JOURNAL OF EMERGENCY MEDICAL SERVICES
I Stroke of the Clock I
‘Time is brain’ when treating stroke patients
By W. Ann Maggiore, JD, NREMT-P
June 2012 Vol. 37 No. 6
38 I Safety First I
Richmond Ambulance Authority creates comprehensive
culture of safety model
By Rob Lawrence, MCMI; Bryan S. McRay, BA; Dempsey Whitt,
NREMT-P/FP-C; Joseph P. Ornato MD, FACP, FACC, FACEP
Products 2012 I
50 innovative new products
showcased at the 29th annual
JEMS EMS Today Conference Exposition
9 I Load go I Now on JEMS.com
14 I EMS in Action I Scene of the Month
16 I From the Editor I Is EMS a Game?
y A.J. Heightman, MPA, EMT-P
20 I Letters I In Your Words
22 I Priority Traffic I News You Can Use
26 I Train the Trainer I Sim for Students
y Al Kalbach, EMT-P
30 I Tricks OF the TRADE I Do No Harm
y Thom Dick
32 I case of the month I Difficult Airway
y Steven R. Allen, MD, Cayla G. Conover
36 I Research review I What Current Studies Mean to EMS
y David Page, MS, NREMT-P
66 I Hands On I Product Reviews from Street Crews
y Fran Hildwine
68 I employment Classified Ads
71 I Ad Index
72 I The Lighter Side I EPI Coasters
y Steve Berry
74 I LAST WORD I The Ups Downs of EMS
Aboutfrom Care Ambulance and an Orange County (Calif.) Fire Authority firefighter/paramedic
assess a female patient in an ambulance in Santa Ana. Patients presenting with stroke can exhibit a variety
of signs and symptoms, including paralysis, sudden onset of confusion or loss of balance. Read “Stroke
of the Clock,” pp. 56–65, to learn more hallmarks of stroke, treatment options and a personal account of
how stroke can affect the lives of the victims and their families. Photo Vu Banh
Premier Media Partner of the IAFC, the IAFC EMS Section Fire-Rescue Med
6. Choose 15 at www.jems.com/rs
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JUNE 2012 JEMS
JOURNAL OF EMERGENCY MEDICAL SERVICES
JOURNAL OF EMERGENCY MEDICAL SERVICES
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MANAGING Editor I Jennifer Berry I firstname.lastname@example.org
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online news/blog manager I Bill Carey I firstname.lastname@example.org
Medical Editor I Edward T. Dickinson, MD, NREMT-P, FACEP
Travis Kusman, MPH, NREMT-P; Fred W. Wurster III, NREMT-P, AAS
Contributing Editor I Bryan Bledsoe, DO, FACEP, FAAEM
Editorial Department I 800/266-5367 I email@example.com
art director I Liliana Estep I firstname.lastname@example.org
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James O. Page
Choose 16 at www.jems.com/rs
9. Choose 17 at www.jems.com/rs
10. JOURNAL OF EMERGENCY MEDICAL SERVICES
JOURNAL OF EMERGENCY MEDICAL SERVICES
William K. Atkinson II, PHD, MPH, MPA, EMT-P
President Chief Executive Officer
WakeMed Health Hospitals
James J. Augustine, MD
Medical Advisor, Washington Township (OH) Fire Department
Director of Clinical Operations, EMP Management
Clinical Associate Professor, Department of
Emergency Medicine, Wright State University
steve berry, NRemt-p
Paramedic EMS Cartoonist, Woodland Park, Colo.
Bryan E. Bledsoe, DO, FACEP, FAAEM
Professor of Emergency Medicine, Director, EMS Fellowship
University of Nevada School of Medicine
Medical Director, MedicWest Ambulance
Criss Brainard, EMT-P
Deputy Chief of Operations, San Diego Fire-Rescue
Chad Brocato, DHS, REMT-P
Assistant Chief of Operations, Deerfield Beach Fire-Rescue
Adjunct Professor of Anatomy Physiology, Kaplan University
J. Robert (Rob) Brown Jr., EFO
Fire Chief, Stafford County, Va., Fire and Rescue Department
Executive Board, EMS Section,
International Association of Fire Chiefs
carol a. cunningham, md, FACEP, FAAEM
State Medical Director
Ohio Department of Public Safety, Division of EMS
Thom Dick, EMT-P
Quality Care Coordinator
Platte Valley Ambulance
Marc Eckstein, MD, MPH, FACEP
Director of Prehospital Care, Los Angeles County/
USC Medical Center
Medical Director, Los Angeles Fire Department
Professor, Emergency Medicine,
University of Southern California
Charlie Eisele, BS, NREMT-P
Flight Paramedic, State Trooper, EMS Instructor
Bruce Evans, MPA, EMT-P
Deputy Chief, Upper Pine River Bayfield Fire Protection,
Jay Fitch, PhD
President Founding Partner, Fitch Associates
Ray Fowler, MD, FACEP
Associate Professor, University of Texas Southwestern SOM
Chief of EMS, University of Texas Southwestern Medical Center
Chief of Medical Operations,
Dallas Metropolitan Area BioTel (EMS) System
Adam D. Fox, DPM, DO
Assistant Professor of Surgery,
Division of Trauma Surgery Critical Care,
University of Medicine Dentistry of New Jersey
Former Advanced EMT-3 (AEMT-3)
Gregory R. Frailey, DO, FACOEP, EMT-P
Medical Director, Prehospital Services, Susquehanna Health
Tactical Physician, Williamsport Bureau of
Police Special Response Team
Jeffrey M. Goodloe, MD, FACEP, NREMT-P
Associate Professor EMS Division Director,
Emergency Medicine, University of Oklahoma School of
Medical Director, EMS System for Metropolitan
Oklahoma City Tulsa
David E. Persse, MD, FACEP
Physician Director, City of Houston Emergency Medical Services
Public Health Authority, City of Houston Department. of Health
Associate Professor, Emergency Medicine, University of Texas
Health Science Center—Houston
President, RedFlash Group
Founding Editor, JEMS
John J. Peruggia Jr., BSHuS, EFO, EMT-P
Assistant Chief, Logistics, FDNY Operations
Dave Keseg, MD, FACEP
Medical Director, Columbus Fire Department
Clinical Instructor, Ohio State University
W. Ann Maggiore, JD, NREMT-P
Associate Attorney, Butt, Thornton Baehr PC
Clinical Instructor, University of New Mexico,
School of Medicine
Connie J. Mattera, MS, RN, EMT-P
EMS Administrative Director EMS System Coordinator,
Northwest (Illinois) Community Hospital
Robert J. McCaughan
Chief, City of Pittsburgh EMS
Chair, IAEMSC Metro Chief’s Section
Robin B. Mcfee, DO, MPH, FACPM, FAACT
Medical Director, Threat Science
Toxicologist Professional Education Coordinator,
Long Island Regional Poison Information Center
Mark Meredith, MD
Assistant Professor, Emergency Medicine and Pediatrics,
Vanderbilt Medical Center
Assistant EMS Medical Director for Pediatric Care,
Nashville Fire Department
Geoffrey T. Miller, EMT-P
Director of Simulation Eastern Virginia Medical School,
Office of Professional Development
Brent Myers, MD, MPH, FACEP
Medical Director, Wake County EMS System
Emergency Physician, Wake Emergency Physicians PA
Medical Director, WakeMed Health Hospitals Emergency
Mary M. Newman
President, Sudden Cardiac Arrest Foundation
Joseph P. Ornato, MD, FACP, FACC, FACEP
Professor Chairman, Department of Emergency Medicine,
Virginia Commonwealth University Medical Center
Operational Medical Director, Richmond Ambulance Authority
Jerry Overton, MPA
Chair, International Academies of Emergency Dispatch
David Page, MS, NREMT-P
Paramedic Instructor, Inver Hills (Minn.) Community College
Paramedic, Allina Medical Transportation
Member of the Board of Advisors,
Prehospital Care Research Forum
Paul E. Pepe, MD, MPH, MACP, FACEP, FCCM
Professor, Surgery, University of Texas
Southwestern Medical Center
Head, Emergency Services, Parkland Health Hospital System
Head, EMS Medical Direction Team,
Dallas Area Biotel (EMS) System
Edward M. Racht, MD
Chief Medical Officer, American Medical Response
Jeffrey P. Salomone, MD, FACS, NREMT-P
Associate Professor of Surgery,
Emory University School of Medicine
Deputy Chief of Surgery, Grady Memorial Hospital
Assistant Medical Director, Grady EMS
Kathleen S. Schrank, MD
Professor of Medicine and Chief,
Division of Emergency Medicine,
University of Miami School of Medicine
Medical Director, City of Miami Fire Rescue
Medical Director, Village of Key Biscayne Fire Rescue
John Sinclair, EMT-P
International Director, IAFC EMS Section
Fire Chief Emergency Manager, Kittitas Valley Fire Rescue
Corey M. Slovis, MD, FACP, FACEP, FAAEM
Professor Chair, Emergency Medicine,
Vanderbilt University Medical Center
Professor, Medicine, Vanderbilt University Medical Center
Medical Director, Metro Nashville Fire Department
Medical Director, Nashville International Airport
Barry Smith, EMT-P
CQI Coordinator, Regional EMS Authority (REMSA), Reno, Nev.
Walt A. Stoy, PhD, EMT-P, CCEMTP
Professor Director, Emergency Medicine,
University of Pittsburgh
Director, Office of Education,
Center for Emergency Medicine
Richard Vance, EMT-P
Captain, Carlsbad Fire Department
Jonathan D. Washko, BS-EMSA, NREMT-P, AEMD
Assistant Vice President, North Shore-LIJ Center for EMS
Co-Chairman, Professional Standards Committee,
American Ambulance Association
Ad-Hoc Finance Committee Member, NEMSAC
keith wesley, MD, facep
Medical Director, HealthEast Medical Transportation
Katherine H. West, BSN, MED, CIC
Infection Control Consultant,
Infection Control/Emerging Concepts Inc.
Stephen R. Wirth, Esq.
Attorney, Page, Wolfberg Wirth LLC.
Legal Commissioner Chair, Panel of Commissioners,
Commission on Accreditation of Ambulance Services (CAAS)
Douglas M. Wolfberg, Esq.
Attorney, Page, Wolfberg Wirth LLC
Wayne M. Zygowicz, BA, EFO, EMT-P
EMS Division Chief, Littleton Fire Rescue
11. Choose 18 at www.jems.com/rs
12. EMS IN ACTION
Scene of the month
Photo kevin Link
13. catching a fall
aramedics from Lethbridge Fire EMS in Lethbridge, Alberta,
Canada, begin their assessment of a pedestrian who fell from
a curb and became injured. The crew was confronted with a patient
who appeared to be under the influence of alcohol and who was not
able to adequately communicate with them. The crew performed a
complete primary and secondary assessment. Because the patient was
unable to communicate with them, they were unable to safely rule out
a spinal injury. They carefully immobilized and packaged the patient.
He was transported to a local hospital in stable condition.
14. from the editor
putting issUes into perspective
by A.J. HEIGHTMAN, MPA, EMT-P
Is EMS A Game?
Inefficiency can cost patient lives
ou get called to a wedding rehearsal
dinner packed with excited family
members and friends of the brideand groom-to-be. The people are there to
celebrate the wedding of two of their favorite
people when, suddenly and without warning, the bride’s grandmother collapses with
nausea, weakness and respiratory distress.
You were right around the corner from
the restaurant when the call came in, so you
arrived in less than a minute. The crowd’s
emotions were already charged up before
this medical emergency occurred. Now, you
arrive and find the beautiful bride-to-be
screaming over “Nanna,” who’s lying on
her side, nauseous, vomiting and gasping
The bride-to-be’s grandfather and her
“daddy” (Nanna’s son), are all standing in a
circle around the woman when you reach
her and set down your oxygen bag, airway
case and medical kit.
In the game of life, the cards are already
stacked against you.
You, in your role as the lead paramedic,
kneel down to establish communications
with the 85-year-old patient and start an
assessment. She’s drooling and mumbling
incoherently, and she has a confused look
in her eyes as she tries to listen to you.
She exhibits right-sided facial droop and is
unable to follow your request to hold her
arms out straight and level. One side of her
body is clearly weaker than the other.
Your partner readies the cardiac monitor
and tries to politely place leads on her, but
he can’t get them all in place because her
dress, slip, girdle and bra are in his way. He’s
hesitant to cut them open and expose her in
front of her family. So he says, “I think I’ll
wait to hook her up and run a 12-lead when
we get her out to the rig.”
He turns his attention to spiking an IV
bag and readying it to administer to the
patient. He begins to slap her hand to find
a good vein to cannulate. He then says, “I
can’t find any good veins and can’t get to
Running a cardiac EMS call is similar to running a football play. EMS providers should be a well-oiled team.
her antecubital without cutting open the
tight sleeve of her dress.”
You say, “OK, give me a minute, and I’ll
take a look to see if I can find one.” Your
partner then kneels next to her with the
IV tubing dangling from his one hand and
an alcohol prep, IV catheter and tape in his
other hand, waiting for you to take a look.
Engine 52 arrives, and the crew walks
in without any extra equipment or the
ambulance stretcher. One of the firefighters cracks open the valve on your oxygen
(O2) tank, sets the regulator to 10 LPM, tears
open the plastic bag of a high-concentration
non-rebreather oxygen mask and fills it
with oxygen so it’s ready to deliver 80–90%
oxygen to the woman.
A police officer arrives with his own
O2 bag but places it down because he sees
that yours is already on the floor near the
patient. He then stands nearby with his
small notebook open, waiting to hear her
name and age for his police report. The
engine’s company officer stands next to
him with his computer open, waiting to
chart the care being given—as it’s being
given. Another firefighter stands near the
“O2 firefighter” and awaits orders from you.
The “O2 firefighter” dutifully stands by
and awaits the OK from you to place the
oxygen mask on the elderly patient who’s
now very weak, pale and diaphoretic. Early
signs of cyanosis are showing around her
vomit-laced lips. He seems to be waiting
for you to stop attempting communication with her before he places the mask on
The family and other nearby guests can
clearly see she’s in trouble. Then they hear
the lead paramedic say, “Where the hell is
the suction unit?”
The unassigned firefighter responds,
“Out at the rig. Do you want it?”
Suddenly, you hear the patient’s son
shout, “Of course he wants it! She’s got a
ton of vomit in her mouth.”
You pull the radio off your hip and radio
out to Engine 52’s driver/engineer, “Medic
15. Choose 19 at www.jems.com/rs
16. FROM THE EDITOR
continued from page 16
21 to Engine 52 engineer, bring in the suction unit.”
Then you hear comments yelled from
Don’t just stand around. Do some“
thing for her.”
You brought all that crap in here, and
you don’t even have anything to clear
her airway out?”
Give her some oxygen. Why is that
fireman just holding that mask in his
hand? Put it on her face. She’s turning blue.”
Where’s the stretcher? They brought
in a computer and left the stretcher
Quit playing doctor, she’s having a
‘stroke!’ Get her out of here!”
You’ve heard that last statement before,
and it makes your blood boil. You look at
the guy saying it and tell him, “Sir, I am not
playing doctor. I’m a paramedic trying to
take care of this woman. Please let me do
His reply is, “I see what you and your
partner are trying to do, but everybody else
is standing around with their hands in their
pockets. Why are you two the only ones
working on her?”
It’s a rude awakening. His comments hit
you like a wet wash cloth.
You suddenly realize you’re in the middle
of a large crowd of people with a very sick
patient who’s clearly having a cardiovascular accident complicated by an unstable
airway, and only two of the seven responders on scene (28.5%) are actively involved in
You begin to bark out orders.
To the O2 firefighter: “Suction her airway,
put that O2 mask on her and get an 8
endotracheal tube and large straight
blade ready for me.”
To the engineer: “Please get a few peo
ple to go out with you and get our
stretcher in here ASAP. And, while
you’re out there, tell dispatch to call
the stroke center and advise them we
are declaring a stroke alert and will be
there in 20 minutes.”
To the police officer: “Officer, please get a
tablecloth and use a few people to create a curtain to give our patient some
privacy while we cut her clothes open
to put electrodes on her and start a
To the fire captain: “Captain, could you
hold off on charting, get the EZ-IO
drill out of our kit and ready it for my
To your partner: “Mike, cut her clothes,
get that 12-lead running, establish an
IO and draw some blood to check her
Things begin to happen rapidly now. The
patient is cared for. Her frail body is covered
by a sheet and blanket, and you exit the restaurant with your precious cargo.
The woman’s husband is escorted to the
ambulance by the fire captain and told that
his wife is being taken to a specialty center.
He’s then buckled into the front passenger
seat of the ambulance to accompany her to
The police officer sees a large crowd of
“out-of-town” relatives piling into their cars
to attempt to follow the ambulance to the
hospital. He politely orders them not to do
so because it would be unsafe and tells them
weren’t happening quick enough.”
