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Welcome to the Behind the Shield podcast.
As always, my name is James Gearing and this week it is my absolute honor to welcome on
the show Joshua Rose and Dr. Jared Troutman.
Now the reason why this conversation is so important is as you will hear, they are bringing
an incredible solution to removing the non-emergent responses when it comes to the fire service,
which in turn is not only providing better care to the people that call 911, but also
the cost to that patient is greatly reduced and the added ripple effect is another ER
bed stays vacant for a true emergency.
So we discuss a host of topics from Josh's journey through EMS, the GMR response to Hurricane
Helene, viewing 911 as a three tiered system and so much more.
Now before we get to this incredible conversation, as I say every week, please just take a moment.
Go to whichever app you listen to this on, subscribe to the show, leave feedback and
leave a rating.
Every single five star rating truly does elevate this podcast, therefore making it easier for
others to find.
And this is a free library of almost 1000 episodes now.
So all I ask in return is that you help share these incredible men and women stories so
I can get them to every single person on planet earth who needs to hear them.
So with that being said, I introduce to you, Joshua Rose and Dr. Jared Troutman.
Enjoy.
Well Josh and Jared, I want to start by saying two things.
Firstly, thank you to Rob Milano, who was the chief that connected us originally.
And secondly, I want to welcome you both to the Behind the Shield podcast today.
Thank you.
Really excited to be here.
All right.
Well, first question for you, and I'm going to have to obviously point to each of you
because you're sitting in totally different places and we'll get to why Dr. Troutman is
in somewhere interesting at the moment.
But Josh, start with you.
Where on planet earth are we finding you today?
So I am based right outside Pensacola, Florida, the beautiful panhandle on right on the Gulf
Coast.
And we obviously as a state just had two hurricanes recently, you know, and then, you know, one
obviously went north and the other one, as I was saying, when we just hit record, tore
through Indian River County and the tornadoes there were pretty catastrophic.
The rest of us are very fortunate.
So as that as a segue, Jared, where are we finding you and why are you sitting there
right now?
Yeah, so I'm actually in Asheville, North Carolina, which surprisingly enough, we all
know a hurricane hit.
So I'm out here supporting some of our deployed ambulance team members.
So let's expand on that just for a second, because I saw when I was looking at the website,
you have a state response.
So before we dive into your backstories and the real reason why we're here, which is the
nurse navigation, talk to me about the emergency response element that you have nationally.
Yeah.
So we are a primary national responder for disasters, certainly natural disasters.
So for Hurricane Helena and Hurricane Milton, which, of course, we all know happened at
almost the same time, we've had over 800 ambulances, over 2000 personnel deployed out to the front
lines.
And these are personnel from EMS agencies all across the US, literally as far away as
Alaska and Hawaii, and all out here caring for patients.
Even today, still have several hundred personnel and ambulances out there helping backfill
the 911 systems here in Western North Carolina.
What are some of the elements that were underreported to the average person that you're hearing
now with the men and women that are boots on the ground in these places?
So I think for everyone that comes out here, it really is just a rejuvenation as to why
do we do what we do?
Why did we sign up for EMS in the first place?
Sometimes we get in a lull in our home jobs, but to come out here and to come together
with people from across the US and really be able to impact somebody locally on their
worst day, we know when people call 911, they're having their worst day, but this is the worst
of the worst day.
You really see a lot of new smiles and new rejuvenations and people actually leave refreshed
after going out on deployment.
Although it has all its difficulties, but there are so many positive stories and positive
patient care things that happen at one of these.
It really is just great to see all the positives that come out of this for our EMS providers.
I think we've seen that even with the regular people, the neighbors and some of the volunteers
that have come in with every tragedy like this, what I love is all the human stories,
all the elements of community that I would argue is what America truly is, even though
sometimes we get a little partitioned and divided by certain groups.
You're exactly right.
It really brings us all together and really is just a profound positive.
I think it's refreshing and can be a reset for us.
Absolutely.
That's an interesting subtext to what we're going to be talking about later, which is
really getting our responders back to real emergencies again.
Before we go down that road though, let's start with you, Josh.
Tell me a little bit about your early life.
Tell me where you were born and what did your parents do, how many siblings?
I grew up in Boston, Go Patriots, even though this isn't our year.
I grew up right outside Boston.
I have a younger brother and then my parents, both of whom who have passed now, were just
in completely random industries.
My mother was a writer primarily and my father actually was a sound engineer, created radio
commercials and built some of the initial software for podcasts such as this.
Your dad had probably appalled at my editing skills.
So he never listened to the Behind the Shield podcast.
All right.
Then the same question to you, Jared.
What about that?
Where you were born, what your parents did, how many siblings?
Absolutely.
Born in North Texas, a town called Wichita Falls, Texas, my mom stayed at home with my
brother and I.
My dad actually buys and sells wrecked cars, which he still does today.
That's probably a whole other podcast, but it's something that I like to do too in my
spare time and not only wreck cars, but wreck motor homes and pretty much wrecked any kind
of vehicle.
I've probably fixed it and that's what we do and drive today, me and my family.
My late brother was a paramedic for a number of years.
Yeah, that's a little bit about my family.
So Josh, let's go to your journey into EMS.
I know you started working in your kind of home area as a paramedic.
Absolutely.
Thanks.
So actually when I was an undergraduate student in college at University of Rhode Island,
we had a student run ambulance program there, college based EMS.
And I think like a lot of folks, I was intrigued by just the nature of this as an option.
And so I started volunteering between classes and got to the point where it really, like
everybody knows, once EMS gets in your blood, it's there to stay.
And so it became something that I became really passionate about, that opportunity to help
people to step in when people are at their worst moments and provide a real solution
for them, get them to definitive care, whatever that might look like.
It really spoke to me.
And so I got my start back in the early 90s as a volunteer EMT with the college.
And then I started volunteering for the town, took some advanced EMT program classes in
Rhode Island.
Of course, we have the EMT cardiac program.
So I went to the cardiac school.
And then when I graduated, looked at an option of, do I do something within my major that
I went to school for and paid all that money to get a degree in or do I continue to stay
in EMS?
And obviously made the decision at that point to go to paramedic school and then started
working in the 911 systems in Metro Boston.
What have you seen as far as what you witnessed when you first especially became a full time
paramedic and then what has been the evolution or devolution of the core volumes and some
of the things that our responders are sending now?
What have you witnessed?
Because you've been in this for a long time.
Yeah.
When I first started in EMS, we were a BLS ambulance squad when I first started as a
volunteer.
And paramedics and advanced life support were fairly rare in the community that I was operating
in.
And then as I progressed and became a paramedic myself, we started to see this big transformation
in EMS systems towards this two tiered model where you would have BLS providers and then
ALS providers and the advent of emergency medical dispatch where the dispatchers would
screen the call and make a determination based on that call as to the acuity of that patient.
And it would either be an ALS call and we'd send the paramedic unit or it would be a BLS
call and we'd send the BLS unit.
And of course, BLS could get on scene and determine that ALS wasn't necessary.
ALS could get on scene and say BLS wasn't necessary or we could move the patients around
as we needed.
But it was this big emerging trend back in the late 90s, early 2000s to start tiering
EMS systems.
And as a provider working in those systems, we thought it was great.
As a paramedic provider, I knew that most of the calls that are going on, we're going
to be operating sort of at that higher end of my skill set and require interventions
for sick patients.
And that's what I went to school for and that's what I was passionate about and what
I really wanted to do.
Then we started to see as EMS contracts evolved and cities and communities started to look
at what was out there and available, this movement towards all ALS systems.
And so I think the cities and the community leaders probably rightfully so felt that,
look, paramedics are trained at a higher level than an EMT rather than having separate EMT
ambulances and paramedic level ambulances.
Let's combine them.
That's right around the time when we started to see a lot of paramedic basic staffing on
most ambulances out there.
And it would make sense.
So you'd have one of each in the same ambulance and then if it was a low acuity call, the
basic could handle it, get that good patient care skill set, develop their skills and abilities
to manage patients in the back of the ambulance.
And of course, if it was a higher level patient, more acute patient than the paramedic could
work in the back and practice at the upper end of their skill level.
And then that model I think worked really well for a really long time.
And we still today, most of our systems out there are that all ALS system staffed with
a paramedic and a basic in the same ambulance.
The other thing that happened though, back in the early 90s, mid 90s, 2000s and so on
is as an industry, we got very comfortable with saying to our patients, look, if you're
not sure what you need, call 911.
We're happy to respond.
We're glad to take care of you.
We want to make sure that you're getting the care that you need.
It is better for us to be there and be safe rather than for us to miss a potential emergency
because you didn't know what to do and you didn't think it was serious enough to call
911 and then something bad happened.
And so as an industry, I think we got really good at educating people to call 911 in the
event of an emergency.
We never really defined what an emergency was.
But I think most people kind of knew that an ambulance was for these life-threatening
conditions.
Well, the last 10 years or so, and this isn't really a pandemic thing.
I think it started much prior to that.
We started to see this shift and lots of other reasons for it outside of our little world
within the 911 space, but more and more patients, more and more people started to call 911 regardless
of what that emergency was.
And we can go on and on talking about culture wants instant gratification.
We can talk about the change in these high deductible health plans.
And so people become more reticent to use health care, to use primary care because they
don't want to pay out of pocket.
And as a result, they have unmanaged chronic conditions that exacerbate and so on.
There's a lot of factors that push to this.
But what we started to see probably about 10 years ago was this increase in call volume
across 911 systems across the country focused primarily on the lower priority calls.
Now that's not to say that these are not quote unquote emergencies, but we see people using
911 today for scenarios that 10 or 15 years ago, they probably would have just called
their primary care physician for or managed some other way.
The net result of that is our ambulance systems, our paramedics and EMTs out there in the field
are getting called more and more often for cases that are not at the upper end of their
skill set and instead are things that are really could potentially be treated elsewhere.
