JOURNAL OF EMERGENCY MEDICAL SERVICES
I Attacking Cardiac Arrest pART ii I
Feedback-driven team performance impacts survival
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
SEPTEMBER 2012 Vol. 37 No. 9
40 I Check the Rhythm I
Expert safe use of adenosine depends on patient’s cardiac status
Corey Slovis, MD, FACEP; Jared McKinney, MD; Jeremy Brywczynski,
46 I gOING oUT ON A lIMB I
EMS provider becomes patient
By Steve Berry
52 I From the School to the Rig I
Enhance EMS preparation using the field training evaluation
By Skip Kirkwood, MS, JD, NREMT-P, EFO, CEMSO
54 I MCI Magnifiers I
Many factors can complicate an incident of any size
By A.J. Heightman, MPA, EMT-P
58 I Survive Thrive I
Current goals obstacles in cardiac arrest
By Brandon Oto
7 I Load go I Now on JEMS.com
12 I EMS in Action I Scene of the Month
16 I From the Editor I It’s all about the Pump
60 I Deadly Dozen I
Dealing with the 12 types of thoracic injuries
By Mark Cipolle, MD, PhD; Michael Rhodes, MD; Glen Tinkoff, MD
y A.J. Heightman, MPA, EMT-P
18 I Letters I In Your Words
22 I Priority Traffic I News You Can Use
26 I lEADERSHIP sECTOR I First Day
y Gary Ludwig, MS, EMT-P
28 I Tricks OF the TRADE I Stealth Mode
y Thom Dick
30 I case of the month I Life Limb
y Travis Polk, MD, Carrie Sims, MD
32 I RESEARCH REVIEW I What Current Studies Mean to EMS
y David Page, MS, NREMT-P
I employment Classified Ads
I Ad Index
I Hands On I Product Reviews from Street Crews
I LAST WORD I The Ups Downs of EMS
About theFire Department and American Medical Response work in a systematic, coordiCover
Crews from Portland (Ore.)
nated manner at all resuscitations. The “pit crew” approach is proving to be a significant factor in improved
resuscitation and return of spontaneous circulation results. For more, read “Attacking Cardiac Arrest, Part II,”
pp. 34–39. Photo Kent Powlowski
Premier Media Partner of the IAFC, the IAFC EMS Section Fire-Rescue Med
8/28/2012 9:17:07 AM
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A Better Way to Learn
This summer, EMS providers across the nation have
responded to several mass casualty incidents ranging from the
July 20 Aurora, Colo., theater shooting that killed 12 and injured
more than 60 to the Aug. 13 College Station, Texas school shooting that killed three near the Texas AM University campus.
Our hearts go out to the victims. But equally important is the
safety of the providers who respond to these types of potentially unsafe scenes. Check out JEMS.com’s major incidents
page for resources on how to be prepared to respond to mass
casualty incidents, such as active-shooter calls.
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What Makes a Good Instructor?
National Association of EMS Educators (NAEMSE) session
speaker Keith Widmeier, NREMT-P, CCEMT-P, BA, identifies
four things that make a good educator. Do you agree?
Is Gun Violence a Social Disease?
Public health experts, in the wake of recent mass shootings, are calling for a fresh look at gun violence as a social
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SEPTEMBER 2012 JEMS
JOURNAL OF EMERGENCY MEDICAL SERVICES
JOURNAL OF EMERGENCY MEDICAL SERVICES
Editor-In-Chief I A.J. Heightman, MPA, EMT-P I firstname.lastname@example.org
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Medical Editor I Edward T. Dickinson, MD, NREMT-P, FACEP
Travis Kusman, MPH, NREMT-P; Fred W. Wurster III, NREMT-P, AAS
Contributing Editor I Bryan Bledsoe, DO, FACEP, FAAEM
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elsevier public safety
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James O. Page
Choose 16 at www.jems.com/rs
JOURNAL OF EMERGENCY MEDICAL SERVICES
JOURNAL OF EMERGENCY MEDICAL SERVICES
William K. Atkinson II, PHD, MPH, MPA, EMT-P
President Chief Executive Officer
WakeMed Health Hospitals
James J. Augustine, MD, FACEP
Medical Director, Washington Township (Ohio) Fire Department
Associate Medical Director, North Naples (Fla.) Fire Department
Director of Clinical Operations, EMP Management
Clinical Associate Professor, Department of
Emergency Medicine, Wright State University
steve berry, NRemt-p
Paramedic EMS Cartoonist, Woodland Park, Colo.
