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NYS DOH State Emergency Medical Services Council

(SEMSCO) and

State Emergency Medical Advisory Committee (SEMAC)

Meeting Notes – 5/25/21 & 5/26/21

(Official minutes of the meetings will be released later by NYS DOH)

Teresa “Teri” Hamilton, Executive Vice President, is the NYS Volunteer Ambulance & Rescue Association’s representative on and a voting member of SEMSCO and a member of the Legislative Committee.

THE BLANKET Special Edition SEMSCO & SEMAC Meetings - May 2021

QUICK LINKS

WWW.NYSVARA.ORG

www.PulseCheckConference.org

THE BLANKET

214 Kent Avenue #278 Endwell, New York 13760 E-Mail: theblanket@nysvara.org (877) NYS-VARA The BLANKET Co-Editors James B. Downey Nancy Ehrhardt

ASSOCIATION OFFICERS

Henry A. Ehrhardt

President

Teresa A. Hamilton Executive Vice President

Adrian Pezzica Vice President

Adam Shaver

Secretary

Ernie Stonick Treasurer

Brenda Morrissey

Membership Secretary

MEMBERSHIP If you are not a member of NYSVA&RA, please join today and help increase the voice of the community / volunteer / non-profit EMS / First Responder Sector in New York State. How can you or your squad become a member of NYSVA&RA? Visit our membership page at www.nysvara.wildapricot.org Already a member? Forget how to access your information? Contact our membership secretary for information on your login/password. She can be reached at membership@nysvara.org

STATE EMERGENCY MEDICAL SERVICES COUNCIL (SEMSCO)

Wednesday 5/26/21 Meeting Duration: 2 Hours 14 Minutes

Mark Philippy, Chair

Meeting was called to order at 11:37 AM. Pledge of Allegiance was conducted. Moment of silence observed for our colleagues in EMS and fire service who have passed away during the COVID event. Roll call of members conducted. Quorum is present. New member: Andrew Knoell, Big Lakes REMSCO Motion to accept minutes of 1/13/21 meeting was made by Jason Haag and seconded by Alan Lewis. There were 2 minor corrections mentioned. Motion to approve the corrected minutes was passed without objections or abstentions. CHAIRPERSON’S REPORT - Mark Philippy Two new standing committees of SEMSCO have been established:

1. Quality Metrics Committee under Chair David Violante and with BEMS&TS assistance from Deputy Chief Peter Brodie. Other members include Michael Redlener, MD and Maryanne Portoro, RN. Soliciting members from Council and EMS community. If interested sent note to Mark Philippy and Valerie Ozga.

2. EMS Innovations Committee will bring under one house ET3, Community Paramedicine and Treatment-in-Place. Jason Haag has agreed to chair the committee. Soliciting members from the Council and EMS community. If interested sent note to Mark Philippy and Valerie Ozga.

Steno & court reporter service used at the January meeting produced record that was complete and easy to read through. There have been discussions over last 2 days about EMS is in crisis. This has never been more true than now. The 2019 Workforce Report indicated an inability to staff ambulances reliably. Today people are leaving the service and healthcare in general and finding other jobs. There is a need to look at what is being done in agencies and regions to encourage people to join, take EMT courses and make this a career and stay in. This is the worst in nearly 40 years where folks are having trouble turning wheels and getting ambulances out the doors. This is startling. SEMSCO will work on measures to bring that information forward. The Workforce Report will be redone.

1ST VICE CHAIRPERSON’S REPORT - Stephen Cady EMS Innovation and Provider Award nominations are by 7/1/21. Nominations for Provider Awards need to go through local REMSCO and then to BEMS&TS. Innovation Award nominations go directly to Valerie Ozga. 2ND VICE CHAIRPERSON’S REPORT - Michael McEvoy Elections are on the agenda. Nominations were called for at last meeting but no one has reached out. Therefore a slate of the current officers is offered: Chair – Mark Philippy 1st Vice Chair – Steven Cady 2nd Vice Chair – Michael McEvoy There were calls from the floor for any additional nominations but there were none. Motion to close nominations and vote for the slate provided was made by Patty Bashaw and seconded by Carl Gondolfo. There was no discussion. Roll call vote was conducted with Yes-25, No-0 and Abstain-0. Motion passed. BUREAU OF EMS & TRAUMA SERVICES REPORT - Ryan Greenberg, Director See separate section for compilation of reports given at SEMAC and SEMSCO meetings on 5/26/21. STATE EMERGENCY MEDICAL ADVISORY COMMITTEE (SEMAC) - Donald Doynow, MD, Chair. See separate sections on SEMAC, Medical Standards/Protocol Subcommittee AND Education & Training Sub-Committee meetings for additional information. Seconded motion on the NYC Unified Protocols was presented to SEMSCO.

Roll call vote was conducted: Yes-24, No-0 and Abstain-0. Motion passed. Seconded motion on adopting National Highway Traffic Safety Administration (NHTSA) changes to the EMT Scope of Practice was presented to SEMSCO.

Question was asked about EMT-CC being included and reply was that was considered ALS level. Mention was made that Check-and-Inject for EMT level has already been adopted in NYS. Roll call vote was conducted: Yes-25, No-0 and Abstain-0. Motion passed. Informational items:

IV nitroglycerine was added to the formulary to reflect the Collaborative Protocols.

Ebola Transport Advisory is going to a committee for review before approval. Recommended that mask mandate for vaccinated providers in an ambulance

without a patient be rescinded to make them more comfortable. Under current CDC guidelines they can wear a mask if so desired.

Community Paramedicine is in jeopardy if/when Governor’s Executive Order expires. Currently there are 50 programs covering 40 counties.

EDUCATION & TRAINING SUB-COMMITTEE - Michael McEvoy, PhD, RN, Chair See separate section on Education & Training Sub-Committee meeting for additional information. Major topic areas discussed at the Sub-Committee meeting:

Bureau of EMS & Trauma Systems Education Branch Report. Policy Statement 19-01 Instructor Certification. Federal EMT Scope of Practice Changes. iGel Supraglottic Airway Pilot Project. New SEMSCO Committees. Regional Issue Question. Geographic Boundaries for Course Sponsors.

EXECUTIVE COMMITTEE - Mark Philippy, Chair

Nothing to report. FINANCE COMMITTEE - Steven Kroll, Chair There are 3 things being worked on in the committee, 2 being new:

1. Educational Cost Survey would allow measure what it costs to put on an EMS certification course, be it original or recertification and contrast that with the reimbursement and what is budgeted by the state to pay for training. Electronic version of survey was put together by BEMS&TS staff and it almost ready to go out in next week or two. Regional organization will be asked to encourage Course Sponsors to complete the survey. Since originally constructed the survey was modified to include COVID-19 extraordinary costs.

2. Revision of 2018-2019 Workforce Survey that covered recruitment and retention difficulties and has been useful in conversions with others. Reasonably confident the situation in no better but worse. May just re-release survey but may add questions related to current times. It will be an electronic survey this time.

3. Fiscal Sustainability Project. It will look at the different financial models used in NYS and their strengths and weaknesses and then make recommendations to improve finances in NYS. There are many different factors to consider – forms of revenue, jurisdiction, ownership, staffing, home rule, Medicaid payment rates. Capstone of project is that information needs to be communicated to policy makers and the public because people do not know how EMS is financed.

LEGISLATIVE COMMITTEE - Alan Lewis See separate Legislative Committee meeting report for complete information on the committee meeting. Major topic areas discussed at the Committee meeting:

AMERICAN RESCUE PLAN ACT of 2021 - Public Law 11702 passed 3/11/21. Proposed NYS legislation of interest to EMS. Need for funding for illness and or death benefits for first responder affected by

COVID-19. Seconded motion requesting SEMSCO support for A1561C Santabarbara / S3503C Hinchey regarding NYS Rural Ambulance Services Task Force and to send letter to DOH Commissioner asking for support in the Legislature:

Motion passed by consensus without objection or abstentions. Seconded motion requesting SEMSCO support for A151 Gottfried /1590 Rivera regarding Community Paramedicine and to send letter to DOH Commissioner asking for support in the Legislature:

Nurses’ unions oppose EMS in Community Paramedicine. Other comments were made in support. Maryanne Portoro, RN, Emergency Nurses Association suggested group reach out to nursing associations. Invitation was extended to attend ENA meeting in August Motion passed by consensus without objection or abstentions.

Seconded motion requesting SEMSCO support for S1018 Kaminski expanding eligibility for the Low Interest Rate Program (LIRP) of the State of New York Mortgage Agency (SONYMA) to volunteer fighters and volunteer ambulance workers and to send letter to DOH Commissioner asking for support in the Legislature:

Legislation needs an Assembly sponsor. Motion passed by consensus without objection or abstentions. SEMSCO writes letters of support for legislation and BEMS&TS submits the letters to the Commissioner through proper channels. A2561 Woerner / S4085 Hinchey: Relates to the availability of air transport ambulance service providers to store and distribute human blood and blood products and to initiate and administer transfusions of the same Assembly & Senate passed the legislation and it is awaiting action by the Governor. EMS SYSTEMS COMMITTEE - Patty Bashaw, Chair See separate EMS Systems Committee meeting report for complete information on the committee meeting. Discussed 3 topics and possibly taking them on as initiatives:

CON process. Is it antiquated? Is it working? Does it need to be tweaked? It is being done differently at the regional level. Can the regions be helped by tweaking some of the processes?

Deliverables – how every region is handling those. Overall view of EMS system in the state. Seeing if there are best practices.

Seeing if there are some things we can tweak and help impact. Possibly write a white paper.

