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Jems201206 dl
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  • 1. JUNE 2012 Always En Route At
  • 2. Choose 11 at www.jems.com/rs
  • 3. Choose 13 at www.jems.com/rs
  • 4. Choose 14 at www.jems.com/rs
  • 5. The Conscience of EMS JOURNAL OF EMERGENCY MEDICAL SERVICES 56 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 Contents I 38 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 I Hot 50 innovative new products showcased at the 29th annual JEMS EMS Today Conference Exposition Departments columns 9 I Load go I Now on JEMS.com 14 I EMS in Action I Scene of the Month 16 I From the Editor I Is EMS a Game? y A.J. Heightman, MPA, EMT-P B 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 B 30 I Tricks OF the TRADE I Do No Harm y Thom Dick B 32 I case of the month I Difficult Airway y Steven R. Allen, MD, Cayla G. Conover B 36 I Research review I What Current Studies Mean to EMS y David Page, MS, NREMT-P B 66 I Hands On I Product Reviews from Street Crews y Fran Hildwine B 68 I employment Classified Ads 71 I Ad Index 72 I The Lighter Side I EPI Coasters y Steve Berry B 74 I LAST WORD I The Ups Downs of EMS Aboutfrom Care Ambulance and an Orange County (Calif.) Fire Authority firefighter/paramedic the Cover EMS providers 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 www.jems.com June 2012 JEMS 7
  • 6. Choose 15 at www.jems.com/rs
  • 7. LOAD GO  log in for EXCLUSIVE CONTENT A Better Way to Learn JEMSCE.com online continuing education program n us o follow App-licable Apps Photo istockohoto.com Do you love your smartphone or tablet? Device-lover and EMS instructor Keith Widmeier, NREMT-P, CCEMT-P, EMS-I, does. So he rounded up some of the latest EMS-related apps available for Apple and Android devices in four EMS-friendly categories. If you have an app-capable device, “EMS Apps Assist Providers in the Field” might just help you help your patients. JEMS.com offers you original content, jobs, products and resources. But we’re much more than that; we keep you in touch with your colleagues through our: Facebook fan page; JEMS Connect site; Twitter account; LinkedIn profile; Product Connect site; and Fire EMS Blogs site. like us facebook.com /jemsfans s jems.com/article/technology/ems-apps-assist-providers-field Sponsored Product Focus The Practi-MAN Featuring patented ventilation system engaging both mouth and nose, the Practi-Man BLS manikin from WNL Safety is TWO manikins in one. A turn of the dial changes manikin from adult to child. It also includes: An audible clicker that verifies proper hand positioning correct compression depth; The only BLS simulator that requires head tilt/chin lift real pinching of the nose to get visible chest rise; Half the weight of competing products. s Check out their JEMS.com ad and Hands On review (p. 67). 54% May Poll Results How do you celebrate EMS Week? 17% I recognize it with coworkers. I don’t even know when it is! 17% My agency hosts an event. polling our Fans How long have you been in EMS? p ess than one year. L p years. 2–5 p years. 6–10 p years. 11–20 p More than 20 years. follow us twitter.com /jemsconnect get connected linkedin.com/groups? about=gid=113182 ems news alerts jems.com/enews s jems.com/poll2012/ Check it out jems.com/ems-products 13% Other. best bloggers The mobile version FireEMSBlogs.com s m.facebook.com/ques- tions/10150693378539794/ www.jems.com JUNE 2012 JEMS 9
  • 8. Conscience of EMS JOURNAL OF EMERGENCY MEDICAL SERVICES The Conscience of EMS JOURNAL OF EMERGENCY MEDICAL SERVICES Editor-In-Chief I A.J. Heightman, MPA, EMT-P I a.j.heightman@elsevier.com MANAGING Editor I Jennifer Berry I je.berry@elsevier.com associate eDITOR I Lauren Hardcastle I l.hardcastle@elsevier.com assistant eDITOR I Allison Moen I a.moen@elsevier.com assistant eDITOR I Kindra Sclar I k.sclar@elsevier.com online news/blog manager I Bill Carey I bill@goforwardmedia.com Medical Editor I Edward T. Dickinson, MD, NREMT-P, FACEP Technical Editors Travis Kusman, MPH, NREMT-P; Fred W. Wurster III, NREMT-P, AAS Contributing Editor I Bryan Bledsoe, DO, FACEP, FAAEM Editorial Department I 800/266-5367 I editor.jems@elsevier.com art director I Liliana Estep I alildesign@me.com Contributing illustrators Steve Berry, NREMT-P; Paul Combs, NREMT-B Contributing Photographers Vu Banh, Glen Ellman, Craig Jackson, Kevin Link, Courtney McCain, Tom Page, Rick Roach, Steve Silverman, Michael Strauss, Chris Swabb Director of eProducts/Production I Tim Francis I t.francis@elsevier.com Production Coordinator I Matt Leatherman I m.leatherman@elsevier.com advertising director I Judi Leidiger I 619/795-9040 I j.leidiger@jems.com Western Account Representative I Cindi Richardson I 661-297-4027 I c.richardson@jems.com senior Sales coordinator I Elizabeth Zook I e.zook@elsevier.com Sales Administrative Coordinator I Liz Coyle I l.coyle@elsevier.com SENIOR eMedia campaign manager I Lisa Bell I l.bell@elsevier.com advertising department I 800/266-5367 I Fax 619/699-6722 marketing director I Debbie Murray I d.l.murray@elsevier.com Marketing manager I Melanie Dowd I m.dowd@elsevier.com Director, Audience Development Sales Support I Mike Shear I m.shear@elsevier.com Audience development coordinator I Marisa Collier I m.collier@elsevier.com SUBSCRIPTION DEPARTMENT I 888/456-5367 REprints, eprints Licensing I Wright’s Media I 877/652-5295 I reprints@jems.com eMedia Strategy I 410/872-9303 I Managing Director I Dave J. Iannone I dave@goforwardmedia.com Director of eMedia Sales I Paul Andrews I paul@goforwardmedia.com Director of eMedia Content I Chris Hebert I chris@goforwardmedia.com EMS Today Conference Exposition reed exhibitions I Christine Ford I 203/840-5391 I cford@reedexpo.com ems today exhibit sales I 203/840-5611 Jeff Stasko I jstasko@reedexpo.com elsevier public safety vice president/publisher I Jeff Berend I j.berend@elsevier.com founding editor I Keith Griffiths founding publisher James O. Page (1936–2004) Choose 16 at www.jems.com/rs
