Of Course We Have to Start With Hurricanes!
As I sit here preparing this column, we are in the end stages of wrapping up one hurricane (Florence) and are preparing for another (Michael) which hopefully will not like our fine state as much as his sister and not linger around like she did! We are sending resources to Florida at this very moment and we wish them Godspeed and safe passage.
This past month was like a whirlwind across the state as we waited and waited for Florence to pick a path and arrive, and then she just wouldn’t leave. Our neighbors to the north received the brunt of the initial impact, but we certainly did not go unscathed as we once again waited for the flood waters to rise and rise and rise across the Pee Dee at comparable or even higher levels than Matthew just a couple years ago.
One of the best quotes passed on early to me that I have shared many times is that this storm was like being “chased by a turtle”! All told it was our longest operation at the state level for response in the DHEC Command Center at just over 21 days of activation and staffing. The time frame of this storm and aftermath made it very taxing on resources and especially personnel. We called, and you responded; over and over again with everything you had and we never had a request go unfilled.
We could sense the wearing down and physically see it in the crews faces well in to the affair and we did what we have rarely ever had to do and we engaged the Federal FEMA Contract for resources. We supplemented several 911 agencies with these trucks, used them in a last minute flood related evacuation almost NINE days after the storm made landfall, and used them to assist us in moving more than 300 patients to Special Medical Needs Shelters (SMNS) that were scattered across the regions. To put that in perspective, during Michael we arranged about 40 SMNS transports! Team SC EMS never gave up and left it all on the field.
The evacuation phase initially floored us all. The entire coast, all zones. Wow. We often drill and plan for these scenarios, but almost always just in one or two of the three coastal zones, never all three. Our resources were definitely strained, we activated two Ambuses from our friends in Tennessee to assist, and with a last minute coastal pardon from the Governor for the Southern region, you were able to move more than 6000 patients out of harms way from more than 115 facilities including four hospitals. Some went as far away as Macon, Georgia to be relocated due to the massive numbers of patients needing to be evacuated. No reports of injuries to patients or providers was reported to DHEC, and although one Ambus did unfortunately have to respond to one of their patients experiencing a cardiac arrest, and that patient was successfully resuscitated and transported to a local ER on the way up Interstate 26! Amazing stories.
I’ll close this topic by repeating what I’ve said innumerable times since this event started. We work with the most professional and dedicated EMS agencies any state Bureau of EMS could ask for. We called, you responded. I need to plug my staff here too. BEMS staff left their homes and families for days, up to a week and more to live in hotels and assist the counties in the worst shape during this event. Not one whimper, moan, or “Why?” was heard. Everyone stepped up and got it done. The best state office personnel you could ask for are without a doubt living and working for you right here in South Carolina.
We have heard from many of you on what went right, what needs improvement, and what we should plan on not doing next time and we encourage those comments. Please continue to keep those coming to us and certainly if your municipality, county, or region has a debriefing we’d love to send representation to it, just let us know when and where!
Topics and Trends in EMS
It’s amazing how much things change and much they still tend to stay the same when we think about trends in EMS. Resuscitation guidelines, long spine immobilization, advanced airway placement (or not?), and a continuing trend of not having enough providers, especially volunteers, all top the list when we get in to discussions about hot EMS topics. The topic I’ll hit on first though; the same argument we have ranted on for 30 years still haunts us today as much as it ever has, except in a few pockets of sunshine: The general public still doesn’t understand what EMS is and what services we provide.
This leads to funding issues, recruiting and retention issues, and an ongoing identity crisis of are we — transporters or are we medical providers? Who do we have to blame for this? Well, as with most of our issues we only have to travel as far as the bathroom, look up in the mirror and lay the issue square on that persons shoulders. The average citizen knows if they call 911 an ambulance comes. They go to the hospital for some real or perceived emergency and they get a bill. Is that what we do or is that what they perceive we do?
They don’t know the thousands of hours of training and con-ed that go into becoming an EMT or paramedic. They don’t know the maintenance we perform or the cleaning we do. They never ask the questions because — we never go out and offer to educate. We run calls, haul patients, drop them off and repeat. This isn’t enough to brand ourselves, educate our public, or win over hearts and minds.
Let’s try to make a concerted effort over the next three years to overcome this shadow and market ourselves for what we KNOW we are: Outstanding providers of pre-hospital medicine, NOT ambulance drivers! DHEC stands with you to assist in whatever way we can to help you (us) to rebrand the image of EMS in South Carolina.
