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EMS on the Hill: Vol. 3 No. 4, October 2009
Welcome to the latest issue of EMS on the Hill, a newsletter representing the work of a broad group of EMS organizations dedicated to achieving positive change and recognition for emergency medical services at the state and federal levels. In July 2007, this group of organizations met to review the recommendations of the 2006 IOM Crossroads report and develop priorities and action items to help make these recommendations reality. This newsletter will provide updates on those action items, plus discuss other critical industry issues.
Stories in this article:
- Out With a Roar
- NEMSAC's To-Do List
- WASHINGTON WATCH
- Views From RETTmobil
- Baby Gap: Children In Disasters
- No Better Teacher Than Experience
- Permanent Relief: Still Searching
Good news for EMS on infectious disease notification, leadership training and more as 2009 winds down
With so much bad news in the EMS world lately--H1N1, potential negative impacts of healthcare reform, the eternal tightening of the budgetary screws--there were some good tidings announced at the national EMS Town Hall Meeting in October that should buoy the spirits of ambulance industry proponents as the year comes to a close.
The meeting, hosted by Advocates for EMS during EMS EXPO in Atlanta, consisted of updates from federal partners and an "Ask the Feds" session of audience questions. Panelists included representatives from NHTSA's Office of EMS; the office of the HHS Assistant Secretary for Preparedness and Response (ASPR); the Department of Homeland Security's Office of Health Affairs; the USFA/National Fire Academy; and the CDC's Division for Heart Disease and Stroke Prevention and National Center for Injury Prevention and Control/Division of Injury Response.
While there were no new national EMS administrations or dedicated federal spending packages announced at the event, attendees heard of positive developments on several key issues.
On behalf of Advocates for EMS, industry lobbyist Lisa Meyer, of Cornerstone Government Affairs, reported that the Ryan White HIV/AIDS Treatment Extension Act, having successfully passed both houses of Congress, was ready to be signed by President Obama (and, five days later, was). The law reinstates first responder infectious disease exposure notification requirements deleted from the Ryan White CARE Act.
Prior to the CARE Act, medical facilities often focused only on testing their own employees after exposures to transmissible diseases--EMS, fire and law enforcement providers who had contacted infectious patients weren't automatically tested, or even informed of their exposure. The CARE (Comprehensive AIDS Resources Emergency) Act included these responders in postexposure notification processes, but that protection was dropped during a 2006 reauthorization.
Its restoration has been sought by EMS leaders ever since, so this is a major success. However, it comes with a caveat: Under the new language, the notification provisions may be waived, in whole or part, during a federally declared public health emergency. This resulted from concerns in the public health and hospital communities that the requirement notification could overwhelm hospital and health department staffs during crises when they should be caring for patients.
Advocates for EMS argued that only the requirement to make such notifications within 48 hours should be waived, not the requirement in its entirety, but ultimately agreed to the provision to get the language included. Advocates will continue to remind officials of the importance of quickly notifying first responders exposed to infectious diseases.
In the latest U.S. Fire Administration reauthorization, the agency was given formal authority to address EMS operations and management issues, and will be providing advanced EMS training courses comparable to the high-level fire offerings available through the National Fire Academy.
This expanded involvement should help address a conspicuous void in management/leadership instruction for EMS professionals. Administration officials say they will cover system- and program-level management, rather than provider-level training, and have worked with an expert steering committee to evaluate these new needs. Content now being developed covers quality assurance programs and situation-based ICS training specific to EMS scenarios. "A lot of our EMS personnel aren't quite sure where to start with that [ICS] system," said NFA EMS training specialist Michael Stern, "so our scenarios are going to drive that experience."
ASPR's Emergency Care Coordination Center, established as a federal base for coordinating the various aspects of emergency care, will likely be the home for the four previously reported regionalization demonstration projects created by the healthcare reform bill. While the ECCC is already operational, it should be formally authorized in the coming bill.
The National EMS Information System (NEMSIS) is likely to get a big funding boost in current Congressional budgeting.
Around 100,000 copies of the CDC's new National Trauma Triage Protocol have been disseminated this year, and Centers personnel will next develop an implementation plan for it.