  • 9. Choose 17 at www.jems.com/rs
  • 10. JOURNAL OF EMERGENCY MEDICAL SERVICES The Conscience of EMS JOURNAL OF EMERGENCY MEDICAL SERVICES EDITORIAL board William K. Atkinson II, PHD, MPH, MPA, EMT-P President Chief Executive Officer WakeMed Health Hospitals James J. Augustine, MD Medical Advisor, Washington Township (OH) Fire Department Director of Clinical Operations, EMP Management Clinical Associate Professor, Department of Emergency Medicine, Wright State University steve berry, NRemt-p Paramedic EMS Cartoonist, Woodland Park, Colo. Bryan E. Bledsoe, DO, FACEP, FAAEM Professor of Emergency Medicine, Director, EMS Fellowship University of Nevada School of Medicine Medical Director, MedicWest Ambulance Criss Brainard, EMT-P Deputy Chief of Operations, San Diego Fire-Rescue Chad Brocato, DHS, REMT-P Assistant Chief of Operations, Deerfield Beach Fire-Rescue Adjunct Professor of Anatomy Physiology, Kaplan University J. Robert (Rob) Brown Jr., EFO Fire Chief, Stafford County, Va., Fire and Rescue Department Executive Board, EMS Section, International Association of Fire Chiefs carol a. cunningham, md, FACEP, FAAEM State Medical Director Ohio Department of Public Safety, Division of EMS Thom Dick, EMT-P Quality Care Coordinator Platte Valley Ambulance Marc Eckstein, MD, MPH, FACEP Director of Prehospital Care, Los Angeles County/ USC Medical Center Medical Director, Los Angeles Fire Department Professor, Emergency Medicine, University of Southern California Charlie Eisele, BS, NREMT-P Flight Paramedic, State Trooper, EMS Instructor Bruce Evans, MPA, EMT-P Deputy Chief, Upper Pine River Bayfield Fire Protection, Colorado District Jay Fitch, PhD President Founding Partner, Fitch Associates Ray Fowler, MD, FACEP Associate Professor, University of Texas Southwestern SOM Chief of EMS, University of Texas Southwestern Medical Center Chief of Medical Operations, Dallas Metropolitan Area BioTel (EMS) System Adam D. Fox, DPM, DO Assistant Professor of Surgery, Division of Trauma Surgery Critical Care, University of Medicine Dentistry of New Jersey Former Advanced EMT-3 (AEMT-3) Gregory R. Frailey, DO, FACOEP, EMT-P Medical Director, Prehospital Services, Susquehanna Health Tactical Physician, Williamsport Bureau of Police Special Response Team 12 JEMS JUNE 2012 Jeffrey M. Goodloe, MD, FACEP, NREMT-P Associate Professor EMS Division Director, Emergency Medicine, University of Oklahoma School of Community Medicine Medical Director, EMS System for Metropolitan Oklahoma City Tulsa David E. Persse, MD, FACEP Physician Director, City of Houston Emergency Medical Services Public Health Authority, City of Houston Department. of Health Human Services Associate Professor, Emergency Medicine, University of Texas Health Science Center—Houston Keith Griffiths President, RedFlash Group Founding Editor, JEMS John J. Peruggia Jr., BSHuS, EFO, EMT-P Assistant Chief, Logistics, FDNY Operations Dave Keseg, MD, FACEP Medical Director, Columbus Fire Department Clinical Instructor, Ohio State University W. Ann Maggiore, JD, NREMT-P Associate Attorney, Butt, Thornton Baehr PC Clinical Instructor, University of New Mexico, School of Medicine Connie J. Mattera, MS, RN, EMT-P EMS Administrative Director EMS System Coordinator, Northwest (Illinois) Community Hospital Robert J. McCaughan Chief, City of Pittsburgh EMS Chair, IAEMSC Metro Chief’s Section Robin B. Mcfee, DO, MPH, FACPM, FAACT Medical Director, Threat Science Toxicologist Professional Education Coordinator, Long Island Regional Poison Information Center Mark Meredith, MD Assistant Professor, Emergency Medicine and Pediatrics, Vanderbilt Medical Center Assistant EMS Medical Director for Pediatric Care, Nashville Fire Department Geoffrey T. Miller, EMT-P Director of Simulation Eastern Virginia Medical School, Office of Professional Development Brent Myers, MD, MPH, FACEP Medical Director, Wake County EMS System Emergency Physician, Wake Emergency Physicians PA Medical Director, WakeMed Health Hospitals Emergency Services Institute Mary M. Newman President, Sudden Cardiac Arrest Foundation Joseph P. Ornato, MD, FACP, FACC, FACEP Professor Chairman, Department of Emergency Medicine, Virginia Commonwealth University Medical Center Operational Medical Director, Richmond Ambulance Authority Jerry Overton, MPA Chair, International Academies of Emergency Dispatch David Page, MS, NREMT-P Paramedic Instructor, Inver Hills (Minn.) Community College Paramedic, Allina Medical Transportation Member of the Board of Advisors, Prehospital Care Research Forum Paul E. Pepe, MD, MPH, MACP, FACEP, FCCM Professor, Surgery, University of Texas Southwestern Medical Center Head, Emergency Services, Parkland Health Hospital System Head, EMS Medical Direction Team, Dallas Area Biotel (EMS) System Edward M. Racht, MD Chief Medical Officer, American Medical Response Jeffrey P. Salomone, MD, FACS, NREMT-P Associate Professor of Surgery, Emory University School of Medicine Deputy Chief of Surgery, Grady Memorial Hospital Assistant Medical Director, Grady EMS Kathleen S. Schrank, MD Professor of Medicine and Chief, Division of Emergency Medicine, University of Miami School of Medicine Medical Director, City of Miami Fire Rescue Medical Director, Village of Key Biscayne Fire Rescue John Sinclair, EMT-P International Director, IAFC EMS Section Fire Chief Emergency Manager, Kittitas Valley Fire Rescue Corey M. Slovis, MD, FACP, FACEP, FAAEM Professor Chair, Emergency Medicine, Vanderbilt University Medical Center Professor, Medicine, Vanderbilt