In the wake of Verizon’s Cal Fire throttling scandal during last year’s deadly Mendocino Complex fires, AT&T and FirstNet have risen as the white knight for first responder cellular services. Launched in March of 2018, FirstNet is a congressionally-funded standalone network dedicated to prioritizing and protecting first responders. AT&T, the sole FirstNet partner under a new 25 year contract, has begun intense marketing as it enrolls paramedics, firefighters, and law enforcement onto the new service.

However, the FirstNet rollout is not without issue, and AT&T, under apparent pressure to meet enrollment targets through its contract, has continued deploying the service zealously. Many first responders are reporting a lack of transparency regarding ongoing issues such as hardware, network services, and savings.

FirstNet was created after the 9/11 Commission noted technology hindered first responders during the attack and subsequent disaster management. The commission recommended increased radio spectrum for public safety to allow for better interoperability and new technology to enhance disaster response. In 2012, congress acted and authorized the FCC to implement the new network.

FirstNet offers brutal preemption for first responders, meaning first responders get first access to available radio towers and can boot other users to make room during congestion. It categorizes users into three service blocks– A primary block of first responders (paramedics, police and fire) a secondary block of delayed responders (e.g. nurses, physician, infrastructure) and a third block of regular users.

To gain access to the first block, enrollees must receive a special FirstNet sim card. And yet curiously, many FirstNet enrollees are reporting they are not being given these cards. In our discussion with AT&T, a company representative stated that users without the FirstNet-specific sim card would end up in the second block, getting priority over regular users but not first priority as advertised. A southern California retailer we spoke with stated they have been directed to minimize distribution of the cards for an unknown reason.

First responders that are receiving new FirstNet sim cards have also reported issues with overseas travel, as the FirstNet cards only work on domestic towers. Anyone heading abroad will need to return to a store and switch back to a non-FirstNet sim card prior to traveling. A headache for a family vacation, but a significant problem for members of international disaster response teams or those who travel for work.

As a part of the contract award, AT&T was granted a special radio spectrum dedicated to public safety.  Called “Block 14,” the band is part of the lucrative 700mHz radio spectrum which performs well in building penetration and large area coverage. Yet only Iphone X and Galaxy S9 phones have receivers to utilize this frequency range. Paramedics we spoke with stated AT&T retailers had upgraded them to lesser phones, without informing them of their inability to utilize this important band.

The transition to FirstNet is also presenting challenges for some. Because FirstNet is an entirely separate service, previously joined family plans must be split with the primary user heading to FirstNet, and the remaining family on an AT&T unlimited data plan. This means two bills and two logins. AT&T markets the FirstNet plan at $40, which by all accounts is a great deal if an individual is only securing one line. But in the context of a family plan where each additional phone line would only cost $35, it actually appears to be a wash in terms of savings.

FirstNet will no doubt benefit first responders as it grows and becomes more fully baked. However, the current rollout appears to lack transparency regarding the shortcomings early adopters will face. It is our recommendation that first responders have an honest and transparent discussion with FirstNet and AT&T regarding family plan cost savings, international coverage, and hardware requirements as they consider enrollment.

 

EMS World Expo; Nashville, TN— This week California paramedics Anne Jensen and Shawn Percival hosted two events centered on the continuing evolution and advancement of community paramedicine (CP) programs. Joining national leaders in the community paramedic space, they led vibrant discussions on navigating systems of care in at-risk populations and moderated discussion on approaches for overcoming difficult, recurring patient profiles.

The first discussion on Wednesday, a joint presentation between Anne Jensen and Dr. Dan Swayze of the Center for Emergency Medicine of Western Pennsylvania, focused on unique systems of care that must be navigated in at-risk populations. Community paramedics intervene with patients at the frontend of healthcare where they must make critical choices to efficiently and successfully guide these patients to appropriate, non-emergent treatment. Jensen and Swayze focused on three new systems that they have found to be important subcomponents to the whole— drug and alcohol recovery, food security, and income subsidy.

