As a student at Georgetown University in Washington, D.C., Sabina Braithwaite, M.D., M.P.H., decided she’d better get some firsthand experience working with sick and injured patients before she took on tens of thousands of dollars in loans to go to med school. She’d seen too many of her fellow budding doctors change majors when they discovered they were unable to deal with blood and other body fluids.
So she got some EMS training and joined the campus rescue squad, Georgetown Emergency Medical Response, cheekily known as GERMS. “The guy who started it had a real sense of humor,” Braithwaite says. Turned out she liked the work and later volunteered for nearby Fairfax County Fire Rescue.
“I learned that people need help in lots more ways than just by stopping the bleeding, that sometimes you can be even more useful by being an empathetic human being, listening to them and understanding what their needs are,” she says. “I was also hooked on the whole emergency part of it, the team atmosphere of being in the trenches where you get to know each other pretty well and when you function together well it helps the patient.”
Braithwaite worked as an EMT for Central Virginia Ambulance Service (later Richmond Ambulance Authority) when she was a med student at Medical College of Virginia and became a paramedic during a four-year emergency medicine internship and residency. After brief stints working in emergency departments at hospitals in Halifax and Richmond, Va., she joined the faculty at the University of Virginia, where she spent the next 12 years. She also served as medical director for Albemarle County Fire-Rescue and received a master’s in public health.
In August 2010, Braithwaite became medical director for Sedgwick County EMS, which includes the city of Wichita, Kan., and encompasses about a half-million people over a 1,000-square-mile region.
“When you work in the back of an ambulance, you can help one patient at a time,” she says. “When you work in an emergency department, in a busy shift you may see 40 people. When you’re an EMS medical director, you’re responsible for a whole lot more people. Even making small changes can have a positive impact on a large number of people.”
Braithwaite, who is also the EMS committee chair for the American College of Emergency Physicians and chair of the steering committee on ACEP’s “Creating a Culture of Safety in EMS” project, spoke with Best Practices about what the public needs to know about EMS and the importance of improving safety for both patients and providers.
How did the Creating a Culture of Safety in EMS project come about, and why is safety in EMS emerging as such an important issue now?
It’s something that’s been on people’s minds more and more. The idea for this came out of discussions at NEMSAC, which recommended the project to NHTSA. There was a feeling that although there are many strong efforts to promote safety from every perspective in EMS, they are not well linked together and not broadly adopted, and there was a need to create a path to lead us to a place where safety permeates everything we do.
The airline industry used to have plane crashes all the time, and now they don’t because of some of the changes that the industry made. Some things in aviation are comparable to EMS, but other things aren’t, because dealing with patients is different than dealing with airplanes.
We had a national EMS stakeholder meeting at the end of June ,2011. We had presentations to get everybody thinking in different ways about what safety is, what the obstacles are, what we need to do from a management level, and how we can support it on an institutional, agency and legislative level, but also how we can make it work all the way down to the individual provider taking care of a patient.
What are the central issues that are emerging?
What we’re trying to do is not get too far down in the weeds of what needs to be done, but create a mentality in EMS that looks for the safest way to do any given thing, whether it involves provider, vehicle or patient safety.
When we go to work in an EMS system, we want to know that the systems are aligned in a way that we won’t crash the truck, we’ll give the right medication, we will be able to do all the interventions we need to do for the patient, we’ll deliver the patient safely, and we will communicate all the appropriate information to the receiving facility. We also need to be able to evaluate what we do, institute changes as we learn more and make sure the funding is in place to support those kinds of things.
What’s holding EMS back in terms of its development as an equal partner to fire and police?
Is EMS supposed to be an equal partner to fire and police? That’s part of the struggle that EMS has. There isn’t unity on where EMS belongs. What’s certain is it needs to establish itself as part of the medical professional community. Even though we operate in an environment similar to fire and police, our core function is medical care of patients —and in a larger sense, medical care of a community from that systems level.
A lot of that identity crisis issue has been talked about in various places as the Field EMS Bill has been developed, and a lot of high-level folks in the government have been listening to that. The Field EMS Bill is advocating for the primary federal agency for EMS to be housed in the Department of Health and Human Services. I think that’s a good idea. But the funding streams that have evolved to support EMS infrastructure have come from a number of different places, and part of the challenge is ensuring those funding streams continue and coalesce, that long-standing initiatives continue and that NHTSA’s leadership isn’t disrupted.
NEMSAC was created by NHTSA as an advisory council and led to this Culture of Safety initiative. EMS wouldn’t be where it is without the vision of people who have led the Office of EMS at NHTSA over the years. They have created some far-reaching projects that have helped us better understand what we are providing, how we are providing it and how we can do it better, such as the National EMS Information System. But at this point EMS needs to embrace medical function as its primary function. It’s not a transportation function anymore.
