a database of AED locations throughout the world that can be accessed by smartphone. Both of those projects are also on a medical version of Kickstarter called "Medstartr." Click, read, pledge. Good stuff for all of us and our patients.

Another big topic going on with EMS in the USA is the expansion of EMS practice in certain areas to help provide non-emergent (or "less-than-emergent") care to our patient populations. I got to attend a few talks and chat with a few players in these programs. By whatever name it’s called, "Community Paramedicine," "Mobile Integrated Health Practice," it’s an emerging reality in the United States and, like many new things in EMS, not entirely without controversy. I’ll try to do justice to the scope of the issue and provide my own viewpoint of this emerging change in our work.

So, that’s a short preview of upcoming posts. I’m always a bit overwhelmed by the sheer volume of enthusiasm and smarts I find at these conferences and I really want to do them justice in my reporting. I’ve got a long plane ride ahead of me back to the Middle East. I’ll not be bored.

Stay tuned!

–maddog

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What’s a “Blog?”

This is the first year I’ve come to EMSToday as “maddogmedic” instead of my own actual name. I wanted to engage the conference and the people in it from my perspective of the storyteller, “maddog.” I also realized that, at 10 years and 1 month, my blog is as old (if not older) than Facebook.

Often, when I tell people that I have one of the (if not, the) longest-running EMS blogs on the Internet, a blank look comes over the face. Yeah, I’m not that famous or well-read. I’m trying to change that this year with more relevant content, better stories and a more consistent posting regimen.

Someone asked me why I was still writing in a blog rather than exclusively using Facebook and Twitter. Granted, I’m quite active on both of those places but there’s something more to writing on my blog/website. I consider my blog as a place to put forth my more polished ideas and writings. When I have an interview with someone, I put a lot of effort into prepping for the interview, engaging with the interviewee and then writing up the interview afterwards. When I find an interesting subject and want to write about it, I don’t just post a link and my opinion. I try to provide either a deeper understanding of the subject, or a perspective with which I am knowledgeable. (In fact. I’ve already spent more time editing this post than writing it and I’m only 3 paragraphs deep!)

My blog is where I try to write something worth reading. I’m not a traditional news and opinion source. I’m not Wired magazine, JEMS or even The Onion but I do try to make sure whatever content I put up here is interesting and relevant.

That is what my blog is for. It’s for meatier, worthier and, I hope, better quality content than you can read on Facebook or in 140 characters on Twitter.

I’ve spent all of this Thursday at EMSToday gathering great material for some excellent articles/blog posts. In the next few days, my readers can look forward to:

  • An interview with someone who wants to change the way we design ambulances and help people use their smart phones to  find AEDs and guide them through CPR.
  • An extensive article about the evolution of paramedic practice in the changing health care environment in the USA.
  • An interview with some VERY interesting Paramedics from around the world who do are trying to make our profession better and better.
  • More photos and impressions at EMSToday by yours truly.

I really don’t have the time to “live blog” the conference. The amount of time and effort to sit and write the “copy” (The words you are reading here) and then edit, modify and format them, defeats me if I want to also keep up with all the stuff going on.

I hope you keep reading. I’ll do my level best to keep you interested in doing so.

Stay tuned.

–maddog

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EMSToday, Day 1: Photos.

Having a fancy new camera, I was excited about pulling it out and snapping some photos as I arrived at the Walter E. Washington Convention center in Washington DC for the 2014 EMSToday conference.

As soon as I walked in the door, I spotted the JEMS games getting set up. I’ve always enjoyed them (even judged a year or two) and I was kinda cool to see them getting ready:

DSCF2905

Of course, the welcome signs were up:

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I got the chance to run into the infamous A.J. Heightman, Editor-in-Chief of JEMS and Col Allen, a paramedic with Team Australia EMS.

DSCF2911

Thanks to kindly exhibitor, I’ve got a pass which let me into the exhibit floor before they officially opened. I love this sort of stuff so I got in and took some snaps of the “Pre-exhibit carnage!”

Oh the carnage!

Oh the carnage!

