Happy 4th of July from PAAW!

by Samantha Hilker

Elizabeth "Ela" Rybczyk (pronounced rib-chick) is the new Region 4 & 5 Coordinator for the Wisconsin EMS Office.  She officially started the role on May 14^th, 2018, and has been hard at work learning the EMS system, building relationships and responding to questions.  I had the opportunity to speak with her over the phone about her history in EMS and her vision for EMS in Wisconsin. 

S: Ela, can you share a bit about your history in EMS?

E: I started in EMS in 2008 as an EMT Basic for an urban commercial agency in Rochester, New York, and became a paramedic in 2010.  I have worked in a variety of different settings including both urban and rural  I have had the opportunity to treat a diverse population of patients. In 2012I became a critical care paramedic and began to focus on inter-facility transports.  I have also worked as a training director for my agency.   

S:  What brought you to make a move to Wisconsin?

E:  I was looking around at different job opportunities when I found the job posting for this role.  Honestly, it just felt right.  I have always loved Madison, and everyone in Wisconsin is so outdoorsy; I enjoy being outdoors, too.  The EMS system in Wisconsin is quite progressive, and I enjoy that as well.  EMS is my passion, and I feel lucky to have the opportunity to come here and work in a different arena of EMS. 

S:  What are your goals for EMS in Wisconsin?

E: My immediate goal is to learn the region, state, and EMS system as a whole.  There are a lot of similarities between New York State and Wisconsin, but a lot of differences as well.  My long-term goal is to be supportive of the EMS community and to see the system succeed.  I’m going to do my best to be here to answer questions and support services and providers as best as I can.  I am still learning, but Ray and Mark have been great at leading me through the process and getting me trained up. 

I have to say that Ela’s energy and excitement for EMS came through even on the phone.  PAAW looks forward to working with her over the years to come.  She also shared that she loves mountain climbing and, with Wisconsin being quite flat, she’s open to suggestions on great climbing spots.  If you have any recommendations (or questions) for Ela, you can find her at Elizabeth.Rybczyk@dhs.wisconsin.gov.

By Samantha Hilker

Jonathan “Mark” Lockhart started as the EMS Section Chief on May 29, 2018.  I had the opportunity to speak with him about his history in EMS, and his hopes for Wisconsin. 

S:  Mark, we saw the short bio and description come out from the state when your acceptance of the position was announced, but can you share a little bit more with us about your history in EMS?

M: Well, I initially got my start with EMS as a Boy Scout explorer in high school.  My 36  year EMS career jumped off in 1982 when I started as a volunteer EMT with a service outside of St. Louis, MO.  From there, I was hired by a fire department in 1983, about six months after I had finished paramedic school.  I stayed with that fire district for eight years.  I also flew with the air medical service during that time (for about 1.5 years) then started teaching and doing some quality assurance in St. Louis County.  Working with QA and teaching led me to a full-time position within the hospital full time as the Director of EMS Education.  As part of this role, I worked very closely with Medical Control which included writing policy, procedure, and protocol.  After some time, the fire department I had previously spent eight years with asked me to come back as their EMS Chief, and I did for the next 12 years.  The Chief retired and, after acting as interim Chief, I was appointed as Fire Chief.  I began thinking about how I had been in the same area for my entire life, and it was time for a change of scenery.  That is what led me to the for Stafford County, VA, where I have been for the past five years as Fire and EMS Chief and two years as an Assistant Chief before that. 

S:  What made you want to come to Wisconsin?

M: My passion has always been EMS, so after 36 years in the fire service, and some soul searching, I had a bit of an epiphany and decided to refocus on that passion and get back to what I genuinely love doing.  I saw the position posted for Wisconsin and thought it seemed like a natural fit.  I had heard and read a lot of great things about the EMS system in Wisconsin regarding how progressive it is, including the legislative changes that went through last year, and the community EMS initiative that is taking root.  I’m excited to be here and be a part of it. 

