Archives for June 2018

Ongoing legislative battles regarding paramedicine in California have begun to highlight a growing divide between emergency physicians and medical directors. The nuanced difference between the two roles can be difficult to articulate at times. Medical directors are generally board-certified in emergency medicine and have their roots in hospital emergency departments. However, the continued growth of prehospital care systems and the advancement of paramedicine has warranted change.

CalACEP President Aimee Moulin speaks to medical directors of California regarding their recent opposition.

In recent years, the medical director community has seen a fast growing sub-specialization in the field of EMS. As with other sub-specializations of medicine, the move recognizes the need for experts,  not generalists, to lead the increasingly complex realm of prehospital care.

A recent national effort to discuss the future of EMS, called EMS Agenda 2050, highlighted the importance of patient-centric care. It proposed a prehospital model that will require refinement and advancement in the way care is delivered. This type of change will require the expert leadership of these specialized EMS medical directors. However, recent efforts to modernize California paramedicine through legislation has seen medical directors at odds with their very own emergency medicine base.

A California Assembly proposal (AB-1795) sought to divert specific, non-emergent patients to alternative destinations. This bill was supported by medical directors, hospitals, emergency nurses and insurers. Yet emergency physicians, through their industry organization CalACEP, opposed the bill alongside the CA Nurses Association. Both of these groups see a reduction in emergency room traffic as a hit to their demand, and ultimately their wallet.

Another legislative effort, CA Senate Bill 944, seeks to formalize community paramedicine. Community paramedicine, which puts paramedics in new public health roles, is generally seen as a positive initiative, yet the bill is not without significant issue. As written, SB-944 would tie the hands of medical directors and give control of community paramedics to a newly formed oversight committee. The bill was successfully lobbied by CalACEP and the CA Nurses Association  to allow them significant representation on this committee.

The bill also stands to make community paramedicine cost-prohibitive for private ambulance providers, which many find troubling as private services were critical to starting some community paramedic pilot programs. The bill is widely seen as a power grab by fire departments who may be trying to get ahead of new non-transport EMS reimbursement models taking hold in California. The proposal currently includes language that local EMS authorities must accept non-competitive bids from fire departments, excluding private ambulance services.

At a recent meeting of medical directors in Sacramento, the president of CalACEP made efforts to reconcile the two groups. The message fell flat when she was unable to explain why CalACEP would continue support for SB-944 despite its attack on medical directors, paramedics and public health efforts. CalACEP has generally deferred its position to subspecialties in matters directly affecting those subspecialties, but in the current environment labor interests are upsetting this norm.

The modernization and advancement of paramedicine requires physician-leaders who understand the complexity of EMS and choose to make the public health of 40 million Californians a priority despite physician and labor group resistance. Current medical directors have overwhelmingly shown they support this effort and their unique role.

We will continue to follow this developing story.

In September 2017, San Diego Paramedics joined an effort to suppress a Hepatitis A outbreak.

Viruses are an ever present threat to our society. Each year 5% to 20% of Americans will face influenza, with around 200,000 being hospitalized. The 2017-18 flu season saw more than 4000 deaths per a week at its peak. In 2014, the Ebola virus epidemic terrified the world with a 70% mortality rate and secondary international infections.

Recently, San Diego faced its own epidemic with the 2017 Hepatitis A outbreak. The event saw 578 infections and 20 deaths. Despite the heavy toll, the actions that helped wind-down the epidemic now stand as a model for probable future occurrences.

Public health officials, the San Diego Mayor, and others noted that the massively increased vaccinations during September 2017 were the turning point in their battle to get the virus under control. Prior to September, only 27,000 individuals had been vaccinated. It was at that point, local and state officials declared a state of emergency.

This declaration of emergency put in action many things, one of which was the ability for paramedics to administer immunizations. Under current California statute paramedics are not allowed to administer these highly effective treatments. The ability of paramedics from San Diego Fire Rescue to treat at-risk individuals was viewed as an effective component of a major public health undertaking.

Ultimately, the Hepatitis A outbreak was controlled after over 120,000 San Diegans received vaccination. Now the question looms, what will California do to prepare for next time? Hepatitis A has a mortality rate of up to 2% in at risk populations. Some viruses, such as the H7N9 Bird Flu, have mortality rates of 30% or greater. The World Health Organization recognizes several viruses, including the bird strain, as threats with pandemic potential.

The Avian Influenza (H7N9) is incredibly dangerous for humans, with a 30% mortality rate, and the WHO is concerned it may be the next pandemic virus.