Planning on monthly committee meetings. SAFETY COMMITTEE - Mark Philippy, Chair See separate Safety Committee meeting report for complete information on the committee meeting. Major topic areas discussed at the Committee meeting:

Policy Statement 00-13 The Operation of Emergency Medical Services Vehicles is 21 years old and needs revision.

Patient lifting and handling injuries. Resiliency and fatigue. Mental health, emotional health and physical health – a

holistic plan for providers. Training and resources on the issues. Carl Gondolfo volunteered to take the lead in assembling information on resources.

Committee needs Chair for the next term. QUALITY METRICS COMMITTEE - David Violante, Chair See separate Quality Metrics Committee meeting report for complete information on the committee meeting. Committee held its inaugural meeting on 5/25/21. Major topic areas discussed at the Committee meeting:

1. There is a draft of 7 quality metrics. Number 5 dealing with Percentage of Pediatric Patients in Acute Respiratory Distress Receiving a Respiratory Assessment is in drafting stage. Will work on and define some of the characteristics of what quality is. Find ways to measure it through data, processes and analytics and getting information to the state and regions, dashboards, getting agencies to move from Point A to Point B.

2. Reviewing the QA program and the manual associated with it. Using other national resources such as NEMSQA and NEMSP Quality Course for that program and moving it forward.

3. Reporting out at the Vital Signs Conference with information, education and training.

Anyone interested in joining the committee should reach out to Davis Violante, Mark Philippy and/or Valerie Ozga. EMS FOR CHILDREN (EMSC) PROGRAM

No report. STATE TRAUMA ADVISORY COMMITTEE (STAC)

No report.

OLD BUSINESS

Part 800 Regulation changes over the last 2 years are moving forward. ePCR and paper PCR portals are open. 200 EMS agencies have committed to

transition to either the paper portal, the free state ePCR through ImageTrend or a commercial ePCR platform. The deadline for a decision is 6/30/21. There is a new BLSFR documentation standard since they have a limited on-scene patient contact time. Agencies wishing to continue in the CME Refresher Program need to be documenting electronically by 12/31/21 as use of the paper PCR would not qualify. The new documentation standards allow for inclusion of medications administered and BLS procedure modalities. Still doing info sessions. If there are issues or questions send an e-mail to emsdata@health.ny.gov

BEMS&TS Informatics Branch has added 2 interns for summer. More data = better decisions

NEW BUSINESS

Bylaws Article 6, Section 2 requires formal SEMSCO approval of new standing committees. Motion to approve establishment of Quality Metrics Committee and EMS Innovations Committee was made by Stephen Cady, seconded by Teri Hamilton. Question was asked about elimination of any committees. Mark Philippy advised the PIER Committee has been somewhat inactive with no work or interest in it and at next SEMSCO meeting there may be a motion made to dissolve it. Roll call vote was conducted with Yes-25, No-0 and Abstain-0. Motion passed. Donald Hudson read a question from the Nassau Regional EMS Council: Since Nassau REMSCO is listed as in addition to faithfully and actually performing the duties of a Regional Program Agency why doesn’t the Nassau REMSCO have access to the same financial support as other Regional Program Agencies? Ryan Greenberg responded that the Program Agency existed up until just a few weeks ago and was under contract. Now that the Program Agency has informed us that they will no longer exist the state is working on a process to determine how to either to determine a new Program Agency or have those services taken over by another Program Agency in the interim. Our contracting process is not the quickest and we are trying to get the support in a more timely fashion than the normal process would take. Contract periods covering this and next year were mentioned. Ryan Greenberg advised the next meeting will be most likely in October. Meeting is expected to be in the second or third week. Goal is for SEMSCO members in-person with no guests. This is subject to change. Vital Signs Conference is 11/11/21 to 11/14/21 in Saratoga Springs. Jason Haag asked about expiration of Executive Orders on virtual stuff for the local REMSCOs or will it be continued. Ryan Greenberg advised all the Executives Orders are subject to expiration at any time. They get extended on 30 day increments and there has been no sign they will expire any time soon based on the need of certain things that are in many of them. They have been expiring based on needs of certain components. Don’t think that part will expire in the near future. Is also one of the things being looked at for handling the October meetings. Meeting was adjourned at 1:52 PM

NY STATE EMERGENCY MEDICAL ADVISORY VOMMITTEE (SEMAC)

Wednesday 5/26/21 Meeting Duration: 1 Hour 55 Minutes

Donald Doynow, MD, Chair

Call to order at 9:07 AM. New members announced:

Joshua Lynch, DO, Wyoming-Erie REMAC Tiffany Bombard, MD, Mountain Lakes REMAC

Pledge of Allegiance conducted. Roll call of members conducted and quorum present. Minutes of the 1/13/21 meeting were approved. BUREAU OF EMS & TRAUMA SERVICES REPORT - Ryan Greenberg, Director See separate section for compilation of reports given at SEMAC and SEMSCO meetings on 5/26/21. MEDICAL STANDARDS SUB-COMMITTEE - Lewis Marshall, MD, Chair See separate Sub-Committee section for additional details of the sub-committee meeting and discussions. NYC Unified Protocol changes were brought forward as a seconded motion for approval. Changes were explained at the Sub-Committee meeting and were discussed. Dr. Marshall again went over the changes before the SEMSCO vote. There were no questions or issues raised at SEMAC.

Roll call vote was conducted with Yes-19, No-0 and Abstain-0. Motion passed.

IV NITROGLYCERINE TO FORMULARY Motion to add IV Nitroglycerine to the state formulary was made by David Kugler, MD, seconded by Robert Wicelinski, DO and passed by consensus without opposition. VIRAL TRIAGE PANDEMIC PROTOCOL Dr. Marshall indicated there have been discussions regarding the Triage Protocol put in place during the 1st wave of the pandemic and make it more applicable to more types of disasters not just limited to a pandemic. This could involve revising it or even to the point of developing a limited number of statewide disaster protocols to be in place and would allow regions to activate them based on regional needs/regional conditions. Volunteers were asked for and there are 2 already. Notify Dr. Marshall or Valerie Ozga if interested in serving on the workgroup. Ryan Greenberg commented that these would be generic statewide protocols and a region could turn them on/off. Providers would know what they are. Now is the time to do it. Have already started to look at what other states are doing. IGEL SUPRAGLOTTIC PILOT PROJECT FROM HUDSON VALLEY Pilot was approved by SEMAC at its last meeting and is open to agencies from other regions. It would allow use by an EMT of the IGel supraglottic airway. Project still needs to be approved by SEMSCO and the DOH Commissioner before it can begin. EBOLA TRANSPORT ADVISORY Steven Dziura, Deputy Director, BEMS&TS repeated somewhat the comments he made at the Medical Standards Sub-Committee meeting. This concerns the transfer of known Ebola patients from the initial receiving hospital to an Ebola treatment facility. David Kugler, MD asked about a patient going into cardiac arrest and whether patient would continue to an Ebola facility that could better manage the patient. Should there be language about CPR for a known Ebola patient? Question was about return of deceased to originating hospital which may be contaminated. Ryan Greenberg commented that diverting to another hospital and amount of time for it to prepare to treat the patient vs. continuing to an Ebola treatment facility that would be able and prepared to treat the patient would probably be equivalent. Some of these transports would involve air medical and other components that limit the amount of time. Treating patient in cardiac arrest is deferred to SEMAC. Language of the advisory could be edited by SEMAC. Another thing to look at is what is the pathway for a SEMAC advisory. Jeremy Cushman, MD commented that these are complex interfacility transports involving high risk patients and would require an EMS physician team to be involved in providing guidance on the transfer so paramedic does not have to make a very challenging decision on their own. A policy cannot cover every possible situation. Risk of death during transport is considered. Nikolaos Alexandrou, MD commented about NYC’s interfacility transfers and the airports in the area. Work was done with NYC DOH&MH, NYC OEM and even New Jersey to address concerns. Death during transfer would continue to the Ebola facility that had expertise and set up to receive the patient. Unstable patient would divert to closest hospital because CDC guidelines indicate every hospital is supposed to be able to receive, isolate and treat an Ebola patient. There would be no invasive procedures, no intubation, no IVs, maybe IO to do an IV. Providers would be protected from contamination. Jack Davidoff, MD commented about this being a very complex situation involving ethical questions and needs committee discussion.

Donald Doynow, MD asked Dr. Davidoff to form a committee which he agreed to do. A state ethicist and someone from the Office of Health Emergency Preparedness would be added to the group. EDUCATION & TRAINING SUB-COMMITTEE - Michael McEvoy, Chair See separate section on Education & Training Sub-Committee meeting for additional details. Report to SEMAC covered the following general subjects:

Bureau of EMS &Trauma Systems Education Branch staff report Issues with Policy Statement 19-01 Instruction Certification Changes to Federal Scope of Practice for EMTs IGel Supraglottic Airway Pilot Project Geographic restrictions on Course Sponsors

National Highway Traffic Safety Administration – Changes to EMT Scope of Practice Motion below was made by Jeremy Cushman, MD and seconded by Jack Davidoff, MD.

Michael Daily, MD questioned in chat box “Why are we adding what we have already approved in the past? We had previously approved both the IM injections for EMT and the immunizations for EMS providers in NYS”. Michael McEvoy answered The Commissioner prohibits EMTs from immunizing without a physician or NP present. Roll call vote was conducted. Results were: Yes-19, No-0 and Abstain-0. Motion passed. EMS FOR CHILDREN (EMSC) PROGRAM - Arthur Cooper, MD Pediatric readiness project is proceeding. There are 2 working groups:

1. Early recognition of sepsis in the field. 2. Excited delirium in pediatric patients.

Findings are expected to be reported at the next meeting.