“Systems of care,” a phrase coined by Jensen and Swayze, is an effective format to discuss the core offerings of community paramedic programs. In a traditional sense, paramedics are trained to understand systems of care in medical and trauma patients. Interventional cardiac services, neurological services, trauma services, or psychiatric services— each represents a distinct system of care in which paramedics are familiarized. They are familiarized so that their patients receive appropriate, effective care from the beginning of their interaction together. In the complex healthcare landscape, these systems of care are interwoven across multiple providers and facilities, where each facility or network cannot control the whole, and thus paramedics become a glue for their strategy of care.

Community paramedicine builds on this foundational approach by broadening the systems of care available for paramedic consideration in patient triage and care. Jensen and Swayze have identified additional systems of care as substance abuse, food security, and income are common areas of intervention in frequent 911 users.  The systems-based approach acted as an elegant framework for their discussion, and the value was broadly enjoyed.

On Thursday of the expo, Anne Jensen joined fellow San Diegan Shawn Percival for an open discussion on the management of difficult and recurring patient profiles. The pair started the conversation with examples of common examples on which their guidance is sought. The conversation took on a life of its own, as paramedics from across the country shared trials, successes, and advice. Treatment of 911-super-users is not always linear and almost always long term. These forums present in an incredible opportunity for community paramedics new and old to refine their approach in tough circumstances.

Anne Jensen and Shawn Percival are paramedics from San Diego, CA where they initialized one of the first community paramedic programs in the country. They additionally work at the California Paramedic Foundation where they drive an community paramedic ecosystem centered on policy, education, and operations in their home state.

On September 30th, 2018 California Governor Jerry Brown vetoed Assembly Bill 3115, the Community Paramedicine or Triage to Alternate Destination Act. The bill sought to formalize the long-running community paramedic pilot program into state law. Community paramedicine is widely viewed as a good and necessary change in how EMS delivers care. However, the language of AB3115 created controversy which culminated in its demise. Instead of empowering local medical director leadership, the Bill sought to change the make-up of the state EMS commission, and also required alternate destinations to be federally qualified health centers, an unnecessary burden to EMS systems. Governor Brown referenced both of these issues in his letter to legislators.

 

Assembly Bill 3115 was the latest iteration in a now two-years-long battle to put community paramedicine into state code. It was sponsored by the California Professional Firefighters Association, a union with a stated mission of “serving the needs of career firefighters.” It is this mission that potentially led to the AB3115’s troubling language. The union sought to leverage the implementation of community paramedicine for additional seats in the state’s highest oversight body, the EMS Commission. They proposed the removal of two long-standing nonprofit members from the commission to be replaced by fire and nursing union members. Their language also required that public agencies, further defined as fire departments, get first-rights to run any proposed community paramedic programming.

Community paramedicine has been successful in large-part due to the dedication of local stakeholders in each pilot site working under the oversight of state offices such as the EMS Authority, the Office of Statewide Health Planning and Development, and the California Healthcare Foundation. The proposed changes to the state EMS commission ran contrary to this historical success. Despite widespread and public opposition from California medical directors, EMS administrators, and county administrators, the Professional Firefighters held their ground with the hope that the need to pass community paramedicine would outweigh these concerns.

AB3115 also faced challenges regarding its proposal for triage paramedics and alternate destinations. Currently, California prehospital systems must transport all patients to a hospital emergency department. This leads to emergency departments often becoming inundated with patients, some of which do not require the assessment and treatment of these advanced facilities. The ability for paramedics to triage those specific patient populations, such as mental health and alcohol intoxication, to alternate destinations allows for more efficient prehospital and emergency department operations, but it would also allow at-risk populations to receive appropriate care in these new, centralized destinations.

A bill proposed by the California Hospitals’ Association earlier this year sought to implement this alternate destination system, but that bill was defeated by both the California Nursing Association and California chapter of the American College of Emergency Physicians, who viewed the loss of these patients as a hit to their bottom line. The reincarnation of alternate destinations in AB3115 answered the concerns of both groups by requiring these destinations to be Federally Qualified Health Centers, or FQHCs. FQHCs are comprehensive primary care facilities that furnish services typical to an outpatient center and require both nursing and physician staffing. While good in theory, the requirement of alternate destinations to be FQHCs is cost-prohibitive and defeats the premise of that program.