Healthcare Reform
News on the healthcare reform front wasn't quite as happy. The House released its Affordable Health Care for America Act, H.R. 3962, on Oct. 29 without the strong public option sought by speaker Nancy Pelosi that would have reimbursed providers at 5% over Medicare rates. Instead, the bill--which was bound for the Rules Committee, then debate by the full House in November--lets the HHS secretary negotiate reimbursements on an individual basis. That's a concession to moderate Democrats whose votes are required for passage, but the bill's overall prospects were uncertain early in the month. It also requires employers to provide health coverage to employees or subsidize their buying insurance through a new national exchange.
On the Senate side, the public option will likely have an opt-out clause for states, but the passage of any version is even less certain than in the House. Moderate Democrats there remain wary of any public option or employer mandate.
For more as the process works toward culmination, see www.advocatesforems.org.
--John Erich, Associate Editor
Council completes two-year term with recommendations for NHTSA's Office of EMS
By Susan Nicol Kyle, EMSResponder.com
Officials in NHTSA's Office of EMS have their work cut out for them as they peruse reports and recommendations from the National EMS Advisory Council (NEMSAC).
"This has been a very active group," NHTSA OEMS Director Drew Dawson says. "They really did a tremendous amount of work."
The panel--consisting of EMS officials from around the country--has made suggestions on a number of priorities. Following its creation in 2007, members established several committees to tackle the core issues facing EMS. Experts in those fields were appointed as ad hoc members to assist with research.
Dawson says he's impressed with the caliber of work the council has since submitted. In addition to their face-to-face meetings, committee members have held conference calls and exchanged information by e-mail.
Susan McHenry, EMS specialist at NHTSA, says her office was fortunate to have such talented people selected for the council.
"It's incredible when you think they all volunteered," McHenry says. "They've taken their appointments and assignments very, very seriously, and they've offered some invaluable advice."
Reports from the various committees were being finalized at press time.
New Members
The first version of the council will meet for the last time as a group in mid December: Members' two-year appointments expire in January.
Some members have indicated they will apply for reappointment in an effort to continue their work, McHenry says. Some new members will likely join them, and NHTSA is currently seeking candidates. The application process closes in mid November, but for more on the council and its membership and activities, see www.ems.gov.
Mission Statement
At a recent meeting, the council adopted a mission statement urging that EMS be considered a vital part of the overall healthcare system. It states: "An accountable and sustained community-level emergency medical care system is essential and must be assured in the debate and implementation of healthcare reform. Emergency medical services (EMS) is the practice of medicine at the community level and a window to a community's health status, including social care and stability. The emergency care system is a 24-hours-per-day, seven-days-per-week front door to the healthcare system and faces unique challenges in the urban, rural and frontier areas of our country. The NEMSAC believes that these key guiding principles must be included in the healthcare reform discussion."
Those key factors the council cited include:
- That any reform to the healthcare system must first ensure the stability and performance of a viable, funded EMS system;
- Financial sustainability of the EMS system must include a ready workforce as a key healthcare infrastructure investment essential to protect the public.
- It is difficult to improve outcomes or efficiency without meaningful and consistent data and evaluation. Permanent funding of the National EMS Information System (NEMSIS) is essential to ensure EMS integration into health information technology (HIT).
- EMS research should be funded in order to evaluate the effectiveness of emergency healthcare.
- The Institute of Medicine's 2006 recommendations for regional, accountable and coordinated evidence-based emergency care systems should be implemented.
- EMS is and remains the healthcare system's safety net to ensure equity of and access to emergency medical care. Ensuring core and sufficient new grant funding to maintain the readiness of emergency response is an essential public interest.
- Providing core funding specifically for EMS, regardless of delivery model, to ensure surge capacity and response to public health emergencies and natural or man-made disasters is an essential public interest.
- Any healthcare insurance reengineering must include EMS in the minimum benefits set.
- The framing of models that address the health-home or medical-home concepts must include EMS as a partner in the public health, disease management and healthcare support priorities.
- 9-1-1 based prearrival instruction and medical prioritization systems must be considered an integrated and essential element of the healthcare system.
For news on new and reappointed members and the council's activities in 2010, see future issues of EMS On the Hill.
