EMS Innovations 2009: A Five-Part Series

Each February, the cutting edge of prehospital care comes to Dallas. The EMS State of the Sciences Conference, more commonly known as A Gathering of Eagles, brings together medical directors from EMS systems in the largest U.S. cities, plus various bright and important invited guests, to share ideas and innovations, debate current problems and recent developments, and generally chew the fat on all matters clinical, operational and social. This year's conference attendees--among them EMS providers, chiefs, directors, educators and researchers, as well as physicians, nurses and others--were treated to nearly 60 brief but chock-full presentations over just two days, including "lightning rounds" that brought the speakers together to tackle issues as a group.

Again this year, EMS Magazine followed up on a few of the most interesting presentations, soliciting additional thoughts from the docs behind them and presenting them here for your consideration. All are geared toward improving patient care and system function. Could they be adapted to your system? Read on and ponder.

Part 5: Reinventing Quality Improvement--How the Memphis Fire Department Survived "Middle Management Paralysis"

By J. Harold "Jim" Logan, BS, EMT-P/IC

The Memphis Fire Department's EMS Division began its quality journey when the state of Tennessee mandated "quality assurance" in 1992. Most state EMS services still use that era's outdated QA document, which includes templates of check boxes that would make most people's eyes bleed and fall out. The document is well intended, but does nothing in the way of improving patient care or service to the community. This type of "quality enhancement" tool was viewed by field providers as Big Brother looking over their shoulders and was seen as a punitive. It was a tool for assurance, not improvement.

With no direction or top-down support for this state mandate, the QI culture within the department was dismal to say the least. We could identify problems but had no effective mechanisms to improve them. Our system was dysfunctional, with no field supervision, no active education or training to help providers identified in the QA process, and no active medical direction.

Fast-forward to 2005. With new leadership in place, we reanalyzed and overhauled our service completely, including our quality improvement efforts. Under our new leadership, we established a robust EMS rank structure, increased our education staff and course offerings, and employed a full-time and very involved medical director. Quality improved rapidly in this new environment. Given his success with other organizations, consultant Mike Taigman was called in to consult on quality at the beginning of our restructuring, and he offered suggestions to provide better prehospital care and customer service. We employed several of his suggestions and instituted methodologies that improved trust between our QI team and field providers. Our medical director and quality improvement team began meeting with providers about trends and issues discovered in reviews of patient care reports. This was done nonpunitively, and gave providers good suggestions for improving their care and service. Our new vision and efforts let us work with our education department to incorporate education and training focused on trends found during chart and case reviews and system problems found by our officers in the field.

But while the service we were providing to our citizens seemed outwardly to be improving, the data to support our efforts was not as impressive. We were still missing a piece of the puzzle. So in 2008 we invited Taigman back for a checkup. We provided him with all the information related to the changes we' made, including quality peer review, a mentoring program for new employees, and monthly QI meetings with our EMS officers. We explained to him our dilemma: Our system had improved by leaps and bounds, but it appeared our patient care and protocol compliance had hit a wall, and improvement had reached a plateau. We asked Mike if there were other services we could look to for possible benchmarks.

"I could suggest other EMS services to you, but it I don't think it would be of any use," he said. "Sometimes the treasure is in your own backyard."

The FedEx Example

FedEx is a leader in delivering quality and outstanding customer experiences. It is also based in Memphis. Mike suggested we allow him to make a few phone calls and see if he could put us together. Soon, we were at the table briefing the FedEx quality management team of Brooks Wolfe and Roger Forsyth on our successes and shortcomings. After a few meetings, we reached a diagnosis: It seemed we had "middle management paralysis." Each month we would gather data, identify issues in need of addressing, consult with providers and share information with EMS field officers. Each month we'd invite officers, both training and field, to attend a briefing to this end. Training officers attended regularly; however, EMS officers in the field had been fully subscribed to our previous culture of quality improvement. These officers would come to the meetings, see the dismal numbers and hear what was being said about their providers, then go on their way with the thought that it was someone else's problem. They believed quality improvement was the responsibility of the EMS QI office. Recognizing this, we found the missing piece of the puzzle that would allow successful change.

Top-down Buy-in

The FedEx quality management team greeted us with open arms and a willingness to help. One of the first things they relayed to us was that they'd experienced some of the same obstacles early in the formation of FedEx's current quality model. The FedEx solution was top-down buy-in to facilitate ownership of quality.

