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December 28, 2011

Father Time on life support in 2011

What a year 2011 turned out to be. Many disaster drills were preempted by actual disasters, quite often achieving epic magnitudes: earthquakes, a tsunami, floods, a nuclear meltdown — all requiring herculean mitigation efforts. Hopefully in 2012 we can get back to worrying about more mundane bedbugs and WikiLeaks.

Events of the year gave us pause to think and remember. The loss of Steve Jobs will in all likelihood change the face of technology. Ten years after the horrific events of September 11th, some closure came from the death of Osama Bin Laden. Most incredibly, the ethical behaviors of two major colleges continue to make headlines. Pay attention in 2012: how Penn State and Syracuse handle their coaches sexual abuse scandals will provide huge public relations lessons for EMS.

Major study
I predicted 2011 would see the publication of a major accuracy study of the RAD-57. This pulse CO-oximeter is capable of measuring not just oxygen but carbon monoxide, a common cause of poisoning, in the blood. In July, the largest study ever done was published in Annals of Emergency Medicine by Roth and colleagues in Vienna, Austria who conclusively found the device reliable.

I also predicted that masses of EMS services would keep their heads in the sand until they woke up disconnected from radio communications January 1st, 2013. If you're not familiar with the term, "narrow-banding," you need to hustle in 2012. The International Association of Fire Chiefs has a spectacular reference page if you find yourself needing a clue.

The EMS Educational standards rolled out in 2011, leaving virtually every state and EMS educational program befuddled with implementation. The National Registry added to the confusion by announcing that exams and recertifications would phase into the new National Scope of Practice, catching nearly every state without a mechanism to deliver the new material. Guidelines 2010 finally finished their roll out with the release of the PALS textbook and teaching resources at the end of 2011. As happens with every revision, change comes slowly.

Drug shortages
Speaking of slowly, 2011 saw record breaking drug shortages across the health care spectrum.  EMS went without dextrose, epinephrine, fentanyl and a host of other medications as services scrambled to replenish stocks. The problems have not ended and, despite efforts by the feds, seem to be getting worse. Keep a watchful eye on both the FDA medication shortage site, and the ASHP Drug Shortages Resource Center in 2012.

You may have been too distracted by Justin Bieber exceeding Kim Kardashian's mentions on Facebook and Twitter to notice some big EMS sales during 2011. In February, EMSC, the parent company of AMR was purchased by Clayton, Dubilier & Rice (CD&R), a New York equity firm.

In June, Rural Metro was acquired by the international equity firm Warburg Pincus.  Medtronic sold their Physio Control division to Bain Capital, another international investment company in November.

What's all this mean? While some worry about hidden plans for AMR and Rural Metro to take over the EMS world, the meaning is really quite simple: EMS looks to be a profitable investment! "What, what, what?" you say. It really is. Currently, private EMS serves 34% of the $14 billion dollar annual US ambulance market; AMR has 21% and Rural Metro 10% of that private EMS pie.

Aging population
With Health Care Reform and an increasingly aging population, investors see the writing on the wall. Bain Capital, by the way, purchased Physio Control once previously (and made a killing selling it years later). They obviously know that Physio can kick butt in the industry. So put your conspiracy theories to bed and watch how these investment companies steer their EMS vehicles into the future.

Speaking of future, you'd better get out your handkerchief: an old EMS tradition is fading fast.  That's right, Father Time is officially on life support and 2011 made him a DNR. We've known for several years that the so called, "Golden Hour" has no real basis in science. In fact, if you dig back to its roots, someone made it up.

Don't get me wrong – there are patients where time is of the essence. The first rule of hemorrhage control is to find the bleeding. If you have a shocky trauma patient and you can't find the bleeding, it's probably inside. The only way to get to it is with what surgeons refer to as "cold, hard steel." The patient needs a scalpel and without delay.  Those numbers are few and far between. The rest can wait.

In 2011, the pile of evidence questioning response times grew bigger. So much so that the standard arrival in 8:59 at least 90% of the time can't continue to be justified. Does that mean the end of emergency response? Not at all. Response times are an integral component of customer service. In some cases, such as AMI, they do affect outcomes. The future will match response times to patient perception, that is, did we arrive in a timely fashion according to the caller? It requires community assessment and continually soliciting feedback from our customers.

Two important lessons
As we mourn the impending death of Father Time, we must take away two very important lessons: speed does not equal patient outcomes, and everything we do in EMS should be based on the outcomes it produces for our patients. That requires research and continually measuring what we do and how our patients perceive us.

Lastly, Ryan White finally arrived back on scene in 2011, as a late Christmas present.  You wanna talk about the slow pace of government; this is a prime example of foot dragging and passing the buck.

In October 2009 when Ryan White was reinstated by Congress, the Secretary of Health and Human Services (HHS) was directed to revise the reportable disease list needed to put the law back into action. In July 2011, HHS passed the buck to the CDC who finally got the job done. The revised list and full Ryan White protections for emergency responders took effect in December 2011.

Happy holidays!

About the Author

Mike McEvoy, PhD, NRP, RN, CCRN is the EMS Coordinator for Saratoga County, New York and a paramedic supervisor with Clifton Park & Halfmoon Ambulance. He is a nurse clinician in cardiothoracic surgical intensive care at Albany Medical Center where he also Chairs the Resuscitation Committee and teaches critical care medicine. He is a lead author of the “Critical Care Transport” textbook and Informed® Emergency & Critical Care guides published by Jones & Bartlett Learning. Mike is a frequent contributor to EMS1.com and a popular speaker at EMS, Fire, and medical conferences worldwide. Contact Mike at mike.mcevoy@ems1.com.
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