S: Now that you’ve been in Wisconsin and the role for a few weeks, what are your initial thoughts and goals for EMS in Wisconsin?

M:  I had the opportunity to attend my first round of EMS meetings at the beginning of June, and I’ve already learned a lot.  I enjoyed the opportunity to listen, learn and get a feel for the perspectives represented.  I look forward to working with everyone to move EMS in Wisconsin forward. 

S: What do the EMS providers in Wisconsin need to know about you, and your plans for us?

M:   I come from a really broad background in that I’ve worked for rural, volunteer, career fire, air medical and hospital services.  I have also been involved with professional associations at a local, state and national level.  I am very blessed to have seen EMS in many different settings and from many different perspectives, and I want to be able to leverage that experience here so we can build on what is already a very solid foundation.  I believe there are significant opportunities for further growth and development.  I am excited about what I am hearing discussed in meetings and around WI, and happy to have met everyone so far.  I look forward to meeting more EMS providers from around the state and working with the local trauma advisory councils as well. 

While it was a short conversation with Mark, his energy and excitement were apparent.  He brings a diverse history and perspective to the table, and I believe he wants to make a positive impact on Wisconsin EMS. PAAW looks forward to working with him in the years to come. 

If you have questions for Mark, you can contact him at Jonathan.Lockhart@wisconsin.gov

by Samantha Hilker
Gold Cross Ambulance Service, Inc., a longstanding member of PAAW, is doing some great things in their corner of the world, so we’re shining the spotlight on them!

The team at Gold Cross is taking community involvement and public outreach to heart, and it is making a difference for the community as well as the EMTs and paramedics on staff. 

“Gold Cross Ambulance believes that to be truly involved in pre-hospital healthcare you must educate the public to help improve patient outcomes.  At Gold Cross, there are many areas of public education and community outreach that help engage and educate our community.  We partner with the local healthcare systems, Ascension, and ThedaCare, to help provide many of these educations.   Our public education and community outreach initiatives include our HeartStart Foundation public AED placement, PulsePoint, Stop the Bleed training, Hands-Only CPR education, and participation in Stroke education.   We hope that with education and engagement we create a healthier community” explains Nick Romenesko, Clinical & Quality Manager for Gold Cross. 

Gold Cross’ flagship event for the last several years has been the CPR at the Park Night, a collaborative event planned by representatives of Gold Cross, Ascension, American Heart Association, ThedaCare and the Wisconsin Timber Rattlers.  The event starts with free HOCPR, and AED awareness demos and participants are encouraged to download the PulsePoint Respond app.  In June of 2017 Gold Cross launched the Pulse Point Respond app through their dispatch center.  The app alerts CPR trained citizens to a cardiac arrest in a public location and tells them the location of the nearest public access AED, so they may respond, initiate CPR, and apply the AED when they are within 0.25 miles of that patient’s location.  The Timber Rattlers include in-game messaging about cardiovascular disease, healthy choices, symptoms of acute coronary syndrome, and several survivors take to the field along with their family, bystander rescuers, pre-hospital and in-hospital care teams to highlight the import role each of them plays in the chain of survival.    

The main goal of the CPR at the Park event was to educate the public on the importance of bystander action in the chain of survival through highlighting survivors and their rescuers willing to share their stories.  This event also provides an opportunity for survivors and their families to reconnect with the responding EMTs and paramedics – an opportunity that makes a difference in the lives of those responders. 

"It is incredibly humbling to know that I was part of a team that contributed so profoundly to the positive outcome another person's most perilous moment. Meeting someone, and their family members, face to face after having witnessed them so close to death was extremely inspiring. So far in my career, this success has been the ultimate expression of why we do what we do in EMS.  In particular, it was amazing to have the opportunity to meet our young patient's father. He was present during a portion of the resuscitation attempt, and I remember feeling guilty that in the midst of the resuscitation efforts I couldn't give him more detailed information about what was happening to his daughter. I recall that as we left the scene, the only thing I was able to tell him was "she has a pulse again." So, to later shake that man's hand and see him standing alongside his healthy and happy young daughter was something I will remember for the rest of my career" shared John Drees, paramedic with Gold Cross. 