And probably the best evidence of that is when you look at any EMS system across the
country, in most cases, we see this rise of what we call dry runs.
And so those are the calls that a unit responds to, went lights and sirens and got there as
quick as they could and they got on scene.
And then the patient, the 911 caller said, you know what, I changed my mind.
I really don't want to go to the hospital.
And they signed a refusal and then the crew leaves.
I think that's a big dissatisfier just across the industry.
I think it's bad for the patients who didn't know what to do.
So they called 911 and then had a second thought afterwards and said, well, maybe I don't want
to go spend the next 10 hours sitting in a waiting room in an emergency department.
And if there was only some other way that I could get care, I think it's a dissatisfier
for the individual EMTs and paramedics that have to respond to that call who frankly put
their lives at risk to respond lights and sirens to what they're anticipating to be
an emergency.
And then they get there and discover that the patient changed their mind and didn't
want to go to the hospital.
And I think it's a dissatisfier for the system in general, because every time that that ambulance
is tied up on one of those dry run calls, it means that they're not able to respond
to higher priority emergencies that really need a rapid response and an intervention
as quickly as possible by trained EMTs and paramedics.
And so those are just some fundamental underlying challenges that I saw as a provider.
And of course, I think every provider that's listening to this would recognize and agree
that when we get that call at one in the morning for the person who twisted their ankle three
weeks ago, and it's now throbbing in the middle of the night and they don't know what else
to do.
And maybe they've called their doctor's office and got the message, if this is an emergency,
hang up and call 911.
We've all responded to cases like that.
I think individual providers recognize that this is a growing problem.
And I think system administrators, EMS directors, hospital directors, healthcare folks, public
health leaders, elected officials, I think everybody's starting to recognize that unless
we do something different than this traditional model of sending the most expensive form of
transportation and the most expensive type of emergency healthcare out to individuals
for every single time they call 911 and then taking them to an emergency department for
the most expensive resource for their care can end up becoming really just not an effective
way to manage these situations today.
And so that's why I'm excited about our nurse navigation program.
Absolutely.
When I look back at most of the time, ironically, it was when I was in Florida, when I worked
out in California for a few years, they had a great relationship between the hospitals
and FD and they hardly ever held the wall.
But that aside, all the transport units, all the rescues I worked on, when the pandemic
hit there were these reporters saying, there's people in the hallways and it's so terrible.
And I just remember going, and of course it's a real thing and it was having an impact,
but that was my entire career, hour, hour and a half, sometimes two, three hours holding
the wall, especially if you had a low acuity patient because they were getting jumped over
and over and over again.
So through your eyes, through your career, before we get to Dr. Troutman and within the
hospital, what were you seeing as far as that very element, the inability to provide beds
for patients because of the increasing calls and the low acuity of a lot of them?
Absolutely.
I think it's just frustrating, period.
I think there's frustration for the patient who, let's face it, our ambulance stretchers
are not very comfortable.
And for that patient that we've had to pick up and transport and then sit with them in
the hallway of the hospital, well, they see nurses and doctors and technicians and everybody
running past, dealing with other patients and we're just sitting there.
I think it's frustrating for them.
They called 911 with the expectation of being able to get to the hospital and be treated
relatively quickly.
It's obviously a tremendous frustration for the paramedics and EMTs who are listening
to the radio and hearing dispatchers screaming for units saying, hey, we need somebody to
clear up ASAP.
We have a chest pain on the other side of town and we can't.
And we get stuck there and then that gets very frustrating.
It's obviously a frustration for the hospitals as well.
They recognize that having these patients in their emergency rooms, again, it's a finite
resource.
And those hospital beds ideally should be filled with the patients who have the higher
acuity, higher priority needs and should be treated.
It's not first come, first serve.
It's treated based on the degree of need.
And if there are people who don't have as high a priority, then the hospitals are really
stuck and they don't have too many other options of what to do with them.
And so this challenge and to your point, James, right?
Some parts of the country, this has been a challenge for years, not just triggered by
the pandemic, but I think across the country, it's ubiquitous now that in 2024, we simply
don't have enough paramedics and EMTs on the road.
We don't have enough ambulances out there.
We don't have enough hospital beds to keep pace with this growing number of lower acuity
911 callers that are flooding the system.
100%.
Well, speaking of hospitals, let's go to you, Jared.
I'd love to walk through why you chose medicine and then again, the front door perspective
that you've had and either evolution or devolution through a physician's eyes.
Well, so certainly found myself in emergency medicine because I realized I like just seeing
everything.
I like that element of not knowing what's coming through the door next and being able
to take care of anything and everything.
So that drew me to the specialty of emergency medicine very early in my med school career.
If you asked before I was going to med school, I wanted to be a pediatrician and I can tell
you now, I would not have been happy doing that.
I love kids.
I love taking care of kids, but I could not do that all day in and out.
Now interestingly enough, so finished with residency, ended up back in Lubbock, Texas
and I got to say guns up and go Texas Tech out there at the big university level one
tertiary care trauma center.
Was there just a handful of months and literally got a, Hey, you're the new guy.
Our ambulances, we need an EMS medical director.
Since you're the new guy, why don't you do that?
And I said, Oh, that sounds fun.
I have no idea what that means.
That was goodness about 13 years ago, I think now.
So I found myself as an EMS medical director and found out real quick one, I had no idea
what I was doing.
And fortunately fast forward a few years, met a lot of great mentors, really became
really engaged, certainly in the state of Texas EMS scene, if you will, and learned
a lot those first few years and gained some good mentors and just learned about EMS and
certainly learned about all the high acuity stuff.
And even if we talk today, I'm a big proponent of doing things like whole blood and pre-hospital
and RSI, DSI, all those fun things, but there'd always had been this overarching, whether
in practicing medicine in the hospital or talking to our EMS crews and ultimately looking
at the patient, are we really doing the right thing for some patients that have real low
acuity complaints?
They just don't know what to do.
So what do they do?
They either come to the emergency department because they show up there or they dial 911.
They can't get into their doctor.
They don't know if it's okay.
And that's the easy access.
So I found myself really struggling with what is the right plan?
What is the right thing to do with this?
So I left the hospital-based practice and me and another couple of doctors actually
built three freestanding ERs, two in one city, one in another.
I operated those as our CEO.
I've always kind of liked the business side of medicine and how all the economics and
such works, but really viewed that as an alternative for a place for patients to access quick care.
Now we could get all into why today I'm not certain that freestanding ERs are the right
solution.
I think they probably have a role, but ended up out of that.
Kind of didn't do much for a year other than really focus on EMS.
A few other agencies that I worked with became board certified in EMS and then essentially
was approached to working with global medical response as our national medical director
and really with a focus on we need to be healthcare.
That's what EMS provides.
Even still today, we know that transport is where the world lives, but we know, and I
think the needle's moving a little bit, we are healthcare.
EMS is an important integral part of providing healthcare to patients and part of that healthcare
system.
And how do we get there?
How do we get recognized?
Everything from funding to our healthcare partners, et cetera.
And part of that is what do we do with those low acuity patients?
And really it was a realization that, you know, look, patients call 911 just looking
for a solution to a problem.
You know, the issue is in the EMS world, our solution to every problem is what it's sending
fire engines, fire trucks, and ambulances, maybe a helicopter.
But is that really the right thing to do for the system, for the healthcare system?
Is that the best way to provide healthcare for every patient?
Is there a safer, better way to do it?
And that's what really also drew me into the nurse navigation program, which we've had
a lot of growth in and I know we'll get into that a little bit more, but how we are ongoing
every day showing the safety and efficacy on how we can really connect patients to really
the right type of care that they need, even though they called 911, but it doesn't need
to be an ambulance.
And we, it has so many positives.
I always say that with nurse navigation type program, it's like every rock we looked under
is a positive, whether it's for the patient, whether it's for the operations, whether it's
for the personnel, whether it's the finances for the patient, every single thing is a positive.
And I just love that obviously from a physician perspective.
And I know we kind of kicked it off.
Josh wants to kick on that operation centric stuff, which I get as important, but also
I got to be the doctor and bring it back patient centric.
It really all becomes patient centric and which to me also directly relates to the fact
that EMS is healthcare.
That's what we do each and every day.
Well, I want to go to the proactive conversation for a second when it comes to people even
getting sick.
What I've realized now through this career and then obviously this podcast and learning
from literally this is more than a thousand interviews now I've done.
So a lot of very, very smart people is there's areas where at the time, obviously people
thought it was the right thing to do, but there's a certain point where you've got
to have the humility to go, it's not working.
And if you look at the first responder professions, it's not working.
You know, we have a recruitment crisis, we have 911 abuse, we have all the things.
When you talked about residency, one of the big things I'm very passionate about is sleep
deprivation and getting our responders more rest and recovery.
Dr. William Halsted was the physician who was behind the residency program.
And people always ask your community, why do they work so many hours as a resident?
But when you go to the origin story, Dr. Halsted was also a cocaine addict.
And so, you know, he was awake for hours and hours and hours.
His students obviously were expected to do the same and that kind of bled in forward.
So looking back and realizing that maybe a 56-hour work week for firefighters and paramedics
is pure insanity, we need to change that.
Same with residency.
But another area with your profession specifically that I hear over and over again from physicians,
I don't know if you ever cross paths with Dr. Chris Colvin from Texas, but he's been
one of the ones on the show a couple of times now.
But the absence of education on sleep, nutrition, exercise when it comes to med school versus
pharmacology.
You know, great point.
And I'll segue a little bit into that on a personal story of mine.
When you talk about good sleep, good exercise, eating right, etc.
I'm sitting here before you about 115 pounds lighter than I was about four years ago.
At the start of COVID, I was large and I was a bit unhappy with my weight.
And I got with a health coach.