DSCF2913 DSCF2921 DSCF2920 DSCF2914 DSCF2923

Look at the shiny ambulances! *Drool*

DSCF2930 DSCF2925 DSCF2942 DSCF2947 DSCF2941DSCF2953

Lots of people were hard at work:

DSCF2919DSCF2940 DSCF2944 DSCF2949 DSCF2948 DSCF2934DSCF2951

 

And this just doesn’t look the same without all the gear and, of course, the people:

DSCF2937

 

Lots of stuff happening. (& about to) EMSToday has been much more active on social medial this year and I might just drop in on an event or two tonight. If you’re at the conference, look for me. If not, I’ll help you attend vicariously. Of  course you can follow my antics in a more timely manner on twitter at @themaddogmedic and on F’Book.

–maddog

 

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EMSToday, Day 1, Part 2 (+1 for funny)

This is a really funny article by Rob Lawrence of the Richmond Ambulance Authority that I came across by way of Phillydan’s Twitter Feed.

I’m ashamed to say, the author has pegged me in part of it:

Create a medic-tastic handle to call yourself, such as “EMS Pundit” or “Amboman” and use phrases like how “blogging is your great catharsis.”

Yep.

–maddog

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EMSToday Day 1

I’m at the EMSToday Conference in Washington DC. Keep an eye out. You might see me. I’ll be posting updates to Twitter and Facebook and you can follow me on twitter at @themaddogmedic or on Facebook at https://www.facebook.com/maddogmedic.

I’ll be running my silly #findmaddog game again this year with clues as to my whereabouts posted on Twitter and Facebook. Chase that hastag and you might win "fabulous prizes!" I’ll also be talking to a lot of people. I’ve always been interested in storytelling and I’m keen to hear some of the stories of the people I meet.

Stay tuned!

–maddog

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Go Sports!

I drop in on America to attend EMSToday in Washington DC. Because my family lives nearby, I’ve added a few days of time on the front and back of the conference time to visit and re-acquaint. My oldest brother and his wife are big football (NFL) fans so, of course, I accepted their invitation to spend Super Bowl Sunday at his house.

I got to teach one of his kids to play the ukulele and we all had some fun. Food was laid out and we all settled into a darkened room to recline, dine and watch the spectacle of the game. Those of you who follow me on Twitter and Facebook have certainly gleaned many of my opinions about the sport, the game and the crass exploitative nature of commercialism. I’m not writing about that here.

I’m writing about why we (American Society) is so obsessed with "Sports" that we would allow these "athletes" to commit felonies, rape and widespread ethical wrongs yet still get paid so much more than any single person needs. What is it about "Sports?"

Athleticism?

Are we impressed by the physical effort and commitment required to perform these tasks of playing the sport? Yes. Wow. Run. Catch a ball. Run more. Knock someone down. Good sport. Good effort.

What about the athleticism of a Firefighter, carrying 55-70lbs of gear, climbing 10 flights of stairs and wrestling with a fully-charged fire hose in extreme heat? Or the police officer that, while wearing 15-30lbs of body armor, gun-belt and gear, sprints down the street in pursuit of a criminal and then has to fight/wrestle and restrain said criminal? What about the EMT who, in the back of an ambulance that’s hurtling down the road at 60mph, slams her body weight on someone’s chest 100-120 times per minute?

If your "sports" player fails, someone doesn’t get a trophy. What happens if the firefighter, cop or EMT fails? Athleticism. Think about it.

Competition?

I want my team to win. I want my team to beat the other team so my team can have the trophy and I can wear the team colors with pride.

I want my paramedic to win. I want my teacher to win. I want my nurse to win. I want my cop to win. I want my firefighter to win.  If they win, someone lives, someone learns and has a chance to become better, someone is a little bit more safe someone still has a family and, hopefully, a home.

Role Model?

My Sports Athlete is a good role model. He works hard, plays a difficult sports and shows kids the value of that hard work. Even though he may be convicted for running a dog-fighting ring, drunk driving, drug usage or have his college cover up an alleged rape, he’s a good role model.

