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IMMEDIATE ACTION DRILLS edge and skills, but must also ensure their students' ability to demonstrate mastery of those skills while faced with the pressures of functioning in dynamic environments. Immediate action drills (IADs) involve a programmed sequence of actions performed in response to predetermined triggers. This type of skill development technique eliminates the students' anticipation of skill performance and raises our level of training to accommodate challenges representative of our environment. This allows us to train our students to react in ways more consistent with what will be expected of them in the field. REFERENCES 1. American College of Emergency Physicians. International Trauma Life Support for Prehospital Care Providers (6th ed.). Upper Saddle River, NJ: Pearson Education, 2008. 8. Beilock SL, Carr TH. On the fragility of skilled performance: What governs choking under pressure. Journal of Experimental Psychology, 2001; 130(4): 701–725. 2. Institute of Medicine, Committee on the Future of Emergency Care in the United States Health System. Emergency Medical Services: At the Crossroads. Washington, D.C.: National Academies Press, 2006. 9. Beilock SL, et al. When paying attention becomes counterproductive: Impact of divided versus skill-focused attention on novice and experienced performance of sensorimotor skills. Journal of Experimental Psychology: Applied, 2002; 8: 6–16. 3. U.S. Bureau of Labor Statistics. Emergency medical technicians and paramedics. Occupational Outlook Handbook (2010–2011 ed.). 10. Duhigg C. The Power of Habit: Why We Do What We Do in Life and Business. New York: Random House Publishing Group, 2012. 4. Bledsoe BE, Porter RS, Cherry RA. Essentials of Paramedic Care (2nd ed.). Upper Saddle River, NJ: Prentice Hall, 2006. 11. Carlson NR. Physiology of Behavior (11th ed.). Upper Saddle River, NJ: Pearson Education, Inc., 2013. 5. Carmona R, Kester D. Integration of medical and immediate action drills. Tactical Edge, 2000; 18(3): 75–76. Elliot Carhart, EdD, RRT, NRP, NCEE is an assistant professor in the Emergency Services program at Jefferson College of Health Sciences in Roanoke, VA. He earned his doctorate from Nova Southeastern University, focusing on healthcare education. He is a former frefghter/ paramedic and currently practices as a registered respiratory therapist at Carilion Roanoke Memorial Hospital. Contact him at carhart.elliot@gmail.com. 6. Hockey J. Switch on: Sensory work in the infantry. Work Employment Society, 2009; 23(3): 477–493. 7. Adams L. Learning a new skill is easier said than done. www.gordontraining.com/free-workplace-articles/learninga-new-skill-is-easier-said-than-done. continued from p. 41 Such systems direct the sickest patients to hospitals with the greatest expertise in caring for their critical illnesses.28 The most appropriate hospital may not be the one closest or the patient's first choice, so it is important for EMS to understand what resources are available in its region. A regional approach was first taken with trauma care. Based on injury severity score, the 2008 Eagles benchmark paper states that one death is prevented for every 11 seriously injured patients transported directly to trauma centers. For patients over 65, one death is prevented for every three patients taken to trauma centers.1 Based on the model of trauma systems, regionalized care has been developed for other conditions. For STEMI care the Eagles paper recommends patients be transported to medium- to high-volume interventional cardiac facilities.1 Improved stroke care has also been found at primary stroke centers, and the American Heart Association now recommends EMS direct patients to those centers.29 Improved survival has been found at hospitals that treat higher numbers of patients resuscitated from cardiac arrest. The AHA recommends that this group be transported to hospitals capable of inducing hypothermia and comprehensive critical care, even if they are not the closest.30 Rare situations such as an upper airway obstruction require rapid trans- 54 JUNE 2013 | EMSWORLD.com port to the closest hospital. More often, however, sick patients are best served at regional specialty centers. This means paramedics in many areas will spend even more time treating the sickest patients they encounter. Patients deserve to have systems in place that direct them to the most appropriate hospitals and paramedics capable of managing them during transport. Conclusion In his book Resuscitate!: How Your Community Can Improve Survival from Sudden Cardiac Arrest, Dr. Mickey Eisenberg says brutal self-assessment is an EMS system's first step toward improvement. "The simple fact is that nothing will change if the status quo is to be tolerated," Eisenberg writes. "And the status quo in virtually every community is indifference combined with insufficient data—a powerful duo on the side of inaction."3 These performance measures are a start but certainly not all that is needed for a system to be successful. The authors of the 2008 Eagles benchmark paper said they hoped more benchmarks would be researched and published.1 From the patient's perspective, it doesn't matter if the people who show up when they need help are called EMTs or paramedics. It doesn't matter if their service is funded by donations, transport revenue or taxes. They expect their heart attack to be detected and to be taken to the hospital best equipped to manage it. They expect to receive medication to open their constricted airway. And they expect their pain to be treated before being moved. When they don't get these things, their EMS system has failed. How does your EMS system stack up? How does your cardiac arrest survival rate compare to other communities'? Do patients get transported to hospitals without CPAP or seizure medication? Do they continue to fight against cloth restraints without chemical sedation? When they arrive at the hospital, are they in more or less pain than when you arrived? The time for excuses is over. This is a case to make the following interventions available to every patient who calls 9-1-1 for EMS: 12-lead ECGs incorporated into regional STEMI systems; CPAP; nebulized bronchodilators; seizure medication; pain medication; and chemical sedation It is based on evidence of how effective they are, their frequency and the difficulty in predicting over the telephone when they are needed. It is time to look past the way EMS has always been delivered and toward getting every patient the interventions they need. Bob Sullivan, BA, NREMT-P, is a paramedic with New Castle County EMS in Delaware. The views expressed in this article are his and do not represent those of New Castle County EMS. Reach Bob through his blog, The EMS Patient Perspective, at emspatientperspective.com. Find the references for this article online at EMSWorld.com/10930211.