You walk away realizing there was a lot to
be learned from this call. You were operating
at only 28.5% efficiency and in an uncoordinated manner. You also realize that if it was
your grandmother lying on the floor and the
same approach was taken to her care, you’d
be upset like the patient’s son was.
At the station, the captain calls you all
together for a quick post-incident discussion
of the call and says that it wasn’t managed as
well as it could have been. He tells the crews
that this was an example of how they need to
function as more of a team on medical calls,
much like they do at a structure fire.
He compares it to a football team that has
to go out on the field and march down the
field in the last two minutes to score a winning touchdown.
He points out that, in football, each play is
planned and called in advance—like an ALS
You suddenly realize that you’re in the middle
of a large crowd of people with a very sick
patient who’s clearly having a cardiovascular
accident, complicated by an unstable airway,
only two of the seven responders on scene
(28.5%) are actively involved in patient care.
to follow his cruiser to the hospital.
After turning over your patient to the
hospital emergency department (ED) staff,
you come out to clean and restock your
ambulance and find a few of the crew standing around the back of the ambulance. One
pulls out a cigarette to have a smoke. Two
others are laughing about a skit they saw
the night before on Saturday Night Live.
As this is occurring, you see the family arriving and heading toward the ED
entrance. You tell the crews, “Folks, the
call’s not over until we’re out of sight of the
family. Let’s clean up and save all the nonwork related stuff for back at the station.”
The patient’s son then walks over and
thanks you and the rest of the personnel involved for taking such good care of
his mother. He apologizes for getting too
“wound up” at the scene but says he just
got upset because he felt like things “just
protocol—and everybody is expected to execute their assignment without the quarterback having to tell each team member who
they need to block, where to run or how to
hold the football.
The crew gets the analogy, understands
their inefficiencies and realizes that their
inactions, or delayed actions, could cost a
patient their life. They then agree to follow
the “pit crew” approach that the department’s EMS training coordinator has been
preaching for months.
In an odd, but practical, way, EMS is, in
fact, very much like a game. There’s always
an objective to each patient situation and a
prescribed action plan (and tasks) that are
developed in advance of “playing the game”
to enable the best, most organized and
methodical players to win.
The winner of the game of EMS is your
17. Comprehensive, Credible, Educational...
Help You Save Lives.
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who are EMS professionals
in the field, JEMS provides
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• May the G-Force Be With You
• CPAP in EMS: The Standard of Care Argument
• Top 5 Ways an In-Vehicle Router Improves EMS Operations
• CPR Quality Improves Survival
• Breathe Deeply: How CPAP and Ventilation Can Help Your Patients
• Simulating Work: How to Effectively Incorporate Simulation
into Prehospital Care
• Connecting Care Teams and Collecting Data:
How it helps both you and your patient—The Houston
• Blast Injuries: What You Need to Know
• CPAP for Everyone!
• Effective Documentation in a Digital World
• How Mechanical CPR Devices Are Changing EMS Protocols
• Decide to Save Lives
• CPAP: Filling The Sails to Respiratory Relief
• Influenza: Is This an Emergency?
• Technologies Practices: Is EMS Driving Hospital Care?
• Top 5 Ways an In-Vehicle Router Improves EMS Operations
• Universal Capnography: What, When, How and Why!
Go to www.JEMS.com
in your words
This month, readers chimed in on
two feature articles: one from May
JEMS that discussed the prevalence
of bedbugs (“What’s Buggin’ EMS:
How to rid your rigs of a bedbug
infestation,” by Wayne Zygowicz,
BA, EFO, EMT-P) and one April
clinical education article on treating penetrating trauma wounds
(“Breaking the Surface: Arm yourself with knowledge about penetrating trauma,” by Bryan E. Bledsoe, DO, FACEP, FAAEM, EMT-P; Michael Casey,
MD, Ryan Hodnick, DO).
In addition to the interest these two articles garnered, a Street Science review on
JEMS.com by Keith Wesley, MD, FACEP Marshall Washick, NREMT-P, added to
the long-standing debate over the effectiveness of endotracheal intubation (“Study
Analyzes Use of ETI vs. King LT-D for Cardiac Arrest Patients).
Finally, we asked our Facebook fans to fill in the blank: “You know you’re a
medic when ______.” Read what they said.
Bedbugs Bugging You?
We have ambulances getting patients with bedbugs on a weekly basis. It’s become a huge epidemic among our “hometels” in San Diego. We
subcontracted with a company that comes out
and completely disinfects the entire ambulance
from top to bottom. This involves taking every
single piece of equipment out of the ambulance
that isn’t bolted to the ground.
They take you out of service immediately
after you notify a supervisor that you had a contamination. Four hours later, they put you back in
service. I suppose they’re using such an aggressive approach because a few of our fire stations
got infested with bedbugs after contact with a
This study’s researchers have reanalyzed that first
attempt “placement” is more successful for King
LT-Ds over endotracheal intubation (ETI). There is
no data included in this study to support patient
outcomes with regards to cardiac arrest outcome
data. It’s certainly possible that a bag-valve mask
(BVM) plus an orophayrangeal airway (OPA) until
intubation is indicated in the patient would provide better end-result outcomes than either of
these options. Just because something is more
successfully inserted doesn’t mean it’s a better
option for use.
A pediatric study comparing ETI and King Airway
LT-Ds is about to be published in Prehospital
Emergency Care. It was a small study in simulated
patients, but it’s the first pediatric study looking
at the King Airway that I’m aware of. Examining
illustration steve berry
Our department uses Tyvek suits for everyone,
including the patient. We carry a can of pyrethrum that we can spray down
the crew, inside a bus. Then,
we call an exterminator who
comes out who treats the
entire truck. Next, we strip
down and place our clothing
into a dryer on high for 30
minutes. We are placed out of
service for the duration. This is
a daily occurrence.
Choose 46 at www.jems.com/rs
6/15/2012 3:20:47 PM
19. There are simply too many providers with not
enough [endotracheal intubation] skills. It’s easy
to say ‘train more,’ but large departments are hard
pressed to have the time, money tracking ability to
keep medics properly trained.
alternative airways for pediatrics in the prehospital
setting is a perfect area for further research.
be and leave the subtle politics out of it.
Andrew Friedman, NREMT-P
I would say ETI no doubt. It’s a tube that goes into
the trachea; King tubes rarely do. It’s a blind airway
device that’s fine for a rapid need to provide ventilation, but why not just use an OPA and a BVM?
We got rid of practicing rapid sequence intubation
because many couldn’t properly intubate, wouldn’t
cooperate with capnography or couldn’t figure out
that they tubed the stomach. I personally think
there needs to be a rigorous airway course in all
schools, and I also think all ALS agencies need to
drill on the importance of ETI, the proper techniques and the appropriate use.
Author Bryan E. Bledsoe, DO, FACEP, FAAEM
responds: First, I am a hunter and a gun owner.
There was a great deal of discrepancy in these
numbers, and multiple sources were reviewed.
We had two weapons experts, one military and
the other civilian, review the document and they
made no comments. There appears to be a great
deal of irritability regarding this, and the purpose
was primarily to give relative examples—not be
totally precise in terms of ballistics.
The purpose of the article is more related
to penetrating trauma than ballistics, and in the
future it might be prudent to leave the ballistics
out. There was no hidden agenda.
A King is obviously easier and causes minimal disruption of the most important part, which is CPR.
Endotracheal tubes are important when they’re
needed, but it depends on which medics are doing
the tubing. There are simply too many providers
with not enough skills. It’s easy to say “train more,”
but large departments are hard pressed to have the
time, money and tracking ability to keep medics
Let’s just stick to the science please. In the article,
it mentions “assault rifles.” Epic fail gang. Most
“assault” rifles are of smaller caliber than hunting
rifles. They’re nothing more than military-style
rifles, and the term “assault rifles” is a political term
that isn’t needed in a magazine like JEMS.
To nitpick some more, the ballistic charts are far
from accurate, nor do they list a source.
The AK 7.62 X 39 doesn’t come in 168 grain and
doesn’t achieve the optimistic figures you give it,
just as the 30-06 is bit more potent than you state,
and it’s a more common hunting round. This begins
to make me wonder if there is an agenda behind
this article because the numbers aren’t exact. So
let’s be accurate as a science-based article should
What MAkes a MEdic?
Eric Henry: You find yourself staring at everyone’s
veins, from family friends to total strangers.
Crystal Haynes: The term “frequent flyer” has
nothing to do with getting on a plane.
Tiffany Johnson Groves: You sit down with
your family at dinner, and your food is gone in 90
Dylan Beickman: You run on a regular patient,
and play the game “how much of the patient
healthcare record can I complete before I
Michael White: When you were an EMT, friends
always introduced you as a paramedic, and now
that you’re actually a paramedic, friends introduce
you as an EMT. Also, you know every homeless
person in town on a first-name basis and have no
problem having a casual conversation with them
even while you’re off duty, even while all your
friends are trying as fast as they can to get away.
Cheryl Menkhorst: You’ve stopped at a red light,
made sure it was clear and went through ... in your
personal car, followed by “oh crap, I am not in an
Choose 20 at www.jems.com/rs
NEWS YOU CAN
Breaking the RULES
Is it always a bad thing?
Types of Errors
LeSage stressed learning to identify and distinguish the three types of errors: human
error (HE), ARB and reckless behavior (RB).
LeSage is a proponent of not punishing individuals for HE or ARB. Instead, these are
coaching opportunities for management.
For example, LeSage introduced the severity outcome bias. He believes the natural
tendency is to punish employees for ARBs or
HE based on severe outcomes. More simply
stated, an entire agency might be pencilwhipping their checklists before the start
aul LeSage, assistant chief (ret.) for
Tualatin Valley (Ore.) Fire and Rescue,
talked at the Fire-Rescue Med conference about high-reliability organizations
(HROs). He told a story about a law enforcement officer who accidentally shot a naked
man out of a tree.
The story goes that two law enforcement
officers were called to a large urban mall
where a naked man in a tree had drawn
quite the crowd. Fire and EMS was called to
standby. Law enforcement officers decided
they’d have to use a Taser to get the man out
of the tree.
They asked EMS what they thought about
that plan. “Awesome,” was their unified
response. The first officer aimed and missed.
He instructed his partner to shoot. She did,
and she hit the man. As he fell to the ground,
they realized she had mistakenly grabbed her
gun and not the Taser weapon.
LeSage explained that 74% of errors are
caused by a failure to intervene. EMS could
have realized this was a poor plan, but they
let law enforcement continue. More to the
point, the law enforcement personnel were
demonstrating at-risk behavior (ARB). One
of the factors in this situation was that the
law enforcement policy was to carry both
their weapons on the same side of their
body. Had the policy dictated wearing the
weapons on opposite sides, this story might
have had a different outcome.
best kind, according to LeSage, is
peer-to-peer coaching. If you can
get the entire system involved, it
may deter that behavior. Finally,
reckless behavior warrants punishment. Reckless behavior is a conscious disregard for a substantial
and unjustifiable risk. Although
LeSage believes these types of
errors are rare, they are the type
The idea of HROs originated in the Navy, to enable anyone to
that deserve punishment.
stop dangerous actions from occurring.
Again, the key is educating yourof their shift, but no one is punished until self, your staff and your external imposers
something goes wrong. LeSage says this how to differentiate between these errors.
just encourages an environment in which
employees hide their mistakes, leaving man- Event Investigation
agement with little understanding about the So your agency has an error. Now what?
problems in their agency.
Now comes the event investigation. LeSage
It’s a difficult balance of accountability says one of the biggest mistakes you can
vs. punishment. Not punishing employees make during the investigation is to first ask
sounds great in theory, but how do you the employee what the procedure requires.
satisfy an angry board of directors or city He suggested that the only people who
councilmen who want to see someone fall know the procedure manual back to front
on the sword?
are your new recruits. And what happens
when a new EMS provider says after a call,
“That’s not how we’re supposed to do it?”
Internal External Imposers
Instead of hammering out the policy
Internal and external imposers are those
who keep the rules. Externally, a lawyer that no one follows, the better approach is
may find the ARB or HE negligent, but the to identify what the normal procedure is.
internal imposer (e.g., chief) coaches the There’s likely an ARB occurring throughout
employee not to make the mistake again and the agency. LeSage introduces five quesensures proper training for the entire agency tions, numbered in both chronological
order and order of importance:
to reduce the ARB.
1. What happened?
The key to keeping those external impos2. What normally happens?
ers satisfied—which admittedly may be no
3. What does procedure require?
small feat—is to get their buy-in up front.
4. Why did it happen?
Involve these decision makers in your event
5. How were we managing it?
investigation. LeSage provided algorithms to
Following that line of questioning will
help determine the difference between HE,
allow internal imposers to identify the probARB and RB.
His system means HE results in counsel- lem, tie it to a current practice (likely an
ing. Explain to the employee that you’re ARB), reflect on the actual policy and prosorry the mistake happened but also tell pose a new solution. Numerous agencies
them they have an obligation to tell you across the U.S. are using this practice to minhow to avoid it from happening again and imize errors and learn from their mistakes.
identify the problem within the organiza- Keep an eye out for more about HROs from
tion’s training. ARBs require coaching. The LeSage on JEMS.com. —Lauren Hardcastle
For more of the latest EMS news, visit JEMS.com/news
21. Choose 21 at www.jems.com/rs
22. continued from page 22
f you haven’t been affected yet, it’s probably just a
matter of time until you are. The national drug shortage is really starting to hit home for EMS agencies, and
there’s no relief in sight for the foreseeable future.
Nearly half of the drugs on a shortage list recently
released by the Federal Drug Adminstration (FDA) are
administered by EMS providers, and many of those
medications are used to treat seizures, cardiac arrests
and other life-threatening conditions that occur in the
As a result, many EMS agencies have been forced
to make hard choices among alternatives that range
from bad to worse. Some use alternative medications,
or even expired medications, in the face of this crisis.
Other agencies are simply waiting for direction from
their state or regional EMS agencies and hoping for
the best. But this raises an important question: Could
an EMS agency incur liability for taking these kinds of
actions or for failing to take any action at all?
The more prepared you are to weather a drug shortage, the less likely you are to incur liability. Of course,
EMS agencies can never completely inoculate themselves from lawsuits. But devising clinical strategies
that best promote patient care in the event that critical prehospital drugs become completely unavailable
can decrease the likelihood of being sued successfully.
Fortunately, prehospital professionals are protected from liability if they act in good faith and
without gross negligence in most states. Some states
specifically provide immunity for EMS personnel if they
follow applicable protocols or medical direction from
an authorized physician, again presuming the EMS provider acts in good faith and without gross negligence.
Many states also provide similar liability protection for
the EMS agency itself, and for physicians who develop
protocols or provide medical direction, if such activities
are done in good faith and without gross negligence.
That means that in most states, a plaintiff will likely
have to prove that an EMS agency went far beyond
“ordinary negligence” if they want to successfully sue
the agency. But that may not be the standard in every
state, and the immunity statutes and gross negligence
standards may not apply to decisions regarding which
medications to carry.
Regardless of whether a simple negligence standard
or gross negligence standard applies, most courts will
ultimately look at things like whether EMS agencies
acted in the best interests of their patients, followed
applicable rules and protocols, and actually took reasonable and timely action when faced with a potential
drug shortage. Generally, courts understand we’re
often faced with circumstances beyond our control.
There may be circumstances for which there’s simply
no viable alternative to a medication that’s unavailable. In such cases, courts are often reluctant to
impose liability. But EMS agencies still need to prepare
for contingencies so that it’s clear what happens in the
event that there are no alternatives.
Photo A.J. Heightman
Could EMS Drug ShortageS Present Liability Risks for the Industry?
State laws and local protocols may dictate how your
agency can address drug shortage concerns. For examIs your EMS agency at risk with how you manage
ple, in some states, medical directors are given wide the drug shortage crisis?
latitude in determining which drugs will be carried on
the ambulance and in developing local clinical proto- agencies and facilities. State ambulance or EMS assocols. In these states, alternative therapies that involve ciations may be able to help organize group purchasmore widely available medications can be more eas- ing options to increase EMS buying power. There are
ily implemented. In other states, changing a drug may also established purchasing cooperatives that may be
require going through a bureaucratic process that could able to help. Hospitals may have much better buying
power with drug manufacturers and can obtain prefertake several months.
States that rigidly regulate EMS drug lists, or have ence in purchasing drugs that are in short supply. Just
statewide protocols that include specific medica- make sure these agreements dictate that you’ll pay fair
tions, may need to invoke an emergency rule-making market value for the medications and have the agreeprocesses to respond to these challenges and allow ment reviewed by your legal counsel for potential Antitheir EMS agencies to continue to provide high-quality Kickback Law concerns.