My local cop would lose his badge if he was arrested for drunk driving. The EMTs and paramedics at my local station would lose their licenses for testing positive for drugs. Teachers lose their jobs for felony convictions. Even the allegation of rape is cause to remove a public-safety employee from the line of duty immediately. Yet millions of men and women do these jobs for low pay, against restrictive protocols and in the face of strict regulations. They certainly don’t do these jobs for the money. They do, however, protect us, rescue us, teach us and our children, comfort and treat us when we are injured and sick and give us the rock-solid foundation upon which we can build our lives and society.

Tell me again about what role model you want for your children.

Play sports. Watch sports. Enjoy sports. By all means. I do. I enjoy them very much.

Just remember what’s really important.

–maddog

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Ten Years.

I just realized that January 4th has just slipped by. On that day, 10 years ago, I wrote my first post in this blog.

Wow!

Ten years ago, I was an EMT-B and a paramedic student. In the past 10 years, I’ve moved around a bit, had a few jobs, been through a half of a marriage (Herself and I are coming up on our 20th anniversary!), traveled to 16 countries on four different continents (4 1/2 if you count the Indian Sub-continent of Asia), and have had a LOT of fun!

I covered some of those adventures in my blog. I wrote about my experiences as a paramedic student. Some of them are funny, some of them are strange and some are downright heartwarming. I also wrote about my fears as I realized the weight of responsibility I was assuming as a paramedic. I also wrote about some of the amazing, amusing and affecting calls I’ve run as an EMS volunteer in my hometown. I’ve also written about some of my personal loss.

As I go through these older posts, I find that I often reflect on death and my place at the point where people meet it.

I took jobs that I didn’t like and worked with people I did. I even did a stint as a teacher and had a chance to get young students thinking.

I wrote less and less about the particular calls I ran but still made time to discuss how I feel about the various facets of my work and profession. I still have a nightmare every now and then.

I managed to save a life or two. I found a funny thing or two.

I moved to the Middle East and have been having interesting adventures there. (Someone called me a "Murderer") I’ve also started talking to other people in EMS who write about their experiences and I have had the good pleasure to meet some truly interesting and inspirational people.

I learned to play the ukulele.

I became a CCEMT-P with the help of some really neat people.

It’s been a good 10 years, overall. Ups and downs, sure but I think I’ll keep at it. Let’s see where the next 10 years take me. I hope you’ll come along.

–maddog

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Two Hundred Years of Tradition, Uninterrupted by… Wait! WHAT?

Last year, the Mesa, Arizona Fire and Medical Department did a pretty cool thing. They published the results of a study they performed in the field having to do with assisted CPR and survival rates. In short: working with Zoll’s Real CPR Help ™  technology, a 4-person "Pit Crew" formation and an aggressive training program for their firefighters, Mesa Fire and Medical Department broke with the notion of resistance to change and doubled their cardiac arrest survival rates.

You can read Zoll’s press release here and the published study here.

At last year’s EMS Today, I got the chance to sit down with Scott Crawford, the then EMT Training Coordinator for Mesa Fire and Medical Department and John Tobin, EMS Captain for the same. Due to some technological errors and a foolish choice of voice recording software, I lost the interview I conducted until I could recover an old laptop and salvage the transcript I made soon after meeting with them in March of 2013.

Even after almost a year, I still remember the enthusiasm and pride those two showed for the impressive change they helped bring about for the citizens of Mesa, Arizona. I sat with them in the lobby of the convention center and we talked about their work. Scott Crawford is tall, whip-thin and has the contagious energy of an enthusiast. His excitement for whatever he sets his mind to is contagious and makes me see how he was an instrumental part of bringing about this program.

John Tobin is as still as Scott is mobile but it’s not a stillness of passivity. He is exactly the kind of calm, deliberate person you’d want at your family member’s side in a crisis. While he may not be as outwardly energetic as his companion, it’s clear that he misses very little and has the meticulous intelligence and determination that is needed to help bring about a significant change in a traditionally change-resistant establishment. Let’s get to the interview:

What did you do?

