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  1. 1. AUGUST 2012 Always En Route At
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  4. 4. The Conscience of EMS JOURNAL OF EMERGENCY MEDICAL SERVICES 34 I Primer Non Nocere I Why EMS should be timely, thorough cautious in implementing new approaches to patient care B y Paul E. Pepe, MD, MPH, Sandra M. Schneider, MD August 2012 Vol. 37 No. 8 Contents 42 I It Takes a Village I Are community health partnerships the wave of the future? By Jennifer Berry Integrated training simulation at the 2012 JEMS Games By Chad Brocato, DHSC, CFO, JD; A.J. Heightman, MPA, EMT-P Good science enthusiasm drive survival rates in Oklahoma By Jeffrey M. Goodloe, MD, NREMT-P, FACEP; T.J. Reginald, NREMT-P; David S. Howerton, NREMT-P; Jim O. Winham, RN, BSN, NREMT-P; Tammy Appleby, NREMT-B I 60 How we can influence the ‘ambulance driver’ media epidemic By Rollin J. (Terry) Fairbanks, MD, MS Be prepared to treat anaphylactic incidents before it’s too late By Rick Rod, RN, CEN, NREMT-P 48 I Sim Success I 52 I Attacking Cardiac Arrest I 58 I More than Words I Departments columns 7 I Load go I Now on 12 I EMS in Action I Scene of the Month 14 I From the Editor I Doubles Backups 60 I Sudden onset I y A.J. Heightman, MPA, EMT-P B 16 I Letters I In Your Words 18 I Priority Traffic I News You Can Use 22 I lEADERSHIP sECTOR I System Costs y Gary Ludwig, MS, EMT-P B 24 I HIGHER LEARNING I Old Dogs New Tricks y William Raynovich, NREMTP, EdD, MPH, BS B 28 I Tricks OF the TRADE I Psych Transfers y Thom Dick B 30 I case of the month I Risky Anticoagulants y Patrick Harvey, MD B 32 I RESEARCH REVIEW I What Current Studies Mean to EMS y David Page, MS, NREMT-P B 66 I employment Classified Ads 67 I Ad Index 68 I Hands On I Product Reviews from Street Crews y Fran Hildwine B 72 I The Lighter Side I EMS y Steve Berry B 74 I LAST WORD I The Ups Downs of EMS I 48 About the Cover leadership article, “Primum Non Nocere: Why EMS should be This month’s cover announces an important timely, thorough and cautious in implementing new approaches to patient care,” pp. 34–40. This article by Paul E. Pepe, MD, MPH, and Sandra M. Schneider, MD, points out that although many EMS therapies have been implemented to diminish patient morbidity and discomfort through early intervention, we have also inadvertently applied practices that may have been detrimental or ineffective. This article is a must-read for all EMS providers, managers, researchers, educators and administrators who want to make sure they “first do no harm.” Photo Premier Media Partner of the IAFC, the IAFC EMS Section Fire-Rescue Med August 2012 JEMS 5
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  6. 6. LOAD GO  log in for EXCLUSIVE CONTENT A Better Way to Learn online continuing education program n us o follow Most the country is in the hot grip of summer. We asked our Facebook audience: Do all the ambulances at your agency have air conditioning? The answers were all over the map, but it seems some states and counties require it, while providers in other areas have to hope for the best. Jon Kledzik: Not mine. Today was 104 in the cab :( David Gaver: Well mine did ’till about 10 minutes ago when it started blowing hot air. C.J. Cornell: All of ours have 2/60 A/C: Two windows at 60 mph. Amanda A Griffin: Yes. Most of the time. They get repaired pretty quickly in Alabama. :) Eric Leland: The Texas heat and department of state health services require it. Samantha Tucker: Yes. And if either A/C goes out, the unit is 10-7. Even our A Star has A/C. It’s Mississippi folks. Bombero Rescate: Yep, except on those 90-plus degree days when the 88 year-old female patient says, “Can you turn down the air? I’m freezing!” Diana Ledford: The question should be: Does it work properly in the patient and crew compartments? Jeff Schneider: Mandated by county policy. Plus this is the central valley of California. Average summer temps of 90–95 degrees. Highs of 105–114. Evan Basim Monaghan: I’m just thinking you would think all ambulances should have working A/C and heat. I mean, we have hypothermic patients and patients who have heat stroke in the back of the ambulance. s Photo Sweatin’ The Heat? offers you original content, jobs, products and resources. But we’re much more than that; we keep you in touch with your colleagues through our: Facebook fan page; JEMS Connect site; Twitter account; LinkedIn profile; Product Connect site; and Fire EMS Blogs site. like us /jemsfans follow us /jemsconnect Sponsored Product Focus Rescuer Emergency CPAP System The Rescuer Emergency CPAP System from BLS Systems Limited 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. s Check out their Hot Product listing on! get connected about=gid=113182 ems news alerts Free online Learning Opportunities Bryan E. Bledsoe Steve Wirth We believe learning is a lifelong commitment. We also think there’s a lot of knowledge to be had in EMS, and we bet most EMS professionals would agree. So join us for our upcoming webcasts on July 25 and August 22. At 1 p.m. Eastern on July 25, Doug Wolfberg, Esq., and Steve Wirth, Esq., will focus on how you can reduce your documentation errors on patient care reports in “Maximizing Your Revenue.” And at 1 p.m. Eastern on Aug. 22, Bryan E. Bledsoe, DO, FACEP, FAAEM, will detail evolving changes in prehospital airway management in “Securing the Airway.” Register for one or both of Doug Wolfberg them today. s Check it out best bloggers AUGUST 2012 JEMS 7
  7. 7. Conscience of EMS JOURNAL OF EMERGENCY MEDICAL SERVICES The Conscience of EMS JOURNAL OF EMERGENCY MEDICAL SERVICES Editor-In-Chief I A.J. Heightman, MPA, EMT-P I MANAGING Editor I Jennifer Berry I associate eDITOR I Lauren Hardcastle I assistant eDITOR I Allison Moen I assistant eDITOR I Kindra Sclar I online news/blog manager I Bill Carey I Medical Editor I Edward T. Dickinson, MD, NREMT-P, FACEP Technical Editors Travis Kusman, MPH, NREMT-P; Fred W. Wurster III, NREMT-P, AAS Contributing Editor I Bryan Bledsoe, DO, FACEP, FAAEM Editorial Department I 800/266-5367 I art director I Liliana Estep I Contributing illustrators Steve Berry, NREMT-P; Paul Combs, NREMT-B Contributing Photographers 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 Production Coordinator I Matt Leatherman I advertising director I Judi Leidiger I 619/795-9040 I Western Account Representative I Cindi Richardson I 661-297-4027 I senior Sales coordinator I Elizabeth Zook I Sales Administrative Coordinator I Liz Coyle I SENIOR eMedia campaign manager I Lisa Bell I advertising department I 800/266-5367 I Fax 619/699-6722 marketing director I Debbie Murray I Marketing manager I Melanie Dowd I Marketing Conference Program Coordinator I Vanessa Horne I Director, Audience Development Sales Support I Mike Shear I Audience development coordinator I Marisa Collier I SUBSCRIPTION DEPARTMENT I 888/456-5367 REprints, eprints Licensing I Wright’s Media I 877/652-5295 I eMedia Strategy I 410/872-9303 I Managing Director I Dave J. Iannone I Director of eMedia Sales I Paul Andrews I Director of eMedia Content I Chris Hebert I elsevier public safety vice president/publisher I Jeff Berend I founding editor I Keith Griffiths founding publisher James O. Page (1936–2004) Choose 16 at 15
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  9. 9. 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 Keith Griffiths President, RedFlash Group Founding Editor, JEMS 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 Dave Keseg, MD, FACEP Medical Director, Columbus Fire Department Clinical Instructor, Ohio 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 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 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 Thom Dick, EMT-P Quality Care Coordinator Platte Valley Ambulance 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 Charlie Eisele, BS, NREMT-P Flight Paramedic, State Trooper, EMS Instructor Mary M. Newman President, Sudden Cardiac Arrest Foundation Bruce Evans, MPA, EMT-P Deputy Chief, Upper Pine River Bayfield Fire Protection, Colorado District Joseph P. Ornato, MD, FACP, FACC, FACEP Professor Chairman, Department of Emergency Medicine, Virginia Commonwealth University Medical Center Operational Medical Director, Richmond Ambulance Authority Jay Fitch, PhD President Founding Partner, Fitch Associates Ray Fowler, MD, FACEP Associate Professor, University of Texas Southwestern SOM Chief of EMS, University of Texas Southwestern Medical Center Chief of Medical Operations, Dallas Metropolitan Area BioTel (EMS) System Adam D. Fox, DPM, DO Assistant Professor of Surgery, Division of Trauma Surgery Critical Care, University of Medicine Dentistry of New Jersey Former Advanced EMT-3 (AEMT-3) Gregory R. Frailey, DO, FACOEP, EMT-P Medical Director, Prehospital Services, Susquehanna Health Tactical Physician, Williamsport Bureau of Police Special Response Team Jeffrey M. Goodloe, MD, FACEP, NREMT-P Professor EMS Division Director, Emergency Medicine, University of Oklahoma School of Community Medicine Medical Director, EMS System for Metropolitan Oklahoma City Tulsa 10 JEMS AUGUST 2012 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 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 John J. Peruggia Jr., BSHuS, EFO, EMT-P Assistant Chief, Logistics, FDNY Operations 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 Walt A. Stoy, PhD, EMT-P, CCEMTP Professor Director, Emergency Medicine, University of Pittsburgh Director, Office of Education, Center for Emergency Medicine Richard Vance, EMT-P Captain, Carlsbad Fire Department Jonathan D. Washko, BS-EMSA, NREMT-P, AEMD Assistant Vice President, North Shore-LIJ Center for EMS Co-Chairman, Professional Standards Committee, American Ambulance Association Ad-Hoc Finance Committee Member, NEMSAC keith wesley, MD, facep Medical Director, HealthEast Medical Transportation Katherine H. West, BSN, MED, CIC Infection Control Consultant, Infection Control/Emerging Concepts Inc. Stephen R. Wirth, Esq. Attorney, Page, Wolfberg Wirth LLC. Legal Commissioner Chair, Panel of Commissioners, Commission on Accreditation of Ambulance Services (CAAS) Douglas M. Wolfberg, Esq. Attorney, Page, Wolfberg Wirth LLC Wayne M. Zygowicz, BA, EFO, EMT-P EMS Division Chief, Littleton Fire Rescue
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  11. 11. EMS IN ACTION Scene of the month 12 JEMS AUGUST 2012 Photo Glen Ellman
  12. 12. Extended Extrication A crew from the Fort Worth (Texas) Fire Department performs an extrication of a male patient who was trapped in his vehicle after a motor vehicle collision. The extrication process was extended because the patient’s feet were pinned beneath the seat of the vehicle, so the crew decided to use a bag-valve mask to ventilate him and then perform endotracheal intubation on scene. The patient was extricated successfully and transported by Careflight Air Ambulance to a hospital center. MedStar EMS ground ambulance service provided ALS care to the patient on scene and turned care over to Careflight. AUGUST 2012 JEMS 13
