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  1. 1. MAY 2012 Always En Route At
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  6. 6. The Conscience of EMS JOURNAL OF EMERGENCY MEDICAL SERVICES 38 I Beyond the Tape I Law enforcement officers make major impact as initial care providers B y David Kleinman, NREMT-P, Tammy Kastre, MD May 2012 Vol. 37 No. 5 Contents I 62 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 W Departments columns 9 I Load go I Now on 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 B y Gary Ludwig, MS, EMT-P 27 I Management Focus I Extra Set of Hands y Richard Huff, NREMT-B B 30 I Tricks OF the TRADE I Numbers B y Thom Dick 32 I case of the month I Miracle in the Desert B 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 B 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 communities By Keith Widmeier, NREMT-P, CCEMT-P, EMS-I, BA; Emily Coffey, BA, NREMT-P 68 I ultiple Airways I M Rapid assessment is key for managing numerous patients By Paul E. Phrampus, MD I 68 74 I Ad Index 75 I employment Classified Ads 78 I The Lighter Side I Zombie EMS B 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 the Cover 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 MaY 2012 JEMS 7
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  8. 8. LOAD GO  log in for EXCLUSIVE CONTENT A Better Way to Learn online continuing education program n Photo Gary Jackson Innovators Dine 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 us o follow offers you original content, jobs, products and resources. But we’re much more than that; we keep you in touch with your colleagues through our: Facebook fan page; JEMS Connect site; Twitter account; LinkedIn profile; Product Connect site; and Fire EMS Blogs site. like us /jemsfans Sponsored Product Focus Speechmike With more than 50 years of experience in the voice technology market, Philips Speech Processing provides innovative, practical dictation and transcription solutions that allow professionals to increase productivity and efficiency. As the leading dictation device on the market, the SpeechMike is specifically designed to enhance productivity for optimal speech recognition results. Its ergonomic, intuitive design boasts dictation control, playback speakers, and PC navigation in a single device, and it allows users to send sound files for transcription at the press of a button. s Check out their ad on! May poll question follow us /jemsconnect get connected about=gid=113182 How do you celebrate EMS Week? April Poll Results Which is a more dangerous location for EMS providers driving an ambulance? 34% 27% 39% I nterstate or rural highway Rural streets p y agency hosts an event. M p recognize it with coworkers. I p don’t even know when it is! I p Other ems news alerts To vote, do a keyword search on for “polls.” s Check it out Suburban streets. The mobile version s best bloggers MAY 2012 JEMS 9
  9. 9. Conscience of EMS JOURNAL OF EMERGENCY MEDICAL SERVICES The Conscience of EMS JOURNAL OF EMERGENCY MEDICAL SERVICES Editor-In-Chief I A.J. Heightman, MPA, EMT-P I MANAGING Editor I Jennifer Berry I associate eDITOR I Lauren Hardcastle I assistant eDITOR I Allison Moen I assistant eDITOR I Kindra Sclar I online news/blog manager I Bill Carey I Medical Editor I Edward T. Dickinson, MD, NREMT-P, FACEP Technical Editors 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 art director I Liliana Estep I Contributing illustrators Steve Berry, NREMT-P; Paul Combs, NREMT-B Contributing Photographers Mark C. Ide, Craig Jackson, Ray Kemp, Kevin Link, Julie Macie, Jeffrey Mayes, Courtney McCain, Rick McClure, Tom Page, Rick Roach, Steve Silverman, Chris Swabb, Grant Therrien, Raul Torres Director of eProducts/Production I Tim Francis I Production Coordinator I Matt Leatherman I advertising director I Judi Leidiger I 619/795-9040 I Western Account Representative I Cindi Richardson I 661-297-4027 I senior Sales coordinator I Elizabeth Zook I Sales Administrative Coordinator I Liz Coyle I SENIOR eMedia campaign manager I Lisa Bell I advertising department I 800/266-5367 I Fax 619/699-6722 marketing director I Debbie Murray I Marketing manager I Melanie Dowd I Director, Audience Development Sales Support I Mike Shear I Audience development coordinator I Marisa Collier I SUBSCRIPTION DEPARTMENT I 888/456-5367 REprints, eprints Licensing I Wright’s Media I 877/652-5295 I eMedia Strategy I 410/872-9303 I Managing Director I Dave J. Iannone I Director of eMedia Sales I Paul Andrews I Director of eMedia Content I Chris Hebert I EMS Today Conference Exposition reed exhibitions I Christine Ford I 203/840-5391 I ems today exhibit sales I 203/840-5611 Jeff Stasko I elsevier public safety vice president/publisher I Jeff Berend I founding editor I Keith Griffiths founding publisher James O. Page (1936–2004) Choose 16 at