OLD BUSINESS None.

NEW BUSINESS Michael Doynow, MD brought up removing an order and permitting vaccinated EMS providers in an ambulance to be without masks if there are no patients in the rig. Ryan Greenberg indicated rescinding it will be looked at. Community Paramedicine agencies and counties covered with will be put on Boardable. New SEMSCO Committees have been established:

1. Quality Metrics Committee: 7 metrics have been established. New analytics program is coming to allow comparisons with state overall and similar sized and situated agencies. David Violante is chair and committee had first meeting 5/25/21. Committee is looking for members and anyone interested in becoming a member should contact Mark Philippy or Valerie Ozga.

2. EMS Innovation Committee: Will focus primarily on the future of EMS including ET3, Community Paramedicine and Treatment-in-Pace. What will be the future of pediatric care, adult care evolution of deployment models, etc. Committee will also work with the 25 Community Paramedicine programs in 4 geographic regions and act as a sounding board. Committee is still being formed and has not yet held its first meeting. Committee is looking for members and anyone interested in becoming a member should contact Mark Philippy or Ryan Greenberg.

STATEWIDE ALS PROTOCOLS Lewis Marshall, MD indicated one statewide ALS Protocol is getting closer with majority of state using the same medicine. The Collaborative Protocols have been adopted by most of the regions, other regions are following the Collaborative Protocols and NYC Unified Protocols follow the medicine. Suffolk County is strongly encouraged to at least follow the protocols. Jason Winslow, MD, Suffolk County EMS Division advised REMAC has not been able to move towards the Collaborative as it has not been able to meet and continue to work on policy section in the area before using the medicine in the Collaborative. Question was added about NYC adopting the Collaborative as well. Current [Suffolk] protocols are in line with the Collaborative if not the same format. Josef Schenker, MD spoke of crux of difference being NYC using protocols as operational tool for regional control because of call volume and the rest of state uses guidelines vs. protocols. Medicine should be the same because EMS medicine is EMS medicine regardless of where you are and should be the same. NYS HERO ACT Jack Davidoff, MD asked if the BEMS&TS had a chance to review the NYS Hero Act and how it will effect EMS as we move ahead with pandemics, infectious diseases, etc. Facetious comment was added about the need for taking a seat out of the front of each ambulance and using 6 foot extensions on BVM to keep people distanced properly. Ryan Greenberg advised he will look into it. [A2681B / S1034A requires state agencies to create clear, enforceable health and safety standards and all employers in New York to implement certain safety standards and adopt a prevention plan to protect against further spread of COVID-19 and other airborne infectious diseases in the workplace.]

HEMORRHAGE TRAUMA PROTOCOL Daniel Olsson, DO put in chat box “Use of TXA in an EMS region must be approved by the corresponding Regional Trauma Advisory Committee”. He indicated his RTAC in a letter stated “The committee was not strictly opposed to the use of Tranexamic Acid but suggests that if used it’s use be monitored for efficacy and presence of serious side effects”. He stated this is not a glowing endorsement Tranexamic Acid and the statement exists in the protocol. Brian Walters, DO asked about TXA and other protocols approved at SEMAC previously and have they been approved by the Commissioner and is there a time line? Ryan Greenberg responded that there is no time frame on that and they are looking at changing the process and ways to speed up things. NASSAU COUNTY ISSUE ON REGIONAL PROGRAM AGENCY FNANCIALS David Kugler, MD indicated he was asked by his REMSCO Chair to pose a question: Since Nassau REMSCO is listed as in addition to faithfully and actually performing the duties of a Regional Program Agency why doesn’t the Nassau REMSCO have access to the same financial support as other Regional program Agencies? Ryan Greenberg responded that financial support is there where all the Program Agencies are. Up until several weeks ago there was a Program Agency under contract and it has indicated they will no longer be under contract. State contract process is not quick and BEMS&TS is working on short and long term solutions to getting program support and what the contract would look like. The funding is there. NYC HOSPITAL SURGE CAPACITY PLANNING Cherisse Berry, MD indicated currently hospital volumes are surging across NYC with non-Covid-19 patients. If hit with another pandemic there is no state or regional plan in place to handle the surge. Regarding developing state disaster protocols is there a plan in place to involve regional leadership and stakeholders and will the state provide financial resources to develop plans. Ryan Greenberg replied participation in planning would be welcomed from SEMAC. Would have to have an understanding of what financial support is looked for and then propose it up to the Division of Budget to determine if there are funds and where they are coming from. BEMS&TS LETTER REGARDING ALS UPGRADES Michael Dailey, MD spoke about a letter from BEMS&TS to Hudson Valley REMSCO regarding their ALS upgrade policy and authority as granted in Article 30. His region received notice advising an agency was approved to upgrade to ALS level but the request had not gone through the region. State representatives advised authority for upgrade to AEMT, CC and EMT-P was with BEMS&TS and not with a region regardless of regional or local conditions. Article 30, Section 3004-A indicates REMACS have authority to develop policies and procedures, triage & treatment and transportation protocols. Have there been any changes in interpretation of Article 30 or prior precedent? There is issue of authorization to be an ALS agency vs. authorization to practice as an ALS agency which falls to a Region. Steven Dziura advised that the letter that went out was very specific to Hudson Valley REMSCO because their policy had created a pseudo public need process for the establishment of ALS services in that area. In reviewing the policy against the current statute there is no requirement or enabling language for that type of process to occur. There were communications about how the REMSCO policy was developed and its history. The only factors that can be considered by law are in Section 3031 and that was outlined in the letter. BEMS&TS did have to come out and do an inspection to

verify everything was in place prior to permitting the certificate. Have not gone back to revisit to entire policy as this this was a one-off situation and was not aware of a second situation. There is a need to ensure policies align with Article 30 and regulations. Region’s policy on public need and hearing process came into being about same time as ALSFR came into picture and may have unintentionally incorporated ambulance agency upgrades to ALS into the policy. COURSE SPONSOR GEOGRAPHIC REGION Ryan Greenberg advised a legal brief came out determining there is no restriction for Course Sponsors for a geographic region. However, further review brought out REMSCOs have a very specific authority to create a Training & Education Plan and that courses should be following that plan. This is going back to the old pathway. BEMS&TS is working on having a clear process on how regulatory change occurs. Working with Division of Legal Affairs on this. Meeting was adjourned at 11:05 AM. Next meeting may be in October 2021. No date is set yet.

BUREAU OF EMS & TRAUMA SERVICES REPORT

Ryan Greenberg, Director

This is a compilation of information provided at the SEMAC and SEMSCO meetings on 5/26/21

70% staff out on COVID-19 related activities such as vaccinations, testing and other things for the DOH.

Processing a lot of invoices for Regional Program Agencies, REMACs and REMSCOs. There has been a 4 times increase due to COVID-19 functions. If there are any issues reach out to Lynn Farruggia.

Policy Statements recently issued were highlighted: 20-01 Community Paramedicine Vaccination Program Application Process

Community Paramedicine is permitted through an Executive order that is still in place. It expanded from 3 or 4 programs that were borderline to just under 50 covering 40 counties. Goal is to have at least 1 per county. They are restricted to COVID-19 related functions which is broad with the bulk doing vaccinations. Agencies covering counties are working with local health departments

20-02 Prevention and Control of Ebola Virus Disease There was an outbreak elsewhere in the world. Lacking information on the pathway where the outbreak was going the Policy Statement was issued as a precaution. A SEMAC Advisory is being discussed.

20-03 2nd Interim Guidance for EMS Education Courses The 30% non COVID-19 activity in the office is primarily related to education. CME programs to expand. Testing program with PSI continues to progress quite nicely with fewer issues than before. Seeing about same problems as with prior Thursday testing nights when there were upwards of 20,000 to 30,000 providers testing yearly. Policy Statement goes into Course Sponsor extensions, provider cards and certifications. Shows transition to NREMT exams for original paramedic certifications. Starting in 2022 all paramedics need to take NREMT written and practical skills (PSE). There are 6 internal BEMS&TS staff and another 10 that will go out and proctor the NREMT paramedic exams. EMT-CC to EMT-P bridge students will take an NREMT assessment exam. Starting in 2022 all paramedic training programs must be accredited or in transition to being accredited. BLS students have option to take NREMT or NYS exams.

20-04 Submission of Patient Care Reports as of July 1st, 2021 Paper PCRs will no longer be accepted by Regional EMS Program Agencies and will need to be scanned in and transmitted to a paper portal. Those agencies using paper can also transition to an ePCR platform,

either a free state platform or a commercial platform. A large number of agencies are going electronic.

EMS for Children (EMSC) is progressing along and expanding. 4 sets of equipment for the safe transport of pediatric patients were purchased. There was a road trip to a conference in the Mountain Lakes Region bringing out all the different devices to talk to providers, show them how to put the devices onto stretchers and let them determine what they might want to get for their agency. There will be a box for each region.

During EMS Week on an overnight the Director went to a local hospital about 1:00 AM and observed a crew carry in a 2 month old. He later asked the Chevra Hatzalah VAC crew about the method of transport and was advised they used a device strapped to the stretcher. Medical Directors are encouraged to ask their agency how a stable baby would be transported. He believes the initiatives are making a difference.

Trauma world is going well. Participating in virtual hospital visits. Trauma Needs Assessment Committee under Cherisse Berry, MD has involved the Chairs of all the Councils from BEMS&TS – EMSC, Trauma, SEMAC and SEMSCO. They are working on helping to define capabilities around the state and the areas that need more resources, access to trauma services, EMS and other things.