  13. 13. from the editor putting issUes into perspective by A.J. HEIGHTMAN, MPA, EMT-P Doubles Backups They can save your day I Photo A.J. Heightman Photo A.J. Heightman sources of carbon monoxide (CO), he ’ve written about my dad told me that it made no sense to carry many times in JEMS. He just one oxygen (O2) tank equipped wasn’t just a good care provider throughout his 40-plus with a regulator and four spare O2 years as an “ambulance man” tanks. He called these “naked soldiers,” with the Scranton (Pa.) Fire which was a reference to how useless Department; he was also a great a soldier would be in battle without innovator and mentor to me and his rifle. He noted how inadequate many others in “first aid” and it would be if an ambulance arrived EMS circles. He always seemed at the scene of a CO poisoning at a to think things through to resohome, found a mother, father and two lution of the worst-case scenario children lying out on the front lawn and paid close attention to risk in need of oxygen, and EMS providers management, resource manage- When you have multiple patients, you need multiples of your equipment. had just one complete portable O2 unit ment and disaster preparedness and four spare bottles. Once again, he petroleum jelly to grease up the ears of a child said, if it happened to him once, he would long before it was fashionable to do so. For example, he not only had all critically whose head was simply stuck between the never let it happen to him or his crews again. needed tools and devices positioned where rails of a fence to “extricate” them but would, My dad also carried two separate resuscitathey were easy to access, but he also had a instead, have a big rescue truck dispatched to tion devices (a bag-valve mask and a Robertprofessional sign painter outline the items so do it. Boy did he have that one correct! shaw demand-valve system), as well as two Another thing he ingrained in me was separate suction systems and two separate, he could ensure they were returned and properly secured in their exact location and posi- that, “If one is good, two are better.” It was a identically-equipped trauma bags. He did so tion after a call. This included non-traditional philosophy he carried over to his ambulances to be able to care for two separate patients tools, such as Partner PryAxes, tin snips, Hal- and storage areas. at the same scene and to ensure he had a I remember asking him one day, way back “backup” in case one of the devices failed, or ligan bars, hacksaws, ring cutters, hammers and chisels, fire extinguishers, multi-purpose in 1970, why he insisted on the department’s so he was never delayed from immediately fencing pliers and other “unusual” (not on the ambulance carrying two OB kits, two fire doing a “turnaround” and responding to a ambulance essential equipment list) items (a extinguishers and liter flow regulators on every critical trauma case. jar of petroleum jelly) that he found useful in oxygen tank in the ambulance. That question His advice hit home for me recently when got me a polite, but educational, 30-minute I heard a chief officer from Regional EMS the field. He had thousands of calls and field experi- lecture that I never forgot: Authority (REMSA) present lessons learned He told me he had delivered multiple sets from their management of the victims injured ences under his belt. And he often remarked that some of the people authoring the essen- of twins in his career and realized after the first at the Reno (Nev.) Air Races crash in 2012. tial equipment lists “never rode on an ambu- set that if it could happen once, it could hap- Although each of the five ambulances stalance” or were what he called “windbags” pen many times. Thus came another famous tioned on site was equipped with one tourwho rode an ambulance for a year or two quote, “Find a problem; fix a problem.” niquet, there were 15 amputated extremities He pointed out that, in his experience, just at the scene. Crews were forced to improvise and then got promoted, moved on to medical school or off to some other administrative about the time a five-pound fire extinguisher with men’s belts on several patients. achieved a 90% knockdown position, only to surface later The REMSA official was quick to point of a car fire it ran out, so it out that almost immediately after the incion some high-powered comwas best to carry two to “fin- dent, his agency added multiple tourniquets mittee where they could use ish the job.” their “extensive” EMS experito each REMSA unit so each unit was better Living in the coal region prepared to manage multiple simultaneous ence to change or influence of Pennsylvania, and having amputations in the future. When I heard the the industry. provided emergency care fast action REMSA took to address this issue, He pointed out that these to many families overcome I had to pass my dad’s “If one is good, two are self-proclaimed “experts” by coal gas fumes and other better” advice on to you. JEMS would never think to use Two are better than one. 14 JEMS AUGUST 2012
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  15. 15. LETTERS in your words Photo vu banh A Thousand Words As the saying goes, “a picture is worth a thousand words.” One such picture, an image featured on the cover of June JEMS, struck a chord with a reader concerned with how the photograph represented an EMS culture of safety. Read why he had an issue with it, as well as JEMS Editor-in-Chief A.J. Heightman’s response. I’m writing to ask for your assistance in adopting a culture of safety in EMS. In your June issue, you have a great article on the Richmond Ambulance Authority creating a comprehensive culture of safety model. On the front cover of this particular issue, you have a photo of CARE Ambulance providers and an Orange County Fire Authority firefighter/paramedic assessing a female patient in an ambulance. Recognizing that a picture is worth a thousand words, I feel the cover demonstrates the lack of embracing the culture of safety, although not intentionally. In the picture, one of the CARE personnel is standing unrestrained while trying to take a patient’s blood pressure. The patient is also lacking the shoulder restraint belts that all major stretcher manufacturers say are necessary for proper safety. Through the windshield, you can see what appears to be a red stop light centered, making me think that this is an ambulance that is in traffic and not sitting at a scene. Even if stopped at a light, the medic should be securely seated and restrained. The help I am asking for is a simple request. Please have your staff review photos, particularly those on the cover, from an “is this what we should be doing?” perspective. illustration steve berry What? Choose 19 at 16 JEMS AUGUST 2012
  16. 16. All the articles and seminars on safety will have a hard time convincing the troops if major influential publications such as JEMS portray unsafe operations as being how we operate. It may seem like a nit-picky point, but if we are really going to change the fundamental thought process in EMS to a culture of safety, we must all embrace it and demonstrate it from the top down. Because JEMS has been the leader in EMS publications since the beginning, I would challenge you and your staff to be the first to implement a culture of safety in EMS publications. Thank you for your consideration, and for providing the industry with a state-of-the-art publication for so many years. Ken Beers Chief, Canandaigua Emergency Squad Canandaigua, New York JEMS Editor-in-Chief A.J. Heightman, MPA, EMT-P, responds: We appreciate your comments and concern over the June JEMS cover photo. This was a carefully pre-planned and executed static photo shoot conducted in Orange County, Calif., under the watchful eyes of the medical director and supervisors from the Orange County Fire Authority and CARE Ambulance, two respected, professional EMS agencies. This photo was taken in a stationary “at scene” ambulance positioned in the ambulance bay at an Orange County fire station, not in a traffic area. We should have presented that information on the “About the Cover” area on the table of contents. We understand that without that information you and others could have perceived this was an actual patient in an ambulance en route to a hospital. JEMS embraces a culture of safety in EMS. We make every effort to portray the “right ways” of performing EMS and admonishing the “wrong ways” and simply did not give enough context to the photo for our readers.  We fully support the efforts underway by National Association of EMTs, the EMS Safety Foundation, the International Association of Fire Fighters, the International Association of Fire Chiefs, the National Highway Traffic Safety Administration, and other industry leaders to change current behaviors and create a comprehensive culture of safety throughout EMS. We will be more careful in our captioning in the future.  Thanks for reading JEMS with a discerning eye. CORRECTION In June JEMS, “Hot Products” featured 50 of the top, innovative products at this year’s EMS Today Conference and Exposition. Several product descriptions have incorrect photo listings. We’ll be running the correct product photos and descriptions in September JEMS “Hands On.” JEMS Do you have questions, comments or concerns about recent JEMS or articles? We’d love to hear from you. E-mail your letters to or send to 525 B St. Suite 1800, San Diego, CA 92101, Attn: Allison Moen. Choose 20 at
  17. 17. PRIORITYUSE TRAFFIC NEWS YOU CAN Federal Law Addresses critical Drug issues By Doug Wolfberg, Esq; Steve Wirth, Esq; Ken Brody, Esq; Franklin Banfer, RN, EMT-P T he Food and Drug Administration Safety and Innovation Act (Senate Bill 3187) was signed into law by President Barack Obama on July 9. This mammoth bill is designed to ensure both the safety and adequacy of the nation’s drug supply. Three parts of the law that will affect EMS are Title IX: drug approval and patient access, Title X: drug shortages and Title XI: Subtitle D—synthetic drugs. Drug Shortages Nearly half of the drugs on the FDA’s shortage list are administered on ambulances. Many of those drugs are used to treat seizures, cardiac arrests and other life-threatening conditions. Hampered by shortages, EMS providers have used expired or alternative medications, and have been forced to follow modified treatment protocols that don’t represent best practices in patient care. Title X of the new law is designed to reduce drug shortages and improve information sharing regarding certain drugs, including those used in emergency medical care. Manufacturers will be required in most cases to provide at least six months notice to the government of the discontinuance of the production of a drug or interruption in its manufacture. And Health and Human Services (HHS) will now be required to disclose both the discontinuation and manufacturing interruption of critical drugs to all appropriate healthcare providers, including EMS agencies. Also, if HHS determines that there’s likely to be a shortage of any critical drug, it must expedite the review of new drug applications for which doing so would mitigate or prevent the drug shortage. Moreover, if HHS determines that an enforcement action against a manufacturer—who has notified HHS of a discontinuance or interruption in drug production—could reasonably cause or exacerbate a shortage of the drug, HHS is to evaluate the risks associated with such shortage on patients before determining what enforcement measures, if any, to impose. Additionally, the new law calls for a federal task force to develop and implement a strategic plan to enhance HHS’s response