As Cool As Us

   No money. No clout. Fighting with the big dogs for every morsel we get and scrapping just to keep functioning day by day.

   That's the reality for a lot of American EMS, and it's an identity many of us have internalized. But it's not wholly accurate. EMS does indeed often have leverage, and in some very important areas. As the first caregivers to our communities' sick and injured, we diagnose their problems, initiate their treatments and chart the preliminary courses of their care. Increasingly, as EMS grows in sophistication and capability, the methods and tools and interventions we employ in doing so directly determine what our hospitals do next, and how.

   Take a classic example, therapeutic hypothermia for cardiac arrest patients. If we begin it in the field, we can't very well deliver resuscitated patients to facilities that can't continue cooling. An EMS system that cools in the field can therefore tell its potential destination hospitals that they won't be getting those oh-so-profitable cardiac cases until they can cool them too. That's a shot we can call--and some of us have.

   "We basically said, 'We're doing this. Hospitals, let us know who's going to continue this care,'" says New Orleans EMS Director Jullette Saussy, MD. "The hospitals all suddenly said, 'We can do this!' They really want those patients, and our decision really kind of drove intrahospital, intra-ED, intra-ICU cooling. The cardiologists were on board, the neurologists were on board, and it really kind of brought the system together."

   That's a happy bonus, but the main driver for any EMS intervention is of course what's best for patients. For resuscitated cardiac arrest patients, cooling is--so why not flex some muscle in doing what's right?

   It needn't stop there. In New Orleans--a city's whose entire healthcare infrastructure was essentially gutted not so long ago--EMS has been able to help push numerous other interventions into hospitals: end-tidal CO2 monitoring (patient benefit: no more unrecognized esophageal intubations). Adult intraosseous access (immediate access for ED staff; no unnecessary central lines). Fentanyl for pain relief instead of morphine (faster-acting, fewer reactions). Work is ongoing in other areas, including resuscitation bundling. "Those numbers are looking great; hopefully at the end of it we can find the best combination," says Saussy. "And hopefully, that will drive resuscitation centers."

   Ultimatums like New Orleans EMS' cooling mandate represent a kind of hard power, but it's worth noting that EMS can wield a softer power too, and impact patients' welfare and hospitals' care in more traditional ways that shouldn't be forgotten. Those involve bringing safety messages to the community and being active in injury- and accident-prevention. Many EMS systems do this kind of thing already: CPR classes, car seat and bike helmet giveaways, towing crashed cars to schools for anti-drunk driving presentations and so forth.

   Somewhere in between lie things like paramedic activation of cath labs for STEMI patients. In New Orleans, they can do it without sending EKGs ahead for confirmation--certainly a way of determining hospital care and simultaneously benefiting patients.

   "The cardiologists are pretty happy with the way this has worked, including our lack of false positives," says Saussy. "But I think once we have the technology, we'll transmit [EKGs ahead]. I'm not necessarily sure we need to, but the benefit I see is in transmitting to a hospital where a patient's been before, and they can pull up an old EKG and say, 'Is this old or new? Tell me what's going on with this guy's history.' If you have some funky EKG, but it's really your baseline, we need to know that."

   Life is always easier when EMS and its hospitals get along, and that's particularly true when EMS is trying to influence hospitals' behaviors. Turf, politics and resource limitations can derail the best of intentions. For advances to work, there has to be free communication, good personal relationships and lots of feedback both ways.

   With the STEMI activations, for instance, New Orleans' EMS teams get QA and after-action followup from hospital cardiologists. They discuss false positives, things that were missed, and provide general education on matters of the heart.

   "We work really hard on all those relationships," says Saussy. "It's really about getting to know the people--the CEOs and emergency department directors and nursing administrators--and really having one-on-one sorts of relationships. These people are in my cell phone. If I have a problem, I pick up the phone and call. We meet on a regular basis. So it's just keeping the lines of communication open and building consensus. We all want the same thing, which is what's best for our patients."

The Argument for Temps in the Field
The H1N1 outbreak of 2009 demonstrated the importance of EMS and hospitals working closely together. For healthcare providers in New Orleans, it also demonstrated the merit of EMS taking patients’ temperatures.
“With H1N1, it made a huge difference,” says New Orleans EMS Director Jullette Saussy, MD. “How do I tell whether you have an influenzalike illness if I can’t even tell whether you have a fever? How do I alert that crew? How do I alert the hospital?”
In a pandemic situation, with urgent precautions to be taken, that’s an imperative for the protection of caregivers. Care of the patient doesn’t change, but staff need to protect themselves.
“If somebody is unconscious, and I come in and tell you they have a temperature of 106ºF, doesn’t that change your care?” asks Saussy. “Of course it does! To my mind, it has a clear benefit, it’s cost-effective, and it gives you a tremendous amount of information.” ?