gregory a. russell president john e. gray iii secretary-treasurer ndw f&es based emergency...

Gregory A. RussellPresident

John E. Gray IIISecretary-Treasurer

NDW F&ES Based

Emergency Medical ServicesInternational Association of Fire Fighters, Local F121

National Capital Federal Fire Fighters



NDW Regional FD Based EMS

This IAFF Local FULLY SUPPORTS EMS responsibilities assigned to the Fire Department.

Firefighters ARE the right people to be carrying out this essential emergency service provided they are given the proper resources and support services. This IAFF Local believes EFFICIENCIES are obtainable if an EMS Program is properly managed.



A Little History

EMS in the Navy has been applied haphazardly at best.• Mixed EMS programs with no real direction

• F&ES Based• BUMED/Hospital/Clinic Based• Contracted EMS Services• None At All – Rely on Outside EMS Agencies

“90% of the United States covered by Fire Based EMS” started in 1960s - Navy starts 2007!• Source: IAFF/IAFC “Fire Service Based

EMS”



A Little History (cont)

CNIC spent a couple of years “designing” the program to be rolled out to the regions.

• Looks like a version of a MIEMSS Program - Poorly Implemented

• Where are the “Checks & Balances” – Not Implemented!



A Little History (cont)

Roll out did not go smoothly at NDW, despite our best intentions. All players not operating on the same team – labor was united!

Continuation on the current path is NOT advised. RISKS ARE TOO GREAT!

Program modifications needed NOW – NOT LATER



Program Roll Out – The NDW Perspective

CNIC Initiated EMS discussions with regions more 2 years ago but local activities began only about 30 days prior to the Oct 1, 2007 implementation date.

Labor was never officially notified. Learned of NDW plans through word of mouth from Firefighters, not Management!

First substantive meeting with labor did not occur until Sept 25, 2007 – 6 days prior to planned implementation.



Program Roll Out - MORE

Labor & Management met for bargaining on Sept 27. In good faith Local agreed to rapidly move ahead with implementation prior to conclusion of bargaining. To date bargaining HAS NOT been completed! WON’T HAPPEN AGAIN!

Oct 1, 2007 Program Implemented – Where’s is the guidance, directives and SOPs – Months will pass before any of it arrives! (~Jan 26, 2008)



Program Management: CNIC

CNIC M-11320.1 – Signed by Admiral Conway Mar.11, 2008

A “Good Start” but operating an entire coast to coast EMS system out of a 100 page manual is far from realistic!

As previously promised by Regional Fire Chief, manual is identical to May 2007 draft under which we have operated for 6 months. But did not implement all facets of the manual



Program Management: CNIC

EMS is DYNAMIC and MULTIFACETED – “Oneway” of performing EMS services across the entire US is impossible – Broad Brush theory destined to FAIL!

CNIC F&ES EMS Manager must be accessible to the boots on the ground! Risks are to great for “traditional” military style “Chain of Command” – Too Much Time Elapses Awaiting COC!



Program Management – NDW Region

Fire Chief responsibilities not fully fulfilled? – Issues remain unresolved? • Two states & DC – Medical Direction challenges

remain! • Specific example: Annapolis providers certification in jeopardy due to OMD issues. Dr

Myers (current OMD) wants answers from Navy’s Dr Dennis. Dr Dennis “unreachable.” Dr Myers worried about legalities of blended Navy/MIEMSS Hybrid entity. MIEMSS’ Dr Alcorta involved!

• Budget Issues – Local Chiefs reports no or little $$$ for consumables and equipment purchases.

• Not all BuMed Clinics willing to offer a helping hand – Annapolis less than friendly while Pax River clinic fully supports. ONE REGION - ONE FIGHT ???

• Region NOT meeting minimum program requirements

• Come Audit the NDW Program – See for yourself!



Program Management: NDW Region

Regional EMS Manager – Full time responsibility but assigned to a Training Officer as a Collateral duty?

Indication of the lack of PRIORITY placed on this essential EMERGENCY response mission

Either Training or EMS will suffer!



Program Management: NDW Region

Regional EMS Advisory Council: Per CNIC M-11320.1

• “Assist in coordinating the delivery of the highest quality EMS…” (1-4)

•MIA!



