Thursday, February 1, 2018

Times a' Changin' in Peoria

Peoria Fire Department--Advanced Life Support
January 29, 2018

I was at a location the other night and a person suddenly passed out. PFD E3 arrived in a matter of minutes and began evaluating the patient. AMT arrived about 4 minutes later. Both teams of medics worked together very well. E3 just became ALS-First Response on January 1.
Nothing I have to say in this post has anything to do with the providers from AMT or the PFD who are working the streets in real time. The EMTs' assessment of the patient when first evaluated and the evolution of the patients' course with their interventions was very important for me as I evaluated the patient upon arrival in the ER.
John Carroll---Forum Article, PJS--January 27, 2018
Let Peoria firefighters provide advanced life support
On Jan. 1, Peoria Fire Rescue 1 on Monroe and Engine 3 on Armstrong became Advanced Life Support First Response.
They join three other advanced life support engines in Peoria — Engine 12, Engine 20 and Engine 4. This is the first time Peoria firefighter-paramedics from Rescue 1 and Engine 3 have ever been able to provide independent advanced life support when they arrive at a 911 call. Sick and injured patients no longer need to wait precious minutes for Advanced Medical Transport (AMT) to arrive.
Why did our local project medical director, Matt Jackson, M.D., allow these two Peoria fire engines to upgrade to Advanced Life Support First Response now? During much of the last two years, Dr. Jackson had opposed any PFD engine upgrade from basic life support to advanced life support.
In August 2017 Illinois House Bill 1952 was signed into law by Gov. Bruce Rauner. It stated that the “ambulance assistance provider shall be authorized to function at the highest level of EMT license … held by any person staffing the ambulance assistance vehicle.” This means that if there is a Peoria fire paramedic on a basic life support engine, and if Dr. Jackson approves, this paramedic can now provide advanced life support immediately upon arriving at the scene of a 911 call.
There were more than 19,000 medical 911 calls last year in Peoria. Peoria Fire has enough paramedics to staff all 12 engines. This law should help level the playing field in Peoria between AMT, which is supported by the powerful medical and business communities, and the shackled Peoria Fire Department, which wants to provide advanced life support for all the people of Peoria.
This two-decade-long EMS saga in Peoria shows how medicine, politics and money intersect at a dangerous point. The project medical director in Peoria should keep money and politics out of the equation and allow all of the remaining Peoria fire engines that are basic life support to become advanced life support.
John A. Carroll is a medical doctor. He lives in West Peoria.
Now the following paragraphs will be a "deeper dive" into the above article, and I will start out with this quote from Councilman Jim Ardis from the PJS in 2002--
Councilman Jim Ardis: ”If we want to have a highly trained fire and medical department in the city, there is nothing that AMT can do to prevent us from doing so.” I don’t think that anyone can make the argument that anybody would not want the best-trained people to be there for them all the time in case of an emergency. Why would you not want that?”
1. Two Engines, Rescue 1 and E3 just became ALS for the first time.
Over the last two years, there have been frequent discussions at the City Council, AMT, PAEMS, and the Peoria Fire Department. The PFD wanted to upgrade Engine 19 from BLS to ALS. The PFD has firefighter-paramedics at the station now who are not able to provide paramedic skills when they arrive at a 911 call before AMT arrives. But Engine 19 was denied their upgrade. E19 on the northwest side of Peoria is still BLS.
Dr. Jackson made a power point presentation to the City Council in 2017 and wrote several letters to the City Council stating that he saw no reason for the PFD to upgrade ANY Engine in Peoria to ALS.
It is amazing there was no media coverage when the PFD was allowed to upgrade two Engines on January 1. The silence in Peoria over this upgrade is incredible but understandable for the powers who control EMS in Peoria.
Most of Peoria has no idea that the PFD is mainly BLS. Most people have no idea that these two stations just became ALS. Most people have no idea that Dr. Jackson gave his approval for these two stations to become paramedics. Most people think that the PFD paramedics can function as paramedics...but the truth is that today when 911 is called, most PFD paramedics on duty cannot offer independent life support. And I will explain why.
We have 12 Fire Stations in Peoria but only 5 of them are ALS--12, 20, 4, 1, and 3. However, all 12 Engines could be ALS because we have 55 PFD Medics. I will come back to this in a second.