to preventing and mitigating drug shortages. A component of the strategic plan will include an evaluation of whether to establish a manufacturing partnership program through which a qualified manufacturer would have the capacity and capability to supply, within a rapid time frame, drugs determined or anticipated to be in short supply. Further, within 18 months after the bill’s enactment, the Comptroller General of the U.S. will be required to conduct a study to examine the cause of drug shortages and make recommendations on how to prevent and alleviate such shortages. Title IX addresses the need for expedited drug approval while maintaining safety and effectiveness standards. EMS providers will be primarily concerned with “fasttrack products” (i.e., a drug that is intended for the treatment of a serious or life-threatening disease or condition) and accelerated approval for such drugs. It remains to be seen how effective this legislation will be in addressing the drug shortage dilemma. The problems can’t be resolved overnight, and implementation of some of the provisions in Title X may need to await the adoption of regulations, which the law requires within 18 months (although many federal agencies often don’t complete the task of issuing new regulations within the time frames established by Congress). Regardless, there’s no “quick fix” for drug shortages that limit treatment options and threaten patient care, but the enactment of this bill is a move in the right direction. Bath Salts Bath salts have had serious implications for EMS. Patients under the influence of bath salts can present with altered mental status, auditory and visual hallucinations, agitation and violence. Subtitle D of Title XI is the Synthetic Drug Abuse Prevention Act of 2012. It expands the list of Schedule I controlled substances. Schedule I drugs include substances with high potential for abuse, no currently accepted medical use in the U.S., and a lack of accepted safety for use of the drug or other substance under medical supervision. Unless specifically authorized, the manufacturing, distribution, dispensing, possession or the intent to engage in such conduct is illegal. The Synthetic Drug Abuse Prevention Act adds bath salts as a Schedule I controlled substance. This means the possession of bath salts will be a violation of federal law. Of course, EMS providers encounter patients under the influence of all sorts of drugs, both legal and illegal, and merely classifying bath salts as illegal drugs will not stop their use. Hopefully, the act will reduce the frequency with which they’re encountered in the field. Like any new massive federal legislation, the new federal drug law will have its share of bureaucratic tangles. However, several provisions of this law promise a new beginning in addressing drug supply problems that have plagued EMS agencies across the U.S. Pro Bono is written by attorneys Doug Wolfberg and Steve Wirth of Page, Wolfberg Wirth LLC, a national EMS industry law firm. This month’s column was also written with the assistance of PWW attorney Ken Brody, Esq., and PWW clinical specialist Franklin Banfer, RN, EMT-P. Visit the firm’s website at Supreme Court Ruling Affordable Care Act intact On June 28, the Supreme Court issued its historic ruling on the constitutionality of the Affordable Care Act (ACA). This ruling moves the country one step closer to the full implementation of the healthcare reform that passed Congress and was Conduct a keyword search for “drug shortage” at for more information 18 JEMS AUGUST 2012
  18. 18. Comprehensive, Credible, Educational... JEMS Products Help You Save Lives. Jems, Journal of Emergency Medical Services Website With content from writers who are EMS professionals in the field, JEMS provides the information you need on clinical issues, products and trends. Your online connection to the EMS world, gives you information on: • Products • Jobs • Patient Care • Training • Technology Available in print or digital editions! eNewsletter Product Connect Sign up now for the weekly eNewsletter. Get breaking news, articles and product information sent right to your computer. Read it on your time and stay ahead of the latest news! 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 Watch live or in the archives! NEW Webcast! Securing the Airway: The expanding role of extraglottic devices August 22, 2012 , at 1 p.m. ET/10 a.m. PT Sponsored by: The role of extraglottic airways is expanding in both the prehospital and hospital setting. These devices have evolved significantly in terms of safety, efficiency, and ease of insertion. In this webcast, Bryan E. Bledsoe, DO, FACEP, FAAEM, will detail evolving changes in prehospital airway management. He will discuss traditional airway techniques, endotracheal intubation and RSI, as well as a detailed discussion of the use of extraglottic airways in the prehospital setting. Register at Go to
  19. 19. continued from page 18 signed into law by President Obama more program within broad federal guidelines. than two years ago. Personal opinions aside, Eligibility for the Medicaid recipients is this ruling will have broad implications for largely left up to the individual states, with dramatic differences among them. everyone in the healthcare industry. The ACA required states to standardIn one of the most watched cases in recent history, the court kept the law largely ize Medicaid eligibility to include everyintact. The most controversial issue was body who has income less than 133% of the regarding the constitutionality of the indi- federal poverty level. For some states, this vidual mandate provision that requires vir- would represent a large increase in covertually everybody who can afford health age, and costs. To ease the financial burden insurance to buy it. In a 5 to 4 decision, the on the states, the federal government will court ruled that the federal government has cover all the costs of the Medicaid expanthe authority to penalize individuals who sion for the first three years and 90% starting in 2020 and beyond. choose not to purchase health insurance.* The Supreme Court ruled that the fedOne of the main goals of the ACA is to reduce the number of U.S. citizens with- eral government can’t withhold Medicaid out health insurance. It does so primarily funding from states that don’t expand their through a combination of requiring peo- coverage. Effectively, this enables states ple who can afford health insurance to buy to decide whether they’ll expand Medicaid, and some have already it, requiring more businesses stated their reluctance to to provide health insurance * There is a nuanced do so. Many experts believe to their employees and dradistinction between whether the penalty falls under the that the Medicaid expansion matically expanding Medicregulation of interstate comis a good deal for the states aid coverage. Medicaid is the merce or a taxing authority. and that state legislatures joint state-federal health covFor all practical purposes, and governors will be under erage for low-income and the court upheld one of the intense pressure from hospidisabled individuals. Each lynch-pins of the ACA. tals, healthcare providers and state administers its Medicaid constituents to use the generous federal funds to cover more low-income people, but politics and ideology are sure to play a role as this plays out over the next few years. Implications for EMS Most experts feel that healthcare reform offers many opportunities for expanded roles for EMS in community healthcare. Reducing the uninsured will increase demand for health services, especially for primary and emergency care. Numerous innovative EMS agencies in the U.S. are learning from international experiences and working to deliver high-quality, cost-effective healthcare delivery models using EMS personnel in expanded roles and unique deployment strategies. For more on advanced practice paramedic programs, read “It Takes a Village,” p. 42. Despite the fact that the Supreme Court ruling affirms the constitutionality of the ACA, the federal and state elections in November are sure to play an important role in how healthcare is delivered in this country for decades to come. —Keith A. Monosky, PhD, MPM, EMT-P QUICK TAKEs photo Heat Wave across the U.S. As temperatures rise across the country, so does concern over the effect of this ongoing heat wave. The National Climatic Data Center reported more than 4,500 record daily highs nationwide in the past month. At least 30 heatrelated deaths have been reported across the country, including 10 in Virginia, where many homes have been without power due to thunder storms. Laura Stokes, MPAS, EMT-P, with Maryland’s Anne Arundel County Fire Department, says, “Since January, we’ve had 51 heat-related calls. [In] June we had 26. And just in the 10 days starting July, we’ve had 19. So we’re already way above what we would expect.” She advises her EMS colleagues to be aware that not all heat-related problems have obvious symptoms and that heat can exacerbate such existing conditions as chronic obstructive pulmonary disease and asthma. David Miramontes, MD, FACEP, the EMS medical director and assistant chief of fire and EMS for the D.C. Office of Fire and EMS, also offered recommendations about dealing with hot temperatures and patient influx. He advises eating foods high in carbohydrates and drinking plenty of fluids throughout one’s shift, but avoiding caffeine. Dehydration due to such diuretics as caffeine and certain medications can be problematic for both EMS workers and patients alike. —Jackie Krah CHICAGO put ems bus in service When Chicago Fire Commissioner Raymond Orozco saw an EMS bus at a conference in Washington, D.C. about four years ago, he knew it would be a helpful asset for the Chicago Fire Department (CFD). And thanks to a grant from the Department of Homeland Security and May’s North Atlantic Treaty Organization (NATO) Summit, it’s now part of the fleet in the Windy City, potentially freeing up some seven to 13 units for major events. Leslee Stein-Spencer, manager of medical administration and regulatory compliance for CFD, wrote the Urban Area Security Initiative grant, which was approved because of (and rolled out for) the NATO Summit. It was officially unveiled to the public on June 15. “We can transport up to 13 non-critical patients to different hospitals,” she says. “We staff it with four paramedics, and if someone took a turn for the worse, we can provide critical care.” Reaction to the approximately $500,000 vehicle has been positive. “Hospitals that oversee our medical license love it. The Allied Department of Public Health, which is our regulatory agency, thinks it is great,” she adds. Medical Director Eric Beck, DO, EMT-P, says, “The bus has advantages beyond transport and mass casualty events. It also has value at larger incidents where an air conditioned base would be desired or for rehab at a large fire.” In the future, Beck says the department is working on obtaining a similar vehicle but with specific resources for burn patients and a large cache of burn supplies. —Devin Greaney For more of the latest EMS news, visit 20 JEMS AUGUST 2012
