Guest Editorial: 9 Pressing Issues in EMS

In his weekly staff newsletter, Medical Officer Ed Racht, MD, shares what he thinks are the 9 most pressing issues facing EMS systems today. Dr. Racht is a keynote speaker at EMS World Expo, October 3–7, in New Orleans, LA. During his keynote address, he will take attendees on an inspirational journey into the EMS of tomorrow. Register today at EMSWorldExpo.com.

A physician friend of mine asked me a few weeks ago what kept EMS docs like me up at night. I’ve had a little time to think about just that. I also had the privilege of co-presenting with Bruce Moeller and Bill Metcalf at the Pinnacle EMS conference last week. Both are highly respected career fire chiefs now doing consulting work on EMS and fire systems.

We had the “what’s happening in the world of EMS discussion” at breakfast one morning. We compared notes on what we each felt were the biggies.

This year marks the 50th anniversary of the publication of Accidental Death and Disability: The Neglected Disease of Modern Society, the landmark white paper often cited as the birth of modern EMS. Who would have ever imagined we would be where we are today? The journey has been phenomenal. We’re now faced with challenges that lie ahead of us as we think about navigating the next 50.

So I thought tonight I would lay out what (IMHO) the biggest challenges are that face us as an industry/profession. I base the list on things I hear from many of you and things I personally spend a fair amount of brain time on. So here’s what I think the top 9 (yes 9, not 10) most pressing issues are in EMS today that demand our full attention.

1. Every town is now a potential war zone.

Tactical Emergency Combat Care principles and practice must now become a skill set of every EMS provider. We can no longer believe that the events are isolated to a particular community or situation. They can (and will) happen when we are not expecting them in places and circumstances that are difficult, if not impossible to predict.

So just like universal precautions—when we used to believe we could determine who “might” be infectious instead of assuming everyone was—it’s time EMS develops a unified approach and philosophy for managing active shooter/hostile events (ASHE). We can no longer accurately predict when and where so we adopt the sound approaches of always being alert, vigilant and prepared (just like we learned to do with infectious diseases).

EMS has to evolve. We plan on doing exactly that.

2. Every lay person must learn hemorrhage control.

One of the most powerful lessons we’ve learned from our military colleagues is the clinical value of hemorrhage control. Just like rapid provision of CPR and defibrillation in cardiac arrest, immediately stopping rapid blood loss is literally life-saving.

With more and more community efforts to get appropriate messaging and equipment into the public arena, it’s time for EMS to formally adopt hemorrhage control as a public education mission.

It can make a major difference in survival and is an easy set of interventions that can be learned by just about anything.

3. EMS is the front line on emerging infectious diseases.

We’ve known this is the case for some time. Truthfully, the Ebola outbreak two years ago was a powerful event that forced changes in the way we prepare for and respond to infectious agents as we rapidly learn about the diseases, infectivity, protection, etc. As I type this tonight, this is the breaking news in my community—I live 4 miles from Williamson County. While events like these can be terrifying for our neighbors, we know what to do and we know what’s real and what’s not. Zika is here and EMS will be on the front lines of patient access, questions and care. We know how to do this (see Ebola). We will do the same with this.

4. Sepsis is our new time-sensitive condition.

I won’t climb on the soapbox tonight, but I think we all know how critically important early identification and appropriate treatment is for this population of patients.

We made a huge dent in trauma, STEMI and stroke morbidity and mortality by focusing our efforts on rapid identification and partnership with appropriate receiving facilities.

For us to realize the true EMS potential to impact, we have to evaluate dispatch criteria, assessment criteria, role of blood cultures, potential treatment (several EMS systems now administer antibiotics) and follow up. Much is still based in local accepted practices.

One thing is crystal clear. EMS can make a positive difference in earlier identification. Earlier identification means the potential for earlier treatment.

5. EMS provider suicide and despair is an inadequately recognized and addressed occupational hazard.

This one is really hard and thanks to the efforts of organizations like the Code Green Campaign, we’re starting to raise awareness of this dirty little secret.

The EMS profession attracts those that pride themselves with maintaining calm in the face of the storm—even when the storm is in ourselves. As we better understand the stressors we face, we’re better prepared to proactively address them.

This one deserves our aggressive attention. Recognition of despair is tough. Choosing to try to help and figure out exactly what that help can be is extraordinarily complex. I think we’ve made some progress, but we have a really long way to go.

6. Identification, management and triage of stroke must be managed in an evidence-based way—be cautious of political/financial pressures.

The science of treating strokes has evolved at lightning speed over the past few years. Once a futile disorder that was suspected in the field and we then proceeded to provide “supportive comfort care” for, stroke is now appropriately recognized as a time-critical medical emergency with every effort focused on restoring blood flow to affected brain when appropriate.

What’s new in managing these patients is the evolving difference in management of “large vessel occlusions” or LVOs at centers specifically credentialed and equipped to manage these patients. While there is spirited debate about appropriate screening criteria in the field, aggressive efforts are underway in many communities to route these patients to specific centers of care. While certainly appropriate, EMS must make sure and be an active player in those discussions.

Add a stroke CT ambulance to the mix and it’s critical that decisions regarding management of these patients are based in sound medicine and practice with an effort to recognize the huge political and financial challenges communities and health systems face.

7. It’s time for EMS to be transparent about outcomes.

There’s a ton of discussion about healthcare reimbursement strategies (shocker, I know) and EMS is not immune.

One thing most clinicians and politicians seem to agree about is the value of being transparent about outcomes. Consumers (patients) have begun to embrace the idea and clearly it’s here to stay.

The challenge for EMS as a profession is to agree on what’s important and how it’s measured and reported. Mark my words on this one. The day is coming when EMS will be evaluated/reimbursed based on how we perform. And if I’m a patient, that’s exactly what I want.

8. Evolving drug use/abuse is our next major public health crisis.

The opiate crisis has become a top public health problem in the U.S. There are a host of efforts nationally to address the issue including the recent decision by CMS (Center for Medicare & Medicaid Services) to eliminate the patient experience question from their HCAHPS survey that specifically asks if the healthcare provider recognized and addressed your pain. Why was it removed? There is a concern that prescribers aggressively provided narcotic relief to make sure that particular experience question was addressed.

9. ALS & BLS designations no longer have value or meaning.

This is my cliffhanger. I believe this one is so important that it deserves significant space and discussion. Stay tuned.