JOURNAL OF EMERGENCY MEDICAL SERVICES
I Beyond the Tape I
Law enforcement officers make major impact
as initial care providers
y David Kleinman, NREMT-P, & Tammy Kastre, MD
May 2012 Vol. 37 No. 5
46 I Prepared for the Worst I
Tactical training offers many benefits to EMS
By William Justice, NREMT-P; Lt. Kerry Massie, NREMT-I; & Jeffrey M. Goodloe,
MD, NREMT-P, FACEP
52 I Partners in Crime I
EMS provides a training program for local law enforcement
By Capt. Mario Ramirez, MD, MPP; Andrew N. Pfeffer, MD; Greg Lee; & Corey M.
Slovis, MD, FACEP
56 I hat’s buggin’ ems I
Departments & columns
9 I Load & go I Now on JEMS.com
14 I EMS in Action I Scene of the Month
16 I From the Editor I On the Front Lines
By A.J. Heightman, MPA, EMT-P
18 I Letters I In Your Words
20 I Priority Traffic I News You Can Use
24 I LEADERSHIP SECTOR I Crisis Management
y Gary Ludwig, MS, EMT-P
27 I Management Focus I Extra Set of Hands
y Richard Huff, NREMT-B
30 I Tricks OF the TRADE I Numbers
y Thom Dick
32 I case of the month I Miracle in the Desert
y Jeff Westin, MD; Pat Songer, NREMT-P, ASM; Kelly Buchanan,
MD; Loren Gorosh, MD; Ryan Hodnick, DO; & Bryan E. Bledsoe,
DO, FACEP, FAAEM
36 I Research review I What Current Studies Mean to EMS
y David Page, MS, NREMT-P
How to rid your rigs of a bedbug infestation
By Wayne M. Zygowicz, BA, EFO, EMT-P
62 I Breaking Barriers I
Practice cultural sensitivity to provide care to immigrant
By Keith Widmeier, NREMT-P, CCEMT-P, EMS-I, BA; & Emily Coffey, BA,
68 I ultiple Airways I
Rapid assessment is key for managing numerous patients
By Paul E. Phrampus, MD
74 I Ad Index
75 I employment & Classified Ads
78 I The Lighter Side I Zombie EMS
y Steve Berry
82 I LAST WORD I The Ups & Downs of EMS
About(Ariz.) Sheriff’s Department deputy demonstrates the value of early law enforcement officer delivery of EMS treatment, particularly at an active-shooter incident or
A Pima County
situations where it’s unsafe for EMS to enter. Find out how training and equipping first-arriving police officers, sheriff’s deputies and highway patrol officers can help save patients (and other
officers) in “On the Front Lines,” p 16; “Beyond the Tape,” pp 38–45; “Prepared for the Worst,” pp. 46–51; and “Partners in Crime,” pp. 52–55. Photo Matthew Strauss
Premier Media Partner of the IAFC, the IAFC EMS Section & Fire-Rescue Med
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The EMS 10: Innovators in EMS award winners pose at the dinner where they were honored for their achievements. Pictured from top left are Tom Bouthillet, Michael Millin, Seth Hawkins, Will Smith, Pat Songer,
Rob Lawrence, Stephanie Haley-Andrews and David Reinis. Not pictured are Mary Meyers, Paul Paris,
E. Reed Smith and Todd Stout. In case you’ve missed the past winners of this annual award, make sure
to check them out at jems.com/ems10
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MAY 2012 JEMS
JOURNAL OF EMERGENCY MEDICAL SERVICES
JOURNAL OF EMERGENCY MEDICAL SERVICES
Editor-In-Chief I A.J. Heightman, MPA, EMT-P I email@example.com
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Medical Editor I Edward T. Dickinson, MD, NREMT-P, FACEP
Travis Kusman, MPH, NREMT-P; Fred W. Wurster III, NREMT-P, AAS
Contributing Editors I Bryan Bledsoe, DO, FACEP, FAAEM; Ann-Marie Lindstrom
Editorial Department I 800/266-5367 I email@example.com
art director I Liliana Estep I firstname.lastname@example.org
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JOURNAL OF EMERGENCY MEDICAL SERVICES
JOURNAL OF EMERGENCY MEDICAL SERVICES
William K. Atkinson II, PHD, MPH, MPA, EMT-P
President & Chief Executive Officer
WakeMed Health & Hospitals
James J. Augustine, MD
Medical Advisor, Washington Township (OH) Fire Department
Director of Clinical Operations, EMP Management
Clinical Associate Professor, Department of
Emergency Medicine, Wright State University
steve berry, NRemt-p
Paramedic & EMS Cartoonist, Woodland Park, Colo.
Bryan E. Bledsoe, DO, FACEP, FAAEM
Professor of Emergency Medicine, Director, EMS Fellowship
University of Nevada School of Medicine
Medical Director, MedicWest Ambulance
Criss Brainard, EMT-P
Deputy Chief of Operations, San Diego Fire-Rescue
Chad Brocato, DHS, REMT-P
Assistant Chief of Operations, Deerfield Beach Fire-Rescue
Adjunct Professor of Anatomy & Physiology, Kaplan University
J. Robert (Rob) Brown Jr., EFO
Fire Chief, Stafford County, Va., Fire and Rescue Department
Executive Board, EMS Section,
International Association of Fire Chiefs
carol a. cunningham, md, FACEP, FAAEM
State Medical Director
Ohio Department of Public Safety, Division of EMS
Thom Dick, EMT-P
Quality Care Coordinator
Platte Valley Ambulance
Marc Eckstein, MD, MPH, FACEP
Director of Prehospital Care, Los Angeles County/
USC Medical Center
Medical Director, Los Angeles Fire Department
Professor, Emergency Medicine,
University of Southern California
Charlie Eisele, BS, NREMT-P
Flight Paramedic, State Trooper, EMS Instructor
Bruce Evans, MPA, EMT-P
Deputy Chief, Upper Pine River Bayfield Fire Protection,
Jay Fitch, PhD
President & Founding Partner, Fitch & Associates
Ray Fowler, MD, FACEP
Associate Professor, University of Texas Southwestern SOM
Chief of EMS, University of Texas Southwestern Medical Center
Chief of Medical Operations,
Dallas Metropolitan Area BioTel (EMS) System
Adam D. Fox, DPM, DO
Assistant Professor of Surgery,
Division of Trauma Surgery & Critical Care,
University of Medicine & Dentistry of New Jersey
Former Advanced EMT-3 (AEMT-3)
Gregory R. Frailey, DO, FACOEP, EMT-P
Medical Director, Prehospital Services, Susquehanna Health
Tactical Physician, Williamsport Bureau of
Police Special Response Team
Jeffrey M. Goodloe, MD, FACEP, NREMT-P
Associate Professor & EMS Division Director,
Emergency Medicine, University of Oklahoma School of
Medical Director, EMS System for Metropolitan
Oklahoma City & Tulsa
David E. Persse, MD, FACEP
Physician Director, City of Houston Emergency Medical Services
Public Health Authority, City of Houston Department. of Health
& Human Services
Associate Professor, Emergency Medicine, University of Texas
Health Science Center—Houston
President, RedFlash Group
Founding Editor, JEMS
John J. Peruggia Jr., BSHuS, EFO, EMT-P
Assistant Chief, Logistics, FDNY Operations
Dave Keseg, MD, FACEP
Medical Director, Columbus Fire Department
Clinical Instructor, Ohio State University
W. Ann Maggiore, JD, NREMT-P
Associate Attorney, Butt, Thornton & Baehr PC
Clinical Instructor, University of New Mexico,
School of Medicine
Connie J. Mattera, MS, RN, EMT-P
EMS Administrative Director & EMS System Coordinator,
Northwest (Illinois) Community Hospital
Robert J. McCaughan
Chief, City of Pittsburgh EMS
Chair, IAEMSC Metro Chief’s Section
Robin B. Mcfee, DO, MPH, FACPM, FAACT
Medical Director, Threat Science
Toxicologist & Professional Education Coordinator,
Long Island Regional Poison Information Center
Mark Meredith, MD
Assistant Professor, Emergency Medicine and Pediatrics,
Vanderbilt Medical Center
Assistant EMS Medical Director for Pediatric Care,
Nashville Fire Department
Geoffrey T. Miller, EMT-P
Director of Simulation Eastern Virginia Medical School,
Office of Professional Development
Brent Myers, MD, MPH, FACEP
Medical Director, Wake County EMS System
Emergency Physician, Wake Emergency Physicians PA
Medical Director, WakeMed Health & Hospitals Emergency
Mary M. Newman
President, Sudden Cardiac Arrest Foundation
Joseph P. Ornato, MD, FACP, FACC, FACEP
Professor & Chairman, Department of Emergency Medicine,
Virginia Commonwealth University Medical Center
Operational Medical Director, Richmond Ambulance Authority
Jerry Overton, MPA
Chair, International Academies of Emergency Dispatch
David Page, MS, NREMT-P
Paramedic Instructor, Inver Hills (Minn.) Community College
Paramedic, Allina Medical Transportation
Member of the Board of Advisors,
Prehospital Care Research Forum
Paul E. Pepe, MD, MPH, MACP, FACEP, FCCM
Professor, Surgery, University of Texas
Southwestern Medical Center
Head, Emergency Services, Parkland Health & Hospital System
Head, EMS Medical Direction Team,
Dallas Area Biotel (EMS) System
Edward M. Racht, MD
Chief Medical Officer, American Medical Response
Jeffrey P. Salomone, MD, FACS, NREMT-P
Associate Professor of Surgery,
Emory University School of Medicine
Deputy Chief of Surgery, Grady Memorial Hospital
Assistant Medical Director, Grady EMS
Kathleen S. Schrank, MD
Professor of Medicine and Chief,
Division of Emergency Medicine,
University of Miami School of Medicine
Medical Director, City of Miami Fire Rescue
Medical Director, Village of Key Biscayne Fire Rescue
John Sinclair, EMT-P
International Director, IAFC EMS Section
Fire Chief & Emergency Manager, Kittitas Valley Fire & Rescue
Corey M. Slovis, MD, FACP, FACEP, FAAEM
Professor & Chair, Emergency Medicine,
Vanderbilt University Medical Center
Professor, Medicine, Vanderbilt University Medical Center
Medical Director, Metro Nashville Fire Department
Medical Director, Nashville International Airport
Barry Smith, EMT-P
CQI Coordinator, Regional EMS Authority (REMSA), Reno, Nev.
Walt A. Stoy, PhD, EMT-P, CCEMTP
Professor & Director, Emergency Medicine,
University of Pittsburgh
Director, Office of Education,
Center for Emergency Medicine
Richard Vance, EMT-P
Captain, Carlsbad Fire Department
Jonathan D. Washko, BS-EMSA, NREMT-P, AEMD
Assistant Vice President, North Shore-LIJ Center for EMS
Co-Chairman, Professional Standards Committee,
American Ambulance Association
Ad-Hoc Finance Committee Member, NEMSAC
keith wesley, MD, facep
Medical Director, HealthEast Medical Transportation
Katherine H. West, BSN, MED, CIC
Infection Control Consultant,
Infection Control/Emerging Concepts Inc.
Stephen R. Wirth, Esq.
Attorney, Page, Wolfberg & Wirth LLC.
Legal Commissioner & Chair, Panel of Commissioners,
Commission on Accreditation of Ambulance Services (CAAS)
Douglas M. Wolfberg, Esq.
Attorney, Page, Wolfberg & Wirth LLC
Wayne M. Zygowicz, BA, EFO, EMT-P
EMS Division Chief, Littleton Fire Rescue
Choose 18 at www.jems.com/rs
EMS IN ACTION
Scene of the month
>> Photos Associated Press
roviders from Southwest Ambulance prepare to initiate
the transfer of U.S. Rep. Gabrielle Giffords (D-Ariz.) to
TIRR Memorial Hermann Rehabilitation Hospital in Houston on
Jan. 26, 2011. Providers use extreme caution to provide followup treatment for Giffords’ critical head injury after she was
shot at a Congress On Your Corner event at a Safeway shopping
center outside of Tucson, Ariz. This high-profile case serves as
a reminder to EMS providers that they’re never able to predict
what patients they may have the opportunity to treat or transfer. Thanks to the excellent care delivered to Giffords and the
team effort between law enforcement and EMS, Giffords was
transported in a safe and coordinated manner and has made
outstanding progress in her recovery.
from the editor
putting issUes into perspective
>> by A.J. HEIGHTMAN, MPA, EMT-P
On the Front Lines
Updating the training & care capabilities of law officers
Go to www.youtube.com/
The clip shows a firefight that occurred on
the streets of Miami on April 11, 1986, between
eight FBI agents and two known murderers/
bank robbers: Michael Platt and William Matix.
Before the fight was over, multiple FBI agents
were killed by .223 gunshots from a Ruger
mini-14 in the hands of Michael Platt.
The brave FBI agents who were engaged in
this street battle were not armed with weapons
or ammunition that could make the most pronounced impact on their targets. Platt himself
had sustained 12 gunshot wounds (9 mm, .38
and 00 shot) but continued to fight.
This firefight and the resulting aftermath
resulted in dramatic changes in the way we
equip law enforcement officers. It was the genesis of the 10 mm and .40 S&W rounds and use
of more advanced weaponry by law officers.
When I watched this powerful docudrama
in 1988, it dramatically affected me as an educator and EMS system planner. It also significantly changed the way I thought about
the EMS/law enforcement interface and the
need for better frontline care by (and for) police
officers and other members of the emergency
At this year’s National Association of
EMS Physician Conference in Tucson,
Ariz., in January, I heard a hidden message
during a keynote lecture by Brad Bradley,
EMT-P, of the Northwest Fire Rescue District,
and Joshua B. Gaither, MD, of the University
of Arizona Medical Center, on the mass shoot-
ing near Tucson involving Congresswoman
Gabrielle Giffords (D-Ariz.)
Gaither pointed out that the Pima County
Sheriff’s Department deputies who were in the
initial hot zone arresting the would-be assassin
and ensuring scene safety, used the recently
updated EMS training and small specialized law
enforcement Individual First Aid Kits (IFAKs) to
treat 14 of the 19 surviving victims.
In the early stages of this incident, the deputies retrieved their IFAKs, carried conveniently
behind the front headrest of their police cruisers, and used tourniquets and hemostatic clotting agents to control significant bleeding and
prevent the onset of shock. They also used
chest seals to seal open wounds and combat
It was a subtle statement that begged for
more explanation. So I contacted David
Kleinman, a detective with the Arizona
Department of Public Safety and a tactical
Photo Matthew Strauss
o truly understand the importance of
the content in the May 2012 issue of
JEMS, which focuses on updating the
training and equipment carried by law enforcement officers in your EMS system, I’d like you
to watch a gut-wrenching clip from the 1988
movie, In the Line of Duty. The clip is only eight
minutes long, but I think those eight minutes
will be some of the most stressful, and emotionally-charged of your career.
Contents of the Pima County Sheriff’s Dept IFAK.
paramedic with Pima Regional SWAT. I
learned that Kleinman had developed a specialized training program, called The First
Five Minutes, which was adopted by the Pima
County Sheriff’s Department.
That training, plus the up-to-date medical
supplies they carried in each patrol vehicle,
allowed the Pima County deputies to have a
major effect on the survival of many of the
victims at the Safeway shooting scene. The
content involved the most up-to-date treatment and supplies for hemorrhage control and
Military research on the care rendered to critically injured soldiers in Iraq and Afghanistan
has shown that if you combat and control
hemorrhage before the onset of shock, mortality
decreases significantly.1 So this training for law
enforcement officers was not just up-to-date,
but it was also timely.
I asked David to write an article for this
month’s JEMS that detailed the training and
how it was used effectively to keep many of
the critically injured victims alive on Jan. 8,
2011. We found that several other innovative
law enforcement initiatives were implemented
in 2011 to train and equip officers to save
themselves when injured, save their colleagues
and save citizens during natural or man-made
disasters and mass casualty incidents. It was
clear to us that this new wave of updated training was significant and worthy of our attention, and yours.
The strong message for fire and EMS agencies is that law officers are often on the front
lines long before fire and EMS units arrive.
Please follow this educational trend, work to
have updated training provided to the law officers in your service area, and “arm” each officer
with the essential equipment they need to save
their lives and others.
The contents I believe each patrol officer
should carry in a compact gear pouch include:
>> 4" compression dressing;
>> Hemostatic clotting agent dressing;
>> Tactical tourniquet;
>> Chest seal;
>> 3 x 3 x 2 (gauze sponges);
>> 4-1/2" Kerlix sterile roll bandages;
>> 1" Transpore surgical tape;
>> Trauma shears;
>> Ventilation mask;
>> Three pair of Nitrile gloves; and
>> SAM Splint
The cost per kit is less than $100—but it’s a
small investment to save an officer or civilian
when time is critical. JEMS
1. Kragh J, Littrell M, Jones J, et al. Battle casualty survival
with emergency tourniquet use to stop limb bleeding.
J Emerg Med. 2011;41(6):590–597.
Choose 19 at www.jems.com/rs
in your words
This month, Facebook users
chime in on “EMS Providers
Should Train like Fighters,” a
JEMS.com article by fitness columnist John Amtmann, EdD, on
why it’s important for EMS providers to train for the worst-case
scenario. Would you be prepared
to defend yourself? Also, users
share feedback on a March JEMS
article by Bryan Bledsoe, DO,
FACEP, FAAEM, on EMS in the Pennsylvania Amish community (“Simple Way
of Life: EMS in Amish country”).
I definitely think we should be prepared for any harmful
situation. I was involved in a situation that went bad
fast. I was assaulted by a patient who was on numerous
illegal drugs. Initially, he presented with hypoglycemic
symptoms, but after loading him into the unit, he began
to exhibit signs of paranoia and hallucinations. Luckily,
the police department was on scene, but unfortunately
he had a chance to grab me.
It took the fast thinking of the officer to physically
make him release his hold on me, and for my partner to
administer Versed, which did absolutely nothing, to get
me freed. It happened so fast, so I agree that it would
have been helpful if I’d known some self defense. That
way, I would have known how to break the death grip he
had on me when he wrapped his legs around me, without injuring him. He not only physically harmed me, but
he also made me lose the trust I had prior to that day.
my own training to ensure scene safety by doing what
the rest on scene couldn’t.
I wrapped the patient up in a Brazilian Ju Jitsu hold.
Once I had him fully restrained, the officers assisted in
putting restraints on the man while they systematically
strapped both me and the patient to the backboard.
After we were both strapped in and he was much better
restrained, they loosened one strap at a time, so I could
slip my limbs out and prepare the patient for transport.
If a patient’s aggression causes this kind of situation,
knowing how to defend yourself is literally a lifesaver.
with people from all over the country and from all
walks of life.
However, treating the Amish themselves can be a
real challenge. I ran on a call for a child with a traumatic injury after being kicked by a horse. My partner
and I wanted to fly the child to a nearby hospital, but
the family said ‘no helicopter; just take the patient
to the hospital and let God decide the outcome.’ As
a healthcare provider, sometimes they do tie your
hands as far as treatment and transport go.