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  21. 21. LEADERSHIP SECTOR presented by the iafc ems section by gary ludwig, ms, emt-p System Costs What’s the average price tag for an EMS system? W hat does your EMS system cost to operate? It seems like everyone is chasing the golden answer to that question. I know it sounds simple. If you’ve got the answer, e-mail me. Now before you e-mail me, I need to know what your “system” costs you to operate—not just ground ambulances or what your budget is. When I talk about a “system,” I’m speaking about the whole system, which includes communications, first response and transport, and whether it is ground, air or both. Defining EMS Systems Even within my explanation of what an EMS system is, there’s debate. Some think an EMS system is just the ground ambulance costs. Others think it’s the ground ambulance coupled with the first response agency. Still others, like me, think an EMS systems comprises dispatch, the first response agency and ground ambulances. So if we can’t even agree on what an EMS system is, how can you determine its costs? The quandary of trying to determine the true cost of EMS system has evaded EMS managers, consultants and city managers for years. Some of the problems related to determining what your EMS system costs vary from place to place. As the saying goes, “If you’ve seen one EMS system, you’ve seen one EMS system.” Why? The theory is that no two EMS systems are alike. Systems may have the basic foundations of a third service, fire-based, private, volunteer or hospital-based, but they all have nuances. Within those foundations, many systems have such variations as the level of service that might be provided, the size of the service area, response time requirements or the readiness of the EMS system and the cost of compensating the personnel. (Or in some cases, such as with volunteers, there’s no compensation.) 22 JEMS AUGUST 2012 Other Cost Factors Other factors that can affect the cost of an EMS system are its levels of clinical sophistication. Is it an all-BLS EMS system for which first response (if first response is included) is BLS and the ground ambulance transport is BLS also? Or is it an all-ALS system for which every first-response vehicle and ground ambulance has paramedics with ALS equipment? Or is it a combination of BLS and ALS? If there’s ALS within the system, what’s the clinical sophistication of your ALS delivery? Are there aggressive ST-elevation myocardial infarction programs, continuous positive airway pressure, mechanical CPR devices, auto-ventilators, a wide-array of drugs, intraosseous infusions and other levels of clinical delivery? Other things to consider are the population size and economic and poverty levels of the community. Populations and economic conditions of a community affect EMS call volume. Poverty of the community is also a major factor that affects costs. Traditionally, you’ll see higher call volumes in urban areas than in suburban and rural areas. My experience has shown me that an urban community of 800,000 may have 100,000 EMS calls with one in eight people calling for an ambulance during the course of a year, whereas a rural community of 3,000 with only 250 EMS calls may equate to one EMS call for every 12 people. One major factor that makes it difficult to determine an EMS system’s costs is first response. Traditionally, fire departments provide first response in a community regardless of whether the ground ambulance is fire-based or not. But some fire apparatus and firefighters don’t handle medical calls, instead responding only on fire calls, as well as other service calls (e.g., child locked in a car). So the process of looking at a fire department budget and trying to determine a cost-allocation model to figure how much of the fire department is allocated to EMS calls, fire calls and other service type calls can be challenging. Some would even argue that such government costs as the city manager, city attorney, finance manager, human resource manager and others add to the cost of the EMS system because part of their time in government is spent dealing with EMS issues. Another component that makes it difficult to determine an EMS system’s costs is volunteers. Although they generally receive no compensation, their contributions should be factored into operating an EMS system. If it wasn’t for their volunteer status, the money needed to operate the system would be much higher. This makes it difficult to truly measure the labor cost of an EMS system. Conclusion Attempts have been made to determine an EMS system’s cost. An effort by the National Association of EMS State Officials and the Medical College of Wisconsin called the EMS Cost Analysis Project ( designed to create a framework that would determine the cost of providing EMS care from a societal perspective. The framework includes a 12-step tool to determine the cost of an EMS system. Some contend that the framework isn’t complete and still needs additional revisions, but it’s a start. One thing we know for sure is that the reimbursement many EMS agencies receive from Medicare, Medicaid, private insurance and from those who self-pay doesn’t come close to matching the costs of operating an EMS system. JEMS Gary Ludwig, MS, EMT-P, is a deputy fire chief with the Memphis (Tenn.) Fire Department. He has 34 years of fire and rescue experience. He’s chair of the EMS Section for the International Association of Fire Chiefs and can be reached at
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  23. 23. Higher Learning Practice Educational Theories Put into by William Raynovich, NREMTP, EdD, MPH, BS Old Dogs New Tricks Teaching changes in traditional EMS practices I t’s easy to introduce a new drug, device or procedure. EMS responders welcome innovations. It’s also easy to remove drugs, devices or procedures that haven’t shown to be effective. In most cases, you simply taking them off the rigs. Bringing about more subtle changes in practice, however, can result in resistance, resentment and outright rejection. This article is about how to effectively anticipate and overcome resistance to bringing about changes in practice. So let’s discuss how to effectively anticipate and overcome this resistance. EMS has many “sacred cows”—practices that are almost universally considered to be the “gold standards” for care and have been deeply ingrained as the standard of practice for many years. It’s inconceivable to many EMS responders that there could be a better way of delivering patient care. When reflecting on past practices, however, many of the former standard practices that were once thought to be critically important to good patient care were subsequently shown to be useless, or worse, more harmful than beneficial. This article will focus on how an instructor can effectively teach a change in practice that, in effect, reverses one of those “gold standards.” Instructors may face a great deal of skepticism, resistance and, often, outright hostility. Still, it’s “the job” of the EMS instructor to effectively deliver the new practice recommendations. The Theory L mastery as a provider, no matter how well founded in theory and practice, can be barriers to learning.4 For example, experienced practitioners or educators may have accurate but insufficient prior knowledge. This can occur if they’re technically excellent at performing the skills but they lack theoretical understanding of the underlying pathophysiology or mechanics of how the procedure or medication works was never learned at depth or was forgotten over several years. The experienced EMS responders may also have inappropriate or erroneous knowledge based on prior theories that have evolved to newer thinking. TBF began by developing a self-contained Train-the-Trainer course that would be delivered in the traditional classroom setting.6 The TBF instructors received a comprehensive training manual, instruction provided by a nationally recognized EMS educator and peer, a complete package of the scientific evidence and rationale for the change in ventilation, and lesson plans and support materials (e.g., instructor notes for slides and workshops, new algorithms, guidelines for instruction to each EMS provider level, sample scenarios, quizzes and cases, ventilation rate exercises, procedure algorithms, and pre- and post-tests). Such an impressive, well-designed and expertly presented course provided instruc- tors with convincing evidence of the benefit of the new ventilation recommendations and extensive resources to present the instruction to their regional EMS communities. The change in thinking about care of TBI patients moved quickly in the industry. The TBF initiative, however, was supported by a respected national organization that had substantial federal funding. Individual instructors who want to accomplish this type of change on their own are unlikely to have that level of funding, nor the capability of producing such comprehensive courses, evidence, experts and support materials. Thus, the instructional goal at the local level is to deliver training on the new protocol or procedure within the Photo asting learning can’t take place when barriers are raised.1–3 Instructors must be 100% invested in the instruction and prepared to convey the information with authenticity and commitment. Half-hearted and begrudging deliveries, with facial gestures and wisecrack comments, will only result in mockery and wasted time. Instructors should also understand that extensive EMS experience, education and How do you teach the old dogs in EMS new medical “tricks?” The practice I n the early 2000s, the Traumatic Brain Foundation (TBF) started a reversal in the way patients with traumatic brain injury (TBI) were ventilated. The long-standing, “logical” and universally established way of ventilating patients with suspected herniation of the brain was to hyperventilate them.5 The current recommendation is to limit the depth and rate of ventilations in the adult to no more than 20 breaths per minute to avoid hyperventilation. The TBF’s approach to reversing the practice serves as an effective model for bringing about a revolutionary educational change. 24 JEMS AUGUST 2012