FEMA Boss Knows What You're Going Through
New FEMA Administrator Craig Fugate knows what it's like being in the trenches as an EMS provider.
The former Florida paramedic shared some of his experiences recently at the International Association of EMS Chiefs' Leadership Summit.
Fugate said the only way a patient can survive is for the entire system to "click." Everything has to work, from the EMS system being activated by someone calling 9-1-1 to the quick arrival of crews with the proper training and equipment.
He added that members of the general public don't see the overall response, and don't know all that is set in motion by someone dialing 9-1-1. For them, "a successful outcome is that they walk out," Fugate said--nothing else matters.
Fugate admitted with a laugh that he is a fan of realistic drills--ones that truly challenge responders. "I favor no-notice exercises," he said. "Ones that don't give prep time." Responders need to be put to the test, he said, to see how they will handle actual incidents. Having to physically move patients to a hospital and set up decontamination areas, for instance, will determine how crews will complete these tasks during real-life situations.
Communication and education are the keys to promoting EMS issues, Fugate said. He encouraged EMS chiefs to take every opportunity to educate citizens and politicians.
The IAEMSC was formed in 2008. Its members work together on a myriad of issues, says President Paul Maniscalco. For instance, "budget issues, right now, are crucial to all of us," Maniscalco says. "We need to do whatever we can to keep our services afloat."
Through the IAEMSC, new EMS leaders can find a wealth of knowledge from seasoned chiefs. "We're all looking at ways to manage efficient services to care for our citizens," Maniscalco says.
During the summit, participants heard from a number of experts about everything from hiring practices to EMS billing issues, research needs, legal matters and emerging technology. Many visited their Congressional representatives on Capitol Hill. Another summit is planned for next year. --SNK
The Big Picture: Coordinating Emergency Care
The Emergency Care Coordination Center (ECCC) is a new strategic entity located within the Office of the Assistant Secretary for Preparedness and Response in the Department of Health and Human Services.
The ECCC was established after DHHS identified problems within the emergency medical system, particularly the effect of millions of people using local emergency departments as their primary healthcare providers. According to the ECCC, with fewer hospitals and higher ED use on top of staffing and financial pressures, it seems as though the already stressed emergency system may be reaching a breaking point.
"The ECCC was created in response to Homeland Security Presidential Directive #21, which called to create an office to help coordinate, promote and fund efforts around emergency medicine and trauma care," explains ECCC's acting director, Michael Handrigan, MD. "We're really intended to work specifically in close coordination with the folks at NHTSA and the Office of EMS to help coordinate the entire spectrum of emergency care, at least at a federal level." The center is charged with promoting regional partnerships and more effective emergency medical systems in order to enhance appropriate triage, distribution and care of routine community patients and promoting local, regional and state EMS systems' preparedness for response to public health events.
The ECCC's board of directors represents a variety of backgrounds. "I'm an emergency physician," says Handrigan, "and we have a staff of public health analysts, folks with legal backgrounds, and a number of others who can help us understand and address the entire range of policy, clinical activities, research and everything you can imagine." Although there are currently no Congressional representatives on the board, Handrigan believes it's important that they're aware of the ECCC and understand its goals. "We really do represent a resource for subject expertise and policy expertise in emergency care," he says. "We're interested in serving as a resource to legislators and interested in seeing how the whole healthcare debate works itself out and how we can potentially participate in that."
The ECCC is committed to promoting programs and creating resources that will improve both emergency medical and emergency behavioral healthcare services. By coordinating overall government efforts, its goal is to ensure that emergency services are meeting the nation's needs.
"This is an exciting time," says Handrigan, "and there will be a lot of active debate and change to healthcare in general, as well as determining how to best integrate EMS services into the healthcare system. Creating the ECCC represents a great opportunity to help the federal government work out the issues it can and coordinate programs that will help the entire emergency care enterprise."
For more, see www.hhs.gov/aspr/opeo/eccc and www.hhs.gov/aspr.
--Marie Nordberg, Associate Editor
NAEMT: H1N1 Emergency Could Lead to EMS Chaos
President Barack Obama declared the H1N1 epidemic a national emergency in late October, a move that gives hospitals greater latitude in dealing with surges of patients and could greatly impact EMS.
