Equipping EMS

Editor's Note: This is the second installment in a three-part series on medical transportation and EMS. Read the first part, "Trauma in EMS."

Paramedics and emergency medical technicians get respect for the high-risk care they provide under often stressful conditions, but they haven't always had access to innovations in medical technology to make their jobs easier.

That's changing as emergency medical services providers are adopting new technologies for use in the field that take advantage of the ability to transmit larger amounts of patient data electronically, are more durable and are designed to lighten the load for the equipment-heavy EMS personnel. In addition, EMS systems are deploying computer software that can help predict higher incidence of emergency calls, allowing them to strategically locate their ambulances for quickest response.

“New technology is what's moving EMS, improving it,” says Scott Matin, vice president of clinical, education and business services in mobile health services for the Monmouth Ocean Hospital Service Corp., or MONOC, a Neptune, N.J.-based not-for-profit cooperative serving 15 acute-care hospitals in the state. Technological change is allowing the industry to improve EMS quality, whether it's through gathering and transmitting patient data more quickly or by using devices that weren't previously available in the pre-hospital setting, Matin says.

Many of the advancements in EMS technology revolve around the use of wireless information technology, now being used in electronic health records or to track and transmit a patient's vital signs. The electronic recording of EMS' patient-care reports is moving toward becoming the standard, experts say. Most EMS providers now use some type of electronic patient-care record, and some of them are being electronically transmitted to the hospital ahead of the ambulance's arrival, says Jeffrey Lindsey, professor of EMS at St. Petersburg (Fla.) College. A patient-care record is the EMS' version of a chart that eventually is folded into a patient's medical record.

American Medical Response, a Greenwood Village, Colo.-based ambulance company recently rolled out a national standardized electronic patient-care record that will allow the for-profit EMS operator to gather and analyze clinical data from a broader perspective.

“Everyone is recording patient data the same way” after the rollout, says Gail Cosgrove, vice president of information technology at Emergency Medical Services Corp., AMR's parent. “That's a huge win for us,” Cosgrove says. The company can identify trends and work to improve clinical care and quality at a national level, she says. The change also allows the company to participate in clinical research, as it did in a study of stroke care conducted by Tufts Medical Center in Boston, Cosgrove says.

Beth Israel Deaconess Medical Center, Boston, has taken the use of electronic patient-care records from EMS providers a step further by integrating them into their electronic health record. Beth Israel's emergency room has been fully electronic for years, says Dr. John Halamka, a national expert in health information technology who is chief information officer at Beth Israel Deaconess Medical Center and professor of medicine at Harvard Medical School. But connecting the EMS electronic patient-care record, the record of what an EMT or paramedic has learned and done in the field with a particular patient, proved more difficult.

“The challenge in the past is EMS hasn't had the equipment to capture that narrative in a structured logical way,” Halamka says.

Beth Israel's integration, which went live this spring, also allows for the record to be sent in advance of the ambulance, Halamka says. The hospital has seen “extraordinary satisfaction among the clinicians” using the new system, he says.

Similarly, technology is allowing high-quality patient health data to be collected in advance of the ambulance's arrival. MONOC's Matin says new ECG and EKG technology has made great strides in recent years in improving the quality and speed of the data transmission.

While hospitals have had some access to such data in a very basic form for a long time, the current technology provides information from an ambulance that is the same quality found in a hospital, he says. As a result, the technology is becoming more widely used and is giving hospitals time to get prepared in advance, such as by prepping cardiac catheterization labs.

“All of this stuff is extremely time-sensitive, even getting … 20 minutes is a big, big deal,” Matin says.

Instead of having a patient tethered to equipment as they are being treated and transported, Bluetooth communication technology in equipment can connect patients to equipment wirelessly, making patients more easily moved. “You don't have to move the patient with the equipment,” which can weigh a significant amount, says Dr. James Kempema, an emergency medicine specialist and medical director for Travis County STAR Flight, a public safety air rescue program, and assistant medical director for Austin-Travis County (Texas) EMS.

Newer hand-held ultrasound equipment has been adapted for the rough and tumble use that takes place in the back of a speeding vehicle, and is proving useful as well. The ultrasound can be used in a variety of ways by EMS personnel, checking for such traumatic injuries as a collapsed lung or to check to see if the heart is beating, Kempema says.

“There's a lot of really important data that can be collected before they get to the hospital,'' he says. But they are very sensitive devices and have had to be adapted for EMS use so they don't break as easily if dropped or jostled in the field.

Kempema notes that video laryngoscopes, which make it easier to intubate a patient, also are becoming available for EMS providers. While they are easy to use and the evidence is strong that they help, cost becomes a factor, he says. Video-equipped models proved in studies to be useful cost $8,000 to $10,000, which adds up quickly if outfitting multiple ambulances, he says. Newer versions, whose efficacy has yet to be established, cost closer to $1,000, while traditional laryngoscopes are low-budget items costing in the hundreds of dollars.

Another technological advancement for EMS has been the EZ-IO vascular drill, Matin says. Seriously injured trauma patients may have such a low blood pressure that installing an IV line the traditional way is difficult. The EZ-IO drills straight into the bone, where fluids and medications also can be delivered to the patient. “It sounds kind of barbaric, it really isn't,” Matin says. “It is very, very effective.”

An area that has gotten attention and been adopted relatively widely concerns power-assisted stretchers, which can vastly reduce the amount of weight an EMS responder has to lift in a given day, reducing the odds the responder will suffer a back injury, historically a common problem in the industry. The issue has been given a higher priority as more important as Americans become more obese, with some EMS units now carrying equipment specifically for overweight patients.

“We've seen a pretty significant reduction in injuries with the use of those stretchers,” says Ron Thackery, senior vice president of professional services for AMR. The company spent $10 million on power stretchers for roughly 1,800 front-line ambulances, Thackery says. The stretchers have an extendable frame that raise or lower as needed to get a patient in or out of an ambulance.

Ambulance dispatching also has been improved through the use of predictive modeling software that can estimate where EMS calls might be coming from at a certain time by analyzing past calls, allowing for improvement in ambulance deployment.

“It'll actually tell you (that) on weekdays at 5 o'clock you're more likely to get calls on (certain) blocks in the city,” Matin says. As a result, MONOC might have an ambulance deployed to a certain street corner in advance of anticipated calls in that area at a given time. “Of course, it's not the most popular thing from a crew standpoint,” Matin says, but the EMS system can use the information as it sees fit depending on their needs.

Training is also an area where technological advancements have been made in recent years through the use of human patient simulators, allowing for future and current EMS personnel to get realistic exposure to different kinds of injury and illness. The state of South Dakota purchased mobile EMS training equipment with such simulators to train its largely volunteer rural EMS workforce with a $5.6 million grant from the Leona M. and Harry B. Helmsley Charitable Trust, while Scottsdale (Ariz.) Healthcare makes extensive use of the simulators with its military and civilian training program.

Officials for both say their respective simulators are eerily human-like. Sandra Durick, administrator of the South Dakota Office of Rural Health, says the simulators take time to get used to for those being trained.

“It's so realistic, people freeze up” when first using them, Durick says, speaking at an April conference. In an interview, she says that response to training on their simulation trucks has been “extremely positive.”

Likewise, the simulators in use at Scottsdale can pretend to breathe, normally or abnormally as directed by the operator, produce a certain kind of pulse and “their pupils respond to light,” says Laurel Fountain-Beilfuss, senior associate and Air Force Medical Modeling and Simulation Training simulation coordinator in the Scottsdale Healthcare program. “They can bleed just about anywhere.”