University Medical Center Medical Director, Metro Nashville Fire Department Medical Director, Nashville International Airport Barry Smith, EMT-P CQI Coordinator, Regional EMS Authority (REMSA), Reno, Nev. Walt A. Stoy, PhD, EMT-P, CCEMTP Professor Director, Emergency Medicine, University of Pittsburgh Director, Office of Education, Center for Emergency Medicine Richard Vance, EMT-P Captain, Carlsbad Fire Department Jonathan D. Washko, BS-EMSA, NREMT-P, AEMD Assistant Vice President, North Shore-LIJ Center for EMS Co-Chairman, Professional Standards Committee, American Ambulance Association Ad-Hoc Finance Committee Member, NEMSAC keith wesley, MD, facep Medical Director, HealthEast Medical Transportation Katherine H. West, BSN, MED, CIC Infection Control Consultant, Infection Control/Emerging Concepts Inc. Stephen R. Wirth, Esq. Attorney, Page, Wolfberg Wirth LLC. Legal Commissioner Chair, Panel of Commissioners, Commission on Accreditation of Ambulance Services (CAAS) Douglas M. Wolfberg, Esq. Attorney, Page, Wolfberg Wirth LLC Wayne M. Zygowicz, BA, EFO, EMT-P EMS Division Chief, Littleton Fire Rescue
  • 11. Choose 18 at www.jems.com/rs
  • 12. EMS IN ACTION Scene of the month 14 JEMS JUNE 2012 Photo kevin Link
  • 13. catching a fall P 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. www.jems.com JUNE 2012 JEMS 15
  • 14. from the editor putting issUes into perspective by A.J. HEIGHTMAN, MPA, EMT-P Is EMS A Game? Inefficiency can cost patient lives 16 JEMS JUNE 2012 Photo istockphoto.com Y 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 for air. 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 her face. 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 the crowd: 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 outside.” 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 my job.” 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 patient care. 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 humeral IO.” 18 JEMS JUNE 2012 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 partner please?” To your partner: “Mike, cut her clothes, get that 12-lead running, establish an IO and draw some blood to check her glucose level.” 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 hospital. 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.” Lessons Learned 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 patient. JEMS
  • 17. Comprehensive, Credible, Educational... JEMS Products Help You Save Lives. Jems, Journal of Emergency Medical Services jems.com Website With content from writers who are EMS professionals in the field, JEMS provides the information you need on clinical issues, products and trends. Your online connection to the EMS world, JEMS.com gives you information on: • Products • Jobs • Patient Care • Training • Technology Available in print or digital editions! Product Connect jems.com eNewsletter Sign up now for the weekly JEMS.com eNewsletter. Get breaking news, articles and product information sent right to your computer. Read it on your time and stay ahead of the latest news! Giving you the detailed product information you need, when you need it. We collect all the information from manufacturers and put it in one place, so it’s easy for you to find and easy for you to read. Go to www.jems.com/ems-products FREE WEBCASTS did you Miss a live webcast? Check out the archives at www.JEMS.com/webcasts. • 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 Patient Care • 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 Experience • 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 Patient Care • Universal Capnography: What, When, How and Why! Go to www.JEMS.com
  • 18. LETTERS 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 patient. Gross. ETI Debate 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. Lauren Dengate Via Facebook 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 Tom Steiner Via Facebook   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. Jeffrey Mancini Via Facebook Choose 46 at www.jems.com/rs 20 JEMS JUNE 2012 020_021LETTERS.indd 20 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. Alabama EMSC be and leave the subtle politics out of it. Andrew Friedman, NREMT-P Leesburg, Virginia Via Facebook 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. Manda Lin 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. Via Facebook 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 properly trained. Stuart Rhinehart Via Facebook Surface Issue? 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 seconds flat. Dylan Beickman: You run on a regular patient, and play the game “how much of the patient healthcare record can I complete before I get there?” 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 ambulance.” JEMS Choose 20 at www.jems.com/rs www.jems.com JUNE 2012 JEMS 21
  • 20. PRIORITYUSE TRAFFIC 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 Photo istockphoto.com P 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 22 JEMS JUNE 2012
  • 21. Choose 21 at www.jems.com/rs
  • 22. continued from page 22 I 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 prehospital setting. 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? General Rules 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. Protocols 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 EMS agencies. 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. 24 JEMS JUNE 2012