Always follow laws and protocols: When considpatient care. Nevertheless, certain strategies can be
applied universally, and applying these strategies can ering and/or using alternative treatments and medications, or when using drugs with lapsed expiration
help reduce the risk of liability for EMS agencies.
Inventory frequently: EMS agencies should inven- dates, always adhere to applicable laws, protocols
tory all their drugs and check their expiration dates and medical direction. If there’s a way to relax those
on a frequent basis. Agencies should assign drugs with laws and protocols, pursue those avenues. Consider
more recent expiration dates to be used before those obtaining an emergency exception from the state if
with later expiration dates. It’s a good practice to look one is available.
Consider viable alternatives: EMS agencies, in
at historical usage rates for your organization so the
organization knows when it has fallen below a critical conjunction with their medical directors, need to be
level. Also, ensure medications are properly distrib- proactive in making protocol recommendations when
uted among vehicles and establish benchmark levels a drug is in short supply or when a drug will likely be in
for medications on each ambulance in adherence with short supply. Is there an equivalent medication that’s
safe? If so, consider any side effects and other contraapplicable laws and protocols.
Track shortages: EMS agencies should also assign indications of its use. If there’s a way to have medicaan individual or committee to track drug shortage tions approved beyond their expiration date, consider
information and trends on a local, regional and national this option. Or the agency may wish to consider using
level. The American Society of Health-System Pharma- compound medications.
Have a contingency plan: The
cists (ASHP) maintains the most current
Pro Bono is written by
agency should have a contingency
list of drugs in short supply and anticiattorneys Ryan Stark,
plan in place in the event there’s no
pated dates of resolution. You may also
Doug Wolfberg and Steve
drug, or viable alternative, available.
wish to work with state and regional
Wirth of Page, Wolfberg
Consider other treatments, besides
Wirth LLC, a national
medication, that might assist the
Work cooperatively: Other providEMS-industry law firm. Visit
patient. Work with medical direcers may have what you need. If state
the firm’s website at www.
tors to develop protocols that deal
law permits, consider implementing
pwwemslaw.com for more
EMS law information.
with worst-case scenarios. JEMS
purchase agreements with other EMS
Conduct a keyword search for “drug shortage” at JEMS.com for more information.
23. Choose 22 at www.jems.com/rs
24. Higher Learning Practice
Educational Theories Put into
by Al Kalbach, EMT-P
Sim for Students
Master the use of simulation in your classroom
MS has used simulation for decades in the form of CPR manikins, task trainers and standardized patients (i.e., real “victims”
moulaged and simulating illnesses and injuries).
However, with the advancement of high-fidelity (HF) manikins
and the use of standardized patients in critical-thinking exercises,
we’re now capable of offering scenarios that immerse students
and providers in real-world exercises. And it’s had great results in
improving the educational process and changing a lot of the traditional behaviors.
Case in point: the 2012 JEMS Games. The use of HF manikins
proved essential in providing a scenario that simulated a deterio-
rating patient and provided the participating teams a platform to
perform all necessary treatments in a realistic environment. The
Laerdal/JEMS folks strategically designed and implemented an integrated educational approach by creating an article about asthma
and announcing that asthma would be seen in the competition.
In conjunction with this new educational approach, Laerdal
provided its comprehensive Discover Simulation Toolkit to each
JEMS Games attendee. The teams obviously paid attention, which
emphasizes a key point of simulation: It’s designed to be constructive, not critical. Simulation is a safe place to learn, make mistakes
and take away positive reinforcement.
imulation in healthcare is used for education, evaluation, research
and system integration.
The goal of this article is
to assist the instructor in building a relevant
scenario and providing a positive learning
experience for the student. We can divide the
simulation experience into the four “Ps:”
Learn your simulator’s capabilities: Many institutes and departments have purchased HF
manikins to augment their training program. Their use ranges from critical-thinking exercises to using the simulator as an
advanced “task trainer.”
Although all positively enforced training
is good, it’s recommended that the instructor
participate in training sessions offered by the
manufacturer, and simulation-based training
offered by such recognized organizations
as the Society for Simulation in Healthcare
(www.ssih.org), to understand the components of a successful simulation program.
Skilled educators and technical consultants are also available to assist with planning and developing simulation learning.
EMS conferences now regularly have simulation as a topic, so this can help the opera-
photo glen ellman
This year’s JEMS Games competitors demonstrated ALS skills on Laerdal’s HF manikins.
tor keep current on trends.
High-stakes risk assessment: Every training institute and department has its own
unique risks and encounters. A primary
goal of your simulations should be how
to address the high-stakes situations that
your students/EMS providers encounter. Is
there a trend your students are struggling
to grasp? Is there a new method or protocol you want them to learn? Has a prob-
lem been encountered that affects crew or
You can gather the information from
classroom and exercise performance,
patient charting/documentation, crew
reports, hospital/command feedback and
any stakeholder resource. Once the risk is
identified, you can begin to plan your strategy for a simulation exercise.
Critical-thinking points: No matter the exer-
25. Choose 23 at www.jems.com/rs
26. Higher Learning
continued from page 26
cise, critical-thinking points should be limited
to the main point of the exercise.
Let’s take the subject of identifying an
ST-elevation myocardial infarction (STEMI)
patient and transporting the patient to an
appropriate facility. The provider should be
able to do the following:
1. Identify STEMI;
2. now of and be capable of directing
3. ommunicate with command physiC
cian and recommend STEMI alert; and
4. ommunicate well with receiving facilC
This example stays within the parameters
of care, treatment and transport of a STEMI
patient. It doesn’t add complications or “gotcha” points.
advanced cardiac life support and pediatric
ALS and standards.
This saves you from having to build these
programs from scratch. However, you should
ask yourself whether the program meets the
needs of your simulation education because if
it doesn’t, you’ll have to build or modify your
program to suit your specific needs.
Scenario building/environment: We emphasize that instructors need to be able to
program and operate their simulator efficiently. Sketch out your scenario into a
logical flow. Using a template or flow chart
is an ideal way to lay out the scenario on
paper. Check all sections for accuracy and
have your key instructors check and agree
that all points are included in the template.
Building scenarios in your simulator’s program: This will vary by each manufacturer
and even between models from any manufacturer. Consider your critical-thinking
points as key trigger points in your simulation. Other triggers can be skills and procedures that normally would be encountered
in the given scenario. Simulator manufac-
turers provide a good number of skills and
procedures, but you may want to add more
to meet your specific needs.
Running a program “on the fly:” This type of
program is completely manual. It depends
on the simulation operator to make all
necessary parameter changes and record
all critical-thinking and skills assessments.
Obviously, the operator needs to be familiar
with the simulator and its systems to be able
to run an “on the fly” program successfully.
This type of program can also be used for
situations in which a preprogrammed or
built scenario fails to advance and critical
parameters need to be changed.
kills: Simulators are
also valuable because
they can be used effectively to develop, maintain or augment various
lifesaving skills. This
can include the administration of drugs,
advanced airway care, medication and
most BLS and ALS skills.
Simulators have the ability for instructors to log skills in real time as they occur,
and some skills are automatically logged
by the program. The instructor can also
log in during the scenario run and make
comments that may aid in instruction after
the scenario is complete.
Pre-programmed scenarios: Many simulator
manufacturers have common, frequently
seen (and seldom seen) simulations for
clinical (medical and traumatic) cases, to
get you started.
They also offer programs you can purchase that are designed to meet the needs
of specific healthcare practices. For example, you can purchase programs that meet
Now that your simulation is operational and
loaded with key simulation scenarios, you
should do run-throughs with key instructors
and personnel to be sure that all key criticalthinking points have been met, correct procedures are implemented and all teaching
points are included. Running the program
will alert the instructor to possible conflicts
or errors in the program as well.
A checklist of critical-thinking points and
skills should be provided to each instructor
to ensure all training criteria have been met.
Use this “shake-down run” to ensure you
work out any bugs and eliminate surprises.
photo glen ellman
Presenting to the Masses
After starting the simulation, allow students to immerse themselves into the care of the patient.
You’re now prepared to present your simulation to the learners. Make sure that everything they need to learn is presented in
advance and that all required equipment is in
place before you start.
The learner should be made aware of the
type of simulation they’ll be participating in
and given an outline of what’s expected of
them before they start.
Allow sufficient time for learners to check
equipment and environment for their comfort. It’s recommended to advise the students
to check their environment and ask any
questions they may have before starting.
27. Start the simulation and allow the students to immerse themselves
into the care of the patient. You should only interrupt if there’s a safety
concern or if the student(s) prompt you. If possible, it’s best for the
instructor to be in a separate room or other remote location where
you can view the entire process.
Let the scenario flow. You should have an on-screen checklist
of the points and skills you want covered. This will help you in the
debriefing process. The instructor running the simulation usually
acts as the voice of the patient via microphone and headset.
Video recording is another tool commonly used in the simulation
process. Students should be made aware they’re being recorded for
educational purposes only and that the video won’t be stored or used
to embarrass or show negative outcomes.
Student debriefing (review) should be accomplished immediately
after the scenario is concluded or as soon as feasible. Debriefing is
the process by which students interactively review their performance
after completing a simulation exercise. The procedure should be
guided by session objectives, course material and student comments
and questions. Instructors should serve as a resource and interject
goals and outcomes of the scenario in a positive manner, not act as a
lead voice in the debriefing process.
Instructors should debrief and review participants to reflect on
the presentation and its benefits in the learning process as soon as
possible after the simulation presentation. The instructor can have
debriefing files generated during the simulation. Some simulators
have the capability of recording video that synchronizes with the
debriefing file. Key points that occur can be marked in the file for
fast retrieval and playback during the debriefing.
In your review, consider the following:
ere the main critical thinking points covered in the simulaW
ere all skills addressed and completed?
id the participants respond appropriately to the presented
ere crew and patient safety appropriate?
as there anything else that should have been covered to meet
the goals of the scenario?
hat’s the feedback from the participants?
Healthcare HF simulation is advancing and has joined the ranks of
aviation, space flight, military and other high-stakes roles. With the
continual advancement of computer science and simulation design,
we can provide a safe learning environment for EMS providers and
produce a more effective and efficient EMS system. JEMS
Al Kalbach, EMT-P, is a simulation specialist for Good Fellowship Training Institute in
West Chester, Pa. He’s also the owner of Safety Watch LLC. Contact via e-mail him at
Choose 24 at www.jems.com/rs
28. TRICKSour patients ourselves
OF THE TRADE
by Thom Dick, EMT-P
Do No Harm
It’s important to not inflict unnecessary pain
Photo Thom Dick
ust when you think you’re never going
to be surprised again in your life, you
get the surprise of your life.
I recently spent a week in a hospital
because I had to have an ankle removed.
I learned a ton, Life-saver. Then, I spent a
week in a skilled nursing facility (SNF) and
learned another ton. Gotta say, I received
some great care (and a renewed sense of
humility) in that SNF. You’ll probably be
reading about my stay there, someday. But
that’s another story. This one’s about something that happened in the hospital.
I’ve often marveled that the word “hospitality” is mostly made out of “hospital,”
and yet the staff in so many hospitals seem
to understand so little about hospitality.
(Small wonder there’s a joint commission.)
As evidence, I’d like to tell you about my IV.
That’s it, just the IV. I won’t bore you with
the rest of a very long list of observations
I made before and after the Versed part,
which came right after the IV. (I think.)
My wife and I reported to a surgery center, where a nurse named Karen gathered
my clothes and a whole lot of information
about me. Now, I have great veins. I know
that because they’ve all been found by student EMTs and medics. In particular, I have
great “intern’s” veins. (You know the ones.
They’re the veins formed by that big branch
of the cephalic vein that intersects with the
crease of the lateral wrist.)
Well, Karen started exploring the veins
on the backs of my hands before she settled on my left intern’s vein, which was so
prominent I could see its shadow. I don’t
know how she could have missed it with
that big 20, but she managed. Finally, after
poking, digging and stabbing, she nailed it.
I have hairy arms. I noticed Karen was
going for the IV without shaving the hair
on my wrist and thought maybe I should
say something. But I was too slow, so she
poked me and slapped an OpSite on top of
all that hair, then plenty of tape on top of
that. Writing this, I would like to tell you
Taking the time to shave a patient’s arm before starting an IV may seem simple, but they’ll appreciate it.
(and her what happened in the course of the
next five days.
On the day after surgery, the site had to
be re-taped because the IV became unstable.
To secure it, another nurse simply added
more tape (circumferentially, I might add).
The day after that, another nurse ripped
all the tape off (but left the original OpSite,
clinging only to my hair) and just replaced
the tape. When I asked her to moisten
the tape with alcohol before ripping it off,
she said she was too busy to do that. Two
days later, I mentioned to a fourth nurse
that the IV was falling out (again). By that
time, a lot of congealed blood was visible in
The nurse cleared the line by flushing it
and shoving the congealed blood into my
vein. I’m sure it’s now a space-occupying
lesion in one of my lungs. Then he asked if
I minded having a newly graduated nurse
start a replacement IV. I agreed, and within
five minutes, a pair of really young nurses
entered the room with an IV tray.
When they started ripping the
tape off, I asked them if they would
please moisten the tape with an alcohol prep. One of them kept on ripping, saying he didn’t have time for
that, so this time I insisted. Sure enough, the
alcohol soaked through the backing on the
tape, and within seconds it had softened the
adhesive. The tape came right off. But then
they treated me like a smart ass for making
“Sorry,” I said. “I’ve started a lot of IVs in
my life, and I just know it works.”
That didn’t impress them, especially after
I asked them to shave the site this time. In
fact, one of them looked at me as though I
was being a jerk.
“You know,” he said. “We’re not students.
“I’m just telling you,” I said. “It really hurts
when people rip that tape off of somebody’s
hairy skin. Not to mention the added risk
I know you start lots of IVs on hairy people. And sometimes when you do, you’re in
a real hurry. But do them a favor. Hell, do
me a favor. Give ’em the benefit of a onesecond shave.
They may never know the difference. In
that case, let me say this in advance. Thank
Thom Dick has been involved in EMS for
42 years, 23 of them as a full-time EMT and
paramedic in San Diego County. He’s currently
the quality care coordinator for Platte Valley
Ambulance, a hospital-based 9-1-1 system in Brighton,
Colo. Contact him at firstname.lastname@example.org.
29. Choose 25 at www.jems.com/rs
30. CASE OF THE MONTH
DILEMMAS IN DAY-TO-DAY CARE
BY Steven R. Allen, MD Cayla G. Conover
Providers treat patient with multiple gunshot wounds
Providers learned that the patient was allegedly in an altercation with another man outside a bar. The conflict became violent, and
the patient sustained multiple gunshots to his
chest and right thigh. The patient was unresponsive with labored breathing and unstable
vital signs. He did not present with signs
of external exsanguinations. In addition to
his hemodynamic instability, the patient was
noted to have crepitus over his left chest.
The patient was unresponsive and had a
Glasgow Coma Scale (GCS) score of 3. He
was unable to protect his airway, so providers
attempted an endotracheal intubation (ETI)
with a 7-0 endotracheal tube (ETT) by the firstarriving EMS crew. However, this was aborted
because of the patient’s strong gag reflex. The
patient was transported
to the landing zone,
where a PennStar flight
crew performed rapid
On the first attempt,
the patient was noted to
have a very swollen airway with poor visualization of airway landmarks.
The plain radiograph of the head and neck shows the bullet hole, which
is marked by the paperclip. The patient was transported emergently to
undergo a computed tomography (CT) scan with an angiogram of the
neck and left lower extremity to assess for vascular injuries of the neck
and injured leg, respectively.
After two failed attempts with standard
laryngoscopy, the providers successfully
placed the ETT using the King Vision video
Successful ETI was confirmed with endtidal carbon dioxide (EtCO2), and breath
sounds were confirmed bilaterally. Providers
noted subcutaneous emphysema, which was
demonstrated with palpable crepitus over the
patient’s left chest and hemodynamic instability, which prompted needle decompression
of the left chest.
The patient’s vital signs improved with
these interventions. A rapid evaluation of his
wounds at the scene identified a single wound
just inferior to his left clavicle and multiple
wounds to his left thigh, all of which weren’t
actively bleeding. A C-collar was placed on
the patient, and he was transferred to the
flight stretcher and transported to the trauma
center by an air medical crew.
Trauma Center Care
On arrival at the trauma center, the trauma
Images Courtesy Steve Allen
fire rescue crew responded to a call
that described someone who was
reportedly “shot in the chest.” The
scene was secured by law enforcement before
EMS arrival. On arrival at the scene, EMS
providers discovered a patient reportedly in
his 30s who was unresponsive in the supine
position with multiple gunshot wounds to his
chest and extremities.
This CT scan shows the angiography of the neck. Note the degree of tracheal deviation due to hematoma and swelling.