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  25. 25. Higher Learning continued from page 24 constraints of a refresher course, a routine continuing education session or through other some other medium. Individual Approach To teach changes in procedures that have been thought to be highly effective for years, the instructor needs to first become thoroughly knowledgeable about the changes and develop a deep rationale for them.. This step is essential because the skeptical learner will sense any doubt the instructor has, and the instructional process will be compromised. The instructor doesn’t need to work in isolation. It’s best to begin by assessing the receptivity for the new recommendation through casual conversations. The discussion should focus on the risks and benefits of the new recommendation and the underlying rationale. A major “prior knowledge” barrier to overcome is the powerful anecdote. That’s prime face evidence, or evidence which appears so logical and obvious that it is undeniable. In fact, prime face evidence underlies most of the practices of prehospital care, as well as most medical practices today. There will likely be a number of instances for which the well-established, “effective” procedure has “saved patients.” Those anecdotes are difficult to counter, especially when the recommendation is based on weak clinical trials with complex statistical analyses that are difficult to comprehend. Still, the anecdote can’t hold up as the “best evidence” when compared with randomized and blinded clinical trials that have been independently validated by other respected researchers. The point is that the statistical clinical research evidence must be presented in a clear and understandable way. One way to overcome this barrier is to approach a statistician at a local university, or even correspond by e-mail or telephone with the authors and researchers who published the articles. They can help to explain the results in clear language that will make sense to everyone. Instructors should acknowledge the beliefs in the effectiveness of the traditional practices and address them head on with the new evidence (research studies), analytic arguments (critical thinking) and an appeal to keep an open mind.1 After the instructor has taken the initial steps to gain thorough knowledge about the new recommendations, they can begin to plan ways to deliver the instruction effectively. EMS instructors can use several core principles to deliver the recommended practice changes when anticipating resistance. Consider using the following approaches: reparation (nothing is more imporP tant than solid preparation); Expert presenters (e.g., having a nationally recognized educator present in person, and when not available, possibly presenting remotely by using a DVD, YouTube or Skype); vidence (e.g., handouts with source E citations, abstracts, original articles, and expert interpretations and opinions); resentation materials (e.g., videos, P PowerPoint presentations); ase presentations (ideally, real cases C for which the proposed treatment would have made a difference in the outcome and the established method was either ineffective or harmful); orkshops (opportunities for applied W practice sessions, which are ideal for reinforcing the theory and cognitive learning); and uizzes (having the learners acknowlQ edge the new practice by marking the “correct answers” on the quizzes will not only validate the instruction, but will also imprint the commitment to the learner as the quiz is taken). Instructors can use several other subtle ways for instructors to make a lasting impact. Silence. Learning is most effective when the environment, the body and the mind are silent. In this context, the “silence” is really a state of mind. Outside distractions and preconceived ideas are set aside, and the collective minds are prepared to receive the new information. To clear the mental clutter, the instructor can begin by “resetting” the minds of everyone in the room with an icebreaker or an amusing anecdote or joke. Lighthearted videos are especially effective introductory approaches for resetting the minds in the room to be ready to learn. Von Restorff effect. Another way to lower tension and open minds for learning is to make it fun, new and dynamic.7 Instructors should be imaginative and search for ways to be innovative, engaging and amusing when presenting the new recommendations. The overall effect will be greater, and the students will remember the material longer. Poetzel effect. The instructor can use subliminal influences to have instruction taking place without direct mental engagement.8 In the Poetzel effect, the instructor might “seed” the environment with posters or displays that depict the procedure, drug or device. A video about the recommendation can be playing as the students enter the classroom. The instructor can start with stimulating casual discussions about the changes. Conclusion It’s an honor and a privilege to teach EMS. EMS is powerful because it makes a difference between life and death, recovery and health or permanent disability after illnesses and accidents. It’s disconcerting when practices that were held to be highly effective are proven to be harmful or ineffective. Worse, it seems that if one practices EMS long enough, the “old ways” return in cycles. Thus, the challenge of presenting new and radically different treatment recommendations is one that must be met with dedication, commitment, deep knowledge and understanding, and savvy educational mastery. JEMS William Raynovich, NREMT-P, EdD, MPH, BS, is the associate professor for EMS education at Creighton University in Omaha, Neb. References 1. Bridges W: Managing Transitions: Making the Most of Change. Harper-Collins: New York, 1991. 2. Newcomb T, Hartley E: Readings in Social Psychology. Henry Holt and Company: Troy, Mo., 1947. 3. Schein E: Process Consultation, Vol. 2: Lessons for Managers and Consultants. Addison-Wesley: Reading, Mass., 1987. 4. Ambrose S , Bridges M, DiPietro M, et al: How Learning Works: Seven Research-Based Principles for Smart Teaching. Jossey-Bass: San Francisco, 2010. 5. New York State Department of Health. (2008) Statewide Basic Life Support Adult Pediatric Treatment Protocols EMT-B and AEMT. In Scribd. Retrieved July 5, 2012, from 6. TBF (2005). Prehospital Management of Traumatic Brain Injury Instructor Course. 7. Smith A: Keys to Student Mastery of EMT Training. National Association of EMS Educators: Pittsburgh, 2010. AUGUST 2012 JEMS 27
  26. 26. TRICKSour patients ourselves OF THE TRADE caring for by Thom Dick, EMT-P Psych Transfers Know how to deal with these types of patients 28 JEMS AUGUST 2012 Photo Thom Dick W hen was the last time you attended a talk on psychological transfers? How about the last time you ever even heard of such a talk? I can’t even guess how many hundreds of times I’ve personally transferred people with behavioral issues between facilities in the middle of the night. There was a raging value conflict in those days between people who had fought for their lives in World War II and their children, who were being forced to fight for something much more nebulous in a faraway place called Vietnam. It was also a time of widespread use of amphetamines, barbiturates, narcotics, cocaine and a whole array of psychogenic substances. When we transferred those folks, it was standard practice for the discharging facility to seal the transcript before they gave it to us. And, standard practice for us not to open it—or else. You’ve probably heard there’s a recession, Life-Saver. I don’t know if you’re seeing what we’re seeing, but we’re seeing a lot of angry, scared and disoriented people, beset by circumstances they didn’t necessarily create. Our little town’s behavioral emergencies have increased 100% since 2008, while our community hospital’s emergency department (ED) has one psych bed. One. So once more, our crews are transferring lots of psych patients. Behavioral emergencies can be simple, or they can be immensely complex. You don’t have to be a genius to understand that scared people can be very dangerous just because they’re scared. They can suffer from the effects of external factors that have nothing to do with medicine, like the loss of a job, a home and a car. Throw in a divorce, all in the span of a year, and you can expect them to be devastated. They’re the ones who need your kindness as much as anything. Others suffer from internal factors, such as imbalanced chemicals in their brains. In the span of a one-hour transfer, you likely don’t have the wherewithal to assess or alleviate those kinds of problems. I think you deserve to know everything the Don’t hesitate to physically restrain anybody who triggers your Spidey-sense. Restraints don’t have to be painful or even uncomfortable. When you use them, incorporate all the cot’s safety straps. discharging facility knows about any patient for whom you accept responsibility. You should definitely read the transcript before you even meet the patient. It should describe circumstances, suicidal risk, flight risk, medications and behavioral history prior to and during their stay in the ED. (If it doesn’t, you should ask and expect a straight answer.) You also deserve to know whether they’ve been treated with physical or chemical restraints prior to your arrival. One of the best things about being with JEMS for some 30 years is I’ve met a lot of wonderful people. Aside from having a fine name and spelling it properly, Thom Dunn, PhD, is one of them. Thom is not only a seasoned medic, but he’s also a licensed clinical psychologist. A couple of years ago, he gave the only talk I’ve ever heard on psych transfers (and behavioral emergencies in general). You may not have ready access to Thom’s work, but you can access a great article he published on the subject in 2008 at www. 1 It’s full of practical suggestions that could only have come from someone who has handled his share of these potentially high-risk calls. Thom’s suggestions include the following and numerous others: Dispatchers and supervisors should choose experienced crews, not neophytes, to transfer patients with behavioral issues; patient who presents in A physical restraints should stay in physical restraints; sk every patient in advance: Are you A planning to harm us or try to escape? Warn every patient in advance: Touching the buckles will be perceived as an ominous behavior; physically restrained patient’s hands A and feet should be kept visible during transport; et into the habit of turning your strap G buckles upside down on the cot. It gives you a few seconds’ extra warning if a patient acts to unbuckle them; atch the patient’s eyes. If you notice W them sizing up your location in the patient compartment, consider the possibility they’re considering an attack or an escape; f you’re wondering whether or not to I physically restrain, restrain; Incorporate the cot’s buckle straps— all of them—into every application of physical restraints; eware of physically restrained patients B who attempt to negotiate their way out of restraints; and xercise special caution any time an E ED staff seems especially anxious to discharge a patient with a behavioral issue. JEMS References 1. Dunn TM. Handle with Care: The challenges of transporting suicidal patients. JEMS. 2008;33(10):86–92. Thom Dick has been involved in EMS for 41 years, 23 of them as a full-time EMT and paramedic in San Diego County. He’s currently the quality care coordinator for Platte Valley Ambulance, a hospital-based 9-1-1 system in Brighton, Colo. Contact him at