And because it was frustrating to me as a physician because I knew what I needed to
do, but I just couldn't do it on my own.
But work closely with a health coach to really have a better understanding things that really
weren't learned in medical school.
What is the appropriate diet and stuff?
What is the appropriate way to work out?
Literally this morning, I walked about two and a half miles around downtown Asheville.
I tried to, you have to prioritize exercise.
You have to prioritize appropriate diet and you have to prioritize sleep.
And when you bring those three together, you end up as a healthier version of you and a
healthier version of you, I think is a better productive person out there.
So it is absolutely a gap in all of medicine.
It's a gap, of course, as you pointed out in the physician world, it's a gap in the
paramedicine world as well.
We just don't do a good job at educating and teaching it.
Yeah, well, I think as well, whether it's crushing residencies, whether it's shift
work in doctors and nurses, whether it's, again, we mentioned the insane firefighter
work week and add in mandatory overtime.
Now you've got these men and women working eight plus hour weeks sometimes.
And then you look at their physical health and the outside, you're like, well, they see
people die every day.
Why are they not in great shape and not smoking and all these things?
But you've got to factor in the work environment, which I think is one of the conversations
of solving the recruitment crisis is simply investing in your people and using, you know,
seeing them as your most important resource.
Absolutely.
You know, I'd agree.
And you look at and certainly in the EMS world, what we potentially take a rather young person
from a life experience standpoint and put them on an ambulance and what they potentially
could go experience on that first call is unbelievable when you really lay that out
to the general public.
And of course, I could lay out a number of examples, but anybody in EMS knows what those
are.
And how do you do that on day one, but let alone on day 10 years or day 20 years?
And how do you process that all in between and remain successful?
And oh, by the way, I know that call just finished, but we also have this holding that
you need to get to because we don't have another truck available.
And I need you to show up mind game, ready to go, be ready to perform that DSI perfectly.
And I need a smile on your face and treat the patient with respect.
That's tough.
And I wish I knew a magic answer to get over that.
But that is the big question.
Absolutely.
Well, I would argue enough rest and recovery so they get close to baseline and then a high
standard.
You know, when you create a healthy work, you can put that bar back where it needs to
be and then most of the time you're going to get that result.
Yeah, I agree completely.
You know, having resources, having mechanisms in place, which we try to do that when there
is a tough call that, you know, there's a phone call or something, hey, let's come in,
let's sit down at the table, let's chat before we just put you back on that next call.
And so that is absolutely important for resiliency and mental health and being able to process
that.
I think things can be processed.
We can get over that, but we have to as a profession engage and do it in a healthy way
in order to protect our workforce and to be able to be good providers of health care.
Absolutely.
Yeah, I think that's what I've said a lot about the mental health conversation is the
hope that's in post-traumatic growth that you can take a struggle, find your own personal
toolbox, which is not really discussed too.
We're all different.
We've all got, you know, different, you know, ways of losing weight, ways of exercising.
It's the same with our mental health, but I truly, truly believe that on the other side
is a more resilient version of you and therefore you will be an asset on that rig once again.
Well, I want to go to the kind of origin story of the telehealth before we really dive into
nurse navigation.
I had a guest on the show, a former firefighter that was in a company that was doing a similar
thing but on a much smaller scale.
And he was kind of explaining how much red tape there was when it came to telehealth
pre-COVID and then how some of those shackles were kind of broken as they progressed through
that.
So what were the restrictions?
I'll go to you, Josh.
What were the restrictions as far as the ability to deliver this, say, in 2019?
And then what has changed to allow this metamorphosis of medicine that we're going to talk about?
Yeah, you know, that's a great question, James.
And when I first got involved in my role at American Medical Response at the time, now
of course we're Global Medical Response, it was about 11, 12 years ago.
And one of the things that I was responsible for when I first came aboard was trying to
expand and grow this fledgling mobile integrated healthcare concept, MIH.
And lots of various elements that were part of that, telehealth being one of them.
Really it was around trying to find alternative ways to use our paramedic and EMT resources
in addition to the 911 system and transporting patients.
But as Dr. Troutman pointed out, at the end of the day we're healthcare.
And how can we deliver better healthcare to this constituent of patients that are in the
out of hospital environment?
And so we developed a number of different programs related to MIH, community paramedicine,
telemedicine, various elements and permutations of that.
And where we kept getting hung up, especially pre-pandemic, was trying to find an appropriate
funding source for these.
And it came down to one of those things where, look, this is a great idea.
We're very capable of doing it.
Paramedics, EMTs, they know how to go into somebody's home and deliver care in an unscheduled,
unplanned format.
That's what we're really good at.
But if we can't find somebody to pay for it, then it becomes a non-starter.
It's not sustainable.
And the challenge that we had and still have to a certain point today is that the funding
for emergency medical services, as you probably know, the primary source of funding is based
on transports, not taking care of patients in their homes or providing alternative options
for care.
We get paid by the mile.
And if we don't transport a patient, then there's no revenue associated with that in
95% of the systems out there across the country even today.
And so while we had developed a number of innovative approaches to this and identified
stakeholder groups, whether it was on the far end of the spectrum with hospice and palliative
care or with the subacute patient or recently discharged patient from the hospital and managing
that readmission process and so on, ultimately, we could not find a sustainable payer source
that was willing to fund the cost associated with that type of service.
And again, I don't want to speak for the payers, but the traditional model of, hey, you call
911, we'll pay for you to bring somebody to the hospital.
That's what we've signed up for.
That's our responsibility, whether it's Medicare, Medicaid, private insurance, et cetera.
That's what the fee schedules are based on.
Again, it's based on reimbursement per mile plus a base fee.
And that's the way that that system had been built.
So fast forward to 2016, 2017.
And city in particular, Washington, DC, was having tremendous issues with their EMS system.
I think in many ways they were a leading indicator for what's going on with a lot of the EMS
systems across the country today, not just urban systems, but large suburban and even
some rural systems.
And the challenges that they had were really just one compared to supply and demand.
There was a growing demand for their resources within the district and not enough supply
of their available fire engines and ambulances and paramedics and first responders in order
to meet that demand.
And so with Fire Chief at the time, Chief Gregory Dean engaged with AMR and said, hey,
you guys, you know how to run ambulances, but what else do you know?
Are there ways that we can come up with some type of innovative workaround to help reduce
and decompress the pressure that is on my department?
Because they were having issues with ambulances that would go out the door first thing in
the morning as part of their shift and then would not return to the station until past
the end of their shift because they're literally running call to call to call.
And that left no time for the members to do any training, to do any type of repair and
maintenance on the vehicles.
Just it had gotten to this crisis point.
And so we worked with Chief Dean, developed this concept of nurse navigation.
He called it at the time, Right Care Right Now for Washington, D.C. and ended up launching
that program in 2018, which was really prophetic in a way, two years before the pandemic and
allowed us to not just with nurse navigation, there are certainly some other things that
we did as part of that launch in D.C. being able to decompress the workload with additional
VLS units and things like that that are obviously critically important, especially for these
metropolitan fire departments that are facing these resource challenges.
But nurse navigation, Right Care Right Now became a fundamental part of that program.
And I think it showed, especially when we got into the pandemic, that wait a minute,
we can be successful in introducing what I like to call a third tier of EMS.
So we have the ALS tier, we have the BLS tier.
And now when that caller calls into the 911 system and the call taker does the initial
EMD screening, the call taker can identify, hey, this call might be appropriate for a
nurse to do some additional screening on.
And so that third tier of sending those calls over to a nurse that the ones that, certainly
not every call, you know, 85, 90 percent of the calls that are coming into the dispatch
center are still going to go out for an immediate either ALS response or BLS response.
But for those other 10 to 15 percent, we can screen them and determine is an ambulance
really going to be clinically required on this?
And if so, absolutely, let's get them into the queue and get an ambulance sent over to
them.
But maybe there's some alternate options where they can get care outside of the emergency
department.
And that's where that nurse navigation really comes in.
Was there any element of rules being changed during the pandemic that made it even easier
though?
Or was that purely just that the creation of this happened to be a couple of years prior
to it?
So for the most part, I don't think it's really been an issue with rules and regulations.
You know, certainly as we go bringing these systems into new parts of the country, they're
looked at very closely by regulators.
You know, we're in the process right now of launching a number of programs out on the
West Coast in California and California, as you well know, James, from working out there,
that's a very unique EMS system and a very heavily regulated EMS system down to the county
level with different LEMSAs and so on.
And so that becomes part of those discussions, certainly, and we need to make sure that the
medical directors and LEMSA directors and other parts of the country, the state or local
regional EMS directors are all aware of and supportive of this program.
It's not something that we do in a vacuum, certainly.
But we really haven't run into scenarios where state regulations or statutes need to be changed
for this.
I think the bigger thing that we saw shifting primarily during the pandemic, but again,
with DC, it was prior to that, it's really the mentality of EMS providers.
You know, I love EMS.
I've been in this my entire career.
It is going to be my entire career.
This is what I really enjoy doing.
But let's face it, there are many, many things that we do because we've always done it that
way.
And we get into our own habits and mentalities of, well, this is the right way to deliver
EMS because it's what we've always done and it's how we're going to continue to do it.
And it can take a significant paradigm shift in order to start to get the decision makers,
the regulators, the people, again, not to change regulations or develop new laws or
anything like that, but just to understand that there is a potential outcome of somebody
calling 911 and us not sending an ambulance.
And that's okay when we can determine that this is a low priority call that doesn't require
an ambulance.
And for so many people, not just the authorities and EMS directors and folks like that on our
side of the house, but for the public at large, that becomes something that takes a while
for community acceptance.
When we put these programs into a community, one of the things that we do is work very
closely with local media to publicize this program, make sure that people are aware that
this is an additional outcome that could now occur when you call 911.
