Northwest Georgia Region 1 Emergency Medical Services Council Rome, GA April 26, 2012 Minutes Chairman Randall Pierson thanked Bud Owens and Floyd Medical Center for sponsoring meal. Rick Cobb gave the invocation. The meal was served. The meeting was called to order with a quorum present by chairman Pierson. The first order of business was approval of the minutes of the last meeting. Jim Cutcher made a motion and it was seconded by Larry Owens to approve the minutes as circulated. The motion carried. David Foster gave a report on the status of the council. He reported that only one member has not received a re-nomination to the council from the county commission. That person is Chad Taylor of Floyd County. [The chair may declare this a mid-term vacancy and reappoint Chad Taylor]. Randall Pierson gave the Executive Committee report. Mr. Pierson stated that all the issues discussed will appear on the agenda except for one issue. This issue is a request from a vendor to present a program on the Glideslope intubation instrument at the next EMS Council meeting in Gilmer County on July 26, 2012. The request will be accepted on the stipulation that the vendor will sponsor the meal at the meeting and will be given 15-20 minutes during the meal to present the program. Dr. Jill Mabley gave the Georgia Office of EMS and Trauma report. She urged all EMS personnel to immediately complete the re-licensure requirements. Only 8,000 EMS personnel out of 18,000 have completed the requirements at this moment. Dr. McDougal gave the Regional Medical Director report. He had three topics to discuss. His first topic was to urge all EMS providers to immediately complete the re-licensure requirements. On July 1, 2012 all personnel not completing the requirements will have their license revoked and cannot work on a licensed vehicle. If the personnel complete the re-licensure paperwork and falsify that they have completed all requirements, their license will be revoked and they may be charged with a felony. Glenn Downes suggested that services should have an April deadline for all personnel to complete the relicensure requirements to continue employment. Larry Owens complained about the videos used in the update for EMS personnel. David Foster explained that the videos were necessary to upgrade the EMS personnel to the new national levels adopted by Georgia. Shane Garrison of Puckett EMS asked if the updates could be done live instead of videos. Dr. Jill Mabley stated that there is no mechanism for groups to watch the videos. David Foster stated that the videos were necessary for consistency statewide. Lana Duff asked about the citizenship requirements for this re-licensure period. Dr. Mabley explained that the Georgia legislature required proof of citizenship for all licenses issued by Georgia to eliminate the possibility of issuing a license to an illegal alien.
The second topic presented by Dr. McDougal was the nationwide drug shortage. He stated that the shortages are due to multiple causes. He explained that EMSMDAC has created a letter to Dr. Fitzgerald of the Department of Public Health asking for permission to establish guidelines for EMS Services dealing with the shortages. The letter asks for the following guidelines: 1. An extension of the expiration date if the drugs are proven to meet the manufacturer s storage requirements. 2. Use of drugs from the strategic national stockpile He explained that this is a national problem not a problem for Georgia only and therefore federal agencies must be involved such as the FDA. The letter suggests that the shortages are a public safety emergency. Federal agencies that must approve these measures include FDA, DEA and CMS. Without permission from CMS, the agencies that use expired drugs may have their Medicare reimbursement privileges revoked. The Georgia agencies involved include the Pharmacy Board and State Licensing agencies which can revoke the license of personnel who administer expired drugs. The process of approval to implement these suggestions may take from 12 18 months. The United States Senate has assigned the issue to a committee but the United States House of Representatives has not taken action. The drugs currently involved in the shortage are opiates, benzo-diazopines and drugs to treat nausea. He suggests that EMS Services monitor the supply and use of these drugs and keep a supply of expired drugs under proper storage in anticipation of the approval to use the drugs. He also suggests that Service Medical Directors should examine the treatment protocols