Vital Signs Conference will be a hybrid event this year. There are only about 400 in-person slots vs, about 1,600 people at past conferences.

Vital Signs Academy will be doing 3 presentations a week for the summer. 6/11/21 there will be an EMS Education Day with 8 hours of on-line education for

CICs, CLIs and other instructors. 6/18/21 will be EMS Leadership Day with a number of different topics geared for

new supervisors. Bi-weekly BEMS&TS briefing calls for EMS agency leadership and providers

continues. Anyone can join the calls. Information will be going out on how to sign for Health Commerce Systems

(HCS) accounts. It will become a web page on the DOH web site. New EMT cards are coming in June. They have a QR box enabling validation of

the cards which will also be able to be done through the HCS. A downloadable digital version will be coming in the summer through the HCS. The cards are of a different material and are expected to survive at least one wash.

Balance Mental Health & Wellbeing for EMS Providers page will be going up on the BEMS&TS website by mid-June. It has a number of resources and contacts specifically targeted for EMS. It also has programs that EMS agencies can start.

EMS Memorial Service was moved to Thursday 9/30/21 at 11:00 AM. 17 names will be added this year with 3 of those from 2020. 10 are directly related to COVID-19.

New SEMSCO standing committees are being established and need members: 1. Quality Metrics Committee 2. EMS Innovations Committee

MURU is a new free protocol app launched last week for EMS providers in NYS. Steven Blocker, CEO of the company presented a brief high level presentation for situational awareness.

Regions will have access to a longer demo. It will be geared to a provider’s primary EMS agency and will cover NY statewide, collaborative and NYC Unified protocols from official sources only. App works offline. Discussions on the app covered verified updates, hyperlinks in protocols, adding OLMC numbers, nearest hospitals and their capabilities, statistics on access to specific protocols, equipment listing among other things. After COVID-19 the medication dosage calculator will be an add-on option with a cost but there may be ways to fund the cost. From 100 to up to 700 people in a day have download the app to their smartphone. Contact information for the company is www.Murumed.com and info@murumed.com

Teri Hamilton commented on Ryan Greenberg’s, Steven Dziura’s and DOH Commissioner’s attendance at a ceremony at the EMS Memorial during EMS Week.

Protocol/Medical Standards Sub-Committee of SEMAC Tuesday 5/25/21

Meeting Duration: 1 Hour 27 Minutes

Lewis Marshall, MD, Chair

Meeting called to order and roll call of members conducted. NYC UNIFIED PROTOCOLS No red-lined version was provided. Dr. Marshall advised most of the changes were formatting and wording to bring them more in line with the Collaborative Protocols. Some other things were added. Significant changes are:

Non-traumatic cardiac arrest combined and removed some of the sub-protocols such as V-FIB, Pulseless V-TAC and PDA.

Pediatrics changed assisted ventilation rates to reflect PALS recommendations based on AHA update. All other protocols were brought in line with most recent AHA update.

Respiratory Distress added Nitroglycerine IV bolus dosing based on a 2020 article in Pre-hospital Emergency Care. Minimum systolic BP for dosing of Nitro was changed from 100 to 120.

Excited Delirium medication standing orders and Medical Control option medications were changed to weight based dosing to increase patient safety profile.

V-FIB and V-TAC with a pulse added lidocaine as an option. Pediatric Dysrhythmias is new and reflects uniformity with adult protocols. Some

of it was previously included under Septic Shock. It should bring NYC more in line with Collaborative Protocols.

Obstetric Emergencies included paramedic treatment of eclampsia with Magnesium Sulfate under standing orders. This is also available under the Collaborative and NY under the Seizure Protocol where they can administer Magnesium Sulfate under standing orders.

Adult & Pediatric wheezing added Ipratropium Bromide at the EMT level consistent with changes in the National Scope of Practice which does allow Medical Directors to determine which of these medications can be used.

Dexamethasone added under steroids. It is one of the medications approved as an alternative medication years ago.

Undifferentiated Shock newly added for the general management of patients in shock despite treatment under other specific protocols. Vasopressors included here are Norepinephrine, Epinephrine, Dopamine and Vasopressin.

Stroke protocol exclusion criteria for NYC is greater than 24 hours from last known well with score of greater than or equal to 4, consistent with the current guidelines for thrombectomy for large vessel occlusion.

General Pain Management is new and organizes all analgesic medication options in one protocol and eliminates pain medications in specific protocols.

Procedural Sedation is new and removed a lot of these treatments from the General Operating Procedures (GOP) where they were available. Pediatric patients requiring sedation will still require On-Line Medical Control contact.

General Trauma Care is new and brings all trauma related protocols into one place and removes some redundancy of previous protocols such as chest injuries and abdominal injuries. Includes treatment for open chest wounds and impaled objects.

Jack Davidoff, MD commented that several protocols mentioned IV but not IO. Josef Schenker, MD advised that GOP has language that IV and IO are interchangeable.

Ryan Greenberg advised BEMS&TS is working on a waiver under an Executive Order on the packaging of the IV nitroglycerine bolus but waiver would only last as long as an Executive Order exists. A number of agencies are looking for the waiver to occur. A statewide approach could also be looked at if there is widespread interest. ALSFR agencies have a separate process in current regulations to carry the glass vials. Donald Doynow commented that nitroglycerine not listed in Collaborative formulary. Jack Davidoff, MD comment that nitroglycerine is listed for STEMI for IV dosing.

David Kugler, MD questioned about NYC REMAC adopting NY statewide protocols and adding NYC specialty protocols as needed.

Josef Schenker, MD advised protocols have not changed and these are same protocols approved last year with ALS added and clarified to match current literature and streamline things. 95% of providers were trained. Discussions have been held multiple times about Collaborative vs. regional protocols and it boils down to the medicine is not that different but is an overarching difference of opinion on how to use protocols, the state has more of a guideline and NYC has more of a protocol because of the operational requirements of a system of the size we have. We have been trying to mirror and close the gap on the medicine and get them closer.

Brian Walters, MD asked about areas of difference and standing orders in the protocols. Josef Schenker, MD advised there very minimal differences. Medicine is the medicine. A large part of it is using the protocols as an operational tool because of the size of the system.

Donald Hudson commented that looking in the Collaborative Protocol vs the MURU APP and does not see IV nitroglycerine listed for ST elevation. There were other comments that it was not listed in the formulary and it needing to be added and brought to SEMAC.

Motion to approve the NYC Unified Protocols was made by Dan Olsson, MD and seconded by Nikolaos Alexandrou, MD. Roll call vote was conducted. Vote was: Yes-17, No-0 and Abstain-0. Motion Passed. VIRAL PANDEMIC PROTOCOL

Lewis Marshall, MD advised that there have been discussions about what to do about the current Viral Pandemic Protocol which is still activate and can be activated by a region based on its needs and conditions at the time. There have been some discussions about establishing a workgroup to revise it to make it more general to cover

more types of disasters with the thought of keeping it in place and active and able to be activated at the regional level based on local conditions with notification to the BEMS&TS. Ryan Greenberg commented about a set of 4, 5 or maybe 10 disaster protocols for the state that could be “turned on” by a region based on what was going on such as a hurricane on Long Island or an ice storm in the North Country. Theses would be pre-approved and allow providers to learn the protocols and know what is available. Volunteers for the workgroup should send an e-mail to Lewis Marshall, MD. COMMUNITY PARAMEDICINE

There have been discussions on what will be the status of Community Paramedicine programs once the pandemic is over. Ryan Greenberg commented that under an Executive Order there are just under 50 programs covering 40 counties throughout the state partnering with local health departments and different agencies. There are limitations but are pretty well accepted. Most recently are Community Paramedicine partnerships with school districts to vaccinate children in school districts. When the Executive Order expires all this goes away but this is not seen to be happening soon because of all that is going on and there is possibility of a booster shot in the fall. It is something that needs to be addressed at a global level. It expanded from 3 or 4 programs that skirted whether or not they were doing Community Paramedicine. It also gives more career opportunities to paramedics. There has been a lot of positive feedback. IGEL SUPRAGLOTTIC AIRWAY PILOT PROJECT

Dr. Marshall indicated pilot was approved at last Medical Standards and SEMAC meetings. It came from Hudson Valley REMSCO initially for one specific agency involving EMT during cardiac arrest only. End Tidal CO2 monitoring was required. It would be open to other agencies through Hudson Valley REMSCO. It would have to be approved by SEMSCO and by the DOH Commissioner as a pilot project. Ryan Greenberg commented that there was a group looking at additional edits, quality benchmarks, whether it would be a statewide project, limiting it to one device and expanding it to others for data. Dr. Bombard commented that the pilot was open to everyone and agencies could contact Dr. Murphy for additional information and to sign up for project. Dr. Bart added comments including change in Scope of Practice but indicated support. Brian Walters, DO commented about other devices. Dr. Alexandrou commented about dispatch of ALS and pilot not including the King device. Ryan Greenberg advised that information will be posted on Boardable. (ED Note: At the January 2021 meetings the Education & Training Sub-Committee brought the pilot project to SEMSCO as a seconded motion where it was approved. DOH Commissioner would still be needed.) SEMAC ADVISORY FOR TRANSFER OF EBOLA PATIENTS

Steven Dziura, Deputy Director, BEMS&TS advised the Office of Health Emergency Preparedness is asking SEMAC to consider a draft Ebola Transfer Policy Statement. Language is open. They are looking for a protocol or advisory that deviates from closest appropriate facility for known Ebola patients who have been seen at a hospital and are being transferred to a primary Ebola facility. This came up due to recent outbreak in Africa and screening at JFK airport. These are interfacility transports in the event patient decompensates during transfer from initial receiving hospital to Ebola capable facility. Mickey Forness, RN commented about lack of facilities in MidState Region. Brian Walters commented about changing Policy Statement 21-02 in lieu of additional documents. Steve Dziura advised once the advisory comes out 21-02 can be revised.

