 This is Think Tech Hawaii, Community Matters. Welcome. This is Craig Thomas, your host for Much More on Medicine, part of the Think Tech Hawaii live stream series. We're assisted today by Rich and Ray, our engineers. And our guest is Al Bronsty. Nice to see you again. Yes. Al is a medical toxicologist and that's pretty cool, but relevant to today's discussion, he's the branch chief of the Emergency Medical Services and Injury Prevention part, which is crucial of the Department of Health. Thanks for coming. Yes, thank you for having me, Craig. Yeah, I'm happy you're here. So to recap, the last few shows have been talking about various elements of the medical system and what's working, where there are opportunities, and just to put it out there, my bias is there can be a lot of change in medicine over the next few years because to date we've been mostly measuring our product by the amount of services provided rather than the outcomes we produce. And you're in charge of several key areas of the whole health care chain. What happens between the community and the hospital, how you keep bad things from happening in the first place, which probably has had less attention in the past than it should have, and honestly, what's working, what isn't, I'm interested in the right care in the right place. So with that, I was hoping you'd sort of paint a picture of the current status and then particular challenges, maybe related to time or location or utilization patterns or need for, I don't know what, people, equipment, new ways of doing things, and also then lead into opportunities. So thanks again. Well, thank you. Well, thank you for having me here. I want to explain a little bit about the branch, the Emergency Medical Services Injury Prevention System branch, Department of Health, a big word, a lot of words. We have a variety of responsibilities, and it really is a spectrum for the state of Hawaii for both the residents and the visitors. The branch is responsible for the provision of all 911 emergency care throughout the state. And we are responsible for management of the state trauma system, as well as we have an Injury Prevention Program and the State Poison Center. So I should break it down a little bit. We have a very unique system in Hawaii where the state actually contracts with providers, designated providers for all 911 service throughout the state. This was done originally through the foresight of the legislature, because if we did not do that, there would be small areas, very rural, that might not have 911 service. So I am happy to say, and this was done before my time, but I can say that there is 911 service statewide everywhere. Which is no mean feat, because you range from Waikiki to Ka'u. It's interesting to me, you didn't mention it, that the state contracts with rather different entities depending on which island you're on. Yes, I was, yes, thank you, thank you. On Oahu, we contract with the city and county of Honolulu EMS. On Big Island, it's with Hawaii County Fire Department. They're a combined fire and EMS service. And on Kauai and Maui, we have contracts with AMR, a private company that provides a service for both counties. So it's a different model in each county, but there is a unity in the model in that all of the providers use one electronic medical record system, which is transmitted to a central hub. So we have all the medical records in one place. And the state does the billing and collections for all services. So we are able to return about $42 million back to the state general fund, which I think is very good and this helps to defray the expenses are about $75 million. So it's very important. So it's really a system and we have looked at our rates here compared to the mainland and ambulance rates here are very economical. So that's the overarching picture. We work very closely with the providers as well as Capilani Community College, which is the state's designated paramedic training institution. So it's all one system and I am very pleased that all of the providers work together for the betterment of the entire state. And so that's with the EMS system. And of course we have eight trauma centers plus Tripler Army Hospital and they receive some state support. So it's a spectrum in that if there's an accident, if there's a car crash or a heart attack, EMS takes care of the patient, taken to the hospital. If it's trauma, a car crash, we have the trauma center. And of course on the other end we have a very robust injury prevention program from senior fall prevention to drownings to suicide and to a traffic program. Which is of course why you said car crash rather than car accident. That's the new term actually, they're not accidents. Few things in life truly are. It may have been an accident, there was probably some predisposition behind it and that's I know part of your role in trying to figure out what is predisposing to sudden bad events and trying to ameliorate it so they don't happen. And the same thing with exposures to poisons, we don't call them accidental exposures anymore. They're either intentional or they're unintentional because some say there aren't no such thing as accidents like you alluded to. So in addition to the trauma system, the EMS system and injury prevention, we are responsible for the