Scott Crawford: We got our department to look at resuscitation in a different light. In the past, pretty much nationwide, most of the time in the emergency response genre we look at resuscitation as one of those things that sometimes we get right but most of the times it doesn’t happen. Back, probably about 6-7 years ago, the state medical director, Dr. Ben Bobrow, came to the Mesa Fire Department and he had this concept and he was working with the University of Arizona and the Sarver Heart Center and we have this thing called AZ Share were we collect data. He asked us to be a part of that to be a part of collecting data on all cardiac resuscitations.

John Tobin: State wide.

Like a trauma registry but for cardiac arrests?

Scott: Right. And Zoll, at the time, wound up partnering with us on that project. We utilized their E series monitor with CPR feedback technology and See-Thru CPR that was part of our program. But at the time, the data collection, we didn’t have access to any of that. So, we just kept doing what we were doing and after a couple years, we looked at the data we had collected and saw how abysmal our resuscitation program was and how embarrassed we were by it. It was a great motivator.

What kind of numbers were we looking at?

John: We still didn’t have bad numbers. but as far as everything coming out about evidence-based research; How rate matters, depth matters, time on the chest matters, compression fraction matters, that’s the stuff we were doing really bad at. When we started we were around 26% witnessed V-Fib arrest saves, which is not bad.

That’s not bad at all!

John: Ok. So we implemented a new protocol. Scott was our champion for that, I was one of the trainers under Scott and we have, what, 11, 12 trainers?

Scott: Yes, we have about 12 trainers, hand selected.

And these were Zoll trainers?

Scott: They were our paramedics and EMTs that we trained to our specifications to deliver this training. You know in the fire service, change is painful.

Two hundred years of tradition, uninterrupted by change!

(Laughter)

Scott: Right! So we knew what a challenge it would be because we were going to throw a complete curve ball at ‘em and expect that they were going to go ahead and swing at it. We knew that wasn’t going to be easy so we identified the best trainers we had, with the most street cred, that were the most accountable that I knew were going to hold the rest of our department accountable and we put this program together and delivered it to the crews.

We brought the crews in. We had a 4-to-1 ratio. We gave them a presentation, showed them what we wanted to do and fielded their questions, which you know how painful that can be. We had a room of 32 people and 30 of them were skeptics.

Zoll was great. Gary Freeman,  Zoll’s Vice-President for research (Clinical Affairs), was there for almost every presentation as were a number of representatives, and Doctor Bobrow as well. So, they were all there if there was something that needed a little more in-depth explanation.

We delivered all the information. By the time the sessions were over, they kinda believed it; they kinda believed that that’s what they wanted to do. But the proof was really in the pudding. Once they got out and implemented what we wanted them to do, they saw an increase in our ability to save people. Then it became infectious and it spread throughout the department like wildfire.

How did you convince your department to even let you start on this? What was the hook? Was it dogged advocacy? Was there blackmail involved?

Scott: Ok, you need to turn that off right now (pointing at the recorder).

(Laughter)

Scott: John, go ahead. Tell him how easy it was to implement.

John: It was pretty easy!

Scott: Super easy.

Really?

John: Our (Mesa Fire and Medical Department’s) medical director, Doctor Gary Smith has a really good relationship with the state medical director (Dr. Bobrow). They basically sat down for lunch and said, "This is what we really want to do."

It sounds like your medical director has a lot of clout.

John: He used to be a firefighter-paramedic.

Aha!

Scott: It was also easy because we looked at all the science. We brought all the science to the table and, though it was all done in clinical  and research settings, we thought if we can duplicate that in the field, we can get similar results. And so that was the key to convincing everyone signing the checks: we’ll be able to duplicate that in the field.

We think we have a pretty high level group of ‘Medics and EMTs as it is. I felt comfortable that we could convince them. Understanding how their minds work, we tailored the training to meet their specific needs as far as:  answer every question, be completely honest with them, and create a system of immediate feedback.

John was integral in getting this whole thing set up. We had an email address that went to all the trainers for anyone involved in EMS so they could contact them the minute something came up.

John: We had a website with all the powerpoint presentations and videos from the training as well as all the studies Scott referred to in the training sessions so they could go and refer to them, if they wanted to.

You used social media, something that fire and EMS departments typically shy away from.