  • 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 E 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. The Theory S 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:” Prepare; Practice; Present; and Post-review. 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- 26 JEMS JUNE 2012 photo glen ellman Prepare 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 patient safety? 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 K appropriate care; 3. ommunicate with command physiC cian and recommend STEMI alert; and 4. ommunicate well with receiving facilC ity staff. 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. The practice S 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 Practice 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. 28 JEMS JUNE 2012 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. Post-Simulation Review 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 tion? ere all skills addressed and completed? W id the participants respond appropriately to the presented D scenario? ere crew and patient safety appropriate? W as there anything else that should have been covered to meet W the goals of the scenario? hat’s the feedback from the participants? W Conclusion 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 al@safetywatchtraining.com. Resources https://ssih.org/about-simulation www.jems.com/article/training/simulation-play-key-role-2012-jemsgames Choose 24 at www.jems.com/rs www.jems.com JUNE 2012 JEMS 29
  • 28. TRICKSour patients ourselves OF THE TRADE caring for by Thom Dick, EMT-P Do No Harm It’s important to not inflict unnecessary pain 30 JEMS JUNE 2012 Photo Thom Dick J 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 tubing. 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 the suggestion. “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. We’re nurses.” “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 of infection.” 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 you! JEMS Thom Dick has been involved in EMS for 42 years, 23 of them as a full-time EMT and paramedic in San Diego County. He’s currently the quality care coordinator for Platte Valley Ambulance, a hospital-based 9-1-1 system in Brighton, Colo. Contact him at boxcar414@yahoo.com.
  • 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 Difficult Airway Providers treat patient with multiple gunshot wounds Assessment Treatment 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 sequence intubation. 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. 32 JEMS JUNE 2012 After two failed attempts with standard laryngoscopy, the providers successfully placed the ETT using the King Vision video laryngoscope blade. 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 A 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 www.jems.com JUNE 2012 JEMS 33
  • 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. Discussion 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 many reasons: 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 34 JEMS JUNE 2012 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 was imminent. 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 Conclusion 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. References 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 Med. 2011;18(7):692–698. 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. 2010;32(2):276–282. Resources 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 www.jems.com JUNE 2012 JEMS 35
  • 34. RESEARCH REVIEW ems What current studies mean to by David Page, MS, NREMT-P Epinephrine’s Effects 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 receive epinephrine. 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 from it. 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 36 JEMS JUNE 2012 Photo david page E 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. Bottom Line 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. B 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 review.”) 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 prehospital treatment. 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 already started. 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 myocardial infarctions. 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]. T 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 audio commentary. David Page, MS, NREMT-P, is an educator at Inver Hills Community College and a paramedic at Allina EMS in Minneapolis/ St. Paul. He’s a member of the Board of Advisors of the Prehospital Care Research Forum. Send him feedback at dpage@ehs.net. Choose 30 at www.jems.com/rs www.jems.com JUNE 2012 JEMS 37
  • 36. Richmond Ambulance Authority creates comprehensive culture of safety model The Richmond Ambulance Authority has worked hard to create and foster a culture centered on safety in all areas. 38 JEMS JUNE 2012
  • 37. By Rob Lawrence, MCMI; Bryan S. McRay, BA; Dempsey Whitt, NREMT-P/FP-C; Joseph P. Ornato, MD, FACP, FACC, FACEP T 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 of Excellence. 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 of Safety Choose 31 at www.jems.com/rs www.jems.com JUNE 2012 JEMS 39
  • 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 national average. 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. healthcare providers. 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 an injury. from other high-quality, safety-oriented industries, such as nuclear • Transportation-related Fatalities and aviation. (per 100,000) 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 (per 100,000) Safety Reporting System (ASRS) devel- National average: 5.0 injuries 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 human errors. 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 may arise. key pieces of equipment, safe and skilled audible tones. Monitored parameters include operation of vehicles, and correct appropriate patient transfer techniques. Pre-Hire Process 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. predictive tool. 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. 40 JEMS JUNE 2012