It's an additional set of resources and really a benefit for the community.
But for the person who's not aware of that, when they call 911, they have an expectation
that an ambulance is going to be at their door six to eight minutes later.
And when they call 911 and the dispatcher or call taker says, you know, this sounds
like something where you might benefit from speaking to a nurse before we send an ambulance.
Would you like to speak to one of our nurses?
That can catch a lot of people off guard.
And we do get those folks who say, no, no, no, just send me an ambulance.
I want one because I pay my taxes and I demand an ambulance and that's how it's going to
be.
But we start to see a shift in the community's mentality as these programs get underway,
as they start to gain adoption in the community and neighbors start telling neighbors about,
yeah, you know, I didn't know what to do.
I called 911 and instead of sending an ambulance, I got to talk to a nurse and she got me connected
to the urgent care center and I went in and had an appointment.
It was great and only cost me 200 bucks.
I didn't have a big ambulance bill and I didn't have a big ER bill and I didn't have to wait.
And as people start to talk about that, then we see that shift in adoption in the community.
Going back to you, Jared, you mentioned about the young medical EMT and their first call.
The first call I had at Hialeah, the very first one is a firefighter EMT.
We go into this gentleman's house and you're obviously hoping you're going to get some
ripping structure fire or something on your first call.
And there's this older gentleman and Hialeah was like 98% Cuban.
So it was the call was in Spanish and he's got this tiny little condom looking thing
on his finger.
And he starts talking to the medics and I hear him say the word caca.
I'm like, I'm not Spanish, but I know what that word means.
And what he wanted one of us to do was to put this little condom on our finger and fish
around and get whatever was stopping him from completing his bowel movement.
When I think of that kind of person, I had another one that was, he called us because
he didn't like the taste of his new dentures.
So you've got your Alpha Omega call, which we see over and over again.
And depending on where you are, like for example, Hialeah, a lot of immigrants, there was, you
know, it's just, it is what it is.
There was clearly some sort of sub conversation that you use as magic card and you call 911
and they'll take you wherever you want to go.
So I would argue it's probably more abuse in some areas, less than others, but it's
a real thing that absolutely is continuing to wake up our first responders.
So as you mentioned, you know, Josh and I obviously understand the station life element,
but where I see so much value in what we're about to talk about every single patient that
shouldn't have gone to the hospital.
And I'll even put, you know, medical directors on blast too.
I've worked for agencies.
They said, just take everyone.
Don't, don't, you know, question it.
And then also ask them which hospital they want to go to.
Like really?
This is 911 and oh, I want to go to the one, you know, 40 minutes away, you know, so it's,
I see again, this kind of broken system versus being available and ready for a true medical
emergency.
But you've got this patient being taken to the ER.
So now you are using a bed that could be used for a chest pain, for a stroke, for a shooting,
whatever facility you are.
You've got a first responder crew being woken up and in the less intelligent fire departments,
that means the entire station.
If they haven't figured out, you don't need to wake up everyone for two guys to go on
a call.
And then from the patient, which again, going back to the patient centric element, you know,
it might be a child who's worried parents and they've got a fever and they threw up
once and they think they're going to die of dehydration.
And now that child's in the ER between a drunk and a psych patient all night with the lights
on and you know, screaming and everything.
And then you've got the patients getting a bill for thousands and thousands of dollars
on top of the fact that the fire department bills them for the ER ride.
So I see all these different layers and how this is going to be such an incredibly powerful
tool to eliminate, as you said, that bottom tier, empower these people to start learning
that there is another option and then go back to having units available with well rested
crews that now will respond to that wreck and extricate a child and then do pediatric
algorithms as they rush into the hospital.
Well, so one thing on the whole thing you explain there, and this is another paradigm
shift.
I don't like the word abuse of 911 because I really think what the problem is, is we
have failed the 911 system because our only offering has been an ambulance.
So you know, I think we have to remain that patients are going to call 911.
We can't stop that and we shouldn't stop it, but we shouldn't view it as we only send
an ambulance, right?
I mean, that's an overarching theme to those patients, all those patients you just described
in their world, they had a problem and they did not know what to do and they were legitimate
problems.
They weren't legitimate problems that maybe needed an emergency department, but they were
problems to those patients and we fail them by thinking or having only in place an ambulance
and ER as a solution.
And it's back to, we have to provide them the appropriate level of healthcare, whatever
that is, from nurse advice to send in a helicopter for that rural ejection patient that we need
to get to level one trauma center and everything in between.
I think, you know, you're absolutely right on correcting me on that.
I think it's a lack of education and what I've underlined a lot recently is fire and
EMS, which is my world.
We've just done a horrible job at even educating the public on what we do.
You know, why is there a fire engine in my medical call?
You know, what are we buying you when we're in the store?
You're buying me nothing.
I'm just borrowing money.
You know, we haven't told the story very well.
So before we dive into nurse navigation, what does, you know, what do the first responder
professions need to start to do to actually tell the real story?
What we do, what is an emergency?
And as you said, you know, using 911 in a tier system.
So I would say that we cannot tell a person what an emergency is.
You know, I very much believe in the prudent lay person standpoint and none of us here
are prudent lay person.
Prudent lay people are the house painter, the vice president of the bank, the school
teacher, the mayor.
So if they believe it's an emergency, I don't think we should restrict them from contacting
911 and getting a solution to their problem.
And I think that's a dogma we have to stand by because trying to educate a patient on
what's an emergency or not, it's a failure, right?
I mean, at the end of the day, an emergency physician is probably the tip of the spear
for defining an emergency.
Paramedics even not, right?
I mean, sure, they have a much better understanding than a lay person, but they're still not
at the tip of the spear for that.
Nor can I often figure things out without x-rays and lab tests and physical exams and
all the tools that we utilize to work through a differential diagnosis to say, oh, this
is actually GERD.
This is not a STEMI because it could be a STEMI.
I don't know until I have an EKG or perhaps troponin test.
How many times do we roll our eyes and say, oh, they called us because they're having
a little acid reflux and the reality is they're having a STEMI.
So it happens.
So we do have to protect those type patients and very important to do so.
Yeah.
And just to echo that, add to that, I agree with Dr. Troutman 100%.
I don't look at this as an abuse of the EMS system or the 911 system.
The challenge is that we've always had just a one size fits all model.
But I think if you go back to the first 911 call that was placed over 50 years ago now,
we have done such a great job in this country of educating everybody to call 911.
If you don't know what to do, call 911.
And now we have two year olds that can dial 911 all the way up to 102 year olds.
And to me, that's a big success and that's an important part of our social safety network
across the country and how we care for our neighbors.
I also think that we see communities who have gotten frustrated with how many people are
using 911 and they've tried to introduce alternates and you see the 311 programs or the 211 programs,
some other three digit number and saying, hey, if it's not a quote unquote real emergency,
then don't call us.
And in my mind and I think the data will show that just doesn't work.
We want people to know that 911 is there for them.
And I think that's really important.
We need people to be able to rely on 911.
We don't need people to be able to make a decision on what type of resource 911 is going
to send.
I think that's where the dispatcher and the nurse come into play.
But we're not asking them to do that.
So if there's a question, call 911 and let us help you figure out what the appropriate
resource is going to be.
Let us provide healthcare.
Exactly.
So the most important person at this point then we're realizing is the dispatcher.
That is kind of the gatekeeper of whether it's nurse navigation, whether it's Josh and
I go on a medic unit or whether it's even a helicopter, like you said.
What I've seen again nationally is that there's a real crisis within that profession.
So before we go to the actual, what someone would experience once they go through nurse
navigation, what are some of the solutions or some of the issues that need to be addressed
so that we can make sure this first line of defense is actually well staffed and rested
as well?
That's a great question.
And I'm a huge fan of dispatchers.
I've spent a little bit of time in dispatch.
It is not something I could ever do successfully myself.
And I'm in awe of the ability of call takers and dispatchers to manage that process.
I think it's, as you said, it's really an under recognized portion of this and it is
the tip of the spear for the delivery of healthcare, of this out of hospital emergent healthcare.
And I think we have today, we have some really strong, really dedicated dispatchers and fortunately
there are some good systems supporting them, whether it's the Pro QA and PDS system or
a complaint based determinant system that can help them work through a series of questions
and identify based on the answers to those questions, what an appropriate tier of resources
our nurse navigation program plugs in pretty seamlessly with that.
So that if it's determined to be, as you said, James and Alpha and Omega, and actually there's
even some Bravo and a few Charlie level determinants that are appropriate for nurse navigation,
then we can certainly help push them into that nurse process based on the dispatcher
asking those questions.
We're also doing some pretty innovative things now using machine learning, large language
model decision support tools to identify and basically sit over the dispatcher shoulder,
listen to that call in real time and say based on the feedback that the caller is providing,
provide some decision support to the dispatcher to proactively prompt them and recognize that,
hey, this is something that was probably appropriate for nurse navigation.
Or on the other end, hey, this appears to be a STEMI or a cardiac arrest or some other
type of high acuity challenge.
Just get those resources out right away and I think those are really cutting edge in terms
of being able to leverage some of this advanced emerging technology in the dispatch center.
Dr. Troutman, you've got a lot of experience with that.
Yeah, absolutely.
I think one of the keys for dispatch is we need standardization and reproducibility.
And Josh mentioned there's certainly a couple of companies or a couple of programs out there
that do accomplish that.
That isn't in every dispatch system across the US by no means.
It isn't a lot of them.
But I think that that also helps with the, if you call it resiliency of the dispatcher
because even if I just take an EMT or paramedic and put them in dispatch and just say, talk
to the patient, that's a lot on them just to have a discussion and make a decision.
And the reality is what's the decision generally going to be?
This sounds like it could be really bad.
I'm just going to send lights and sirens versus having a rather scripted ask questions to
where if that goes to 10 different people, I shouldn't get six different answers.