Program Management – Reg. EMS Manager Regional EMS Manager: Approval of FTE

MUST HAPPEN! • Incumbent must be given FULL program

authority:• Financial Resources• Budgeting Responsibilities• Personnel

Administrative / Logistical Training

• Policy Creation Authority

ANYTHING LESS LIMITS SUCCESS OF THIS VITAL

PROGRAM



Program Management – Installation Level

EMS System Manager: A lot of responsibility to apply to someone as a collateral duty and then expect them to maintain other duties and proficiencies! Translation: Do More With Less = Drift to Failure

Local Installations need a FTE just to meet the required responsibilities. Must be at least equivalent to the “Lead” level. Compare to municipal jurisdictions = EMS Duty Officer performing similar duties.

CNIC M-11320.1 assigns this position 21 areas of responsibility – Well beyond the scope of duties for a GS-7 Firefighter



Program Management – EMS SOPs

NDW EMS Program went regionally operational on Oct 1, 2007 at Pax River, USNA and Indian Head.• USNA FD provides ambulance services since

70s• IHFD provides ALS ambulance services since

90s• Pax River FD all new EMS service Oct 2007• Dahlgren FD all new EMS service Feb 2008

EMS SOPs not released to the field until Jan 26, 2008• Failed to provide to Union as agreed!

TRUST?



Program Management – EMS SOPs (cont) EMS SOPs were written by a single person and

released without being properly vetted.• Some not consistent with CNIC Program

Fire Chief blindly signs SOPs without understanding what he was signing!• HUGE Liability Issues

Terminology usage inconsistent• Assistant Chief of EMS• EMS Program Manager• EMS Command Officer• EMS Division



Program Management – EMS SOPs (Cont)

Per CNIC M-11320.1: EMS system policies including clinical and administrative protocols shall be established and, where appropriate, incorporated into the Operational Plan, which addresses, in detail, the aspects of these services, including, but not limited to, the following: …

30 CNIC SOP topics followed• 45 NDW SOPs “signed out” to the field• 11 CNIC SOP Topics not released to the field

• Example of Missing SOPs Ambulance Diversion Criteria Cancellation of EMS response Infectious Disease Precautions Jump START Triage



Program Management: Specific SOP Issues NDW SOPs are formatted in different

“formats” which unnecessarily interferes with ease of understanding and raises interpretation concerns• Sample Formats:

SOP 100 SOP 101 SOP 102SOP 103Purpose Purpose Purpose PurposeScope Scope Definitions ScopeResponsibility Application

Procedure

SOP 104 SOP 105 SOP 106Policy Purpose Policy

Procedure Definition Authority Policy Crime Scene Classification

Evidence Preservation

Quality Organizations Have Quality Policy Manuals!



Program Management: Specific SOP Issues NDW SOP 101: Protocol & Standing Orders

• SOP appears to state that this SOP manual will contain SOPs. It lists a number of SOP topics that are not present in the manual.

• Do we need an SOP to say that we will have SOPs?• No meat with this meal!

• Recommend removal and rewrite



Program Management: Specific SOP Issues NDW SOP #102: Refusal of Patient Care

• III Application• A: “This policy applies to any patient who refuses care or

transportation. 1. The paramedic shall document the patient’s refusal of the PCR…”

• Is a BLS provider required to document the patient refusal? Of course they are! But not according to this SOP.

Haste Makes Waste!

• Recommend recalling & rewriting SOP



Program Management: Specific SOP Issues NDW SOP #103: Triage

• Purpose: “To provide a uniform procedure…• 1. Personnel shall utilize Local Protocols for all

Patient Care Procedures.”

• Topic heading is all wrong! #1 Applies to all EMS patient care PERIOD – Triage or not!

• This is not a Triage SOP

• Recommend recalling SOP and Developing actual SOP



Program Management: Specific SOP Issues NDW SOP #104: Baby Surrendered at

FIRE/EMS Station

II. Procedure• 5. “Fire service personnel will notify the

Commanding Officer” -- Not part of CNIC Manual!

• Who in the fire service is to notify the CO? – Give me their numbers and I will call!



Program Management: Specific SOP Issues NDW SOP #105: Continuing Education

• “To provide continuing education to NDW F&ES personnel”• SOP in place but that is where the road ended.