Many articles and books have been written on quality management. All seem to have one main principle: To succeed, quality must have support from the top of the organization. That means not just a blessing from on high, but full support and commitment for improvement. FedEx applied a creative spin to this principle that set them apart: Instead of leading quality efforts, their quality management team began to strictly facilitate them. They took themselves out of the driver's seat and gave the wheel to top management. FedEx began to have its highest-level senior officers chair its quality meetings.

With that, top-down buy-in came to mean something other than just support of an effort. Senior officers held vice presidents accountable for improving productivity and customer satisfaction and loyalty. The FedEx quality management team would gather data related to operational metrics and customer satisfaction and loyalty, help the senior officers—the process "owners"--analyze the data, and develop agendas for quality review meetings. Each vice president gained responsibility for identifying root causes of deficiencies in their areas, recommending actions for improvement and putting those ideas into practice. The quality management team remained available to assist the vice presidents and their analysts in a supporting role.

After a few meetings with FedEx, the Memphis FD quality management team brought the idea to top EMS brass. They loved it. Implementing it was rocky at first, as it represented a culture change for both middle management and the provider base. The FedEx quality management team joined us in meetings, observed our processes and made suggestions that helped us realize an increase in protocol compliance of more than 30% in little over three months. Through the data generated, processes enhanced and top-down leadership dedicated to quality, we were able to establish better interaction with providers and supervisors, improve customer service, identify system problems and ensure excellent prehospital care.

Conclusion

We still have much to learn and accomplish as we continue on this quality voyage. The FedEx quality management team continues to assist us with advice and lessons learned. As providers of services that can mean life and death, we owe it to the people we serve to deliver our best. The attitude of "We've always done it this way!" is a dangerous one. Seek out successful leaders in customer service, learn from their misfortunes and insights, and model their behavior to reinvent yourself and improve your service delivery.

Customer Service Key to FedEx Success

More than 35 years ago, Fred Smith launched the air-express industry with an idea forged during his college years at Yale. Legend has it that he received a C on his visionary paper that outlined what would make him and his company a leader in customer service and parcel delivery: management and quality values emphasizing people first, service second, and a belief that profit could ensue from those. Over the years, Smith's company achieved high levels of customer satisfaction and loyalty and experienced rapid growth. Annual revenues exceeded $1 billion within 10 years of the company's founding. FedEx became a standard in the air and ground delivery of America's packages and parcels. In 1990 it was the first service-based recipient of the coveted Malcolm Baldrige National Quality Award.

The company's growth led to various levels of services. Soon FedEx was providing international shipping and catering to the delivery needs of the world. With expansion and growth came the realization that ever-higher goals for quality performance and customer satisfaction had to be realized by enhancing and expanding service, investing in advanced technology and building on the company's reputation as an excellent employer.

Tradition Can Be a Hindrance

The fire service is notorious for being steeped in tradition. This affinity has sometimes been a hindrance in improving its quality of service and system issues in need of change to enhance service and productivity.

In the 1980s, I worked for a large metropolitan fire department that worked 24-hour-on/48-hour-off shifts—not so unusual, right? Well, the odd thing was that we began our shifts at 3:30 in the afternoon and ended them at the same time the next day. Then a new administration came in and added EMS to its list of responsibilities. Before long, the new EMS chief, seeing his busiest crews exhausted, asked why we had such odd hours. No one had an answer. He asked for the hours to be changed to something more standard: 0700 to 0700. This would allow a full 48 hours of off-duty normalcy for employees, making them more rested and productive. The fire chief was against the change because--are you ready?--"We've always done it this way."

A bet was made. If the fire chief could show, with written documentation, why maintaining these hours was beneficial, they would remain the same. If he could not, he would agree to change them, giving employees two "normal" days off. People were interviewed, news articles researched, log books and journals scanned, and there it was: Back in the 1800s, the oncoming shift tended to the horses at 3:30 p.m. each day. This was the only thing we found that seemed to account for the 3:30 shift change. The fire chief, losing the bet, then moved to an 0700-0700 schedule.

J. Harold "Jim" Logan, BS, EMT-P/IC, is a lieutenant firefighter/paramedic with the Memphis Fire Department, specializing in EMS consequence management and quality improvement. Contact him at jim.logan@memphistn.gov.