I had the privilege of speaking with Don, one of the cardiac arrest survivors that participated in the 2017 CPR at the Park game.  Don ran one of the local 5k’s in May 2017; after completing the race, he didn’t feel well and found a shady place to rest near the finish line.  A few friends and medical volunteers recognized the warning signs and flagged down the paramedics from the staged ambulance for further evaluation and treatment.  Don was having a STEMI, went into cardiac arrest in the ambulance, was resuscitated and transported to a local hospital for definitive treatment.  Don ran the same 5k this year, on the one-year anniversary of his arrest.  Gold Cross arranged for the treating crew and the bike team to support Don through the 5k and meet him at the finish line.  Don shared what it meant for his heroes, as he calls them, to be there to support him:

“I am so very thankful for those who helped not only me but all the others who need the emergency help.  The people were very professional and friendly. I enjoyed talking to them after the Sole Burner Run.  I appreciated the gal who joined in with me up the Hill of Hope! It gave me a boost!  You certainly have a great team!  I know that many times there are people who are not as lucky as I am. It must be hard on one’s mind to go through that.  My father passed away from heart disease when he was only 50. I never knew his parents, my grandparents, because of the same.  I thank God and your team at Gold Cross Ambulance.”

Gold Cross has a busy summer ahead of them with public education and outreach events to include hands-only CPR, AED and Stop the Bleed.  They are also in the process of rolling out PulsePoint Verified Responder; they will be joining five other agencies in the country in alerting their off-duty EMTs and paramedics to a cardiac arrest in private residences, so they can respond and administer CPR.  This program is completely voluntary for employees and is in addition to the existing PulsePoint Respond app.  They will be sharing more about their community outreach program, and PulsePoint, at the Paramedic Systems of Wisconsin conference this September. 

By Samantha Hilker

Amid a national opioid crisis where there seems to be heroin everywhere you look, EMS services are struggling to obtain medications needed to treat patients.  As we continue to have conversations about the impact of these drug shortages on local, state and national levels a quote from The Rime of the Ancient Mariner keeps rattling around in my head; 

“Water, water, everywhere and all the boards did shrink.  Water, water, everywhere, nor a drop to drink” Samuel Taylor Coleridge

Many have cited the over-prescribing and easy availability of opioid medications as the underlying cause for the current opioid crisis and, in response, the FDA and DEA reduced the number of opioids that could be produced in 2017; on the list of reductions was morphine, fentanyl, and hydromorphone among others.  The overall goal of implementing the quota system as outlined HERE was to “reduce the potential for diversion of schedule II medications for non-medical use while maintaining production for legitimate medical use through a 25 percent buffer for supply levels in 2013 through 2016.”  According to the article, much of the reduction ordered for 2017 is a result of eliminating the overstock related to the 25 percent buffer. 

The ordered reduction of schedule II drug manufacturing coupled with Puerto Rico (the home of a major medical supply and drug manufacturing facility) being essentially wiped out by hurricane Maria is leaving EMS services across the country between a rock and a hard place.  On the surface, it seems like a relatively easy fix – one medication is in shortage and becomes hard (or impossible) to obtain, so you chose an alternate and amend your protocols.  But what do you do when your alternative hits the shortage list and becomes hard (or impossible) to get?  How do we appropriately balance delivery of high-quality patient care while constantly adjusting protocols and supply while avoiding medication errors? 