state poison center, which is a 24 hour number reachable by anyone toll free. I don't know how this will reject, but it's a toll free number 800-222-1222, 24-7, confidential. Calls are answered by specially trained nurses in medical toxicology and they are backed up by medical toxicologists. So it's one of the few services where one can get a physician 24 hours a day just like the emergency department. And I'd like to say as the denizen of the emergency department, I have called it on numerous occasions. It's been very helpful. Sometimes the nurses are what I need, sometimes someone like yourself. And we also, of course, if someone in the community calls and are advised to come to see us, we get a heads up from the poison center saying here they come, let us know what you find, we need to talk about this, which is fabulous. So it's a way of getting real resource any time day or night. So thank you for being part of that. Well thank you. And about approximately 20% of the calls come from emergency departments or physicians or healthcare provider offices. So it's, medical toxicology is a relatively small specialty, but this way we can provide a specialty that one wouldn't see generally in many localities. I'll tell you an amusing anecdote. The most recent time I called the poison center was for a herbicide exposure on Palmyra. The victim thought that he had hepatitis as a consequence. We determined that actually if he had hepatitis it was in his right or quadrant and it was actually appendicitis. But poison center was helpful because I needed to know the risk of hepatitis in this case and they gave it to me, it was low. So thanks again. You're welcome. Why is a rather far-flung place? Palmyra is about a thousand miles from here, but it works. Well and through the poison centers were one of the original hella health systems, which now is very much talked about using electronic modalities, our remote presence to provide medical care, and poison centers have been doing this for a long time. And now of course we have new modalities with not only audio, but we can do video and to move this along to the 21st century as well as we know we've talked about. Someday we'd like to see telemedicine in the pre-hospital arena. Which is starting to happen on the mainland and there's some platforms that do that and honestly it seems really full of potential. We do a small amount of telehealth to remote islands like for example Palmyra or Curie and it works. If you can get an image of something or a video clip and have a two-way conversation with a provider, often with a different training level, you can do a lot. And so I think this has got tremendous potential. We have to have new ways of doing things. Well and it's new and old all together at the same time because if you remember when paramedics, when the specialty of paramedicine started in paramedics, they were known as the eyes and hands of the physician in the field and they were connected back to the base station hospitals via the MediCom system. Right. I mean it's a mobile patio system. And now we're going to the next stage. Not only do we have eyes and hands in the field but we can virtually now bring the physician to the field which is a new concept and I think will allow us to do a lot more with less. You're right and I do remember those days because I trained at Harborview and Harborview was at the forefront of that and where a lot of paramedicine was actually developed. So you're right and my sense is done properly. This could tremendously change what happens in the field. Not everyone needs to be transported to the emergency department. Not everybody needs to be transported at all. But they do need input often from another resource, perhaps an emergency doctor, perhaps somebody else, and a destination. So I'm excited about this. Right. It's true. Not everyone needs to go to the hospital and the art is knowing who should go and who can stay at home or who can go to the clinic because anyone who's been in the hospital, hopefully not, but we know that in say 10, 15 years ago people stayed for a long time. I had a baby. It was like three days mandatory when I was in training three days. I think there's even a law that put a minimum on it which is gone now. So now it's much different recognizing there are limited resources and that people do better at home in their own environment with their family around them than in the hospital environment. I think that the thing that's becoming recognized that every intervention needs to have benefit because they all have harm. And hospitals can certainly provide benefit just like transportation and an ambulance can provide benefit, but not without the risk of harm. And if there is little benefit that, say, a hospital can provide after a certain period of time or for many conditions, all's left is harm. And even if there weren't harm and there is, you can catch diseases from your neighbor, things happen. There are also miserable places to be. There was a hilarious new study that came out that suggested who knew you don't get to sleep very well in hospitals. And anybody who's been in a hospital or with someone will know it's the 1.30 blood draw. There's the 2.00 a.m. vital signs. There's the 3.00 a.m. code announcement overhead. There's that