Bryan E. Bledsoe, DO, FACEP, FAAEM
Professor of Emergency Medicine, Director, EMS Fellowship
University of Nevada School of Medicine
Medical Director, MedicWest Ambulance
Criss Brainard, EMT-P
Deputy Chief of Operations, San Diego Fire-Rescue
Chad Brocato, DHS, REMT-P
Assistant Chief of Operations, Deerfield Beach Fire-Rescue
Adjunct Professor of Anatomy Physiology, Kaplan University
J. Robert (Rob) Brown Jr., EFO
Fire Chief, Stafford County, Va., Fire and Rescue Department
Executive Board, EMS Section,
International Association of Fire Chiefs
Jeffrey M. Goodloe, MD, FACEP, NREMT-P
Professor EMS Section Chief
Emergency Medicine, University of Oklahoma School of
Medical Director, EMS System for Metropolitan
Oklahoma City Tulsa
David E. Persse, MD, FACEP
Physician Director, City of Houston Emergency Medical Services
Public Health Authority, City of Houston Department.
of Health Human Services
Associate Professor, Emergency Medicine,
University of Texas Health Science Center—Houston
President, RedFlash Group
Founding Editor, JEMS
John J. Peruggia Jr., BSHuS, EFO, EMT-P
Assistant Chief, Logistics, FDNY Operations
Dave Keseg, MD, FACEP
Medical Director, Columbus Fire Department
Clinical Instructor, Ohio State University
W. Ann Maggiore, JD, NREMT-P
Associate Attorney, Butt, Thornton Baehr PC
Clinical Instructor, University of New Mexico,
School of Medicine
Connie J. Mattera, MS, RN, EMT-P
EMS Administrative Director EMS System Coordinator,
Northwest (Ill.) Community Hospital
Robin B. Mcfee, DO, MPH, FACPM, FAACT
Medical Director, Threat Science
Toxicologist Professional Education Coordinator,
Long Island Regional Poison Information Center
carol a. cunningham, md, FACEP, FAAEM
State Medical Director
Ohio Department of Public Safety, Division of EMS
Mark Meredith, MD
Assistant Professor, Emergency Medicine and Pediatrics,
Vanderbilt Medical Center
Assistant EMS Medical Director for Pediatric Care,
Nashville Fire Department
Thom Dick, EMT-P
Quality Care Coordinator
Platte Valley Ambulance
Geoffrey T. Miller, EMT-P
Director of Simulation Eastern Virginia Medical School,
Office of Professional Development
Charlie Eisele, BS, NREMT-P
Flight Paramedic, State Trooper, EMS Instructor
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
Bruce Evans, MPA, EMT-P
Deputy Chief, Upper Pine River Bayfield Fire Protection,
Jay Fitch, PhD
President Founding Partner, Fitch Associates
Ray Fowler, MD, FACEP
Associate Professor, University of Texas Southwestern SOM
Chief of EMS, University of Texas Southwestern Medical Center
Chief of Medical Operations,
Dallas Metropolitan Area BioTel (EMS) System
Adam D. Fox, DPM, DO
Assistant Professor of Surgery,
Division of Trauma Surgery Critical Care,
University of Medicine Dentistry of New Jersey
Former Advanced EMT-3 (AEMT-3)
Gregory R. Frailey, DO, FACOEP, EMT-P
Medical Director, Prehospital Services, Susquehanna Health
Tactical Physician, Williamsport Bureau of
Police Special Response Team
Mary M. Newman
President, Sudden Cardiac Arrest Foundation
Joseph P. Ornato, MD, FACP, FACC, FACEP
Professor Chairman, Department of Emergency Medicine, Virginia
Commonwealth University Medical Center
Operational Medical Director,
Richmond Ambulance Authority
Jerry Overton, MPA
Chair, International Academies of Emergency Dispatch
David Page, MS, NREMT-P
Paramedic Instructor, Inver Hills (Minn.) Community College
Paramedic, Allina Medical Transportation
Member of the Board of Advisors,
Prehospital Care Research Forum
Paul E. Pepe, MD, MPH, MACP, FACEP, FCCM
Professor, Surgery, University of Texas
Southwestern Medical Center
Head, Emergency Services, Parkland Health
Head, EMS Medical Direction Team,
Dallas Area Biotel (EMS) System
Edward M. Racht, MD
Chief Medical Officer, American Medical Response
Jeffrey P. Salomone, MD, FACS, NREMT-P
Associate Professor of Surgery,
Emory University School of Medicine
Deputy Chief of Surgery, Grady Memorial Hospital
Assistant Medical Director, Grady EMS
Kathleen S. Schrank, MD
Professor of Medicine and Chief,
Division of Emergency Medicine,
University of Miami School of Medicine
Medical Director, City of Miami Fire Rescue
Medical Director, Village of Key Biscayne Fire Rescue
John Sinclair, EMT-P
International Director, IAFC EMS Section
Fire Chief Emergency Manager,
Kittitas Valley Fire Rescue
Corey M. Slovis, MD, FACP, FACEP, FAAEM
Professor Chair, Emergency Medicine,
Vanderbilt University Medical Center
Professor, Medicine, Vanderbilt University Medical Center
Medical Director, Metro Nashville Fire Department
Medical Director, Nashville International Airport
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
EMS IN ACTION
Scene of the month
Photo Rick McClure
MS providers from Los Angeles County Fire Department, American
Medical Response, Bowers Ambulance Service and MedResponse
Ambulance Inc. work together alongside personnel from the Los
Angeles County Sheriff’s Department and California Highway Patrol
to triage 17 people involved in a major vehicle pileup on the Antelope
Valley (14) Freeway. The freeway traverses a mountainous, remote area
in northeastern Los Angeles County. The crash happened on June 26
near the town of Agua Dulce. For more details on how providers managed, treated and transported patients in this complex mass casualty
event, see “MCI Magnifiers: Many factors can complicate an incident of
any size,” pp. 54–57, by A.J. Heightman, MPA, EMT-P.