I should get the same answer with very little variability.
So I think we see positives when we do that.
Josh touched a little bit about on, I'm going to throw out AI because I am, and we'll talk,
we can dissect in that a little bit more.
AI is a little bit of a scary term to healthcare people, right?
Because of course, some people say it's going to come take us over.
We're not even going to need doctors anymore because AI is just going to, you're going
to talk to it and it's going to spit out your medication.
I don't believe that's where we're going to be anytime soon.
But I think we're fooling ourselves if we don't see AI as a clinical decision support
piece, something that can make our lives easier as clinicians out there and not just easier,
but more accurate and ultimately better for the patient.
And just to expand a little bit more on a way that we've been utilizing some clinical
decision support is the technology that can listen into a call.
And when we first heard about this, it would listen to a call and it could pick up things
to say, this sounds really high acuity.
This sounds like a stroke, STEMI, cardiac arrest, and it would alert the dispatcher.
And there's a scientific paper out there that showed that alert came up more accurate and
quicker than going through the entire question and answer process.
So of course we know that response times don't matter except when they do matter and things
like strokes, STEMI, those response times are very important.
So we heard about this technology and we liked it, but of course we asked the question, that's
fantastic, that's very important.
I want to take it to the other end of the spectrum.
I want to be able to listen in and for the technology to say, this sounds like a good
call for a nurse because this doesn't sound like this patient needs an emergency department
or having any sort of life-threatening illness.
So let's maybe send this to a nurse to do something with.
So we've utilized that technology in a few places and it's one we're expanding and working
actively with, with really positive results.
It's funny when you talk about the AI, because if you think about it, Josh, well, both of
you, the more you progress through your medical career, the more you can walk in, look at
a patient, not immediately go, this is what it is, but right at the beginning you're like,
this is serious, this is not serious.
And that just comes with time.
So I can see how the more learning an AI model does, the more it's basically doing what a
human, a veteran of medicine already does themselves.
Absolutely.
And even, you're seeing now where we can take essentially a device in, have a conversation
with a patient, whether it's a doctor in the hospital or a nurse or a medic in the back
of an ambulance.
And by the time you get on your PCR, there's the entire chart all typed up and you essentially
give it a once or twice over and it sounds pretty darn good and pretty accurate.
And look at what that does when we start talking about, you know, what makes my job happy.
I'll tell you what doesn't make it happy is a lot of paperwork and a lot of patient charting,
although it's extremely important.
It's the right thing to do.
It's all those things.
But if we can make that easier, sign me up every day of the week.
I don't care if it's AI or whatever's doing it.
I'm happy to be on board with that.
And I think most people would agree with that.
On that subject, just to go on a tangent for a second.
I've told this story a few times, very, very briefly.
When I first moved to the States, I remember looking at the yellow pages from the side
and there was this one section, almost like almost an inch.
It was huge and it was different color from the side.
And I was like, oh, that must be physicians.
You know, there's lots of doctors in the world, but it wasn't, it was lawyers.
And again, coming from England, where back in those days, there weren't the frivolous
lawsuits.
Sadly, they're mirroring the American model now, from what I understand.
You know, you just see all this and then you start working as an American firefighter.
Oh, okay.
Because every time I go to a wreck, the guy's already on his phone to the lawyer and there's
these billboards by the road saying, I got you a million dollars and all this stuff.
But then you start to realize how that factors into paperwork, to paralysis by analysis for
the paramedic.
So, what impact is that frivolous lawsuit element having in medicine?
And if you were king for a day and could make that go away, where only obviously the medics
and EMTs that did something wrong would be held accountable, you know, what would change?
Because I almost felt like there was so much paperwork and there was this absolute terror
of litigation that a lot of our medics and EMTs were doing reports that were really kind
of benign in a way.
You know, it was, you know, he sneezed his stomach, you know, he pulled a muscle, he's
fine, he's refusing.
You've got to do a full on three page conversation on it.
So maybe I'm naive, but obviously I respect the law process.
You know, I respect the potential for litigation, et cetera, and the practice of clinical medicine.
But I subscribe by the dogma of always do what's right for the patient, you know, document
it appropriately.
What should be document, document if it doesn't need documented, it's not important to not
germane doesn't need to be documented.
And lastly, treat the patient right and with respect.
And I think if you keep those three aligned, the chance of a lawsuit situation becomes
very low.
You know, yes, we live in a world where a frivolous quote lawsuit can always happen.
But you know, I also believe in a jury of our peers and I hope that they can see through
that is that we were trying to provide appropriate health care for the patient in a meaningful
way with all the things that we had together.
So I know there are people out there that kind of the scare of a lawsuit kind of hangs
over their head.
And I hate that.
I do think that maybe sometimes that comes if you've been subjected to a lawsuit or multiple
lawsuits and I get that perhaps my perspective will change someday if I remember in that
way.
But I still would stand by do what's right for patient document what's right and treat
them like you would want to be treated.
That just goes a long way on just being a good person and a good health care provider.
I went to a great medic school here where I live.
Great great program.
The bar was held incredibly high.
I think we did like 30% more clinicals than was required you know statewide.
But they did bring a guy in who paraded like a peacock, told us how he was an expert witness,
told us how many paramedics he's put behind bars and it was I think it was a very negative
conversation doing the right thing, understanding that if you deviate from that, yes there are
legal consequences but putting the fear of God into young EMT or medic students I think
does you know has a detrimental effect not the other way.
I would agree.
Yes I'm not one to look at fear.
I mean I think you have to again you got to respect it and be cognizant that it is out
there but just focus on the positive.
Absolutely well Josh let's go to you again.
I don't know if you want to if you have an example already or if it's little Sally the
you know the two-year-old with the febrile or just the fever you know and thrown up once
and the worried first-time parents but whatever that nurse navigate or appropriate call would
be walk me through that 911 call and then let's get to all the resources that people
will find if they use this program.
Yeah great and look I think little Sally is a perfect example of this because I remember
when I was a first-time parent and even though I was a paramedic at the time, my wife was
an RN at the time, we still ourselves as medical providers, healthcare providers when our two-year-old
got sick and had a fever and was throwing up we didn't know what to do and it's very
easy for parents in that situation and of course this isn't just for those worried
parents I think there's a lot of patients who call 911 simply because they don't know
what to do.
So let's talk about little Sally and get your two-year-old who has a medical concern all
of a sudden they've got a fever maybe they threw up a couple of times the first thing
the parents are going to do is call their pediatrician's office which is great Monday
through Friday 9 a.m. to 4 p.m. but if it's after hours the first thing that they're going
to hear is if this is an emergency hang up and call 911 and every time you call a healthcare
provider or a pharmacist anybody these days that's the very first thing that you hear
and again we want to encourage people to call 911 that's what we're here for let us be the
tip of the spear for being able to enter that side of healthcare.
So we're not looking at that as a wrong use of the 911 system it's absolutely appropriate
use of the 911 system.
The challenge is that today in the systems that are out there that don't have a nurse
navigation program the dispatcher is going to answer the call get the basic information
say we have a sick child and we're going to send an ambulance and potentially first responders
out to that home they're going to get on scene and really what the patient needs from a healthcare
perspective is for somebody to tell the parents the appropriate dose of pediatric Tylenol
and to tell them that you know they should try to drink some Pedialyte and they'll be
okay and they can follow up with their physician and so on but we don't have that option as
paramedics you know getting back to what you were talking about a few minutes ago with
living in this litigious society when a paramedic or an EMT shows up on scene they're obligated
by the healthcare regulations in those communities to offer the patient a transport to the hospital
that's what we're here to do and if the patient says yes that's good great then we put them
in the ambulance and we transport them if the patient says no I just need some help
with this or I need to know the you know the right dose of Tylenol to take or anything
else like that something that's going to deviate from those protocols for the EMT and paramedic
that's where those alarm bells start ringing and that's when we start to go back to thinking
about when we were in paramedic school and the expert witness came in and said yeah I'm
going to put all of you guys out of a job so that's when we say well you know what I'm
really not able to tell you that but let's just put you in the ambulance and bring it
to the hospital and then the doctors can help you.
We recognize that's just not the right thing to do from a healthcare perspective from treating
that patient appropriately and so in the case of little Sally if she lives in a community
that has nurse navigation as part of the 911 system when the parents call the dispatcher
and dispatcher asks the initial questions hey tell us what's going on what are the symptoms
and so on they use whatever EMD process they're using for emergency medical dispatch and based
on the outcome of those initial questions determine hey this is a low priority call
and maybe it would benefit from speaking to a nurse and whether they're using the machine
learning tools to help get them there or they're following the card prompts or whatever the
case may be that call taker dispatcher is going to say to the caller look this could
be something that would benefit from speaking to a nurse would you like to speak to a nurse
before we dispatch any units.
Assuming the caller says yes and today we're not in any community automatically putting
people over to the nurse without their consent this has to be with the consent of the caller
but assuming the caller says yes then the dispatcher will hot transfer that call over
to our nurse navigation center.