I work in northeast Indiana, and we have a large Amish
population. We have a very good relationship with
them, perform occasional safety days for them and
have several medics who travel to Amish schools
with an ambulance to interact with the kids. We have
several EMTs and medics who grew up Amish, which
is helpful for speaking with the young kids who don’t
speak English. As mentioned, there are sometimes
differences in opinions, as far as flying patients (they
strongly prefer not to use the helicopter), and they
definitely don’t call unless things are very serious. The
one thing you can always count on, with the Amish,
though, is that they’re very grateful for our help and
are supportive of what we do. JEMS
As a former EMT with Lancaster EMS as well as Strasburg
EMS, I’ve worked with several of the Amish EMTs, and I
must say they’re very dedicated and caring for the entire
community—not just their own people. The area that
they cover is a large tourist area, and they work well
Do you have questions, comments or concerns
about recent JEMS or JEMS.com articles? We’d love
to hear from you. E-mail your letters to editor.jems@
elsevier.com or send to 525 B St. Suite 1800, San Diego,
CA 92101, Attn: Allison Moen.
While I was responding to a code orange (a suicidal
psych patient), who had just been struck by a vehicle in
an attempt to take his life after assaulting his mother in
her home, police and sheriff were on scene as my unit
arrived. I’ve done mixed martial arts for a few years, and
when three law enforcement officers and one of my
two partners couldn’t restrain the patient, I fell back on
Due to graphic content,
discretion is advised.
illustration steve berry
Like I was taught, I don’t plan to fight; I plan to end it.
And I’m not referring to irrational, overdose or dementia
patients. I’m referring to the rational patients who might
turn on us one day. Everyone is always happy to see EMS.
Cops are always immediately on hand and helpful, and
happy endings are guaranteed, right? The truth is, you
never know when something might happen. I believe in
doing no harm first and foremost. I also believe in coming home safe and in one piece after every shift.
Heather Gaff Mewis
Comprehensive, Credible, Educational...
Help You Save Lives.
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NEWS YOU CAN
EMS on the HILL
NAEMT hosts third-annual event
the line of duty; and
>> he legislation to establish new
EMS grant programs; enhance
research initiatives; and promote
high-quality, innovative and costeffective field EMS.
To assist active members in attending EMS on the Hill Day, NAEMT
awarded grants of up to $1,200 each to
four active members.
One of the grant recipients was Jason
Scheiderer, EMT-P, of Indianapolis,
Ind. He’s employed by Indianapolis
EMS and teaches paramedic courses at
Indiana University-Purdue University
Indianapolis. Scheiderer has advocated for local issues, walking the
fine line between concerned taxpayer
and public employee. NAEMT’s state
advocacy coordinator for Indiana,
Scheiderer appreciates NAEMT’s focus
on improving EMS on a grand scale. “Not
getting into local issues like fire department
vs. private EMS providers,” he says.
W. Mike McMichael III, EMT-B, and 2011
NAEMT grant recipient from Delaware,
returns to Washington for the 2012 event.
McMichael says, “I’m tickled to death to be
involved” in this endeavor that “will help
everyone in the country.” Although he
personally knows his representative and
Delaware’s two senators, he liked the opportunity to see them working.
On May 4, 2011, in Washington, D.C., 145
EMS professionals from 39 states and the
District of Columbia and Puerto Rico met
with more than 217 U.S. Senators, House
Representatives and their congressional staff
at the second annual EMS on the Hill Day.
The fourth EMS on the Hill Day is tentatively scheduled for the first week in March
2013. That would coincide with 2013 EMS
Today, so you could attend both on one
Mark your calendar and watch the NAEMT
site for more details in the months to come.
ook out, Washington, here
comes EMS. Paramedics and
EMTs from across the country went to the hill for the third
time to talk to members of Congress
about what’s important to the EMS
community and its patients.
There’s only so much that can
be done on the local and state levels. Federal funding and guidance
is needed in some areas. And that’s
why we saw the third EMS on the
Hill Day, hosted by the National
Association of Emergency Medical
Legislators have to hear from
their constituents if there’s any
chance of them understanding what’s going on outside of
Washington. EMS providers go to
talk to their representatives and senators about what they see as a non-partisan
issue: providing quality care to their patients.
NAEMT President Connie Meyer, EMTP, EMS captain for Johnson County MedAct in Olathe, Kan., was excited about
this year’s EMS on the Hill Day. She says
they expected 190–200 EMS personnel to
attend—up from 145 in 2011. Something
new this year was a partnership with the
American Ambulance Association (AAA).
AAA participation replaced their regular
EMS on the Hill Day attendees were invited
to participate in AAA’s Reimbursement Task
Force meeting on Tuesday afternoon, March
20, for discussions on reimbursement issues,
healthcare reform, Medicare ambulance relief
and other emergent topics.
Tuesday evening included a pre-visit briefing with the opportunity for attendees to
mingle and see old friends or network with
Wednesday morning, the visits to
Congressional offices began. Armed with
their talking points (more on that below),
EMS professionals met with their representa-
tives and senators or staffs. The meetings not
only gave EMS personnel the chance to speak
of legislature issues that touch them professionally and personally, but they also allowed
the legislators the opportunity to learn more
about EMS. During a previous visit, one staffer
asked, “So you’re not a fire man?”
And the knowledge exchange has already
led to an event that Meyer characterized as
“huge.” What she’s referring to is a request
from a federal legislator for NAEMT input
on a bill being written. An elected official in
Washington came to NAEMT for advice.
While visiting the Congressional offices,
attendees have talking points, supplied by
NAEMT. This year’s issues include the following talking points:
The Medicare Ambulance Access
Preservation Act of 2011 to provide for a
more permanent solution to below-cost
Medicare ambulance reimbursement;
>> he extension of death and other benT
efits under the Public Safety Officers’
Benefits (PSOB) program to non-profit,
nongovernmental paramedics and
EMTs who die or are severely injured in
For more of the latest EMS news, visit jems.com/news
Mardi Gras No
Party for EMS
New Orleans EMS responded to more
than 2,000 calls during a 10-day
period in February.
That’s 67 more than
all the strange
weather across the
country this winter, the increased call volume in New Orleans wasn’t
because of hurricanes or other natural disasters.
It was Mardi Gras—definitely a man-made, and perhaps unnatural, event. Weeks of reveling take their toll on the thousands of
residents and tourists who show up for the 60 Krewe parades and
Deputy Chief of EMS Ken Bouvier says, “Obviously, there’s a lot of
alcohol poisoning.” Perhaps, not unrelated, there are also falls from
ladders and balconies in the French Quarter.
Bouvier says their transportation fleet included 25 ambulances, six
Fast Cars, an ASAP mini-ambulance, two bicycles and an 18-stretcher
mobile ambulance bus.
The parade route is approximately 60 city blocks, according to
Bouvier. “We try not to cross parades, so we have staff on both sides
of the streets.”
The Red Cross saw about 1,000 patients in its four first aid tents.
The tents were staffed with six to eight volunteers ready to treat such
minor complaints as sprains, foreign objects in the eye or requests for
a Band-Aid. Red Cross first responders also wandered through the
crowds keeping an eye open for anyone in need of medical assistance.
Armed with radios, the first responders called EMS as needed.
Bouvier characterized this year’s Mardi Gras as “well attended”
without violence along the parade route—evidently that’s noteworthy when you talk about Mardi Gras.
Planning is paramount for a city-wide, three-week celebration.
Bouvier says they start planning for the next year about a week after
Mardi Gras ends. They look at the statistics and reports to see what
worked and what could be improved. For example, the city made
more use of the Red Cross this year, “because it works,” says Bouvier.
The mini ambulance and bike teams are new additions, too.
As Mardi Gras draws near, New Orleans EMS has to make sure it
has enough medications on hand, enough staff ready to work—forget about ever getting time off to enjoy the festivities with your family
or friends—and enough ambulances ready to roll.
Next year’s Mardi Gras will be an enhanced challenge, says
Bouvier. New Orleans hosts Super Bowl XLVII on February 3, 2013,
so the city has decided to split up the Mardi Gras events to bookend
the Super Bowl. That is, there will be a week of Mardi Gras celebration, a week devoted to Super Bowl activities and then another week
of Mardi Gras.
Bouvier says they will be ready. And they’ll all probably be ready
for a long vacation in March. —Ann-Marie Lindstrom
Choose 20 at www.jems.com/rs
>> continued from page 21
Debunking HIPAA Myths
he healthcare industry has come a long way since Health Insurance Portability and Accountability Act
(HIPAA) went into effect almost a decade ago. For the most part, EMS providers now have a much better understanding of how HIPAA applies to their day-to-day operations. Nevertheless, many “HIPAA myths”
still exist. Here are some of the top myths in the EMS industry today.
>> Myth: HIPAA prevents EMS agencies and facilities
from sharing patient information.
All healthcare providers should know that HIPAA permits them to freely
share patient information for treatment-related purposes. That means that
facilities can give EMS providers medical records about patients, and crews
can look at those records for treatment purposes. It doesn’t matter that
another provider created the medical record.
Ambulance services may also provide a copy of their trip reports to
facilities because such practice would also fall under the “treatment”
umbrella. Under HIPAA, “treatment” includes
the provision, coordination and management of
healthcare between providers.
Pro Bono is written by
attorneys Doug Wolfberg,
Ryan Stark and Steve
Wirth of Page, Wolfberg
& Wirth LLC, a national
EMS-industry law firm. Visit
the firm’s website at www.
pwwemslaw.com for more
EMS law information.
photo courtesy NEMSMBR
>> Myth: Law enforcement offi-
EMS providers travel across the country for
the National EMS Memorial Bike Ride.
The National EMS Memorial Bike Ride
(NEMSMBR) is gearing up for the 2012 Ride,
with routes beginning in Boston, Mass., or
Paintsville, Ky., on May 19—both finishing in
Alexandria, Va., on May 25.
During the ride, participants will travel
through the states of Massachusetts, Kentucky,
Rhode Island, Connecticut, New York, New
Jersey, Pennsylvania, Maryland and Virginia.
“To see these parts of the United States on
a bicycle is such a unique perspective,” says Tim
Perkins, NEMSMBR public information officer.
“It’s also great to interact with the providers and agencies along the route, not to
mention the reason for the ride: honoring over
30 individuals who have given the ultimate sacrifice providing EMS care,” says Perkins.
Additional rides are scheduled for
Colorado in June and Louisiana in September.
For more information
about the bike ride,
Many EMS providers believe that if a law
enforcement official asks for information about
a patient, they’re automatically entitled to it.
Although there are circumstances under which
ambulance services may release patient information to law enforcement, there’s no general provision in HIPAA that broadly permits providers to
release patient information to law enforcement.
To the contrary, providers can only give patient information to law enforcement officials under specific
If an ambulance service receives a request for healthcare information from law enforcement, the service
must check to see whether HIPAA contains a specific exception that permits the release of the information.
Some of the more common exceptions include reporting a crime in an emergency or disclosures that are
required by state law (e.g., gunshot wounds and dog bites). Check with your HIPAA privacy officer before you
release information to law enforcement. If you improperly disclose information, you risk violating HIPAA, and
that information might not be allowed to be introduced as evidence because it was improperly obtained.
>> Myth: It’s OK to post as long as the patient isn’t identified.
EMS providers have a legal and ethical duty to refrain from posting any “protected health information”
(PHI) on the Internet. Most of us know that PHI is anything that could directly identify a patient. However,
what many fail to consider is that some information might reasonably identify a patient, even though it
doesn’t mention a patient by name. The bottom line is that if someone reading the post might be able to
figure out who the patient is, the information might be PHI, and posting it could violate HIPAA.
For example, a post stating, “Was on a pretty crazy trauma on I-95 tonight … that guy had no shot,” might
convey enough information to enable friends or family members of the deceased patient to identify him
because they undoubtedly know about the incident.
Because others can determine the identity of the patient from the limited information provided, this
post improperly divulges PHI. Generally, no legitimate reasons justify posting any information about a
patient on the Internet. Moreover, it’s unethical—and unprofessional—to refer to a patient, in any manner,
on the Internet.
Check out all the upcoming free webcasts JEMS has to offer: www.jems.com/webcasts
cers are automatically entitled to patient information.
Choose 21 at www.jems.com/rs
presented by the iafc ems section
>> by gary ludwig, ms, emt-p
Rudy Giuliani advocates for managing things, not people
e’re familiar with the usual type
of leadership that a manager at
IBM, Bank of America or the corner grocery store shows when managing their
operation and people. Usually these managers mistakenly try to manage people when
they should be leading people. The important thing to remember is that we manage
things and we lead people. We manage budgets,
inventory and fleets.
It’s rare that the manager working at IBM,
Bank of America or the corner grocery store
need to lead people in a crisis. That isn’t true
for the EMS manager. Not only do they have
to lead people under normal everyday conditions, but they also may be asked to show
their leadership during high-intensity events,
such as tornadoes or mass-casualty incidents.
EMS managers may be thrust into a leadership role during an active shooter attack.
The leadership skills that an EMS manager
must exhibit during a crisis are much different from the leadership skills that they use
in their day-to-day operations. In their dayto-day office operations, they have the ability to sit back and use discretionary time to
make a decision. If someone comes into their
office with a problem, the EMS manager has
the luxury of requesting more information,
maybe making some phone calls, sitting on
it overnight or even checking with their boss
before they make a decision.
Unfortunately, that isn’t the case on the
scene of an active shooter or a bus crash.
Sometimes split-second decisions must to be
made. Sometimes decisions have to be made
with limited information. And sometimes
the EMS manager may have to make some
tough decisions that have a direct affect on
someone’s life. The leadership skills that an
EMS manager must show during these critical times are crucial.
In my opinion, one of the finest examples
of leadership was former New York City
Mayor Rudolph Giuliani’s management of
‘It is in times of
crisis that good
9/11. Don’t forget, the U.S. president was
sheltered away until late in the evening to
protect the head of our federal government.
President Bush wasn’t seen on television; it
was Giuliani who became the face of reassurance on television for the American people.
But 9/11 wasn’t the only time Giuliani was
thrust into a crisis. He routinely showed up
at emergency scenes in New York City.
Giuliani describes four steps for crisis leadership in his book Leadership. “It is in times of
crisis that good leaders emerge,” he says.
He says the first step is to be visible. Giuliani
says, “While mayor, I made it my policy to see
with my own eyes the scene of every crisis so
I could evaluate it firsthand.”1
Who can forget those scenes of Mayor
Giuliani walking on the streets of New York
with his contingent of staff and department
heads while being interviewed by the news
media? EMS managers must respond to
scenes and take charge of their operation.
Many times, they fall into the incident management structure. Although they may not
have overall command of an event,
EMS managers are still responsible for
the medical operations branch.
Giuliani’s second step is to be composed. He writes in his book, “Leaders
have to control their emotions under
pressure. Much of your ability to get people to
do what they have to do is going to depend on
what they perceive when they look at you and
listen to you. They need to see someone who
is stronger than they are, but human, too.”
Many times in my career I’ve seen an incident commander yell or even scream into a
radio. Yelling on the radio or at employees
on a scene, or giving an appearance of being
out of control, is a prescription for crisis—the
situation EMS managers are trying to control.
Giuliani’s third step is to be vocal. He
writes, “I had to communicate with the public
to do whatever I could to calm people down
and contribute to an orderly and safe evacuation [of lower Manhattan].”
EMS managers must demonstrate the
same trait during a high-intensity event.
You need to be able to give people firm
directions and instructions. You need to
give your employees or others clear and
concise instructions or action steps.
Giuliani’s fourth step to crisis leadership
is to be resilient. Giuliani describes himself
as an optimist. With his words during some
of his press conferences about 9/11, he gave
Americans hope that they would meet this
challenge and overcome it.
EMS managers must also show the same
resiliency. They demonstrate through actions
and words that whatever the challenge that
the EMS organization and its employees are
facing, they’ll be able to deal with it.
And, most importantly, always remember
there are times to demonstrate everyday leadership and times during emergencies that you
have to demonstrate true leadership skills. JEMS
1. Giuliani R: Leadership. Hyperion: New York, 2002.
Gary Ludwig, MS, EMT-P, is a deputy fire chief
with the Memphis (Tenn.) Fire Department.
He has 34 years of fire and rescue experience. He’s chair of the EMS Section for the
International Association of Fire Chiefs and
can be reached at www.garyludwig.com.
Choose 22 at www.jems.com/rs
The medical director units that arrive
on-scene with a physician are especially
beneficial during mass casualty incidents.
Emergency physicians assist their prehospital counterparts
>> By Richard Huff, NREMT-B
f a call for a mass casualty incident (MCI)
goes out in northern New Jersey, there’s
a good chance James Pruden, MD, the medical director for emergency preparedness
at St. Joseph’s Regional Medical Center, is
going for a ride.
Pruden is part of a breed of physicians
who are just as comfortable working outside
of the confines of an emergency department
(ED) as they are in the field—where they can
be more helpful controlling a scene.
“There’s a subset of physicians, wild and
crazy guys, who get that surge and pleasure
being out there in the environment,” says
Pruden, who heads up St. Joseph’s Emergency Physician Response Vehicle program, MD-2.
The St. Joseph’s program, which is part
of the New Jersey EMS Task Force system, is
used to respond to everything from school
bus rollovers, to fires and planned events
throughout the region.
The parameters for the units being dispatched are wide open, but the common
thread is that the doctors responding are different from their hospital-bound brethren.
“It’s not just about having an emergency physician,” says Scott Matin, vice
president of Mobile Health Services at the
Monmouth Ocean Hospital Services Corporation (MONOC), which also launched
mobile physician unit MD-1 in January.
MONOC’s MD-1 unit is headed by Mark
Merlin, MD, a new member of MONOC’s
Medical Advisory Board, chair of the EMS/
Disaster Medicine Fellowship at Newark
Beth Israel Medical Center and medical
director of the New Jersey EMS Task Force.
MD-1 is stationed with Merlin or a member
of his team.
“It’s about having someone with emergency experience. It is different doing
something in the emergency room than it
is having to do it in the field. You’re not on
a table, but in the back of [a] crashed upside
down vehicle,” says Matin.
And that’s where the mobile physicians’
units come into play, especially at times
when there may be an MCI or some other
incident in which the scene could use a
physician on hand.
In some ways, the MD units are a
“force multiplier,” says Robert J. Bertollo,
MICP, LRCP, MBA, the program manager of Life Support Education and Emergency Response Operations for St. Joseph’s
Regional Medical Center.
St. Joseph’s Regional Medical Center has
operated an MD unit for two years that was
funded through the Urban Areas Security
Initiative. Pruden recalls a scenario a few
years ago—before MD-2 existed—during
which employees at a local factory were
overcome by a chemical odor that traveled through the building. There were hundreds of potential patients involved, and 50
Extra Set of Hands
>> continued from page 27
ended up being transported to local EDs.
“What you can do is send the physician to the site, where you then
have the ability to express people on the scene,” Pruden says.