  • 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 vehicular safety. 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 Self-Reporting Program 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 Wasn’t repetitive. 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. Reducing Risks 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 www.jems.com JUNE 2012 JEMS 41
  • 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) Date Total Emergency Non-Emergency 7/25 28 28 28 7/26 27 26 27 7/27 31 26 32 7/28 28 27 28 7/29 25 25 25 7/30 26 29 26 7/31 29 29 29 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, and month. 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, 42 JEMS JUNE 2012 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 information. 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 Public Administration. 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. References 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 new products showcased at the 29th annual JEMS EMS Today Conference Exposition 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. 44 JEMS Hot Products JUNE 2012 Rip Shears info@ripshears.com www.ripshears.com 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 carbon blades. LOLA Advanced Assessment 818/530-7900 www.lolaadvanced.com/about-us/ 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 America Inc. 424/218-8712 Bernd.bay@karlstorz.com www.karlstorz.com 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 615/575-0099 matt@board-armor.com www.board-armor.com Physio-Control 800/442-1142 www.physio-control.com 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 backboards. 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 888/355-2220 EMS@LevelFoods.com www.levelfoods.com 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 delicious flavors. Ferno 877/733-0911 info@ferno.com www.ferno.com/powertraxx 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. www.jems.com JUNE 2012 JEMS 45
  • 44. Stryker Medical 800/327-0770 www.ems.stryker.com 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. ICEdot 918/592-3722 www.icedot.org Action Training Systems 800/755-1440 ext. 3 info@action-training.com www.action-training.com 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 your family. Clear Advantage Collar www.theclearcollar.com emsCharts Inc. 866/647-8282 sales@emscharts.com www.emscharts.com 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. 46 JEMS Hot Products JUNE 2012 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 Corporation 312/520-8311 rmueller@bridgford.com www.bridgford.com 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. AeroClave LLC 407/788-3300 info@aeroclave.com www.aeroclave.com 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 m2 Inc. 802/655-2364 info@m2inc.biz www.m2inc.biz 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. 604/422-2613 Will.tomkinson@xantrex.com www.xantrex.com 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. Philips Healthcare 800/453-6860 Cmslead-andover@philips.com www.philips.com/mrx-ems C3 SoftWorks 888/333-1969 info@c3softworks.com http://c3softworks.com/products/classroom/pronto 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. 800/22-Braun sales@braunambulances.com www.braunambulances.com 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. Jones Bartlett 800/832-0034 info@jblearning.com www.jblearning.com 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. 48 JEMS Hot Products JUNE 2012 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. Simulaids 800/431-4310 info@simulaids.com www.simulaids.com/642.htm 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.
  • 47. TransLite 281/240-3111 sales@veinlite.com www.veinlite.com 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 LLC 760/727-1900 info@intubrite.com www.intubrite.com 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. FastTrack Medical Solutions LLC 612/281-8577 kim@fasttrackmedicalsolutions.com www.fastratckmedicalsolutions.com 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 gentle, adhesive. Choose 35 at www.jems.com/rs www.jems.com JUNE 2012 JEMS 49
  • 48. Rescue Essentials 866/711-4843 info@rescue-essentials.com www.rescue-essentials.com Mercury Medical 800/237-6418 lsouder@mercurymed.com www.mercurymed.com 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 America Inc. 424/218-8712 Bernd.bay@karlstorz.com www.karlstorz.com 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 800/818-4726 customerservice@sammedical.com www.sammedical.com 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 in proximity. CoolShirt Systems 800/345-3176 sales@Cooshirt.com CoolShirt.com Digital Ally Inc. 800/440-4947 sales@digitalallyinc.com www.digitalallyin.com 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. 50 JEMS Hot Products 044_055hotproductsLayout.indd 50 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. JUNE 2012 6/15/2012 1:38:35 PM
  • 49. EKG Concepts 262/498-5047 www.ekgconcepts.com 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. Talon Rescue 860/269-7289 info@talonrescue.com www.talonrescue.com 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 the USA. Choose 36 at www.jems.com/rs RAE Systems 408/952-8200 raesales@raesystems.com www.raesystems.com 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 www.jems.com JUNE 2012 JEMS 51