Part 4: Painkillers--North Memorial Medics Reducing the Hurt

Everybody hurts. Not everybody who calls 9-1-1 for pain gets the relief they could in the prehospital environment. One late-1990s study in Ohio found that of 1,073 patients with suspected extremity fractures, just 18 (1.7%) received analgesia from EMS providers.

EMS can do better at treating its patients' pain, and medics with Minnesota's North Memorial Ambulance Service are demonstrating how. By emphasizing this often-overlooked aspect of care and arming its crews to address it aggressively, the service reduces suffering and delivers patients to hospitals as pain-free as possible.

"What we're trying to do," says Associate Medical Director Marc Conterato, MD, FACEP, "is help people through a difficult time, and help them understand that while nothing will magically relieve their pain, we can do things that will help."

North Memorial began examining the pain issue a few years back when surveys revealed its patients, on the whole, didn't feel its crews were treating their pain as well as those crews did. Resolved to reduce this discrepancy in perception, department leaders identified some key questions: Were medics giving enough medication? Were they giving it fast enough? Were they giving appropriate initial doses, and redoses of appropriate strength at appropriate intervals? Were there adjuncts they should be using?

"On almost every level, we weren't giving adequate doses in the first place, and we weren't rebolusing at the proper time," says Conterato. "Also, we weren't really assessing how patients were doing after the pain medication."

An internal reorientation for better pain management followed. It emphasized several key concepts. These included asking the right assessment questions (i.e., the OPQRST assessment); busting some stubborn myths about prehospital treatment of pain; and promoting the concept of a pyramid of integrated pain management.

To better gauge how these efforts would work, the traditional idea of the pain scale had to be recalibrated. Since everyone handles pain differently, having a patient's pain described as, say, an 8 out of 10 isn't truly meaningful. What medics began looking for instead was the degree of reduction in pain with treatment. A 50% reduction, the service decided, was a reasonable goal.

Achieving this wouldn't just be about narcotics. Instead, North Memorial envisioned a pyramid with four levels of pain relief (see Figure 1). In descending order, it defined ALS care (i.e., narcotics), BLS care, position of comfort and emotional support. The latter elements would represent the foundation, as it were, with care progressing up the pyramid as needed, narcotics being the final resort. Nonpharmacological measures any EMT can employ--splinting, bandaging and stabilizing, positioning to reduce pain, application of cold packs--often reduce the problem. "Most of our medics didn't realize," Conterato says, "that with cold packs, once you lower the temperature in that tissue, you decrease localized pain response."

The service strongly emphasizes basic understanding and support. Pain is never discounted. Patients are assured and reassured that crews know they're hurting and will do all they can to reduce it. That helps control anxiety, and hence pain. Soothing the mind, in this case, is an adjunctive treatment.

"We're dispensing empathy," Conterato says. "We're dispensing acknowledgement of their discomfort, and that we know how to treat it and will help treat it."

This makes for more satisfied patients, and patients who exit the healthcare system sooner. With reduced pain response on ED arrival, patients respond better to treatment and move through the hospital more quickly. Prehospital pain management is a long-term investment.

Medication Doses

North Memorial uses morphine and Dilaudid in the field, and tends toward the aggressive in both its initial and follow-up doses. It gives morphine at 0.1-0.2 mg/kg, titrated for effect and adjusted for size, weight and age, up to an initial dose of 10 mg and a maximum of 20. With Dilaudid, it's 0.01-0.02 mg/kg, titrated to effect, up to an initial dose of 2 mg without verbal orders.

"To some people, that's a huge amount of medication," Conterato says. "It raised fears we were going to oversedate people. We’ve found that happens very little, if at all."

The service is looking to phase out morphine in the future, and go solely with Dilaudid. It may also add ketamine to its arsenal.

Prehospital Pain Myths

This new approach to pain represented a significant change for medics, some of whom held to persistent myths about prehospital pain management that had to be dispelled. Patients don't know what real pain is? OK, just work to reduce what they have. I'm only an EMT and can't give drugs? Help locally, with splinting, stabilizing, cold packs, etc. It can wait till the ED? The ED might be backed up, and tests there take time--your patient could wait hours for relief. Meds will mask their symptoms? No, they'll be more cooperative, and you'll have enough physical findings to diagnose.