Draft advisory is in writing on Boardable SEMSCO 5/20/21 folder. Draft posed advisory shown below was put up as shared screen during the meeting.

One member commented about receiving questions about cardiac arrest and returning patient to initial hospital. There will be more discussion at SEMAC.

OLD BUSINESS None.

NEW BUSINESS Jack Davidoff, MD brought up that there are 3 smartphone APPs available:

MURU NYS EMS Collaborative Protocol Paramedic Protocol Provider (PPP) covering NYC REMAC (3/30/21), NY

Statewide (9/26/19) and Suffolk REMSCO (5/27/21) He indicated they have different wording mentioning IV Nitroglycerine and Agitated Patient vs. Excited Delirium possibility of agitated patients becoming apneic and need for control of what is going on by Medical Standards, SEMAC and/or SEMSCO. Steven Dziura advised that this is exactly why MURU was contracted with. MURU takes the PDF that was approved by the Commissioner whereas it is not known where the other APPs get their information from. It could be created by the Regional Collaborative Group but it is not sure it is the final copy that was approved by Medical Standards, SEMSCO and the Commissioner. MURU gives BEMS&TS that control and other APPs could be posting just what was initially presented. Dziura indicated the Collaborative APP was paid for in collaboration with multiple REMSCOs and MURU will replace that when the contract expire. To make it clearer, the money came from State Locality Funding that reimbursed the REMSCOs. PPP is an independent APP creator that is getting its source from somewhere and posting it without approval from NYS DOH nor is it required. MRUR is the NY state approved APP – the source of truth. Jack Davidoff, MD indicated feeling MURU had least accurate information for providers. Lewis Marshall, MD indicated need to set up process with Dziura and Greenberg to ensure accuracy. Nikolas Alexandrou, MD advised FDNY looked at MURO and some hospital designations and sub specialties do not match the NYC system. Jack Davidoff, DO asked about On-Line Medical Control numbers and reply was that numbers will be updated. Ryan Greenberg advised bulk of information for MURU including hospital information comes from DOH website which may not be up to date. Mark Philippy advised he has had conversations with Steven Blocker at MURU and if there are issues Blocker can be contacted directly through the APP.

EDUCATION AND TRAINING SUB-COMMITTEE OF SEMAC Tuesday 5/25/21

Meeting Duration: 61 Minutes

Michael McEvoy, Chair

Meeting began at 9:50 AM. Roll call of members in attendance was conducted. BUREAU OF EMS & TRAUMA SYSTEMS EDUCATION BRANCH REPORT - Jean Taylor, Deputy Chief

Staffing: Holly Proper-Platt is back, Edwin was promoted, Liz Donnelly had a major medical emergency in mid-March and is still out but progressing. Current staff is herself, Gene Myers, John MacMillan, Holly Proper-Platt and Latisha Williams.

Have opened up 2nd and 3rd attempt at written exam with PSI. After 48 hours to allow PSI systems to update students can themselves schedule the additional attempts through the same process they previously used. If student fails all 3 attempts they need to remediate which means they need to go through a refresher course with a new course number which would allow them 3 more attempts at passing the written exam.

Renewals for Course Sponsors are due 9/3/21. That date is still up for discussions

Testing is going so much smoother than in the past. Number of new EMTs is down for 2020 vs. 2019. Classes were cancelled or

extended. However, students are waiting months after completion of their course to take the written exam. Seeing people who completed courses in March-April-May of 2020 taking exams in March-April-May of 2021. The longer the delay the less time available to get in for a retest and the more likely of failing the exam.

Regulations give students 1 year to take the written exam. Some sponsors have a policy giving students 3 months for the 1st exam attempt but this is not regulation. Another sponsor send a bill if exam is not taken within 30 days. BEMS&TS may look at what can be done.

BLS skill sheets are still in the approval process. Implementation date for the new sheets will be announced. All courses starting after the implementation date will use the new sheets. Up until that time continue to use the old sheets.

CME Recertification portal is just about ready for trial phase with a couple of agencies. Implementation date will be announced and will advise when the rollout begins.

Instructor certifications are being handled by Jean Taylor. CLI certifications are a little behind but should be caught up by the end of the week.

POLICY STATEMENT 19-01 INSTRUCTOR CERTIFICATION

Jefferson County noticed that certification form is missing category for EMT-CC which would be under the ALS category. Follow-up is needed with Education Branch and guidance is expected by the next meeting.

Advanced Standing was discussed off line. Anne Smith advised there has been some confusion with instructors who advanced from CC to EMT-P and feel they can teach at EMT-P level. Policy Statement only differentiates BLS and ALS and instructor certification letter may need clarification of provider level certification and/or teaching level certification. Course Sponsor may need to be involved. Jean Taylor advised all original instructors are certified at BLS level and need 7 additional hours to be certified to teach at the ALS level. AEMT is accepted for paramedic level. Course Sponsor determination of teaching level may be a problem. Letter wording is outdated. Adding a box for CC to the letter would be helpful until the CC level is sunset. It will be discussed further off-line.

CICs seeking recertification need to have taught a class and be the CIC of record. Classes are 148 hours and other CICs have been recruited to help but some have been reluctant because only the CIC of record gets credit for teaching. It is easier to recertify CIC by doing an EMT refresher with a couple sessions/practical skills exam. Is there a way to modify the requirements for teaching to follow what is allowed by AHA where an instructor teaches or participates in a certain number of classes in a certification period and that counts for continuation as an instructor? Workaround could be breaking an EMS course into multiple smaller sized classes each with its own CIC and every CIC would do some paperwork as required. It was stated there is an inequity with the way requirements are and the work cannot be divided up and it is making it difficult to maintain CICs. A Course Sponsor commented that sometimes to maintain certification the CIC of record’s class was actually taught mainly by other instructors. Another Course Sponsor commented that the big agencies in the region had gone to on-line CME recertification and only refreshers for AEMT and are not getting any takers. Question raised if on-line CMEs count and answer was no as there is no course number. A downstate sponsor spoke of doing 2 didactic audit reviews and it has been accommodated. McEvoy closed out discussion by indication some draft changes would be developed.

FEDERAL SCOPE OF PRACTICE CHANGES National Highway Traffic Safety Administration issued 2 change notices:

1. Add IM injection to the EMS scope of practice. 2. Add immunization during a public health emergency to the EMT, AEMT and

Paramedic levels and add specimen collection via nasal swab to the EMT, AEMT and Paramedic skills.

Typically NYS adopts these federal changes. It may require extra curricula at the EMT level but we already teach Check-and Inject. These are not temporary emergency measures but permanent except that immunizations are limited to a public health emergency. It was advised that feds are concerned that adding immunizations as a routine scope of practice to the level would cause some difficulty with some other professions. There is no problem during a public health emergency but during normal times would be questionable. The changes would be presented to SEMAC as a seconded motion.

IGEL SUPRAGLOTTIC AIRWAY PILOT PROJECT

There was a little bit of confusion at last Medical Standards and SEMAC meetings. Last Education & Training Sub-Committee comment was that it was not within the scope of practice of an EMT but the pilot project had some value and merit and perhaps would change the scope of practice depending on the outcomes. Not really much to say at this point.

OLD BUSINESS None.

NEW BUSINESS NEW SEMSCO COMMITTEES Ryan Greenberg advised 2 new committee would be added.

1. Quality Metrics Committee This will be based off of the 7 quality metrics have been developed with only 1 of those left to finalize. Committee will be working on measuring them statewide, initiatives to roll them out, initiatives to have them used and benchmarking around the state for agencies looking to be more data and quality driven.

2. EMS Innovations Committee Will be looking at what EMS will be in the future including ET3 and the 25 agencies currently involved, Community Paramedicine and Treatment-in-Place which is similar to ET3 but different.

New analytics platform is coming for comparison and benchmarking. It will help in sharing data and making comparisons with similar sized agencies around the state. REGIONAL ISSUE QUESTION

Question was raised about AEMTs and cardiac monitors. AEMTs are being used around the state as ALS level providers but cardiac monitoring and cardiology is not part of their curricula? How are regions using them as ALS? It was eventually sorted out that this is a Suffolk Region issue concerning EMT-P hand off of a stable patient to an AEMT after a proper assessment. The questioner indicated that in the Suffolk County system once a monitor is put on a patient the EMT-P must accompany patient to a hospital. GEOGRAPHIC BOUNDARIES FOR COURSE SPONSORS Ryan Greenberg advised that a Course Sponsor raised question to BEMS&TS about 2 weeks ago asking what is used to determine geographic boundaries they can offer courses within. Senior staff from BEMS&TS and Education Branch and DOH Division of Legal Affairs reviewed the information related to the questions and determined there should not be geographic boundaries for current Course Sponsors based on regulations and statutes in place. It was also found that most regions are not following requirements for a Regional Education Plan to be submitted. These plans would outline how many EMTs are needed in the area, expected number of classes needed and where those classes are needed to be held. BEMS&TS is working on a Policy Statement to further explain how things will operate in the future, the requirements of what will be required from the REMSCOs which would come from their Training & Education Committees determining the need in the area for classes to be taught and submit those plans to the BENS&TS.