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  11. 11. JOURNAL OF EMERGENCY MEDICAL SERVICES The Conscience of EMS JOURNAL OF EMERGENCY MEDICAL SERVICES EDITORIAL board 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, Colorado District 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 12 JEMS MAY 2012 Jeffrey M. Goodloe, MD, FACEP, NREMT-P Associate Professor EMS Division Director, Emergency Medicine, University of Oklahoma School of Community Medicine 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 Keith Griffiths 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 Services Institute 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
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  13. 13. EMS IN ACTION Scene of the month Photos Associated Press High-PRofile Care P 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. 14 JEMS MAY 2012
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  15. 15. 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 watch?v=lBGfKtuo2AM 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 SW 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 response family. 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- 16 JEMS MAY 2012 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 tension pneumothorax. 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 T 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 shock abatement. 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 References 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.
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  17. 17. Photo LETTERS in your words This month, Facebook users chime in on “EMS Providers Should Train like Fighters,” a 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”). Self Defense 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. Misty Bortz Via Facebook 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. Joe Lee Via Facebook 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. James Adams Via Facebook 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 Julie Shoemaker Via Facebook Amish Perspective 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 articles? We’d love to hear from you. E-mail your letters to editor.jems@ 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 18 JEMS MAY 2012 Due to graphic content, rubbernecking 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 Via Facebook
  18. 18. Comprehensive, Credible, Educational... JEMS Products Help You Save Lives. Jems, Journal of Emergency Medical Services Website With content from writers who are EMS professionals in the field, JEMS provides the information you need on clinical issues, products and trends. Your online connection to the EMS world, gives you information on: • Products • Jobs • Patient Care • Training • Technology Available in print or digital editions! eNewsletter Product Connect Sign up now for the weekly eNewsletter. Get breaking news, articles and product information sent right to your computer. Read it on your time and stay ahead of the latest news! 4 NEW Webcasts! Giving you the detailed product information you need, when you need it. We collect all the information from manufacturers and put it in one place, so it’s easy for you to find and easy for you to read. Go to Register at Watch live or in the archives! n EMS Strategies for Improving Cardiac Arrest Survival May 21 2012, at 1 p.m. ET/10 a.m. PT Sponsored by: n Drug Shortage Action Plans for EMS Sponsored by: n Are You Bagging the Life Out of Your Patients? Sponsored by: n Statewide Trauma System Enables Multi-Agency Coordination with Trauma Centers to Improve Patient Outcomes Sponsored by: Go to
  19. 19. PRIORITYUSE TRAFFIC NEWS YOU CAN EMS on the HILL NAEMT hosts third-annual event the line of duty; and he legislation to establish new T 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 plane ticket. Mark your calendar and watch the NAEMT site for more details in the months to come. —Ann-Marie Lindstrom photo L 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 Technicians (NAEMT). 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 lobby day. 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 new contacts. 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 20 JEMS MAY 2012
  20. 20. photo 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 their normal activity. Despite 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 other celebrations. 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 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 MAY 2012 JEMS 21
  21. 21. continued from page 21 QUICK TAKE T 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. 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. 2012 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, visit 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 circumstances. 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: 22 JEMS MAY 2012 photo cers are automatically entitled to patient information.
