John Tobin - EMS in Arizona
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The document provides information about EMS services in Mesa, Arizona. Mesa Fire/Medical Department is a full service fire-based EMS agency that serves over 450,000 residents across 132 square miles. It has 20 fire stations, over 40 response units, and employs 171 EMTs and 210 paramedics. The department responds to over 50,000 medical calls per year. Paramedics receive extensive training and have many advanced medical skills. The department focuses on continuous education and uses programs like community paramedicine and CPAP/bi-level ventilation to improve patient outcomes.
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John Tobin - EMS in Arizona
- 1. EMS in Arizona, USA
- 2. Boo!
- 8. Mesa Fire/Medical Department • Full Service Fire Based EMS Agency • 20 Fire Stations • 40+ Responding Units • Special Teams – Maz Mat/TRT/Bike • Fire and Life Safety Education • Fire Prevention • 450,000 Residents/132 square miles • Third-Largest City in Arizona • 38th-Largest City in the United States • 171 EMT’s • 210 Paramedics
- 9. Fire Service in AZ • Fire Departments in AZ: 249 – Private: 30 Fire Stations • Career/Mostly Career: 40.7% • Volunteer/Mostly Volunteer: 59.3% • Nationally: 71% is volunteer • Private Ambulance Companies: 80 Source: www.USFA.gov
- 26. MFMD EMS Calls 2013 • 51,013 medical patients • 46,894 incidents • 4,251 EMS patients/month avg. • 28,647 transported patients • 526 dead prior to arrival • 92 dead after arrival
- 27. EMS Call Breakdown 7782 3266 2467 2098 2054 1744 1655 1345 424 2013 EMS Calls Trauma ALOC Dyspnea Chest Pain Weakness Abdominal Pain Dizziness Seizure Cardiac Arrest
- 28. Hospitals 4 Hospitals in Mesa • 3 of which: – Cardiac Receiving Centers – Stroke Centers • 1 Children’s Hospital • We transport to 16 area hospitals Metro-Phoenix Area • 6 Trauma Centers • 2 Pediatric Trauma Centers • 3 Children’s Hospitals • 2 Burn Centers
- 29. Emergency Medical Technician (EMT) • Initial Training –Minimum of 130 hours • Recertification – 2 years –240 hours working as an EMT –24 hours of continuing medical education • Adult, pediatric, & infant CPR for EMT’s • Includes 5 hours of pediatric emergency care
- 30. Paramedic • Initial Training –Minimum of 1000 hours • 500 hours of didactic and practical skills • 500 hours of clinical and field training • State Recertification – 2 years –Minimum of 48 hours • Adult, pediatric, & infant CPR for EMT’s • Includes 5 hours of pediatric emergency care • ACLS
- 31. Medical Skills • MICR • Rapid Sequence Induction • Intubation • King Airway • Cricothyrotomy • Needle Thorocostomy • IV Access • IO Access (EZIO) • Blood Glucose • CPAP • BiPAP • Mechanical Ventilation • Defibrillation • Cardioversion • ETCO2 • 12 Lead EKG • STEMI Activation • Toxicology Medications • Medication Administration
- 32. Continuous Education (CE) • Crew Based Training • EMS Training – On duty training – 18 day training cycle – 4 crews per session – State mandated training – Other training based on QA findings
- 33. Crew Based Training Schedule
- 34. Shift Schedules in AZ • Most are 24 hour shifts –24 on/48 off (1/2 schedule) –48 on/96 off (48/96 schedule) –24 on/24 off/24 on/24 off/24 on/96 off (3/4’s schedule) • A, B, C - shifts
- 35. Medical Direction • All levels of EMT’s must operate under the license of a physician –Direct –Offline • 33 adult algorithms • 19 pediatric algorithms • 103 pages including references
- 36. Standard Medical Response 4 Person ALS Company 2 Person ALS Transport (Private)
- 37. Community Paramedicine TRV Program Mid – Level Provider Behavioral Provider
- 39. CPAP/Bi-Level Ventilation • Trend is to prevent as many patients from getting intubated as possible. • Intubation is necessary, but if we do – Tendency to hyperventilate – Increased morbidity and mortality – Increased cost
- 40. CPAP • MFMD fielded CPAP in August 2012 • Training began with the trainers in January 2012 – Trainers received 24 hours of training – Trainers delivered 250 hours of training • Refresher training – “House Call” training – On duty EMS training sessions