BEMS&TS would also evaluate plans coming from Course Sponsors requesting to teach classes and will match the classes to the training plan to correlate that together. This is more work for BEMS&TS and REMSCOs, however, this is what is currently out there and dictates what REMSCOs should be doing and what is in regulations. Things can always change in the future. If we do not like the way this goes we can look at changing it. This answer was not expected but when looked into this was what the outcome came to. It does not mean a Course Sponsor can teach anywhere – classes would have to align with the training plan of a region and what the needs of the region are. This is a significant change. This also comes at a time when there are more and more questions about hybrid classes, distance classes, class locations, etc. Working on anticipated questions. Things are not changing tomorrow as REMSCOs need time for plans. Steven Dziura commented that they are receiving direct questions about what seem to be well established traditions within EMS systems but when researched do not have a basis in statutes or regulations. We have to align with the letter of the law.

Michael McEvoy commented that 15 or 20 years ago Course Sponsors could not teach a course not in a Region’s training plan. The plan went to BEMS&TS and that was how funding was calculated. That fell by the wayside over time. This was confirmed by a Regional representative. Instructor and specialty courses were also included in the Regional plan.

Ryan Greenberg mentioned that some Regions have been having trouble getting CIC’s and CLIs. Lots of students like distance learning and the pandemic has taught us many things. It has been pointed out by some that if you can get an MBA of PhD online why not EMS education or a portion of it on-line. On-line education continue to grow with 100 to 150 people in every Vital Signs Academy class. Don Hudson made suggestion to add this to the agenda for Program Agency meeting.

FINANCE COMMITTEE OF SEMSCO Tuesday 5/27/21

Meeting Duration: 46 Minutes

Steven Kroll, Chair

Call to order at 10:53 AM. Roll call of members was conducted: REVIEW OF EMS COURSE COST SURVEY 2021 TOOL

Several columns were added at the last meeting to track how COVID-19 related costs have affected Course Sponsors. Survey remains the same as last worked on.

Data dictionary has been filled in. Check boxes lead to more specific questions about courses taught, hours, fees,

etc. Testing is still going on at BEMS&TS Opening and closing language will be added. Contrasts can be made with prior surveys and what reimbursement is provided

under the training fund. Survey will to be sent by BEMS&TS to Course Sponsors. Link to draft survey is at https://apps.health.ny.gov/pubpal/builder/survey/ems-

survey-56

OLD BUSINESS

None.

NEW BUSINESS PROJECT ON FISCAL SUSTAINABILITY OF EMS IN NEW YORK STATE

BEMS&TS Director has suggested a project to determine the fiscal sustainability of EMS in the state. Is the way we finance EMS the best way? What can we do to improve EMS financing? In 2019 a workforce study was published which included information on finances. The pieces of the project are:

1. Define the different models being used to finance EMS in NY. 2. Define the strengths and weaknesses of each model. 3. Develop ideas and proposals that would lead to strengthening these models. 4. Develop ideas and proposals for new models of financing.

An extensive back and forth discussion ensued with several contributing to the dialogue which is summarized for the most part below: Mark Philippy commented about “white boarding” the different issues, that any funding stream is good but some are better than others. Have to involve local government in this. Profession is somewhat schizophrenic in that we want to be - healthcare, a business, a part of public safety and an essential service - and this will evolve and how we involve out communities in the discussion. We need to make a statement backed by some form of numbers. Things have gotten harder for us in the last year with the number of new EMTs being down. Staffing is a big problem. There needs to be a scripted statement. REMSCOs have an obligation to the state to provide information on their EMS training needs and this would provide needed information on updating workforce data. Steve Kroll commented that there are limited pots of money such as taxpayer funded initiatives such as tax districts, contracts with towns, cities or counties, insurance billing, philanthropy and contributions. These sources can work in combinations as some volunteer units exit totally on contributions from their communities while other agencies rely on billing. Towns, cities and counties fund EMS differently. We have non-profit agencies can be 100% volunteer and others that are hybrid, commercial agencies that are fully staffed, municipal agencies that are fully staffed, fire district agencies that may be like hybrids or all volunteer. Most communities do not know how ambulances are financed and this applies to individual citizens as well the people that make funding decisions. When an ambulance shows up it may not be known if the staff is volunteer or paid or if ambulance is government funded or not or by donations. In some areas the tax bills show an amount for ambulance service along with other taxes for such things as libraries. There have been articles in the national press talking about rural EMS being in trouble. Home rule and CONs govern how we operate in NYS and economies of scale are effected if there are situations like having 5 fire departments in one town. A data driven strategy is needed similar to the 2019 EMS Workforce Survey which has been used a document given to those asking for information. There are 18 regions that can supply input. Thomas Pasquarelli commented about every agency facing different challenges depending on its makeup such as commercial, not-for-profit or municipal. Ownership models need to be looked at. Municipalities are not likely to want to support large commercial agencies. We make this job look easy but politicians are not aware of what is going on behind the scenes. Nothing is coming out from the state. Education will be a huge part of this. In one county there were problems and issues and although providers changed there are still problems with the payer mix. This is something that should be expedited and not take a year or 2 to reach the appropriate people. William Hughes commented about large variances in expenses of the different models as are their revenue streams.

Steven Cady spoke of having to educating elected officials on how this actually works and how to educate them as they are likely to make the final decisions. David Violante submitted a chat box comment that there had been issues in Dutchess County with folks and elected officials not knowing about finances and a study was done a few years ago which can be shared with the Committee. Jason Haag commented asking if it is time for SEMSCO Finance Committee to make a collective statement about what other entities are doing. NAEMT, fire associations, NYSVARA and the trade organizations do good work and really well but there is not buy-in from all providers in the state. NYS needs to come out with information. Ryan Greenberg commented that the Workfoce Survey is important and should be done periodically and used as a tool to be used when going to local council or town board. Great takeaways from this meeting:

1. Complete the education cost survey and work with BEMS&TS in tabulating it and doing something with it.

2. Committee has a new project on the Fiscal Sustainability of EMS in New York State.

3. Tied the new project back to the Workforce Survey and its importance. There was also mention of prior efforts on a survey on Medicaid reimbursement.

There is statutory business to take care of before the next meeting such as a template for a budget and briefings.

SAFETY COMMITTEE of SEMSCO Tuesday 5/25/21

Meeting Duration: 39 Minutes

Mark Philippy, Chair

Call to order at 12:05 PM Roll call of members was conducted: Chair commented that after the heavy lift with Part 800 changes it is time to look at some things more in line with what the Committee’s mission has been in the past. POLICY STATEMENT 00-13 THE OPERATION OF EMERGENCY MEDICAL SERVICES VEHICLES

The policy is well overdue for revision. A number of people have looked over it and there is some information from prior reviews. Chair solicited volunteers and Steven Cady, Carl Gondolfo and Richard Parrish offered to participate. COMMITTEE CHAIR POSITION The Chair needs to pass to someone else. At the end of Mark Philippy’s term as SEMSCO chair it is the plan for the Council chair to take over as chair of the Systems Committee because of that person’s knowledge and involvement in issues over the recent past. The chair has to be a SEMSCO member. WHAT IS THE NEXT THING FOR SAFETY COMMITTEE TO TAKE ON? This question opened an extensive discussion summarized below: Steven Kroll asked about what is the biggest safety problem as an occupation. We already have EVOC and accidents. There is already work at the national level on resilience, rest and exhaustion. What are people worrying and thinking about? Mental health of EMS providers and health & fitness were mentioned as reasons for losing providers. There was a TAG on mental health and suicide about 2 years ago that lost its way with COVID-19 and that issue has not gone away. Mark Philippy commented about the number of lifting and handling injuries, workers compensation and training for staff. Being fit and resilient was mentioned. What does the Safety Committee have to offer? Trying to add to the current EMT curriculum is difficult. What do we want to see for a resilient provider? Does SEMSCO need to come out with a position statement? In 2019 there was a large tract on provider mental health at the Vital Signs Conference.

Bryan Brauner commented that resiliency is not just about fatigue but includes mental health, emotional health and physical health – a holistic plan for providers. What is the target audience - providers, organizations or course sponsors or all of them? Should strategies be different? Split into prevention vs. response? Mention was made of CME recertification requiring some non-core mandated training hours. Richard Parrish commented on proper lifting and moving instruction. Carl Gondolfo commented about FDNY losing 13 people to COVID or COVID related issues with 3 to suicide and 1 is too much for any agency. His organization’s Bureau of Training do a physical education and a fitness program for new people. After initial training there is additional instruction on stress management such as box breathing and mental performance in dealing with functioning under pressure and dealing with high stress situations. He suggested short webinars for training. Mention was made of conversations with co-workers about stigma in EMS about being healthy whether it is mental, emotional or physical. People are seeing bad things multiple time a day. He volunteered to take the lead in assembling information on resources. Steven Cady mentioned information put on Boardable for SEMSCO members about a website created with information and resources on mental health. Marie Diglio submitted a chat box comment that NYC REMSCO received a grant to reactivate its Health & Wellness team for provider resiliency on suicide prevention and would be happy to share information. Anne Smith commented that lifting and moving is part of the curriculum. Is it possible to put more focus on best practices and teach ways to promote it in the classroom and for CIC updates? Teri Hamilton submitted question in chat box asking if there was a presenter in the EMS field who is experienced in Post Traumatic Stress who is a prominent member of the service and who be willing to speak about their experience. Many people who look up someone would be more inclined to ask for help knowing someone who has done it. Sean Graves submitted a chat box comment that our nursing colleges have great resources. There is a major change in culture of safe patient lifting. The only state documents he is aware of is the functional job description of lifting limitations.