We have most of our nurses are based out of our headquarters in Lewisville Texas it's
a 24-7 operation at any point it's staffed with you know up to 10 to 15 different nurses
and of course that number is continuing to grow every day as we add new programs into
this and those nurses all have technology so that when the call comes into their system
they get a little ear whisper that says I'm calling from so-and-so community and so they
get the right set of protocols up on their screen they know how to answer the phone and
the nurse will answer the phone to say hi thank you for calling the Seattle nurse navigation
program my name is Josh I am a nurse how can I help you today and so typically the dispatcher
that connected that call they'll stay on as a hot transfer until the nurse picks up we're
picking up the phone in about 25 seconds or less right now for every call once the dispatcher
hears that the nurse has picked up the call generally speaking that dispatcher will disconnect
and the nurse will take over from that point the nurse runs the caller through an algorithm
and this is just like our ACLS algorithms or any other type of algorithm in health care
it's a closed-ended binary type of a if this then that sort of protocol the same way that
you know if we're running our ACLS protocols for cardiac arrest we're gonna do this then
that then that then that the nurse asks those series of questions and based on the answers
to the questions then the protocol will suggest appropriate types of action for that patient
the first few questions that the nurse is going to ask are based around that severity
of the illness or injury and it will help them identify if this is something that actually
is a higher priority call and if it is a higher priority call then the nurse will say hold
on we're going to connect you right back to the dispatch center and send an ambulance
for you and that's typically done within the first 30 to 60 seconds of the phone call so
there's really no delay for those higher priority calls once we get past that series of questions
and the nurse will ask additional questions to determine what we call an m tara level and
tara it's nmtara stands for needs matched time appropriate resource allocation and that's
the name of this proprietary set of protocols that we use for this system as they run through
the protocol they determine what we call an m tara level somewhere between one to five
that helps the nurse identify number one how quickly that patient needs to receive some
type of interventional care and number two what's the best type of care for their needs
now that care certainly could be an ambulance ride to an emergency department there are
a lot of reasons why people call 911 for low acuity complaints that clinically would be
best served in an emergency department and so roughly half the time that the nurses are
screening the call that patient winds up in an ambulance and gets that emergency transport
to an ed and that might be because the ed is at that point the very best place for them
it could be because if it was middle of the day during the week they'd wind up in an urgent
care but because it's after hours and there's no urgent care open at this point they need
to go to an emergency department because that's the failsafe for the health care system or
it could be we go through the full screening process we give options to the patient and
the patient says you know what all that's great but I still just feel more comfortable
with any ambulance to the er if that's the case that's what we'll do as well but separate
from that as the nurse continues that assessment and determines what other options exist then
the nurse can actually direct that patient over to an urgent care or some other type
of alternate destination that could be a walk-in dental clinic it could be a behavioral health
care center it could be a federally qualified health care center some other type of community
clinic but basically an alternate brick and mortar option to receive health care in their
community that would not have been available to the ambulance system because remember in
pretty much every state that we have right now the sorry about that okay maybe we'll
just edit that clip I'll start over because because remember in pretty much every state
where we operate ambulances are only permitted in a 911 system to transport a patient to
an emergency department so even if there are alternate options in communities that would
be better fits for those patients such as these urgent cares or dental clinics or behavioral
health care centers if somebody's called 911 and the ambulance shows up we really don't
have any other option but to bring them to an emergency department without nurse navigation
so the nurse can recommend those other options and we work with every community where we
have this set up to build out a network of those resources so that the nurse can look
and say okay you're calling from 123 Main Street well there's an urgent care two blocks
from you and in a lot of cases can actually go into the urgent care system and see what
they have for availability for appointments that afternoon and get that set up we can
also if the patient doesn't necessarily require an in-person assessment and exam connect that
patient directly over to a virtual care option and so we work very closely with a couple
of different telehealth providers now we're not a telemedicine service ourselves and we
don't have doctors other than Dr. Troutman that that are directly connected into this
program but we can refer that patient over to a virtual care option and the virtual care
partners that we use have physicians and advanced practice providers available around the clock
and so if that's the appropriate option for that patient we'll help navigate them to that
direction we also find probably 25 percent of the time that the call can be managed just
through self-care and the the nurse after going through the screening process can provide
some physician developed guidance for that patient you know maybe it's hey in the case
of little Sally here's the dose of pediatric Tylenol you know she weighs 40 pounds this
is how much Tylenol you're going to give her and then you're going to check again in four
hours and see how she's doing and that could be all that was needed in the case of little
Sally's fever and then the call ends at that point we do callbacks 24 hours later to make
sure that everybody got the care that they actually need and then to ask some survey
questions about what they felt about the program but aside from that that's really how the
program works it makes so much sense on on so many different levels and what I love when
I think back now out in the real world I talk about when I work for Disney's fire department
a bit because that was a unique situation a lot of refusals which really is kind of
the halfway point between you know what we're talking about now but the number of times
that I went you know sometimes the person was just lonely so again we'll obviously get
to that point as well but prescription refills you know the person's slightly hypertensive
it's not a crisis by any means but they're worried that you know they're they've run
out of their meds and the ability to refer to a nurse practitioner or a physician that
can then you know assuming you know if all things align they can write a prescription
and now you have you know we'll talk about Lyft and Uber you have these abilities now
to even get those meds brought to you so there is no better time for that person to be at
home when I was at the the Disney department they there was an abuse of the the 911 simply
because they told the guests we can call you an alpha they didn't tell them what alpha
meant alpha meant call you a an ambulance with paramedics on it you know so we would
get there and it was literally little Sally and so again you would be able to coach the
parents tell them you know unofficially you know read the directions of the the time law
I can't tell you exactly what it is but it's on the box you know don't bundle her up you
know allow her to just be in her underwear and be cool and I think it was probably 90
95 percent that never called us back so the ability to put someone at ease whether it's
a parent whether it's someone who's older because as you said we're you know within
medicine we understand what sounds and symptoms mean a lot of times you know some of these
are terrifying to people especially if you know they saw on ER once that a person just
had you know wrist pain and they ended up dying of a massive heart attack you know so
there's all this kind of misinformation simply being put to a trusted professional I want
to jump in and make a comment about the telehealth piece please and yes and you know we could
even go back and assuming everyone recalls kind of the ET3 project and we could get into
all the nuances with that but the reality is that project ultimately failed and a lot
of people do seem to be surprised at first why telehealth isn't our primary solution
and I think the medication refill is a great example there are other agencies out there
that their plan or the system they're doing is to take that 911 call and connect them
directly to telehealth we think that's a fail because ultimately what we want to do is establish
the patient within their community to care providers so that's why after we've cleared
that this patient doesn't need an emergency department our next goal is to get them plugged
into a local brick and mortar solution right now because of time of day etc etc there may
be reasons why that can't happen so before we end up on the ultimate fallback which is
an ambulance that's when we fit the telehealth providers in and Josh mentioned we have we've
had virtual er which is a board certified emergency medicine physician but just recently
actually added a virtual urgent care and I think we're the only ones that are actually
utilizing both and we decide that based on the acuity level so the higher nemtara acuity
levels would only be accessible to the board certified emergency department the virtual
er but the lower acuity ones that just by sake it's 2 a.m. and there's not a brick and
mortar urgent care we could connect those patients to the virtual urgent care but ultimately
like in that medication refill absolutely you could connect to a doctor an np and get
the prescription written and they could get that prescription tomorrow but what happens
two weeks from now or a month from now when they're out after the patient in florida talked
to the patient and talked to the doctor in new york all they're going to do is call 911
again versus our premise is if i can get them plugged into an urgent care maybe that urgent
care hopefully we'll get them plugged into a primary care and ultimately try to help
break that cycle or at least massage it does it happen every time no but we've had and
teased out some data certainly out of dc when we looked at some of the medicaid data we
did see a decrease in er utilization from those patients that called 911 nurse navigation
and ended up plugged into a system so i think that's a real important caveat to point out
that going straight to a telehealth provider it's a bandaid it is not the ultimate robust
solution of offering all this cod gray of what really fits the patient best yeah and
if i could expand on that a little bit further from the provider perspective so james i'm
sure you remember from your time in the field that we see those high utilizor patients right
there's a whole bunch of nicknames forum frequent flyers etc right but ultimately these represent
patients that are calling 911 on a regular basis generally because they're not receiving
any other type of appropriate health care and so we have to bring them to the emergency
department because there really aren't any other options outside of you know now with
our nurse navigation program but really what they need and and you mentioned a lot of different
reasons for this they could be frequent callers because of loneliness they could be frequent
callers because of um unmanaged chronic conditions diabetes co pd patients etc lots of different
um reasons for them to fall into that bucket but what we can do is break that cycle of
bringing them to the emergency department and instead getting them plugged into an appropriate
as dr trautman said brick and mortar option in their community that's an alternate to
the emergency department and so whether that's an urgent care we also have great success
when we work with our with those federally qualified health care centers fqhc's which
are these community health clinics that receive some additional funding to be able to care
for um those unfunded patients whether they're uninsured or they're have a limited medicaid
program or whatever the case may be and not only are we able to get those patients plugged
in in that case but not but the patient can get that immediate care managed whatever that
immediate challenge might be but then they can also get enrolled with a primary care
physician and get enrolled appropriately in a medicaid program and get their case followed
and then what happens is their medications get refilled on a regular basis their mental
health needs get met appropriately through this fqhc and so on and they stop calling
911 so a lot of times when we go into new communities and we start talking about this
nurse navigation program one of those first questions is well what about the frequent
flyers and really when we get down to the root of these high utilizer patients and and
what's causing them to be high utilizers very often it's low acuity challenges that are
not being met through any other type of health care and when we redirect them when we navigate
them appropriately then they fall out of the 911 system because they don't have to rely
on 911 anymore for those health care needs.
I've heard a lot of people say that the community paramedic program which comes from you know
a great idea it's not having the results of people expected and it kind of makes sense
when you take a step back but you're waiting for a call and then you're dispatching a unit
almost the same way as you would with you know a rescue crew what you've described makes
so much more sense the one barrier to entry obviously that people would think is that
yeah but how can a patient get to this facility and you even talked about you know dental
and optical this is a big misnomer too when you have teeth injuries or an eye injury most
ERs can't handle that so we take them to the ER and they go we can't help them and then
they have to leave again so talk to me about the empowering of these patients through nurse
navigation as far as transportation and your partnership with Lyft.