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  23. 23. LEADERSHIP SECTOR presented by the iafc ems section by gary ludwig, ms, emt-p Crisis Management Rudy Giuliani advocates for managing things, not people W 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. Leadership Tips In my opinion, one of the finest examples of leadership was former New York City Mayor Rudolph Giuliani’s management of 24 JEMS MAY 2012 ‘It is in times of crisis that good leaders emerge.’ 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 References 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
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  25. 25. photo Management Focus 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 I 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 MAY 2012 JEMS 27
  26. 26. 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 ‘force multiplier.’ 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. Protocol 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 28 JEMS MAY 2012
  27. 27. “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 MD-2 team. “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.” EMS Interaction 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 together.” JEMS 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 MAY 2012 JEMS 29
  28. 28. TRICKSour patients ourselves OF THE TRADE caring for by Thom Dick, EMT-P Numbers Reflections on the value of one 30 JEMS MAY 2012 Photo I 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 up trying. 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 their emergencies. 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; they’re individuals. 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 call “one.” 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 special. JEMS 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
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  30. 30. 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 Remote Care 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 B 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 deconstructed annually. 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 EMS providers. 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 aortic dissection. 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 32 JEMS MAY 2012
  31. 31. 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. Discussion 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 76–78 mmHg. 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. Teaching Points 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 MAY 2012 JEMS 33
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  33. 33. 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 react accordingly. Summary 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 carried out. 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 Pat Songer, NREMT-P, ASM, is director of EMS at Humboldt General Hospital EMS. He can be contacted at Kelly Buchanan, MD, is an EMS fellow at the University of Nevada School of Medicine. She can be contacted at 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 References 1. Rogers RL, McCormack R. Aortic disasters. Emerg Med Clin North Am. 2004;22(4):887–908. 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 MAY 2012 JEMS 35
  34. 34. RESEARCH REVIEW ems What current studies mean to by David Page, MS, NREMT-P Gender Matters Study compares cardiac care for male vs. female patients Photo 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]. T 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]. I 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%). 36 JEMS MAY 2012 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 recent literature). 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. T 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 so difficult. 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.
  35. 35. 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 to research. 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 Recovery Expo Oxygen Generating Systems Intl. / / Toll Free 800-414-6474 814 Wurlitzer Drive, North Tonawanda, NY 14120 / / Phone 716-564-5165 Choose 30 at Visit for audio commentary. 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 Choose 31 at MAY 2012 JEMS 37
  36. 36. 38 JEMS MAY 2012
  37. 37. Law enforcement officers make major impact as initial care providers By David Kleinman, NREMT-P Tammy Kastre, MD I 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. MAY 2012 JEMS 39
  38. 38. Beyond the Tape continued from page 39 40 JEMS MAY 2012 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 E 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 like this? 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.
  39. 39. Choose 32 at Choose 33 at
  40. 40. 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. 42 JEMS MAY 2012 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. Early Involvement 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 the battlefield: Hemorrhage from extremity wounds; ension pneumothorax; and T 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 civilians. 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 other patients. 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 E 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 A fire and EMS providers to approach immediately. Any of these complications can
  41. 41. 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) airway/respiratory management. 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 when necessary. 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 MAY 2012 JEMS 43
  42. 42. 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 P changes in mental status; irway control necessary, rates of A breathing and circulation; njuries they saw, who they treated, I and how they treated those injuries; and 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. Other Programs 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 The IFAK 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). Conclusion 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 EMS agencies. 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 enforcement operation. 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 arrival. JEMS 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 at Tammy Kastre, MD, is the medical director for the Pima County Sheriff’s Department SWAT team and a board-certified ED physician. References 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. 44 JEMS MAY 2012 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 duty belt. A pair of trauma shears. Two emergency compression bandages. One package of hemostatic combat gauze. One chest seal. One tourniquet.
  43. 43. Tactical training offers many benefits to EMS By William Justice, NREMT-P; LT. Kerry Massie, NREMT-I; Jeffrey M. Goodloe, MD, NREMT-P, FACEP 46 JEMS MAY 2012
  44. 44. 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 increasingly disoriented. Sounds of multiple shots are heard fired from the subject’s location. Tac Team Alpha: I’ve got visual on wounded hostage. Photos Courtesy OKlahoma highway patrol Command: Copy Alpha on wounded hostage. 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 care initiated. Command: Medics up. MAY 2012 JEMS 47
  45. 45. Prepared for the Worst continued from page 47 P 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. Tactical Training 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- 48 JEMS MAY 2012 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 and graduates. 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 each candidate. 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 through OUDEM. 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 patrol vehicle. Specialized Equipment “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-