LEGISLATIVE COMMITTEE of SEMSCO Tuesday 5/25/21

Meeting Duration: 55 Minutes

Alan Lewis, Chair

Roll call of members was conducted.

Jeff Call - absent Mark Deavers - absent Tim Egan - absent Vincent Faraone - present Lester Freemantle - absent Teri Hamilton - present Timothy Kelly - present

Steven Kroll - present Andrew Lamarca - absent Alan Lewis - present Meryl Montrose - absent Clifford Smith - absent Robert Stoessel - present

AMERICAN RESCUE PLAN ACT of 2021 (Public Law 11702 passed 3/11/21

Steven Kroll presented information on the federal legislation that was signed into law in March. The American Rescue Plan Act included EMS Treat-in-Place provisions. Previously Medicare would only reimburse EMS agencies if a patient was transported.

Under the NYS Pandemic Protocol, however, to relieve burdens on hospitals in crisis EMS crews could assess patients with COVID-19 fears or symptoms and not transport them if the situation did not warrant hospital care at the time.

The American Rescue Plan Act now allows EMS agencies to bill for the COVID-19 related calls where there was no transport under a communitywide EMS protocol adopted by the jurisdiction such as a region or state. The time period is retroactive covering 3/1/20 through 5/5/21 and reimbursement claims must be filed with Medicare by 5/5/22. Reimbursement is at the BLS emergency rate or the ALS-1 rate. There is no mileage reimbursement since the patient was not transported. Agencies must accept the Medicare reimbursement as payment in full and cannot collect any other amount from patients other than an unmet deductible. It does not cover an RMA unrelated to COVID-19.

This act was something that many EMS organizations including the NAEMT, AAA and NYSVARA worked together on. Efforts continue to make reimbursement for EMS Treat-in-Place permanent.

PROPOSED NYS LEGISLATION OF INTEREST TO EMS A1561C Santabarbara / S3503C Hinchey

Authorizes the Department of Health to establish the New York State Rural Ambulance Services Task Force; requires such task force to conduct a study on the unique challenges faced by New York state ambulance services in rural areas.

a) Such task force shall be compromised of: 2 members appointed by the governor, 2 members appointed by temporary president of the Senate, 2 members appointed by the speaker of the Assembly, 1 member appointed by the minority leader of the Senate, 1 member appointed by the minority leader of the assembly, 2 members appointed by the Office of Fire Prevention and Control, and 2 members of the Bureau of Emergency Medical Services.

b) One of the appointments by the governor shall serve as chairperson of the task force.

c) The members of the task force shall receive no compensation for their services, but shall be allowed their actual and necessary expenses incurred in the performance of their services.

d) The task force will be provided with information necessary to carry out its functions and shall keep such information confidential.

Within twelve months of the effective date of this act, the Department of Health shall submit a report detailing the findings of the study to the governor, the temporary president of the Senate, and the speaker of the Assembly. $50,000,000 supposedly allocated for implementation of actions recommended the report but would have to be included in a separate budget bill. In original versions of the bill the Department of Homeland Security was the overseeing agency but this was changed through stakeholder efforts to the Department of Health. Status: 5/11/21 Referred to Assembly’s Ways and Means Committee. 5/19/21 advanced to 3rd reading in Senate Motion for the Committee to support the bills and pass it on to SEMSCO was made by Timothy Kelly, seconded by Teri Hamilton and passed without opposition. A151 Gottfried / S1590 Rivera Authorizes collaborative programs for Community Paramedicine services as part of the hospital-home care-physician collaboration program. Allow hospitals, emergency medical services (EMS), physicians, and home care agencies, in joint partnership, to develop and implement a collaborative program whereby at-risk individuals living in the community can be served by EMS for care other than the initial emergency medical care and transportation to the hospital. There are about 50 Community Paramedicine programs covering 40 counties statewide that sunset when Governor’s Executive Order expires. These are currently limited to COVID-19 related activities such as vaccinations, testing or something else serving the homebound. Ultimate goal is to have at least 1 program covering every county. Status: 1/6/21 referred to Assembly’s Health Committee. 5/24/21 advanced to 3rd reading in Senate. Motion to for the Committee to support the bills and pass it on to SEMSCO was made by Steven Kroll, seconded by Timothy Kelly and passed without opposition. S1018 Kaminski (No comparable Assembly bill as of yet) Expand eligibility for the Low Interest Rate Program (LIRP) of the State of New York Mortgage Agency (SONYMA) to volunteer fighters and volunteer ambulance workers. Eligibility shall be limited to the purchase of residential property which shall be owner-occupied. The interest rate is said to be 1.5% below the standard mortgage rate. Steven Kroll commented that NYSVARA took a look at a number of bills related to benefits for providers who have been involved in active service to their communities and did endorse the bill. These is an existing program for low interest mortgages and this legislation would add EMS personnel and firefighters who are active in their

communities. It is one of a series of bills for example a loan forgiveness program by Senator Kaminski and another worker loan forgiveness program by Assemblyman Burke. S1018, the NYS COVID-19 Heroes Loan Forgiveness Program adds a new section to 903A of the Public Health Law, is pretty straightforward with no punitive or problematic provisions. Status: 1/6/21 In Senate’s Local Government Committee Motion to for the Committee to support the bill and pass it on to SEMSCO was made by Steven Kroll, seconded by Vincent Faraone and passed without opposition.

NEW BUSINESS

Steven Kroll commented that there have been a number of EMS providers who contracted COVID-19 and passed away in what may have been Line of Duty Deaths (LODD). In some cases they have been denied Workers Compensation Benefits because there is no direct establishment of causality. An example is 3 members from the same ambulance crew all having COVID-19 with 1 passing away. There is no definitive proof that the decedent caught COVID-10 from a patient or another crew member. Maybe legislation is needed to clarify how causality is established for a severe injury, illness or death presumed due to COVID-19 using 9/11 legislation on certain disease processes as a precedent. This would be preferential to litigation. Robert Stoessel commented that Senator Brooks has a bill covering volunteers only. He spoke to his aides about a gap in coverage if there was paid and volunteer providers on the same crew but there was no willingness to expand the bill’s language beyond volunteers. There is concern about bills supporting specific segments of responders and this is similar to what happened 20 years ago with 9/11 where they had to go back and fix things. Vincent Faraone asked about Workers Compensation coverage but it was explained that Volunteer Ambulance Workers Benefit Law and Volunteer Firefighter Benefit Law coverage is different and bill would need to be expanded. Alan Lewis commented that Workers Compensation insurance is costly and a special fund may be preferred. A534 Jones / S1286 Brooks - Changes to General Municipal Law 209-b Provides that authorities having control of a fire department or fire company which provides emergency medical services may establish fees and charges for services. There was a chat box question about fire department billing indicating the politicians down here have been telling people it will pass this time? Alan Lewis advised issue is being discussed and it is closer to something happening now than it has ever been. Direct payment is part of the legislation at this time. Senator Brooks and Assemblyman Jones are the sponsors. Steve Kroll advised that not all the interest groups are in agreement with the bill as it exists and there are a series of amendments that are being passed back and forth between fire service industry representatives and non-fire service industry representatives to try reach an accommodation everyone is comfortable with. One accommodation is direct pay. Existing language does not show proposed amendments and it is not known if there will be agreement on the amendments. There is short time left to work things out covering all the concerns from the different parties. Action on amendments is in the Assembly right now and there would have to be negotiations with the Senate about differences in versions. Status: 5/25/21 referred to Assembly Ways and Means Committee, Senate previously passed bill by floor vote of 62 Yes and 1 No.

SYSTEMS COMMITTEE OF SEMSCO Tuesday 5/25/21

Meeting Duration: 38 Minutes

Patty Bashaw, Chair

Roll call of members was conducted:

Brent Ash - absent Patty Bashaw - present Vincent Faraone - present Lester Freemantle - absent Gregory Gill – absent Jason Haag - present Donald Hudson – present Andrew Lamarca - absent

Yedidyah Langsam - absent Melissa Lockwood - present Alan Lewis - absent Robert McCartin - present Michael McEvoy - present Carla Simpson - present David Violante - present

POLICY STATEMENT 06-06 EMS OPERATING CERTIFICATE APPLICATION PROCESS Committee was requested to look at the policy statement making sure it is current. Mark Philippy commented that it has been 15 years since the current policy was written. Common theme in last 3 or 4 CON matters has been the issues with criteria that address determination of need particularly expansions and transfers of operating authority, reallocation of resources and what it means. There have been numerous challenges in the court system over this. Mention was made of Article 30 and how it is being applied. Jason Haag asked if instead of looking at 06-06 would it make more sense to look at Article 30 and legislation on rewriting rules and regulations? Ryan Greenberg suggested instead of Article 30, which would be a long term project, to look at Part 800 regulations and see what can be in there to make project a more achievable task. SYSTEM COMMITTEE GUIDANCE ON GENERAL EDUCATION FOR REGIONAL COUNCILS Patty Bashaw opened the discussion commenting that for new leaders in her area she brought in their BEMS&TS representatives to introduce the region’s state contact people and discuss what does the state does, its different departments, what are the deliverables and provide an overall education. Best practices could be taken from the ones [regions] that seem to be running fairly well. Comment was made directed to Ryan Greenberg about not sure where you are at or are there are discussions still going on about moving some of the regions – I saw a little bit in the chat today and one of the conference calls. If that is going to happen we need to be on the same page with that.