whatever. And I can mention the food. That's a whole other topic which we should stay away from, although as a toxicologist you may be interested. Sorry. But they have come a long way. Hospital food has improved. When I was an intern we snuck into the hospital cafeteria after our kitchen after hours in hopes of scoring dinner and all we found was jello. So I felt bad for the patients honestly. So I think that the point of this conversation so far is do the right thing in the right place and minimize the chance for harm and of course maximize the value for the resource expended because currently 18% of GDP, that's another way of saying 18 cents on every dollar that the U.S. generates goes to health care. Now personally I like my health. I'm okay with spending a lot of money on it but that money needs to be well spent and I think that compared to other countries it could be argued we're spending a lot of money for middling results. Great things in some ways not so good in others and we need to look at everything. Exactly. I think it's expectations too from the physician, the health care provider to the patient all that needs to be looked at and everyone needs to take more responsibility for their own health. I agree completely and after the break we'll resume on that theme because we're all in this together. We all have bodies. We need to take care of them and we need to have access and use the help we need when the time comes. So thank you. We'll be back in a minute. This is Craig Thomas on Much More About Medicine with Al Bronstine from EMS branch of the State Department of Health. Thanks. Thank you. This is Think Tech Hawaii, raising public awareness. You can be the greatest, you can be the best, you can be the king, come play and now your chest, you can be the world, you can be the war, you can talk to God, go baby. Welcome back. I'm Craig Thomas on Much More About Medicine and my guest is Al Bronstine from the Department of Health's state emergency medical services branch and before the break we were talking about the challenges of responding to patients' needs across the state and I think that it'd be nice to paint a picture of what's involved in doing that and kind of the people involved, the number of runs, the equipment, describe for people what you've got to manage this diverse complicated state. Okay, thank you. So as we mentioned before, each of the counties has a designated EMS provider for 911 service and each county the model is a little different from the city and county of Oahu or Honolulu it's through Honolulu EMS and Maui and Kauai, they are on the big island, it's Hawaii County Fire EMS. So roughly we have this nice brochure that was actually prepared by city and county EMS of Honolulu which shows the history of the responses through the state over the years and it's probably a little hard to see on the television but we get about 140,000 responses per year. And I point out that's gone from 125,000 in 2012 so you've picked up more than 20,000 annual response calls in the last five years. Exactly the rates between 3-5% a year and these are both residents and the visitors. One of the things that's very important for Hawaii as a destination vacation site is that we can assure visitors that they can get the same 911 care should they require it that they can get on the mainland. I think that is very important for people who come to the state to visit to know. And about approximately 80% of these responses end up in transport to hospital. And of course the numbers are increasing because our population is aging, there's an increasing homeless population as well as there are people who utilize the system several times in a given month or year. You know a couple things I'd like to circle back on. One is on the order of 20% of your calls don't result in a transfer for a variety of reasons. Maybe nobody's there, maybe somebody refuses but clearly there's an opportunity. The other thing I'd like to touch on and you mentioned a couple categories, people without other resource including sadly a place to live but also those of us who are getting old tend to be what we call in the emergency department low acuity, high complexity. What that means is maybe not too medically ill and in fact not likely to benefit from a medical intervention but doesn't mean things are working and whether you can't get out of bed or can't do any of a number of other things or need some rather low tech intervention or maybe just a place to stay. In fact when I was a resident we used to give lobby passes so people wouldn't freeze. I know you were in Denver, you were aware of this phenomena. The in fact this was long ago before some regulations and we used to up front like hey Joe I know it's cold tonight are you sick or are you cold because if you're sick we'll take care of it and if you're cold we'll give you a lobby pass we'll get you a sandwich and a hot coffee and you get to hang out there tonight because it's cold out there. Well there's a lot of that not cold here but other needs and so there have to be other ways of intervening and we don't where we need to think creatively is that the traditional medical model doesn't always fit and sometimes we attempt in our zeal to help people to put them into the medical model so that for instance every