Yeah I'm so glad you brought that up so one of the things that we learned really early
on in this program is that transportation is a big barrier to accessing health care
and a lot of people will call 911 knowing that if they had a car and could drive themselves
to an urgent care that's what they would have done but they don't and if they don't have
that ability for transportation they really don't have any other option but to call 911
not for the health care services but for the ride and so when we recognize that we built
into the program this partnership that we have with Lyft now AMR if you're familiar
with American Medical Response as the organization now GMR for a long time had a subsidiary company
called Access to Care it's actually no longer part of our organization but we still have
a lot of those relationships and so on and what Access to Care did was non-emergent medical
transport they still do it's now again it's not part of our company but through those
relationships we built strong national relationships with Lyft and with Uber as well though Lyft
is certainly our primary so that we can offer ride share to patients who the nurse has screened
has determined are not clinically appropriate for an ambulance but would work in you know
can safely be transported through some other type of alternate vehicle and so the way that
that works is once the nurse completes the screening identifies it here's an appropriate
resource for that patient that could be an urgent care or brick and mortar facility a
dental clinic eye clinic as you mentioned behavioral health or it could even be an emergency
department once the nurse determines that hey this is the right location for you then
the nurse determines what's the appropriate form of transport if it's anything other than
an emergency department obviously the ambulance is not the right form in the ER case it's
possible that an ambulance still isn't the right form if the patient is clinically stable
enough to go by alternate means then let's set that up for them if nothing else it's
better for the system and better for the patient from a cost perspective and so the nurse will
then get into our software that's plugged into the lift system and be able to order
that transport that lift ride for the patient if the patient has a smartphone and the nurse
will send a link over to the patient with details about the ride so that they can track
it just like anybody else using ride share would be able to see when their car is coming
and so on if the patient doesn't have a smartphone then the nurse will provide instructions such
as okay Mary is your lift driver she's driving a red Kia with this license plate and she
will be outside of your door in 30 minutes to take you to the urgent care and then provide
that information as well we also in addition to providing the ride to that alternate destination
wherever it might be we give the the caller instructions if you need a ride back including
a stop off at the pharmacy on the way here's our phone number call us back and we'll set
up a return trip for you and there is no out-of-pocket cost for that caller the cost of the ride
share program is built into our overall nurse navigation program.
Beautiful.
Well Jared I saw on the video when you go to your website nurse navigation the Cobb
County in Georgia had gone to this model so let's go back even though I care deeply about
the patients let's talk about you know my men and women in uniform what are you hearing
as far as the reduction of calls and therefore the impact on the the firefighters and paramedics
and EMTs themselves?
Right so I love this topic like I said every rock we seem to turn over is positive and
I like to say and actually give a talk at various conferences called putting the E back
and EMS and we know that at the end of the day most people in emergency care we came
to this or had a calling to this specialty why because of that emergency piece we like
those sick patients we'd like to be able to think and work through some of those difficult
situations and the low acuity stuff becomes a dissatisfier and as those dissatisfiers
build up I don't like my job as much I don't like going to work I don't look forward to
it and so we've always felt anecdotally like look we're taking these low acuity patients
out of the system doing what's better for the patient it's helping operations how is
it is it really positively impacting our providers out there so we have what's called a GMR cares
program so several years ago we realized you know whenever we look at clinical stuff how
do we improve it the number one thing we have to do is do what we have to measure it if
we don't know what our IV start rate or our first pass success rate is if I don't have
that number I can't put plans into place to correct it so we started surveying all of
our clinicians and providers and asking them questions and one of the as far as I know
one of the first EMS agencies to really do that do you like your job do you enjoy showing
up to work do you you know all these questions about the day-to-day activities and so then
we can learn from that and put things in place to work that through positive well what we
found kind of as a sidebar we were just looking at some of the data and we noticed a few particular
spikes that were higher on a few questions that I'm going to turn to Josh in a second
because I think he knows those particular points but there was statistically significant
higher positive ratings over essentially the clinicians like their jobs better they liked
showing up to work and caring for patients in places where we do nurse navigation now
obviously there can be lots of confounders in that but of course as part of the nurse
navigation team I like to think it's all because of the nurse navigation but I think we do
know that this is certainly a large part of that because we do pull those dissatisfiers
out of the system yeah James you talked earlier about recruiting and retention in EMS and
what a challenge that is and as Dr. Troutman mentioned one of the initiatives for GMR is
trying to figure out what can we do to take better care of our own people and so as you
said to that point we actually commissioned Gallup the survey company to conduct these
surveys and we do them every six months or so across the organization every provider
gets asked a series of questions and what we found is when we looked at the nurse navigation
markets compared to the non nurse navigation markets and tried to match up everything else
around call volume how busy the system is things like that to try to get an apples to
apples comparison what we found is almost a 5% increase with field providers who said
that they felt like their job is important 6% increase in field providers who said that
they feel like their training and skills were well utilized and most importantly almost
a 12% increase in the field providers who said that they have high job satisfaction
and so when we look at those three metrics you know certainly we're not able to ask the
question hey do you think nurse navigation has stopped you from going out on that call
at 2 in the morning for little Sally who's two years old and has a fever but I think
when we look at these questions about how satisfied somebody is with the job that they're
doing and we recognize that we can make some systemic changes to the delivery of EMS then
ultimately these are going to benefit those field providers and we're really proud of
this impact again not just for our patients and our communities but for the men and women
who are working on our ambulances or as you've been telling this story and I'm thinking again
what another beautiful string to the bow for department and their community I mean this
this affects everyone but as a bragging element to say hey young recruits if you're looking
for someone to work we have nurse navigation here so this is really positively affecting
you know the the way that we do medicine and improving the chance of responding to you
know the emergency calls that I know you guys trained to do when I think of the dispatcher
side the ability to pass off a call that may take 10-15 minutes of their time you know
now it goes immediately nurse navigation you know now you freed up some more time there
and again you know we have those pending pending pending and I would argue even on the law
enforcement side we didn't really touch on it much but you know the the mental health
side of this again you know high acuity of course of course it's got to go one certain
way but the lower acuity the you know the the depression the anxiety the loneliness
a lot of the calls that we are sent to the ability for the law enforcement to pass that
on to you know a culturally competent provider who would be able to interact even better
with that person because that's what they're trained to do so from a recruitment point
of view this seems like such a powerful element to provide and to talk about as far as recruiting
I'm sure people listening though are wondering yeah but what's this going to cost my department
so let's break down that that side I mean we all know that if someone calls 911 and
they take an ambulance ride and they go to an ER and they are given you know two hundred
dollar aspirin pills you know that patient's getting a large bill so what is the cost or
what are the different kind of models that you have for a cost or not a cost to a fire
department and then also what is the reduction in costs to that patient what is the selling
point to the individual themselves yeah that's that's a great question and so we're going
to take it from a couple of different standpoints from the patient in the community when we
look at calls that would have resulted in an ambulance transport to an emergency department
we can assign a specific cost to that because we know BLS ambulance ride is you know certainly
it's going to get charged out at different rates but by the time it all washes out between
different payers and different rate schedules and so on there's a cost of that that you
know we can find an average cost in every community call it say 450 to 500 dollars we
also know when that patient goes into an emergency department there's a cost associated with
that care now again it's going to be different for every individual patient between what
the payer is responsible for depending on what type of insurance they have how much
that patient has to pay out of pocket and so on but we know that just the physician
engagement alone can be north of two thousand dollars and then whatever the cost is going
to be associated with a different additional ed fees and again if there's x-rays associated
or lab studies and so on then all of that adds to additional cost but we can say hypothetically
that the cost the bare minimum cost of the patient going to an emergency department is
about three thousand dollars between the ambulance the physician the ed costs and so on and again
how much of that is the responsibility of the patient compared to their payer that's
going to be different in every circumstance but but we know what that total number is
going to be when we look at that and then we compare it to the cost of alternate care
whether that's an urgent care visit or virtual care ed or virtual care urgent care or some
other type of alternate option for that patient that cost is a fraction right it's maybe two
hundred dollars compared to that three thousand dollar bill so there's a significant delta
there's 2800 2500 dollars easily in every case when we take a look at the hundred and
seventy five thousand patients that we've now navigated through nurse navigation since
the inception of this program and we can break it down and we look at okay well how many
of those patients still wound up in an emergency department compared to alternate care what
the alternate care option was and then how many wound up with self care and so on we
can come up with a number pretty accurate as to what that savings has been and i don't
have it off the top of my head but i want to say last year when we looked at this for
twenty twenty three is about thirty five million dollars in savings for the health care system
just in twenty twenty three alone and that is hard fast concrete that we can point to
say hey these are patients who would have wound up in an emergency department but we
were able to navigate them to an alternate care option instead and that's even including
a discount for the folks that we think probably just would have refused care so they wouldn't
have incurred any type of cost we factor that into that thirty five million calculation
as well so that's the overall savings to the health care community and again some of that's
payers individual patient out of pocket etc different every place where we go but let's
talk about the cost and savings for the ems system now it is different every different
place where we do this if it's a market where we are already the ground nine one one provider
then we're going to take a look at that market and see if it makes sense and it's something
sustainable for our organization to cover the cost of nurse navigation and in a lot
of cases it is because when we take a look at the calls that we're not having to respond
to we see a corresponding decrease in the dry run rate which means that we can be a
lot more efficient with our paramedics and emt's and our ambulance resources that are
out on the road and so in turn we don't have to necessarily staff as many ambulances out
there on a regular basis because we know that a certain portion of calls are going to go
to nurse navigation and not require response we also look at communities where today we
might not be able to fulfill the response time requirements for that contract and again
this is because of all the challenges that are facing ems nationwide between recruiting
and staffing and supply chain of vehicles and everything else out there and we can look
at this as a way hey if we put this program in place we're going to be more efficient
with our resources and we don't have to you know respond to as many calls which means
we can be more effective in meeting our response time compliance and that in turn helps to
support the overall contract and the overall program.