Scott: Absolutely.

The way you describe the training, it seems you made some advocates for the program. You convinced them in the classroom.

John: That came from the trainers. The trainers were one hundred percent sold on it and they just exuded that to our members.

How did that translate to applying the program in the field?

Scott: It was almost instantaneous. We had a crew that the day after their training, they ran a call and they had a save. This was one thing that helped us really build on the program: every time we ran a code, they’d upload the code, make a phone call to EMS, send an email out to all the trainers and then somebody’s giving them immediate feedback. With Zoll, we were able to go back and look at the entire code. We could go through the code and pull out the things that we wanted were able to give them immediate feedback on their performance in the field. "These were the things that worked out great. These were the things that you can still improve on." That’s how we kept building on the program.

Did you share that with the other providers?

John: Yes. But we would redact information to protect the patient and the provider before we used it in our continuing training.

Scott: The re-training was key. It was such a cultural change for us. I can tell you that they struggled with it. Even though we had success, there were so many struggles. John was sending out emails every week. The tip of the week, "Bag at this rate. Don’t forget your (compression) depth should be this deep. Here’s the overall algorithm." So we continued that on a consistent basis throughout the process so that there was always something in their face about our program.

John: Right. Every EMS training we had for the next year included something from the protocol in it. We were hitting them from all different angles.

Scott: Another thing that we did, we made our trainers available 24-7 so that any crew that wanted to improve on their proficiency, all they had to do was call up a trainer or call the EMS division and schedule it. The trainer would show up with a manikin and a Zoll trainer and we would spend as much time as they required, asked for or needed, to help build their skills. We also partnered with the ambulance companies. We put it on the crews. We said, "You call up the ambulance companies you work with and get them to come down as well." They’re an integral part of our system. They’re showing up as well so we want to make sure that everybody’s on the same page walking through the door.

John: We use a contracted transport agency. We don’t do our own transports. We had to incorporate them too. We have 2 EMTs and 2 Paramedics on every unit.

Scott: And the ambulances have an EMT and a Paramedic as well.

So you’ve painted this rosy picture of how you implemented a substantial change in a traditionally change-resistant organization. What about the bad parts? What made it difficult?

Scott: I think one of the hardest parts was collecting data.

John: That’s something we’ve never done as an organization.

Scott: Right, and that made everyone nervous. You understand the world of EMS.

John: "They’re watching me now! They’re recording me now!"

Scott: The last thing a provider wants is to be recorded, to have every skill that they do documented, as it’s happening, and then have that information available out there. They were very nervous about what would happen to that information if something goes wrong. Is it discoverable? We contacted out legal department from the outset and, over four or five sessions, we felt very comfortable about it but our providers did not. We had to give them the best possible answers, that the information was not discoverable, it was part of the QA program.

John: Since it’s Quality Assurance, it’s not directly discoverable.

Scott: That made our members feel a lot better. That helped them buy into it right there. That was one of those first things that they just put a stop sign up on and said, "Woah, woah woah, wait a second." Even though, we’ve been collecting all that data prior. For two years we’ve been collecting data. Somebody said something about it two years ago and everybody was like, "Yeah, whatever." But now that we’re talking about it in this setting.. well you know how it is in the fire service. You tell one person and by the time training’s over the entire department knows about it.

Three fastest forms of communication: Telephone, television and tell a firefighter, eh?

Scott: Absolutely (laughter)

John: They were worried that we were going to show them something and say, "You’re doing it wrong." Instead we said, "You did great here. You did great here but you need to work on this piece right here and then you’re gonna *snap* nail it."

And that kept them from getting scared about it? You did have to go back to them, right?

Scott: Oh my gosh, yes! Every question they asked, we answered as quickly as possible as well as share the question by posting them on the website. They got posted, boom, boom, boom, they got answered. Everybody knew what was going on. We were completely open with everything that was going on with the program.

Ok, name names. Who are the biggest cheerleaders for this program? Is it just you two guys?

Scott: We like to say we’re the true believers.