And I want to emphasize that AMT is the only provider in Peoria who can transport the patient. AMT is supported by the titans of Peoria--Peoria's three hospitals, influential businesses, and by many of our politicians. AMT's revenues are 23 million dollars transporting patients around the state of Illinois. That is where the money is. I want to make it clear that during the last two years the PFD was not asking to transport anyone. The PFD does not own an ambulance.
2. Bill 1952
What did Bill 1952 really mean?
The idea for the creation of this bill came from Peoria but was sponsored by representatives from different parts of Illinois...specifically NOT by Peoria's representatives. The feeling is that our sponsors representing Peoria could shy away from supporting Bill 1952 due to the hot politics in Peoria regarding EMS.
What do I mean by hot politics? How can an issue of prehospital care in Peoria be a hot topic? The answer is AMT wants to remain the only transport/ALS business in Peoria like it has been for the past 25 years. And when AMT is supported by Peoria's bosses, the influential business and medical community in Peoria, beware if you rock the boat. There is a lot of money involved. And when AMT and PAEMS, which is located at OSF, put obstacles in the way of the firemen, politicians are simply afraid of AMT and OSF and the business community. The politicians want their support and their money. Big businesses stick together. OSF supports AMT. In other words, our local politicians don't want to make AMT and OSF upset with them.
Well, this bill was written to help Peoria Fire Fighters give advanced life support in Peoria.
Having said that, Bill 1952 passed unanimously except for Ryan Spain who voted "present" due to several family members being on the Board of Directors at AMT. In other words, all of the state representatives voted that they believed that paramedics on a basic engine anywhere in the state of Illinois should be able to offer ALS at the medical 911 call. This, of course, makes sense. The bill was signed into law in August by Gov. Rauner. Every representative in the state of Illinois voted "yes" except for Ryan Spain.
I want to make clear that R1 and E3 in Peoria did not become ALS under this new law from Bill 1952. I happen to believe they were "gifts" to the PFD by the project medical director. Why do I call them gifts? I think that since Bill 1952 now gives all the Peoria Fire Engines ability to be ALS if the PMD signs off. Unfortunately, I believe that the PMD has plenty of pressure put on him to keep the PFD as "basic" as possible.
However, did you know attempts were made in Springfield to stop Peoria from being covered by Bill 1952? Oh, yes. There is a lobbyist in Springfield named Molly Rockford who was hired by the Illinois College of Emergency Physicians (ICEP) and represented ICEP. She lobbied that Bill 1952 should pass for the entire State of Illinois...except for Peoria. Sounds incredible, doesn't it? Why would she lobby for this? Why would ICEP not want Peoria included where the PFD paramedics would not be allowed to provide advanced life support at the scene? I don't know for sure. But I do know that George Hevesy, who still works at OSF and is the President of the Corporate Board of AMT, was the President of ICEP years ago and is a councilor on the Board of ICEP now. (Another OSF physician holds a similar position on the ICEP Board.) In other words, ICEP lobbying to exclude Peoria from Bill 1952, MAY lead right back here to Peoria.
3. So, this brings up the next question: I wonder what the PFD needed to do to swap this time with AMT and PAEMS to give more Peorians advanced care.
Why do I say swap? Because it is a matter of politics and money and making deals in Peoria. This discussion has never been about providing improved patient care.
Right now our politicians in Washington, DC are bartering for the lives and futures of about 2 million immigrants under DACA and the Dreamer's children versus a 25 billion dollar wall and enhanced border security. In DC they are bartering 2 million lives for a 25 billion dollar wall to be built along the Mexican-US border. That is how politicians work.
So what does this have to do with Peoria? I will tell you.
In 1996, the PFD wanted to upgrade their service from BLS to Intermediate Life Support for the people of Peoria. But the PFD didn't quite make it. In fact, the headline of an article in the Journal Star from May 1, 1996 stated:
“Ambulance Plan Abandoned–Fire Department to Add Defibrillation Program”.
The PFD met resistance in 1996 from AMT's CEO Andrew Rand and from George Hevesy, MD who was PMD and receiving a salary from AMT and from OSF.
Rand, of course, did not want the PFD to upgrade.
Rand stated that the PFD should spray the "wet stuff on the red stuff" and stay out of EMS. Dr. Hevesy, his sidekick, explained to the City Council during those years that there would be "duplication of services" if the PFD upgraded.
The PFD finally backed down to the powers that be but were able to do something very incredible for the people of Peoria. The PFD stated that if you give us the ability to defibrillate patients we will not seek to upgrade. This was truly amazing.