Now there are other markets where we look at it and maybe we're not the 911 provider
today in that community then we're going to look at saying okay does it make sense for
us to partner with that fire agency you know particularly these big urban markets because
we know urban fire the big metropolitan cities out there like Washington DC like Seattle
Washington like that metro Atlanta area in DeKalb County these places that are high volume
high performance ems systems that are on constant demand and maybe they're running their own
ALS units today but they just don't have enough units on the road well let's figure out the
right way to partner with them so that we can use nurse navigation as a point of entry
and then for those calls that the nurse determines hey this is still clinically appropriate for
an ambulance but not for that immediate high priority ALS response well let's bring some
ambulances into that market too through American Medical Response AMR and have some additional
ambulances out on the road to handle those lower priority calls that get identified as
part of nurse navigation we can do that for these communities and then we can work with
them in a least unit hour model or something similar so that while certainly there's a
cost associated with putting our ambulances out on the road there's a benefit on the back
end for that urban fire department because they're able to bill and collect for the trips
that we're running on their behalf and so there's a cost offset there so it becomes
cost neutral for that fire department and not a big impact on their budget and then
finally there are some other markets out there you know take a look at Washington State for
example so we started nurse navigation in the city of Seattle a couple of years ago
the Seattle Medic One program nationally known for high performance CMS really a very high
level program that works very well run through Seattle Fire Department we brought nurse navigation
to that as part of our BLS support for that system a couple of years ago since that point
and we've shown how well it works up in that community then the rest of King County Washington
which is where Seattle is located just recently hired us to put nurse navigation in place
in the rest of that county so that now the entire county is covered with the nurse navigation
program that will be going live here in the next couple of months I think we're very close
to launch on that that's a scenario where the county public health department has said
look we want nurse navigation we recognize all these benefits for our EMS system AMR
is not part of the 911 system outside of the city of Seattle and so because of that we're
going to pay the cost or you know King County is paying the cost associated with that nurse
navigation program it's not something that we can do ourselves as AMR we need to have
appropriate funding in order to make it sustainable I think that's an important differentiator
though because we know Dr. Troutman mentioned this a little earlier that there are some
911 systems out there that have looked at adding just a virtual care telehealth program
so the dispatcher will just connect those patients over to a telehealth doc the challenge
with that is that that telehealth doc is going to charge that 911 caller no matter what and
it generates an out-of-pocket cost immediately as soon as that 911 provider or caller gets
connected to that telehealth program you know we recognize that just shifting that cost
for somebody who called 911 perhaps just didn't know what to do and wasn't quite sure what
the right outcome would be that's not necessarily the right way to approach this we want people
to continue to rely on 911 as a free service because that's what it is it's set up in our
communities not like you have to pay a toll to call 911 today we want to continue that
and so with nurse navigation when you call 911 there's no cost passed from us to that
911 caller now certainly if there's services that result from that such as an ambulance
transport then there's going to be an ambulance bill or if we connect them to an urgent care
the urgent care is going to charge them for their service the same way as they would have
to pay if they went to an emergency department but for the nurse advice the self-care options
any of the other things that we do even that lift ride there's no cost to the patient for
the nurse navigation service itself i think when i spoke to rob there like you said there's
different models was there is there a cost to the fire department or are there some models
where you're billing the patient and that's where you're getting your your your financial
side from so so as i was saying we don't bill the patient for for any of this for the nurse
navigation piece if the patient is referred to an urgent care then the urgent care is
going to bill them if the patient's referred to virtual care then that virtual care service
is going to bill them but there's no bill coming from nurse navigation to the patient
in some models we are billing the fire department to provide this service for their community
because again just like amr benefits in the systems where we're the the 911 provider and
we're able to make that fully self-sustainable there's other systems like in vancouver where
rob is the chief where there is a cost associated with nurse navigation some of that cost gets
offset by the benefits that amr receives but then there are other costs that aren't offset
just through the benefits that amr gets which means that we have to go charge the system
for for the rest of that that uptick now from the system perspective if you take a look
at a system like vancouver i can't remember the specific numbers off the top of my head
but out of the you know let's say 100 calls get sent from the 911 system over to nurse
navigation i can tell you just based on our historic performance across the country 97
out of those 100 calls do not require first responders be in and the nurse is going to
assess them determine this is not something that's a high priority emergency that requires
the lights and sirens immediate response from first responders so if you think about that
from a fire department perspective for every 100 calls that i send over to the nurse 97
of them i don't have to send a fire engine on there's real costs associated with that
you know there's less wear and tear on the vehicles less fuel costs less supplies that
are getting utilized and let's face it gloves aren't cheap and every time you show up on
scene with your fire engine with three or four guys on it and they're going through
a set of gloves each there's a cost associated with that and we can avoid that cost through
nurse navigation the other thing that's important is even in the departments where the department
does transport and build that fee for service revenue associated where emergency transports
to the hospital very often that the utilizers of nurse navigation are typically unfunded
or underfunded people because those are the folks who generally call 911 for lower priority
complaints and so while you may have a payer mix in your community that has a certain amount
of medicare and medicaid and private insurance and so on when we look at the payer mix of
the utilizers of nurse navigation specifically it's heavily skewed towards uninsured and
medicaid because those are those callers with low priority complaints what that means is
that even in the cases where we're taking somebody who would have gone by ambulance
to an emergency department and of course that represents revenue for that department the
reality is the likelihood of collecting on that revenue at the same rates that you would
collect from a private insured or even a medicare patient is very slim and so the calls that
we're not transporting not only is it the right thing to do for the patient but frankly
it's the right thing to do for for the bottom line because more likely than not that department
was losing money on that transport in the first place when i think about the 100 or
97 calls that you know that didn't require a rescue in that particular situation and
we're talking really this is more utilized after hours that means that the people operating
these vehicles are probably going to be sleep deprived and it's going to be dark and in
florida here it's probably going to raining as well there's also the risk management element
every time we leave there at the station there's a high high chance especially the more tired
we are that we're going to get into something and now you're talking about you know potentially
hundreds of thousands if not millions if we hurt someone so i think that's an important
part of this too there's simply us not leaving is safer for the entire workforce and and
the people that are you know the risk management you know i'm sure they would love the fact
that we do a hundred less runs um jared i want to bring you in is there anything you
want to add because i know we've been josh for a while now before we close this up we
kind of step through like all the different options that generally are out there on where
we connect the patient to but one of the things that i really love is that the options are
endless it's what are the options that you have in your community and there are options
in the future that we haven't even thought of but the reality is the nurse and the system
can tap into any option that's out there that exists i know community paramedicine was brought
up briefly but you know we do uh tag into mobile health crisis type stuff if we talk
about psychiatric illness or in special uh special groups that can work closely with
say the unhoused uh we work with uh uh like a mobile urgent care system that can go out
and see the patient um we've never connected with but we've had discussion on what about
an oncology clinic or maybe an orthopedic clinic is there a time and place when the
right kind of patient should be connected directly to that so i i just love how the
it's an endless cadre of options as to how we can best solve that patient's 911 problem
that they called for so for people listening where are the best places to go online to
learn more to maybe start this conversation for their own department
so first thing i would do is direct people to global medical response dot net uh which
is the home page of gmr global medical response from there and learn about all of our solutions
including nurse navigation um it's pretty easy to navigate over to the nurse navigation
section and be able to fill out uh information form and ask for for more information obviously
our phone numbers are on there as well uh and yeah we do invite anybody who's looking
for for more information about this to reach out to us uh we'll be happy to talk to them
about it in in addition to that um dr troutman especially myself as well we're frequently
speakers at different ems related events um and uh this is such an emerging topic right
now in the delivery of 911 systems that uh we wind up uh finding ourselves uh more often
than not in uh in various conventions and speaking roles and talking about this nurse
navigation program so i would encourage the listeners if you're attending an event at
some point in the future we just went through a whole series of them over the spring and
summer uh please take a look at the agenda see if there's a nurse navigation uh offering
on the on the agenda and uh and come and meet us and let's talk about seeing whether or
not this is something that could work in your communities well we have hit on so many areas
and i think you know what i love about this is is this solution like i said you know there's
things that we've done and it worked you know maybe 50 years ago and here we are in 2024
and it's okay to say we need to change things but when you look at each one of these patients
and the comfort level for little sally as we talked about you know the the much greatly
reduced medical bill that they will have if there's some sort of interaction um the ability
to leave another er bed open and therefore less medics lining up and holding the wall
um and then you know not waking up a crew for every single one of these that gets sent
through nurse navigation is one less call in a fire station which i think is imperative
because if we're going to attract young people to be excited about the first responder professions
we've got to fix the things that are broken they're too smart you know they're looking
at this and going this does not look good this does not look healthy for us so the 2472
is something i'm trying to push nationally for the fire service and there's a the dominoes
are falling florida people are starting to go to it and i think along with that now is
going to be the conversation of fitness standards is going to be the conversation of telehealth
or nurse navigation so that we can address all of these things and hopefully the young
first responders will look around in 10 years and it will look completely different and
once again there'll be thousands of candidates lining up for a handful of jobs and so we
can take the best of them so i want to thank both of you so so much for being so generous
with your time telling this whole story there was elements where i'm listening to you i've
been saying this wrong because i'm a complete white belt still in this conversation so i've
learned so much myself but i'm guarantee there's so many people listening going this is the
thing this is one of the elements that we've been wondering what is the solution and here
it is now so thank you so much for being so generous and coming on the behind the shield
podcast today yeah thank you so much if i just got one closing word it's don't forget
ems provides health care sing that from the top of the mountain that's what we do each
and every day our patients depend on it thank you yeah thank you james big pleasure for
us to be here as well we appreciate you all of your listeners and and and what's really
exciting is how we are on this paradigm shift in the delivery of ems and this transition
to truly a three-tiered model and all the things that that's going to allow us to do
in the future so so thank you for letting us talk about it we really appreciate it