Regionally there is not a CE program in place.• At a minimum, 3 annual EMT recert classes are

needed. A number of providers are expiring in the coming 90 days but region has yet to announce recert training classes for the remainder of FY08.

• SOPs are worthless unless followed!



Program Management: Specific SOP Issues NDW SOP #106: Crime Scene Management

• IV. Evidence Preservation• C2. “If clothing is bloody allow it to dry… Never

put wet or bloody garments in plastic bags”

-Bloody Clothing – We are not CSI. PD or CSI should handle this!

-Basic EMT training – Bloody articles are BIOHAZARDS! Those items are to be placed in a BIO Bag (normally red plastic)

-EMS doesn’t handle anything on crime scene except viable life – Dead = Crime Scene = PD – NOT EMS

Recommend recalling SOP and remove erroneous section



Program Management: Specific SOP Issues

NDW SOP #107: Donor Cards• “Purpose: To establish guidelines for

NDW F&ES personnel that they search for organ donor information on an imminent death patient”

• Delay patient care while we search? Huh?• Searching is a PD function to ensure chain of

custody of potential evidence

• Recommend Recalling and Revising



Program Management: Specific SOP Issues NDW SOP #109: Privacy Practices…

• Iv. “NDW EMS is permitted to use Protected Health Information without a patient’s written authorization…

… (may) release to a close personal friend? For Military, national defense and other special government functions?”

WHAT? So we give all patient info to the CDO because he is military? Can’t check ID over the phone! Very confusing! This HAS huge liability

implications.

• Who may release PHI, just any NDW EMS Provider?• CNIC Requirement for HIPPA Training has not been carried out• SOP is written in a manner that is not easy to understand and leads to

many ?????? Violations ARE likely!



Program Management: Specific SOP Issues NDW SOP #110: Transfer of Patient Care

• Policy• 6. “In a situation where a BLS unit has requested ALS service and

had already loaded the patient on the BLS unit for transportation, that patient shall not be moved from the BLS unit to the rendezvousing ALS unit. Instead, the ALS provider should move to the BLS unit…”

• Not Practical given that EVERY place, but IH, ALS is provided by mutual aid agencies. We can not apply our SOP to M/A personnel!

• Literally taken, this section prohibits transferring a patient from a BLS ground unit to an ALS air ambulance.

Recommend the removal and rewriting this SOP to eliminate #6



Program Management: Specific SOP Issues NDW SOP #111: Nocturnal Field Operations

• Policy: When operating in low light or nocturnal conditions personnel shall wear…

• ANSI approved reflective safety vest• Personal Protective Gear with reflective stripping• Department issued weather jacket with reflective striping• Department issued jumpsuit with reflective striping

• Good policy, poor execution: None of the above items have been issued region wide outside of firefighting turnout gear – which should not be entered into a patient care environment – think cross-contamination!

• Meanwhile, night time operations continue to occur – NO PPE!



Program Management: Specific SOP Issues NDW SOP #112: EMT-B IV Technician

Guidelines• “I.V. Technician Qualifications

• IV: Have completed 3 years as an EMT-B either as a career or volunteer EMT-B

• VI: Will have been on at least 100 working calls as the primary care provider, Officer in Charge as a volunteer or career EMT-B”

How does NDW verify volunteer services? What are the liability implications of accepting volunteer experiences? What about a person that responds on 100 calls over a 3 year period vs a person that responds to 100 calls in 1 year. How does a municipal FD release an ALS care provider to the field after rookie school? Seems arbitrary!

Recommend recalling SOP and removing volunteer service as an acceptable experience. Accept only NDW or Gov’t experiences!



Program Management: Specific SOP Issues NDW SOP #112: EMT-B IV Technician

Guidelines• “Scope of Practice:

• 1. Certified IV Tech may perform cannulation skills under direct supervision of ALS

• 2. Certified IV Tech may perform cannulation skills without direct supervision of ALS”

• 3. IV Tech may make two attempts per patient

» If patient requires fluid then 2 attempts or 10 attempts – patient still in NEED! Where is the medical justification for only 2 attempts?

• Looks like a conflict to me – either you can or you can’t!