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  28. 28. CASE OF THE MONTH DILEMMAS IN DAY-TO-DAY CARE BY Patrick Harvey, MD Risky Anticoagulants Meds have the potential to turn minor trauma into a major disaster Anticoagulants have been on the market for more than 80 years. They’re used to treat a variety of disorders, including atrial fibrillation, pulmonary embolism and acute myocardial infarction. Until recently, the mainstays of treatment have been heparins and Vitamin K antagonists (e.g., warfarin). 30 JEMS AUGUST 2012 heparin for deep venous thrombosis prophylaxis. Despite this variety, these medications are prescribed disproportionately to geriatric patients who are at the greatest risk for bleeding complications.2 Physiology Different classes of anticoagulants target different parts of the body’s normal coagulation pathways. Coagulation works as a cascade Prehospital providers need to be familiar with comwith earlier parts of the system activating monly used anticoagulants and their risk factors. later parts, leading to a positive reinforceSide effects, dietary restrictions and expen- ment cycle. sive monitoring have fueled a search for alterThe final common pathway for all the native agents to these traditional treatments. enzymes is the enzyme thrombin. Once In the past few years, novel anticoagulants activated, thrombin cleaves fibrinogen into have started to enter the American market. fibrin, the main component in the fibrous It’s important for EMS providers to be famil- mesh that makes up a clot. Warfarin and iar with both old and new anticoagulants and other Vitamin K antagonists block function their implications for triage and treatment of of upstream enzymes of the clotting cascade, the injured patient. preventing thrombin from becoming active. Heparin activates a thrombin inhibitor, slowing fibrin formation. Newly developed agents Patient Population Anticoagulants have a large and increasing can bind to thrombin, directly decreasing its presence in the American healthcare sys- activity. The mechanism of action has important implications for tem. The number Figure 1: Blood Thinner Card the strategies of reversal of dispensed outpaRed are high risk; patient should go to a of these medications in tient prescriptions for trauma center. the bleeding patient. Warfarin increased Trade Name Generic 45%—from 21 million in 1998 to nearly Implications Coumadin Warfarin 31 million in 2004.1 As for EMS Jantoven Warfarin the above case illusAs the case presenLovenox Enoxaparin trates, the presence tation illustrates, Plavix Clopidogrel of an anticoagulant anticoagulants can Pradaxa Dabigatran on a patient’s medicaturn a low-risk injury tion list can change a into a life-threatening Yellow are potential risk; consult with medical command. minor fall into serious hemorrhagic event. trauma. The patient Anticoagulation is key Trade Name Generic population that takes in the treatment of ASA w/ Aggrenox Dipyridamole these medications many conditions, but Brilanta Ticagrelor varies from a young the focus in prehospital Effient Prasugrel woman on therapeutic and emergency settings anticoagulation for a is often on reversing Persantine Dipyridamole pulmonary embolism these drug’s effects. Plental Cilostazol to a nursing-home resiUnderstanding the Ticlid Ticlodipine dent on subcutaneous mechanisms of action Figure Courtesy Victor Berg Anticoagulants Photo A 76-year-old woman slips and falls while walking through her home. She sustains a minor laceration to her forehead. Her daughter, who is with her, calls 9-1-1. At the scene, you find her alert, reporting pain only at the site of the laceration. She and her daughter report no loss of consciousness. Her medical history is significant for hypertension and atrial fibrillation. The daughter hands you the medication list, which shows Toprol XL, Pradaxa and Colace. Vital signs are unremarkable, and her Glasgow Coma Scale (GCS) score is 15. Her finger stick blood sugar is 98. An 18 g IV is placed in her right anticubital vein. You elect to take to her to a nearby community hospital. En route, she becomes agitated and attempts to pull out her IV. After you arrive at the hospital, the staff gives her 1 mg of Ativan via IV to help with agitation. A computed tomography (CT) scan of her head shows a traumatic subarachnoid with an overlying moderately sized subdural hematoma. After the patient is out of the CT scanner, she becomes more combative, and her GCS deteriorates to an 8. She’s immediately intubated for airway protection. The patient is given fresh frozen plasma (FFP), prothrombin complex concentrate and activated Factor-VII in an attempt to stop the bleeding. The community hospital doesn’t have neurosurgical capabilities, so the patient is transferred to a trauma center. At the trauma center, she’s taken to the operating room. Unfortunately, a post-op head CT scan shows brain herniation. She doesn’t awaken, and her family withdraws her life support two days later.
  29. 29. Types of Agents Warfarin Initially discovered in naturally occurring sweet clover, warfarin and other Vitamin K antagonists inhibit the formation of Vitamin K-dependant clotting factors II, VII, IX and X. As the first effective oral anticoagulant, warfarin has gained wide use and popularity. Its narrow therapeutic window and many drug and dietary interactions make it a cumbersome medication to manage. Bleeding is a major concern with warfarin therapy. After insulin, warfarin is the most common drug implicated in the U.S. emergency department visits for adverse drug events.1 Its ability to inhibit all aspects of the coagulation cascade can make relatively minor vascular injuries life-threatening bleeds. All bleeding patients require source control and, if necessary, replacement of blood products. Patients who bleed while they’re on vitamin K antagonists also need to take exogenous vitamin K and fresh frozen plasma (FFP) to reverse their coagulopathy. Heparin Used commercially since the 1920s, heparin is a naturally occurring sugar polymer. Medical heparin ranges in size from 5,000 to more than 40,000 daltons. Heparin activates antithrombin III, a potent inhibitor of thrombin and other coagulation proteins. Low-molecular weight heparins (LMWHs) are purified polysaccharide chains that weigh less than 8,000 daltons. They can be given subcutaneously less frequently than traditional heparin, making them useful in bridging patients to Coumadin or for patients who can’t tolerate oral agents.2 The most common LMWHs in the U.S. are enoxaparin (Lovenox) and dalteparin (Fragmin). Heparin can be reversed with the peptide molecule protamine sulfate. This positively charged molecule will bind to and inactivate heparin. The protamineheparin complex is then removed from the body. Low molecular weight heparins are also typically reversed with protamine. This antidote is less effective for LMWH, however. Protamine reverses only about 60% of the anticoagulant activity of LMWH, leaving significant amounts of active agent in the body.3 Dibigatran Marketed as Pradaxa, dibigatran etexilate is the first orally available direct thrombin inhibitor in the American market. It’s been investigated for use in prevention of deep venous thrombosis (DVT) after orthopedic surgery, treatment of DVT and prevention of stroke in patient with atrial fibrillation. It has predictable pharmacokinetics that allow for twice-daily dosing without regular lab monitoring.4 Despite the predictable dosing, bleeding has become a major concern with this drug. Currently, no reversal agent for dibigatran exists, which raises concerns about treating severe bleeding. Such traditional reversal agents as FFP or prothrombin complex concentrates (PCC) aren’t thought to be effective at reversing this agent for these agents is important because the target of a particular anticoagulant will determine the best strategy for its reversal. Caring for a bleeding patient who has been anticoagulated can be complicated, often requiring various blood products and reversal agents. In the case of some of the newer anticoagulants, these reversal measures may not be effective, placing increased emphasis on early and effective source control and adequate supportive measures. It’s imperative that prehospital providers be familiar with the commonly used antico- because they don’t have sufficient amounts of thrombin to replace the depleted stores. Dialysis has been discussed as a possibility to reverse bleeding complications. It’s estimated that up to 60% of the drug can be removed from the body using hemodialysis.5,6 Currently, treatment of bleeding while on dibigatran focuses on stopping the drug, source control and supportive care. The drug company that makes dibigatran, Boehringer-Ingelheim, has confirmed that there were 260 fatal bleeding events worldwide between March 2008 and October 31, 2011.7 The Food Drug Administration is currently reviewing the safety concerns of Pradaxa in light of these data. Future Therapies Based on proteins isolated from leeches, rivaroxaban and apixaban inhibit factor Xa. Marketed as Xarelto and Eliquis respectively, these medications have been approved for prophylaxis of DVT in Europe. Phase III clinical trials are currently underway in the U.S. for prevention and treatment of DVT. In small studies, these agents have been show to be effectively reversed by PCCs.8 References 1. U.S. Department of Health and Human Services. (Aug. 16, 2007). FDA Approves Updated Warfarin (Coumadin) Prescribing Information Events. In U.S. Food Drug Administration. Retrieved Feb. 2012, from PressAnnouncements/2007/ucm108967.htm. 2. Lee A, Levine M, Baker R, et al. Low-molecular-weight heparin versus vs. a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer. N Engl J Med. 349(2):146–153. 3. Warkentin T, Crowther M. Reversing anticoagulants both old and new. Can J Anaesth. 2002;49(6):S11–S25. 4. Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009;361(12):1139–1151. 5. Lichtman M, Beutler E, Kaushansky K, et al. Williams Hematology, 7th Edition. McGraw-Hill, New York: 261–271, 2006. 6. Eisert WG, Hauel N, Stangier J, et al. Dabigatran: An oral novel potent reversible nonpeptide inhibitor of thrombin. Arterioscler Thromb Vasc Biol. 2010;30(10):1885–1889. 7. U.S. Department of Health and Human Services. (Dec, 7, 2011). Pradaxa (dabigatran etexilate mesylate): Drug safety communication—Safety review of post-market reports of serious bleeding events. In U.S. Food and Drug Administration. Retrieved Dec. 7, 2011, from 8. Eerenberg ES, Kamphuisen P, Slipkens M, et al. Reversal of rivaroxaban and dabigatran by prothrombin complex concentrate. Circulation. 2011;124(14):1573–1579. agulants and their effects on bleeding. Some EMS systems have developed quick reference cards to assist providers in identifying drugs that cause coagulopathy (see Figure 1, p. 30). A bleeding or potentially bleeding patient who’s taking these medications should be routed to the nearest facility capable of giving large volumes of blood products, performing hemodialysis and surgically controlling a site of bleeding. JEMS Patrick Harvey, MD, is a senior resident in the University of Pennsylvania’s emergency medicine program in Philadelphia and is active in both prehospital and wilderness medicine. Contact him at Patrick.Harvey@uphs. References 1. Wysowski D, Nourjah P, Swartz L. Bleeding complications with warfarin use: A prevalent adverse effect resulting in regulatory action. Arch Intern Med. 2007;167(13):1414–1419. 2. Hylek E, Evans-Molina C, Shea C, et al. Major hemorrhage and tolerability of warfarin in the first year of therapy among elderly patients with atrial fibrillation. Circulation. 2007;115(21):2684–2686. AUGUST 2012 JEMS 31