31. team performed the primary survey and
placed the patient on the monitor to measure
vital signs. They recorded a heart rate of 106
beats per minute; blood pressure of 79/48
mmHg and EtCO2 of 31 mmHg.
During the primary survey, the trauma
team used direct laryngoscopy and color
change capnography during their primary
assessment to confirm the patient’s airway
was in the correct position.
Because the patient underwent needle
decompression of his left chest, a left tube
thoracostomy was immediately placed in the
standard fashion without a return of air or
blood. The patient was sedated after intubation and remained with a GCS of 3. Although
movement of extremities couldn’t be assessed
on this evaluation due to sedation, the patient
presented with priapism, which is concerning
for a spinal cord injury.
The wounds were again identified and
marked, and plain radiographs were obtained
to assess the trajectory. A single wound was
identified over the left chest just inferior to the
clavicle with a primary bullet fragment in the
This intra-operative photograph demonstrates the near-complete transection of the left common carotid
artery near the level of the clavicle.
midline of the neck. Two wounds were identified on the left thigh. There was no active
bleeding from the wounds.
The patient was transported emergently to
undergo a computed tomography (CT) scan
with an angiogram of the neck and left lower
extremity to assess for vascular injuries of the
neck and injured leg, respectively.
Cessation of blood flow was recorded in
the left common carotid artery with reconstitution above the bifurcation. The CT angiogram of his left leg was normal. The patient
was moved emergently to the operating room
for exploration of his neck to identify and
Choose 26 at www.jems.com/rs
32. Case of the month
continued from page 33
repair the injury to the carotid artery and
assess for injuries to the trachea, esophagus
and surrounding structures.
The patient underwent a median sternotomy that was extended up onto the neck to
better expose the carotid artery. A destructive
injury of the common carotid artery at the
level of the clavicle was identified.
The carotid artery was controlled in the
chest and repaired with a saphenous vein
interposition graft. The trachea was assessed
and found to be uninjured. An endoscope
identified a small area of ecchymosis on the
esophageal wall. However, because of the
presumed injury and the patient’s inability to
eat for a prolonged period of time, a percutaneous feeding tube was placed in his stomach.
The patient was found to have a complete
spinal cord transection at C-6 with associated
quadriplegia. He suffered ventilator-dependent respiratory failure and required a tracheostomy for prolonged ventilator support.
He was weaned from the ventilator and discharged to an inpatient rehabilitation center,
where he continues to improve.
ETI is the standard of care for definitive airway
management. Success rates of ETI in the prehospital setting vary significantly in the literature. The presence of a difficult airway in any
setting is a life-threatening scenario, which
requires significant skill and forethought with
other alternatives in the event that standard
strategies fail. Multiple reports have demonstrated higher incidence of unanticipated difficult intubations in the prehospital setting
compared to those in the operating room.
Although the incidence of difficult intubation is only 2% in elective anesthesia care,
the incidence in the prehospital environment
approaches 10%.1 Management of an airway
in the prehospital setting may be difficult for
The patient is in extremis, hemodynamically unstable or uncooperative;
The patient has particular injury patterns, such as fractures and trauma to the face
and neck with associated bleeding and swelling in and around the neck and orpharynx; or
The patient has emesis and aspiration.
Choose 27 at www.jems.com/rs
Although controversy surrounds the use
of ETI in the prehospital setting, there’s also
a body of evidence that demonstrates the
benefits in patient outcomes with prehospital intubation in patients with traumatic
brain injury, cardiac arrest and risk for loss
of airway patency or aspiration.2 Prehospital
providers must weigh the risks and benefits
to the establishment of an artificial airway.
Complications related to ETI include
unrecognized esophageal intubation with
associated hypoxia and hypoventilation,
oropharyngeal or tracheal injury or even
hyperventilation, which may lead to cerebral
ischemia.1 With these risks in mind, providers need to consider the risks of not establishing a definitive airway prior to transport
of the patient. In the case presented here, in
which the patient had labored breathing and
increased swelling of the patient’s neck, a
delay in airway control could’ve been a mortal decision because loss of airway patency
Multiple airway management algorithms
have been established. One study defines a
33. difficult airway as a failure of tracheal intubation after a single attempt in a patient with
a Cormack-Lehane class IV airway or two
failed attempts in a patient with a CormackLehane class of III or less.2
Most recently, a variety of video laryngoscopes (VLs) have been advocated to facilitate successful ETI in the case of a difficult
airway. The proposed benefit of using a
VL is improved visualization of anatomy
with improved graphics on the monitor in
contrast to the minimal view one may see
on a traditional laryngoscope—especially in
dark, austere environments.
Early studies have demonstrated quicker
intubation and improved success rates in ETI
with a VLs when used by medical students,
nurses and paramedics.1,3
However, these data are preliminary
and haven’t been reproduced. Other
studies have demonstrated the advantages of VLs in patients with difficult
anatomy compared with a Macintosh
laryngoscope. Although video-assisted
intubation may have its advantages, it’s not
recommended as a first-line technique in standard intubations.3
Penetrating wounds to the chest and neck
may present EMS providers with significant
challenges related to airway management.
It’s important to use sound judgment whenever a case requires definitive airway management because it’s key to act quickly to
secure the airway in cases involving traumatic brain injury or impending airway loss.
A difficult airway may be encountered in
those patients with penetrating injuries to
the head, neck or chest.
The provider must be skilled at ETI. In the
case that standard intubation is unsuccessful,
the provider must be able to use other means
to establish the airway, which may include a
bougie, laryngeal mask airway, video laryngoscopy or even a surgical airway. JEMS
Steven R. Allen, MD, is an assistant professor of surgery
at the University of Pennsylvania in Philadelphia. He’s board
certified in surgery and surgical critical care and practices
as a trauma surgeon and surgical intensivist. He can be
contacted via e-mail at Steve.Allen@uphs.upenn.edu.
Cayla G. Conover is an undergraduate student at
Temple University in Philadelphia. She’s a biology major
with plans to attend medical school.
1. Butchart AG, Tjen C, Garg A, et al. Paramedic
laryngoscopy in the simulated difficult airway:
Comparison of the Venner A.P. Advance and
GlideScope Ranger video laryngoscopes. Acad Emerg
2. Warner KJ, Sharar SR, Copass MK, et al. Prehospital
management of the difficult airway: A prospective
cohort study. J Emerg Med. 2009;36(3):257–265.
3. Dupanovic M, Fox H, Kovac A. Management of
the airway in multitrauma. Curr Opin Anaesthesiol.
Combes X, Jabre P, Margenet A, et al. Unanticipated
difficult airway management in the prehospital
emergency setting: Prospective validation of an
algorithm. Anesthesiology. 2011;114(1):105–110.
Choose 28 at www.jems.com/rs
34. RESEARCH REVIEW ems
What current studies mean to
by David Page, MS, NREMT-P
Study examines drug’s influence on cardiac arrest survival
Hagihara A, Hasegawa M, Abe T, et al. Prehospital
epinephrine use survival among patients with outof-hospital cardiac arrest. JAMA. 2012;307(11):1161–1168.
pinephrine has been the mainstay of
cardiac arrest management for decades,
but is it effective? These authors used a
Japanese national database of prospectively
collected cardiac arrest data to see whether
epinephrine was associated with positive
outcomes. This analysis included 417,188
arrests between 2005–2008.
Return of spontaneous circulation was
observed in 18.5% of patients who received
epinephrine (2,786 of 15,030), and 5.7%
(23,042 of 402,158) of patients who didn’t
The overall survival rate for the epinephrine group was 5.4%, but only 1.4% had good
neurological outcomes. The non-epinephrine
group had a 4.7% survival rate, and 2.2% had
good neurological outcomes.
Although this study sampled a large
number of patients and was published in
a prestigious medical journal, we need to
be careful about the conclusions we draw
The authors discuss some major limitations: Japanese EMS personnel started
giving epinephrine in 2006, but the data
doesn’t include the amount that was given.
Hospital care was variable. The authors
don’t know whether in-hospital epinephrine was given or whether therapeutic
hypothermia was used.
I also think the study needs information
on immediate conversion of v fib and v
tach without prolonged resuscitation, rate
of compressions, mechanical compression/
decompression, ventilation rates, oxygen
administration, excessive pauses and use of
an impedance threshold device.
Effective, outcome-driven cardiac arrest
management is multi-factorial. The authors
addressed the need for a randomized
placebo controlled trial, and I completely
agree. Obtaining ethics board approval for
Photo david page
Researchers examined whether epinephrine was associated with positive cardiac arrest outcomes.
a trial of such a standard medication as
epinephrine will be challenging. We should
applaud these authors for taking another
step to lay the groundwork for more intentional studies in the future.
The bottom line is we should remind
ourselves that all interventions come with
unintended consequences. We need to continue with practicing the status quo, but we
also need to be careful with epinephrine
and get more involved in research.
What we know: Epinephrine is used widely.
Studies in 2007 and 2009 showed increases in
ROSC but not in survival to hospital discharge.
What this study adds: This study provides
evidence that epinephrine is associated with
ROSC but not with survival to discharge.
I IV Analysis I
Selker HP, Beshansky JR, Sheehan PR, et al. Outof-hospital administration of intravenous glucoseinsulin-potassium in patients with suspected acute
coronary syndromes: The IMMEDIATE randomized
controlled trial. JAMA. 2012;3;307(18):1925–1933.
y way of disclosure, I want to state that
one of my medical directors is involved
in this study. So I claim immediate bias
and conflict of interest, but I still think it’s
a good idea to report on this study and
its results, especially because this column
previously reported the initial use of the
“ACI-TIPI” predictive ischemia scale used
in this trial. (Search JEMS.com for “research
The group of researchers studied the
use of glucose insulin and potassium (GIK)
to protect from myocardial injury during
acute coronary syndromes. The idea was
to give agents that might protect the cells
from metabolic derangements (promoted
by elevated free fatty acids, or FFAs) and
reperfusion injury. Cellular FFAs and their
derivatives are believed to accumulate during ischemia, disrupt the mitochondria,
increase intracellular calcium and promote
arrhythmias. GIK might be a relatively safe,
cost effective and plausible way to begin
The original goal of this study was to
enroll more than 15,000 prehospital
patients because the benefits were thought
to be dependent on early administration.
Unfortunately, the National Institutes of
Health changed the study due to the lack
of resources and funding to include in-hospital administration, and enrollment was
curtailed at 880 patients. One-year outcome
data is still being collected. So the final data
isn’t yet available.
For now, this paper reports that GIK
didn’t seem to stop further myocardial
damage (i.e., no statistical difference was
found in the patients who progressed).
The authors suggest this may be because
35. the medication wasn’t administered
early enough because the damage had
Interestingly, although not statistically
significant, the mortality rate at 30 days
was 4.4% with GIK and 6.1% without GIK.
If we add a composite end point of cardiac arrest in combination with mortality
(e.g., patients who arrest, as well as those
who died), then the difference would be
statistically significant (6.1% with GIK and
14.4% without GIK; P=0.01). GIK needs to
be tested more, but it appears that it may be
a safe and effective therapy to decrease cardiac arrest and death in patients with acute
I Emotion Work I
Williams A. A study of emotion work in student
paramedic practice. Nurse Educ Today. 2012;Apr 2
[Epub ahead of print].
oo often we focus on research that’s
quantitative (research that attempts
to measure something numerically).
Qualitative research is focused on descriptive and human factors. In this project,
Williams interviewed eight paramedic
interns in England. The objective was to
describe the emotions and coping mechanisms that a new paramedic student has
when they’re faced with cardiac arrests and
other critical cases.
This study is a great reminder that our
new clinicians need support as they’re
involved in new critical events. They
observe these through the lens of a novice,
like a magnifying glass that accentuates
their emotions and reactions. Williams discusses two main themes: “getting on with
the job” and “struggling with emotion,” the
latter of which relates to students struggling
to control and suppress their emotions.
Educators beware: It’s essential for you
to prepare for and support your students
through these emotions. JEMS
Choose 29 at www.jems.com/rs
Visit www.pcrfpodcast.org for
David Page, MS, NREMT-P, is an educator
at Inver Hills Community College and a
paramedic at Allina EMS in Minneapolis/
St. Paul. He’s a member of the Board of
Advisors of the Prehospital Care Research
Forum. Send him feedback at email@example.com.
Choose 30 at www.jems.com/rs
36. Richmond Ambulance
of safety model
The Richmond Ambulance Authority has
worked hard to create and foster a culture
centered on safety in all areas.
37. By Rob Lawrence, MCMI; Bryan S. McRay, BA;
Dempsey Whitt, NREMT-P/FP-C; Joseph P. Ornato,
MD, FACP, FACC, FACEP
he Institutes of Medicine’s landmark publication
To Err is Human estimates that at least 44,000 and
perhaps as many as 98,000 Americans die in
hospitals each year as a result of medical errors.1
And hospital patient safety incidents account for $6 billion
in extra costs annually in the U.S.2 Is EMS any different?
In a 2002 Prehospital Emergency Care study, the authors
wrote a consensus statement that represented the views
of several respected operational medical directors regarding the national state of EMS safety.3 The group identified
common EMS errors and concluded, “Standard operating
procedures to prevent and recover from such errors in
the field are in their infancy.” Shortly thereafter, several
researchers conducted a survey of 283 EMS providers
attending a North Carolina EMS conference and found that
one or more errors had occurred during the previous year
in 44% of those surveyed.4 However, only half of the errors
were reported to their supervisor or medical director.
In 2008, two authors wrote an editorial calling for the
establishment of a national center for EMS provider and
patient safety.5 A national center doesn’t exist yet. However,
a number of local and state initiatives, such as the Missouri
Center for Patient Safety, are beginning to focus on at least
some aspects of safety in EMS.
This article describes the comprehensive, multidimensional safety program developed and implemented
at the Richmond Ambulance Authority (RAA), a highperformance EMS system serving Richmond, Va.
RAA is a self-operated public utility model EMS system
employing a system status management approach to its
deployment, command, control and communications. It’s
a member of the Coalition of Advanced EMS Systems and
is accredited by both the Commission on the Accreditation
of Ambulance Services and the National Academy of
Emergency Medical Dispatch as an Accredited Center
RAA employs unit hour utilization (UHU) as its
currency to ensure that all available income is transformed into helping deliver world-class EMS. A
unit hour is equal to one hour of service by a
fully equipped and staffed ambulance available
for dispatch or assigned to a call. UHU is a
measure of productivity, which compares the
available resources (i.e., unit hours) with the
actual amount of time those units being
used for patient treatment and transport or
Photos Richmond Ambulance Authority
Transformation to AN EMS Culture
Choose 31 at www.jems.com/rs
38. Safety First
continued from page 39
productive activity. UHU is the
measurement of unit hours “conTaking Safety to the
sumed” in productivity compared
Streets 2011 Data
with the total staffed unit hours. In
Fatality rate for EMS providers
simple terms, UHU monitors the
is 2.5 times higher than the
provision of resources available in
the right quantity, at the right time
Non-fatal injury rate for EMS
practitioners is five times
and in the right place to perform,
higher than the rate for other
treat and transport efficiently.
Conceptually, RAA operates
EMS providers are seven times
within a total quality and safety
more likely than the average
bubble, employing lessons learned
worker to miss work as result of
from other high-quality, safety-oriented industries, such as nuclear
• Transportation-related Fatalities
In 2008, RAA’s operational
National average: 2.0
medical director, a pilot with first Firefighters: 5.7
Studies comparing and contrasting EMS with both national and public
Police officers: 6.1
hand experience in how aviation
safety incident data reveals a telling story and provides focus in the immehas achieved a high level of safety, insti- EMS practitioners: 9.6
diate need to develop and embrace a safety culture across EMS.
gated a successful error self-reporting
• Fatal Occupational Injuries
program patterned after the Aviation
non-work related governing emergency driving and RAA’s 12
Safety Reporting System (ASRS) devel- National average: 5.0
and standards of driving adopted from the Allsafe
oped by the National Aeronautics Firefighters: 16.5
miss 10 shifts or Driving System.
and Space Administration (NASA). Police officers: 14.2
more must pass
Focus on safe vehicle operation is main EMS providers: 12.7
The NASA system was designed to
the PAT before tained through consistent reiteration of the
detect all near misses and to translate
they’re cleared to 12 standards of driving via periodic safety
lessons learned into operational process permanently return to work.
campaigns as well as safety talking points
changes rather than blaming individuals for
highlighted by field providers and safety and
risk staff during everyday operations. Checks
Induction to the Organization
RAA’s approach to safety pervades all lev- Introducing, developing and embedding a and balances are kept on drivers via an onels and departments, from the frontline to the culture of safety are core functions of the board road safety system. The “black box
back office. This starts in the pre-hire phase. new employee orientation program. The ini- technology” interactively monitors preset
Conceptually, RAA also looks ahead to plan tial classroom-based induction covers scene driving parameters, giving the vehicle operaand anticipate the next set of safety issues that safety, the operating principles of all of RAA’s tor immediate feedback through the use of
key pieces of equipment, safe and skilled audible tones. Monitored parameters include
operation of vehicles, and correct appropriate
patient transfer techniques.