Should there be new initiatives for the regions. Is there a vision you want us to help impact? Ryan Greenberg commented that every Council is different in their priorities and what they concentrate on and what statutes require them to do. One of the things is the education plan that has to be submitted yearly. A lot of the Councils have turnover and through no fault of their own something gets lost or does not happen. The Systems Committee as the state lead can come up with a bullet point checklist of roles and responsibilities of what Regional Councils are obligated to be doing by statute and regulation and move that forward. His visions include:

1. More consistency amongst the Regions to meet statutory and regularity obligations. What is needed to help them meet statuary obligations?

2. CON process and how to improve including regularity changes. 3. Systems Committee looks at EMS systems. Is it time for the Systems Committee

to look at more of the EMS system and perhaps write a “white paper” on what the ideal EMS system should look like in the future? There are 1,100 agencies in the state. North Carolina has 1 system for each county.

Priorities should be determined by the Systems Committee. Projects can be defined and people can be recruited to help with working on more than one priority at a time. David Violante commented on issues of home rule and different components on how service is delivered across the state. EMS is being delivered by different models sometimes by people who do not understand the model. Maybe there is a need to move beyond what the Northeast is used to. Looking at system components was mentioned and comparing agencies against standards with caveats for different regional circumstances to determine how a region is doing. Donald Hudson indicated his region has encountered over the last few months many of the problems and difficulties everyone is echoing. As we get more data on response times, quality assurance issues and look at metrics, geography, level of care and disparities is it even achievable to set statewide benchmarks for out the door time, response time and on-scene time regionally or statewide? There is little reliable data and unfortunately politicians do not know that because of parroting these things with no literally no data. With the home rule thing coming up he asked what responsibilities come with a CON if an agency does not want to go to an address or is too busy. It has gotten to questions of where does it say we have to do anything. Comment was made that there are not enough people available and willing to do the jobs and there is bidding war starting at $30.00 an hour for new out of the program zero experience paramedics to sit at a fire house waiting for a call. It begins from there and is crescendoing which is great for wages. Vincent Faraone commented that in the past a senior BEMS&TS staff member said that a CON is permissive but not obligatory so there is a right to respond but not an obligation. This has been the position of the 2 BEMS&TS Directors before the current one. COVID-19 made this worse. A lot of fire departments are struggling with personnel and stopped going to falls and lift assists. Unless it is a major cardiac event or MVA they are no longer responding. A lot more mutual aid and automatic response is being used and people are being told to call this other agency first between 8:00 AM and 8:00 PM. Fighting over areas may be gone. It comes down to money from Medicare, Medicaid and insurance to have enough money to pay employees.

Ryan Greenberg indicated the pandemic brought out issues with responses to certain call types but before that is was issues with responding to locations. When people advise they did not go to a particular call, place or fill in the blank there is not really anything in a regularity statute that obligates. Is the model today the right model? Should it change to a larger territory or system based approach rather than a CON indicating Route 87 to Route 9 or half joking from Bob’s convenience store south to Mrs. Jones’ house? Some CONs have wacky geography.

QUALITY METRICS COMMITTEE of SEMSCO Tuesday 5/25/21

Meeting Duration: 44 Minutes

David Violante, Chair

This is the inaugural meeting for this new committee. David Violante commented that the Committee will be looking at quality metrics and what that relates to in terms of quality and measures we can ascertain in a variety of ways and quality improvement and assessment moving forward. These are the starting points. There is a draft of 7 quality metrics. Number 5 dealing with Percentage of Pediatric Patients in Acute Respiratory Distress Receiving a Respiratory Assessment is still being developed. Peter Brodie, Deputy Chief, Informatics Branch, BEMS&TS brought up a draft and shared it on his screen. The 3 aspects of respiratory assessment being looked are pulse oximetry, respiratory rate and respiratory effort.

As of January 2020, 98% of care is documented at NEMSIS 3.4.0. ICD-10 coding was used which is more complicated having thousands of codes vs. ICD-9 which was the previous standard used for medical billing purposes. IDC codes are broken down as IDC-10-CM for diagnosis and ICD-10-PCS for procedures. Looking at stream lining first impressions. Data Summary: 2/01/20 - 1/31/21

# of transports analyzed = 3,121 out of 2.500,000 calls. # of transports documenting Pulse Oximetry, Respiratory Status and Respiratory

Rate at least once = 3,098 (99.26%)

# of transports documenting Pulse Oximetry, Respiratory Rate and Respiratory Effort = 3,051 (97.76%)

# Documenting Pulse Oximetry = 3,059 (98.01%) # Documenting Respiratory Rate = 3,088 (98.94% # Documenting Respiratory Effort = 3,092 (99.07%)

Comparison to 12/01/19 - 11/30/20

# Transports Analyzed = 3,396 # of Transports Documenting Pulse Oximetry, Respiratory Status and

Respiratory Rate at least once = 3,373 (99.32) # of transports documenting Pulse Oximetry, Respiratory Rate and Respiratory

Effort = 3,323 (97.855) Documenting Pulse Oximetry = 3,333 (98.14%) Documenting Respiratory Rate = 3,361 (98.97%) Document Respiratory Effort = 3,365 (99.09%)

Michael Redlener, MD posted a link to national EMS Quality Alliance (NEMSQA) Pediatrics Measure Package at: https://www.nemsqa.org/wp-content/uploads/2020/11/F.-NEMSQA-Pediatrics-01.pdf It was noted that this measures SPO2 and respiratory rate buy not respiratory effort. A question about any relationship between NEMSIS codes and IDC-10 codes could not be answered during the meeting. Jason Haag advised he would be able to send a list of IDC-10 codes that are applicable for ambulance transport reimbursement. The focus for the Committee going forward is to look for improvements to make the metrics more comprehensive and provide feedback. Report to SEMSCO will cover where the project is at currently. Ryan Greenberg commented that this is a big project for him and we need to be moving forward. 60% of agencies do not benchmark anything, do not look at anything. They say they do quality assurance but that may mean getting the signature of a nurse when they got to the ER. A full set of vitals is great but if it wasn’t measured where the vitals are it does not mean anything. National quality measures were looked at. Benchmarking does not mean setting a standard. He does not care that a ROSC rate is 3% as long as agency is trying to get to 5% or figuring out how to go from 20% to 22%. Don’t compare yourself in rural areas to urban areas with more resources. Use peer pressure. Agencies may not be superstars in every category. Vital Signs Academy can be used to help in education. There is a new analytic program to take all state data. It may take up to 6 months to roll out. Every agency is to get a log-in to see own its data vs similar located agencies and also statewide. This is a brand new committee and there are opportunities for seated SEMSCO members as well as non-members to be a part of the committee. Quality Assurance documents were put on Boardable that the older QA Committee had worked on. David Violante indicated people have different ideas on what quality is. How do we bring the QA Manual up to date? A dashboard was suggested to measure data and see changes over time.

Michael Redlener, MD talked about a quality improvement model to foster real improvement in the system. Need to hone in on the right measures. He advised that NEMSQA will be looking at reduction of use of lights and sirens as an important safety issue and would be happy to discuss it more at the next meeting. Mark Philippy commented comparing similar things. Trauma metrics may talk about getting patient off the scene within 10 minutes but response times vary and may be 20 to 30 minutes. Transport to a Regional Trauma Center maybe a problem if it is an hour away. Where did the NFPA get its response time goal? Need to come up with things people will buy into because its patient centered and evidence based. He spoke of establishing in each agency a Clinical Care Coordinator similar to the EMSC’s Pediatric Emergency Care Coordinator and position would be great for a junior officer. Maryanne Portoro commented we have to EMS learn the fact that evidenced based date will help to improve practice and get things. We need to educate them on this and how they can benefit from all this. Robert Stoessel spoke of a robust QA plan in his region that is great at the global level but not so at the agency level. He will share a plan with yes/no choices that makes it easier for agency to work with the Committee. Ryan Greenberg spoke of inspections similar to trauma inspections and asking Show me you have a process to improve, Show me who your Clinical Coordinator is, What is the way you share information with your members and provide feedback? Some solely EMS agencies are just about the number of transports they do while some small agencies are really dedicated to EMS and quality of care. This in one of the ways to streamline everyone to a common goal that is focused on the patient getting better care and the provider getting positive feedback and not a negative thing. Future actions for Committee:

Look at Quality Metrics. Look at the QA Manual. Look at the NEMSQA information.

EMS Memorial DedicationEmpire State PlazaSeptember 30, 2021 · 11 a.m.

For further information, including group attendance or emergency vehicle registration, please contact Valerie Ozga at (518) 265-6092.

Please join us forremembrance of our fallen

Emergency MedicalServices Providers

Idris Bey FDNY

April 21, 2020

Joseph Braganza NYU Langone Hospital

February 26, 2020

Paul Cary Ambulnz

April 30, 2020

Jonathan Damon Tupper Lake

Volunteer AmbulanceApril 23, 2020

Thomas DeFrancisci Bellmore-Merrick EMS

April 12, 2019

Michael Field Valley Stream FD

April 8, 2020

Evelyn Ford FDNY

December 22, 2020

Donnell Ben-Levy FordBrookdale Hospital

November 20, 2020

Gregory HodgeFDNY

April 12, 2020

Irving IsenbergTwin Cities Ambulance

November 1, 2019

Salvatore MancusoBlooming Grove Vol. Amb. Corp.April 30, 2020

Michael Rutnik Delmar Volunteer

AmbulanceOctober 2, 2020

Rene SanchezFDNY

September 16, 2020

Ingrid SowlePort Washington FDFebruary 19, 1990

Anthony ThomasNYU Langone Hospital

April 12, 2020

Charles Victor WorkWallkill Volunteer

AmbulanceMarch 8, 2018

Yitzchok ZylbermincChevra HatzalahMarch 25, 2020