Dr. John Russell, President, Cape County Private Ambulance, and Chair, AAA Professional Standards Committee offered the following insight:

“Morphine is short for a couple reasons, prefilled syringe manufacturing issue being one, the second being the FDA and DEA sets a limit on how much narcotic can be manufactured in a year. Fentanyl has become the drug of choice for most EMS medical directors for narcotic pain control due to its predictability, short half-life (wears off quick) and it has less hypotension potential than morphine. Again, Fentanyl prefilled syringes are short because of the syringe issue but ampules and vials seem to be available, we just have to practice good drug administration techniques (filter needle to draw up from the ampule, double check dosing with our partner etc.) Hydromorphone (Dilaudid) has been a popular alternative to morphine particularly in hospital but it too is now in short supply mostly from increased demand and hoarding. As you can see there is a domino effect on the drug class when one goes short the demand is moved to another and it becomes a vicious cycle.

Alternatives to opiate pain meds include IV Acetaminophen, Ketorolac (Toradol), and even oral meds such as naproxen and ibuprofen. Certainly, the armed services have successfully used Ketamine for pain but generally speaking it’s a niche drug for trauma use and comes with a whole set of side effect and management issues most paramedics are not familiar with.

When we are forced into an alternative presentation of a drug such as epinephrine or fentanyl vials, we prepackage everything needed to administer in a Ziploc bag and label the bag.  a vial of med, appropriate syringe or saline if the drug needs to be diluted, a filter needle if the drug is pulled from ampule or a safety draw needle if from a vial. We also put a cheat card in to make clear the amount to be administered for a particular dose.

We eliminated D50W and D25W from our drug list and instead now just infuse a bolus of D10W from a 250cc bag at 1 ml/kg of patient weight. Works well. Cheap fix.

As for epinephrine we package a 1cc 1 mg 1:1,000 vial or ampule with a 10 cc saline flush syringe and draw needle. We instruct the medic to waste 1 cc of the flush, draw up 1cc of 1:1,000 epi and mix well (functionally now 1:10,000) or 1 mg in 10 cc of 1:10,000 which is the same as the prefilled syringes commonly used. Similar kits can be put together for other drugs.”

Several services in Wisconsin have a state-approved protocol to utilize expired medications in times of shortage – Bell Ambulance has graciously shared their expired medication policy, so others can use as a template for creating one for their service.  Dr. Suzanne Martens, Medical Director, Orange Cross Ambulance and State of Wisconsin EMS Medical Director encourages services to put together reasonable training plans and protocols for alternative medications that can be submitted to the state for approval, and potentially shared as models for other services. 

DOWNLOAD SAMPLE EXPIRED MED POLICY

This is an issue that is affecting EMS and hospitals across the country and there are no magic answers, only band-aids, and workarounds.  New protocols, different medications in varying concentrations and packaging, and use of multiple vendors are all tactics used by services to manage the supply chain interruption.  Dr. John Russell illustrates the current situation brilliantly with the following statement:

“… these are stop-gap measures and certainly raise the chance for medication error and take more time to use but until the supply system gets fixed I’m afraid we will be playing McGyver with a lot of our drugs.”

References

Affairs, D. P. (2016, October 4). DEA Reduces Amount of Opioid Controlled Substances to be Manufactured in 2017. Retrieved from DEA: https://www.dea.gov/divisions/hq/2016/hq100416.shtml

Braithwaite, MD, MPH, S., & Myers, MD, MPH, B. (2013). Retrieved from http://www.naemsp.org/Documents/2013%20Annual%20Meeting%20Handouts/HANDOUT%202013%20Myers%20Drug%20Shortage.pdf

Drug Shortage. (2018, March 26). Retrieved from U.S. Department of Health and Human Services: https://www.fda.gov/Drugs/DrugSafety/DrugShortages/default.htm

Lynch, S. N. (2018, April 17). U.S. drug agency proposes rules to rein in opioid manufacturing. Retrieved from Reuters: https://in.reuters.com/article/us-usa-justice-dea-opioids/u-s-drug-agency-to-propose-rules-to-rein-in-opioid-manufacturing-idINKBN1HO2U1