headache that comes to the emergency department is not a simple to be muscular tension headache it's something much more a severe has to be ruled out and we the medical model is appropriate sometimes and it's not so appropriate other times and we need to know we need to pick the right treatment for the right patient and that's not always easy and people have been struggling with this and this has given rise to the idea not only can paramedics respond for 911 care or emergencies car crashes trauma heart attacks strokes they can we can also have what's known as the community paramedic that works with people who have more chronic medical problems such as diabetes asthma high blood pressure recent discharges from the hospital to keep them going back to hospital and so this is a new field that we're hoping and we want to bring to Hawaii and I do want to say there are certain medical issues or conditions that do merit 911 and for instance a stroke we know that the more and more the literature is showing the sooner the patient gets to the hospital the sooner interventions can be begun and and we can save brain tissue time is tissue so we also know that and I'm a guilty of this myself I don't want to call the ambulance I want to take myself in but first things like strokes are the arm doesn't move quite right my speech isn't quite right I'm not thinking right right it's time to call 911 don't delay as we say call 911 don't come in by private car and the other reason to do that is the paramedics will notify the hospital through our communication system and say we have a patient who is showing signs of a possible stroke and then the hospitals activate the stroke team so when the patient gets there everything is done very precisely to diagnose as quickly as possible now obviously not all things are a true stroke which is good but it's hard to tell sometimes so we really urge people for strokes heart attacks chest pain call 911 don't don't try to brave it by private car don't wait till the family comes home because time is tissue for both strokes and heart attacks and the sooner we can intervene the better the outcome absolutely and so a couple things about that Hawaii I think culturally people are definitely alert about I don't want to make a right and so about 20 years ago this was a big problem because instead of calling dispatch was getting calls from Boston and because what would happen is someone would be having a stroke let's say their spouse would call their family to say what do you think we should do and their family would call Hawaii dispatch that's not how it should work so I don't know if you've noticed but fire trucks the police cars don't stall call that's where that slogan arrived and I think it's better but still speed is of the essence guys in particular have trouble admitting reality so we need to remember this ourselves the other thing you alluded to is an opportunity to plug telemedicine which is not only do the crew perform some screening maneuvers in the field and assess the likelihood of for example a stroke and alert the hospital but that's the hospitals queue not only to make sure there's no one in the CAT scan device or get them out of it so that it's ready but to queue up often the tertiary spoke stroke center via telemedicine link most of the outlying hospitals across the state are connected to the tertiary stroke center and this is important because then you can decide because the treatment valuable is also dangerous and also if it doesn't work there's sometimes other options so queuing that up early is huge yes so so we it's a we emphasize that and telemedicine can be used for more mundane problems although there are problems like wound care yes as Maddox where the physician can see the wound maybe it's a simple treatment that doesn't require coming into hospital or to the doctor to the office and the paramedic can start the treatment and then the paramedic can go back and follow up on the patient and then show the progress of the wound to the physician and it's almost like a house call you know we don't have house calls very much anymore so but this is a high-tech house call it's pretty cool so that's what we like to move to and and hopefully we can start some projects as a bill in the legislature now I was gonna ask you about that to send a pilot both it's a pie would be a pilot on a wahoo a metropolitan area and one of the neighbor islands and to evaluate exactly how to create it for Hawaii there are several models on the mainland and we really need to understand what fits the state the best you know that's exciting we're gonna have to have you back to talk about that okay the you get a brief thing to put out your ask what else do you need and then we're gonna wrap this up until next time well thank you well the other thing we need we need three new ambulances we need an ambulance on a wahoo kawaii and the big island I understand it I work on all three islands and I think you're exactly right you know it's been a pleasure to have you here I want to talk more about a number of these topics we'll have to do it again thank you so this is Craig Thomas with Al Bronstine from the emiss branch state Department of Health and we're wrapping up for today on much more on medicine thanks for attending and listening