Paramedics are just starting to be seen as a valuable component of a modern public health programs. These providers work in the in-between spaces, the alleyways, and homeless populations. The San Diego outbreak saw paramedics going into ravines and hard-to-reach places, often finding people who had not yet to surfaced in the health system.

One of the greatest concerns with any immunization procedure is the potential for allergic reaction to the vaccine. Notably, paramedics are the provider requested for the treatment of persons suffering allergic reactions and therefore seem uniquely positioned for a remote immunization program.

Unfortunately, state labor unions have not Been supportive of such initiatives. In California, these unions often see any expansion of one provider’s scope of care as a threat to their own workforce’s demand. Recently, the major nursing union of California defeated a public health paramedic bill supported by medical directors, paramedics, and hospitals.

Many argue that public health is not zero-sum, and that issues of public health should trump labor group tactics. The outcome is yet to be seen, but the hope is that paramedics can partake in making our communities safer and healthier.

A young paramedic-in-training shows an aggressive, sans-stylet approach to endotracheal intubation.

Today in Sacramento, CA, the medical directors of California granted an extension on pediatric endotracheal intubation to any provider with a CAMTS accreditation. This accreditation is currently held by all aeromedical transport services and Hall Ambulance of Bakersfield. The decision was made to extend pediatric intubation until a new statewide critical care scope of practice can be introduced and operational for at least 6 months.

In September of 2018, the directors, which meet formally through their EMDAC organization, made a quick decision to remove pediatric endotracheal intubation after the safety of the procedure was called into question. Utilizing an airway management study from the Los Angeles region in 2000, these physicians argued that the efficacy of the procedure was unclear yet presented a high risk to the public.

Immediate concerns were raised by many paramedics, physicians, and medical directors. The studies utilized in the removal predate many important technologies such as end tidal CO2 capnography. They also stated that while endotracheal intubation is listed as a procedure for any unmanageable airway, it is truly only performed in catastrophic cases such as respiratory and cardiac arrest. Furthermore, when asked for current data, CalEMSA reported they don’t track pediatric intubation, pointing to a much larger data collection problem in California paramedicine.

The critical care community has responded by asking the skills to be added to a statewide scope of practice for their Paramedics. They argue that advanced airway management is often one of the crucial services they provide in their daily operations. They also argue that preventing a paramedic from administering RSI medications or performing endotracheal intubation effectively requires their registered nurse partner to be in two places at once on high acuity incidents.

Non-critical care services will be left with supraglottic airway devices as a stop gap between the need for airway management and the perceived lack of training and data reporting. The new critical care scope in development will include both RSI medications and pediatric intubation as an answer to this problem. The new scope will require increased training and data collection.

Importantly, the collaboration between directors in creation of this scope is creating optimism of a new wave in potential standardization of California’s paramedic treatment protocols. It also alludes to the need for increased education for California paramedics, as it has become difficult to argue that paramedics are adequately trained alongside other healthcare providers.

Procession celebrating the life of Harvey Hall en route to Rabobank Arena.

Hall Ambulance staff and Central California communities gathered today at the Rabobank Arena in Bakersfield, CA to celebrate the life of Harvey Hall. Hall founded the ambulance service in 1971 and served as its president and CEO for over 45 years until his passing on May 15th of this year. In an impressive showcase of unity, CA private ambulance providers sent strike teams to cover the region’s EMS needs allowing all employees to attend the services.

In addition to founding and leading Hall Ambulance, Hall served four terms as mayor for Bakersfield from 2000 to 2016, making him the longest-serving mayor in the history of the town. He was known for his dedication to community development, education advocacy and business development across the region. During his tenure he initiated efforts to tackle homelessness and city beautification.

He also established the Mayor’s Scholarship Foundation for graduating seniors heading to college and funded it each year with his entire mayoral salary.

Born in Bakersfield, Hall attended Bakersfield High School and Community College, before heading to San Francisco City College. There he studied journalism, Personnel Management and Emergency Medicine. In 1960, he entered the emergency medical services industry where he stayed until the founding of his own company in Bakersfield.

In recognition for his outstanding life achievements in bettering his community, Hall has been previously awarded the Kern Chapter Real Heroes Life of Service Award, Darrel Hildebrand Regional Award of Merit for Distinguished Leadership, the Iron Eyes Cody Award, the Planck Foundation Humanitarian of the Year, the Jim Burke Light and Liberty Award, and the John Brock Community Service Award.

His legacy will long be remembered by his employees, his community, and the California EMS community. He leaves behind his wife and four children.

Harvey Hall, right, at Hall Ambulance in 1983.