A Look to the Future

This is the end of the line for Attack One: After about 150 incidents, the crew is retiring. But at their retirement party, its members discuss the changing directions of EMS. They can foresee a time when responses are targeted specifically to the needs of the patient, and where personnel are deployed ahead of emergencies. They envision a time where patients have access to primary care in a much more effective way, diagnostics are done on the scene and treatments are delivered by automated means.

So they depart with the following look ahead to the Attack One of the future.

It is an evil winter day. The forecasters predicted snow, but instead, at 0500 hours it began to drizzle and freeze. By 0600 the roads and sidewalks are glazed with ice. A communitywide “ice alert” is broadcast, and activities through the city are cancelled. Notification is done by personal communication assistants. While everyone else plans a day off, the members of the emergency response service are placed on immediate notification status, and senior crew member #23, an advanced-level provider, places herself in service.

Emergencies are now managed in a decentralized manner, with individual crew members responding to scenes and meeting with drones that provide necessary special equipment. Today that cannot happen—drones are grounded by the icy conditions. A special group of transport specialists is deployed to equipment sites and is responsible to deliver diagnostic, treatment and transport equipment to emergency scenes by ground vehicle.

Critical personnel are still required to report to worksites, so the morning commute in the city is less congested than usual, but there is still traffic on the roads and sidewalks. People who don’t listen to their communications devices early in the morning still venture out in the dark to walk the dog or take out the trash. And they still fall, with equally poor outcomes to bones, joints and skulls.

So things get busy quickly, and the call volume is largely composed of transport crashes and individuals falling on ice. The traffic crashes have injuries that are relatively minor. At least the cars are smart enough not to let the drivers move quickly, as they automatically detect icing conditions and govern the speed down below 20–25 kilometers an hour (it is now a metric world).

But broken bones from ice falls are still managed best at a hospital, especially when most of the victims are older. The emergency crews must still respond, keep victims from becoming hypothermic on icy walkways, immobilize fractures, and provide pain control and transport to the hospital. Bones are x-rayed en route, and the images projected to bone injury staff at the trauma centers. The operating rooms will be busy today.

Senior crew member #23 gets her first text notification at 0603 hours and responds to a report of an elderly person who has fallen on the ice outside a home. She is guided on the smart streets to the scene. The trip is slow because she is in a self-driving pod, which operates cautiously on ice. Traffic drones have also been grounded, so surface lights guide vehicles through intersections.

Arriving first on the scene, the crew member finds a 110-year-old man who was taking his dog for a walk when he slid. He has an ugly left upper arm fracture and injuries to his face and left ear. The crew member scans his identification, and his medical record pops up. He is, of course, on blood thinners and has had low bone density for years. His pain will be best managed by fentanyl, according to his genetic profile. He will need to have his wounds covered by dressings that contain a blood-clotting agent specifically designed for his blood thinner. His mental status is evaluated by a Glasgow Coma Scale head visor, which finds him at his baseline level of function.

“Great” the crew member tells the patient, “no sign of any brain injury. Please hold still while I scan your cervical spine and left arm. Those results will go to the trauma center where we will need to transport you.”

She covers him with a warming garb and his head with the trauma head cover. A neighbor will care for the man’s dog, which is very upset about the injury to its human.

“Are you going to get his vital signs?” the neighbor asks.

“The probes on his finger and head have already calculated his perfusion index, and he is fine,” the provider replies. “His hemoglobin level is OK, and his left arm still has good circulation to the fingers. I won’t need to undress him any further in these cold conditions.”

The transport vehicle approaches the scene, with the basic crew member in attendance. It is pulling onto the street when another vehicle, with a person driving it, spins out of control and slides at the transport vehicle. Fortunately the transport vehicle has external air bags, which deploy toward the sliding vehicle. Neither vehicle is damaged when they collide, and the air bag is removed from the vehicle by the attendant. Within 30 seconds an incident report is generated for both vehicles and their insurance companies, and the transport vehicle automatically scheduled for a replacement installation at the expense of the offending driver.