All new employees are immersed in safety
RAA’s approach to safety begins even before
the employees receive an offer letter. RAA from orientation through field preception.
contracts with an occupational health ser- For 26 shifts, RAA’s field training officers
vice that conducts a pre-hire physical agility carry on where the classroom left off, providtest (PAT) on all field operations candidates ing practical instruction and leadership by
to determine their existing muscular skeletal example in a controlled environment, ensurstrength, which is often predictive of future ing that providers are prepared to operate
physical problems, such as a back injury. The safely as RAA crew members. RAA instruccomputer-based system RAA has used for the tors also teach the National Association of
past two years has proven to be an effective EMTs’ safety course to its employees.
For example, RAA now factors the PAT Safe Driving
results into its decision whether to offer New hires are required to be emergency vehiemployment to an applicant. Some highly cle operator course (EVOC) qualified prior
qualified candidates have failed to make it to employment at RAA. From this baseline,
to the initial New Entry Orientation because safe and skilled vehicle handling is built on
they haven’t met the PAT requirements. with the successful completion of the inAs a prudent risk-reduction measure, staff house driver training program. This program RAA uses data and reports to identify and correct
members who have suffered either work or includes a review of EVOC material, state laws potential safety issues before they occur.
39. seatbelt compliance, lights and sirens usage,
acceleration and deceleration forces, turn signals and safe vehicle reversing.
The latter feature also requires the use of a
spotter who activates a reverse button located
in the rear of the vehicle to alert the driver of
any hazards. A weekly league table of emergency and non-emergency driving that scores
vehicle operators is produced. In the rare
event of a vehicle collision, road safety data
is downloaded to analyze the activity of the
vehicle at the time of the incident. This ability
to instantly review the incident helps create a
clear picture of what occurred, which allows
RAA to fully understand the root cause of the
incident so the operational changes can be
made to prevent a recurrence.
just regarding patient care but also regarding
The driver and the paramedic crew member are both responsible for the vehicle’s
safety. They must work as a team to coordinate navigating to calls, obtain additional
information from the mobile data terminals, work the siren and communicate on
the radio. The single most important thing
employees can do for their patients and for
themselves is to have both sets of eyes looking
outside the unit as much as possible.
Crews are discouraged from performing
any tasks during the response phase that
aren’t absolutely critical to the current call.
This is similar to the “sterile cockpit” rule used
in aviation, which dictates that a crew isn’t
allowed to have non-task critical conversation or distracting activity during the takeoff,
approach and landing phases of flight.
Safety All Day Every Day
RAA’s operations are designed with efficiency and effective response in mind. The
by-product of this planning is safety. We’re
convinced that lights and sirens responses
The RAA self-reporting program provides an
employee who makes a mistake the opportunity to report that incident without fear of
punitive action, as long as it’s not a criminal
act. Once reported, an investigation and root
cause analysis are conducted by the clinical
safety review committee, which is chaired
by the operational medical director and
attended by the chief operating officer, chief
clinical officer and director of safety and risk.
The goal is to identify whether a systemic
issue needs to be addressed. As in the ASRS,
an individual who self-reports is deemed to
have an appropriate, positive attitude regarding safety and won’t have punitive action
(including termination) taken against them
provided the action:
Was reported promptly;
Was inadvertent and not deliberate;
Wasn’t a criminal offense;
Wasn’t due to a substantial lack of qualification or competency; and
Training, remediation and changes in
protocols, processes and procedures typically result from self-reports to minimize the
likelihood that a similar incident will occur
involving any provider in the future.
The greatest risk and exposure to fatal
vehicular accidents occurs during the
response phase of any call. The team effort
to deliver each vehicle and its crew to a call
safely is of paramount importance. RAA
emphasizes crew resource management
(CRM) in its training and operations, not
Choose 32 at www.jems.com/rs
40. Safety First
continued from page 41
Table 1: Standard Driving Report for July 25–31, 2011
Total Driving: 17,138 miles
Emergency Driving: 2,217 miles
Non-Emergency Driving: 14,921 miles
Average Daily Fleet Speeds (mph)
reduce musculoskeletal injuries. An outward
success in the past year has been the purchase
of pneumatic lifting cushions. Patients are
placed and then elevated by compressed air
to a sitting position, from which they can be
assisted to their feet. RAA is currently equipping its entire fleet with powered stretchers to
reduce the amount of lifting required. Better
back care is an issue RAA takes seriously in
its effort to reduce staff injuries and attrition.
One role of RAA’s operational team is to keep
the workforce rested and prepared for the
rigors of busy shifts, so RAA’s scheduling and
shift-building rules prevent a member of staff
from returning to work within eight hours of
their last shift.
should be used sparingly—and only when
medically justified—to reduce the risk of
vehicular accidents. Instead of basing units
at fixed locations and requiring fast driving, Communication
RAA uses system status management to RAA’s philosophy is that communication
place units to post locations throughout the isn’t a skill reserved for the radio. Root cause
city dynamically based on computer predic- analysis in aviation as well as EMS frequently
tions of where the next most
likely life-or-death calls will
occur. This has proven to
be highly accurate using historical data factoring in the
time of day, day of the week,
The result is that RAA’s
ALS units arrive on scene in
less than or equal to eight
minutes from the time of
A team effort is essential for implementing a safety culture.
the call receipt 93–96% of
the time in all sectors of its service area on identifies a lack of communication between
life-threatening calls, despite the fact that crew members on a day-to-day basis as a
our average fleet speeds aren’t much differ- significant contributory factor to safety incient between emergency and non-emergency dents. RAA’s supervisors and managers train
responses (see Table 1 ).
crews to have open, frank and honest diaA response to calls in which dangerous logue with each other any time any issues—
activity is suspected enacts the call staging even seemingly minor ones—occur.
safety procedure. Crews are required to wait
We also stress the importance of CRM,
off scene until the area is cleared and deemed making it clear that each crew member has
safe by police. Similarly, a crew on scene the responsibility to speak up promptly
potentially compromising their safety has the within the chain of command whenever
discretion to evacuate and await further back they have a concern that something isn’t
up. All crew members have personal radios quite right. This is especially true if it might
equipped with mayday buttons that issue a constitute a safety risk to the patient or
silent alarm to dispatch and place the radio responding personnel.
into continuous transmit mode. A mayday
triggers an immediate top priority police Measuring Safety Success
response to the ambulance location, which RAA’s transformation to a culture of safety
is constantly monitored in dispatch using culture is an ongoing journey. Its mission is to
RAA’s automatic vehicle locator system.
provide world-class EMS, and we recognize
Regarding the more common situations of we can’t do that without striving to be among
lifting and moving a patient, RAA is always the safest EMS agencies in the world. Success
looking for better devices and techniques to must be measured on multiple dimensions,
both for employees and patients.
RAA has reduced worker’s compensation injury claims since it began a “culture
change,” which reduced our NCCI experience
modification factor (an insurance premium
adjustment that recognized the merits or
demerits of individual risks) from 1.04 to
0.83. This translates into a 20% premium
reduction. RAA’s insurance carriers use RAA
as a model of a best practice, and they refer
clients with similar operations to RAA for
Finally, for RAA, overall success is defined
by keeping the promises we make to employees during orientation: “Our primary goal is
to get you home in the same way you came to
work. No injuries and no illnesses. You may
be sore and tired, but you aren’t hurt or sick.”
We work hard each day to meet or exceed
this challenge. JEMS
Rob Lawrence, MCMI, is chief operating officer at
Richmond Ambulance Authority and was named a JEMS
EMS 10: Innovator of EMS for his work on the Rider Alert
program in 2011.
Bryan S. McRay, BA, is the safety and risk director for Richmond Ambulance Authority. He has been
involved in EMS for 22 years both in volunteer and
career agencies. He’s currently pursuing his master’s in
Dempsey Whitt, NREMT-P/FP-C, is the director of
operations for the Richmond Ambulance Authority and
serves in the Virginia Army National Guard’s 29th Infantry
Division as the chief medical non-commissioned officer.
Joseph P. Ornato, MD, FACP, FACC, FACEP, is professor
and chairman of the Department of Emergency Medicine
at Virginia Commonwealth University and Operational
Medical Director for the Richmond Ambulance Authority.
He’s also a member of the JEMS Editorial Board.
1. Institute of Medicine. To Err is Human: Building a
safer health system. Washington, D.C.: The National
Academies Press, 2000.
2. Levenson D. Hospital patient safety incidents account
for $6 billion in extra costs annually. Rep Med Guidel
Outcomes Res. 2004;15(16):1–2,6–7.
3. O’Connor RE, Slovis CM, Hunt RC, et al. Eliminating
errors in emergency medical services: Realities and recommendations. Prehosp Emerg Care. 2002;6(1):107–113.
4. Hobgood C, Bowen JB, Brice JH, et al. Do EMS personnel identify, report and disclose medical errors?
Prehosp Emerg Care. 2006;10(1):21–27.
5. Paris PM, O’Connor RE. A National Center for EMS
provider and patient safety: Helping EMS providers
help us. Prehosp Emerg Care. 2008;12(1):92–94.
41. Choose 33 at www.jems.com/rs
42. 50 Innovative
at the 29th
This year at the EMS Today Conference and Exhibition, a team of judges
reviewed and evaluated numerous
new products and innovations in EMS
equipment, vehicles and programs on
display by the nearly 300 exhibitors.
These products were released to the
EMS market within the previous eightmonth period.
They reviewed products designed
to not only improve your ability to
deliver optimal emergency medical care
to sick and injured patients, but products that also allow you to do it safely,
more efficiently and with enhanced
comfort for the patient.
The review team rated each of
the new and innovative products on
their originality, functionality, ease of
use and need in the EMS setting. Their
selection of the 50 hottest products
at EMS Today 2012 are presented here
in random order for you to check out.
Look for additional coverage of many
other products reviewed in upcoming
JEMS Hands On columns.
RIP SHEARS is an innovative, compact, removable dual-blade cutter that attaches to almost
any size and style trauma shears. It enables
you to more rapidly remove the toughest and
thickest clothing and turnout gear in seconds.
Once you insert it in an opening, or start a cut
with the shears, all you have to do is pull it
through the material and it zips through it like
a hot knife through butter. The replaceable
blades used in the RIP SHEARS are made of
440 surgical-grade stainless steel that improve
your cutting ability and sharp-edge retention
and will last five times longer than standard
The LOLA Advanced Assessment stethoscope is an innovative tool that combines multiple patient assessment tools into one package:
the stethoscope, penlight, pupil gauge and ruler.
Each stethoscope comes with a clear set of comfortable earbuds, three extra pairs of earbuds and
an extra battery for the light. The stethoscope
head is stainless steel, and the tympanum is a
clear plastic. A push button located conveniently
on the top of the head activates the LED light. A
pupil gauge with examples of pupil sizes from 1–8
mm is located right on the LOLA stethoscopes
non-latex tubing, making it easy to see and use.
There’s also a 40 cm ruler printed on the tube,
complete with millimeter markings.
Karl Storz Endoscopy
Karl Storz offers the portable C-MAC Video Laryngoscope, which has virtually no learning curve
owing to its use of standard Macintosh and Miller blades for adults through neonates. The new
C-MAC Pocket Monitor now offers even more portability as it sits right on the laryngoscope
handle and can be used with all existing durable stainless steel C-MAC blades. The screen is movable and can be folded to the side of the laryngoscope for transportation and storage.
43. Board Armor
Have you ever wondered, “Is this backboard
clean?” The science says they are dirtier than you
think. A pilot study performed by the University
of Miami found a 100% contamination rate on
“clean/in-service” backboards. The results indicate 11 different pathogens, many of which can
cause serious antibiotic-resistant infections. Do
you want to protect patients from dangerous
microbes undetectable to the naked eye? The
solution is a clean surface you can have confidence in: “Board Armor,” the first disposable
backboard cover with integrated head-blocks.
Benefits: It protects patients from cross contamination and reduces body-fluid transfer to your
The ReadyLink 12-Lead ECG is a new, small,
lightweight solution for BLS teams designed to
improve care for heart attack patients. It’s the
only stand-alone ECG device designed for BLS
teams to acquire a 12-lead ECG and transmit it via
the LIFENET System Data Network, the broadest
EMS/hospital data network in the U.S., to multiple locations and care teams for remote physician interpretation and decision support. Users
don’t need to know how to interpret a heart
rhythm, and no special ECG training is required.
With a simple-to use, three-step operation, it
focuses on one activity and condition vs. the
multiple capabilities of an ALS monitor.
Level Foods was started by a person with diabetes. Level Glucose Gel is a 15 g glucose gel
that’s used by EMS to treat low blood sugar or
hypoglycemia. It’s significantly less expensive
than the tubes of glucose gel currently used in
the EMS community and comes in a variety of
The EZ Glide with Powertraxx provides maximum safety when
going up and down stairs using an electronically controlled motor and
direct drive transmission with chair tracks. The tracks and motor carry the
patient load, not the operator. Enjoy maximum performance on every call
with an intelligent power system that runs up to 20 flights of stairs per
charge. The chair’s easy operation when climbing or descending stairs with
intuitive, easy-to-use, paddle-style controls keeps you in control.
JUNE 2012 JEMS
44. Stryker Medical
The Power-LOAD cot fastener system
improves operator and patient safety by eliminating the need to steer the cot into and out
of the ambulance, minimizing patient drops by
supporting the cot throughout the loading and
unloading process, meeting dynamic crash-test
standards for maximized occupant safety. It features an easy-to-use manual back-up system. It
lifts or lowers the cot into and out of the ambulance, eliminating spinal loads that can result in
cumulative trauma injuries.
Action Training Systems
800/755-1440 ext. 3
This custom version of Brady’s Emergency Medical
Responder: First on Scene Manual includes instructor and student chapter references to Action Training System’s new EMR multi-media training series. The manual,
DVDs and computer-based training all teach to the NEMSES. Pairing the manual and training programs provides a
comprehensive and competency-based training solution.
Emergencies happen, but preparedness can have
a significant impact on the outcome. ICEdot
provides the right information to the right people at the right time. By sharing emergency health
information and emergency contact information,
ICEdot helps first responders treat you and notify
Clear Advantage Collar
emsCharts Mobile is the real-time field supplement to
the emsCharts Web-based charting program. The featurerich application allows EMS providers to use tablet computers in the field, accessing powerful features, such as
rapid-entry mode, protocol-driven wizards and advanced
calculation tools. Other innovative features include pageby-page validations, PDF e-signature forms, age- and
gender-specific rotating body diagram, and more. It has
unlimited users and application downloads and no end-user
licensing. All at a flat fee based on your agency’s call volume.
Clear Collar’s Clear Advantage Collar’s
adjustability allows for a perfect fit every time
with every patient. It provides constant visual
assessment and allows for early detection of JVD,
tracheal shifts, blunt traumas, hematomas and
more. It minimizes legal liability for undetected
injuries and has large posterior and anterior openings for easy palpation and access. It’s lightweight
and clinically superior.
45. Bridgford Foods
The Ready to Eat Pocket Sandwich
was originally developed for the U.S. military and is currently incorporated into the
“First Strike Ration” for Special Operations
Forces. No refrigeration is required, and
each sandwich is 270–360 calories. They
have a three-year shelf life if maintained
at 80° F or less. Nine sandwich varieties are
offered for breakfast, lunch and dinner.
They’re designed to be eaten straight from
the pouch but can be heated.
The newest addition to the AeroClave family of sterilization products, the RDS 1110-P is
the fastest, safest and easiest way to ensure all
of your facilities, vehicles and assets are germ
free. Using a unique energized Hydrogen Peroxide (eHP) process, the RDS 1110-P is capable of
achieving a consistent full-spectrum 6-log sterilization. The RDS 1110-P is lightweight (44 lbs.)
and easy to transport (19.7 L x 12 W x 18 D),
making it the ultimate tool in the battle against
bacteria and viruses in the EMS industry.
Choose 34 at www.jems.com/rs
Ratcheting Medical Tourniquets (RMTs)
are “tactical tools” for hemorrhage control. The m2 Ratcheting Buckle (Gen 3) is,
fast, effective and self-locking. Instructions
are printed on every RMT. Each model is
designed for specific operators (e.g., EMS,
law enforcement, SWAT and military).
46. Xantrex Technology Inc.
The Freedom HF is one of the smallest, lightest,
most-affordable EMS inverter/charger systems
on the EMS market. It's available in two models: 1000W/55A and 1800W/40A. The Freedom
HF comes pre-wired with AC and DC cables. DC
cable with Anderson connectors and 3-prong AC
input cord enable easy wiring and quick installation. Ignition-controlled power module operates
DC loads. Tested to KKK-A-1822.