Part 3: Get the Picture? The Future of Ultrasound in EMS

A review of EMS ultrasound use appearing in the December 2008 International Journal of Emergency Medicine found that using it may help EMS care. "As cost, machine size and ease of use continue to improve," authors Bret Nelson, MD, and Kevin Chason, DO, of the Mt. Sinai School of Medicine concluded, "the applications of field ultrasound may continue to increase. Ultrasound may provide additional diagnostic information to guide therapy. The utility of this information will depend on the transport time as well as the training level of the provider in the ambulance or helicopter."

Further studies are needed and ongoing, but the notion of benefit seems to have a certain face validity--enough that it may be time to start weighing if, when and how EMS ultrasound use might help patients in the U.S.

"The literature is limited, based mostly on case reports and initial training," says Craig Manifold, DO, medical director for the San Antonio Fire Department. "I think we have a ways to go to be able to prove a difference in patient outcomes. But I think we're headed in that direction, and will be able to give some definitive answers soon.

"There's a significant responsibility in putting this equipment out there. We need to make sure it's a benefit to our patients."

With that caution in mind, San Antonio providers may soon help open the door. The department is putting together a pilot project to try to answer key questions about medics' ability to use ultrasound to answer basic diagnostic questions in the field.

Manifold became a believer in ultrasound through his work in EDs and the military, where he served in Afghanistan. He brought it to the San Antonio AirLIFE medevac service, for which he's also medical director, training medics and nurses to use it. But implementing it broadly across an urban 9-1-1 system doesnt happen so easily.

"There are important questions to answer first," Manifold says. "Is this technology paramedics in the field can use safely? Can the information be accurately interpreted? Can we transmit the images, which creates a need for significant bandwidth, or can we trust paramedics' judgment on them? What's the right environment--do all systems need it? And finally, is there a patient benefit? Can we identify injuries or get patients to the OR faster, and does that make a difference?"

"There was controversy in the beginning even for emergency physicians utilizing this kind of technology," says Manifold. "We found that in the emergency department, it's an invaluable tool. I think it's a natural progression to look at it for the prehospital environment. It's a logical extension; we just have to make sure we're doing it the right way."

How Field Ultrasound Cound Benefit Patient Care

Based on experiences elsewhere, there are several areas where field ultrasound might potentially benefit patient care.

• Trauma: Studies reviewed by Nelson and Chason found that doing a FAST (focused assessment with sonography in trauma) exam early in the evaluation process can help decrease hospital admission lengths, treatment costs and time to surgery; and that early diagnostic ultrasound decreased traumatic mortality among U.S. Marines. In Germany, ultrasound led docs in the field to modify their on-scene trauma management in a third of cases. Their FAST exams were 93% sensitive and 99% specific compared to later ED diagnoses. "In trauma cases, I think there's a great benefit to being able to determine if there's something like blood in the abdomen," says Manifold. "Having that knowledge in the prehospital environment will let our trauma centers and receiving facilities be more attuned to those patients as they arrive, and maybe confirm their exams and move them quickly into the operating room."
• Cardiac evaluation and resuscitation: In Germany and Italy, providers use ultrasound in their prehospital cardiac evaluations. Studies have found an absence of cardiac activity on bedside echocardiography to be associated with 100% mortality, regardless of the rhythm on the monitor. "By putting the probe on the patient's chest and not seeing any cardiac activity," Manifold says, "that tells me our efforts, in most cases, are going to be futile."
• Medical illness: A French study of physicians in the field found prehospital ultrasound evaluation improved diagnostic accuracy in two-thirds of cases.
• Procedural assistance: To expedite things like IV placement.

Major manufacturers of portable ultrasound equipment include:

• GE Healthcare: www.gehealthcare.com
• Philips: www.medical.philips.com
• Siemens: www.siemensultrasound.com
• SonoSite: www.sonosite.com

Part 2: Have It Your Way

London's patient-specific protocols deliver care on a case-by-case basis

School officials didn't want to administer the rectal paraldehyde.

The child suffered from epilepsy, but the usual treatment for seizures in London, Diazemuls (an injectable emulsion of diazepam), had been linked to respiratory depression on a previous use. The preferred treatment was instead the paraldehyde, kept at the school. But who could give it? Backed by the child's doctor, the school approached the London Ambulance Service for help. They didn't carry the drug, but could they administer the child's own medication in a pinch?

"It was clear the child wasn't going to get the medication otherwise," says LAS Medical Director Fionna Moore, MD. So LAS did something counterintuitive for a service of its imposing size and call volume (more than 3,500 a day): It wrote an individual protocol for use only with this child.