Pharmacists, A. S.-S. (2018). Drug Shortage List. Retrieved from American Society of Health-System Pharmacists: https://www.ashp.org/Drug-Shortages/Current-Shortages/Drug-Shortages-List?page=CurrentShortages

Thomas, K. (2017, October 23). U.S. Hospitals Wrestle With Shortages of Drug Supplies Made in Puerto Rico. Retrieved from New York Times: https://www.nytimes.com/2017/10/23/health/puerto-rico-hurricane-maria-drug-shortage.html

By Samantha Hilker

Gundersen Tri-State Ambulance, a longstanding member of PAAW, is doing some great things in their corner of the world, so we’re shining the spotlight on them!

This past December, conversations about the use of essential oils to support patients experiencing pain, nausea and anxiety started shaping a new program for the La Crosse-based service.  The national opioid crisis is causing many healthcare organizations, and individual providers, to look at the way some conditions, like pain, are addressed.  When Dr. Chris Eberlein, Medical Director for Tri-State Ambulance and ER Physician for Gundersen Health System, started seeing the way essential oils were used to support patients within Gundersen, he wondered if there might be an application for EMS.  “I noticed that many of the patients given small doses of Fentanyl or other narcotic pain medications in the field were not leaving the ER with a prescription for painkillers – they didn’t need it.  I thought there must be something different we can do to support them without administering opiates.  The field providers (and their patients) didn’t have any other options, until now” recalls Dr. Eberlein. 

Essential oils work on the limbic system, the same system that controls our fight or flight response.  When someone breathes in the oil our olfactory nerve cells carry the essential oil into our brain. They bypass the thalamus and enter the limbic system through the cerebral cortex which lies just above it.  Scent is a powerful thing that, for many of us, triggers an immediate and intense response such as memories or nausea; it only makes sense they can have a calming effect on the senses as well.  Dr. Eberlein, Nick Eastman, Operations Supervisor – Clinical Services, connected with Denise Nicholson, Registered and Certified Clinical Aromatherapist, who leads the essential oil program at Gundersen Health System.  Denise is also an RN, BSN, Advanced Care Plan Facilitator and Nursing System Specialist with Gundersen and has studied essential oils extensively; she believes in their benefits and application for use because she has seen the patient response.  Both Gundersen and Tri-State follow the British and German models of use (inhalation and absorption), not the French model (ingestion).  “The oils are delivered by putting a few drops on a cotton ball, then taping that to the patient’s chest or by rubbing a small amount of diluted oil on the pads of a patient’s feet.  Inhalation is the fastest and safest way to deliver essential oils to a patient, but absorption can be beneficial in certain circumstances as well,” Denise explains. 

Tri-State is now carrying six (6) different essential oils on their paramedic units and has a specific procedure for their use.  “I want to make it clear that the oils are an adjunct, not a replacement for standard treatments or medical protocols.  Although we didn’t implement these oils to manage the current narcotic shortages EMS services everywhere are experiencing, we are hoping the use of the oils allows us to support patients without using as many narcotics.  We have also added non-narcotic pain medications to our pain management protocol,” Dr. Eberlein clarifies. 

DOWNLOAD PROCEDURE

Company-wide use at Tri-State has just started and although Gundersen has been using them for some time, they have not done any formal clinical trials.  Anecdotally, however, the results are changing skeptics into believers. 

“We have one long-time paramedic who was part of our pilot group who is a bit of a skeptic.  During his introduction and education on essential oils, he decided to try some for his plantar fasciitis.  He purchased some from Gundersen (available in the hospital gift shops) and applied it to the soles of his feet…within 30 minutes his feet were pain free for the first time in years.  I think it’s safe to say he’s now one of the programs biggest supporters,” Nick Eastman shared. 