Why is ACEP so interested in promoting EMS Week every year?
Part of what ACEP wants to do is thank EMS providers for what they do every day, to help increase public awareness of the services EMS provides and of the tight linkage between the emergency physician community and our EMS providers.
We very much think of EMS as partners and part of our team as we provide emergency care. Over the past number of years, it’s become more and more obvious how tight that partnership is. When we work closely together, we do a better job taking care of our patients both inside and outside the hospital. To some degree, we’re trying to emphasize that there is a very strong linkage as we work together to create a bridge for patients to have a seamless experience from outside to inside the hospital.
Those things include having the systems in place that facilitate that. How do we create those systems? Evaluate clinical importance? How do we make decisions about what treatments we need to offer? How do we make sure our providers have the education and the clinical confidence to provide those services, that they have an appropriate scope of practice and that we are doing active research to evaluate that, learn how to do it better and push the time envelope on interventions for time-critical illnesses?
Part of EMS Week is also about educating public servants on what EMS does, and what kind of support we need from them for funding research and reimbursement so we can provide the services that are needed.
What message does the public need to hear about EMS in general?
They need to understand in what ways EMS has a meaningful impact on emergency care in their community, and how the entry point to the emergency care system is as close as your phone and dialing 911 and yet there is a lot more to EMS than something with four wheels and a siren. There is a whole system that needs to be in place and ready—from the education of providers to a system that’s integrated with the other partners in emergency care.
You contrast that to 40 years ago. I was recently looking at a current statute, and it still refers to ‘ambulance drivers.’ I thought, Wow, we still have a long way to go. We’re not ambulance drivers. EMS is a much stronger partner and advocate for the emergency patient and is really pushing the envelope in emergency patient care even more so than we did 10 years ago. That is incredibly exciting. Now, with the EMS subspecialty certification for physicians, it’s being recognized that EMS is a unique field of knowledge and physician practice and that there are very specialized things we do to take care of whole communities through EMS systems. An integral partnership between physicians and EMS helps promotes improvement in emergency care across the board.
Does the public have misconceptions about EMS?
When people don’t know what else to do or who else to call, they pick up the phone and call 911. They call if there’s a squirrel in their chimney. We don’t handle that, but in a way, you don’t want to take that away from people. 911 is the entry point into the emergency care system, especially for the people who have the least access to care. EMS is part of the safety net for health care.
In the era of rapidly shrinking budgets and having to decide how we’re going to allocate ever smaller resources, we need to help the public understand that sometimes when you call 911, we’re going to need to figure out if you have a time-critical issue or not, and when we find out you don’t, we don’t need to have somebody come screaming across town with lights and sirens.
It doesn’t mean they have no medical needs, but the public needs to have their expectations managed so that every call to 911 doesn’t have to be answered immediately by an ambulance. There may be other ways to deal with that, which may involve directing you to other resources. Every problem is not solved by calling 911.
What can individual EMS agencies do to promote themselves to the public and to other public safety and health care providers?
It’s largely educational. What can we deliver? Where are the opportunities in our community, and what things can we do with partners that we couldn’t do as individual health care agencies? How can we bend the traditional prehospital vs. in-hospital ideas to get better patient care?
In many ways the mindset of EMS is that we function outside the hospital. We need to mature that linkage and say we are just part of what happens, that we tee things up for the hospital and we can make things happen in the field that normally happen in the hospital. There really isn’t a brick wall. You look at the things related to STEMI or stroke and trauma — we have really decreased time to definitive care if you come in through the EMS system.
What I’ve done here in the past year is go around to meet people from the coroner’s office to the hospice agencies to the organ donation people to the health department to the medical school that you wouldn’t think of as obvious partners but that very much intersect with what we do. If we have a better understanding on both sides of what we can do, we can better service the needs of the patients.
Did anything specific come out of those meetings?
With the hospice folks, we’ve had long conversations about do-not-resuscitate orders and how we can coordinate what we do. Patients say they don’t like to have do-not-resuscitate orders over their beds because it’s creepy. When we arrive, a hospice nurse will tell you the legal document is on file, but the paperwork isn’t available when we walk through the door. The patients have made their wishes known, and we want to respect their wishes, but without the legal document we have a problem. We’re working on a centralized way to log DNRs.
What types of candidates do we need to attract to EMS to help it thrive? What do we need to do as a profession to attract those candidates?
We need people who understand they are entering a health care profession and all that entails. As a health care professional, you have a public trust. The public has certain expectations you need to be prepared to meet.
Improving pay goes along with being a professional. Nobody tries to pay a respiratory therapist $5 an hour. EMS providers are health care professionals, taking care of people who are critically ill. Is that a $23,000 a year job? No.
We have to educate the people who make those decisions. Otherwise, EMS providers can work as a tech in the hospital starting IVs, making more money and not getting rained on by the side of the road or shot at.