Then came the Addison's patients, suffering from chronic adrenal insufficiency. Although they often carried their own hydrocortisone for their fast-onset adrenal crises, they could become too unwell too quickly to self-administer it. They, too, asked if LAS crews could give them their meds.

That's how the service's patient-specific protocols were born.

"It snowballed from there," says Moore. "I think the speed with which it became known surprised us a bit, particularly within the pediatric community. We expect that as people within these various groups talk to each other, it will continue to grow."

The PSPs are intended to alert crews to special medical histories and unique aspects of individual patients' care. Around 250 have been written since the idea's inception in 2007, of which 186 were still active in the LAS database as of Moore's Eagles presentation in February. These cover a broad range of conditions and circumstances, the largest of which concern end-of-life care, use of steroids, preferred places of care and transplants. Also represented are patients with seizures, LVADs, respiratory failure and more.

The service maintains a high-risk database in which it flags addresses of patients with PSPs, among others. When a crew is called to one of these addresses, it's automatically alerted and linked to the PSP. Copies, on official LAS letterhead and signed by Moore and each patient's treating physician, are also given to each patient or their caregiver, their physician, the local ambulance station and the LAS clinical support desk, which has experienced medics available 24/7 for consultation and troubleshooting.

This kind of thoroughgoing support--clear authorization from the service's top physician, plus online backup at all times--has made deviations from the comfort of standard care easier for medics to swallow.

"I'm not aware of a crew ever ringing up and saying 'I have this protocol and don't know whether I should use it,'" says Moore. "If they're presented this paper with the London Ambulance Service crest on the top that's something they recognize and is signed by me, they know I'm taking responsibility for their actions. So it seems to have gone down well." Not without certain challenges, however. One child had a PSP kept with her mother, but a father who knew nothing about it. When she needed assistance while with dad, the crew didn't get the information. Another frequent caller with significant chronic pain could be given morphine without transport to a hospital, but as his calls mounted, crews were devoting large amounts of time on scene just trying to keep him comfortable. "That was a risk not so much to the patient, but just because that vehicle was then unavailable to answer other calls," says Moore. "So the challenge there was trying to balance the needs of one individual with service delivery in the area."

The solution in the latter case was a case conference with the various clinicians involved in the patient's care (e.g., primary care, pain consultant, orthopedist) to discuss more appropriate avenues for handling his pain. These are increasingly common for people who call frequently without true emergencies.

The PSPs have helped LAS bring better care to patients with unique needs, and indirectly helped extend it to patients elsewhere. When LAS crews started giving their own hydrocortisone to Addison's patients in London, sufferers elsewhere wanted the same accommodation. National-level lobbying by LAS and patient advocates resulted in National Health Service guidelines allowing easier administration of the drug by ambulance crews elsewhere in the U.K.

Database Maintenance Is Key

The biggest of the challenges involved in PSPs has been simply keeping them current. This entails constant combing and culling and updating. The database has to remain accurate, and the patients within it aren't the most medically stable. It takes a day or two each week for one of Moore's deputies.

"As we deal with a lot of patients approaching the ends of their lives, a lot of them end up no longer requiring protocols," notes Moore. "So we make sure we're not holding protocols on people who are dead, and ensure the ones we have are kept up to date in terms of medications and so forth."

Word-of-Mouth

Much of the growth of the PSP program has been in fits and spurts among certain patient segments--one pediatric advocate or group telling another, for instance, leading to a boomlet in pediatric protocols. It's functioned similarly across the city's palliative care networks. Working with a single respiratory physician resulted in around 50 protocols from one hospital. "That's just an isolated little cluster," notes Moore. "It's not every respiratory physician in London, just one area where they've been keen to do this."

Fast Facts About LAS

The London Ambulance Service (LAS) is the largest emergency ambulance service in the world to provide healthcare that is free to patients at the time they receive it. LAS employs more than 4,500 staff, who work across a wide range of roles based in 69 ambulance stations. The agency serves the 7 million people who live and work in the London area. The LAS service area is approximately 620 square miles, from Heathrow in the west to Upminster in the east, and from Enfield in the north to Purley in the south. The agency's main role is to respond to emergency 999 calls. Other services include providing pre-arranged patient transport and finding hospital beds. For more, visit www.londonambulance.nhs.uk/.