  30. 30. RESEARCH REVIEW ems What current studies mean to by David Page, MS, NREMT-P Stay Protected Studies measure safety of stretchers protective gear I n the coming years, as the culture of safety in EMS project continues, we hope to hear much more about patient and provider safety initiatives, and more routine reporting of errors, adverse events and near misses in all areas of EMS. This Oklahoma-based study helps remind us how simple research can be, and how important it is that all EMS agencies participate in it and then report their findings in a peer-reviewed scientific publication. I Stretcher Errors I Goodloe J, Crowder C, Arthur A, et al. EMS stretcher “misadventures” in a large, urban EMS system: A descriptive analysis of contributing factors and resultant injuries. Emerg Med Int. 2012;2012:745706. his retrospective analysis of quality improvement data in a single Oklahoma-based ambulance service covering two cities (Tulsa and Oklahoma City), the Emergency Medical Services Authority (EMSA), reports a low incidence of adverse stretcher events: 23 events in a one-year period when this urban EMS system transported more than 129,000 patients. The authors randomly selected a year to review and analyzed data with their existing error reporting system. The primary reason for adverse events was a failure of the stretcher to “catch” on the hook in the process of unloading a patient. No patients were injured from stretcher errors during this time period. The intent of the project was to establish a good baseline, and I think this study will help accomplish this for Oklahoma. However, I’m not sure how generalizable these results are to other services. Many factors contribute to accurate reporting and a low instance of errors. The authors discuss that a culture of safety and method of tracking errors already existed in this system. Kudos to them for already implementing these practices. Although we have no reason to doubt 32 JEMS AUGUST 2012 Photo courtesy FISDAP T Stretcher errors were analyzed in a recent study on provider safety. their reporting, and this safety record should be commended, I find myself wondering if all near-misses were actually documented. I hope they continue on this great path of safety, documentation and publication of research so we can all learn more. Who will join them in a prospective multicenter study? For more from Jeff Goodloe, read “Attacking Cardiac Arrest,” pp. 52–57. I Protective Clothing? I Bourlai T, Pryor R, Suyama J, et al. Use of thermal imagery for estimation of core body temperature during precooling, exertion and recovery in wildland firefighter protective clothing. Prehosp Emerg Care. 2012;16(3):390–399. A ccurately measuring core body temperature in EMS is one of our industry’s most challenging present day enigmas. As we progress in our knowledge and treatment of sepsis, therapeutic hypothermia and other temperature-related conditions, determining core temperatures has become essential. In this project, the authors report on a tightly controlled, experimental project with high-sensitivity thermal imaging machines. Although this study was small (six wildland firefighters in turnout gear), it took extra care to avoid some of the common problems associated with temperature research. The subjects ingested a pill with a radio transmitter to accurately measure core temperature, and they had skin sensors placed around their faces and other locations. They were pre-tested for fitness ability, and their diets were controlled during the day before the test. They were also precooled by drinking ice-cold slushies (my kind of research). In full turnout gear, the subjects walked at 4 mph for 45 minutes. The authors found a high correlation between thermal imaging temperature
  31. 31. readings from the face and core temperatures during active exercise. The study discussed the theory that the temperature of blood passing along the facial arteries fed by the carotid artery in close proximity of the aorta appear to mirror core temperatures. However, before you run out and borrow a thermal imaging unit from the fire engine in the station, beware: The facial temperatures while at rest and during recovery were not a good match. The units used in the study were the highest sensitivity possible (older units may not be as sensitive). This study had only six subjects and was conducted indoors. I completely agree with the authors when they suggest that larger studies, under more realistic environments (outdoors), are needed before we can render judgment on this technique. If this method of temperature measurement were to work, the potential applications at large sporting events and other mass gatherings, as well as for patients with other illnesses, could be useful. I know someone reading this will be inspired to try it, so be sure to get institutional review board approval and make it an official study you can publish. We want to know what you find. JEMS I watch box I Photo Fernandez A, Crawford J, Studnek J, et al. An investigation of the association between extended shift lengths, sleepiness, and occupational injury and illness among nationally certified EMS professionals. 2012 SAEM Abstracts;S66. Stay tuned for the full paper from Fernandez and the co-authors. This abstract was presented at the recent Society for Academic Emergency Medicine meeting. The authors used the National Registry of EMTs Longitudinal EMT Attributes and Demographics Study to see if there is a link between extended shift lengths, sleepiness and occupational injury. Answer: Yes. In this large survey that included the Epwroth Sleepiness Scale (ESS), ambulance crashes, missed work due to occupational injury or illness and needle sticks, it appears that 17.5% of respondents (186 out of 1,078 surveyed) experienced an occupational injury or illness within the past year. Working less than or equal to 24-hour shifts was more than one and a half (odd radio of 1.72) times likely to be associated with injury or illness. Sleepiness was also a factor. Does this mean the death of the 24-hour shift? I'll wait for the full paper to draw any dramatic conclusions, but this should cause all of us to give serious thought to how much rest we get and how many hours we work in a row. Visit for audio commentary. David Page, MS, NREMT-P, is an educator at Inver Hills Community College and a paramedic at Allina EMS in Minneapolis/St. Paul. He’s a member of the Board of Advisors of the Prehospital Care Research Forum. Send him feedback at Choose 25 at
  32. 32. By Paul E. Pepe, MD, MPH, Sandra M. Schneider, MD Why EMS should should be timely, thorough cautious in implementing new approaches to patient care F or the past four decades, the evolving medical discipline of EMS has had its demonstrated successes in many communities worldwide.1–7 Not only has there been a documented lifesaving effect, but many EMS therapies also have been used to diminish morbidity and discomfort for our patients through earlier intervention.8–10 At the same time, in our well-intended attempts to provide prompt and aggressive care for our patients, we have also applied practices that, inadvertently, may have been detrimental for our patients or simply not effective.11–32 In some cases, many interventions that could clearly be lifesaving have been used too zealously or have been provided either too early, or simply too late, leading to a negative effect.13,14,16–18,26 In other cases, we haven’t used the procedure properly. As a result, we were unaware of the resulting ineffectiveness and subsequent loss of a potential lifesaving outcome.12,16,33–39 In many circumstances, based on available data, these detrimental practices were considered standards of care and accepted by the majority of practitioners.17,22,27–31 In other cases, it was a poor understanding of how system configuration can lead to a lessthan-optimal result.12,29,30 Fortunately, the ever-evolving EMS focus on “research” and the surrounding emphasis on scientific investigation in the prehospital setting has led to a better understanding of what EMS can and should do for our patients.32,40 The results have saved thousands of lives, raised the stature of the EMS practitioner in the 34 jems AUGUST 2012 house of medicine and increased the value of EMS in the public eye.31,32, 40–42 Most importantly, in many cases, the research effort itself saved lives. Even when the scientific investigations revealed that seemingly logical practices were actually harmful, the study process itself has generally led to improved survival chances over the pre-study levels—for both study and control groups.31,32 This article will provide historical (and even some current) examples of detrimental EMS practices and how we’ve identified and attempted to retool those practices. It will also attempt to provide future considerations for EMS practices while also providing caveats and cautions regarding the limitations of “gold standard” research and how to temper “evidenced-based medicine” with an ever-watchful eye. Revisiting the ABCs Since the origins of EMS practice, airway, breathing and circulation (the so-called “ABCs” of resuscitation) have been heralded as the basics of emergency care. For practitioners, both in the in- and out-of-hospital settings, endotracheal intubation (ETI) is still considered the definitive airway.43 It’s provided not only to better ensure adequate oxygenation and ventilation (carbon dioxide elimination), but also to protect the airway from rapid edema formation (e.g., in burns and inhalation injury) or aspiration of blood or gastric contents.43 In that sense, ETI has traditionally been part of the clinical portfolio for prehospital care personnel.1,2,7,12,43,44 Although it should correlate with a worse outcome (the sickest or most injured patients are the usual recipients), some studies have correlated ETI with good outcomes.7,44–46 However, research initiatives over the past two decades have suggested a detrimental effect or, at the least, no significant advantage, to prehospital ETI, including a controlled clinical trial in a pediatric population.13,15,47–51 Growing sentiment, including standards for cardiac resuscitation, have de-emphasized EMS use of ETI.34,47,52 Nevertheless, the problem may not be the tube, but the way in which it’s used, including prehospital practitioners being facile at placement and their ensuing techniques of providing ventilatory support once ETI has been performed.12–14,16,29,30,48,53–55 The earliest EMS ALS systems were staffed by a core team of skilled physicians or a limited cadre of paramedics whose response deployments were triaged and focused primarily on the relatively smaller group of critically ill patients.1,2,12,29,30 In turn, skill use was frequent and, accordingly, ETI was routinely successful and performed rapidly.2,12,29,30 In the U.S. and many other locales, however, a popular philosophy evolved in the 1970s: More paramedics in a system would provide patients a closer proximity to “advanced” prehospital care. Unfortunately, this deployment strategy also created a dilution of skill use for individual paramedics.29 With a larger pool of advanced providers who must compete for the opportunity to attempt ETI among the relatively small number of patients who require the procedure, skills experience is much less frequent. This dynamic
  33. 33. AUGUST 2012 JEMS 35