  • 50. Philips Healthcare 800/453-6860 Cmsleads-andover@philips.com www.philips.com/mrx-ems Hartwell Medical 760/438-5500 customerservice@hartwellmedical.com www.hartwellmedical.com 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. VORTRAN Medical Technology 1 Inc. 800/434-4034 info@vortran.com www.vortran.com 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 Inc. 800/892-2801 ext. 5 angela.comeau@traumapacks.com www.traumapacks.com 52 JEMS Hot Products 044_055hotproductsLayout.indd 52 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 (www.hartwellmedical.com). 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. BLS Systems Limited 905/339 1069 tedreesor@blssystemsltd.com www.blssystemsltd.com 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 905/339-1069 tedreesor@blssystemsltd.com www.blssystemsltd.com 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. JUNE 2012 6/15/2012 1:38:44 PM
  • 51. Geomet Technologies LLC 800/296-9898 Rapidproresponse@geomet.com www.geomet.com 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 Simulaids 800/431-4310 info@simulaids.com www.simulaids.com/3002.htm 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 Corporation 317/776-6823 kingsystems@kingsystems.com www.owntheairway.com 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 patient care. Choose 39 at www.jems.com/rs www.jems.com JUNE 2012 JEMS 53
  • 52. Medical Safety Solutions Inc. 877/855-1319, www.sharpsterminator.com 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. laerdal medical www.laerdal.com practi-seal www.practiseal.com 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. CareFusion www.carefusion.com/revel 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. Mercury Medical 800/237-6418 lsouder@mercurymed.com www.mercurymed.com 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. 54 JEMS Hot Products JUNE 2012
  • 53. Jones Bartlett 800/832-0034 info@jblearning.com www.jblearning.com 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 EKG Concepts 262/498-5047 www.ekgconcepts.com 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. Knox company 800/552-5669 info@knox.com www.knoxbox.com 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 www.jems.com JUNE 2012 JEMS 55
  • 54. ‘Time is brain’ when treating stroke patients By W. Ann Maggiore, JD, NREMT-P 56 jems JUNE 2012 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 Y 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. www.jems.com JUNE 2012 JEMS 57
  • 56. Stroke of the Clock continued from page 57 Learning Objectives 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 than others. 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 58 JEMS JUNE 2012 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 categorizations. 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 prehospital setting. 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 stroke patients. Download a copy of the Los Angeles Prehospital Stroke Screen at www.strokecenter.org/wp-content/ uploads/2011/08/LAPSS.pdf. 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 KEY Terms 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 Normal Abnormal Facial Droop Both sides of face move equally. One side of face does not move at all. Arm Drift Both arms move equally or not at all. One arm drifts compared to the other. Speech Patient uses correct words with no slurring. Patient slurs, uses inappropriate words or is mute. Source: www.strokecenter.org/wp-content/uploads/2011/08/cincinnati.pdf. 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. Prehospital Treatment 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 stroke recovery. 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 60 JEMS JUNE 2012 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. In-Hospital Care 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 stroke units. 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 possible outcome. 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 www.jems.com JUNE 2012 JEMS 61
  • 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 atrial arrhythmias. 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 stroke survivors. 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. 62 JEMS JUNE 2012
  • 60. Recognizing the Best New Products for 2012 Popular Vote Winners: Sharps Terminator by Medical Safety Solutions R-CAT Rapid - Cardiac Analysis Tool by EKG Concepts The R-CAT window for STEMI is a flexible plastic card with a reversible clear baseline window. Using the R-CAT on an actual patient’s EKG, patterns of ischemia, injury and infarction as well as measurments of heart rate, P-R, QRS and QT intervals can be measured. Saves valuable time when seconds count! Three seconds to save a life! The Sharps Terminator destroys needles attached and not attached to syringes. The unit completely removes the nub of the needle, destroys all bloodborne pathogens along with any biohazards that may be inadvertently exhausted into the unit. In seconds both the needle and the risk are eliminated at point of use. Congratulations to all participating companies for their product innovations! ADVANCED EMS DESIGNS BOARD ARMOR AEROCLAVE RDS 1110-P BANDEL INNNOVATIONS WAUK BOARD BEYOND LUCID TECHNOLOGIES MEDIVIEW DIGITAL ALLY VIDEO EVENT RECORDER ICEDOT IPCR KARL STORZ ENDOSCOPYAMERICA C-MAC POCKET MONITOR LAERDAL MEDICAL SIMPAD MAKING SIMULATION EASIER MERCURY MEDICAL AIR-Q SP MERCURY MEDICAL FLOW-SAFE II NEWPORT MEDICAL INSTRUMENTS NEWPORT HT70 PLUS VENTILATOR PHILIPS HEALTHCARE HEARTSTART FR3 AED PHILIPS HEALTHCARE HEARTSTART MRX XANTREX TECHNOLOGY FREEDOM HF INVERTER/ CHARGER ZOLL XSERIES ZOLL RESCUENETLINK RIP SHEARS ZIAMATIC QUIC-RELEASE D CYLINDER BRACKET For more information on these produc ts, please visit www.emstoday.com