and use substitute drugs if possible as well as limit administration of these drugs to critical patients. One of these protocol changes may be to limit opiate administration to patients only with approval of supervisors. Russell McDaniel asked about the documentation of the use of expired drugs. Dr. McDougal suggests that the dates on the drugs should be extended and the extended date should be used on documentation. Shane Garrison of Pucketts EMS stated that the manufacturers storage requirements for drugs must be followed in order to consider use of expired drugs and this must be documented. Dr. McDougal asked EMS services to begin addressing drug shortages before they run out. He also stated that hypertonic glucose may also be in short supply soon. He urges that all personnel be alerted and trained to accommodate changes in packaging, delivery device or concentration of drugs used by the service to avoid mistakes. Dr. Mabley announced a recall of vials of epinephrine 1:1,000 due to discoloration which may include epi-pens. Shane Garrison of Puckett EMS informed the council about the possibility of using a compounding pharmacy to supply the drugs. He knows that two compounding pharmacies exist in Georgia one in Marietta and one in Macon. The drugs will cost more through this method and the shelf life will be reduced. The third topic by Dr. McDougal was consideration of RSI by EMSMDAC. An RSI committee was formed by EMSMDAC to consider approval of the use of RSI (rapid sequence induction which use paralytics) by EMS Services in a pilot program. The committee is chaired by Dr. McDougal. The committee is also examining DAI (drug assisted intubation). DAI includes the use of sedatives, induction agents such as Etomidate and paralytics. The recommendation came after review of studies such as the San Diego study is as follows:
1. DAI is not included in the national scope of practice for paramedics. 2. The National Association of EMS Physicians (NAEMSP) has standards for training, quality improvement and other elements necessary for RSI. 3. Air medical services presently use RSI but the procedure is performed by nurses and not paramedics regulated by the Office of EMS and Trauma. 4. Current national scope of practice for paramedics do not allow RSI 5. The recommendation by EMSMDAC is that no pilots for RSI will be considered at this time due to studies that show no benefit and documented harm to patients by the procedure. 6. RSI is a subset of DAI and about one third of Georgia EMS Services currently use DAI 7. There is a need for additional studies on the risk vs benefit of advanced airway procedures such as endotracheal intubation by EMS Services. 8. There are varied opinions about these issues within the EMS Community. 9. EMSMDAC should continue to review data, research. The issue of administration of paralytics by EMS personnel is closed but the use of DAI is still being examined for risk vs benefit. The initial review of DAI may demonstrate potential harm to patients by the procedure according to Dr. McDougal. 10. Administration of Paralytics to patients who are already intubated is allowed by EMS personnel. All of the above recommendations by EMSMDAC will be presented to Dr. Pat O Neal for a final decision. Scott Radeker stated that data from studies do not always tell the whole story. His belief from personal experience of more than twenty years of air medical and EMS is that the harm is due to technique which can be improved by training and close monitoring of the procedure. He suggests that in some states the local medical director determines the scope of practice for EMS personnel. He believes that the scope of practice of EMS personnel will expand into areas not anticipated in the future. This expanded scope by certain states may attract paramedics to move from Georgia into these states. He cautions about unnecessary reductions in the scope of practice of paramedics in Georgia because the personnel may begin to move out of the state into more progressive states. Dr. McDougal stated that he is cautious about the local medical directors alone allowing expanded scope of practice because of the low level of involvement of some local medical directors in the EMS Services. He stated that changes in the scope of practice must be guided by good research. He urges the council members to examine the study of RSI in San Diego which stopped the study early because of demonstrated harm to patients. He also states that the scope must be guided by demonstrated benefit to the patient. Russell McDaniel