  34. 34. Primum Non Nocere continued from page 35 predictably has been associated with less facile, failed intubation attempts in the majority of EMS systems.12,29,50 Nevertheless, even when prehospital practitioner performance of ETI is facile and they can rapidly achieve successful tube placement, the procedure may actually lead to more harm if the practitioners’ ventilatory practices are improper.12–14,16 In many venues, prehospital providers have been demonstrated to overzealously ventilate the patient once an ETI has been placed.13,37 Even relatively controlled ventilation (tidal volume and rate) with positive-pressure breaths can have a profound deleterious effect, especially in the bleeding patient who has experienced significant IV volume loss.13,14,16,37,48,54,55 Even if provided infrequently (i.e., five or six per minute), positive-pressure breaths can maintain adequate oxygenation and ventilation in such fragile patients—and even be correlated with improved outcomes.14,16,44,56 However, even so-called “normal” rates of ventilation can be relatively harmful and are likely to be lethal in extremis conditions.7,13,14,16,54–56 Normal breathing is generated by the diaphragm and other respiratory muscles. The lungs are “pulled open” by creation of a relative vacuum in the thorax. This “negative” intra-thoracic pressure sucks air into the chest and enhances venous return to the heart by also drawing more blood into the chest.16,57 In contrast, providing breaths delivers positive pressure to “push” the lungs open. This creates higher than normal intrathoracic pressure, inhibiting venous blood return back into the heart.12,14,16,54,57In most normovolemic adults with normal blood pressure and lung function, this intermittent positive pressure, if not given too frequently, is tolerated without observable clinical effect. However, if the patient has a significant degree of relative hypovolemia (e.g., severe hemorrhage, dehydration and sepsis) or obstructive lung disease impairing the outflow of air, the effect of positive pressure can be dramatic and likely detrimental to outcome if breaths are delivered frequently (e.g., greater than five to six per minute).12,14,16,54,57 Also, in general terms, in low-flow states, “ventilation should match perfusion” (impaired blood flow should be matched with constrained ventilation and CPR is certainly a very low-flow state until normal blood pressure is restored. 36 JEMS AUGUST 2012 Therefore, although ETI may often be an appropriate intervention in the prehospital setting, it also can be detrimental if the system isn’t designed to enhance skills for the practitioners and if the EMS providers aren’t controlling the ventilations properly.12,16.29,30,53 For similar reasons, more current consensus guidelines have supported a renewed focus on minimally interrupted chest compressions and de-emphasized rescuer ventilation altogether in sudden-onset (non-traumatic) cardiac arrest cases.34,35,52,57 In addition to inhibition of circulation by positive-pressure ventilation, there’s another concept of concern. therapies are discovered that require deliberate and controlled CPR interruptions (e.g., stutter re-perfusion concepts) to diminish reperfusion injury.59 The key determinant for return of spontaneous circulation (ROSC) is adequate coronary artery perfusion pressure (CPP) without interruption.16,17,34,35,38,39,57 Current studies show that CPP rapidly falls off when hands come off the chest, and it takes many seconds to build up the pressure head again.35,36 Accordingly, if one stops for too long an interval (and too often) to provide rescue breaths, pulse assessments or a shock, the average CPP calculated over a minute (aka, the “minute CPP”) is dramatically diminished and, thus, the resuscitation efforts generally become incompatible with ROSC.35,36,57,58 On the other hand, if compressions are maintained without interruption, a reasonable minute CPP may be maintained, increasing the chances of ROSC and survival with intact neurological status.17,35,36,57,58 In short, the well intentioned and intuitive concept of providing lots of oxygen to a patient who isn’t breathing normally may be more harmful than helpful.16,17,35,37,57,58 At the same time, following our latest mantras with chest compressions, such as “push hard, push fast” and “don’t interrupt,” may also be detrimental if compressions are applied much too fast or if new promising load, but the relatively slower expulsion of the delivered tidal volume in patients with obstructive lung disease also leads to residual positive-pressure retention at end expiration (i.e., throughout the entire respiratory cycle).52,54,55 The resulting intrinsic positive end-expiratory pressure (PEEP) can impair successful resuscitation, particularly when ROSC would have occurred had ventilations been markedly reduced in frequency.55 Likewise, as previously noted, the effect of even “normal” respiratory rates can be detrimental to those with severe intravascular hypovolemia, such as a hemorrhaging trauma patient.14,16,48 EMS providers have also faced problems with well-intended and intuitively logical attempts to return systemic blood pressure (SBP) to “normal levels” in trauma patients.11,20,22,60–62 Following the publication of improvements in outcomes using experimental hemorrhage models in the 1950s and ’60s, it became standard of care to reverse systemic hypotension, usually through the use of IV isotonic fluid resuscitation and by starting that fluid infusion in the prehospital setting.60,62 Revisiting Trauma Resuscitation The problems with ETI are more pronounced with certain subpopulations of patients, including those with obstructive lung disease, such as chronic bronchitis, emphysema and asthma, and, as noted above, relative hypovolemia.14,16,52,54,55 Not only does the positive-pressure ventilation have a detrimental effect in terms of inhibiting venous return and cardiac pre-
  35. 35. Another attractive modality to raise blood pressure in hypotensive injury patients was the use of the so-called military (or medical) anti-shock trousers (MAST), also known as the pneumatic anti-shock garment (PASG)— a device that was adopted from military aviation experience with G-suits.20,22 The PASG resembled a large blood-pressure cuff that surrounded both legs and the abdomen. It was definitively shown to raise SBP and was also touted to provide a tamponade effect to underlying bleeding and stabilization of possible pelvic fractures.20,22 By the 1980s, considering its use as a noninvasive blood-pressure elevating device that basic EMTs could employ, the PASG became required by state law in two-thirds of the U.S. as required EMS equipment.20,22 However, no clinical trials had ever proven its effectiveness in saving lives. Empirically, it made sense to use the PASG, but subsequent prospective controlled trials not only disproved the ability of the PASG to save lives, but also suggested the devices were actually detrimental. The well-designed studies showed the elevation of SBP, but there was a pronounced trend toward worse outcomes—particularly in patients with distinct vascular injuries.20,22 This later led to a revisiting of the use of IV fluids to raise SBP in trauma patients.23,27,28 The first controlled trials of preoperative administration of isotonic IV fluids for both hypotensive penetrating and blunt trauma patients (with presumed internal hemorrhage) also showed no distinct advantage and a likely detrimental effect, particularly in those with penetrating injuries.20,27,28,62 In retrospect, the original experimental studies that showed a positive effect of fluid infusion and SBP elevation were conducted in models that had a “fixed” hemorrhage.23,60–62 In other words, the severe hemorrhage had been induced but was then controlled (stopped) before the fluid infusion. In contrast, it’s presumed that internal hemorrhage in trauma patients isn’t yet controlled when fluid infusions are provided in the prehospital setting.20,27,28,62 Based on experimental models of “uncontrolled hemorrhage,” it’s now believed that the provision of IV fluids (or SBP elevation with the PASG) leads to hydraulic worsening of the bleeding, dislodging of early soft blood clots that haven’t yet become fibrinous and perhaps a dilution of residual clotting factors with early fluid administration.23–26 The data suggest that delayed, slower infusions are more optimal, even in head-injured models.26 Well Intentioned but often Disadvantageous Therefore, based on the most current data, many well-intended interventions that were originally thought to be lifesaving in given situations are actually disadvantageous under those specified conditions.20,22,23,24,27,63 These interventions were the standard of care in EMS and were also zealously pursued as critical therapeutic modalities.20,22,61,62 Sometimes the revelation that the interventions could be harmful came through a better understanding of the physiology. In some cases, however, it was also the circumstances or the timing of the intervention that needed closer scrutiny.26,62,63 In essence, the story is more complicated than a simplified question such as, “Are fluid infusions, the PASG, ventilations or ETI ‘elemental’ or ‘detrimental?’” They’re all double-edged swords that can be tremendously advantageous or even outright lifesaving if used properly or at the right time. At the same time, certain beneficial interventions can be deleterious if used improperly or in the wrong settings. In addition, their value may not be appreciated if other confounding variables obscure or mask their effectiveness.16,43 For example, some “gold standard” clinical trials haven’t demonstrated a clear lifesaving effect of interventions that work well in experimental settings.18,19,22,32,65,66 At first glance, these studies may be seen as “definitive trials” and the conclusion drawn that the expense of the device or therapeutic modality isn’t indicated, especially after all the time, money and effort that went into their implementation and eventual publication of the studies.19,65,66 However, it has now been suggested that many so-called definitive trials may have been obscured by unrecognized confounding variables.19,32,67 A good example is the original prehospital trial of “high-dose” epinephrine (HDE) conducted in the prehospital setting.19 HDE worked dramatically well in the laboratory. But no overall clear advantage was found in controlled clinical trials. In retrospect, there was no control for ventilation parameters as part of the protocol.16,37 Also, the protocol didn’t follow the timing of drug administration set in the lab because the HDE was given before defibrillation in the laboratory vs. after defibrillation in the trial.18,19 Subsequently, some of the participating EMS agencies were shown to have previously unrecognized excessive ventilation.16,37 Some now speculate that this confounding variable may have overpowered and masked the effect of the HDE.16 Similar concerns have been raised by some when considering the recent trials of the impedance threshold device (ITD) in cardiac arrest.66,67 The ITD wasn’t demonstrated to be effective in one seemingly well-designed, multi-center trial, whereas a parallel study demonstrated a markedly improved outcome when the ITD was used in conjunction with another device.66,67 It’s unclear whether the ITD required use of the other device (e.g., the active compression-decompression pump) to be effective, or whether it simply was a neutral accompanying modality to the pump’s effectiveness.66–68 As alluded to before, however, other unrecognized variables may have obscured the true effect of the ITD and its actual effectiveness including control of the rate and quality of CPR performed.58,64,65,67,68 Again, timing, proper use and other clinical and system factors need to be considered when judging the value of the devices.32,64,65,68 Regardless of the clinical trials’ results, and even the negative outcomes in some studies, it’s clear that the implementation of clinical trials lead to a lifesaving effect AUGUST 2012 JEMS 37