Another trend we see is the declining numbers of people entering and staying in our field. Last year we brought more than three times as many providers into South Carolina and gave them licenses via reciprocity than we taught, graduated, and tested with our own home grown programs! See the above comments on marketing ourselves to the public. Get in the schools, start explorer programs, reach into the hip pocket and sponsor some EMTs from your disadvantaged communities. Trust me, someone whose family has been in Chesterfield, Jasper, or Saluda County for 100 years who is recruited into your agency is going to better serve your community and for a lengthier time than someone who is not.
Please, those of you from Ohio that are about to revolt, don’t take that the wrong way. We have amazing people coming into South Carolina to practice, but homegrown emergency responders historically will remain local and in the field longer than someone from outside it. Recruit local, recruit early, recruit often. If you’re content with huge turnover rates and paying thousands of dollars to onboard someone to have them hop a county line for a buck an hour in six months, then don’t.
EMS Practices and Trends
Other items coming up around the kitchen table include the huge reduction we’ve seen in long spine board immobilizations (66 percent in two years!) and the number of ET intubations vice BIAD placements. Long spine boards were a no brainer, right? We saw the research, we saw we were hurting people more than helping, we applied the research and boom, less secondary wounds to patients, less time on scene, and we are still immobilizing those that truly need it, in most cases. If you’re still blindly back boarding every patient that has a dented fender, you’re doing yourself, your patient, and the EMS profession a disservice. Look over your protocols and modify them to the latest standard of care. Let’s stop hurting patients with spine boards that don’t need them.
Intubations: we could do three columns on this alone, but suffice it to say, if you’re forward looking you’re seeing this skill diminish with direct laryngoscopy and in some areas, a BIAD is the first choice with an ET tube being the back up in many arrest situations. This topic will continue to be front and center on our plates as first time and overall success rates continue to decrease and the availability and quality of BIADs increases. This skill may have a limited lifetime in many EMS agencies unless we improve our rates of success, equipment, and training.
Concurrent with this is also IV success rates. With the advent of IO technology and the reduction in costs of this technology, we are seeing declining IV attempts and success rates. Again, many services have a “one and done” philosophy to IV attempts, and some even go straight to IO as a means of resuscitative medicine from that start of the code. Technology is making our basic skills slowly deteriorate and we need to stay on top of them or our success rates will continue to drop off.
Lastly, our mission is changing. Yes, people will still call 911, and we will still need to transport them. With the coming wave of baby boomers we will probably see a huge spike before a decline. But what about someone who just sewed their sparkle patch on today? Where will they be in 10 years? If you guessed community medicine, you guessed correctly. In order to overcome the wave that is about to hit us in the next few years, we need to continue to embrace Community Paramedicine programs, take the time and funding to implement them, give them the resources they need to be successful.
If you want to have better patient interactions, less transports, and cooperation and funding from your local hospitals you MUST embrace the CP model as one that works, no matter the size or scope of your EMS agency; transport OR First Responder. Fact: Agencies with successful CP programs have fewer transports of these patients, hospitals have lower costs, and the overall health of the community is improved.
The great part about this county and especially South Carolina is you can say “Pfffft ... we are an EMS agency, we transport to the hospital, we go home, repeat as needed” and that I’m full of “bull-oney,” and you can probably still function at a level where minimum service is available to your customers. But, if you want to truly be medical professionals, an integrated part of your community, and a forerunner in pre-hospital emergency care, please, just think about one or two of the things mentioned and implementing them. I promise, you’ll be glad you did or I’ll buy you an ice cream next time I see you. Until then, take care of your gear, take care of your partners, and above all, take care of yourselves. Be Safe. Be Nice. Be Professional.
Rob Wronski is the South Carolina Department of Health and Environmental Control (SC DHEC) Bureau Chief of EMS. He has served in many roles since becoming a firefighter paramedic in 1991, culminating with his selection as Chief of EMS for the state where he has served for nearly three years. He has held several executive positions including Assistant Chief of the St. Andrews Fire Department in Charleston, Medical Officer of the Mt. Pleasant Fire Department, and a Shift Commander in the Beach Park (IL) Fire Department. His experience includes working in fire-based EMS, including ALS and BLS first response as well as fire based and county based ALS transport.