The declaration gives Health and Human Services Secretary Kathleen Sebelius the power to waive certain requirements of Medicare and Medicaid, privacy rules and other regulations. It also raises the possibility of EMTALA waivers, which the National Association of Emergency Medical Technicians warns would let hospitals direct patients to alternative, off-campus sites and transfer patients with unstable emergency conditions (normally prohibited under the law). Should such authority be invoked, CMS will notify covered hospitals through its regional offices or state survey agencies.
Use of this power appears imminent, the NAEMT says, which could "create uncertainty and chaos in the EMS environment." It's urging members to work with their local hospitals toward solutions that accommodate all components of the healthcare system.
For more, see www.naemt.org.
Still Not Ready for Bio Attack, Commission Finds
A new interim report from the Commission on the Prevention of Weapons of Mass Destruction Proliferation & Terrorism concludes that America is still far from ready for a biological terror attack.
The report, The Clock Is Ticking, warns that the U.S. government has taken some of the actions needed, but has not kept pace with the increasing capabilities and agility of terrorists.
The commission's final report is expected in early 2010. See its interim and earlier reports at www.preventwmd.gov.
In related news, the Department of Homeland Security issued new proposed guidance for protecting responder health in an anthrax attack. It recommends protective measures such as using PPE and decontamination and hygiene procedures for first responders. For more, see www.dhs.gov.
EMS to Descend En Masse on Leaders in Washington
The NAEMT will sponsor the first annual EMS on the Hill Day on May 3–4, 2010, in Washington, DC.
This event represents the EMS community's first coordinated effort to visit Congressional leaders and staff on Capitol Hill. It will include representation from all sectors of the EMS community, and help provide a consistent message to Congress on the key issues affecting EMS. Leaders hope to repeat it annually.
A previsit briefing on May 3 will prepare participants for visiting their Congressional leaders, and the visits will occur the next day. Later, NAEMT will host a reception for participants, Congressional leaders and staff, and federal agency staff.
NAEMT, EMS Magazine to Recognize Top EMSers
NAEMT and EMS Magazine have established the National EMS Awards of Excellence program to recognize outstanding achievement in the profession. Beginning in 2010, the organizations (also including Advocates for EMS, the National Association of EMS Educators and the National EMS Managers Association) will recognize an annual EMT, Paramedic, Educator, Executive, Legislator and Paid and Volunteer Services of the Year. Winners will receive monetary awards and free registration and travel to EMS EXPO.
NTSB Offers 19 New Ideas for HEMS Safety
The National Transportation Safety Board followed its helicopter EMS hearings earlier this year with 19 new recommendations for HEMS safety.
Ten recommendations made to the FAA address issues like pilot training; collection and analysis of flight, weather and safety data; development of low-altitude airspace infrastructure; and use of aids like night vision imaging systems. Two made to CMS urge evaluation of the HEMS reimbursement rate structure and its relationship to patient transport safety. Two more, to FICEMS, are to address coordination and integration of helicopter emergency medical transport into local and regional emergency medical systems and selection of the most appropriate emergency transportation mode for trauma victims.
For more, see www.ntsb.gov.
What can we learn from Europe's premier mobile-rescue conference and trade show?
By Charlene Cobb, NREMT-P, Matthew G. Crossman and Kevin W. Peters, AAS, NREMT-P
The 2009 incarnation of RETTmobil drew 23,000 people and filled 13 exhibition halls at a former military base in Fulda, Germany. Among those attending was a delegation from the EMS Safety Foundation. In a special feature appearing on EMSResponder.com, three of its members discussed what they observed in the areas of ambulance safety and other innovations that could benefit North American providers. Those columns are excerpted here; for the complete versions, see www.EMSResponder.com/safety.
Less Lifting, More Efficient Interiors
In the 25 years I've worked in EMS, I have seen many good clinicians leave the industry due to on-the-job injuries. At RETTmobil, I found some truly amazing technology and innovations developed to prevent career-ending injuries.