NDW SOP #201: Hazardous Material Incident Field Policy• II “Policy:

• A. EMS personnel responding to the scene will follow current NDW Hazardous Materials /CBRN Incident SOG”

• No Such Regional SOG EXIST! • IV Procedures:

• C4. The NDW Hazmat Team will be responsible to determining whether or not a potentially contaminated ambulance has been appropriately decontaminated and may be returned to service.

• We are EMERGENCY RESPONDERS not a commercial HazMat Remediation service – Not within our PD. This is outside our scope of training! HUGE Liabilities!!!

• Recommend recalling and revising of this SOP!




NDW SOP #202: Inability to Carry Out Physician’s Orders

• SOP contains a “Purpose” and a “Scope” but lacks a policy or procedure.

• Again, there is phrase that informs the EMT to follow their Local protocols.

• Where is the “real” SOP… MD EMTs Shall… Va EMTs shall… DC EMTs…

• Recommend recalling and revising with subsistence




NDW SOP #302: Exposure to Infectious Diseases & HazMat• “Procedures: a. Report suspicion to first line supervisor

immediately. Follow the procedures that is established by Occupation Health…”

What Procedure? Where is it written? Is Occ. Health an expert in or qualified to treat HazMat exposures? This VAGUE SOP places firefighter safety AT RISK!

PER CNIC M-11320.1 “All patients who require emergency transportation shall be taken to be the nearest appropriate hospital” (page 5-3)Exposure to HAZMAT is a true medical emergency!

Recommend recalling SOP and rewriting to reflect correct policy



Program Management: Specific SOP Issues NDW SOP #402: Decon & Disinfecting PPE

• SOP discusses the contaminates being blood, chemical, biological, radioactive, flammable or petroleum.

• “C3: Said item should be immediately decontaminated or disinfected according to the manufactures instructions.

• C4: Item that require washing in a machine, should be done so in a proper washing machine exclusively for PPE.”

Decon & Disinfection of PPE is OUTSIDE the scope of Firefighter training. Every station is NOT equipped with proper PPE decon washing machine facilities. Utilization of a professional service is essential to reduce liability issues!



Program Management: Specific SOP Issues NDW SOP #500: Ambulance Operations

• This SOP DOES NOT state the policy on Ambulance Operations. Rather, it discusses “Engine Company” First Responder functions.

• SOP provides ZERO guidance or direction on AMBULANCE OPERATIONS!

Recommend recalling and initiating a title change of this SOP to “ENGINE COMPANY FIRST RESPONDER

OPERATIONS”




NDW SOP #502: EMS Ops at Mass Casualty Incidents

SIMPLY PUT: Does Not Comply with NIMS requirements issued by Presidential Directive HSPD-5!

By Presidential Directive we MUST comply with NIMS!

Recommend Recalling and Revising to Meet HSPD-5



Program Management: Specific SOP Issues NDW SOP #506: Medical Resource Standby

• II: Applicable Incidents• G: Other situations as requested

• Abuse of this provision already occurring and going unchallenged!

• Pax 31 EMS Stand-bys Scheduled for April Handled Stand-bys since Oct 07 for: PRT, LE Pepper Spray training, Flu Shot

Clinic, Puggle Stick training, Change of Command, V-22 Air Ops.

• USNA EMS at N-MC Stadium – Private property in City of Annapolis Jurisdiction. AFD Paramedic 39 station one block away

from stadium Small # of people present at Stadium while large crowds present on Academy

grounds

• Recommend Revising SOP - Gain control of abuse of stand-bys



Program Management: Specific SOP Issues NDW SOP #508: Terrorism Responses NDW SOP #509: Natural Disaster Incidents

• These are identical SOPs –word for word; clearly there must be some kind of response differences between these two types of incidents?

• Neither SOP meets required FEMA response criteria

Recommend recalling and revising these two SOPs



Program Management: Specific SOP Issues NDW SOP #510: Vehicle Operations

• VI Response in Personal Vehicles (POV)• 2. While off-duty, responding POV will be permitted…

• HUGE LIABILITY ISSUES! NDW IS ASSUMING A TREMENDIOUS RISK HERE!

• What was the thought process here?

DEMAND REVISING SOP TO REMOVE THIS SECTION



Program Management: Specific SOP Issues NDW SOP #511: Exposure to CS, CN and OC

Spray• Purpose:… to inform F&ES personnel of the practices and

protocol regarding general care• “General” & “Chemical Properties” - two pages that are not

really relevant to patient care; WW1 through early 1960s history is not proper in a SOP!