Governor Brown accurately identified these key issues as non-starters for a community paramedicine bill. Brown directed the extension of the current community paramedicine pilot program, allowing critical services to continue while legislators and stakeholders find a solution. While the formal extension of the pilots requires approval and funding from other regulatory bodies and organizations, it is a strong indication of Governor Brown’s support. It is now up to California EMS stakeholders to move community paramedicine forward yet again.

The California EMS Authority is launching a new, electronic licensure service this fall. Here is what you need to know:

The service will begin operating in late Fall or early Winter and will handle all initial applications, initial challenge applications, and non-audit renewals. Renewals marked for audit, renewals after a lapse in licensure, and name changes will require a paper form. However, you can still use paper forms for all applications if you so desire.

It is important to note that with the implementation of this new system, the Authority will no longer provide same-day, in-house services. The last day in-house applications will be accepted is October 31, 2018. This means the days of driving to the Sacramento office at the 11th hour will be going away, so plan ahead and renew accordingly.

The new online platform does provide new conveniences to end-users. Applications can be viewed online and also printed. Applicants will be able to securely pay for eligible applications with Visa or Mastercard. Applicants will also be able to manage all of their important information, such as employers, phone numbers, and mailing addresses, through their account on the system.

For more information please visit emsa.ca.gov/paramedic where you can read about this new process and also contact the EMS Authority with any questions.

The California Paramedic Foundation works every day to advance paramedicine across the Golden State. Its mission centers on the important areas of education, standardization, prevention, and philanthropy. Working on these issues across the diverse California EMS ecosystem is no small task, but the Foundation is well on its way to effecting change. This success is in no small part to our advisory board. Each advisor is a national leader in their field, and together they provide a wealth of resources to the Foundation and California paramedics. We are happy to announce we have expanded this board to include the following key advisors.

Keith Griffiths is a partner with Redflash Group, a national consulting group that provides marketing and communications outreach for EMS, public safety, and healthcare markets. He is also the founding editor of JEMS, The Journal of Emergency Medical Services, and still sits on their editorial advisory board.

With a professional network cultivated for over 40 years, Keith has a special gift for bringing together stakeholders and building partnerships. He plays a hands-on role with various RedFlash clients, leading marketing strategy and execution, government and nonprofit outreach, consensus projects and other initiatives. Throughout his career, he’s served on numerous boards and is a familiar face at meetings of national importance.

“Having lived most of my life in California, I care about my adopted state and community, and what kind of service my family would receive if they ever needed to call 911. I understand the challenges that EMTs and paramedics have to overcome and the insights they can provide. The California Paramedic Foundation gives them not only a voice but a means to make a difference.”

 

Aaron Byzak serves as Chief Government and External Affairs Officer for Tri-City Medical Center and Senior Advisor to Galvanized Strategies, a full-spectrum strategic public affairs firm offering external affairs and consulting for its clients. Additionally, Aaron is the founder and chief advocate of Hazel’s Army, a community advocacy and education group that in 2014 helped pass the most comprehensive assisted living reform agenda in California’s history.

For more than two decades, Aaron has served in positions of progressive leadership in Emergency Medical Services, health policy, and health care management. He has received numerous best practice awards and national recognitions for his leadership and work in health care, public health, advocacy, and communications including four Emmy Awards.

He earned his master of business administration in health care management and policy from UC Irvine’s Merage School of Business, and a bachelor’s degree in social science from Chapman University. Additionally, Aaron earned certificates in leadership from Cornell University and UCLA’s Anderson School of Management. He is Board Certified in healthcare management as a Fellow of the American College of Healthcare Executives (FACHE).

 

Dr. Janet M. Coffman is professor at Philip R. Lee Institute for Health Policy Studies, Healthforce Center, and the Department of Family and Community Medicine at the University of California, San Francisco. Her other research interests include health care reform, access to care for vulnerable populations, and innovations in management of chronic illnesses. Dr. Coffman has authored numerous publications on the health care workforce in California and the United States. She leads the independent evaluation of California’s Community Paramedicine Pilot Project. Dr. Coffman received a master’s degree in Public Policy and a PhD in Health Services and Policy Analysis from the University of California, Berkeley.

