In our first article, we introduced the need for change in California paramedicine. In subsequent articles, we addressed the first two of our “Three T’s,” Training and Treatment, and we now move to our final topic—Transport.

Under the literal definition of Transport, we will first discuss the introduction of alternate destination policies. Recent unsuccessful legislative attempts have focused on helping overloaded emergency departments by diverting mental health and intoxicated patients to arguably more appropriate facilities, including mental health clinics and sobering centers. However, these at-risk populations exist in both our health and criminal justice systems. As our understanding of these complex issues matures, we are beginning to see that a solution must work among both systems concurrently to be effective. Paramedics are well-positioned to increase connectivity in a multipronged approach that includes both decriminalization efforts and diversion to appropriate locations of care, among others.

As an extension of Transport, we will then discuss the issues of physical safety and mental wellness in paramedicine. Often alone with a patient during transport and without other first responders, the paramedic faces real issues of physical safety in an industry where patient-on-provider violence is an all too common reality. Physical violence and constant exposure to traumatic incidents and images has led to an abnormally high prevalence of depression, suicide and PTSD in paramedicine. Unfortunately, many providers lack resources to cope with the nature of their job, just as the paramedic lacks physical safety resources in the back of the ambulance during transport.

Alternate Destinations in California Paramedicine

By: April Sloan, Community Paramedic

California has recently seen two unsuccessful legislative attempts aimed at allowing paramedics with special training to triage patients to destinations other than hospital emergency departments. These bills would have allowed intoxicated or mental health patients to be transported directly to facilities with services specifically for those populations. Conversation around these bills focused almost entirely on reducing unnecessary emergency patient volumes and emergency medical care costs. While these are real benefits of an alternate destination policy, they are only an ancillary bonus of a more effective approach that works on core issues at the center of substance abuse and mental health.

People suffering from addiction or mental health disorders move transiently across our systems of care. One week an at-risk individual may be getting medical attention for health problems related to substance abuse or medication and therapy services for needs stemming from mental illness. The following week that same individual may interact with peace officers, where they face arrest and imprisonment secondary to substance abuse or behavioral issue. In both cases, the precipitating cause is the substance abuse and/or mental illness, however the traditional services provided by emergency medical staff or law enforcement will not address this cause in definitive ways, meaning these individuals will cycle over and over through these systems while their problems remain unresolved. This issue is further exacerbated by the lack of connectivity between hospitals and justice systems. This lack of connectivity hinders progress because care plans are not currently shared or managed across the entire landscape.

New integrative approaches are now being taken in locations across the country to break these ineffective cycles. The Substance Abuse and Mental Health Services Administration (SAMHSA) and their GAINS Center (Gather, Assess, Integrate, Network, Stimulate) have introduced models that outline more effective team-based approaches that can divert juvenile and adult individuals away from unnecessary imprisonment. SAMHSA notes the value of paramedics who bring medical evaluation capability to teams of law enforcement and mental health professionals, expediting the movement of patients toward definitive and effective treatment for their core needs.

In California, we can see both the criminal justice and medical sides of the house actively working to address these populations. Serial inebriate programs in San Diego and Sacramento offer enrollees the opportunity for addiction treatment in lieu of jail time. These programs are highly effective and have seen success in as much as two-thirds of their participants. Paramedics are often incredible assets to these programs, where they help screen patients as they are processed in the field.

Community paramedicine pilot programs in San Francisco and Stanislaus County have demonstrated the effective triage capability of paramedics in diversion of alcohol intoxication and mental health patients away from unnecessary emergency department evaluation. In San Francisco, 400 individuals were transported to alternate destinations over a 9 month period, with only 2% requiring subsequent referral to an emergency department. In Stanislaus County, 251 individuals were transported directly to mental health facilities, with only 4% requiring subsequent transport to an emergency department. No adverse patient outcomes were reported in either of these trials.

It is clear to see that our health and criminal justice systems are working towards common ground in the triage, diversion, and appropriate treatment of substance abuse and mental health issues. Paramedics are uniquely positioned to offer connectivity to this effort, as they extend medical care into their communities and work side-by-side with peace officers. Policy reform allowing paramedics to appropriately screen and move at-risk patients in the prehospital and prejail realm is fundamental to the introduction of this more robust, integrative, and socially conscious approach to substance abuse and mental health systems of care.

Provider Safety in Paramedicine

By: Ben Vernon, BA, EMT-P Paramedic and Aaron Byzak, MBA, FACHE

Walk into a room of 100 providers and ask how many have been assaulted during their time in paramedicine—100 hands will go up. Ask this same group of providers if they are experiencing mental health effects from their work and you will get a very different answer. The truth is both workplace violence and mental health side effects are pervasive in paramedicine. In an industry where toughness and stoicism are celebrated, paramedics will speak openly about workplace violence like a badge of honor, while simultaneously refusing to discuss the mental health effects of their work as they suffer in silence. The time has come to take definitive action to address workplace violence against prehospital providers and reduce stigmas and encourage treatment for depression, anxiety, PTSD, and substance abuse, all of which are the natural byproducts of consistent exposure to trauma in this industry.

Violence against paramedics and emergency medical technicians is undoubted, with 2016 data showing that 16% of 21,900 workplace injuries experienced by these providers are the result of violence, a percentage that is trending upwards. Prehospital emergency medical workers see 7.1 nonfatal injuries per 100 workers, a figure comparable to peace officers who suffer 7.2 nonfatal injuries per 100 workers with 22% of those resulting from violence. Some level of violence is to be expected in law enforcement by the very nature of their training and work, but one would likely not expect such prevalent violence in paramedicine—a field rooted in the provision of care for the sick and injured.