PRONTO! provides quick, customizable, energizers for the
classroom, online and Web conferences. Get your training
off to a great start. Featuring four multi-team challenges that
incorporate fun, interactive game play and action sequences,
PRONTO! gives you a powerful tool to present your training content. Use wireless keypads, smartphones (e.g., iPhone,
Android, BlackBerry), tablets or laptops and get everyone “in the
game” while capturing results. Use PRONTO! via a live webinar
(with PING software) or deliver it through the web and report
scores to any LMS.
Braun Industries, Inc.
Braun Industries has just released
to the market “The Braun Signature Series” model. The
Signature Series is a 150 model
available on the GM and Ford platforms. This new model features
Braun’s exclusive SolidBody construction, MasterTech multiplex
electrical system, the EZ Glide
door, Vital Max Lighting and an
all-LED lighting package. All these
core features of a Braun in a production model with a very economical price.
EMT Interactive is a series of online modules that cover the
entire scope of the National EMS Education Standards. The lectures provide anytime, anywhere access for students in a seamless and convenient training environment that allows them to
learn at their own pace.
The HeartStart FR3 AED is a powerful AED in
a compact, light (3.5 lbs.) and simple-to-use package that significantly reduces deployment time.
Its bright, high-resolution color LCD is easy to see
in all light environments, and its long-life battery
typically delivers 300 shocks or, if configured, 12
hours of monitoring. An integral CPR metronome
helps users deliver consistent chest compressions.
The Xtreme Trauma Moulage Arm represents a dismemberment/gross trauma suffered
during an explosion. Bones are missing, major
flesh is missing, and multiple lacerations and
avulsions prevail. The unit comes with straps for
attaching to either a manikin or human. The purpose of this wounded right arm is to prepare any
critical care provider with visual and tactile stimuli
so they can better cope with the real thing.
Veinlite LEDX, TransLite’s newest and
most powerful portable vein finder, has
twice as many LEDs as the popular EMS
model. Specially designed for use on bariatrics, the LEDX comes with an adapter for
use on slim adults or children, and the number and color of the lights can be varied
to suit all skin tones. It performs brilliantly
under bright indoor light, direct sunlight
and in darkness, reducing IV access time in
all emergency situations.
IntuBrite’s high-resolution video laryngoscope
system, the IntuBrite VLS, uses IntuBrite’s
proprietary white/UV LED lighting system for
bright and glareless illumination, coupled with
the latest in electronics and high-resolution
camera technology. This compact system also
allows use of traditional handle/blade equipment style and intubation techniques.
FastBreathe ThoraCic Seal (FTS) is
the only field- and full-laboratory tested,
valued product designed to manage a penetrating thoracic wound that can be covered by clothing, blankets, body armor, etc.
The seal is formed with an aggressive, yet
Choose 35 at www.jems.com/rs
JUNE 2012 JEMS
48. Rescue Essentials
The FLOW-SAFE II CPAP SYSTEM
with built-in manometer is now
delivering up to 10 cm H2O at 15
LPM while using 50% less oxygen.
Flow-Safe II has all of the benefits
of the original CPAP system with
superior safety features and performance, while consuming less oxygen.
It doesn't require special high-flow
equipment. Flow-Safe II also delivers consistent CPAP pressure on
inhalation and exhalation. No extra
parts—it comes assembled with a
deluxe mask, manometer and pressure-relief valve all in one disposable
setup package. Clinicians can easily
attach a nebulizer in-line for patients
requiring aerosol inhalation medication with CPAP therapy.
Karl Storz Endoscopy
Karl Storz offers the portable C-MAC Video Laryngoscope,
which offers virtually no learning curve owing to its use of
standard Macintosh blades for adults, as well as the D-Blade
for more anterior airways. The addition of Miller blades in
size 0 and 1 makes the system complete for all patient sizes.
These new C-MAC Miller Neonatal Blades also allow
the use of the C-MAC for pediatric EMS trucks as well as
NICU and PICU.
The Slishman Traction Splint is a new
innovative traction device. This is the only traction splint on the market that allows traction
to be pulled from the hip. The lower hitch can
be attached proximal to the calf, enabling traction splinting in case of lower extremity trauma.
It's easily applied during manual traction, another
difference from its competitors. Light, compact
and one-size fits all, the Slishman traction splint
quickly adjusts to every patient.
SAM Medical Products
The extra large SAM Chest Seal features the
advanced adhesion and flexibility properties
of the SAM chest seal and SAM chest seal with
valve, yet is 1,077 cm2 in size, enabling coverage of large wounds or multiple small wounds
Digital Ally Inc.
Digital Ally’s Video Event Data Recorders offer liability, safety and financial benefits by providing proof in vehicular accidents and against fraudulent claims, potential insurance
rate reductions, incident review for training purposes, inspiring safety, monitoring blind spots
or compartments and more. There are no ongoing contracts or additional surprise equipment
or software requirement expenses. The system was also recently selected by one of the largest
ambulance service providers as their vehicle video systems.
Introducing the Porticool II system. This
unique, patented design was engineered to
meet the specifications of the Department of
Homeland Security, weighs only 1.8 lbs. and is
a moisture-wicking and fire-rated garment. The
Porticool II system uses liquid CO2 for cooling.
It uses no electricity and can be used in intrinsically safe areas.
6/15/2012 1:38:35 PM
49. EKG Concepts
The R-CAT Window for STEMI is a flexible
3.25 by 6.75 plastic card with a reversible clear
baseline window that allows you to use the
R-CAT on an actual patient's ECG and 12-lead
ECG patterns of ischemia, injury and infarction,
as well as measurements of the heart rate, P-R,
QRS and RT intervals. It saves valuable time
when seconds count.
The TRECK+ is an alternative to
trauma shears and seat belt cutters, specifically designed to cut multilayered clothing and hard-to-cut items,
such as thick jackets, leathers, racing
uniforms and even turnout gear. The
second generation TRECK+ features an
oxygen wrench, rust-resistant coated
blade, a wider safety guard, carabiner
attachment and a free silicon blade
cover. A new clothing guide widens the
cutting angle, which makes the TRECK+ easy to
use across a wide range of materials. Made in
Choose 36 at www.jems.com/rs
The EchoView Host mini-controller is the cornerstone of RAE Systems’ Closed-Loop Wireless
Solutions for portable gas monitors. This rugged
handheld wireless device can establish a self-contained, self-sufficient network with up to eight
supported RAE Systems’ ToxiRAE Pro monitors.
Applications for the EMS industry include fire
scene, hospital and industrial hazmat response.
Choose 37 at www.jems.com/rs
JUNE 2012 JEMS
50. Philips Healthcare
Same stabilization, smaller size, The FASPLINT
HALFBACK is a shorter version of the FASPLINT
FULLBODY, providing the same quality of spinal stabilization and back support in a compact
design. Measuring 41 in length, the FASPLINT
HALFBACK stabilizes the head, neck and torso
as one unit, eliminating the problems associated with fixed head immobilization and less
than ideal strap configurations. No longer is the
patient’s neck a pivot point. It's compact, comfortable and secure.
Technology 1 Inc.
The VORTRAN-APM (Airway Pressure Monitor) is a battery-operated, portable device
that displays airway pressure and is connected
to the patient to monitor cycling conditions
of resuscitators. The LCD shows Peak Inspiratory Pressure (PIP) and Positive End Expiratory
Pressure (PEEP) in cm-H2O. Other respiratory
functions such as Respiratory Rate (RR) in
breaths per minute, Inspiratory Time (IT) and
Expiratory Time (ET) in seconds, and I:E Ratio
are also displayed.
Tactical Medical Packs
800/892-2801 ext. 5
Tactical Medical Packs has unveiled its newest
product, the Triage Medical Pack, for use
by professional emergency responders. Triage
Medical Packs consist of compact treatment
packs, one for airway emergencies and one for
bleeding emergencies. They’re available individually or in pre-packed kits. Designed for single- or multi-casualty incidents, the packs are
intended for single-patient use in the treatment of “immediate” level patients who are
experiencing a critical airway and/or bleeding emergency. Tx4 and Tx8 Triage Medical
Kits provide a first responder with the essential tools to rapidly treat “immediate” patients
while performing initial triage. The packs are
available exclusively through Hartwell Medical
The Philips HeartStart MRx is trusted by the U.S.
military and EMS agencies around the world.
Designed as a scalable platform, your MRx can
evolve as your needs change. The Tactically
Enhanced Heartsmart MRX has the latest
meaningful innovations, including a new tactical
grey color option, user interface enhancements,
new alarm management options, as well as end-toend ECG system enhancements for improved signal quality. It comes with the MRx’s already proven
capabilities, including 18 hours of monitoring time
with two fully charged batteries.
The FLO2MAX 4-IN-1 OXYGEN MASK was designed to
deliver the maximal amount
of oxygen to the patient. This
mask was designed to eliminate room air dilution using a patented series of
valves. Able to convert to a small-volume nebulizer mask, this mask can function as a true all in
one mask for EMS services. An integrated filter
captures all exhaled bacteria and excess medication, protecting equipment surfaces and staff
from airborne contamination.
BLS Systems Limited
The RESCUER EMERGENCY CPAP SYSTEM was
designed to offer the maximal respiratory support to patients requiring positive pressure therapy. The newest device available to EMS services,
this device offers easy to apply pressure adjustment, separate inspiratory and expiratory filters
and a medication port, while having the lowest
oxygen consumption of any comparable device.
Available in two mask styles, this affordable CPAP
system offers more features than any similar disposable CPAP device.
6/15/2012 1:38:44 PM
51. Geomet Technologies
More functional and user-friendly than
similar models on the market, the Rapid
Pro-Med 1 Flexible Stretcher features six large, thermal handles that offer
rigidity for easier transport while providing increased hand comfort. Three
2 web-securing straps feature a buckle
design that allows for centered strap
adjustment to maintain ideal patient position on the stretcher.
Choose 38 at www.jems.com/rs
The SMART MOM is a full-body patient simulator that's based on Simulaids’ successful
SMART STAT technology, addresses the health
of the mother and the initial care of the newborn. All vital signs and features are controlled
from the iPaq PPC. The baby’s position and orientation, fetal heart sounds rate, contraction
rate, manual baby positioning maneuvers and
fluid flow are all features exhibited. It comes
with a monitor that shows mother and fetal
vital signs, contraction patterns and heart rate.
King Systems introduces a revolutionary
series of high-performance portable video
laryngoscopes. Designed to be your primary tool for all intubations, the King
Vision combines the convenience of
a durable, reusable video display with
an affordable disposable blade. The low
cost per procedure combined with the
high-performance visualization capabilities make this the perfect choice for best
Choose 39 at www.jems.com/rs
JUNE 2012 JEMS
52. Medical Safety Solutions
The Sharps Terminator will destroy needles
attached and not attached to syringes—including IV and Butterfly needles. The unit completely
removes the hub of the needle. There is absolutely NO METAL left on syringe after disintegration process. Both ozone and ultraviolet
decontamination lights activate in the swarf collection container on each disintegration cycle to
eliminate any bloodborne pathogens that may
be inadvertently exhausted into the unit. In seconds, both the needle and the risk are eliminated.
It provides healthcare professionals with simple,
user-friendly methods of compliance with OSHA
safety standards for human exposure to bloodborne pathogens.
The SimPad System is a teaching solution designed to dramatically increase the functionality of the current line of VitalSim manikins. Having the compatibility with Laerdal simulators
and manikins, both new and existing, institutions can integrate this new technology and revitalize their current simulation platforms. With improved features and versatility, including a large,
intuitive touch-screen design, an expanded ECG library, new patient parameters and direct
access to the Laerdal suite of SimCenter products (and the content available on SimStore), SimPad is virtually a “pick up and play” experience. It allows you to easily deliver simulation-based
training and enhance your education environment.
The ReVel ventilator from CareFusion provides portable ventilation on the fly by offering
the critical tools and high-level performance you
demand for your pediatric (≥5 kg) to adult patients
in emergency transport. The patented ActivCore
gas delivery system with unprecedented miniaturization allows this portable ventilator to deliver
powerful technology for managing high-acuity
patients as they transport. Weighing only 9.5 lbs.,
the ReVel ventilator moves easily with the patient
in transport. The hot exchangeable, four-hour battery provides uninterrupted power for extended
transport capabilities. From the initial point of
emergency ventilation to the ER, no manual ventilation and no disconnection of the patient circuit,
just a continuously ventilated patient.
PRACTI-SEAL and SIMU-SEAL are inexpensive, non-medical, practice chest seal devices
employed by military, law enforcement and EMS
personnel to improve repetitive task transfer in
managing sucking chest wounds. The two-pack
version allows for the practice treatment of both
entry and exit wounds, and simulates tear open
medical seals, such as HALO and Hyfin. PRACTISEAL U.S.A. and SIMU-SEAL U.S.A. come in single
packs that mimic peel-open seals, such as Asherman, Bolin and SAM. PRACTI-SEAL and SIMUSEAL eliminate the discomfort and hair loss
experienced when removing medical chest seals
from hair covered skin during training.
Introducing the air-Q SP (self-pressurizing) Masked Laryngeal Airway. The air-Q SP eliminates the
extra step and guesswork for mask cuff inflation and the potential for over-inflation. The new design allows positive pressure ventilation to self-pressurize the mask cuff. The increase in cuff seal pressure occurs at the exact
time you need it—during the upstroke of ventilation. On exhalation, the cuff decompresses to the level of the
PEEP. The intra-cuff pressure cycles between the peak airway pressure usually between 15–30 cm H2O and the
level of PEEP 10cm H2O. This results in a safer, efficient, low-pressure seal during the majority of the cases.
53. Jones Bartlett
Designed as a companion to Emergency
Care and Transportation of the Sick and
Injured, Tenth Edition, Case Studies from
Jones Bartlett Learning offers detailed
cases that align with the chapter content in
the Tenth Edition. An ideal supplement to
any course that utilizes the Tenth Edition,
each case presents SAMPLE history, vital
signs and assessment information in tabular format for ease of use. It also features
a scenario analysis, answer rationales, and a
completed patient care report.
Choose 40 at www.jems.com/rs
The Pocket R-CAT (Rapid Cardiac Analysis
Tool) 12 for STEMI is a 11 panel 3.25 x 6.75 laminated tool that features a unique reversible
baseline window. Using the baseline window
on an actual patients’ ECG, patterns of ischemia, injury and infarction can be viewed and
compared on the Pocket R-CAT 12 for STEMI.
Uses a novel color-coded format to illustrate
classic ECG changes associated with myocardial damage on inferior, septal, anterior,
anteroseptal, lateral, and anterolateral wall.
The Knox MedVault mini narcotics
drug locker is now available in a smaller
size for those applications where space is
limited. It provides the same access control to narcotics as its predecessor, the
Standard Knox MedVault. The MedVault
Mini is available with or without WiFi.
Using the WiFi version, the Knox administrator can update firmware, download
the audit trail or update PIN cokes from
the convenience of their office, saving
time and valuable resources. JEMS
Choose 41 at www.jems.com/rs
JUNE 2012 JEMS
54. ‘Time is brain’ when treating stroke patients
By W. Ann Maggiore, JD, NREMT-P
Types of Strokes
Stroke, or cardiovascular accident (CVA), represents a serious medical condition in which
the blood supply to areas of the brain is interrupted, resulting in ischemia. There are two basic
types of strokes: ischemic and hemorrhagic. The
majority of CVAs (87%) are ischemic.
In ischemic stroke, a blood vessel is blocked.
The tissue distal to the blockage becomes ischemic and will eventually die if blood flow isn’t
restored. Reperfusion therapy is the goal of
treatment for ischemic stroke. The extent and
severity of the stroke will be dictated by the
location of the blockage. An ischemic CVA in
the brainstem is a life-threatening condition.
In contrast, the other 13% of strokes are
caused when a blood vessel in the brain ruptures, causing bleeding into the surrounding
tissue. Fibrinolytic therapy is contraindicated.
Photo vu banh
ou’re called to the home of a 55-yearold female because of a fall. On
arrival, you find her sitting up in a
chair in her living room, which smells
strongly of cigarette smoke. She stares at you
blankly when you attempt to question her about
what happened. Her husband tells you he was in
another room when he heard a thump and that
he found her on the living room floor. He says
he was able to move her into a chair, but says she
has been unable to tell him what happened.
The patient’s blood pressure is 200/110; her
pulse is 88, strong at the radial but irregularly
irregular. You administer oxygen and start an
IV. Her husband tells you she takes a “blood pressure pill,” but her medications are nowhere to be
found. She’s able to follow your commands, but
now when she tries to speak, her words are garbled. You suspect she’s suffered a stroke.