It appears our counterparts across the Atlantic do very little lifting. Not only do they have stretchers that go up and down with the push of a button, but they go a step further and have platforms that act as lifts that move the stretcher up and into the ambulance. The products I surveyed were crash-tested to 10 Gs and stayed mounted in their tracks, which are integrated into the floor. Another great feature is that they can move the platform up or down in the ambulance to bring the patient to an ergonomically correct height to perform interventions--no more bending over to start an IV or kneeling on the floor to intubate.
They also use forward-facing attendant seats where our bench seats are located. These swivel toward the patient for performing care and turn forward when the ambulance is transporting. Therefore, clinicians can spend more time secured in their seat belts. Research has shown that a majority of injuries and deaths occur in the patient compartment due to unrestrained attendants. Our goal should be to keep medics secured as often as possible. The ambulances are smaller, but the closer you are to your equipment, the less likely you are to get up. It's all in the design.
Charlene Cobb, NREMT-P, is education and safety coordinator for Sunstar Paramedics in Pinellas Co., FL.
Conspicuous Colors, Cheaper Chassis
Many things I observed at RETTmobil were quite different than what we're accustomed to in Canada. The first interesting thing I noticed was vehicle conspicuity. In North America, our ambulances are typically white, with some type of striping package in various colors and sizes. At RETTmobil, the vehicles were primarily white or yellow, but with very bright and large orange or yellow striping. I had the opportunity to see some emergency vehicles working in Fulda, and they were very easily identified.
The overall vehicle design concept at RETTmobil was also somewhat different. Primarily, the type of vehicle used was the Mercedes Sprinter. When manufacturers were asked why they used the Sprinter, their typical answer was that they're generally much cheaper to operate compared to typical North American ambulances, and require less overall maintenance. They also explained that all units are dynamically tested for both exterior stability and interior construction constancy.
With all the state-of-the-art equipment and devices we use on ambulances, electrical draw on our batteries is always a concern. One product that was particularly interesting was the lithium battery made by Germany's LEAB Automotive. This particular type of battery lasts four times longer than most commercial batteries, is eight times smaller, and can handle five times the electrical load of a leading North American battery. What's more, the cost is very comparable.
Matthew G. Crossman is manager of vehicle safety programs for New Brunswick EMS.
Secure Stretchers, Safer Seating
One interesting aspect of RETTmobil was the vast differences in equipment available in Europe that is not available in the United States. One example is ambulance stretchers. Here, stretcher and mounting systems are designed to only withstand 2,200 foot-pounds of force prior to their locking system failing--roughly equivalent to 74 pounds moving at 30 mph. The empty stretcher weighs more than that! In Europe, seats, seat belts, stretchers, medical equipment and their mounting systems are able to endure loads 10 times the force of gravity over a crash impulse window of less than 100 milliseconds without failure. In the U.S., we tend to secure our stretchers with a single point of contact and a rack that only prevents the wheels from rolling too far forward. In Europe, there are three points of contact, each of which restrains motion on at least two axes. Of all the stretcher mounting systems I saw, only one vendor had the typical hook-and-rack system we are familiar with.
Another difference involved seating arrangements. Almost every ambulance utilized rear- or front-facing automotive-style seats in the patient care area, with shoulder harnesses and lap belts. Everything in the ambulance was reachable from a seated and secure position.
Finally, helmets for EMS providers are common in Europe but unheard of in the U.S. Why is this? Many of our firefighting brothers and sisters wear helmets every time they're on the apparatus.
Kevin W. Peters, AAS, NREMT-P, is safety and compliance officer for Carilion Clinic Patient Transportation in Roanoke, VA.
Baby Gap: Children In Disasters
New national commission helping meet the needs of big incidents' smallest victims
By Vinicia Mascarenhas
A number of catastrophic disasters in recent years have underscored just how important disaster preparedness is for federal, state and local emergency responders. While recent strides have been made in planning for and responding to disasters, there is still a need to improve the capability of emergency medical services to treat and transport pediatric patients and provide comprehensive prehospital care during both disasters and daily operations.