asked if the study s outcome was caused by failure of the procedure or the number of attempts. Dr. McDougal stated that the attempts were successful but the outcome was the death of the patient. Paul Arnold asked about how the outcome was determined. Dr. McDougal states that the study compared patients receiving RSI with patients not receiving RSI. The compositions of the groups were similar. David Foster asked if the outcome was a result of the drugs used. Dr. McDougal stated that this was not known but the outcome was so bad that the study was stopped due to potential harm to patients. He also stated that the only study with a positive patient outcome was one in which all patients were initially brain damaged. He believes that the drug used will not matter because the harm is from prolonged periods of hypoxia during the procedure. Shane Garrison of Pucketts EMS asked why nurses are still being allowed to
use the procedure despite these studies. Dr. McDougal stated that the Office of EMS and Trauma do not regulate the scope of practice for nurses. Dr. McDougal also asked the council members how many endotracheal intubations are required in initial paramedic training. He stated that the requirement is five but studies have shown that a practitioner must perform 50-70 intubations to maintain competency. The standard for competency is successful intubations on the first try ninety percent (90%) of the time. Most training programs have difficulty even obtaining five intubations in the clinical setting for their students according to Dr. McDougal. Shane Garrison of Puckett EMS stated that EMS personnel still have to manage airways in their patients. Dr. McDougal stated that we must consider the best way to achieve this and is not in favor of completely eliminating endotracheal intubation by EMS personnel in all situations. However, studies have demonstrated harm to patients and we should be guided by this fact. Contact Dr. McDougal at pmcdougal@gmail.com for a copy of the research he quoted. Bud Owens gave the EMSAC report and declared that previous speakers had covered all the issues. The next meeting of EMSAC is on May 22, 2012 at Medical College of Central Georgia in Macon, Georgia. David Foster gave the Regional EMS Office report. He stated that most of the issues were previously covered in other presentations. He suggests that all EMS Directors require their employees to present a printed certificate as proof of completing re-licensure requirements. He also presented information on vouchers issued by the Georgia Office of EMS and Trauma. These vouchers are available to services, schools, etc to buy one or in bulk for their personnel to use to pay the license or re-license fees to the Office of EMS. The Vouchers have no expiration dates. The vouchers have a place to put the person s name in order to apply the voucher to the correct fee. Agencies may still issue a check to pay for multiple persons but no credit cards will be allowed for this purpose. [Services should attach a list of all persons to whom this payment will apply] The voucher program was started because fees to EMS training programs did not cover license fees. Therefore some people who graduated from these schools did not become licensed. The school may purchase vouchers to be used in training programs and the voucher will be included in the license application of the students to the Office of EMS and Trauma. Mr. Foster stated that there are 21 outstanding rosters for approved training programs in Region 1. He urged services and schools to send the rosters to him as soon as possible so students may be given credit. Kelly Buddenhagen gave the EMS-C report. The annual EMS-C conference will be conducted on June 6-7 in Gainesville, GA. The Georgia EMS-C meeting will be held on June 5 at 5:00 p.m. The Georgia EMS-C group is attempting to expand membership to include other agencies such as Safe Kids of Georgia, Child Protective Services and others. There will not be a conference line connection available at this meeting. May 23 will be EMS-C day in Georgia and Medical College of Georgia in Augusta will be conducting free training programs on that day. Erlanger Medical Center in Chattanooga, Tennessee will also be offering training programs at a conference on May 4, 2012. The position of Georgia EMS-C coordinator position is being advertised by the Georgia Office of EMS and Trauma. The position is part-time and applications are being taken now. David Foster had distributed the free Braslow Tapes to services attending the council meeting.