Triage and treatment protocols could have been decided on the
scene of the factory incident, he says, altering the volume of patients
sent to local hospitals.
MD Units Use
There has been an increase in the use of MD units in the field around
the country in recent years. For example, besides the units in New
Jersey and Erie County, New York, has a Specialized Medical Assistance Response Team, which is a volunteer public health emergency
response organization that makes physician response available
around the clock.
For the most part, the MD units are similar. They’re staffed by
physicians like Pruden, who enjoy the challenge of working at an
emergency scene. Typically, the medical teams operate out of nontransport-type sports utility vehicles that mimic paramedic vehicles—although without the required depth of supplies. Some units
include equipment for on-scene surgical procedures.
The initial concept for MD vehicles in EMS responses was for the
more serious patient scenarios in which extrication may severely
cut into the golden hour and reduce survivability. It’s safe to say,
In some ways, the MD units are a
however, the parameters for use are evolving. Although relatively
new in New Jersey, the greatest use so far has been for MCIs and
pre-planned events, such as major festival concerts for which a high
range of injury is likely.
“Its real worth is when there’s a physician on scene and in a medical control capability,” says Bertollo. In those cases, the specially
trained doctors can increase the volume of patients handled on
scene by taking medical control.
“When it gets to the point where you need that, a doctor can make
multiple decisions,” Bertollo says.
“If you are at the scene, you can identify and quickly establish
symptom protocols,” Pruden adds.
The Monmouth Ocean Hospital Service Corporation unit
wouldn’t respond to the typical EMS call, but rather come into play
for cases in which someone is trapped for an extended amount of
time, or when there might be a need for an emergency amputation
to free the patient.
“These are going to be ones where a half-hour response time still
means you’re going to make it to the scene,” Matin says.
At St. Joseph’s, the response parameters for the MD unit have been
pretty broad, Bertollo says, and often left to an on-scene agency to
request the team. When the program was launched, he explains, the
folks at St. Joseph’s visited regional EMS providers to familiarize
them with the operation.
Choose 23 at www.jems.com/rs
“You need a physician because you’ve transcended the ability of
the EMTs or paramedics on scene,” he says. “We’ve had multiple
patients at fire scenes, industrial accidents ... and we’ve certainly dispatched during floods,” he adds. “Also, if there are specialty things,
like a shooting or multiple-patient pediatric calls.”
There will be more use of the unit in mass casualty situations
than a physician strapping on a surgical kit to do an on-scene amputation or blood transfusion, says Bertollo. The dispatch operation
serving St. Joseph’s has put a system into place: When something
on scene seems unusual, a call goes out to the five physicians on the
“Basically, what we’ve said is if you get into a circumstance where
you find something unique or strange looking and the medics say,
‘we wish we had a doc out here,’ give us a call,” Pruden says.
Doing so, of course, gives the physicians in the program real-time
exposure with the frontline emergency responders they normally
wouldn’t see with any regularity, making everyone more comfortable in future scenarios. Likewise, it also gives the physicians experience in situations that are dissimilar from routine ED settings.
And it also expands the program beyond simply preparing EMS
providers to respond to “the big one,” adds Pruden.
There are benefits to the mobile physician teams beyond
responses, too. The folks at MONOC expect to use Merlin and his
team in educational situations and drills.
“What’s nice about this program is, we hope in the end there is not
a lot a huge need for it,” Matin says. “There are added benefits being
involved with this program. We do a tremendous amount of education. Having that number of physicians at hand is a fantastic thing.”
Having a higher medical authority on the scene of an EMS call
does raise the potential for conflicts between providers. Matin says
he understands there could be concerns about how EMS providers react in the field to the arrival of a physician on the scene, but it
shouldn’t be a problem in this case.
“These doctors are going to be coming out on special scenes,” he
says. “I can tell you the medics will be glad they’re there.”
Bertollo agrees, “They’ve integrated well. The physicians that have
staffed those responses have known from the outset they’ve wanted
to be an integrated player. We’re here to augment and lend support.”
Pruden goes a step further, noting the goals of the MD-2 unit are
similar to why he loves disaster responses.
“It’s the unity of purpose,” he says. “In an event, when you’re
responding to some critical event, you and other human beings have
the same goal, to help people, to get a response, to turn this thing
into the most positive outcome you can make. Frequently, those
events suppressed ulterior motives. It’s amazing to work in an environment where everybody has the same goal. It’s an incredible rush
to be engaged with that kind of mindset where people are working
Richard Huff, NREMT-B, is an active member and the former chief of the Atlantic
Highlands (N.J.) First Aid & Safety Squad. He’s a CPR, CEVO and first aid instructor and
multi-dimensional EMS educator. He’s also an award-winning journalist and author.
Choose 24 at www.jems.com/rs
TRICKSour patients & ourselves
OF THE TRADE
>> by Thom Dick, EMT-P
Reflections on the value of one
don’t think you can quantify everything
that’s important in life. But in all of the
science on which emergency medicine
has come to depend, we never seem to give
Think for a moment. We use a numeric
score to rate people’s pain. (I don’t think it
tells us a dang thing.) We use endless scales
to measure the concentration of ions in their
body fluids, the physical pressure of the
blood in their vascular systems, the color
of their urine, and their heart and respiratory rates. We use scales to assess the sizes
of their pupils and describe the shapes of
their upper airways. We use a trauma score
to predict their survival after they get hurt,
and another scale to describe the severity
of their burns. We imprint depth scales on
the tubes we insert in their orifices. We even
use numeric gradients during our runs to
express the urgency of our responses to
We frame our lives in the same way, LifeSaver. A while back, my hometown’s pro
football team (the Broncos) braced itself to
take on the New England Patriots in a divisional championship game. The Broncos
were no better than mediocre this year, but
they had supposedly earned a shot at the
Pats by beating the Steelers a week earlier, in
the first few seconds of overtime. The media
and the Bronco fans celebrated the win;
although, few would have blamed the Steeler
fans for believing they were robbed. The final
score was 29–23.
In reality, there was only the barest
margin of difference between the play of
those two teams, and an objective observer
would probably have awarded the win to
Pittsburgh. In addition, the NFL’s history
won’t reflect the fact that Pittsburgh’s great
quarterback, Ben Roethlisberger, played the
whole game on a painful, unstable ankle.
We seem obsessed with the numbers in
our lives. We’ve developed maps to tell us
the depths of the ocean, as well as its salinity, its temperature and how much water it
Our patients are much more than the numbers of their blood pressure reading or their pH level;
contains. We assess the effects of the wastes
we pour into it by guessing how many living
organisms disappear afterward. (No doubt
some of us believe there are acceptable numbers of those, too, even if we can’t possibly
count them all.)
We’ve developed systems to help us enumerate the stars, assess their color, brightness, size and mass, and measure how far
they are from us (almost as though we still
believe they revolve around us). We think
we know the volume of the vast space they
inhabit (even if it’s so great, we can’t comprehend it). We’ve envisioned ourselves at the
tippy-top of the hierarchy of all life, based
on the complexity of our cognitive thought
processes. Scholars have attempted since the
fifth century to describe the value of nothing.
(What a surprise: We’ve assigned a number
to that, too.)
We even rate human intelligence using
a numerical value. We call it IQ, for intelligence quotient. We discuss people in terms
of their IQs, as well as their age, height,
weight, body-mass index, annual income,
and belt and neck sizes (as though their
dimensions actually help us to understand
anything about them).
The business of helping people in
crisis is a lot bigger than the stuff
we can measure. Measurements are
simple routines, each of which typically reveals no more than a single
answer to a simple question. What’s
the blood pressure? What’s the blood glu-
cose? What’s the pH?
It’s important to respect what those
numbers tell us, but only as puzzle pieces.
Whatever we do, we need to be much more
focused instead on a prime number we
Serving people is all about individuals.
Taking care of them requires a willingness
to admit that we don’t know much about
them. But we have a persistent commitment
to observe, question, examine and think. In
emergency situations, we sometimes need
to do all of those things at warp speed. (If
anybody ever told you this EMS stuff would
be easy, they altered the truth.)
Next time you kneel in front of somebody
you don’t know or sit beside someone in that
ambulance of yours, look them straight in the
eye. No matter how ordinary they seem, how
ugly or even unpleasant, ask for their name.
And use it. And make sure there’s no doubt
in their mind about one thing: While they’re
with you, they’re important. What they say
matters. And how they feel is essential. Not
just any old person has the talent or the desire
to do that. Those who do are called caregivers.
Are you one of those? If so, you really are
Thom Dick has been involved in EMS for
42 years, 23 of them as a full-time EMT and
paramedic in San Diego County. He’s currently
the quality care coordinator for Platte Valley
Ambulance, a hospital-based 9-1-1 system in
Brighton, Colo. Contact him at firstname.lastname@example.org.
Choose 25 at www.jems.com/rs
Choose 26 at www.jems.com/rs
CASE OF THE MONTH
DILEMMAS IN DAY-TO-DAY CARE
>> BY Jeff Westin, MD; Pat Songer, NREMT-P, ASM; Kelly
Buchanan, MD; Loren Gorosh, MD; Ryan Hodnick, DO;
& Bryan E. Bledsoe, DO, FACEP, FAAEM
Miracle in the Desert
Cardiac case at remote Burning Man event presents challenges
On the final day of the Burning Man event,
EMS is summoned to a chest pain call
in a trailer within the encampment. On
arrival, paramedics find a 60-year-old male
in acute distress.
He’s pale and diaphoretic and in extremis.
The patient describes the pain as “tearing”
Photo courtesy Bryan Bledsoe
urning Man is a massive event held
around every Labor Day in the Black
Rock desert in northwestern Nevada.
The encampment is an official city called
Black Rock City, and although it exists for
only a week or so each year, it becomes
the third-largest city in Nevada. The event
attracts in excess of 50,000 attendees.
The purpose of Burning Man is radical
self-expression in various art forms. It’s
truly a one-of-a-kind event. Black Rock
City operates as a functional geopolitical
entity with fire, police and EMS systems.
Each is dispatched from a manned communications center that’s constructed and
In 2011, Humboldt General Hospital
EMS in Winnemucca was contracted to
provide medical care for Burning Man.
Medical care included a fully staffed and
operational EMS system, as well as a field
hospital called Rampart General and two
BLS aid centers.
A total of 2,307 patients were treated.
Three-hundred and eighty-two requests for
ambulances were made, with 185 patients
being transported to Rampart General.
Only 33 patients were transported out of
the desert for care. The following highlights one of those cases that took place
during the event.
Burning Man, an elaborate weeklong festival in the Nevada desert, presents unique challenges to
and can’t get into a comfortable position.
The EMS crew extricates him from his trailer
and moves him to the awaiting ambulance
for a more detailed assessment.
He becomes unresponsive shortly
after they place him in the ambulance.
Paramedics check his pulse, take a quick
look at the monitor, and note the patient
is in a non-perfusing v tach. On a hunch,
they administer a precordial thump, and
it works. The patient converts to a sinus
rhythm. He’s transported to Rampart
General in Black Rock City.
Once the patient arrives at the field hospital, the emergency staff rapidly assesses
him. He’s alert and oriented, but his blood
pressure is undetectable. He’s writhing in
pain on the stretcher. IV fluids are given,
and his blood pressure is finally detectable
at a systolic pressure of 72 mmHg and then
up to 76 mmHg. He remains mildly tachycardic. He receives IV fentanyl for pain.
Rampart General has X-ray capabilities and
a stat chest X-ray is obtained. The emergency physician notes that the mediastinum is wide at 10.5 cm—consistent with
a thoracic aortic aneurysm and dissection.
A medical helicopter is summoned and the
patient is closely monitored and stabilized
by the emergency staff.
As soon as the helicopter arrives,
the patient is moved to the aircraft and
transported to a major medical center
about 150 miles away. Once he arrives, he
undergoes a computed tomography angiogram (CTA) that confirms the suspected
The patient is emergently taken to surgery where the aneurysm is repaired. The
operation is successful, and the patient is
>> A case from university medical center in LAs VEGAS
moved to the intensive care unit (ICU).
Following surgery, the patient suffers a second cardiac arrest
and is taken to the cardiac catheterization lab for evaluation and
subsequent stenting of a coronary artery lesion. He’s returned to
the ICU and remains stable. He’s discharged home with appropriate provisions for follow-up. Despite his ordeal, he’s already planning his next trip to Burning Man.
First, this is not a true “case from University Medical Center”
because it didn’t happen at UMC. However, emergency physicians, emergency medicine residents and medical students from
the University of Nevada School of Medicine provided much of
the medical care at Burning Man. As you can tell, this patient had
all the cards stacked against him. He had a critical thoracic aortic
dissection, and he was in the middle of a Nevada desert more than
150 miles from a medical facility with cardiothoracic surgery capabilities. Furthermore, he suffered a cardiac arrest. Yet despite all of
this, he survived.
Thoracic aortic aneurysms and dissections are life-threatening
conditions that affect the thoracic portions of the aorta. An
aneurysm is a dilation of an artery greater than 50% of its normal diameter. They’re classified based on the region of the aorta
affected (e.g., ascending aortic, aortic arch, descending aortic and
thoracoabdominal), and are at risk for rupture.
A dissection results from a tear in the interior lining of the aorta
(the tunica intima). This tear, referred to as an intimal tear, causes the
layers of the aortic wall to separate thus forming a false lumen. The
pressure from the blood within the aorta causes the false lumen to
expand, or dissect.
As the dissection progresses, blood flow to various blood vessels is affected, causing ischemia to the tissues they supply (e.g.,
the coronary arteries and spinal cord). Thoracic aneurysms most
commonly occur in persons older than age 65. Death from a ruptured aneurysm is typically one of the top 10–20 causes of death
annually. The incidence of thoracic aneurysmal rupture is approximately 3.5 per 100,000 persons.1
Patients who develop cardiac arrest from a thoracic aneurysmal dissection rarely survive. Furthermore, resuscitation with a
precordial thump is even less common.2 Hypotension is common,
and hypertension should be avoided. This patient received enough
fluids to restore perfusion as determined by monitoring his mental status and a maintaining a systolic blood pressure between
Consideration was given to adding vasopressors, but because
dissection was suspected, they weren’t administered. A thoracic
aortic dissection is characterized by widening of the mediastinum
on chest X-ray. Fortunately, limited X-ray capabilities were available at Rampart General. The diagnosis was later confirmed by a
CTA at the receiving hospital.
It’s often difficult to diagnosis aortic dissection, either thoracic or
abdominal, in the prehospital setting. Because of this, EMS providers must have a high index of suspicion when patients present with
signs and symptoms consistent with thoracic aortic dissection.
The most common presenting sign is pain—either in the chest or
Choose 27 at www.jems.com/rs
Choose 28 at www.jems.com/rs
CASE OF THE MONTH
>> continued from page 33
between the scapulae in the upper back. With large aneurysms,
the superior vena cava can be compressed, causing distended neck
veins. A murmur may be heard. Sometimes hoarseness, cough
and wheezing may be present. In other instances, such as this one,
shock and cardiac arrest may be present.
So much of quality EMS is identifying injuries and illness in the
field, recognizing the potential severity and ensuring the patient is
rapidly transported to an appropriate medical facility.
The concerns of EMS crews and a presumptive field diagnosis can also aid emergency department personnel in directing
appropriate resources to critically ill or injured patients. Quality
emergency physicians will listen to the concerns of field crews and
This was a miraculous case that illustrates the importance of seamless interaction between field EMS crews and physicians. First,
this case occurred in one of the most austere and hostile environments imaginable. Next, it included a patient who was resuscitated
from pulseless v tach with a precordial thump performed by a
paramedic crew. The patient was subsequently evaluated and
diagnosed with a thoracic aorta dissection by medical staff in a
tent (with a diagnosis made by plain chest X-ray) and emergently
transported 150 miles to a hospital where successful surgery was
It truly was a “perfect storm,” or perhaps, it was the general
goodwill and spirit of Burning Man. Or maybe those crystals that
were everywhere actually worked. JEMS
Jeff Westin, MD, was a third-year emergency medicine resident at the University
of Nevada School of Medicine. He’s an attending emergency physician for KaiserPermanente in Portland, Ore. He can be contacted at email@example.com.
Pat Songer, NREMT-P, ASM, is director of EMS at Humboldt General Hospital
EMS. He can be contacted at firstname.lastname@example.org.
Kelly Buchanan, MD, is an EMS fellow at the University of Nevada School of
Medicine. She can be contacted at email@example.com.
Loren Gorosh, MD, is a third-year emergency medicine resident
at the University of Nevada School of Medicine. He can be contacted at
Ryan Hodnick, DO, is a second-year emergency medicine resident
at the University of Nevada School of Medicine. He can be contacted at
Bryan Bledsoe, DO, FACEP, FAAEM, is professor of emergency medicine at
the University of Nevada School of Medicine and director of the EMS Fellowship
Program. He is also the medical director for Burning Man. He can be contacted at
1. Rogers RL, McCormack R. Aortic disasters. Emerg Med Clin North Am.
2. Haman L, Parizek P, Vojacek J. Precordial thump efficacy in termination of
induced ventricular arrhythmias. Resuscitation. 2009;80(1):14–16.
Choose 29 at www.jems.com/rs
RESEARCH REVIEW ems
What current studies mean to
>> by David Page, MS, NREMT-P
Study compares cardiac care for male vs. female patients
Aguilar SA, Patel M, Castillo E, et al. Gender differences
in scene time, transport time, and total scene to hospital arrival time determined by the use of a prehospital
electrocardiogram in patients with complaint of chest
pain. J Emerg Med. 2012; Feb 15. [Epub ahead of print].
hese authors retrospectively analyzed
San Diego EMS charts, measuring the
effect of prehospital 12-lead ECGs on scene
times. Out of 21,742 chest pain calls, no significant scene time increases or differences
were found between patients with and
without ST-elevation myocardial infarction
(STEMI). This is nothing new; this has been
studied many times. The researchers did,
however, find that in STEMI cases, male
patients had an average of 17-minute scene
times vs. females, who had 20-minute scene
times. This delay is then projected to a possible increase of 0.25–1.6% greater mortality.
This study adds to a growing body of
literature showing that women experiencing
acute coronary syndromes receive delayed
diagnosis and care. Possible explanations
could include atypical presentations, delayed
symptoms or comorbidities. I’ll add my own
observation that performing prehospital
12-leads on women involves a certain need
for tact and social privacy that may cause a
delay. In any case, now that we are aware of
it … let’s all try to speed up identification and
care for women having STEMIs.
Waldron R, Finalle C, Tsang J, et al. Effect of gender on
prehospital refusal of medical aid. J Emerg Med. 2012;
Feb 9. [Epub ahead of print].
t shouldn’t be any news that patient refusals
often end in adverse outcomes and continue to be a problem for EMS. I applaud
these authors for discovering a new angle
to this issue. This New York City project
retrospectively reviewed one year’s worth
of patient-care reports for a single hospitalbased ambulance service. The staff at this
service is made up of 82 EMTs and paramedics, with 67 men (82%) and 15 women (18%).
Study evaluated IM vs. IV treatment.