California state code provides extra protections for first responders including sentencing guidelines for assault and battery. However in practice, first responders are often hesitant to press charges for simple battery, because there is a perception that the misdemeanor has little consequence and prosecution is unlikely. In some situations, providers are actively discouraged from reporting the assault or pressing charges by the powers that be. Furthermore, prehospital providers often lack access to safety equipment, such as bullet proof vests or body armor, despite the fact they work in and around violent incidents with high frequency.

In addition to workplace violence, paramedics are routinely exposed to incredible psychological trauma. They respond to incidents that sear into the mind, such as suicides and hangings, pedestrians hit by cars and trains, child abuse, horrific car wrecks, people burned in fires, and violent crimes. It has been said that a paramedic may see more trauma in one week than most people see in their entire lives. Paramedics are at a particularly high risk of work-associated mental illness as a result of this trauma, with 10% suffering from clinical levels of depression, 22% having PTSD, and 22% having probable clinical levels of anxiety, as shown in a study of UK providers. It is no wonder recent studies have shown that first responders attempt suicide at more than 10 times the rate of the general population.

We must also recognize that PTSD, depression, substance abuse, and associated mental health issues cannot always be attributed to a singular event and can be born from the cumulative impact of smaller recurring incidents over time. Paramedics, both those currently working in the field and those who have moved on to other careers, can carry the mental scars of their service forever. In recognition of this, paramedics must have access to meaningful resources in the near and long term. Immediate needs should be addressed with robust standardized peer support programs which can seamlessly transition to ongoing care, such as mental health services offered in employee assistance programs. Furthermore, providers who have transitioned out of paramedicine must have access to long term services, something that is not currently guaranteed under employee assistance laws. It is also imperative that prehospital providers not fear employment repercussions for accessing these needed services.

Changing the culture surrounding mental health and workplace violence in paramedicine is no small task. Different regions may have different needs and a overly prescriptive approach would likely be ineffective or possibly detrimental. However, the adoption of general provisions of safety and wellness for first responders could provide an expectation of services upon which first responder agencies can develop programming to meet the needs of their respective workforces. To that end, we introduce these provisions as a bill of rights:

First Responder Safety and Wellness Bill of Rights:

1. First Responders have the right to reasonable training on workplace violence, including avoidance and de-escalation techniques.

2. First Responders have the right to reasonable protective equipment when working in regions with a history of violent crime.

3. First Responders have the right to report workplace violence without discouragement or repercussion, and for those reports to be investigated to the fullest extent of the law.

4. First Responders have the right to a timely and standardized crisis management system with an incorporated referral process for continued, long term services.

5. First Responders have the right to reasonable workers compensation for mental health issues arising from their service including its cumulative impacts that may emerge long after leaving the field.

6. First Responders have the right to seek mental health or substance abuse treatment without fear of detriment to their employment.

The Modernization of Paramedic Transport

The time has come to modernize the California paramedicine in the area of Transport. Alternate destination policy reform offers a gateway to the appropriate care for individuals who would otherwise end up in our emergency departments and criminal justice system. Can we really continue to cycle patients through a system that is so painfully inadequate when alternatives exist that have been proven effective?

We must also resolve to codify protections for both the bodies and minds of those who respond to help us in our most desperate hours. A bill of rights stands to guide a change of culture on topics that have been avoided for too long. Will we continue to send our EMS brothers and sisters into harm’s way without the most basic protections and then abandon them in their time of need?

The California Paramedic Foundation is calling on stakeholders and legislators to work together for the modernization of paramedic transport in California EMS, through the formal adoption of alternate destination policy and the establishment of a health and safety bill of rights for first responders.

About the Authors:

April Sloan, Community Paramedic: April has a career in EMS that spans 20 years and multiple states. Since 2011 she has been located in San Francisco, CA where she has worked in both private and public provider roles. For the last three years she has led the San Francisco-based Community Paramedic Program centered on alternate destinations for alcohol intoxicated individuals and support services for high utilizers of emergency services. Both aspects of this pilot have been highly successful due to the guidance of April and her team.

Ben Vernon, BA, Paramedic: Ben began his career in EMS in 2003 and is currently a firefighter/ paramedic for San Diego Fire Rescue. He’s a member of the Technical Rescue Team, Hazmat Team and California Task Force 8—Urban Search and Rescue Team. He also teaches in the Fire Academy and is an EMT instructor. On June 24, 2015, Ben’s life changed when he was stabbed while responding to a “routine medical assistance” call. The incident and the ensuing ordeal left Ben with a changed perspective. Ben has lead organizational change in his own department and abroad in the areas of mental health and wellness. He is a widely requested national speaker on the topic and is currently co-authoring a book.

Aaron Byzak, MBA, FACHE: Aaron has served for more than two decades in positions of progressive leadership in EMS, health policy, and healthcare management. He 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. Aaron has received numerous best practice awards and national recognitions for his leadership and work in healthcare, public health, advocacy, and communications including four Emmy Awards. Aaron’s career in healthcare was largely shaped through his experiences in EMS, including as a survivor of PTSD. That journey laid the foundation for a career dedicated to public service and his ongoing work addressing the needs of vulnerable populations. He earned his master of business administration in healthcare management and policy from UC Irvine’s Merage School of Business, and a bachelor’s degree in social science from Chapman University. He is Board Certified in healthcare management as a Fellow of the American College of Healthcare Executives (FACHE).