- 42. Studies That Show CPAP Benefit • Keenan et al – Crit Care Med, 2000 • Rocker et al – Chest, 1999 • Wigder et al – Am J Emer Med, 2001 • Brochard et al – NEJM, 1995 • Meduri et al – Clin Chest Med, 1996 • Hubble et al – Prehosp Emer Care, 2008 • CPAP the push for rapid relief., 2011., JEMS Suppliment., Elsevier
- 43. Bi-Level NPPV (Noninvasive Positive Pressure Ventilation) • MFMD fielded in March 2014 • Data forthcoming • Looks very promising! • Training over 1 hour per crew
- 44. Bi-Level NPPV Indications • Exacerbation of COPD • Pulmonary Edema • Pneumonia • Acute Asthma • ARDS mild to moderate • Obesity hypoventilation syndrome • Respiratory Distress/failure with hypercarbia and hypoxia Initial Settings • EPAP – 6 cmH2O • IPAP – 16 cmH2O • I-Time – 0.7 to 1.0 • FiO2 – 50%
- 45. R/T SOB. U/A PT IN TRIPOD POSITION, AWAKE AND ALERT, SPEAKING 2-4 WORD SENTENCES. PT STS BEEN HAVING SOB SINCE SUNDAY, PROGRESSIVELY WORSENING. PT HAS AUDIBLY WET LUNGS, 2-3+ EDEMA IN LOWER EXTREMITIES. PT HAS OXYGEN SATURATIONS OF 70% ON ROOM AIR. PT INITIALLY GIVEN OXYGEN VIA NRB AT 15 LPM UNTIL BIPAP VENTILATOR COULD BE SET UP. OXYGEN SATS WITH NRB IN HIGH 80'S. ONCE MOVED OUT OF CRAMPED BACK BEDROOM, PT PLACED ON GURNEY AND BIPAP VENTILATOR. PT HAS SIGNIFICANT RELIEF ON BIPAP, OXYGEN SATS NOW 100% WITH FIO2 SET AT 100. EKG SHOWS AFIB, NO ST CHANGES ON 12 LEAD. IV STARTED, 20 GAUGE JUST ABOVE THE AC. PT TO BE TRANSPORTED VIA SW 206 WITH MFMD RIDE IN TO BANNER BAYWWOD ER. CN MADE BY MFMD, ANSWERED BY RN LISA, PT CONDITION CONTINUES TO MAINTAIN UPON TRANSFER OF CARE TO HOSPITAL STAFF. Patient Improvement with NPPV
- 46. Toxicological Emergencies Toxicological Emergency • Carbon Monoxide • Cyanide Poisoning • Eye Decontamination • Methemoglobinemia • Organophosphate/N- Methylcabamate/ Nerve Agent Exposure • Sulfide Poisoning Toxicology Medications • CyanoKit • Morgan Lenses/Proparicaine • Methylene Blue • Atropine/2-Pam Chloride • Amyl Nitrite/Sodium Nitrite
- 47. The EPIC Project Prehospital Management of Traumatic Brain Injury In Arizona EPIC Refresher v1.0 4/17/2013
- 48. • Trauma patients from any cause • AND any of the following: –Any loss of consciousness –GCS of 14 or less –Multisystem trauma requiring intubation –Any post-traumatic seizures
- 49. Key Points • Keep SPO2 > 90% • A single episode of hypoxia doubles mortality • Use any airway that maintains SPO2 >90% and ETCO2 at 35-45 • If you choose to intubate – you take the responsibility to meticulously manage ventilation Treatment • Apply O2 before extrication • Preoxygenate with high flow O2 • Even if SPO2 is > 90% • When you think C-Spine – think high flow O2 • If you don’t meticulously manage ventilations – your ALS airway is actually WORSE than a BLS airway
- 50. Key Points • Keep SBP > 90mmHg • A single episode of hypotension at least doubles mortality • Use extreme caution when using pain meds/sedatives • They can rapidly drop blood pressure • Once we give them – we can’t take them back! Aggressively Treat & Prevent Initial 1000mL Bolus Repeat 500mL Bolus’ Repeat to keep SBP > 90mmHg
- 51. Key Points • If we aren’t paying constant attention to ventilation, we will harm our patients • A single instance of hyperventilation doubles mortality • Never hyperventilate! – no matter how bad you think the patient’s injury is Tools for Success • Meticulous Attention • Rate Timers • Pressure Controlled BVM • ETCO2 – 35 to 45 • V-EMT-perfect ventilation • Ventilation Spotter • Ventilator
- 52. Questions?
- 53. Thank You!
- 54. Contact Information: John Tobin Alarm Room Captain Paramedic www.mesaaz.gov Mesa Fire/Medical Department John.Tobin@mesaaz.gov
Editor's Notes
- EPAP = Expiratory Positive Airway Pressure IPAP = Inspiratory Positive Airway Pressure
- 3rd bullet explanation: Multisystem trauma requiring intubation whether the need for intubation was from TBI or other potential injuries