Out of 19,455 total patient encounters, 238
refusals were documented. (If this is accurate,
congratulations are due on a 1.2% refusal
rate. This is one of the lowest ever reported in
Although most of the refusals came during the evening tour, no correlation was
found to it being in the beginning or near
the end of the crew’s shift. The authors did,
however, discover that crews composed of
two male providers were four times more
likely to have an encounter end in a refusal
when compared to a crew that had one or
both female crew members.
In the discussion, the authors note
that differences in communication styles
between genders may lead to perceptions
of behaviors demonstrating greater care by
female healthcare providers.
I Treatment of seizures I
Silbergleit R, Durkalski V, Lowenstein D, et al.
Intramuscular versus intravenous therapy for prehospital status epilepticus. N Engl J Med. 2012;366(7):591–600.
he much anticipated results from the
Rapid Anticonvulsant Medication Prior
to Arrival Trial (RAMPART) study were
published in February in the New England
Journal of Medicine. The study’s main objective
was to show that prehospital intramuscular
(IM) midazolam (10 mg) was just as good as
the in-hospital standard of care: IV lorazepam (4 mg) for status epilepticus.
Because lorazepam has a short shelf life
when it’s stored un-refrigerated, most EMS
systems find it costly and impractical to
carry. Midazolam is widely used, but it
hasn’t been studied well in the prehospital
environment. This landmark prehospital
study will likely be remembered more for its
rigorous scientific methods rather than for
the actual results. It’s a great example of the
“gold standard” of research: double-blinded,
prospective, randomized studies with great
follow through to hospital discharge. The
authors used some innovative and groundbreaking strategies to overcome the usual
hurdles that make prehospital research
First, the details: RAMPART involved
4,314 paramedics from 33 EMS agencies
and 79 receiving hospitals across the U.S.
They enrolled 893 patients and randomly
assigned them to either the midazolam or
the lorazepam group. Neither the patient,
the paramedic nor the receiving hospital
were aware of what medication was administered. The results: IM midazolam stopped
the seizure before hospital arrival 73.4%
of the time while IV lorazepam was 63.4%
effective. They conclude that midazolam is
safe and effective.
Although IV lorazepam had a more rapid
onset, establishing an IV in a seizing patient
was widely variable. Thanks to accurate
time stamps, this study clearly proves that
auto-injectors allow for rapid administration of medications and faster seizure cessation—even if the IM medication is slower
to take effect. Patients who received midazolam were also hospitalized less often and
required fewer intubations.
Now for the unique components that
make this a landmark study. The authors
used a special box that contained both an
auto-injector and the IV medication. The
paramedics were blinded to which treatment they were administering by having
them give all patients an IM shot first, then
starting an IV and giving everyone an IV
bolus. All the auto-injectors and syringes
looked the same, so it was impossible to tell
which had active medication.
I glossary I
Placebo: Simulated but ineffective or inert
medication replacement, such as giving injecting
saline instead giving an actual medication.
If the box contained “active” midazolam
auto-injectors, then the IV bolus was a placebo and vice versa. If the box had “active”
lorazepam IV bolus, then the auto-injector was a placebo. This is clever because
many studies have shown that providers
will go to great lengths (even tasting the
two medications) to uncover which is the
“active” medication. This often destroys the
randomization process that is so critical
Another interesting technique was the
inclusion of an automatic, time-stamped
voice recorder that was activated as soon
as the box was opened. Most studies try
to use the notoriously inaccurate times on
the patient-care report or have providers
fill out an extra piece of paper with study
information—or sometimes they even have
to be interviewed by telephone after the fact.
The paramedics in this study could simply
say what was happening, such as the “IM
shot has been given” and “the seizure has
stopped.” The recordings were later analyzed
and the accurate time stamp extracted.
Note that Seattle’s Medic One program
has measured improvements objectively
for decades with voice recordings for
cardiac arrest patients. This system provides valuable feedback, which the crews
look forward to hearing to help measure
improvements objectively. The technique,
however, is dependent on a cumbersome
ECG monitor add-on, and it unfortunately
hasn’t caught on with the rest of us. It’s
too bad we appear to be more afraid of
recording our errors than we are motivated
to learn from them, and eventually save
more lives. Congratulations to RAMPART
for incorporating state-of-the-art recording
boxes to get accurate data. JEMS
VISIT OGSI at Booth 600
at Disaster Relief &
Oxygen Generating Systems Intl. / www.ogsi.com / Toll Free 800-414-6474
814 Wurlitzer Drive, North Tonawanda, NY 14120 / firstname.lastname@example.org / Phone 716-564-5165
Choose 30 at www.jems.com/rs
Visit www.pcrfpodcast.org for
David Page, MS, NREMT-P, is an educator
at Inver Hills Community College and a
paramedic at Allina EMS in Minneapolis/
St. Paul. He’s a member of the Board of
Advisors of the Prehospital Care Research
Forum. Send him feedback at email@example.com.
Choose 31 at www.jems.com/rs
Law enforcement officers make major
impact as initial care providers
>> By David Kleinman, NREMT-P & Tammy Kastre, MD
Photo Matthew Strauss
t was an otherwise quiet morning
in Pima County, Ariz., when, at
10:11 a.m. on Jan. 8, 2011, the Pima
County Sheriff’s Department received
a 9-1-1 call advising of a shooting in
progress at a local shopping center.
During the next 20 minutes, details of
a horrific and historic scene unfolded,
despite the lone shooter being taken
into custody within five minutes of
the original 9-1-1 call.
Before it was all over, that isolated
shooter had fired 30 rounds into a
crowd gathered for the Congress on
Your Corner event with Congresswoman Gabrielle Giffords (D-Ariz.)
outside a busy Safeway grocery store
Officers who are prepared to provide care during
active shooter and hostage situations can be an
asset to EMS.
Beyond the Tape
>> continued from page 39
Afghanistan war zones to be the key factor in
preventing death from severe hemorrhage.
Emergency department (ED) physicians
and trauma surgeons from Tucson’s level
one trauma center University Medical Center acknowledge that the quick actions of
the Pima County Sheriff Department deputies and their specialized training and EMS
equipment resulted in decreased hemorrhage, improved vital signs and less need for
shock resuscitation for multiple victims.
Initial First Responders
Photo ASSOCIATED PRESS/ James Palka
It’s essential that treatment begin immediately and patients be transported expeditiously in accordance to the severity of their
injuries. And even in an urban environment,
the time it takes for EMS to arrive on scene
can mean the difference between life and
death for the wounded. Too often the first
responder is a law enforcement officer faced
with a tactical situation of providing a law
enforcement function that must quickly
transition into providing first care to civilians or a fellow officer.
The Safeway shooting happened in a geographic location in Pima County that’s readily served by multiple paramedic units from
three large fire departments. But it’s conceivable that this same scenario could occur
with one or more of the following situational complications:
>> xtended EMS unit response to a rural
or remote setting;
First responders work together on Jan. 8, 2011, at the Safeway where the active shooter event happened.
Photo ASSOCIATED PRESS/ Matt York
on the outskirts of Tucson. Facing the arriving deputies were 19 injured and/or dying
people all in close proximity. Luckily, they
had trained for such situations. Is your
department prepared to receive a 9-1-1 call
The Northwest Fire Rescue District
(NWFRD) serves the suburban area of Tucson where the mass shooting occurred.
A NWFRD paramedic rescue ambulance
and three ground ambulances from Southwest Ambulance were dispatched based
on the initial information received by dispatch from the initial 9-1-1 call. Three ALS
engines, a ladder company and EMS Captain and Battalion Chief (BC) Lane Spalla
also responded on the first-alarm MCI
response. Three medical helicopters were
also placed on standby based on the scope
of the incident.
Although the first EMS/fire units arrived
on scene in just five minutes, they were held
off in a safe staging area by law enforcement until 10:23 a.m., when the scene was
declared safe for entry.
This scene was also different from many
other active-shooter mass casualty incidents
(MCIs) because the arriving deputies were
all trained in MCI and advanced care procedures that enabled them to play a major role
in the treatment and survival of the multiple
critically wounded patients who were inside
the incident hot zone prior to the secured
arrival of fire and EMS responders.
In the critical minutes of an incident
involving gunfire and the need to secure
the scene, where patients had the potential
to exsanguinate, the deputies arriving on
scene were armed with special emergency
care packs that were strategically positioned
behind the headrest of each patrol vehicle
for easy access and deployment.
During the 47 minutes that deputies were
with the injured at the scene, they treated 10
of the 19 injured patients. They controlled
bleeding, provided rescue breathing and
chest compressions, deployed hemostatic
agents, bandaged numerous wounds, and
assisted citizens and congressional staffers
in the care of the injured.
The first seven patients were triaged,
treated and transported from the scene by
10:35 a.m. All were transported by 11:01 a.m.
The early combat and control of hemorrhage before the onset of shock has been
proven by the military in the Iraq and
Emergency personnel work together at the scene where Rep. Gabrielle Giffords, D-Ariz., and others were shot.
Choose 32 at www.jems.com/rs
Choose 33 at www.jems.com/rs
Beyond the Tape
>> continued from page 40
First Five Minutes Training
The concept of training law enforcement officers in initial care and providing them with
special medical kits isn’t new. This is a concept
that has been used by the U.S. Secret Service
for decades, with special kits immediately
available to each agent and all agents familiar
with the items in the kit. However, the First
Five Minutes program is one of the first in
which the care provided by officers before EMS
arrival has been lauded as having saved several
patients. The four-hour First Five Minutes training includes the following elements:
>> Scene safety and orientation components,
including familiarity with area fire and EMS
agencies and services.
>> The capabilities of local hospitals and the
availability of helicopter rescue.
>> Body substance isolation (BSI) and realworld applications.
>> Assessment of circulation, airway and
breathing. This includes methods to establish and maintain an open airway, as well as
how to provide rescue breathing and continuous compression resuscitation (CCR).
>> How to contact an injured officer.
>> When and how to remove body armor.
They also learn a 90-second assessment of the
situation and patient medical conditions with
primary focus on hemorrhage control maneuvers and identification of shock. At the end of
each assessment, deputies are encouraged to
make transport decisions: Do they stay at the
scene and wait for EMS, or do they transport the
wounded rapidly via police or private vehicles?
For hands-on training, the deputies participated in a skills lab that includes the use of the
emergency compression bandages, hemostatic
combat gauze, chest seals and tourniquets.
A Pima County Sheriff’s Department deputy
uses trauma shears during the First Five
Minutes training program.
significantly affect the well-being of the
wounded, because the EMS provider would
be markedly delayed in arrival and their
ability to provide essential emergency care.
In a 2007 study published in Prehospital and
Disaster Medicine, the authors noted, “No
widely accepted, specialized medical training exists for police officers confronted with
medical emergencies while under conditions of active threat.”1
Given the knowledge’ acquired from
historical and modern battle, culminating in the trauma combat casualty care
(TCCC) guidelines, we know the following are causes of preventable death on
>> Hemorrhage from extremity wounds;
>> ension pneumothorax; and
>> Airway compromise.
Each of these conditions can be managed early and effectively using relatively
simple techniques and minimal equipment. Unfortunately these techniques and
equipment are rarely taught to law enforcement officers.
Even in an urban environment, the time
it takes for EMS to arrive on scene can mean
the difference between life and death for the
wounded. Law enforcement personnel routinely are the first arriving responders to
arrive at tactical situations. They are also
often the first to arrive at such mass casualty
situations as major traffic collisions involving multiple patients.
At tactical incidents, officers are often
faced with the challenge of initiating law
enforcement functions and almost simultaneously ensuring that needed care is started
on critically injured fellow officers and
Special weapons and tactics (SWAT)
teams have long understood how important it is to have paramedics imbedded in
their teams, immediately available for any
medical need and tactically trained and
aware of how to react and respond in a hostile or active shooter environment. Tactical
EMS (TEMS) providers can readily address
airway, breathing and circulation problems
that create an urgency that transcends the
response times of most staged civilian medical assistance units.
Although it’s not always practical for
law enforcement agencies to employ paramedics to work in the field with officers,
much can be done to train police officers
to care for themselves, their colleagues and
Tactical Paramedic Training
In the spring of 2009, the leadership of the
Pima County Sheriff’s Department recognizing the need for global training for all
staff with “feet on the street.” They took
Photo Courtesy David Kleinman
>> MS resources committed on other
high-priority calls and delayed in
response or arrival;
>> raffic congestion that delays or proT
hibits EMS access to a scene;
>> n unsafe scene that doesn’t allow
fire and EMS providers to approach
Any of these complications can
Photo Matthew Strauss
Photo Matthew Strauss
elements of TCCC and results from the
research done by Valor Project and created
the First Five Minutes, a tactical emergency
medical training program that was rolled
out to all deputies during annual advanced
officer training. This specialized EMS and
law enforcement training program was
developed with assistance from Richard
Carmona, MD, MPH, the 17th U.S. surgeon
general and former Pima County Sheriff’s
Department SWAT team leader and medical director.
Although the First Five Minutes program
isn’t the first medical training course taught
to Pima County sheriff’s deputies, it’s different from their normal medical training
because the primary goal is to give police
officers the training necessary to sustain
themselves or others in situations with lifethreatening medical emergencies.
Along with the training, a special emergency response equipment kit was developed and issued to all deputies after they
completed the training. The law enforcement individual first aid kit (IFAK) was
assembled to include essential supplies and
devices necessary to combat the three most
common causes of preventable traumatic
death, namely 1) hemorrhage in accessible
and controllable regions; 2) hemorrhage in
inaccessible or uncontrollable areas and 3)
Photo Courtesy David Kleinman
An officer responding to a scene that’s unsafe for EMS can use a compact kit equipped with the essentials of hemorrhage control and airway management.
A tourniquet could mean the difference between life and death for an officer pinned down by fire.
Officer safety and tactical considerations
are incorporated into every aspect of the
First Five Minutes lesson plan. Officers are
reminded that they’re police officers first
and medical providers second. The program introduction relates the importance
of providing immediate medical care to
the downed officer. The Fort Hood (Texas)
Police Department shooting and the murder of Phoenix Police Department Officer
Travis Murphy illustrate this issue.
At numerous points during the class,
instructors emphasize that this program isn’t designed to be a first aid class,
but rather a survival class for police officers. A law enforcement IFAK is issued to
each student at the beginning of the class
so become familiar with its contents to
ensure rapid retrieval of essential items
Although the IFAK is designed primarily
for law enforcement professionals to treat
fellow officers, deputies are told to use their
discretion at emergency scenes. They’re
encouraged to use their IFAKs, once the
scene is secure, to stabilize civilians when
they feel it can be life-saving in advance of
EMS arrival. Such was the case at the Safeway/Giffords MCI scene.
Because the assisting officer is often the
first person to contact the injured person,
the training stresses the idea that the officer’s
observations and findings are the most significant issues in long-term care and recovery
Beyond the Tape
>> continued from page 43
of the wounded person. Officers are told to
report the following to EMS providers:
>> T he nature of the injury;
>> atient’s mental status, including any
changes in mental status;
>> irway control necessary, rates of
breathing and circulation;
>> njuries they saw, who they treated,
and how they treated those injuries;
>> A ny unusual findings or concerns.
At the conclusion of the training, the
officers’ skills are evaluated through participation in multiple scenarios. Two evaluators are used for each scenario: one
evaluates officer safety, use of cover and
concealment, tactical movement and other
skills related to police work; the second (an
EMT or paramedic) evaluates the medical
triage and care provided to the patient.
Similar emergency medical training programs address this need. This includes the
specialized tactics for operational rescue
and medicine program (STORM), developed by the Georgia Health Sciences University in conjunction with the National
Tactical Officers Association.
The STORM course provides clearly
defined medical strategies, procedures and
rescue techniques to enhance the safety of
law enforcement personnel and the populations they serve. STORM is tailored to five
unique tactical audiences: self aid-buddy
care, operator, paramedic, medical director and commander. Each course consists of
didactics, hands-on skills stations and tactical scenario-based training.
The Nashville Police Department
recently implemented a modern-day “first
aid” program, which was taught once a
week for five months to their entire roster
of 1,400 active-duty officers. The training
featured lecture and practical skill sessions
training kits, which were issued to each officer as they completed the training program
(see “Partners in Crime,” p. 52–55).
Not all law enforcement agencies consider
emergency care to be part of a police officer’s job. With the ever-increasing call load
and requirements placed on officers, it’s
easy to see how agencies can lessen liability and workload by eliminating a job that’s
already served by fire departments and
However, a wounded officer, or an officer responding to a mass casualty incident
well in advance of EMS, presents an opportunity for lives to be saved by law enforcement personnel.
Every officer should have the necessary training and equipment to provide
on-scene emergency medical self care.
They also should be able to assist other
officers and civilians injured during a law
Key aspects of implementing a successful
law enforcement emergency care program
are simplicity and ease of use in an emergency. Without those two factors, officers
are limited in what they can effectively do
at a scene.
The training and equipment used by
law enforcement personnel prior to EMS
gaining access to the scene of the Safeway
shooting incident proving it to be worthwhile in a time of crisis, resulting in saved
lives. The First Five Minutes program is
easy to teach, simple to understand and
effective in treating the injured before EMS
David Kleinman, NREMT-P, is a detective with the
Arizona Department of Public Safety and a tactical paramedic with Pima Regional SWAT. com. He can be reached
Tammy Kastre, MD, is the medical director for the
Pima County Sheriff’s Department SWAT team and a
board-certified ED physician.
1. Sztajnkrycer MD, Callaway DW, Benz AA. Police
officer response to the injured officer: A surveybased analysis of medical care decisions. Prehosp
Disaster Med. 2007;22(4):335–341.
The individual first aid kit includes supplies and
devices necessary to combat the most common
causes of preventable traumatic death.
Photo Matthew Strauss
The contents of the IFAK are chosen specifically
for law enforcement officers who would need
to provide care to trauma patients before EMS
arrives on scene. The IFAK’ includes the following items:
>> A zippered bag with interior elastic straps
for holding contents in place. The exterior of the bag has multiple attachments
points—allowing it to be mounted in
the vehicle, on a backpack or even on a
>> A pair of trauma shears.
>> Two emergency compression bandages.
>> One package of hemostatic combat gauze.
>> One chest seal.
>> One tourniquet.
Tactical training offers
many benefits to EMS
>> By William Justice, NREMT-P;
LT. Kerry Massie, NREMT-I; &
Jeffrey M. Goodloe, MD, NREMT-P, FACEP
EMS providers should be prepared to
handle any situation because you never
know when a call could go awry.
>> Tac Team Alpha: I’ve got visual on
barricaded subject with hostages.
>> Command: Acknowledge Alpha.
Maintain visual and advise of any
change in behavior or position.
>> Tac Team Alpha: Subject appears
Sounds of multiple shots are heard
fired from the subject’s location.
>> Tac Team Alpha: I’ve got visual on
Photos Courtesy OKlahoma highway patrol
>> Command: Copy Alpha on wounded
>> Command to Tac Team Delta: Go for
entry; go for entry.
>> Tac Team Delta: Going entry.
>> Tac Team Delta: Subject secured.