  • 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 efforts immensely. 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. 64 JEMS JUNE 2012 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 one position. Language problems: At least one-fourth As with all patients in the prehospital setting, assessment of the airway, breathing circulatory status of stroke patients is essential. 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 and writing. 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 more often. 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 Conclusion 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 desertrose@q.com. Resources 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. ninds.nih.gov/disorders/tia/htm?css. 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. nih.gov/disorders/stroke/poststrokerehab.htm. National Stroke Association. (2012.) A Hole in the Heart: Patent foramen ovale. In National Stroke Association. www.stroke.org/site/ PageServer?pagename=PFO. 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/ content/125/1/e2. 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/ facts_about_primary_stroke_center_certification/. 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/ HealthcareTraining/AdvancedCardiovascularLifeSupportACLS/Advanced-Cardiovascular-LifeSupport---Classroom_UCM_306643_Article.jsp. 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. 2006;7(2):171–174. Lechat, P, Mas JL, Lascault G, et al. Prevalence of PFO in patients with stroke. N Engl J Med. 1988;318(18):1148–1152. 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. 2007;49:797–802. www.jems.com JUNE 2012 JEMS 65
  • 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. VITALS Length: 15 Weight: 1.6 lbs. Color: Black Price: $23 www.stanleytools.com Fully Charged 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. VITALS Battery voltages: 6 V and 12 V Output current: 8 amp max Weight: 2.5 lbs. Price: $99.95 www.pulsetech.net 800/580-7554 Electric Itch Stopper VITALS Length: 6 Weight: 6 oz. Power: 9 V Price: $12.99 www.therapik.com 954/578-6909 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 fran100b@zoominternet.net. VITALS Dimensions: 22 x 18 x 8 Weight: 4.5 lbs. Price: $139.95 www.wnlsafety.com 800/884-9629 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 between applications. CPR Manikin 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 66 JEMS JUNE 2012
  • 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, tablets and touch-screen PCs. 5.11’s tactical touch seamless fingertip construction provides excellent dexterity, fit and comfort. VITALS Color: Black Sizes: S–2XL Price: $49.99 www.511tactical.com 866/451-1726 VITALS Version: 1.0 Size: 3.8 MB Requirements: iPhone, iPod Touch and iPad Price: Free on iTunes www.upmc-biosecurity.org 443/573-3304 Biosecurity Resource 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 of disease. Kimberly Clark KLEENGUARD APPAREL Beyond Lucid Tehnologies MEDIVIEW Choose 42 at www.jems.com/rs
  • 65. Employment Equipment ADVANCED BIO-MEDICAL LIFE SUPPORT EQUIPMENT CERTIFICATION AND DEPOT REPAIR CALL 1.800.383.8962 www.advancedbiomedical.com greatservice@advancedbiomedical.com Save 25% - All Services Equipment HAVE OPEN POSITIONS? Get them filled with a JEMS recruitment classified. Reach our audience with your message! Email: classifieds@elsevier.com 68 JEMS JUNE 2012
  • 66. POWERFUL SOLUTIONS FROM SMART THINKERS avoid pending lawsuits research grant funding EMS Research Technology EMS Trend Analysis revenue generating ideas AVOID COSTLY FINES Exclusively for EMS Management EMS Insider provides you with the “inside information” on EMS. It’s a monthly publication from Elsevier Public Safety and affiliated with JEMS (Journal of Emergency Medical Services) so it has the best network of sources in EMS. That means you get only the highest quality reporting . . . insightful, timely, authoritative. . . not available elsewhere. EMS Insider pays for itself. Every issue contains articles to help you, by bringing you money-saving and revenuegenerating ideas. Don’t miss out, order your subscription today! *All Newsletter Subscriptions include access to content and archives from the past 15 years at www.JEMS.com. Subscribe to EMS Insider www.JEMS.com or call 1.888.456.5367
  • 67. Watch Steve Berry and JEMS Editor-in-Chief AJ Heightman tell you why this book is a must-read!
  • 68. ad direct Your source for immediate information on advertisers’ products and services Advertiser RS# Page Advertiser RS# Page AeroClave LLC 30 37 JEMS 19, 63, 69, 70 Alberta College of Paramedics 31 39 Junkin Safety Appliance Co. 38 53 American Heart Association 24 29 Knox Co. 36 51 Baxter Medical 13 4-5 Laerdal Medical Corporation 44 76 Bound Tree Medical 11 2 m2 Inc. 20 21 Cindy Elbert Insurance Services 40 55 Medical Safety Solutions 29 37 Columbia Southern University 39 53 Mercury Medical 21 23 CSI Medical 19 20 Michigan Instruments 22 25 Digital Ally 27 34 New York Methodist Hospital Center for Allied Health Edu. 42 67 Ecolab 26 33 Oxygen Generating Systems Intl. 37 51 Emergency Medical Products/L.A. Rescue 41 55 PANASONIC PCSC 18 13 EMST TODAY 2013 73 Philips Healthcare 14 6 ESRI (Environmental Systems Research Institute Inc.) 25 31 Pulmodyne 16 10 Ferno-Washington Inc. 12 3 Stryker EMS 43 75 Fitch Associates 33 43 Translite LLC 28 35 GlucoBrands LLC 19 17 W.W. Grainger 17 11 Hartwell Medical 34 47 Whelen Engineering Co. Inc. 32 41 IAFC (International Association of Fire Chiefs Inc.) 59 Xantrex Technology Inc 23 27 Informed Publishing 49 Zoll Medical Corporation 15 8 35 FREE advertiser and product information www.jems.com/rs IT’S FAST, IT’S EASY AND JUST A CLICK AWAY! www.jems.com JUNE 2012 JEMS 71
  • 69. thethey didn’t tell you in medic school LIGHTER SIDE what by steve berry Epi Coasters Hang on to the bar ‘L 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 72 JEMS JUNE 2012 don’t remember them and frankly don’t give a $#@%. 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.
