By Dr. James Winslow, Medical Director, NC Office of EMS
We’ve had a long pandemic. At this point, it’s been going on for roughly two years. We’ve all been through a lot, but we’ve also done a lot of good. In this column, I’m going to review some of the topics that I went over from the medical directors update in Wilmington in March. There are several topics I am going to touch on in this column.
• North Carolina’s experience with using prehospital ketamine since it was approved by the North Carolina medical board.
• How we are doing with drug-assisted intubation
• The ongoing opioid epidemic
• The COVID-19 global pandemic
• Possible ways to address current staffing issues
• What lies ahead?
Ketamine — The North Carolina Medical Board added ketamine to the paramedic scope of practice in 2019. A key requirement of using ketamine is that all systems must report their data to the North Carolina Office of Emergency Medical Services (EMS). If you are currently using ketamine for anything other than drug assistant intubation and you’re not reporting your data to the state then please stop immediately and get in contact with your local regional specialist. They can assist you with the data reporting requirements. North Carolina has done well with its use of ketamine. In all of 2021, EMS used ketamine for sedation 236 times. From the data submitted to the state, there were only four unplanned intubations after the use of ketamine. This means that unplanned intubation only took place in 1.7% of the cases where ketamine was used for sedation. This is a very good safety profile. Please remember that only prehospital medical professionals should be making the decision about whether to use ketamine for sedation.
Drug-Assisted Intubation – Drug-assisted intubation is an important skill. The evidence for whether it improves outcomes is quite mixed. Any system which performs drug-assisted intubation must report its data to the state. Any system which is not reporting its data to the state should immediately inform its local regional specialist and stop doing this procedure. The regional specialist can help you with the data reporting requirements, but it is essential that you report data. Drug-assisted intubation is a high-risk procedure. It should only be done by very experienced paramedics who function under a very robust performance improvement system, receive the highest quality medical direction, and receive constant ongoing training. If the system cannot meet these requirements, it should not be performing drug-assisted intubation.
Opioid Crisis – During the pandemic the opioid crisis has gotten much worse. In 2018 the rate of unintentional overdose among North Carolina residents was approximately 25 per 100,000 residents. As of today, the rate is approximately 30 per 100,000 residents. That is about a 20% increase in deaths from opioid overdose in North Carolina. EMS agencies are in a position where they can help more with this epidemic than any other organization. Prehospital professionals are at a person’s side as they are being reversed from an overdose. Prehospital professionals also visit people where they live. They do not wait for them to come to a hospital. Medics can implement harm reduction strategies such as needle exchange which have been proven to increase the number of people who get into treatment. North Carolina has also been a leader in helping patients gain access to medication-assisted therapy with Suboxone. Stanly County and Onslow County specifically are national leaders in this. Other counties such as Orange County have implemented needle exchange programs. Guilford county has also done a huge amount of work with local public health to address the opioid epidemic in their communities. Prehospital professionals have a huge ability to help their communities recover from this epidemic and save lives. I strongly suggest all EMS agencies try to implement harm reduction strategies for their patients and look at implementing medication-assisted therapy programs. There will very likely be a grant coming soon from the North County Office of EMS which can potentially help counties implement medication-assisted therapy drug programs for their patients. Please contact your Office of Emergency Medical Services (OEMS) regional specialist for the details.
COVID-19 Pandemic – As I am writing this column it appears that the Omicron wave of COVID has passed. This latest wave of Covid has been bad. Please keep in mind that we will likely have more waves of COVID. Hopefully, they won’t be as bad as this last one. It is still extremely important for your staff and citizens that they get vaccinated. Please spread the word that vaccination is safe and effective.
Staffing – Many systems are suffering severe staffing shortages. Often EMS systems blame this on the low pay that they can offer. Another reason given for staffing shortages has been the continued, long grind of the COVID pandemic. I think these are all valid reasons. There are still many systems, however who have been able to retain personnel for long periods of time.
I visited one EMS system recently where three of their medics together had over 100 years of experience in EMS. Even more recently an EMS crew made up of two paramedics brought me a patient. The two paramedics together had 65 years of experience. This got me thinking about what allows some systems to retain such seasoned medics. I think a big reason is that they don’t work their medics to death with high volume. In addition, I think they treat the medics like family and make them feel special. In order to create this type of environment, we need to train our leaders and make sure our leaders know how to lead. There are many leadership training programs that are very inexpensive and sometimes even free that we can send our leaders to. In addition, I really think we need to look at how we use our paramedics.
What good is it to have a two-paramedic crew respond to all calls if we can’t keep them for more than three or four years and they never become seasoned paramedics?
I honestly do not think we need to send a paramedic on every single call. At the emergency medical dispatch level, we need to look at ways that we can only send paramedics to calls that are likely to be needed. If we continue to burn through our medics with such high call volumes we will not be able to retain them for the long term. If we want our systems to be able to perform advanced procedures like drug-assisted intubation or give ketamine we must retain medics so that they can have adequate experience to provide optimal care. Even more important than the ability to perform advanced procedures is the wisdom and experience that they need to make the complex decisions needed of prehospital providers.
What lies ahead? We have hopefully made it through the worst of a global pandemic. We have risen to the challenge and dealt with stuff that none of the people who have come before us have had to deal with. You are all heroes. I think we can all legitimately breathe a big sigh of relief.
I do want to caution everyone. I am very worried about the challenges that lie ahead. This pandemic has caused ruptures in our society. We are also facing an extremely worrisome international situation right now. We need to build relationships with each other. We need to concentrate on training. We need to take care of each other. Do not take anything for granted because it is very possible that worse lies ahead of us.
Thanks – Prehospital providers have a very special job and do things that no one else can do. You are the last call and the last hope for many of your patients. Never forget that what you do is special. You make a difference.
Dr. Winslow has worked at Baptist Hospital in Winston-Salem for the past 11 years. He was appointed as the Medical Director of the North Carolina Office of EMS in 2011. This document contains all protocol, procedures and policies for all EMS agencies in North Carolina.