The transport vehicle pulls up to the scene, the stretcher deploys itself to the side of the patient, and the crew members assist the patient onto the warm mattress. As the man is moved into the vehicle, the senior crew member prepares the fentanyl for pain control. The transport vehicle has the latest in drug-mixing equipment, so his dose is mixed with the appropriate nausea-control medication, and a patch with the medicines is placed on his upper left arm. The injured arm is exposed, and a vacuum splint is applied that immobilizes the fracture.

Another patch is created in the drug mixer that contains the clotting agent needed for this patient, and it’s placed inside the dressings used on the man’s face. He is immobilized on the stretcher, and both crew members will accompany him to the trauma center. The senior crew member’s vehicle is hooked to the transport vehicle to meet her at the hospital.

All record-keeping is digital, so the senior crew member can finish her physical assessment during transport in the warm passenger compartment and notify the trauma center in a two-way visual communication with the patient. With his pain under control, the patient converses pleasantly with the crew member as they continue a slow journey to the trauma center.

The turnover at the center is rapid, and the patient thanks the crew. They make arrangements for his safe transport back home. The transport vehicle is sent to the air bag installation shop, and the senior crew member climbs into her vehicle as her next incident is dispatched.

This one is a multiple-victim incident in an apartment building where the ice has caused an exhaust problem. People are complaining of difficulty breathing, so several senior members are needed to do evaluations. There is a complete response of emergency service members on scene, and crew member #23 is placed in charge of the Medical Sector (the Incident Management System is still the very effective system it was in 2015).

On arrival at the scene, the crew member’s digital assistant advises her that the entry crew has found only high levels of propane on the lower floors of the building but wants all apartment residents checked for exposure to carbon monoxide. A rapid triage is done of those residents, and all have low levels of CO in their blood and no other abnormalities in lung function. The Glasgow device finds no altered level of consciousness. The crew member reports her results to command and advises all residents they can return to their homes. All have medical records that are updated with details of the incident and their medical clearance. She advises each person to call the service if any other symptoms develop.

She clears the scene in time to get dispatched to a house fire nearby. A basement fire started when the ice snapped a power connection. The resident of the home tried to fight the fire and sustained burns to his hands. Fire drones extinguished the fire once they arrived by ground vehicles. The crew member assesses the patient and finds no evidence of significant smoke inhalation, but partial-thickness burns to the hands. The man does not want transport, instead preferring to stay and clean up his home.

So she prints off a slow-release pain-control patch, dresses his burns and schedules him for a burn appointment later in the day, when he completes his cleanup and the weather clears. His medical record is updated, and she takes photographs so the burn team can assess any changes later in the day.

The morning rush ultimately clears, and the icing conditions improve as the day warms. The rest of crew member #23’s shift is spent performing follow-up visits on home-care patients. There are a few acute unscheduled care calls for persons with illnesses. These patients all receive evaluation, appropriate diagnostic testing and a videoconference with a primary care physician. Each is given printed instructions for care and an appointment in the next few days.

The shift day ends with a visit to the supply center to replenish the equipment used during the day and download the hard drives on the clinical record device and the vehicle’s information system.

Senior crew member #23 will be on call for the next 12 hours in case the weather turns difficult again. Her next shift will be in the communication center, where her skills will be used to triage unscheduled phone calls and analyze data from this week’s calls to design timely prevention programs. The shift after that is in the education center, to train the next generation of care providers.

One element is clear about her job: It will never get boring or repetitive.

Case Discussion

The Attack One crew will become the unscheduled care provider of the future, with personnel trained in the management of all hazards and equipped with tools to provide acute diagnostic and treatment services, and then refer patients to community health resources that match their needs. A variety of tools being developed now will contribute to the development of this future care model, but it will require the ingenuity of the current generation of providers to unlock the potential of those tools to deliver care in an organized system.

James J. Augustine, MD, FACEP, is an emergency physician and a clinical professor in the Department of Emergency Medicine at Wright State University in Dayton, OH. He serves as medical director for fire-rescue agencies in Atlanta, Naples, FL, and in Dayton. His roles include the Hartsfield-Jackson Atlanta International Airport Fire Rescue Division. He served as assistant fire chief and medical director for the District of Columbia Fire and EMS Department and was the first chair of the Ohio EMS Board.