So the trade was electricity to save lives for PFD BLS engines that would not upgrade to ALS.
When a person's heart stops suddenly and they are in cardiac arrest, their heart is usually beating too fast or quivering and needs to be shocked to start beating again effectively. And for each one minute the heart is not shocked, the chances of recovery go down by 10%. So if the person has a witnessed arrest and five minutes go by before the first shock, the chances of that person coming back are down 50%.
Defibrillation with portable monitors has been done since the 60s. It is the only proven weapon to save people from out of hospital cardiac arrests.
In 1996, defibrillation, or shocking the patient, was standard of care around the developed world even for Basic Engines like all 12 of the PFD Engines. But amazingly the PFD in Peoria was not using the best technique to save lives in out of hospital cardiac arrests--electricity.
AMT WAS using electricity. Why wasn't the PFD? I was a resident physician at OSF in the early 80's and people were shocked frequently in-hospital and out-of-hospital cardiac arrests. It was called "standard of care".
How many people died in Peoria as outpatients prior to 1996 because they were not shocked in time by the earliest arriving EMT which was usually the PFD?
Our Basic PFD, of course, should have been shocking people back to life..but they weren't. Where was Dr. Hevesy? Did he insist to the City Council that the PFD as BLS providers use defibrillators? If he did, I am not aware of it.
Why did our PFD have to barter to shock people in 1996? Because that is how it works in Peoria. I wonder what would have happened if the PFD still wanted to upgrade? Would Hevesy and Rand have told the PFD that they would remain as they were--BLS without the paddles to shock the patient?
4. What happened in the 2000's?
Early in the 2000s, after the death of a man at a restaurant in Peoria where the firefighters were first on the scene but unable to use ALS skills, Rick Miller was the PMD. Behind the scenes, Miller changed the protocol, which stated that the PFD paramedics could use their skills only when the AMT paramedics arrived. This was never published in the newspaper or in the public media in Peoria-- just like we have today with R1 and E3.
And as the years went by in the 2000s, even though I was told it was a dead issue at the City Council meetings by someone who was high up in the ranks, three stations were able to upgrade--Engines 12, 20, and Engine 4. And it took until 2013 for this to happen. Please remember, that even though these three Engines became ALS, they did not have an ambulance and transport was not a possibility. And it still isn't today in 2018 for the PFD. Transport is where the money is for AMT and they don't want to lose it.
Peoria EMS has been fraught with problems for years. In my opinion, the PFD has been obstructed for years in their battle to provide ALS for the people of Peoria.
Last year the PFD voices were silenced for fear of a significant fine or imprisonment. Peorians as a whole are quiet also because they don't want to lose their jobs, their health insurance, and their seat at the Peoria Country Club. And well-meaning citizens have been threatened with possible lawsuits if they dissent too much. And as I said before, THE PFD HAS BEEN THREATENED WITH FINES AND JAIL TIME IF THEY SAY TOO MUCH.
In my opinion, it has never been about patient care in Peoria. It is about money.
People in Peoria don't know that their tax dollars are being wasted. The PFD medics make 2.5% more than a non-medic. And if these medics are not allowed to use their skills for the 911 patient, what is all of this about?
So what needs to happen?
With the recent passage of Bill 1952 into law, the next step should be that the PMD gives his approval for the remaining 7 BLS stations to become ALS. They would need a four thousand dollar box filled with ALS material on their Engine to function as independent paramedics--just as AMT has done for the past 25 years.
I think there has been a concerted effort to keep the PFD from upgrading during the last 22 years. Bill 1952 is law and can be used by the Basic PFD Engines if Matt Jackson, MD, the current Project Medical Director, agrees. Dr. Jackson just signed off on R1 and E3 to become ALS, which goes against what he has been saying and writing during the last two years.
For the Peoria neighborhood not covered by an ALS Engine, it will take a critical mass of people to influence their City Council Members to advocate for the Engine upgrade.
Clearly, the people who have controlled EMS in Peoria for a quarter of a century need to be replaced now. A fire chief of a very large city in Illinois told me years ago regarding EMS: "You have a very unfortunate situation in Peoria." And we still do.
"These titans stick together in the way that many titans do, not because they share some special affection or particular philosophy but because each sees in the others’ stature an affirmation of his own." (NYTimes)

John A. Carroll, MD
January 29, 2018

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