 

 

 

Dr. Daniel Davis completed his undergraduate training in neuroscience at UCLA, where he was a National Merit, Regents, and Alumni Scholar as well as a varsity member of the 1987 NCAA National Championship Volleyball Team. He graduated Magna Cum Laude and attended the UCSD School of Medicine, where he remained for his residency training in emergency medicine. As a resident, he was recognized by his department as Chief Resident and Outstanding Graduating Resident, by his institution as House Officer of the Year, and by the Emergency Medicine Council of Residency Directors as the Outstanding Academic Emergency Medicine Resident.

Dr. Davis spent the first part of his professional career at UCSD, where he received several competitive grants allowing him to complete a fellowship in neuroprotection and resuscitation, studying under Drs. David Hoyt and Piyush Patel. He has published over 200 original articles in peer-reviewed journals, received numerous research awards and grants, and served as Principal Investigator for the prestigious Resuscitation Outcomes Consortium. In addition, he provides medical direction for Riverside County Fire Department and Mercy Air Medical Services and serves as Scientific Advisor for Air Methods Corporation.

Dr. Davis’ most impactful work to date has been the development of the Advanced Resuscitation Training (ART) program, which uniquely links performance improvement data and training to reduce preventable deaths in the hospital and prehospital environments. The ART program has been a singular success in the landscape of resuscitation science and has saved more than 1,000 lives in just a few years. Dr. Davis speaks internationally on the topics of resuscitation and patient safety, offering important perspectives on medical science, healthcare, and the mysteries of life and death.

California Governor Brown is currently considering Assembly Bill 3115, The Community Paramedicine or Triage to Alternate Destination Act. Here is what you need to know.

The bill was sponsored by the California Professional Firefighters and authored by Assemblyperson Gipson, Assemblyperson Bonta, and Senator Hertzberg. It is the latest, and thus far most successful, iteration in a long legislative battle to formalize community paramedicine in California. In addition to creating the community paramedic role, the bill also seeks to create an alternate destination program where triage paramedics can defer patients to facilities other than emergency rooms for select problems such as mental illness and alcohol intoxication.

For the last four years, California has run a community paramedic and alternate destination pilot program through the Office of Statewide Health Planning and Development, also known as OSHPD. The program has been facilitated by the California Health Care Foundation which also oversees independent evaluation of each pilot site. The pilot program has been extended beyond its original scope in duration, and it is most likely that it would not be extended beyond 2018 as the program was only designed to temporarily evaluate the merits of community paramedicine.

Assembly Bill 3115 will require community paramedics and triage paramedics to undergo specialized training prior to working in their respective roles. Each local EMS authority will have the opportunity to create programs in their regions, but their program design will have to be coordinated with new local committees and will also have to meet regulations set forth by California EMS Authority. The regulations and oversight created by the Authority will additionally require approval by the California EMS Commission. The bill’s language requires that local EMS authorities give public agencies a first crack at any proposed program, excluding the involvement of private ambulance services unless the region’s public service so chooses.

The bill also seeks to restructure the California EMS Commission, a group of 18 stakeholders in California EMS. It seeks to remove the California Rescue Paramedic Association (CRPA), a long-standing nonprofit member of the California EMS community, and the Emergency Nurses Association (ENA), a nonprofit representing emergency nurses. These positions will be replaced by the California Labor Federation. It also gives the California Chapter of the American College of Emergency Physicians a second seat that was previously filled by a non-affiliated emergency physician. It then expands the commission with an additional two seats for an addiction specialist and a social worker representative.

The bill’s future is not certain. Community paramedicine is widely supported as a positive addition to California’s treatment of at-risk populations. The pilot programs have shown great success over the last four years, and their formal implementation is viewed positively. However, the significant changes to the oversight mechanism of California EMS have created much conflict. The Commission’s new form would afford further influence to the fire service and nursing union, both organizations that already have voices that are highly influential in Sacramento. This change is viewed negatively by many medical directors, EMS administrators, and privately-employed paramedics as it further marginalizes their perspectives. The governor has until September 30th, 2018, to make a decision on the matter. To voice your opinion on this legislation, contact the governor’s office at (916) 445-2841.

 

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.

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.

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.

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.

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.