"There were services participating at certain times of the day, at certain days of the week, with different priority-level calls," Richmond explains. "We now have all 18 fire departments providing 24/7 response capability to certain priority-level calls at a minimum. Most have also agreed to cross jurisdictional boundaries. So for the first time, we have them thinking about mutual aid for emergency medical calls, not just for fire calls. That's going to have a tremendous impact."
Other innovations have included paramedic fly cars for increased response efficiency, and creating an associate's degree program for medics at the city's Spalding University. Response times have been cut. Protocols have been rewritten to more clearly delineate the duties of LMEMS personnel in things like hazmat and technical-rescue incidents. Medical changes are likely to come next.
"We have a whole list of things we want to get to," Richmond says. "Now that the system's running, we can start to really take apart the protocols and introduce some things. It'd be really neat to pioneer some new approaches and use this as a testing ground for new technologies and skill enhancements, education and training."
With any large-scale EMS transition, there are bound to be bumps. But Richmond's boss is pleased with the first year's results. Says Louisville Metro mayor Jerry Abramson: "We have more EMS personnel than ever before. We have more ambulances than we had adding the old city and county departments together. We've added the fly cars, and this new paramedic program is just superb. We couldn't be happier."
A Statistical Bounty
Serving as medical director for one major metropolitan area can be difficult. Try doing it for two.
As medical director for Oklahoma's Emergency Medical Services Authority (EMSA) and its Medical Control Board, that's John Sacra's job. His agency serves 1.1 million people in central and northeast Oklahoma, including both Tulsa and Oklahoma City.
"It makes things interesting," says Sacra, whose career in emergency medicine spans back more than 30 years. "I spend a lot of time in my car and videoconferencing, but it's rewarding. It gives us a great deal of economy of scale, as well as providing a lot of clinical data."
Data is important, and EMSA has a unique opportunity to collect it. Two major metro areas with the same protocols, same provider training and same quality assurance processes can yield a statistical bounty that might not be possible in other systems.
With a pre-EMS background in trauma systems, Sacra was well aware of the need for data and how useful it can be in evaluating what you do.
"I saw, in organizing resources for optimal trauma care, how some of the things we intuitively thought would make a difference, when you started really looking at the evidence, just didn't," Sacra says. "MAST trousers are a good example. There were a lot of things that fell by the wayside when you started to look at the evidence. And that's what intrigued me about getting into EMS: We've really not tapped into the public-health potential that emergency medical services have for the communities and citizens they serve. You really have to get into looking at the data in order to show that."
In the quest to make better use of the information available to it, EMSA began utilizing electronic patient-care reports and automatically reviewing all its runs. This provides a wealth of information that, in turn, feeds system improvements.
One example: a movement early in Sacra's tenure to put paramedics in all the region's fire stations to improve cardiac arrest survival rates.
"We studied our chain of survival and realized that our weak link wasn't advanced life support, it was time to first shock and bystander CPR," Sacra says. "If we'd just had a knee-jerk reaction and put more paramedics into the system, we'd have missed an opportunity to truly improve. And where we have improved our system now is getting more citizens trained in CPR and encouraging our medics to get to the scene faster with their defibrillators."
Back then, bystander CPR occurred in about 33% of witnessed arrests. Now the rate is around 50%.
Another initiative involved reorganizing the cities' trauma systems based on the types and rates of patients being seen. "We couldn't have done it," Sacra says, "if we didn't have the data."