Repeat, subject secured. But officer down! Officer down! Operator
>> Command: Medics up.
Prepared for the Worst
>> continued from page 47
aramedic Tango reaches the downed
officer, finding blood on the ground
next to a large, mid-thigh gunshot wound
in his right leg. The bleeding is already controlled by a tourniquet applied by another
tactical operator involved in the initial team
entry that occurred 65 seconds before Tango
made patient contact. The patient is awake,
alert and complains of thigh pain. He denies
any other injury, and none is found on a
quick but thorough physical exam.
Paramedic Ocean reaches the wounded
hostage at the same time Tango reaches the
downed officer. Ocean finds three gunshot
wounds in the hostage’s chest and abdomen. This patient is awake, talking, anxious
and diaphoretic, and he has an increasingly
rapid radial pulse. Ocean applies an occlusive seal over the largest wound, which is
to the right of the sternum. He finds no exit
wounds during the remainder of his exam,
and he calls for rapid extrication.
A physician and paramedic await the
patients at the tactical command post.
They have vascular access supplies ready
and aeromedical helicopter resources
responding with an estimated arrival time
of five minutes. The wounded law enforcement officer and the wounded hostage
arrive for tactical field care within six minutes of sustaining their wounds.
Troopers practice chest decompressions on a manikin during a training session.
tions. These officers may be dedicated to
full-time service on such teams or accept
these additional roles beyond their daily
police duties. The presence of specialized
operational teams, with specific training,
tasks and capabilities, creates a strong
infrastructure in which to introduce and
advance medical emergency capabilities,
not only within existing teams, but also for
specialized EMS response teams.
On the day the events described above
occurred, they happened only in training.
But the Oklahoma Highway Patrol (OHP)
EMS Unit state troopers are well aware that
events such as these can occur on any day
at any time.
This knowledge, coupled with a commitment to safety for all Oklahomans,
including their fellow troopers, has guided
OHP leaders in developing an increasingly
sophisticated cadre of all-hazard medical teams for tactical, special event, mass
casualty and natural disaster response
throughout the state. In addition to OHP’s
progressive leadership, many strategically
placed building blocks exist that allow for
law enforcement-related medical emergency success.
Within OHP and other states’ police
organizations, specialized law enforcement teams meet the extraordinary
operational challenges in tactical, riot,
explosive ordinance and disaster situa-
Above & Beyond
Just like their EMS and fire colleagues,
law enforcement officers are hard-wired
for public service. Within an agency the
size of the OHP, a call for troopers interested in new medical duties will typically
result in a competitive process, yielding
top-flight EMT and paramedic candidates
EMS professionals willing to think outside their usual environments and roles
are often conduits for exciting changes.
Leaders within the University of Oklahoma Department of Emergency Medicine
(OUDEM) were approached by OHP with
hopes of gaining medical oversight support for troopers trained and in training as
EMTs and paramedics.
Select OUDEM physicians and paramedics who expressed interest in participating in the program were screened for
their medical knowledge, law enforcement duty awareness, physical abilities
and teamwork attributes. They were also
required to complete extensive security
background checks. Next came an extensive process that included exhaustive database queries and character references for
After the OHP special team orientation, the selected physicians and paramedics received special “boots on the
ground” training and emergency response
experiences statewide before being
approved to serve on OUDEM’s Special
Operations Medical Oversight and Support (SOMOS) group.
Each physician and paramedic has a formal affiliation with OHP, which provides
them with protection from claims while
they’re on duty in special assignments
and allows for medical liability protection
and worker’s compensation for injuries
The physicians and paramedics work
together to ensure coverage is available for
statewide response around the clock, using
response vehicle assets secured under the
Department of Homeland Security funding or responding with a state trooper in a
“High speed/low drag” is the catch-phrase
for expedient, effective operations. Equipment carried on each person and in team
support vehicles is evaluated and imple-
mented with this mantra. Medical equipment primarily designed for emergency
department (ED) and/or daily EMS use
often fails this specialized operations
requirement. Anything bulky can become
an unintentional “target,” and heavyweight
items impede rapid movements often
needed in access and egress maneuvers.
All team members, law enforcement
officers and medical support specialists
carry individual first aid kits, for more
about IFAKs, see “Beyond the Tape,” pp.
38–40. In general, active operational area
equipment is kept to necessary, but effective, “minimums.”
In addition to the IFAKs each officer
carries, space- and weight-efficient extraction devices are also available during all
operations. These devices are specifically
designed to allow for rapid patient movement by a minimum number of law officers
and paramedics. This often includes devices
capable of being used by a single-operator,
such as drag straps/pulls and sleds.
Tactical field care—the next echelon of
care—is planned and carried out at strategic locations using larger medical kits
containing additional hemorrhage control
agents, hemostatic dressings and gauze, as
well as more advanced airway and pharmaceutical supplies. IV and intraosseous
fluids are carried with a constant balancing
of physical weight of fluid against anticipated clinical needs based on probable
patient conditions and times to definitive
Sustained Operations & Care
SOMOS members are also equipped with
72-hour go bags to allow faster deployment to large events that may advance to
extended operations. The “go bags” have
prepacked personal items, such as uniforms, safety glasses, additional protective
equipment, multiple flashlights with extra
batteries, foul weather gear, safety gloves
and self-heating meals. The special bags
also include members’ personal medications, back up contact lens/glasses and
other specific daily required products.
Disaster-specific equipment, designed
to address a multitude of casualties, is carried in a dedicated trailer assigned to OHP
in the state’s regional EMS system disaster
plan. Typical mass casualty supplies for triage, treatment area set-up, basic medical
care and extrication devices and patient
removal equipment are efficiently organized throughout the trailer. Although the
trailer is designated for primary use in one
of Oklahoma’s eight health regions, it can
be mobilized throughout the state as conditions may warrant.
Depth of Training
Putting the right equipment in the hands
of motivated professionals is a good place
to start, but it’s a poor destination. Routine
training for the “non-routine” response is
integral to nearly any special operations
team’s success when it matters most.
Training exercises and didactics that support effective operations primarily address
the following three major medical missions:
>> Injured law enforcement care and
Trainees are educated about and practice suturing in the lab setting.
Choose 34 at www.jems.com/rs
Prepared for the Worst
>> continued from page 49
medical advice on how to minimize the risk
of these injuries;
>> Civilian care in special law enforcement operations settings with coordination
and support for local EMS agencies; and
>> Civilian care in statewide disaster
settings while working alongside local
The training schedule consists of two
mandatory days per month, a yearly
one-week exercise, and additional training as it becomes available from local,
state and federal organizations, such as
Basic Disaster Life Support and Homeland
All medical specialists are trained and
certified as EMT-Tacticals or equivalent,
with a strong basis in tactical combat casualty care (TCCC) philosophy and methodology. Many members are instructors
certified in trauma specific disciplines (Prehospital Trauma Life Support, International
Trauma Life Support and Advanced Trauma
Life Support), which serve as good fundamental trauma support courses; although
modifications in application are necessary
in the tactical environment.
The axiom, “Good medicine can get you
or someone else killed” is often applied to
training drills. For instance, definitive airway management could be desirable, but
intubating in the line of sight of an active
shooter isn’t going to end well for either the
intubator or the intubatee.
All team members, including primary
law enforcement operators, are trained to
proficiencies in performing basic medical/
trauma assessment, controlling bleeding,
using tourniquets and hemostatic agents,
sealing open chest wounds, and performing simple airway management techniques
and patient evacuation.
Advanced certification medical specialists (e.g., paramedics and physicians)
are additionally proficient in airway
management, including surgical cricothyrotomy, vascular access and tension
Bomb technicians at OHP are invaluable
instructors in explosive ordinance awareness level training and bomb suit access
training. Trauma shears are useless in the
access, assessment and care of an explosive
ordinance technician, and operators and
medical support specialists must know the
proper methods for bomb suit removal and
blast-related injury care.
As it is for any special operations team,
the training is rigorous, in-depth and
designed to push members to mental and
physical extremes. Just as special operations medicine was new to the troopers,
working in the hot/warm zones of law
enforcement special operations was eyeopening to the physicians and paramedics. The mutual respect is immeasurable,
with everyone remaining engaged, supportive and enthusiastic for new information and skills.
Although textbooks and medical literature is being absorbed by everyone
involved, the medical director has found
benefit in dedicated weight room “learning” as well.
A specialized tactical casualty care course
was designed and delivered to the tactical team operators. The operators are
instructed to “get off the X,” which means
getting to a place of increased safety before
implementing any detailed medical care.
After the operators are in an area of concealment, and preferably cover, their training in
bleeding control, chest seal application and
basic airway control with nasal or oralpharyngeal airways is designed to save lives
and minimize injuries.
The training and teamwork ensures that
the tactical law enforcement operators
rapidly incorporate medical support for
their peers in tactical operations drills and
Taking it to the Street
Because of the praise from the law
enforcement officer tactical operators,
the training has also been extended by the
medical team to road patrol troopers and
additional staff at the OHP training center. The same approach to simple, noninvasive assessment and aid that makes
lifesaving differences was a success in the
pilot course that now serves as the template for ongoing courses.
Practical scenarios making the didactics come to life play an important role in
this training curriculum’s effects. With
more than 400 state troopers interested
in training, the schedule looks filled for an
Everyone is feeling the crunch of budget
limitations at best and cutbacks at worst.
To mitigate this issue, all avenues of financing are actively considered. Examples of
successful funding to date include U.S.
Department of Homeland Security grants,
criminal activity forfeiture money, and
corporate and private donations, in addition to line-item OHP budgeted items.
The Sustainable Future
Early intervention for controlling bleeding,
minimizing chest trauma, and improving oxygenation and ventilation can make
the difference in life or death in the special
operations environment. Applying the
concepts from law enforcement to additional areas managed by law enforcement
officers and medical support specialists
can offer many benefits, namely reducing
civilian casualties and treating patients
injured in disaster situations.
A realistic training program design and
remarkable enthusiasm will enable the
OHP to offer new and expanded medical
capabilities throughout the state that will
benefit officers and citizens alike.
The benefits of a tactical program are
simple, yet profound. Law enforcement
officers assigned special operations tasks
know onsite medical specialists “have their
back” when they need it most.
Civilians exposed to the dangers of law
enforcement special operations similarly
benefit from immediately available aid
with expertise. The state’s disaster plan is
additionally strengthened by an additional
cadre of medical professionals equipped to
respond for effective medical aid and scene
William Justice, NREMT-P, is the coordinator of
OUDEM’s Special Operations Medical Oversight and
Support group. He can be reached at via e-mail at
Lt. Kerry Massie, NREMT-I, is the coordinator of
OHP’s medical emergency teams and an experienced
law enforcement tactical operator and trainer. He can be
reached via e-mail at firstname.lastname@example.org.
Jeffrey M. Goodloe, MD, NREMT-P, FACEP, is the
medical director of OUDEM’s Special Operations
Medical Oversight & Support group and the OHP’s
medical emergency teams. He’s also a JEMS Editorial Board Member. He can be reached via e-mail at
Photo Joshua Keckley
EMS provides a
for local law
>> By Capt. Mario Ramirez,
MD, MPP; Andrew N. Pfeffer,
MD; Greg Lee, & Corey M.
Slovis, MD, FACEP
ne of our core responsibilities as prehospital medical providers is to offer
care and assistance to not
only the general public, but
also to those who assist and protect us in the
field: law enforcement officers. Despite the
risk of injury that most police officers face
in their daily line-of-duty work, they don’t
often receive good medical instruction on
self care and buddy aid. As a result, they too
represent a medically underserved population that EMS providers are in an excellent
position to assist.
Although most police officers receive
some medical instruction during their training at a law enforcement academy, no federal
or state standard governs the level of training required or the frequency with which
refresher courses must be offered.1
Without such standards, there’s a wide
variety in the medical skill sets of officers
within and between law enforcement agencies. Some officers may have a deep understanding of medical care, while others may
know very little. With all they do to provide
scene safety for us to do our work, it simply
makes sense that we should return the favor.
Today, all U.S.
entering combat do
so with standardized
individual first aid
kits (IFAKs) that have
proven successful in
after injury on the
Partners in Crime
>> continued from page 53
At the conclusion of the course, each officer is issued an IFAK with all contents stored neatly in a single
modular lightweight load-carrying equipment pouch.
Photo Courtesy Nashville Police Department
Although tactical emergency medical services (TEMS) is defined as medical support
for police and law enforcement officers, it
has traditionally focused on high-risk special weapons and tactics (SWAT) units. By
concentrating resources on only these relatively small units, however, we’re making a
strategic mistake: The majority of injuries
in law enforcement are borne by the street
level officer, not the tactical operator.
The Department of Justice/Federal
Bureau of Investigation’s Law Enforcement
Officers Killed and Assaulted database
reported that 57,268 police officers were
assaulted in 2009, with more than 95% of
those assaults occurring against officers in
These assaults resulted in more than
15,000 injuries and 48 deaths. Of those officers who sustained fatal injuries, only five
were involved in tactical/SWAT scenarios. Therefore, although focused “SWAT
medicine” offers an exciting opportunity
to provide direct care in the high-risk tactical setting for officers and perpetrators,
targeting medical instruction toward the
larger population of non-SWAT officers
who sustain a greater number of injuries
may be the smarter move.
Photo Joshua Keckley
Law Enforcements Needs
The inherent danger of law enforcement
work puts officers at risk for motor vehicle
accidents, ballistic injuries, stab wounds and
orthopedic injuries. It follows then, that the
street level officer needs training in the basics
of first aid, including hemorrhage control,
airway and pneumothorax management,
and sprain/fracture treatment. And with
police officers often representing the first
persons on the scene of an emergency, it also
makes sense to instruct them on the use of
automated external defibrillators.
Unfortunately, like other public agencies,
most law enforcement groups are currently
operating on tight budgets. As a result, the
knowledge and supplies to provide immediate casualty care should be easily obtainable
at low cost and provide as much “bang for
the buck” as possible.
Care items should be readily portable so
they can be carried on, or easily reached
by, the police officer at work. These items
should be both durable and survivable
to minimize expiration and turnover of
The purpose of this pilot project was to primarily train the officers in specialty techniques to care for
themselves and their partners. The program has been well received by Nashville police officers.
supplies. As EMS providers, it’s important
that we take the time to teach each officer
how to use these materials, taking care to
provide enough depth to make the concepts understandable without making
things too technical.
Today, all U.S. military soldiers entering
combat do so with standardized individual
first aid kits (IFAKs) that have proven success in improving survival after injury on
the battlefield. Our department felt that
similar success could be achieved in the
civilian sector by issuing kits to our street
level police officers.
The Nashville Experience
In Nashville, every police officer is required
to undergo annual in-service training on
a topic of the leadership’s choosing. At
the request of our local law enforcement
agency, we built a modern day “first aid”
program and taught that program once a
week for five months to the entire roster of
approximately 1,400 active duty officers.
In each weekly course, we taught the
same lecture and practical skill session
using a PowerPoint presentation and training kits that modeled the IFAKs that we
then issued to each officer. We covered the
The airway, breathing, circulation, disability and exposure assessment of first aid;
>> Basic airway opening, including
jaw thrust and head tilt/chin lift;
>> Lacerations and bleeding;
>> Dressing application;
>> Tourniquet use;
>> Ballistic injuries and wound
>> Blunt-force injuries;
>> Burn injuries;
>> Management of impaled objects;
>> E xtraction
To practice their skills with real-time
feedback, we gave the officers an opportunity to apply bandages and tourniquets
and treat mock sucking chest wounds. At
the conclusion of the course, each officer
was issued an IFAK with all contents stored
neatly in a single modular lightweight loadcarrying equipment pouch.
It contains 6" Israeli battle dressing, a tourniquet, a triangular bandage, stretch and sterile gauze, petrolatum gauze, medical shears,
medical tape, personal protective gear (e.g.,
shield, gloves) and a Mylar rescue blanket.
Cost was a key consideration for us. We
were able to obtain the materials above
and supply each of the 1,400 officers with
a complete kit at an individual unit cost
of $56.80. The funds used to pay for the
purchase of these materials came from a
Department of Homeland Security Metropolitan Medical Response System grant.
It’s important to note that we didn’t certify the officers as first responders after the
course was completed. The purpose of our
pilot project was to primarily train the officers in specialty techniques to care only for
themselves and their partners.
The course was also not long enough to
certify the officers to the first responder
standard and wasn’t designed to teach
them to provide care to the general population. That’s what their original academy
training is designed to do. What we were
able to achieve, however, was the instruction of a large population of public safety
officers who are at high risk for frequent
injury in a very short period of time.
The Department of Justice/Federal Bureau
of Investigation’s Law Enforcement Officers
Killed & Assaulted database reported that
57,268 police officers were assaulted in 2009,
with more than 95% of those occurring
against officers in non-SWAT assignments.
There’s no doubt that in the care of the
critically injured trauma patient, two concepts hold true: 1) every second counts and
2) care at a Level I trauma center is associated with improved patient outcomes. We
believe our program will allow officers
to provide earlier care, which will lead to
improved outcomes when injuries occur.
As the experts in prehospital emergency
care, EMS has a duty to improve flaws that
can be fixed easily in our systems. This
low-cost, high-impact program for law
officers presents us with a real opportunity
to improve patient outcomes by designing
some direct lectures on specific topics and
interspersing hands-on skill sessions.
EMTs, paramedics and EMS physicians
can and should teach their jurisdiction’s
law enforcement officers how to deal with
the immediate health threats of such injuries as sucking chest wounds, exsanguinating hemorrhages and airway obstructions.
With the use of public, private or government funds, officers can be equipped
with life-saving emergency supplies for
very little money per officer. By preparing a standardized lecture and practical
skills series that can be taught by EMTs,
paramedics or physicians, there’s a real
opportunity to improve outcomes for an
underserved population that does so much
to make our own jobs as safe as possible.
Author’s Note: The previous statements represent the views of the authors and not necessarily the view of the Department of Defense or its
respective components. JEMS
Capt. Mario Ramirez, MD, MPP, was formerly a tactical
and EMS fellow at Vanderbilt University Medical Center.
He’s now an emergency medicine physician serving with
the United States Air Force.
Andrew N. Pfeffer, MD, is currently a resident in emergency medicine at Vanderbilt University Medical Center.
Greg Lee, is currently an armorer and firearms instructor for the Metropolitan Nashville Police Training Academy
with 31 years of law enforcement service. He’s also a retired
Master Sergeant from the Tennessee Air National Guard.
Corey M. Slovis, MD, FACEP, is chairman of emergency medicine at the Vanderbilt Medical Center in
Nashville, Tenn. He also serves as medical director for
the Metro Nashville Fire Department and the Nashville
1. Sztajnkrycer MD, Callaway DW, Baez AA. Police officer
response to the injured officer: A survey-based analysis of medical care decisions. Prehosp Disaster Med.