• General Treatment Protocol – RFC Has NO authority to issue medical treatment protocols – that is the states duty?

» #6: “Monitor … 15 to 30 minutes” Delayed transport negates the purpose of EMS. Golden Hour will

likely expire given transport times from some bases (IH / Dahlgren)

• General Policies #5: “persons sprayed… and request medical eval either on their own or

by law enforcement shall be transported.” Person retains right to refusal regardless of this SOP or PDs decision. PD CANNOT order medical treatment!!!

• SOP in conflict with the LAW! Repeal erroneous portions!



Program Management: Specific SOP Issues NDW SOP #513: Transport of Pt in Custody of

LE• Policy #6: Anytime the EMS provider is asked to

restrain a patient in custody… with chemical means for the purpose of transport…”

F&ES DOESN’T DRUG PATIENTS FOR TRANSPORT!

Imagine the picture & story in the Newspaper!!!

• PD MUST ride in unit with patient – protect EMS!

Recommend removing all mention of “drugging” a person in police custody! DON’T PLANT THE SEED THAT THIS IS AN OKAY PRACTICE – IT’S NOT IN EMS!



Program Management: Specific SOP Issues NDW SOP #514: Taser Wound Care

• General: Too much superfluous details – example: the distance and speed a probe travels is not important in EMS.

• If patient received “taser” treatment – PD & RESTRAINTS are ESSENTIAL

Recommend revising the SOP to include actual policy and procedure only.



Program Management: Specific SOP Issues NDW SOP #515: Active Shooter Response

• Discusses operations in an unsecured “Active Shooter” arena. Includes guidelines for EMS Personnel to enter “Hot Zone” (see Guidelines SOP page 3)

• THIS IS OUTSIDE A FIREFIGHTER/EMT’s SCOPE OF TRAINING! TACTICAL MEDIC OPS IS A SPECIALTY SERVICE REQUIRING SPECIAL TRAINING AND WEAPONS FOR SELF PROTECTION!



Program Management: Specific SOP Issues NDW SOP #516: Bomb Threat

• Procedures: 8. “Appropriately trained personnel may conduct searches and initiate any evacuations if asked to do so”• What kind of Fire/EMS training qualifies personnel to

search for bombs? Should a detonation occur, who rescues the fire/ems personnel? The presence or threat of Bombs is a crime –PD handles all criminal activities!

• FIRE DEPARTMENT PERSONNEL SHOULD NEVER ENGAGE IN BOMB SEARCHES!

Recommend recalling SOP and Remove any mention of FD personnel conducting Bomb Searches, follow OPNAV 5



Program Management: Specific SOP Issues NDW SOP #517: Fire Responses

• Policy: 6. “When transporting patients to accepting facilities, crew must perform a consult to receiving hospital at least 10 mins prior to arrival”

• Normal transport time may be less than 10 minutes (Example USNA to AAMC normal transport time of 5 to 7 minutes)

• Don’t delay transport! Change the word “must” to lessen this requirement.

DETAILS, DETAILS, DETAILS!



Program Management: Specific SOP Issues NDW SOP #801: EMS Dispatch

• SCOPE: Guidelines for base dispatchers…• Dictates What A Dispatcher Is To Do

Dispatch isn’t an F&ES duty or responsibility Dispatch personnel are not covered by F&ES SOP Two Sentences out of any entire page apply to

F&ES.

• Recommend Recall and Revision of SOP to address target audience – F&ES Personnel



Program Management: Specific SOP Issues NDW SOP #802: Field Safety &

Communications• Standard Communications Procedure???

• A. Dispatcher will… More SOP for a group non-F&ES employees –

USELESS!• B. Portable Radio Emergency Button..

Must be a base specific issues – not every base radio is so equipped (example: USNA). So much for STANDARDIZATION !!!

• C. Use of Duress Code To Declare An Emergency

Nice Thought - When is someone going to share the code with dispatch??? SOP signed 18 Jan – USNA Dispatch unaware of the code 3 Apr !!!