55. Patients presenting with stroke can
exhibit a variety of signs and symptoms,
including sudden blindness.
56. Stroke of the Clock
continued from page 57
Differentiate between the types of stroke.
Learn the symptoms of patients having a stroke.
Determine proper field treatment for stroke patients.
brain, heart, lungs, kidneys
and extremities, although
the patient may have much
more disease in some places
Time Is Brain
Hemorrhagic stroke tends to worsen over
time due to bleeding within the cranium.
The bleeding increases intracranial pressure (ICP) and leads to brainstem herniation. One hallmark of a hemorrhagic CVA is
a patient who complains of “the worst headache of my life.”
Incidence Risk Factors
Each year, about 795,000 Americans have
either a new or recurrent stroke. Every 40
seconds, someone in this country suffers a
stroke. Stroke kills more than 137,000 people each year; every four minutes someone
in the U.S. dies from a stroke.
It’s the fourth leading cause of death
and the leading cause of disability in adults
in the U.S. Approximately 40% of stroke
deaths occur in males and 60% in females.
Although men have more CVAs, women
die of them more often.
Stroke falls under a larger classification
of cardiovascular disease. The American
Stroke Association (ASA), a division of the
American Heart Association, is now heavily focused on stroke prevention and has
identified numerous risk factors for stroke,
including hypertension, age, elevated serum
cholesterol, smoking, diabetes and most
notably, elevated body mass index (BMI)
and the “obesity epidemic.”
Race can also be a risk factor, with 2010
statistics showing that an estimated 2.5%
of Caucasians had a stroke; 3.9% of African
Americans; 2.6% of Hispanics and Asians;
5.9% of Native Americans; and 10.6% of
Hawaiians and Pacific Islanders. Family
history may also indicate a risk factor for
stroke, particularly if family members had
strokes while they were young.
Atherosclerosis—a systemic disease
process in which fatty deposits, inflammation and scar tissue build up within the
walls of arteries—is the underlying cause
of most cardiovascular disease and stroke.
Individuals who develop atherosclerosis
tend to develop it in a number of different
arteries, both large and small. This is especially true in those arteries that feed the
Although the call may come in as a stroke,
it also may come in as a fall, a seizure, an
unconscious person, a person with “difficulty speaking” or any one of several other
Remember: Do NOT delay
transport of suspected stroke
patients. As the saying goes,
time is brain.
Every minute of delay to treatment is
said to cost a patient 1.9 million brain cells.
EMS dispatchers using priority dispatch
systems are trained to place stroke symptoms as high-priority calls for which minutes matter. Because they do.
When EMS arrives, patients presenting
with stroke can exhibit a variety of signs
and symptoms, including paralysis. This
numbness or weakness can appear in the
face, arms or legs. It is usually on the side
of the body opposite the side of the brain
damaged by the stroke. It’s called hemiplegia
if it involves complete inability to move and
hemiparesis if it involves weakness. Patients
may have difficulty swallowing, called dysphagia. Cerebellar strokes can cause ataxia.
Other symptoms include sudden onset
of confusion, difficulty speaking or understanding due to aphasia, trouble seeing in
one or both eyes, dizziness, or loss of balance or difficulty walking due to ataxia.
Some patients will complain of the sudden
onset of a severe headache.
As with all patients in the prehospital
setting, assessment of the airway, breathing and circulatory status of stroke patients
is essential. Administer oxygen if appropriate and obtain a set of vital signs. Gather
patient history and medications, paying
particular attention to whether the patient
is being treated with anticoagulants or
antiplatelet drugs. Try to find out the time
of onset of symptoms because this is the
“start time” from which the three-hour
window for fibrinolytic therapy will be calculated. Obtain IV access and a glucometry
reading because hypoglycemia can mimic
stroke but it’s much simpler to treat in the
Stroke assessment tools, such as the Cincinnati Prehospital Stroke Scale (see Table
1, p. 60) or the Los Angeles Prehospital
Stroke Screen, were created to increase the
accuracy of field evaluations of potential
Download a copy of the Los
Angeles Prehospital Stroke Screen at
Use of a stroke assessment tool improves
prehospital triage in stroke patients. These
evaluations can be performed in less
than one minute. With standard training
in stroke recognition, paramedics have
demonstrated a sensitivity of 61–66% for
identifying patients with stroke; however, paramedic sensitivity for identifying
stroke patients rose to 86–97% after receiving training in use of a stroke assessment
tool. EMS personnel should follow their
local service protocols with respect to
evaluation tools for stroke and triage in
suspected stroke patients to the hospital
best able to care for them.
Evaluation of the three factors of facial
droop, arm drift and abnormal speech can
assist EMS in rapidly identifying potential
stroke patients. To evaluate facial paralysis, ask the patient to smile and show their
teeth so that you can see whether both
Aphasia: A nerve deficit in which there are difficulties with speaking or speech is lost.
Apraxia: Loss of the ability to do simple or routine acts.
Ataxia : Inability to coordinate movements, due to damage to the spinal cord or brain.
Dysphagia: Difficulty in speaking, usually resulting from an injury to the speech area of the brain.
Dysphasia: Difficulty in swallowing.
Ischemia: Poor blood supply to an organ or part, often marked by pain, as in ischemic heart disease.
Hemiparesis: Muscular weakness of one half of the body.
Hemiplegia: Paralysis of one side of the body.
Paresthesias: Heightened sensitivity; tingling or prickling sensations due to disease or body position.
57. Stroke of the Clock
continued from page 58
Table 1: Cincinnati Prehospital Stroke Scale
Both sides of face move equally.
One side of face does not move at all.
Both arms move equally or not at all.
One arm drifts compared to the other.
Patient uses correct words with no slurring.
Patient slurs, uses inappropriate words or is mute.
sides of the mouth elevate the same way.
To evaluate for hemiparesis, ask the patient
to hold out both arms palms up and close
their eyes for 10 seconds to see if one arm
drifts downward or doesn’t move.
To evaluate speech, ask the patient to
repeat a common phrase, such as “You
can’t teach an old dog new tricks.”
If the left side of the brain is affected,
patients often present with right-sided
hemiparesis and such language effects as
aphasia, dysphasia and apraxia, as well as
facial droop and ataxia. Sudden blindness
can also be a symptom of stroke.
Patients may experience such changes in
level of consciousness as decreasing level of
consciousness, cognitive impairment, seizures and even coma. Hypertension may
be present. Patients with right-sided strokes
may present with left-sided hemiplegia.
Obtain a 12-lead ECG. Although no
arrhythmias are specific to stroke, the
ECG can identify recent acute myocardial
infarction or atrial fibrillation as a potential cause for embolic stroke. In general, the
ECG of a stroke patient will be monitored
in the hospital for 24 hours to detect potentially life-threatening arrhythmias.
The goal of stroke care is to minimize brain
injury and maximize the patient’s recovery.
The Stroke Chain of Survival described by
the ASA is similar to the chain of survival
for sudden cardiac arrest, linking actions
to be taken by patients, family members,
and healthcare providers to maximize
The links are 1) rapid recognition and
reaction to stroke warning signs; 2) rapid
EMS dispatch; 3) rapid EMS system transport and pre-arrival notification to the
receiving facility; and 4) rapid diagnosis
and treatment in the hospital.
Target times and goals are recommended
by the National Institute of Neurological
Disorders and Stroke (NINDS,) which has
recommended measurable goals for the
evaluation of stroke patients. The hope is
to meet these goals in 80% of the patients
presenting with acute stroke.
Ischemic stroke patients may be eligible
for treatment with fibrinolytics, but the
time elapsed between onset of symptoms
and initiation of treatment must be within
a three-hour window. Selected patients may
have slightly more time—up to 4.5 hours.
This is why it’s critically important to identify potential stroke patients and promptly
transport them to an appropriate facility to
avoid loss of the chance of an improved outcome with fibrinolytic therapy.
For EMS, destination decisions are critical, and stroke patients should be directed
to an accredited stroke center if one is
available. An early alert to the stroke center
by EMS can get the stroke team activated
while you’re en route, and they can be waiting for your patient when you arrive.
As of Jan. 1, 2011, more than 800 primary
stroke centers (PSC) are certified by the
Joint Commission in 49 states. The Joint
Commission launched the primary stroke
center certification program in 2003 in
collaboration with the ASA, following the
successful model of designated trauma
centers. PSCs must have the capability to
administer fibrinolytic drugs, written protocols for the administration of these drugs
within three hours of symptom onset, a
multidisciplinary team, as well as lab and
neuroimaging available 24 hours a day,
seven days a week.
The Joint Commission has also developed an advanced certification for comprehensive stroke centers, incorporating
all the elements of PSC with additional
requirements for volume of stroke patients,
number of stroke-related procedures performed, research capability, availability of
neurosurgery 24 hours a day, seven days a
week, availability of advanced neuroimaging studies and interventional procedures,
and dedicated neuro-intensive care units
for complex stroke patients.
The prevalence of stroke centers has
lowered morbidity and mortality from
stroke. Studies have documented improvement in one-year survival rates, functional
outcomes and quality of life when patients
hospitalized for acute stroke receive care in
a dedicated unit with a specialized team.
Patients with suspected stroke should
be admitted to a stroke unit when one
with a multidisciplinary team is available
within a reasonable transport time, which
is usually defined as one hour. Receiving
hospitals should make their stroke care
capability known to the community and
to EMS providers in particular, and should
not hesitate to divert or transfer suspected
stroke patients to facilities with dedicated
Critical time goals also exist for in-hospital stroke care. The NINDS has recommended immediate general assessment
by the stroke team, emergency physician
or another expert within 10 minutes of
Harbinger of Stroke: The TIA
A transient ischemic attack (TIA) presents in the same way that strokes do, only the presentation
is temporary, lasting only a few minutes to an hour. TIA occurs when blood supply to the brain
is briefly interrupted. Although the patient appears to recover, EMTs should remember that TIA
is often a warning sign that a stroke is imminent. EMS should treat all patients who present with
TIA as stroke patients and not wait to see whether the symptoms abate. One-third of patients
who have a TIA will have an acute stroke at some time in the future. Some of these strokes can be
prevented by heeding the warning of a TIA and treating the underlying risk factors, such as high
blood pressure, smoking, diabetes and heavy alcohol use. Lifestyle changes in diet, weight loss,
exercise and smoking cessation may also be in order.
58. some patients. These studies should be rapidly interpreted by physicians with experience in diagnostic neuroradiology. In
eligible patients, the performance of these
studies shouldn’t delay the administration
of fibrinolytic therapy.
Currently, some hospitals don’t have the
resources to safely administer fibrinolytics, and this should be made known to the
community so patients can be routed to
facilities with this capability.
The NINDS trials have reported excellent outcomes in both community and
tertiary care hospitals when the hospitals
have, and follow, written protocols for
stroke care. Institutions with commitment
to comprehensive stroke care and rehabilitation have better outcomes.
Photo kevin link
Patent Foramen Ovale Stroke
To evaluate for hemiparesis, ask the patient to close their eyes and hold out both arms to see if one arm
drifts downward or doesn’t move.
arrival, with an urgent order for a computed
tomography (CT) scan without contrast. If
CT isn’t available, the patient should be stabilized and rapidly transported to a facility
with CT capability. Within 25 minutes of
arrival, the stroke team or designee should
complete a neurological assessment, and
the CT scan should be performed.
The CT scan should be interpreted
within 45 minutes of arrival in the emergency department. Patients without contraindication should receive fibrinolytic
therapy within one hour of hospital arrival
and within three hours of onset of symptoms. The total door-to-admission time
should be no more than three hours.
CT imaging will determine the type and
location of the stroke. A critical decision
point in the hospital assessment of suspected stroke patients is the performance
and interpretation of the CT scan. The CT
scan may also identify other structural
abnormalities in the brain that may be
responsible for stroke-like symptoms or
that represent contraindications to fibrinolytic therapy. Patients with hemorrhagic
stroke shouldn’t receive thrombolytics,
aspirin or heparin.
Not all patients with embolic stroke will
qualify for fibrinolytic therapy; those with
mild symptoms, who are outside of the
three-hour window or who do not meet
other criteria may not be candidates.
Exclusion criteria include patients with
head trauma or stroke within the past
three months, symptoms suggestive of
subarachnoid hemorrhage, history of previous intracranial hemorrhage, elevated
blood pressure, current use of antico-
Recent research has identified a relationship between patent foramen ovale (PFO)
and stroke. The existence of PFO has been
cited as a stroke risk factor. PFO is a defect
in the atrial septum that, under certain circumstances, may allow venous blood to
pass directly from the right atrium to the
left atrium without traveling first to the
lungs (right-to-left shunt). This situation is
called a paradoxical embolism.
For patients whose cause of stroke is
unidentified (cryptogenic stroke), the
presence of PFO may be investigated by
When 9-1-1 responds to the potential stroke
patient, it’s critical to remember that ‘time
is brain,’ to quickly assess transport the
patient to optimize their chance for the best
agulants, history of diabetes and previous
prior ischemic stroke or demonstration of
multilobular infarctions on CT.
Children less than 18 and adults more
than 80 years of age generally aren’t candidates. As with all drugs, fibrinolytic drugs
have potential adverse effects, including
intracranial hemorrhage and other bleeding complications, and the stroke team will
perform a risk-to-benefit analysis before
administration of these drugs.
Additional imaging studies, such as CT
angiography or MRI, may be indicated for
transesophageal echocardiogram and
“bubble study.” This may determine
whether the defect exists, as well as its
size and whether right-to-left shunting
is present. Patients are asked to cough or
perform a modified Valsalva maneuver to
increase the pressure and cause the PFO to
open during the study.
Potential mechanisms of stroke in
patients with atrial septal abnormalities
include paradoxical embolus from a venous
source, direct embolization from thrombi
formed within an atrial septal aneurism
59. Stroke of the Clock
continued from page 61
Photo Vu Banh
After the Stroke
Check glucose levels to rule out hypoglycemia as a cause of a seizure with one-sided paralysis.
ovale is controversial; numerous devices,
such as plugs and patches, have been
developed for percutaneous PFO repair by
interventional cardiologists. However, the
procedure still carries a number of serious
risks and the risk-to-benefit ratio of PFO
repair remains in controversy.
Photo kevin link
and the formation of thrombus as a result of
PFO exists in about 25% of the population; in patients with cryptogenic stroke,
the incidence has been found to be approximately 40%.
At present, repair of patent foramen
About half of all stroke survivors are left
with some disability. With an aging population in the U.S., the number of people
disabled from stroke is on the rise. The economic burden of stroke requires increasing
attention from health officials for more
effective healthcare planning and allocation of resources. Informal care is important to maintain stroke survivors within
the community and allow them to function up to the highest level of their ability.
Morbidity and rehabilitation: It’s estimated
that .27% of gross domestic product is
spent on stroke by national health systems.
Stroke care accounts for approximately
3% of total healthcare expenditures. In
the U.S., it’s estimated that $65.5 billion
was spent on stroke in 2008. This figure
includes the cost of physicians and other
healthcare professionals, acute and longterm care, medications and durable medical equipment, and lost productivity of
Early and aggressive rehabilitation efforts
are essential to ensure stroke survivors can
recover as much functionality as possible,
and to increase the likelihood of being able
A 12-lead ECG can identify recent acute myocardial infarction or atrial fibrillation as a potential cause for embolic stroke.
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61. Stroke of the Clock
continued from page 62
to return to being productive members of
the community. Post-stroke rehabilitation
starts during the inpatient phase and may
involve physicians, rehabilitation nurses,
physical therapists, occupational therapists,
speech/language pathologists and vocational therapists. Outpatient facilities often
continue rehabilitation efforts once the
patient is released from inpatient status.
The type and degree of disability following stroke depends on the area of the brain
that’s damaged and the extent of the damage. In general, stroke causes five types of
disability: paralysis or problems controlling
movement; sensory disturbances, including pain; problems using or understanding
The Author’s Personal Account
My husband Dave is a stroke survivor. He was a talented emergency physician who had just paid
off his medical school loans when he had a cryptogenic stroke at the young age of 42. The stroke
occurred while he was on mechanical ventilation for acute respiratory distress syndrome and
wasn’t recognized until he had stabilized and was taken off the ventilator. He was later found to
have a patent foramen ovale, also known as a paradoxical embolism.
He was left with serious disability in the form of aphasia, which affected his speech, reading
and writing. The resulting depression over the loss of a career, and of considerable functionality,
was almost more than both of us could bear. It was extremely difficult to accept that life would
never be the same again and that many of our expectations for the future simply wouldn’t be met.
Living with a stroke survivor has been a challenge, as it always is for caregivers. Were it not for
the unfailing support of our friends and colleagues in the EMS community in the months following
his hospitalization and inpatient rehabilitation, I don’t think we could have made it on our own
through the first year after the stroke.