For the past year, the National Commission on Children and Disasters (NCCD)--an official part of the Department of Health and Human Services, created under the Bush administration--has been reviewing and analyzing gaps and shortfalls within emergency medical services with a specific focus on children and disasters. The 10-member commission is composed of experts from a variety of fields, and three members have devoted their careers to emergency medical services and emergency management. The commission recently released its Interim Report with the following recommendations to President Obama and Congress aimed at improving emergency medical services and pediatric transport:
- Establish a dedicated federal grant program for prehospital EMS.
- Provide additional funding to the Emergency Medical Services for Children (EMSC) program to ensure all states and territories meet targets and achieve progress in the EMSC performance measures for grantees, and to support development of a research portfolio.
- As an eligibility guideline for Centers for Medicare and Medicaid Services (CMS) reimbursement, require first response and emergency medical response vehicles to acquire and maintain pediatric equipment and supplies in accordance with the national guidelines.
Unlike other first-responder organizations, the majority of EMS providers in the nation do not receive federal grant support for disaster preparedness and response. The absence of adequate funding to support appropriate staffing, equipment and training on a daily basis limits the ability to expand surge capability and capacity during a disaster. To remedy this problem, the National Commission on Children and Disasters recommends a dedicated federal grant program for EMS that supports state-level coordination and disaster planning, field-level staffing, pediatric supply and equipment needs, and pediatric-specific training, as well as incorporating pediatric patients into all exercises.
Currently, the EMSC program is the only federal program that provides funding to states and territories to improve the EMS infrastructure for pediatric care. Unfortunately this funding has been inadequate to support the improvement of pediatric training and equipment acquisition by the EMS community. A dedicated federal grant program specific to disaster preparedness for EMS could help ensure that EMS systems are meeting the pediatric-specific performance measures established by the EMSC program.
Additionally, the commission is recommending additional funding to the EMSC program as a means to boost pediatric preparedness in EMS systems throughout the nation. The added funding would assist the EMSC program in supporting the establishment and maintenance of a full-time EMSC administrator in every state and territory to ensure the ongoing needs of children are met in state disaster planning and response.
Over the next year, the commission will be closely reviewing issues concerning the lack of surge capacity for critical care and transport of children, and seeking to provide additional recommendations to improve areas that have fallen behind.
Lastly, the commission is recommending that eligibility guidelines for CMS reimbursement should require first response and emergency medical response vehicles to acquire and maintain pediatric equipment and supplies in accordance with the national guidelines for pediatric equipment for ambulances put forth by EMSC.
Members of the commission are no strangers to the intricacies of EMS and emergency management. Chief Gregg Lord is associate director of the National EMS Preparedness Initiative and senior policy analyst at the Office of Homeland Security at the George Washington University Medical Center. His career in public safety spans more than 25 years. Chief Larry Tan is chief of emergency medical services at the New Castle County (DE) Department of Public Safety. Finally, Bruce Lockwood, CEM, is the public health emergency response coordinator for Connecticut's Bristol-Burlington Health District. Lockwood has 28 years of experience in emergency management, EMS and public safety.
"Protecting our children is a shared responsibility," says Lord. "It is important we work together across the EMS discipline to encourage emergency responders to be properly equipped and trained to manage children not only every day, but in the event of a disaster."
For more on the commission and to see its Interim Report, visit www.childrenanddisasters.acf.hhs.gov.
Vinicia Mascarenhas is the communications director for the National Commission on Children and Disasters. Reach her at vinicia.mascarenhas@acf.hhs.gov.
No Better Teacher Than Experience
Advanced gaming and simulation training can prepare responders like never before
By John Erich, Associate Editor
You'd like your personnel to be ready for anything--a train full of toxic yellow phosphorus, for instance, derailing near an elementary school on Take Your Grandmother to Class Day.
But obviously, drilling with live yellow phosphorus and several hundred kids and their grannies would be prohibitively impractical, expensive and dangerous. So how do you effectively school your personnel to handle the specifics of such unlikely situations, with the realism and variables they'll likely encounter on a scene?
Increasingly, technology provides the answer in the way of simulation training.
"With simulations, you're really exercising group dynamics, interactions and decision-making," says emergency management expert Anthony S. Mangeri, MPA, CPM, a professor in the Emergency and Disaster Management Program at American Military University. "From a capacity perspective, simulations allow you to exercise in the environment in which you're actually going to operate. They let you really focus on the stressors, in the environment where the stressors are going to be."