Program Management: Specific SOP Issues NDW SOP #802: CONTINUED

• SAFETY PROCEDURES LIKE CODE WORDS ONLY WORK WHEN EVERYONE KNOWS THEM

• THIS SOP PURPORTS TO PROVIDE SOME AVENUE FOR FIRE/EMS TO RECEIVE HELP BUT IS REALLY MEANINGLESS! THIS IS A FALSE SENSE OF SECURITY! WHAT WERE YOU THINKING? NOT FF SAFETY



Program Management: Gen SOP Thoughts Proof is in the pudding – these were

rushed to the field without consideration of all facts, details and most of all firefighter safety!

Concern for FF SAFETY should have been paramount – It WASN’T (Just look at SOP #802)

Proactive program development prior to the known program implementation date could have prevented nearly ALL SOP issues!



Program Management: Mutual Aid

EMS Mutual Aid is permitted per CNIC M-11320.1 (page 2-6)

Region lacks STANDARDIZED EMS Mutual Aid policy for the entire region. (Example: USNA not permitted to give automatic M/A per D.C. but relies heavily on M/A ALS services – UNSAT! Meanwhile IH and Pax River are free to offer M/A services to neighboring jurisdictions)

M/A is a MUST- Essential life saving skills can be gained and honed through regular practice obtained during M/A responses




Confidence in skills is gained through regular M/A responses

Skills outside the “Norm” are used more often during M/A responses; • Consider treatment of Cardiac Arrest,

Shootings, Stabbings, Indust. Accidents, Serious MVA, suicides, OD, Peds/Geriatric Illnesses; all rare on base but not in surrounding communities




Final Thought On Mutual Aid:

ASK YOURSELF: Do I want a medic working me with just book smarts or

considerable hands on experience? M/A is the means to achieving the much needed

experience! I’ll bet you want the neurosurgeon with 3000 intracranial surgeries

under his belt and not the the surgeon with 2!

WE OWE OUR PEOPLE & COMMUNITIES AS MUCH!!!



Program Management: Labor Bargaining CNIC Program Manual: “All bargaining

obligations pursuant to reference (d) must be satisfied prior to implementing any changes generated by these provisions”

Well overdue! When?

The delays on managements part has harmed our relationship!!! As previously stated; the courtesy provided with EMS will not occur in the future!!!



Equipment: Vehicles Vehicles in the NDW are not standardized in any

manner.

All NDW Police Units look identical – ALL NDW F&ES Ambulances should look identical – Not Occurring. Adds to the professional appearance of the service!

Equipment and consumables are not standardized – So much for efficiencies through mass purchasing!

Durable medical equipment bulk purchases saves money – not happening!



Equipment: Communications

Nearly 5 years into Regionalization and region wide communications capabilities remain elusive. Where is interoperability?

ELMR Radios have been repeatedly promised, latest was a Jan 08 rolled out, but yet to appear in full system deployment.

Radios in poor working order impact firefighter safety in a negative way!!!



Training EMS Training lacks the PRIORITY it

deserves!

CNIC nor NDW have authorized a much needed FTE for an EMS Trainer! AN EMS TRAINER IS A MUST, not a nice to have!

200+ EMTs in the region justifies 3 or more recert classes per year - currently none are scheduled for the remainder of 2008. Where is the logic? What about CPR / AED / BTLS / PHTLS / PALS / ACLS – all required ALS training?



Summary

FD Based EMS is a GREAT thing when PROPERLY implemented and resourced within acceptable state & national standards.

Rome wasn’t built in a week – Don’t MICKEY MOUSE the EMS Program – work expeditiously with an eye on the DETAILS!

“BLOCK FILLERS” – Just putting a check in the box is UNACCEPTABLE



Summary: Final Thought

Don’t use a banner mission statement -Protecting those that Defend America” –

if your actions indicate that you really don’t believe it!



My Experiences – Not My First Rodeo! Serving in Fire/EMS Roles since 1982

• EMT of the YEAR – Chesapeake, VA 1985 Other EMS recognitions

• Former ALS Provider, two Va juridictions• Formerly Va licensed Physicians Assistant

Served in multiple Law Enforcement positions• Local, State and Federal agencies – trained by

each College graduate

• Admin of Criminal Justice Degree• Current student in Admin & Leadership degree

program

gregory a. russell president john e. gray iii secretary-treasurer ndw f&es based emergency...

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