It is important to note that any service looking to implement a similar program must do their due diligence and research the use, benefits and safety of essential oils before including them in their supportive measures.  Essential oils are not regulated by the FDA and are not an alternative to standard medical treatments; some can interact with prescription medications.  Any service looking to implement essential oils as a supportive measure should also spend time researching the supplier of any oils they might incorporate into their system.  There are a lot of direct-sales companies selling essential oils these days, and you can even purchase them on Amazon.  Gundersen works with a supplier who only works with healthcare providers and is a certified and registered clinical aromatherapist; the oils go through extensive testing, so the providers and patients can be confident in what they are getting. 

PAAW is proud of the work Gundersen Tri-State Ambulance is doing and their willingness to share their experience with other services across the state – a shining example of how we are stronger together. 

Resources:

• Price, S., & Price, L. (2012). Aromatherapy for health professionals. Edinburgh: Churchill Livingstone.
  
• Buckle, J. (1997). Clinical aromatherapy in nursing. London: Arnold.
  
• Tisserand, R.,& Balacs, T. (1995). Essential oil safety, a guide for health care professionals. Edinburgh: Churchill Livingstone.
  
• Kevelle, K. (1999).  Aromatherapy for dummies. Wiley.
  
• Johnson, S. (2015) Evidence based essential oil therapy: The ultimate guide to the therapeutic and clinical application of essential oils. Johnson
  

Visit the Midwest EMS Expo Facebook page to see photos of last week's expo and educational sessions. 

More information about 2019 coming soon!

Our thoughts go out to the Paramount Ambulance team, whose staff member passed away in the line of duty in Iowa this morning. Our deepest condolences to family, friends, and colleagues.

PAAW is deeply saddened to learn of this morning's tragic helicopter crash. Our hearts are with the families, friends, and colleagues of those who passed away in the line of duty. Our deepest condolences to the Ascension Spirit team.

By Samantha Hilker

Patrick Ryan, co-owner of Ryan Brothers Ambulance and current PAAW board member, worked furiously to correct a problem some services may not have known they even had. 

A few weeks ago, Patrick noticed something strange.  The MTM transfers were being reimbursed at $1.75/mile instead of $5.56/mile, and even more curiously, some were being all out denied.  A deeper look revealed a potential cause of the problem: billing codes.  Typically, BLS and ALS transports are submitted to MTM with the codes A0380 and A0390, respectively, whereas the code reserved for stretcher vans is A0425 with a reimbursement rate of $1.75. 

“On some shorter trips, the difference wasn’t that much and might not be immediately obvious as it would on the long-distance transfers.  Depending on the services typical number of MTM transports and their distance, they may not have even noticed a change in their reimbursement rates for MTM trips.  It was a few long-distance trips that really raised the flag for us.”
—Patrick Ryan 

Patrick started making phone calls to other PAAW members to find out if they had noticed any of the same with their MTM authorizations and claims; sure enough, Patrick wasn’t alone.  He then reached out to MTM and DHS to find out more.  After many phone calls and email conversations, it appears the issue was one of miscommunication and misunderstanding. 

DHS has submission requirements that MTM must follow when submitting claims to DHS.  This is not to say that DHS can, in any way, enforce MTM’s provider submission expectations; so, when DHS made a request to MTM regarding code A0425, it should not have affected how ambulance service providers were being reimbursed from MTM.  As of this morning, PAAW received confirmation that MTM has revised their position on the ambulance codes and will allow providers to submit under codes A0380 and A0390 so they can be paid appropriately for the level of service provided.  MTM will also be pulling all claims that were denied for not being coded as A0425 and will be working to get them corrected and paid.  At this point, it looks as though there will not need to be any action taken on the part of the Ambulance Service Provider, however, you may want to look at your recent MTM transfers to see if you were affected. 

This is a great example of how PAAW benefits its members by building a network of professionals who are willing to step in, take the lead and find the answers; not only for their own service but to the benefit of services across the state.  Way to go, Patrick—PAAW is proud to have you!