Evidence suggests this greatly enhances learning. A 2008 study by the Ewing Marion Kauffman Foundation concluded that while a great lecture can improve learning outcomes by 17%, using creative delivery mechanisms like simulations and gaming can boost them by a whopping 108%.
That probably won't surprise a lot of people in EMS; use of simulation training has increased across the emergency services in recent years, especially with the threat of large-scale terrorism. But not all sim training is created equal. To maximize the benefit of such efforts, architects need to incorporate some key components.
Clear objectives--Without a clear scope and defined objectives, size and mission creep can dilute an exercise's usefulness. Projects can be large or small, but know with some clarity what you want to accomplish, and let that guide whom you involve.
"You need to understand the event and its impact on your community," says Mangeri. "You can't exercise everything all at once. Target specific objectives, and that tells you who should be involved."
For something like a simple building fire, in other words, that might be limited to fire, EMS and perhaps law enforcement for scene and traffic control. But for something like our opening rail accident, you'll need to involve railway personnel, the media, potential mutual aid, public health and various regional and state-level entities.
Environmental factors--What are the potential complicating factors for the scenario you're creating? Will a breeze direct that chemical plume toward the fire station next door? Might some visiting grannies suffer incident-related cardiac events?
"In a full-scale exercise, you want to bring in simulants that show cause and effect--things that affect decision-making," says Mangeri. "During TOPFF 3, for instance, they ran simulated news channels and gave news reports. They had to process information coming in, figure out what was real and what was assumption, and make decisions about what went out. That's what's going to happen in the real world--the media will push that EOC pressure up quite a bit."
Another good example was a June exercise in New Jersey that posed a bomb on a bus exploding near a tanker full of hydrochloric acid. The nature of the drill came as a surprise to participants, forcing them to think on their feet, and various sensory inputs kept realism high. "The sounds and sensations and even the smells really caused the first responders to jump to a different standard," says Mangeri. "With all the auditory and sensory stimulation coming at them, they had to work through all the normal reactions of the human condition, and move toward effective critical thought and decision-making."
Data--With the advent of NIMS has come standardization: Jurisdictions should be looking at the same things and calling them the same things. That means measuring the same things the same way. Data is the means to that end, allowing analysis of performance and comparisons across jurisdictions and within jurisdictions over time.
Such analysis is a vital component of improving response capacities. "It's very important to review and debrief from the exercise, and develop a plan for effective action from it," says Mangeri. "The post-incident analysis and after-action review are your plan of action for change."
The data aspect also applies to the training of individual providers on the new breed of advanced patient simulators. Interventions are recorded (down to things like the depth and rate of CPR compressions) and produce and document dynamic changes that can prepare providers like never before.
As young providers from the video-game era come of age and populate the emergency services, their comfort and familiarity with advanced-tech games and simulations will only increase.
"Can you imagine a paramedic who has 100 or 1,000 intubations before he hits the street?" Mangeri asks. "When he's on the street, he'll have a much better of what they look like. When people have seen or experienced something before, even virtually, they're that much closer to understanding the influences coming at them and making effective decisions.
"Like we say, there's no better teacher than experience. We're just building a safe environment for the body to sense that experience."
Permanent Relief: Still Searching
Healthcare reform legislation will likely extend the temporary 2% urban/3% rural Medicare reimbursement increase for ambulance services set to expire this year, but offers no permanent relief or prospect of payments for dispositions like treat-and-release or transport to alternative destinations. But the issue remains on the table.
Through a formal recommendation from NEMSAC, NHTSA's Office of EMS will bring the problem to the attention of the Federal Interagency Committee on EMS for potential action. "The issue's not dead," NEMSAC Finance Committee Chair Kurt Krumperman told Town Hall attendees.
Other legislation, the Medicare Ambulance Access Preservation Act, could provide permanent increases of 6% for urban/rural transports and 17% for transports originating in super-rural areas, resolving identified discrepancies between costs and payments.
CONTACT US: To submit story ideas, questions and concerns, e-mail Associate Editor John Erich at john.erich@cygnusb2b.com.
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