  • 70. SaveDATE the New Location! March 5 – March 9, 2013 Washington, D.C. Advance Your Career at EMS Today … Where People, Products and Ideas Connect www.EMSToday.com
  • 71. LAST WORD EMS The Ups downs of Three years ago, Bear was an 100-pound Shiloh German Shepherd nobody wanted. That was until Debbie Zeisler came to his rescue at a Texas animal shelter. When Zeisler had a seizure, fell down some steps, hit her head and lost consciousness, Bear scratched on every front door in their Millsap neighborhood, trying to help. But nobody answered. A Parker County animal control officer saw the frantic dog, and followed him to his owner. Bear recognizes the signs of imminent seizures and will lean on Zeisler’s legs, so she can sit down before one happens, says the Society’s Ana Bustilloz. However, Bear never had any training. In May, Bear was presented with the 30th National Hero Dog award by the Society for the Prevention of Cruelty to Animals in Los Angeles. The society flew Bear and Zeisler to California and awarded Bear with a year’s supply of dog food. Worthy Honorees A few things are worth recognizing about this special K9: Bear’s innate abilities to care for his owner; Zeisler’s compassionate heart for taking him in, and the Society for the Prevention of Cruelty to Animals for realizing that heroes come in all shapes and sizes. non-clinical innovation and achievements in fire service EMS management. Metcalf has led national initiatives related to strengthening fire service capabilities in EMS, mutual aid and homeland security. “It is both humbling and an honor to receive this recognition from my peers and colleagues in the EMS field. I have been truly blessed to have the opportunity to be present and participate in many of the significant developments that have taken place as EMS has grown and evolved over the past 30 Photo A.J. Heightman Three noteworthy awards were presented during this year’s Fire-Rescue Med conference in Las Vegas: the James O. Page EMS Achievement Award and two Heart Safe Community Awards. The James O. Page award was given to Fire Chief William R. Metcalf of the North County Fire Protection District in Fallbrook, Calif. The annual award is presented to a leader who’s played a positive role on a national scale in creating and promoting Photo Associated Press K9 Hero Pictured (from left) are IAFC EMS section members Rob Brown and John Sinclair, Metcalf, IAFC EMS section chair Gary Ludwig and Physio-Control vice president of global marketing Cam Pollock. years. I look forward to continuing to make leadership contributions to our profession for many more years to come,” says Metcalf. Hilton Head Island (S.C.) Fire and Rescue and Howard County (Md.) Department of Fire and Rescue were honored as this year’s Heart Safe Award recipients for their outstanding achievement in developing creative approaches to implement and maintain systems to prevent and treat cardiac-related diseases. “These departments are doing great work in cardiac care in their community,” said Chief Al Gillespie, International Association of Fire Chiefs president and chairman of the board. We applaud Metcalf, Hilton Head Island Fire and Rescue and Howard County Department of Fire and Rescue for their outstanding efforts in helping improve patient care and advance the field of EMS both on a local and national level. That’s a Wrap The Geneva (Ohio) Fire Department (GFD) was looking for a simple and affordable way to paint an emergency response vehicle. When they discovered how much time and money would go into repainting it, they quickly realized they needed to explore other options. So, after doing some research, the department decided to go with vinyl wraps, made by Avery Dennison. The product is a dual layer film that combines color and clear protective layers to provide a durable paintlike finish. A local sign shop did the finishing design touches. Instead of putting the truck out of commission for four to six weeks like a paint job would have, the wrap took two to three weeks and only a few days to install. “I would recommend a vinyl wrap to any of my colleagues that need to update the graphics on their vehicles,” GFD Chief Doug Starkey said in a statement. We give a thumbs up to Avery Dennison for creating this innovative option and to GFD for thinking outside the box and saving valuable resources in the process. JEMS JEMS (Journal of Emergency Medical Services), ISSN 0197-2510, is pub­ished monthly by Elsevier Public Safety, 525 B Street, Suite 1800, San Diego, CA 92101-4495; 800/266-5367 (fed. ID #13-1958712). l subscriptions: Send $44 for one year (12 issues) or $74 for two years (24 issues) to P.O. Box 17049, North Hollywood, CA 91615-9247, or call 888/456-5367. Canada: Please add $25 per year for postage. All other foreign subscriptions: Please add $35 per year for surface and $75 per year for airmail postage. Send $32 for one year (12 issues) or $62 for two years (24 issues) of digital edition. Single copy: $10.00. Postmaster: Send address changes to JEMS (Journal of Emergency Medical Services), P.O. Box 17049, North Hollywood, CA 91615-9248. Claims of nonreceipt or damaged issues must be filed within three months of cover date. Periodicals postage paid at San Diego, Calif., and at additional mailing offices. Canada Post International Publications Mail Product (CanadianDistribution) Sales Agreement No. 1247948. Advertising information: Rates are available at www.jems.com/jems/advertise/or by request from JEMS Advertising Department at 525 B Street, Suite 1800, San Diego, CA 92101-4495; 800/2665367. Copyright © 2012 Elsevier Inc. No material may be reproduced or uploaded on computer network services without the expressed permission of the publisher. JEMS is indexed in the Cumulative Index to Nursing Allied Health Literature and included in the Medline/PubMed database. JEMS is printed in the United States. 74 JEMS JUNE 2012
  • 72. Choose 43 at www.jems.com/rs
  • 73. Choose 44 at www.jems.com/rs

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