2. Department of Justice Federal Bureau of Investigation.
2009. Law Enforcement Officers Killed and Assaulted. In
Federal Bureau of Investigation. Retrieved March 8, 2011,
How to rid your rigs
of a bedbug infestation
>> By Wayne M. Zygowicz, BA, EFO, EMT-P
t was one of the creepiest calls paramedic/firefighter Darwin Mace had
ever been involved with during his
14 years with Littleton (Colo.) Fire
Rescue. What started out as a routine
call for abdominal pain turned into something right out of the Twilight Zone.
The tones went off for the address of an
office building next to the firehouse. On
arrival, his crew found a well-dressed female
in her 60s sitting in her cubical complaining
of abdominal pain. She was being attended
to by coworkers. Mace ordered two sets of
vitals, took a 4-lead ECG and obtained her
oxygen saturation levels. He reviewed her
medical history and performed a focused
As he concentrated on her treatment plan,
he decided to move her to his ambulance to
avoid any further embarrassment in front of
her coworkers. She was pleasant and talkative as the crew headed to the ambulance
for further assessment and pain control.
“At first, I noticed this small bug on her
shirt so I grabbed it and squashed it. I thought
it had fallen on her as we moved her to our
rig,” he remembers. As he began moving her
clothing to attach 12-lead ECG cables, he saw
something scurry under the cot sheet. Bugs!
Lots of them. At least 20 bugs had fallen out
of her left pocket and were looking for hiding places. “This is bizarre,” thought Mace
as he examined her other pocket. He found
more bugs. Then it dawned on him as he
composed himself. They were bedbugs.
He quickly covered her tightly with a
blanket, attempting to isolate the pests. He
notified the receiving hospital and continued his medical treatment as the bugs wiggled under the covers.
It wasn’t long before other bedbug incidents started popping up. The next time
was a working fire incident—a smoky mattress fire in a basement. Firefighters arrived
quickly, knocked the fire down and removed
the half-burnt, smoldering mattress from
the structure. Embarrassed by the situation, the home owner admitted trying to
kill a bedbug infestation using alcohol and
Next was the notice from the housing
Photo Janice Haney Carr
This digitally-colorized scanning electron
micrograph (SEM) revealed some of the
ultrastructural morphology displayed on
the ventral surface of a bedbug.
authority that 10 days earlier, the fire department had transported a patient from an
apartment so infested with bedbugs that
the unit was posted as unfit for human
habitation. The tenant was vacated immediately, and their belongings were treated
What are these pests; where did they
come from; and what risks do they pose to
first responders? Better yet, how do we stop
them from taking up residence in our stations, ambulances, city halls and homes?
Bedbug infestations are on the rise across
the nation, and first responders will encounter patients and buildings infested with these
creatures. Be aware, be prepared and have a
game plan for dealing with bedbugs.
Bedbugs have made resurgence in the U.S.,
Canada, Australia and the United Kingdom.
These blood-sucking pests were nearly eradicated by the end of World War II by strong
pesticides, such as Malathion and Dichlorodiphenyltrichloroethane, known as DDT.
The most effective pesticides used to kill
and control bedbugs were later banned in
the U.S. during the ’70s due to their toxicity, environmental hazards and human risk.
Bedbugs are back, and the war against them
is being fought in cities around the U.S.
Experts have been tracking the rapid
spread of bedbugs for years. The cause of
their exploding population is still somewhat
of a mystery, but pest-control specialists
believe it’s related to their resistance to
weaker modern-day pesticides. Another
cause is increased domestic and international travel.
Staying overnight in a bedbug-infested
environment can provide a oneway ticket for a hitchhiking
bedbug to be transported to
another location. Bedbug
infestations have been discovered in expensive hotels,
apartment buildings, homes,
cruise ships, airliners, office buildings,
schools, libraries, movie theaters, transportation hubs and fire stations. City leaders are
teaming up with bedbug experts to develop
effective strategies to combat these pests and
What’s Buggin’ EMS
>> continued from page 57
Table 1: Top 10 U.S. Cities for Bedbug Infestations
The common bedbug (Cimex lectularius) can
be found worldwide. They feed exclusively
on blood and are usually found close to their
blood hosts. They’re nocturnal, becoming
active at night. They leave their covert hiding
places to feed on blood. Bedbugs are resilient, have a life span of about 10 months and
can live up 90 days without a meal.
Under ideal environmental conditions
(70–90° F), bedbugs go through five development stages, reaching maturity within
a few months. Females lay between one
and five eggs a day, usually producing 200–
500 offspring during their lifetimes. Their
eggs, which are commonly found near
their host’s bed, are about 1 mm in length
and pearly white. They hatch within three
weeks. Newly hatched bedbugs,
called nymphs, are translucent
and no bigger than the head
of a pin. After feeding on
blood, they may appear reddish
in color. Adult bedbugs are generally brown, a quarter of an inch long
and oval with no wings. They don’t
fly, but they can move swiftly on horizontal and vertical surfaces. They’re good
hitchhikers and can easily latch onto a blanket, sock, shoe lace or bunker coat.
These blood suckers activate when they
sense an increase in heat and carbon dioxide
(CO2) in the room as their human prey comfortably drifts off to sleep. They inject their
victims with an aesthetic and anticoagulant,
usually making their bites painless. Bedbug bites frequently appear in rows of three
to four bites with red welts, and their effect
on people will vary from individual to individual. Itching after a bite can cause redness
and skin irritation, and constant scratching
may cause open sores, which can lead to skin
dermatitis and infection. It’s hard to tell the
number of bugs in the environment by the
amount of bites on one person. One bug may
move around multiple times as they feed or
Hide & Seek
Bedbug infestations aren’t
caused by poor sanitary conditions and aren’t a reflection
of a person’s social status or
hygiene. These bugs have been
found in various setting from
upscale mansions to homeless
Source: America’s top 10 infested cities. (Aug. 24, 2010).
shelters. Infestation begins by
In The Daily Beast. Retrieved Feb. 2, 2012, from www.
bringing an item that has bedthedailybeast.com/articles/2010/08/24/bedbugbugs or eggs attached to it into
an un-infested environment.
But poor sanitation and clutter
make it more difficult to locate, control and
eliminate an infestation after it starts.
Bedbugs play hide and seek well. Most
infestations are only discovered after their
bites appear on their victims. Human dwellings are a perfect environment for bedbugs
to thrive in and provide a reliable and convenient food source—your blood. Their
assault isn’t typically limited to the bed or
bedroom because they generally disperse
throughout the structure via wall cracks,
door frames, plumbing areas and electrical outlets. They live and breed in the tiniest cracks and crevices and are often hard
to detect with the naked eye. Bedbugs can Bedbug infestations have been discovered in
hide or lay their eggs virtually anywhere. residences, public places and even EMS stations.
They like cool, secluded spots, such as mattresses, box springs, wooden head boards, when few bugs are first present, can be chalpicture frames, furniture, carpeting, luggage lenging. It can also be crucial to preventing a
and clothing. They fasten their rice-like eggs full-scale invasion. Although bedbug detecto rough surfaces, which make the eggs diffi- tion and monitoring tools have certainly
cult to dislodge.
improved over the past 70 years, no detecMost people don’t notice the first signs tion tool is 100% reliable. Sometimes capturof the presence of bedbugs. Tiny brown ing the bugs or locating their eggs is the only
or black fecal spots and dots of dried dark way to be certain of their presence.
blood are common in their habitat area. Cast
Visual inspection can be time consumskins—hollowed out bedbug skins shed ing and labor intensive, but it’s still the most
during the nymph stage—are another sign commonly used and least reliable method of
your living space has been invaded. In size- detecting bedbugs. No special equipment is
able infestations, a sweet, foul odor may be required besides a bright flashlight, a good
given off by an oily liquid they emit.
set of eyes and a strong magnifying lens to
help identify eggs or small, freshly hatched
nymphs. These cryptic insects like to hide
Bedbugs lead a secretive life, and detecting and avoid being seen. Detection devices can
them in the early stages of an infestation, be placed under the legs of bed frames and
Photos Wayne Zygowicz/Janice Haney Carr
stop their rapid spread.
Lack of knowledge of common prevention techniques also aids bedbug tourism.
Most people aren’t aware of their comeback
or don’t believe they have a bedbug problem.
Nobody likes creepy bugs, and people whose
homes are infested avoid the topic to escape
the scorn and embarrassment associated
with having “bugs.”
just feed once while others move
in for a snack. Although numerous disease pathogens have
been discovered in bedbugs,
they haven’t shown the ability to
transmit and spread disease as
other insects do.
furniture to intercept the bugs as they migrate to their food source.
Inexpensive “pitfall” traps capture the bugs after they fall into the trap
and they can’t climb out. The traps work 24 hours a day with little
maintenance required, other than occasionally emptying out trapped
bugs and lubricating the traps with talcum powder. Other active trapping devices use CO2, heat or chemicals to lure the bugs into traps.
K-9 scent detection has become a popular and effective option for
detecting low-level infestations. Man’s best friend has been trained to
sniff out drugs, explosives, cadavers, mold, termites and cancer—why
not bedbugs? Specially trained bedbug dogs can inspect places where
humans can’t get too easily or where visual inspection is too tedious
and time consuming. A well-trained bedbug detection dog will detect
low levels of bugs, even as few as one. Good canines can differentiate
active bugs and viable eggs from old infestations with dead bug and
empty egg shells. The National Entomology Scent Detection Canine
Association supports this emerging science and is working to establish standards for all entomology scent detection canines, handlers
and trainers through an accreditation program.
Although bedbug canines are an effective detection tool, they
aren’t always 100% accurate. Dogs rely on a “scent picture” to locate
the bugs and that may be affected by air movement, wind direction,
humidity and temperature. Their effectiveness is directly related to
what they can smell. It’s important that a verification system is used
to confirm the validity of a dog’s positive “alert” to bedbugs. One
method is to have the handler produce physical evidence of the infestation (bugs or eggs) after a positive alert. Another confirmation
approach is to use a second canine inspector to positively confirm the
first dog’s work before spending money on extermination, which can
be complicated and expensive.
Choose 35 at www.jems.com/rs
Bedbugs: Now What?
They may be small and resilient, but don’t panic. Some feel that if
you’re able to see them, they can be killed with a direct spray of 91%
alcohol or simply vacuumed up. That may work in some cases, but
repeated inspections should be conducted in the following weeks to
make sure the dead critter was alone. And you have to carefully secure
and dispose of all vacuum bag contents because survivors can escape.
Most experts will tell you that finding and eradicating an infestation isn’t a simple job. Chances of conquering a large number of
bugs yourself are slim and using the wrong pesticides may drive the
creepy-crawlies deeper into the structure. So the best thing to do is
call in a licensed professional who’s trained in bedbug biology and
behavior to give you sound advice.
The three most common methods used to kill bedbugs are cooling, heating and chemicals. The Environmental Protection Agency
recommends cold treatments below 0° F (-19° C) for at least four days
but using cooling treatments in a large ambulance may be impractical.
Superheating is an effective method to kill bedbugs in all stages of
their lives but requires specialized propane or electric heating equipment. Rooms are superheated and monitored until the bug’s thermal
death point is reached (near 122° F) and maintained for a minimum
of one hour while strong fans circulate the heat. Heating and encapsulating an ambulance, for example, can cost as much as $1,500 per
occurrence. More than 300 consumer products currently on the
market are registered by the EPA to fight bedbugs. But buyers beware:
Before you apply any pesticides, read the label first and follow the
Choose 36 at www.jems.com/rs
What’s Buggin’ EMS
directions closely. Using incorrect chemicals in the wrong locations may make you
or your patients sick and not fix the problem.
The key to eliminating and preventing
bedbugs is to develop an integrated pest
management strategy that includes awareness, prevention and education. Many states
have formed bedbug task forces, and public safety officials (i.e., police, fire and EMS)
should join their collaborative efforts to
understand the magnitude of the bug problem in their community and help reduce the
risk of exposure for first responders.
An Ounce of Prevention
Public safety leaders must take proactive
steps to keep these bugs out of first responder’s vehicles and station facilities. The consequences of taking these small bugs lightly
can have enormous operational implications. Fire stations around the country have
been closed for months due to bedbug infestations, which can directly affect service levels and disrupt personnel.
First responders (and their families) rely
on their managers to wage a proactive battle
against bedbugs before they end up in first
Have a strategy and follow the following
simple prevention techniques:
>> Develop SOPs. These should address
transporting patients with bedbugs or from
properties with known infestations;
>> Flag all addresses with known infestations.
This will give responders early warning of
the problem. Don disposable shoe and head
covers, gloves and gowns before entering,
and avoid pants with cuffs;
>> Develop a bedbug resources list. Include
numbers for immediate inspection, treatment and long-term prevention. Most
agencies don’t have the assets
to allow an ambulance to sit idle
while it waits for
>> Quarantine units,
equipment and clothing
after exposure. This can
prevent transporting the
bugs into your station;
>> Bag and seal uniforms and
linens after exposures. Laundering most clothing with hot
water and detergent, followed by
dry cleaning or drying for at least
20 minutes, should
kill all bedbugs;
>> Watch where
you place your bags.
Leave kits outside
a residence known
to have bedbugs.
Avoid placing medical bags on upholstered furniture,
bedding or carpeted floors on all
calls, or consider
replacing soft medical cases with hard
>> Launder bedding weekly. Clean A verification method to confirm a bedbug canine’s positive alert to bedbugs is
blankets and bed- to have a handler produce physical evidence of the infestation afterward.
spreads in sleeping
quarters with heat;
>> Provide bedding encasements. Mattress >> Centers for Disease Control and Prevention. (n.d.).
and box springs encasements aid in early
Bedbug FAQs. In Centers for Disease Control and
detection and can prevent infestations
Prevention. Retrieved Feb. 2, 2012, from http://
in beds when bedbugs are introduced in
>> Cooper R. (n.d.). Bedbug 101: Avoiding infestations.
>> Vacuum and clean surfaces. Vacuums and
In Bed Bug Central. Retrieved Feb. 2, 2012, from
surface cleaning play a major role in bedbug
management. (Remember eggs may not vacavoiding-infestations.
uum up easily.) Tightly bag up and dispose of >> Cooper, R. (n.d.). Bedbug 101: Canine scent detecvacuum’s contents immediately after use;
tion. In Bed Bug Central. Retrieved Feb. 2, 2012, from
>> Seal personal gear. Keep clothing and gear
in tightly sealed plastic containers to avoid
transporting the bugs to your home;
>> Cooper, R. (n.d.). Bedbug 101: Identification. In Bed
>> Eliminate clutter. Cluttered areas can
Bug Central. Retrieved Feb. 1, 2012, from www.
cause a bedbug control program to fail; and
>> Be on alert. Be on bedbug patrol on every
call, and have a bedbug code word.
>> Miller DM. (n.d.). Non-chemical bedbug management. In Virginia Department of Agriculture and
Consumer Services. Retrieved Feb. 1, 2012, from
www.vdacs.virginia.gov/pesticides/pdffiles/bb-nonOf all the things first responders have faced
over the years, including infectious diseases,
flu and terrorism, these small pests pale in >> Porter MF. (n.d.). Bedbugs. In University of Kentucky,
comparison. Although they may not make
College of Agriculture. Retrieved Feb. 1, 2012, from
you sick, they will ruin your day. They spread
quickly, and killing them can be expensive >> U.S. Environmental Protection Agency. (n.d.). Bedand time consuming. So start working on
bug information. In Environmental Protection
an integrated pest management strategy for
Agency. Retrieved Feb. 1, 2012, from www.epa.gov/
your organization so that when you lay your
head down tonight, you sleep tight. JEMS
>> What you need to know about bedbugs.
(n.d.). In MSNBC. Retrieved Feb. 1, 2012, from
www.msnbc.msn.com/id/11915026/ns/dateWayne M. Zygowicz, BA, EFO, EMT-P, is the EMS chief
line_nbc-dont_let_the_ bed_bugs_ bite/t/
for Littleton (Colo.) Fire Rescue. He has been involved in
EMS and the fire service for 30 years. He also serves as
a member of the JEMS Editorial Board. Contact him at
Photo Wayne Zygowicz
>> continued from page 59
Watch Steve Berry and JEMS
Editor-in-Chief AJ Heightman tell
you why this book is a must-read!
Practice cultural sensitivity to provide care
to immigrant communities
>> By Keith Widmeier, NREMT-P, CCEMT-P, EMS-I, BA, & Emily Coffey, BA, NREMT-P
our unit is dispatched to a motor vehicle collision (MVC)
that’s 10 miles north of your station on the major highway going through the county. Bystanders report one
female patient in the driver’s seat who’s trapped in an
upside-down vehicle. Bystanders advise that she’s in distress but are unsure whether she’s hurt because she doesn’t
As you responded to the MVC, you started contemplating what language your patient speaks. The county you serve
has a large agricultural community with many immigrants who
live there on work visas for eight to 10 months of the year. The
immigrants tend to be from Latin America, with many individuals from Mexico, Guatemala, Honduras and El Salvador. This leads
you to believe that the patient likely speaks Spanish. En route, you
started evaluating the resources you have available to assist you
with communicating with your patient.
On arrival, you note a four-door red sedan on its top. There’s a
Mexican flag sticker on the window. The patient is unrestrained,
attempting to open the door without success. The doors only
open about an inch. The windows are busted out, but the opening
is not big enough to extricate the patient.
Photo Glen Ellman
>> continued from page 63
Your patient is clearly scared. You identify fear in her body language and tone;
however, your Spanish is limited to the
Spanish I class you had your freshman year.
You ask, “Do you speak English?” in Spanish. Your patient responds “no.”
Given the low volume of your service,
funding is rather limited. You contact dispatch in accordance with your local standard operating procedure. They have one
dispatcher who speaks fluent Spanish; however, she’s unavailable. A nun from a local
Catholic church speaks fluent Spanish and
often volunteers her services, but she’s currently assisting another church in a contiguous county and is also unavailable.
Dispatch contacts the local county
hospital to request assistance. They provide you with access to their outsourced
telephone translator service. Using a cell
phone to contact dispatch, they conference
you into the translator.
You advise the translator of your name
and your perception of the situation. You
ask that the translator explain the process of
extrication and spinal immobilization. The
translator writes down everything you said,
and you pass the cell phone to the patient.
She begins to respond to the translator. She
hands the phone back to you. As you continue to evaluate the patient, you notice a
deformity of her right lower extremity.
Based on your assessment, you recommend the patient be transported to the
regional hospital in a contiguous county
that has orthopedic capabilities. You
explain this to the translator. The translator
advises that the patient doesn’t want to go
outside the county. Her family has only one
vehicle, which is no longer usable. She fears
that her husband won’t be able to visit her.
You explain to the translator the likelihood of the patient being transferred due
to the orthopedic injury, but the patient is
adamant about being close to her family.
Ultimately, you compromise and transport
her to the local county hospital. She’s concerned about going to the hospital at all, but
she’s willing to accept this agreement.
EMS providers focus on doing everything
they can to provide quality patient care. As
patient advocates, we focus on scene management, clinical prowess and skill performance. If we’re able to achieve excellence in
these areas, we often feel that we’re doing
everything we can for our patients. However, that clinical knowledge and skill performance is only part of the job. If you
don’t have good bedside manner, you
won’t be treating your patient to your fullest potential.