You drank the Kool-aid, did ya? (laughter)

Scott: Absolutely! It’s in our presentation, as a matter of fact! (laughter) Obviously, Dr. Ben Bobrow.

John: Dr. Gary Smith

Scott: The chief of EMS at the time was Deputy Chief Keith Pyers, and he’s the one that made it all happen. Without his support, and by support we mean financial support, this would have never happened.

John: It was costly, all that training time. We incorporated it into our CPR training, into our ACLS training. It was still money they were going to pay but we had to train trainers for them, pay overtime, et-cetera.

How integral was Zoll to this process?

Scott: We couldn’t have made it work without them. As a matter of fact, between John, myself and a few others, we were practically on the phone with Zoll every day. We worked side-by-side with them in tweaking the software and and the dashboard to really meet out needs and to meet the needs of our providers. When we identified things that just weren’t the way we wanted to do them, Zoll was incredibly responsive and, usually within a couple of weeks, there was a software update coming in to help us deal with that. You’ll see most of what we all worked on in the X-series now.

You implemented policy changes, you trained trainers, you made advocates and then it hit the street. What happened then?

John: It went great!

Scott: It went better than we thought it would. It started with those initial successes. Those few crews who had success right away, they suddenly became champions.

John: Then it became a competition.

Scott: Yeah. Competitiveness is in the nature of the fire service. It just took the right crew to say, "We had three saves in a row." and then everybody else is like, "Ugh! Ok! That’s the way it’s gonna be?" and that’s the way it became. We have areas of the city where they may not run a code all year but we have other areas where they’re running them fairly regularly. It was those groups who really became champions for the process and for the training and the results because they were having success.

So, give me numbers. Show me the data. What kind of success are we talking about?

John: All rhythms, all cardiac arrests: we went from 8.7% saves to 13.9% saves. Survival to discharge with witnessed shockable rhythms: We were at 26.3% before the training to 55.6%. We more than doubled. But we’re not done yet. We want a higher percent.

Scott: Yeah, we’re really not satisfied with that. We have lofty goals.

John: But we’re really happy with that and this happened within a year from when we started. We *snap* turned it around like that.

That’s fantastic! So, what’s next? What’s your next target?

John: We’ve already implemented the new two-question model for dispatch-assisted CPR from the American Heart Association in November, two months before they actually came out. Now our dispatchers are, within one minute, directing compressions to these patients.

Scott: That’s John’s program, he’s been running with that ball and now he’s training dispatchers all over the state with that.

John: We’ve been doing other things to strengthen the chain of survival. The city actually came to us and we have a proposal in to start an AED program within the next year and with that will come Law Enforcement with AEDsn since they’re often the first on scene. 

The next big thing has been with traumatic brain injury patients. We call it the EPIC program in Arizona. It’s the same kind of thing. We use the trauma registry for Arizona and it’s a state-wide implementation under the Brain Trauma Foundation guidelines. It hasn’t been done anywhere in the country on a state-wide basis. Select communities in the US but nowhere as a state.

You gentlemen have done amazing work. Maybe I’ll retire to Mesa. I’ll live longer! (laughter)

Scott: That’s what I tell people: tell your grandparents, this is a great place to retire. (laughter)

Yeah! The air is great and you have a great survival rate! Thanks for taking the time to talk to me today. It’s been my pleasure.

Scott: Thank you. It was nice meeting you.

John: Thanks a lot.

Even looking back through my notes (almost a year old) I’m still impressed with the work that Scott and John brought about with such enthusiasm and drive. They created a system that doubled survival rates for VT/VF arrests. Not content to rest on their laurels, they continue to apply the same evidence-based model to create a positive effect on patient outcome. Change is rarely easy, especially in a large organization but John Tobin and Scott Crawford have applied the perfect blend of enthusiasm, smarts and drive to make it happen, and keep happening.

Even though it comes from a Fire department, this is the exact sort of thing that EMS agencies should be doing everywhere. We should all be using our skeptical, scientific minds, our enthusiasm for saving lives and our access to improving technologies to keep us from ever resting on our laurels.

I can’t wait to catch up with them again at EMSToday 2014 and see what they’ve done this year!

–maddog

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