Randall Pierson gave the Georgia Association of EMS report. The CHANGES conference in Atlanta this year did not have the attendance expected and GAEMS is considering moving the conference back to Augusta. The Educator Conference will be begin on September 22 and will be a four day conference at the Mariott Hotel and Conference Center in Savannah, Georgia. Information may be obtained on the GAEMS website at http://www.ga-ems.com/ [The next event is the annual Georgia EMS Awards Banquet on May 17, 2012 beginning at 6:00 p.m. at the Georgia Public Safety Training Center in Forsyth, Georgia] Mr. Pierson encouraged people to apply for ASPER grants to fund training programs and equipment. A change in the policy of ASPER grants allows services to purchase replacement equipment and not just new equipment. The first item of old business was a report on committee assignments for the Regional EMS Council. See attached assignments. The second item of old business was a report on the progress of creating a 501C3 not for Profit Corporation. Initially the council was waiting for the approval of the amended bylaws which were submitted to Dr. Pat O Neal and the departments legal counsel. It was discovered that the process of approval may take more than a year so it was decided to proceed. Shane Garrison of Puckett EMS informed the council that GAEMS has established a 501C3 for use by Georgia EMS. The name of the corporation is Georgia EMS Preparedness Foundation and he agreed to take in and disperse funds for the Council. He also stated that available grants are also posted on the website. This could be an alternative to establishing a 501C3 by the Council. It may be advisable to avoid creating a 501C3 corporation from the Regional EMS Council. However, members of the Regional EMS Council may decide to voluntarily become members of the 501C3 Corporation. The reason that the 501C3 creation was discussed initially was to provide a mechanism of taking in and dispersing funding for special events such as the awards banquet and educational programs. The Executive Committee decided to proceed with the creation of the 501C3 but not to create it from the Regional EMS Council. A motion was made by Jim Cutcher and seconded by Danny West to proceed in the creation of the 501C3 Corporation. Mr. Pierson stated that a steering committee must be created and bylaws written. Glenn Downes suggested that the bylaws should mirror those of the Regional EMS Council. Lana Duff will provide bylaws from SEEMSDA of Tennessee and Shane Garrison agreed to provide bylaws of the Georgia EMS Preparedness Foundation. It has been suggested that David Foster should attend the first meeting but thereafter not be involved because of the potential conflict with his position. Russell McDaniel stated that lawyers hired to assist in the formation of a 501C3 use a template for the bylaws. The third order of old business was a report on the creation of the RTAC (Regional Trauma Advisory Committee) in Region 1. The steering committee has created a partial list of potential members of RTAC at the last meeting. Billy Hayes of Northside Cherokee Medical Center in Canton has agreed to chair the RTAC. Randall Pierson suggested that after initially meeting with Billy Hayes and members of the Georgia Trauma Commission, a large meeting should be held for all interested participants. The next Georgia Trauma Commission meeting will be on May 18, 2012 in Savannah where the 2013 budget will be approved. Region 9 has begun the process to create an RTAC. The goal of the Georgia Trauma Commission during the next budget year ending on June 30, 2013 will be to create 8 RTACs. The last two regions will be Regions 2 and 4 which do not have trauma centers. The grant for EMS uncompensated care will end on May 15, 2012 and only 6 services have applied for a portion of the $754,000. Contact Judy Geiger at the Georgia Trauma Commission for more information. Also contact Chad Taylor of Floyd Medical Center at 706-504-6685 if you regularly transport patients to Floyd Medical Center. The July 1, 2012-June 30, 2013 budget will be $15,900,000 and $2,500,000
will be available through grants to EMS Services. Georgia Trauma Commission has a new member, Linda Cole of Children s Healthcare of Atlanta. Her focus will be to increase the role of the State Communications Center funded by Georgia Trauma Commission. Randall Pierson stated that Kurt Steunkle of Floyd Medical Center has agreed to take in and disperse funds for the Region 1 RTAC until another mechanism can be established. A motion was made by Jim Cutcher and seconded by Carlton Firestone to accept this offer. The motion carried. David Foster gave the Education report. Kelly Buddenhagen reported that the next installment of the Educator Update series in Region 1 will be held in Dalton on June 28 and will be proceed by an Advanced Stroke Life Support Instructor course on June 27. The update will involve presentations on Revitalizing Instructors by Chuck Baerd, an I-85 bridge program outline and a program on Autism by Children s Medical Center of Chattanooga, Tennessee. Glenn Downes asked if there is any mechanism for contributions to the family of an EMS professional killed in the line of duty. David Foster stated there is no mechanism except for individual donations. A motion was made to adjourn by Carlton Firestone and seconded by Brian Walker. The motion carried and the meeting was adjourned.