Research demonstrates that good bedside manner greatly reduces the risk for malpractice litigation.1 Without understanding
the various cultures that exist in your service area, your bedside manner can only go
so far. True patient advocacy requires both
an understanding of the cultures and groups
most prevalent in your service area and a
general cultural skill set that will enable you
to interact with groups with which you’re
unfamiliar. It’s important that you’re able
to empathize with the patient and their cultural context. Although it isn’t imperative
to experience the situation firsthand, good
patient advocates are able to understand the
cultural point of view of the patient.
The LEARN Model
The LEARN model is an effective tool for
working with your patient to develop a culturally sensitive solution.2
patient feel at ease.
The provider should acknowledge and
discuss the differences and similarities in
the perceived issues at hand. Remember,
your foremost goal as a patient advocate
should be the resolution of the medical
emergency or traumatic injury. But the
patient’s cultural concerns may inhibit
standard treatment and may require the
provider to think outside of the box.
The provider will then need to recommend a course of action. This can be
complicated if the course of action you
recommend contradicts the patient’s cultural beliefs, which can be so strong that
the patient may see the risk of betraying their values as greater than the risk of
After evaluating the situation, both perspectives and the recommended course
of treatment, the provider should attempt
to negotiate a treatment plan that will
be acceptable to the patient and maximize the ability to provide the physical
care required. Remember we can’t force
patients to choose the treatment plan that
we feel is in their best interest.
Every patient has the right to choose if
and to what degree they’d like to consent to
care. If we refuse to budge on our recommendations, the patient may refuse care. If
that decision is made due to our own stubbornness, then we aren’t looking out for
the patient’s best interest.
Immigrant Patients & Families
The first step is to listen to your patient’s
perception of the problem. Although this is
a universal principle during patient assessment, it’s imperative to evaluate from a
cultural perspective when the patient’s
experiences are profoundly different from
your own. The use of active listening skills
can reveal valuable information about the
patient’s concerns of the perceived emergency, as well as religious, moral, ethical or
cultural issues that may arise.
The next phase is to explain your perception of the problem at hand. It’s important not to discuss your personal beliefs on
religion, politics or morality. You should
only share the information you interpret
to be medically relevant. Remember, it’s
not our job to preach, witness or lobby for
a particular viewpoint; our focus should be
on providing medical care and making the
The U.S. immigrant community varies
widely. Depending on your location, you
may regularly interact with a variety of immigrant communities. EMS providers should
know how important it is for people to hold
onto their culture, which may interfere with
what’s generally accepted as the best course
of action from a clinical perspective.
When considering implied consent,
we generally maintain that treatment
should be performed in accordance with
the assumed desires of a reasonable person of sound mind. However, some cultural beliefs prohibit specific practices that
would be of no concern within American
culture at large. For example, most Americans aren’t opposed to porcine insulin, but
Jewish and Muslim patients might choose
to accept the risks of hyperglycemia rather
than receive this particular medication.
Although many Americans aren’t concerned about the origins of medication or
the gender of the EMS provider, such concerns may arise. Other cultures may object
to care that’s provided by members of the
opposite sex, or they may have certain
requirements that must be met to ensure
modesty while care is provided. In those
cases, we should use the LEARN model and
make the appropriate accommodations.
When people move to the U.S., some are
more likely to move to places in which
family members or acquaintances also live,
or to areas with well-established ethnic or
racial neighborhoods. Communities based
on cultural identity often develop from
an influx of people from a specific region.
These communities can vary in size and
diversity. In larger metropolitan areas,
you may notice distinct divisions between
communities: Puerto Rican, Mexican,
Honduran and El Salvadoran, for example.
In areas with smaller populations,
though, you may notice a Latin American
community that comprises individuals
from various countries throughout Central and South America. Generally, as the
population of the service area grows larger,
so do the opportunities for differentiation.
Communities with strong racial or ethnic identities may have their own grocery
stores, recreation centers, restaurants and
places of worship. This isn’t to say if you
aren’t a member of the community, you
can’t enter, but these facilities tend to be
tailored to the communities they serve.
This may mean that the written information and verbal communication within the
facility (other than state and federally mandated information) may not be in English.
Generational differences also exist
among immigrants to the U.S. First-generation immigrants, or those who were born
abroad, will generally relocate to communities that resemble the country from
which they moved. Geographic mobility
is often limited among these individuals,
because they may be less comfortable with
American culture and more at ease with
the culturally delineated areas to which
they first move.
These communities have accommodations that ease the process of assimilation and reduce cultural tensions.
First-generation immigrants may also be
hesitant to summon assistance or to trust
public safety workers, particularly when
they move from areas in which governmental corruption is high.
Second and subsequent generations
tend to demonstrate their culture along
with the American culture. The language
barrier in these generations may be nonexistent, because these individuals tend to
grow up speaking English and the language
of their parents. Second-generation Americans are often educated in U.S. schools
and are socialized into mainstream American culture. Because of this socialization to
the broader norms of the U.S., individuals
from second and later generations may be
more comfortable with public safety workers and less adherent to specific cultural
practices that might impede patient care.
Many major metropolitan areas across
the country have created some type of
immigrant community liaison program
from public safety.3 Most of these endeavors have been led by law enforcement and
public health agencies, but as a profession,
EMS is fully capable and well-placed to
take an active role in community outreach
for the immigrant community.
As a profession, one of the things we truly
lack is community outreach. When we perform community outreach, we don’t specifically exclude the various immigrant
communities within our service district
from coming. However, a variety of reasons often prohibit those populations from
attending the outreach activities.
One reason may be a lack of knowledge
about the available courses. Large metropolitans may have a local newspaper or
other media source that’s specifically targeted toward an immigrant community.
Regardless of language ability, many immigrants may choose this avenue of media for
their local news. Therefore, if EMS providers aren’t making their community outreach presence known within these media
sources, they may not be doing their best
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to incorporate all the citizens within their
Another issue may be immigrant populations fearing the unfamiliarity outside of
their community. It’s common for immigrants to remain among their own people.
However, this doesn’t mean they’re choosing not to receive the education that your
service is providing—just the location
where it’s held.
The solution is to hold some classes on
their turf. Discuss the idea with a community center or organization that serves the
population you’re trying to help. Bringing
this education to their location will help
spread the message of safety and emergency preparedness.
Language barriers can be an issue for
community outreach as well. Although
many of the educational materials (e.g.,
American Heart Association.) are available
in a variety of languages, it may be difficult
to teach without speaking the language
yourself. Fortunately, a variety of studyat-home material is available in languages
other than English.
It may also be beneficial to partner with
other healthcare providers in the community to ensure your service’s message
spreads. An added benefit of working with
others in the community is that your agency’s exposure is increased, and you may
learn some additional phrases within the
language. Also, the community will be
familiar with you and your service.
Language barriers are a multifaceted issue.
An inability to communicate with the
patient, patient’s family and other individuals on the scene can cause a variety of hardships, misunderstandings and accidents.
Furthermore, the risk of complications
from language barriers is elevated when
providers have a false sense of the effectiveness of communication.
Scene safety can be difficult to ascertain
if you’re unable to understand the verbal
information on scene. On-scene conversations in another language might not reveal
the normal clues about potential violence
against providers, drug use, family violence or environmental hazards. EMS providers lose the ability to understand and
control the scene in which they’re working.
Body language is extremely important in
Photo Craig Jackson
>> continued from page 65
Most Americans aren’t opposed to porcine insulin,
but Jewish and Muslim patients might choose to
accept the risks of hyperglycemia rather than
receive this particular medication.
these situations, particularly when considering scene safety.
Ultimately, provider safety is paramount, and if you feel that the scene may
be deteriorating, you should attempt to
retreat to a safe distance in accordance with
local policies and procedures. Although
an overestimation of the hazards at hand
might be embarrassing, it’s always best to
take the safest course of action regarding
your own welfare.
When communicating with patients
whose predominant language isn’t English, it may be difficult to obtain a full and
accurate account of the present event or
the patient’s past medical history. In times
of stress, individuals who are fluent in English may use their primary language instead,
simply because it requires less active management and thought on their behalf.
Calls in immigrant communities aren’t
exempt from hysterical family and friends
on scene, just as they aren’t in “normal”
American families. Unfortunately, without the ability to communicate with these
individuals, the de-escalation skills that
many EMS providers have either learned
or developed over time may become ineffective. Although some tools exist to assist
with language barriers, such as translation
by phone, many of them are costly, burdensome or time consuming.
One relatively inexpensive and common
solution to a language barrier is to attempt
to use a translator on scene. However, this
may cause a variety of ethical dilemmas.
One example is when a younger, secondgeneration American needs to translate for
first-generation Americans. The secondgeneration immigrant may be a child.
So EMS providers need to consider
whether it’s appropriate to share the information. Will the child be able to accurately
reflect the message that you’re attempting
to transmit in the necessary tone? Beyond
inflection and communication issues, you
may need to expose the child to potentially
scarring situations to use them as a translator. Consider the thought of requesting a 10-year-old child to ask his mother
whether she’s sexually active, uses any illegal drugs or abuses any prescription drugs.
In some cases, the family may travel for
the husband’s employment. Because the
husband is interacting with other English
and non-English speaking people, he may
become acclimated quicker than his wife.
The husband may be an ideal translator, but
some problems could arise from his translation. In cases of suspected family violence,
the suspected abuser wouldn’t necessarily
translate their victim’s answers correctly.
Another option for translation is using a
bystander. EMS providers should exercise
caution with using bystander translation.
You may be forcing the patient to share medical information with someone else who
isn’t a medical professional. Although that
person may be a coworker or friend, you
truly have no way of obtaining informed
consent to include this person into the case
without speaking the language.
Other options for addressing language
barriers include telephone services, translation apps and flip guides or “cheat sheets.”
Many hospitals and EMS systems, such as
the ones in our case, use telephone-based
translator services. Although this can be
extremely effective and beneficial, rates
for these services may be $4 per minute or
more, meaning they aren’t financially feasible for many services.
One thing to note with translator apps
on smartphones and tablets is that most
require you have a basic knowledge of the
language. A patient speaking a regionalized dialect of a common language may not
translate in the app.
Many flip guides printed in the U.S.
include common medical phrases in Spanish. Some pocket charts are laminated and
have pictures identifying specific medical
and traumatic problems. These products
may be useful and tend to be fairly cost
effective. When you use them, try to focus
on short, literal statements and use yes-orno questions, so you aren’t faced with the
translation of a lengthy answer.
When communicating across a language barrier, remember to speak slowly
and steadily. Many individuals who don’t
speak English may understand spoken English quite well, so you may be able to communicate more than you originally thought.
The key is to be patient and not to
make assumptions. The U.S. doesn’t have
a national language, so you should never
think of individuals who don’t speak English as stubborn or assume that they’re
refusing to fit into mainstream culture.
Patient advocacy is important whether
you’re caring for someone who’s similar to
you or someone who comes from a vastly
different cultural background. Cultural sensitivity and an overall concern for the physical and emotional well-being of all patients
will establish a good framework from
which you can become a patient advocate.
Remember that the individuals who
belong to the groups we’ve discussed often
face discrimination and prejudice daily;
you may be one of the few people outside of
their community who seems to truly care
about their feelings or concerns.
When you’re able to provide quality
care that incorporates the patient’s values,
beliefs and cultural practices—and allows
the patient to feel that their culture is important—you’ll know that you’re well on the
way to being a culturally competent provider. JEMS
Keith Widmeier, NREMT-P, CCEMT-P, EMS-I, BA, is the
training officer for Wayne County EMS in Monticello, Ky.
He’s responsible for all initial, continuing and community
education for Wayne County.
Emily Coffey, BA, NREMT-P,is a paramedic at Wayne
County EMS and an instructor and graduate student of
sociology at Western Kentucky University. She received
her bachelor’s degree in sociology and sexuality studies
from Western Kentucky University in 2010.
1. ucco A. A Friendly Approach to ReducB
ing Medical Malpractice Litigation. Berkeley:
2. erlin EA, Fowkes WC. A teaching frameB
work for cross-cultural health care: Application in family practice. West J Med.
3. ational League of Cities. (n.d.). Public
Safety Programs for the Immigrant Community. In National League of Cities. Retrieved
Apr. 1, 2012, from www.nlc.org.
For more about practicing
culutural sensitivity, visit
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Photos Douglas County (Ga.) Fire Department
Lt. Stacie Farmer, Douglas County Fire
Department, demonstrates how to
insert a King LT-D.
Prior to insertion, EMS providers
should check the cuffs for proper inflation and deflation.
Without using excessive force, advance
the King LT-D until the base connector
aligns with the teeth or gums.
Apply a water soluble lubricant and apply a tongue jaw
lift. Begin insertion by introducing the King LT-D to the
corner of the mouth.
Rapid assessment is key for managing numerous patients
>> By Paul E. Phrampus, MD
ou’re one of the first-arriving units
at the scene of a multi-story nursing
home fire. A significant fire is being
battled by firefighters, and there’s smoke
pouring from the building. Patients are arriving at the triage intake area, and it’s obvious
numerous patients are in respiratory distress ranging from mild to severe. You’re the
senior paramedic and will need to begin the
treatment decision making.
The ability to rapidly assess the need to
provide airway management to a patient is
a critical component of the EMS provider’s
skill set. Not many decisions in EMS are
both time sensitive and critically important.
Airway management is a combination of
skills that includes the ability to properly
assess the patient, followed by the formulation of a plan and then the ability to carry
out the psychomotor skills associated with
devices and procedures.
When encountering a situation during
which multiple patients require active management, our assessment skills won’t change
dramatically; however, our decision-making
and plan formulation will vary depending
on a number of factors, such as expertise,
human resource and equipment availability. A discussion of airway management for
the individual patient will help to segue into
some of the different thought processes,
decision making and plans associated with
managing a scene that has multiple patients
requiring airway management.
Advance the tip of the King Airway between the
tongue and soft palette, rotating the tube midline.
Figure 1: Airway Assessment Diagram
airway, providing oxygen and observing,
through advanced procedures, such as
endotracheal intubation (ETI) and surgical
cricothyrotomies. It’s important to remember there’s no “one size fits all” approach to
airway management. Avoid a thought process of “airway management equals ETI.”
For example, ETI has to be recognized as a
time- and equipment-intensive procedure
when considered from beginning to end in
a mass casualty incident (MCI).
Patients may require airway management
for a variety of reasons, including medical, trauma and environmental conditions.
Essentially, the need for airway management
falls into three broad categories: mechanically opening the airway to facilitate the passage of air/oxygen, facilitating the delivery
of positive-pressure ventilation and finally,
protecting the airway against potential aspiration and other major contamination of the
Need for airway management
Need to open airway only?
Head tilt chin lift
side if possible
Need positive pressure and/
or aspiration protection
Airway management spans a wide variety of potential treatments ranging from
the basics of inserting an oropharyngeal
>> continued from page 69
>> Compare and contrast the practice of prehospital airway management between routine
single-patient encounters and those situations involving multiple patients.
>> Describe ways to engage laypersons or minimally trained providers in the care of airway
management at the scene of a mass casualty incident involving multiple patients requiring
>> Describe the indications, contraindications and limitations of supraglottic airway
>> Describe the indications, contraindications and limitations of subglottic airway
The need for mechanically opening the
airway arises from conditions that prevent
the patient from doing so on their own. The
most common airway compromise results
from depressed mental status leading to a
relaxation of the tongue, which falls posteriorly and occludes the airway of the supine
patient. Other examples include swelling of
the airway, blood and foreign body obstructions, as well as direct and indirect trauma
to the airway. Indirect causes include inhalation and ingestion of toxic substances, as
well as thermal injuries—all of which can
cause significant swelling.
The need to deliver positive-pressure
ventilation can arise in any condition during which the patient is suffering from
hypoxia and has an impairment of respiratory function. Depressed mental status,
pulmonary edema or bronchospasm from
asthma, chronic obstructive pulmonary
disease or toxic inhalation are common
causes of situations that may require positive-pressure ventilation.
Protection against aspiration is needed
for patients who are unable to mount protective reflexes that assist in clearing the
airway. Often, this patient population has a
depressed mental status or unconsciousness.
Risk of aspiration may include blood in the
airway, as often occurs after traumatic injury,
conditions causing excessive salivation and
the vomiting of gastric content. In some situations, the entire airway management plan
for the patient may revolve around the need
for suctioning and mechanically assisting
the patient to reduce the aspiration risk.
Pertinent airway anatomy to consider begins
with the upper airway structures, including
the oral pharynx, tongue and epiglottis. The
glottic opening is the opening between the
vocal cords, or larynx, which serves as the
dividing point between the upper and lower
Anterior to the larynx is the thyroid cartilage and the cricoid ring. The latter two
prominent structures serve to protect the
glottic opening and also provide the palpable
landmarks to perform a surgical cricothyroidotomy or transtracheal jet ventilation
through the cricithyroid membrane. The
lower airway includes the trachea, bronchi
and distal to the lungs.
The assessment of a patient with a potential need for airway management generally
focuses on the patient’s respiratory, neurologic and cardiovascular systems. In general, the assessment begins the moment you
see the patient.
A simple assessment of the neurologic
exam is important to determine whether
the patient has the mental status capacity
to maintain airway protective mechanisms.
In the unconscious patient, this is assessed
by noting the presence or absence of a gag
reflex. In the case of patients exhibiting
delirium and other forms of altered mental
status in which they may be speaking, yelling
or screaming during the initial assessment
while they have serious underlying injury, it’s
likely they won’t require immediate airway
assistance other than supplemental oxygen.
Special attention to the respiratory
rate and pulse are important when assessing a patient’s vital signs. Oxygen saturations should be measured. You should also
observe for additional signs of respiratory
distress, such as tachypnea and accessory
muscle use. It’s important to remember
that in a patient with depressed mental status, the signs of respiratory distress may be
blunted or absent—even in the presence of
Skin color, temperature and moisture
can provide such information as the level
of sympathetic nervous system activation.
Oxygenation may be important information to consider as well. Pale skin can indicate shock, while cyanotic skin is a critical
indicator of severe, systemic hypoxemia.
Auscultation of the lungs can provide
valuable information when assessing the
patient’s need for airway management. The
most important assessment from auscultation is to determine the presence or absence
of airflow into the lower airways. Having
none, or diminished sounds of air movement, suggests obstruction or lack of respiratory effort on the part of the patient. Once
the presence of air movement is established,
noting the quantity of air movement, along
with sounds indicating obstruction, is the
next logical step.
Snoring or sonorous sounds are indicative of a partial obstruction most often
caused from the tongue. Stridor is a highpitched inspiratory sound associated with
the obstruction of the upper airway, such
as that associated with swelling of the glottis opening.
Wheezing is generally an expiratory
sound associated with bronchospasm of the
lower airways, but in more severe cases, it
may involve an inspiratory component. As
bronchospasm worsens, there’s an increase
in the overall obstruction of the lower airways and may begin to also include inspira-
Epiglottis: Leaf-shaped structure located posterior to the base of the tongue.