My former fellow Bernalillo County (N.M.) Fire Department paramedics organized themselves
into shifts so that someone was always at the house with Dave during those early post-stroke days,
when there was considerable fall risk, so that I could continue to work.
Dave underwent significant physical, occupational and speech therapy in the first year after the
stroke and made considerable rehabilitation gains. There was little in the way of advanced rehab
available in our home state of New Mexico, and we traveled to the University of Michigan at Ann
Arbor for cutting-edge intensive adult aphasia therapy. As a result of this therapy, he was able to
regain some of his speech—enough to be independent within the community. Fortunately, Dave
retained his ability to understand language and his auditory comprehension is good.
Although he had to give up his career in emergency medicine, he’s now able to run, hike and
even ski the expert slopes. In addition, he has found a new vocation in woodworking. His left
brain was severely damaged, but his right brain has brought him tremendous artistic creativity and
pleasure in woodworking.
We’re fortunate to live in a rural area where Dave remains integrated into the fabric of the
community and where he has been able to form lasting friendships. Dave is also active with a
stroke survivors support group. Recognizing that stroke crosses all socioeconomic groups, and
being around a group of positive-thinking stoke survivors, has helped his ongoing rehabilitation
Dave uses an iMac computer, with a text-to-speech function that provides him some independence through its ability to highlight text that is then read by the computer. He listens to audiobooks and loves his iPod and iPhone because they employ icons and images that are simple for him
to recognize and work with. We’re always in search of new methods to accommodate his disability
and decrease his frustration level.
Out of necessity, we rearranged our roles within our household, focusing on what Dave is able
to do rather than on what he is unable to do. He has moved into the role of maintaining the house
and grounds, and I continue to work outside the home. We were fortunate that Dave had good
disability insurance and we were able to maintain the rural mountain lifestyle we had chosen when
we married 15 years before his stroke. It’s hard for him to be in a roomful of people talking because
he can’t communicate under those circumstances, so we live a quiet life.
We can’t look back and think about what would have been; instead we have had to accept the
drastic changes and move forward with what life has handed us. Every day Dave is grateful for what
he calls “one more day,” and every day I’m happy to still have him here with me. I’ve grown to love
his crooked half smile.
language; problems with thinking and
memory; and emotional disturbances.
Sensory disturbance and pain: Stroke survivors may lose their sense of touch, pain,
temperature or position, or may experience
pain, numbness or paresthesias. They may
also initially become incontinent, although
permanent incontinence is uncommon.
Neuropathic pain may be present due to
nervous system damage, and patients with
weakened or paralyzed arm muscles often
experience moderate to severe pain radiating from the shoulder, often resulting
from lack of movement in a joint causing
tendons and ligaments to become fixed in
Language problems: At least one-fourth
As with all patients
in the prehospital
setting, assessment of
the airway, breathing
of stroke patients
of stroke survivors experience language
impairments. The dominant language
centers are located on the left side of the
brain, known as Broca’s area. Damage to
this area causes expressive aphasia which
is characterized as difficulty with speaking
Damage to a language center in the rear
of the brain known as the Wernecke’s area
results in receptive aphasia, which is characterized as difficulty understanding spoken language and reading. Global aphasia,
a more severe form of aphasia, is caused by
damage to several areas of the brain involved
in language function; these patients are significantly impaired by inability to communicate or understand language.
Thinking and memory problems: Stroke
survivors may have dramatically shortened attention spans, short-term memory
deficits, or they may lose the ability to perform complex mental tasks. Patients with
apraxia find themselves unable to plan
the steps involved in a complex task and
carry them out in the proper sequence. The
extent of brain damage will dictate how
62. well these patients will be able to function
independently. Cognitive rehabilitation
efforts using computer programs with
increasingly difficult tasks have proven
helpful in regaining some function.
Emotional disturbances: Stroke survivors
often feel fear, anxiety, frustration, anger
and a sense of grief for their physical and
cognitive losses. Some emotional disturbances are caused by the structural effects
of brain damage.
Clinical depression, a sense of hopelessness that disrupts an individual’s ability
to function, is commonly experienced by
stroke survivors. Signs of clinical depression include sleep disturbances, lethargy,
social withdrawal, irritability, fatigue and
suicidal thoughts. Treatment may involve
counseling and antidepressant medications, although exercise has also been
shown to be helpful.
Approximately 40% of stroke deaths occur
in males 60% in females. Although men
have more strokes, women die of them
There’s a large role for EMS in community
education, stroke awareness and prevention activities. The National Stroke Association’s Act FAST (face, arms, speech and
time) program teaches community members to be aware of the signs of stroke, and
to act quickly in summoning EMS personnel to the scene for rapid evaluation and
transport to an appropriate facility.
EMS personnel can become involved in
community awareness programs, teaching
the community how to recognize the signs
of a stroke and encouraging an immediate
9-1-1 call for help. When 9-1-1 responds to
the potential stroke patient, it’s critical to
remember that time is brain, and to quickly
assess and transport the patient to optimize
their chance for the best possible outcome.
Stroke is a costly disease from human,
family and societal perspectives. It’s a
global epidemic that isn’t limited to a particular socioeconomic group. Thus, reduction of the frequency and severity of stroke
by preventive measures is essential to avoid
the natural trend of increasing the human,
economic and social burden of stroke. JEMS
W. Ann Maggiore, JD, NREMT-P, is an attorney and a
paramedic in Albuquerque, N.M. She’s a shareholder in
the Albuquerque law firm of Butt, Thornton Baehr,
P.C., where she practices law full-time, defending physicians, police and EMS personnel against lawsuits. She’s
a frequent lecturer on EMS legal issues at national
Photo Vu Banh
conferences and holds a clinical faculty appointment at
the University of New Mexico School of Medicine. She’s
a member of the JEMS Editorial Board and the 2012 winner of the James O. Page/JEMS Leadership Award. Contact her at firstname.lastname@example.org.
Office of Communications and Public Liaison. (April
20, 2012.) Transient Ischemic Attack Information
Page. In National Institutes of Health National Institute of Neurological Diseases and Disorders. www.
Office of Communications and Public Liaison. (July
26, 2011.) Post Stroke Rehabilitation Fact Sheet. In
National Institutes of Health National Institute of
Neurological Diseases and Disorders. www.ninds.
National Stroke Association. (2012.) A Hole in
the Heart: Patent foramen ovale. In National
Stroke Association. www.stroke.org/site/
Roger VL, Go AS, Lloyd-Jones DM, et al. (Dec. 15,
2011.) Heart Disease and Stroke Statistics—2012
Update: A report from the American Heart
Association. In Circulation. circ.ahajournals.org/
Di Carlo A. Human and economic burden of stroke.
Age Ageing. 2009;38(1):4–5.
Joint Commission. (February 2011.) Facts about
Primary Stroke Center Certification. In The
Joint Commission. www.jointcommission.org/
Joint Commission. (2012.) Final Certification Eligibility Criteria for Comprehensive Stroke Centers
(CSC). In The Joint Commission. www.jointcommission.org/certification/advanced_certification_comprehensive_stroke_centers.aspx.
American Heart Association. (2011.) Advanced Cardiovascular Life Support. In American Heart Association. www.heart.org/HEARTORG/CPRAndECC/
American Academy of Orthopaedic Surgeons:
Nancy Caroline’s Emergency Care in the Streets,
Sixth Edition. Jones and Bartlett: Burlington, Mass.
Chapter 28: Neurological Emergencies, 2008.
Beacock, DJ, Watt VB, Oakley GD, et al. Paradoxical embolism with a patent foramen ovale
and atrial septal aneurysm. Eur J Echocardiogr.
Lechat, P, Mas JL, Lascault G, et al. Prevalence
of PFO in patients with stroke. N Engl J Med.
DiTullio MR, Sacco RL, Sciacca RR, et al. Patent
foramen ovale and the risk of ischemic stroke
in a multiethnic population. J Am Coll Cardiol.
63. HANDS ON
PRODUCT REVIEWS FROM STREET CREWS
Basic Access Demolition
You can’t treat the patient if you can’t get to the patient. Ambulances carry a variety of tools to gain
access to buildings and vehicles so we can get to a patient without needing to call the fire department. FuBar from Stanley Tools is a compact, multi-function demolition tool with a precision ground
chisel and a prying end for ripping and cutting material. A resistant, strong surface makes it easy to
remove molding from around a door or window to gain access. Bolt-on hand grips provide added
comfort and reduced slipping. And if all else fails, you can just hack a hole through the drywall.
Weight: 1.6 lbs.
Ambulances and most emergency vehicles have multiple batteries. Many EMS services use such
vehicles as golf carts, Gators, all-terrain vehicles and boats for special operations and events.
Keeping a seldom-used—although important—piece of response equipment ready for immediate deployment can easily fall through the cracks of a busy operations cycle. The new QuadLink
4 Channel Battery Charger Multiplier allows you to use a single battery charger to maintain up to
four batteries at the same time. The wiring is fairly straightforward. The simple plug-and-play system charges the batteries sequentially in 10-minute intervals. This four-channel charger will maintain the charge of multiple 6 V or 12 V batteries in 24, 36 and 48 V series connected configurations.
Battery voltages: 6 V and 12 V
Output current: 8 amp max
Weight: 2.5 lbs.
Electric Itch Stopper
Weight: 6 oz.
Power: 9 V
Fran Hildwine, BS, NREMT-P,
CCEMT-P, coordinates the monthly
Hands On column in JEMS. He’s
the administrative director of the
Paramedic Training Institute at Crozer Chester Medical
Center in Delaware County, Pa., and an adjunct faculty
member at Delaware County Community College with
more than 20 years’ EMS experience. Contact him at
Dimensions: 22 x 18 x 8
Weight: 4.5 lbs.
With all of the silly reasons for an EMS dispatch,
I don’t recall being sent for mosquito bites. But if
you’ve ever had the displeasure of operating at
an outdoor scene for which the state bird is the
mosquito, you might find it darn near impossible
to think when you’re scratching. Therapik is a
new treatment that neutralizes the venom of
more than 20,000 different species of insect and
sea creatures. How does it work? Most insect
venom is thermolabile (sensitive to heat), and
the Therapik’s small electric bulb produces the
proper amount of heat to reduce or eliminate
the burn and itch of the venom. Simply hold the
blue button to activate the light and place the
tip against the site of the bite for as long as the
heat is bearable. The average application time
is 30 seconds and may be reapplied as often
as necessary as long as you wait 60 seconds
For many in EMS, the CPR manikin is the first training tool we use when
we start down this career path. Building muscle memory is a key to consistent performance. The Practi-MAN CPR Manikin from WNL Safety can
simulate both adult and child CPR with the simple turn of a dial. An audible
clicker verifies proper hand positioning and compression depth. You can
also choose to not hear the clicker with another turn of the dial. The nose
pinch/head tilt design mimics actual mouth-to-mouth breathing and must
be done properly to get proper chest rise.
IN THE NEXT ISSUE: ZOLL X-Series EMS Monitor Xtreme Green Pro UTV EMS Lola Advanced Assessment Stethoscope Bbraun Bodyguard Twins IV Pump Hartwell Medical Fasplint Half-Back
64. For more product reviews: www.jems.com/products
Smart Gloves for Smartphones
Smartphones are everywhere. States have changed laws
and departments have changed policies due to text
messaging and digital photography. The smartphone’s
functionality and the number of available EMS apps
have made it an invaluable tool for EMS workers. Have
you ever tried operating your touch-screen phone or
tablet with gloves on? Not too fun, huh? Screen Ops
Duty Gloves from 5.11 Tactical have specially constructed
fingertips that enable the wearer to operate capacitive
resistance touch-screen devices, such as smartphones,
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Hazmat, weapons of mass destruction, bioterrorism and pandemic flu are all
issues EMS is aware of, but can we identify a patient exposed to a biological
agent? Do you know the treatment protocols for these unusual substances? The
Clinicians’ Biosecurity Resource (CBR) is a clinical reference app for healthcare
providers, providing information on the six biological agents that are highest
priority for biological attacks. This app, developed by the Center for Biosecurity
of the University of Pittsburgh Medical Center (UPMC), is intended primarily for
clinicians as a mobile reference during response to a biological attack. It’s used
for learning about these diseases and how they might present in victims of biological attacks/bioterrorism, or as they come across suspicious or unusual cases
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69. thethey didn’t tell you in medic school
by steve berry
Hang on to the bar
ife is truly a ride. We’re all strapped in, and
no one can stop it. ... I think the most you
can hope for at the end of life is that your
hair’s messed, you’re out of breath and you didn’t
throw up.’ —Jerry Seinfield
I’d bet my minimum-wage income that
most of us EMS types would prefer the experience of riding a roller coaster over that of
a merry-go-round. I doubt few would argue
(and I don’t care if they do) that the prehospital provider’s unique appetite for adrenaline far exceeds that of the average Homo
sapien … unless the post-primate in question
is an extreme sport enthusiast who, ironically, feeds EMS’ own insatiable hankering for
adrenaline by providing them the opportunity to respond to and treat injuries
indirectly incurred by the very same
high doses of adrenaline extreme
sports participants crave themselves.
So, it’s fair to say EMS is addicted
to adrenalin—the most potent
stimulating hormone of our primal
sympathetic nervous system that
increases vitality, hyper-vigilance,
confidence, stamina and strength;
it delays pain response, provides
moments of deep euphoria—along
with an increased will to survive—
during instantaneous moments of
intense drama, chaos, danger, unique challenges, mayhem, insanity and lawyers? Naw!
(Sigh.) Like anything that gives you
moments of exhilaration, there’s a catch.
Apparently, epinephrine and norepinephrine, two components of adrenalin, were
meant to only provide 3–5 minutes of good
times during bad times. Evidently, a prolonged tachycardia and increased cardiac
output leads to high blood pressure, high
glucose levels, caused by cortisol (the third
component of adrenalin), sleeplessness, gastrointestinal irritability and forgetfulness,
which in turn leads to stress, anger, apathy,
depression and forgetfulness—and the tendency to repeat oneself.
There are other negative side effects, but I
don’t remember them and frankly don’t give
Now I’m not knocking this brief but tantalizing gift of survivalist juice provided by
nature. Heck, we even give a manufactured
version of the stuff to help those in severe
cardiac, respiratory and anaphylactic distress. Indeed, this particular catecholamine
has saved my butt many a call when I’ve
found myself in danger. Adrenalin gave me
the unusual strength to place my resistant
partner between me and a combative patient.
On the other hand, try to perform a fine
motor skill of EMS, retain pertinent shortterm memory of what a patient reports or
try to calculate emergent medication doses
when your adrenal glands are pumping faster
than an epi I-med drip of 10 mg of 1:1,1000
epinephrine in a 250 cc saline bag 60 drops/
cc set at a rate of 2 mcg/kg/min, and you can
find yourself spazzing out.
Maybe that’s why we consistently train
in EMS. Simply put, we train to forget what
we’ve learned. We reach a point at which we
don’t have to think about what we’re doing
to help others. Our treatment becomes an
automatic response of composure and skill
unworthy of an epi response, which tends
to bypass the rational cognitive part of the
brain. These are the calls where you and your
crew may never even say a word to each
other while you treat the patient, because
each care provider is already aware of their
finely tuned and orchestrated roles. Just make
sure you keep talking to the patient because
they’ve never heard the music before.
I once read that adventures weren’t meant
to have predictable outcomes. Ride the
same EMS roller coaster long enough and,
sure enough, you’ll be able to predict what’s
around every bend. Many have been down
the same track for so long that they know
the name of the patient and their patient’s
chief complaint before they even arrive on
scene simply based on the patient’s address.
For many disgruntled EMS providers, the
epi rush’s trigger then comes not from the
adventure, but from the anger and negative
perception Mr. Johnson created for the crew
who has to put him back into his bed
every Thursday when he forgets to
take his insulin.
Similar to EMS management,
adrenalin doesn’t have a mind of its
own. It simply reacts to a perceived
threat regardless of its rationality.
And like any drug, the body can
build a tolerance or even immunity
to adrenalin’s effects—requiring an
even greater stimulus to get the same
previous response despite there never
being enough good calls or coffee to
feel good about oneself.
Does my heart still skip a beat when tones
go off? Like Pavlov’s dog, hell yes (including
salivation). But my endorphins now come
from a different fix: the laughter of working
with a good partner and crew, including a
shared laugh with Mr. Johnson.
Ever ride a roller coaster by yourself? Of
course not. Share the ride with those who
appreciate your humor and you theirs, and
then collectively hang on to the bar … unless
they’re prone to throwing up on the curves.
Until next time, pass the Zofran. JEMS
Steve Berry is an active paramedic with Southwest
Teller County EMS in Colorado. He’s the author of the
cartoon book series I’m Not An Ambulance Driver. Visit
his website at www.iamnotanambulancedriver.com to
purchase his books or CDs.
March 5 – March 9, 2013
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