Part 1: Demand & Control

Three solutions to lessening the patient load

Almost everywhere you look, EMS call and transport volumes are on the rise. As services struggle to keep up, it becomes increasingly important to develop alternative ways to deal with demand. Several Eagles presentations dealt with innovative solutions in large urban systems. In Texas' largest city, the Care Houston program is aimed at reducing nonemergency 9-1-1 calls from frequent flyers. Across the pond in London, clinical telephone advisors help callers find alternatives to ambulance transport. And back in the Lone Star State, Dallas is working to streamline its transport policy to better use medics' skills and time.

1. Care Houston

The idea originated in 2005 with some veteran firefighters tired of responding to the same addresses for the same nonemergency callers. They realized many of these callers needed human or social, not emergency medical, services. Their solution was targeted interventions to link these callers with resources to help them, thus ending the inappropriate calls.

This idea paralleled an existing program whereby volunteers and workers from the city Department of Health and Human Services visit underserved neighborhoods to bring food, clothing and medical resources to the needy. In Care Houston's case, those calling 9-1-1 eight times or more in 90 days would be contacted by letter, telephone or home visit by a public health nurse and case manager. These advocates would help connect them to appropriate avenues of assistance (e.g., Medicare/Medicaid, food stamps, Meals on Wheels, etc.).

"That whole infrastructure already existed within the health department, so we just piggybacked onto that," says David Persse, MD, the city's EMS physician director and public health boss. "A lot of it's getting people hooked up with social services they weren't previously aware of. You'd be surprised how often that's the problem." The program was targeted at residences, rather than business or institutional addresses, and rolled out first in the city's Sunnyside neighborhood, then citywide. Results have been consistent: In the 90 days after intervention, calls by targeted individuals drop by about 70%. Over the next 90, they fall by another 10%. "The real-life savings to that," says Persse, "come next year when the fire chief only has to increase his fleet by one ambulance instead of three."

2. Telephone Advice

The London Ambulance Service dispatches around a million responses a year. Its clinical telephone advice (CTA) program is aimed at averting some through review and retriage of lower-acuity calls.

Only Category C (routine) calls under MPDS are eligible for CTA. These calls are directed to LAS' Urgent Operations Centre, where call-takers question callers and determine if CTA is appropriate. If it is, the caller is called back by a trained advisor to discuss their problem. That advisor considers their current condition and history, and uses clinical decision support software (Psiam) to help determine a course of action. Callers still may get emergency resources if they need them, but can also be directed to self-care, urgent care, alternative pathways like their primary physician or a nursing service, or to self-transport to a hospital.

The CTA call volume averages around 9,000 a month, and almost half end up with no ambulance sent.

"It saves us a lot of journeys," says LAS Medical Director Fionna Moore, MD. "It's reduced the frustration of our crews, who sometimes feel they're sent to inappropriate calls, and provided a career development pathway, because you need different assessment skills over the telephone than you do face to face. It's been a way for some staff who are no longer physically able to work on the road to stay involved in patient care."

3. Closest Destination

That otherwise-healthy person with a stubbed toe who wants to go to a hospital 45 minutes across town is the kind of patient who can drive you mad. Under a new Dallas Fire-Rescue pilot program, that patient goes to the closest hospital, or doesn't go.

Participating medics still fully assess all patients and offer them transport. But for those with normal vitals who don't meet explicit criteria for going to specialty hospitals, it can only be to the closest suitable ED.

"If they don't have a true emergency as defined in the policy, then we transport them to the closest open ED so our unit can get back in service," says DFR Medical Director Marshal Isaacs, MD. "We need to get back to being available to respond to the patients who need us most."

There are exceptions: pregnant women receiving prenatal care at a particular hospital, for instance, or cancer patients getting ongoing treatments like chemo. But for everyone else, if you don't like the destination, you effectively decline transport. Consultation with medical control is only required for higher-risk decliners. The new policy carefully defines what a patient is and who needs to be assessed, and limits possible incident dispositions to make after-the-fact analysis easier. All dispatches and PCRs will be reviewed during the 90-day pilot, which involves a limited number of units. Then officials will weigh taking it department-wide.

Results thus far? Promising: No patient complaints to date, and no adverse outcomes identified.

"I think we did a good job training the paramedics functioning under this new policy," says Isaacs. "It's consistent with a philosophy to provide the highest level of service to those who need it most. If we're transporting patients with minor medical conditions all over Dallas, before long all our ambulances are just going to be glorified taxis. That's not acceptable or appropriate."