Hypopharynx: The laryngeal part of the pharynx extending from the hyoid bone to the lower margin of the
Larynx: The portion of the airway connecting the throat with the trachea.
Nasopharyngeal Airway: A basic airway that is inserted via the nose into the posterior oropharynx, behind
Oropharyngeal airway: A basic airway that is inserted via the mouth into the posterior pharynx, behind
Treatment and treatment options will vary
significantly based on the resources available in the case of a multi-patient airway
encounter. In this context, resources include
the availability of personnel, as well as their
abilities, and the specialty equipment that
may be needed in such a situation. Another
consideration in overwhelming multiple
patient encounters is the engagement of
untrained medical providers and laypersons in realistic tasks that can assist until the
situation is stabilized.
After rapid assessment and determination of the need for airway support using
the categories suggested, the provider(s) can
then begin to implement treatment plans
being mindful of the fact that MCI situations may require deviations from typical
standard treatment options. One of the biggest differences for MCIs is that we do not
use ETI routinely for airway management.
In multi-patient airway encounters, this
method of securing the airway often isn’t
practical due to the extensive amount of
needed equipment, setup time, and the skill
and expertise level.
In MCI situations, EMS providers should
immediately try to determine which patients
will need only supplemental oxygen. In the
setting of constrained resources, the application of oxygen should be limited to those
exhibiting signs of respiratory distress with
alterations of their oxygen saturations.
A category of patients who may be treated
fairly quickly involve those who require only
minor mechanical assistance that can be
accomplished by opening their airway. This
includes patients with altered mental status
illustration courtesy lma North america
tory wheezing and progress to not hearing
any air movement at all in the worst cases.
As a rapid assessment process is being
carried out, it’s worth thinking about the
categorization described above: 1) Does
the patient need their airway mechanically opened; 2) Does the patient require
positive-pressure ventilation; and 3) Does
the patient need protection for aspiration or
some combination of the three situations?
The proper assessment of the patient will
assist you in forming an airway management plan. However, formulating airway
plans will change when dealing with a MCI
during which multiple patients require airway attention.
or those who are exhibiting excessive salivation or vomiting but are otherwise able to
maintain their own airway. These patients
can be simply placed on their side in a lateral
recumbent position to assist them in clearing
their airway. Depending on the availability of
resources, a lesser-trained provider—or perhaps even a layperson—can be assigned to
the patient with a suction apparatus to assist.
In situations that involve only a single
patient, this can be remedied by a number
of things: a head tilt chin-lift maneuver, the
insertion of an oral or nasal pharyngeal
airway or the application jaw thrust with
bag-valve mask (BVM) assistance. In situations involving multiple patients for which
resources are strained, other forms of treatment may be necessary.
In the formulation of the plan, it’s important to remember that the most common
cause of airway obstruction in the unconscious patient is the tongue falling backward
to occlude the hypopharynx. In such circumstances, removing an article of clothing
from the patient, such as a shoe, may serve
as an appropriate prop to place behind the
patient’s C-spine to maintain the head in a
head tilt-chin lift position that will serve to
elevate the tongue from the posterior hypopharynx, thereby creating a patent airway.
Patients who aren’t responding to a
mechanical opening of the airway may
require more advanced intervention, which
may include positive-pressure ventilation to
deliver oxygen to avoid hypoxia. In such circumstances, the next logical choice is BVM
ventilation as a temporizing measure.
BVM ventilation can be accomplished
by one skilled rescuer but many times will
require two. In cases for which it’s difficult to
Illustrated above are the key components of the
LMA airway. Note the integrated bite block and
fixation tab that helps maintain proper cuff depth.
maintain a seal with the mask, or for which
the patient requires simultaneous application of a jaw-thrust maneuver to maintain a
patent airway, a two-person BVM ventilation
technique is essential.
When performing two-person BVM, the
more experienced person should be maintaining the seal of the mask, and the lesser
experienced or even a layperson can perform
the part of squeezing the bag.
When BVM ventilation is necessary, it’s
often enhanced by an adjunct, such as a nasopharyngeal or oropharyngeal airway. Adjunctive
basic airway devices are designed to creative
patent passage posterior to the tongue to
allow effective exchange of gases for the
patient requiring this level of support. It’s
important to remember the patients that
have an intact gag reflex won’t tolerate an
oropharyngeal airway. A nasopharyngeal
airway should be avoided with patients who
have severe facial trauma and the potential
for skull fractures.
Simply opening the airway of the patient
who needs positive-pressure ventilation
assistance or protection from airway aspiration gastric contents isn’t enough. In these
circumstances, more advanced measures
of airway care are necessary. In such situations, several options exist.
Advanced airway treatment options can
be divided into two broad categories: supraglottic and subglottic—depending on how
the device or procedure is designed to function. The decision of which method to use
will often be determined by the clinical cause
necessitating airway management, along
>> continued from page 71
with the presence or absence of a gag reflex
and whether local protocols support the
use of sedative and paralytic medications to
facilitate airway management.
Supraglottic airways are designed to be
used above the vocal cords, or glottis opening. They’re placed using a blind technique
and create a seal around the glottic opening but don’t actually cross the vocal cords.
Supraglottic devices are contraindicated
in situations for which the glottic opening
is compromised, threatening the patency
of the airway. Examples include laryngeal
swelling from thermal burns, anaphylaxis
and direct trauma to the neck with an
Similar to oropharyngeal airways, supraglottic devices aren’t tolerated in patients
with intact gag reflexes. ALS providers
should consider use of sedative medications
for patients with an intact gag reflex requiring a supraglottic device..
Common supraglottic devices include
laryngeal mask airways (LMAs), as well as
King airway devices. Advantages of both
the LMA and the King tubes include overall
ease-of-use, requiring little extra equipment
and set up, as well as a rapid insertion time.
When properly inserted, these devices
afford some level of airway protection
from aspiration. In general, supraglottic
devices require only the device itself and a
syringe to inflate either the cuff or the balloon of the device.
LMAs have had a long history of use in airway management in the hospital setting.
They have a long track record of being safe
and relatively easy to use. During the past
several years, they’ve been introduced into
the prehospital care setting. The LMA is
designed to create a seal around the entire
glottic opening by leveraging itself against
the posterior pharyngeal wall. An inflatable
cuff that surrounds the laryngeal opening
creates a seal that facilitates the ability to use
positive-pressure ventilation and provide
some protection against aspiration.
The size of the LMA is selected on the
basis of the patient’s weight. Once the proper
size LMA is identified, the device is initially
prepared by checking the seal of the mask.
Once complete, the air is completely evacu-
Inflate the cuffs per the manufacturer’s recommendations until a seal is obtained. Connect
the King Airway to a BVM, ventilate, and slowly
withdraw the King Airway until ventilations
become easy and free flowing.
Listen to epigastric region and lung sounds to
confirm proper tube placement.
ated from the cuff prior to placing the device
into the patient. The placement of the LMA
is a blind technique assisted by elevating the
tongue, often with the blade of a laryngoscope or gloved thumb. The device is placed
in and guided into the posterior pharynx
anatomically. Once placed, the cuff is inflated
with a syringe with the proper amount of air
indicated on the packaging of the LMA.
Once the LMA cuff is inflated, a BVM
should be connected and ventilation
attempted. Observation of chest rise, auscultation of the lung sounds and the presence
of end-tidal carbon dioxide (EtCO2) indicate
a properly placed device that’s functioning.
Assess for the possibility of an air leak by listening during the positive pressure created
by the squeezing of the BVM.
If a leak is encountered, place additional
air into the cuff and reassess ventilation and
seal quality. In some cases, the LMA will
need to be removed and replaced to be able
to obtain an adequate seal that allows for
positive-pressure ventilation and protection.
A common cause of an irresolvable leak during the placement of an LMA is the folding of
the distal tip of the LMA cuff back onto itself.
The King airway has rapidly become a popular device for airway management in the
prehospital care setting. Its ease of use, quick
setup and insertion are ideal features for this
supraglottic device. Newer versions of the
tube also facilitate gastric emptying through
a suction port that allows a gastric tube to be
placed in the stomach through the tube. This
is an important consideration for reducing
the risk of aspiration during the definitive
management of the patient when the King
tube will need to be removed.
The device features a high-volume,
low-pressure balloon system that creates
a seal in the hypopharynx and distally in
the esophagus. This effectively isolates the
glottic opening and allows for the use of
positive-pressure ventilation and provides
some protection against aspiration. Unlike
its predecessor, the combitube, King tubes
are designed to be placed into the esophagus
every time. The decision making surrounding the use of the device is also much simpler.
The selection of a properly sized King
tube is based on the height of the patient.
Once the proper tube is selected, the
tongue is lifted, and the device is placed in
the patient until reaching the guide marks
on the tube, which is similar to the placement of an LMA. Once placed, the balloon
is inflated with proper amount of air that’s
indicated on the package for the device with
a syringe. An assessment of effective ventilation is conducted similar to that described
for the LMA.
If a leak is detected, additional air can be
placed into the balloon. If an air leak persists
after adding additional air to the balloon,
the device should be gently pulled back
approximately 1–2 cm; that will often create
a seal. Studies have shown that the King tube
is so easy to use that laypeople were able to
successfully place it with instructions given
over the phone.
Subglottic Airway Management
Subglottic airway management techniques
involve devices or procedures that either
cross the vocal cords or are performed below
the vocal cords. Most commonly, subglottic
airway management is accomplished by ETI.
Other forms of subglottic emergent airway
treatment include surgical cricothyrotomy
and trans-tracheal jet ventilation.
ETI has long been the mainstay of airway
contraindication, or where there’s ineffective
use of a supraglottic device and an inability
to perform ETI. A cricothyrotomy can be
accomplished fairly quickly with a minimum amount of required equipment.
A cricothyrotomy is accomplished by
identifying the cricothyroid membrane and
making an incision through the skin. Then,
through the membrane itself, a tracheal tube,
such as a 6.0, is placed directly into the trachea. Once the tube is placed, the cuff of the
tube is inflated and an assessment of adequate ventilation is performed.
Potential complications of surgical cricothyrotomy include bleeding, placement of
the tube into a false passage in the neck but
outside of the trachea, as well as dislodgment
of the tube after it’s placed—because they’re
notoriously difficult to secure.
In dire emergencies when a patient is suffering from persistent hypoxia in the setting of being unable to otherwise oxygenate
them, transtracheal jet ventilation may be
considered. This involves performing a needle cricothyrotomy through the cricothyroid
membrane and providing oxygen through a
catheter via a high-pressure oxygen source.
Encountering a situation that necessitates
the assessment and management of patients
requiring airway management can present
a significant challenge. It will require a different thought process and set of decisionmaking skills that vary from the routine
practice of airway management during a
2. When conducting a rapid assessment of a patient
for the purposes of considering airway management, you hear stridor. This is an indication of
a. occlusion of the upper airway by the tongue
that may require an oropharyngeal airway.
Paul E. Phrampus, MD, is an associate professor in the
departments of emergency medicine and anesthesiology at the University of Pittsburgh School of Medicine.
He’s the director of the Winter Institute for Simulation,
Education and Research (WISER). He’s also a former paramedic and remains an EMS educator. He can be reached
d. none of the above.
Test your comprehension with this post-article quiz. Answers are provided at the end. Photocopying is permitted
for nonprofit training purposes only. For readers in need of continuing education credits, please visit JEMSCE.com to
choose from courses that are CECBEMS approved and meet NREMT refresher requirements.
1. The most common cause of the obstructed airway in the unconscious patient is
a. a swelling of the glottic opening.
b. a foreign body.
c. relaxation of the tongue causing an occlusion of the hypopharynx.
d. a result of vomiting and excessive salvation.
single patient encounter.
Rapid triaging of the need for airway
management is important. Creating a categorization of those patients who simply
need supplemental oxygen from those
who require assistance with the mechanical opening of the airway, a need for positive-pressure ventilation and those who
require protection from aspiration can be
a useful starting place for the creation of a
Treatment decisions will depend on
the amount of equipment and personnel
resources that are available. Non-traditional decision procedures and positioning
may need to be implemented, such as placing patients in a lateral recumbent position
to use gravity to assist in keeping the airway patent.
In the setting of multiple patient encounters requiring airway management, it’s
important to consider the length of time each
procedure will take and the amount of equipment that will be required. A rapid securing
of the airway by a supraglottic device in suitable patients may be favored over traditional
approaches of ETI secondary to the relative
complexity of the procedure. JEMS
b. upper airway swelling that may require a
subglottic airway treatment plan.
c. bronchospasm of the lower airways that
may require a bronchodilator.
d. bleeding or excessive salivation that is
occluding the upper airway.
3. An airway management task that can be easily
assigned to a layperson during a mass-casualty
a. the placement of an laryngeal mask airway.
b. squeezing the bag during two-person BVM
c. holding a mask seal during two-person BVM
4. Which of the following is a contraindication to
the use of the oropharyngeal airway?
b. Facial trauma
c. Potential skull fractures
d. Intact gag reflex
5. The disadvantages to ETI during multiple patient
a. no protection against aspiration.
b. the amount of time and equipment
c. the inability to use positive-pressure ventilation.
d. the inability to measure EtCO2.
1. C; 2. B; 3. B; 4. D; 5. B
management in patients requiring airway
opening, positive-pressure ventilation and
protection from gastric aspiration. ETI may
have a role in multi-patient encounters, but
such factors as the amount of equipment
required, the setup time and the skill and
expertise of the provider must be considered.
Although the intubation is usually
accomplished quickly, the amount of
setup and equipment required will limit
its usefulness in multi-patient encounters.
Additionally, ETI requires more aseptic
precautions and that the laryngoscope be
cleaned between each patient encounter.
This becomes another complicating logistic
in the setting of multi-patient encounters.
Advantages of ETI include positive
control of the airway, affording maximal
amount of airway protection against gastric
aspiration (although it can still occur) and
minimizing problems associated with air
leaks that can commonly occur with the use
of the supraglottic devices.
During ETI, the tongue is moved in a
way that allows access to the vocal cords
with a laryngoscope or similar device. Once
the view of the vocal cords is obtained, an
endotracheal tube is passed across the vocal
cords into the trachea. Once inside the trachea, a low-pressure balloon is inflated to
create a seal that facilitates being able to use
positive-pressure ventilation and protection from aspiration.
Surgical cricothyrotomy may be indicated in the setting of a patient who requires
advanced airway management and has a
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thethey didn’t tell you in medic school
>> by steve berry
Providing care to the undead
aramedic: That’s a nasty bite you got there,
big fella. How’d you get it? Not talking, are
we? Suit yourself, but your insistent moaning and yowling is starting to get on my nerves. And
stop looking at me like I’m someone you could sink
your teeth into. I’m not the one who tased you—not
that it phased you a bit.
I gotta admit, I’ve never seen anyone with such
stamina and total disregard toward painful stimuli— especially when the police officers took you
down with that subtle shotgun blast. Oh, arggh,
yourself. There’s no use at fighting the restraints with
your rudimentary attempts of biting and clawing,
Big Guy. I used to work in a rodeo after all. Ha ha!
Hey, you look familiar. Have I transported you to
detox before? Your clueless wandering and poorly
coordinated ataxic gait looked familiar.
I can’t smell alcohol on your breath,
but holy latrines, your breath reminds me
of death warmed over. Not that you’re
warm by any means. You’re chilled to the
bone, including the various ones sticking out from your decomposing, skinsloughing limbs, which explains why
I’ve encased myself in protective MRSA
(monster repellant safety attire).
What I can’t understand is how you
can keep bleeding with a pulse rate of
zero, but ah hell, what do I know? I’m just
a brainless ambulance driver. Hmmm.
That last comment seemed to have calmed you down
quite a bit.
What is it with all this zombie mania
over the past several years? How else do you
explain the plethora of zombie films, zombie
websites, Facebook and high gas prices? Our
brains are as infatuated with zombies just as
much as zombies are infatuated with ours.
From a psychological perspective, zombies
may symbolize fears we’re inescapably drawn
to: death, mayhem, mindless conformity, the
collapse of social order and the need to floss.
Maybe zombies amplify our trepidation of
an incurable disease, or perhaps they profess
an innate aggressive need to shoot people in
the cerebrum. For me, it’s finding any excuse
not to pay taxes.
Whatever the reason is for this social
escapism into the realm of reanimated pulseless people, it’s time EMS takes advantage of
this basic brain stem functioning craze and
inaugurate zombieism into our training and
public emergency preparedness programs—
not that it hasn’t already happened.
More than one million copies of the Zombie
Survival Guide—a comprehensive book about
surviving and adapting to a world of flesh
eaters—have been sold in the U.S. Taking
note of this zombie infatuation, the Center for
Disease Control and Prevention, aka CDCP
(creeping decomposed crowd pestilence), put
this same premise into an educational handbook on how to prepare for a real emergency.
Capitalizing on the undead faddism, communities are taught to prepare for a blitzkrieg of famished cannibals the way they
would a hurricane, pandemic or presidential
election year. This includes finding the cause
of the illness (e.g., virus, bacteria, toxin, radiation or high-dose epinephrine IV), source
of infection (zombie), how it’s transmitted
(e.g., bite, unless zombie is toothless sans
dentures—sad to watch really), how readily
it’s spread (surprisingly fast seeing as zombies move at the speed of a sloth on valium),
aggressive quarantine strategies (i.e., shoot
anyone in the head who comes to your door,
even if they say “trick or treat”) and how to be
self-sufficient for a long siege.
Usually it takes some effort to gather
volunteers to act as patients when putting
together a disaster drill, but officials from
the Department of Emergency Management in Delaware and Ohio managed to get
10 times that number for their simulated
I began to incorporate zombie didactics
into a few of my EMS lectures to prevent my
students from going into a zombie state of
consciousness from cerebral overload. The
living dead have served as narrative themes
of the central nervous system while exploring the science of the brain. I’d use a clip
from a zombie film. Based on the zombie’s
behavior, students would use the science of
their neurological function to identify which
part or parts of the zombie’s brain
were interacting with the real world
and which weren’t.
The 2009 movie Zombieland
cleverly integrated a list of rules to
enhance your chance of survival
should you find yourself alone in a
world of brain-sludged humanoids.
I’ve taken the liberty to incorporate
most of those same rules teaching
scene safety … except the No. 2 rule of
using a “double tap.” That’s considered
to be bad form as an EMS responder.
EMS is no stranger to zombies. Just
work a 48-hour shift, and you can experience
it firsthand. And yes, many of you have resuscitated the dead only to see them become
alive and dead at the same time. The difference in zombie resuscitation is that zombies
can resuscitate themselves by the very nature
of the wound, thus freeing you to do more
important things like run away, with your
arms flailing, screaming like a girl.
Until next time, Scott Adams once said,
“One way to compensate for a tiny brain is to
pretend to be dead.” JEMS
Steve Berry is an active paramedic with Southwest
Teller County EMS in Colorado. He’s the author of the
cartoon book series I’m Not An Ambulance Driver. Visit
his website at www.iamnotanambulancedriver.com to
purchase his books or CDs.
February 28-March 3, 2012
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