from the editor
putting issUes into perspective
by A.J. HEIGHTMAN, MPA, EMT-P
It’s All about the Pump
Maintaining the basics is key to effective cardiac resuscitation
Photo A.J. Heightman
t a conference I participated in
recently, Jason McMullan, MD, associate medical director for the Cincinnati Fire Department, made a statement
during a lecture that I want to pass along
because it illustrates the critical importance
of consistent, uninterrupted compressions
and care delivery to cardiac arrest patients.
He pointed out that if his heart were
interrupted in its pumping functions for
even a few precious seconds, he would
experience an interruption in oxygenated
blood flow and pass out.
He also noted that the longer the heart
was allowed to be dormant, the longer the
risk was for bad things to occur and the
more difficult it would become to return
the heart to its essential pumping efficiency
and sustain life. So resuscitation is really
all about the pump: timing, efficiency
I think back to my early days as a paramedic and the infrequent cardiac arrest
“saves” I had. In almost all my successful
resuscitations, someone was performing
effective CPR early, a shockable rhythm was
present, and I was able to rapidly draw the
paddles from my defibrillator and shock the
rhythm while it was primed, well oxygenated
In the wild, wild West days, if a gunfighter
delayed in getting his gun into action, his
chances of winning the battle were less than
50%. The same is true in cardiac arrest resuscitation. You can chuckle about me using those
old-fashioned paddles to shock v fib, but I bet
I can still get my paddles on a patient’s chest
faster than you can dig out, unpackage and
deploy your pre-packaged defibrillator pads.
The point: Technology can sometimes present
delays in care delivery if not performed rapidly and in a consistent, systematic manner.
The September issue of JEMS focuses on
cardiac issues, from our regular content to
the special 32-page EMS State of the Science editorial supplement developed and presented
to you and attendees at the bi-annual Emer-
As with any task, a continuous supply of a fluid and the initial priming of the pump is key to success.
gency Cardiac Care Update (ECCU) Conference in Orlando, Fla.—where the latest
information on cardiac care and resuscitation
will be discussed.
In the supplement, developed in cooperation with the U.S. Metropolitan Municipalities EMS Medical Directors Consortium and
multiple sponsors, we feature a host of key
articles, backed up by 150 pieces of research,
that demonstrate why delivery of resuscitation processes in the field needs to be quickly
administered and, most importantly, consistently delivered.
In addition to the supplement articles, each
of the JEMS articles in this issue presents
significant messages that are important for
you to read, digest and discuss with your
medical director, management team, supervisors, training staff and field crews. Each also
emphasizes important processes or procedures that can increase your efficiency and
effectiveness in the field, particularly in the
resuscitation of cardiac arrest patients and
improvements in return of spontaneous circulation (ROSC).
In “Attacking Cardiac Arrest,” pp. 34–39,
we focus on a systematic approach to resuscitation in the Tulsa and Oklahoma EMS
systems. In “Check the Rhythm,” pp. 40–45,
we discuss the correct and effective use of
adenosine, the drug of choice for paroxysmal supraventricular tachycardia (PSVT) and
for differentiating PSVT with aberrancy from
v tach in patients with monomorphic wide
Like many other potent medications
designed for a specific effect on the heart,
adenosine, if used inappropriately or for the
wrong arrhythmia, can prove fatal.
A thought-provoking question-andanswer session by EMS blogger and writer
Brandon Oto, “Survive and Thrive,” pp.
58–59, rounds out the issue by presenting
multiple important procedures that we currently deploy in the field, or may deploy in
You’ll read several common elements of
cardiac resuscitation in both September JEMS
and the editorial supplement. But the real
take-home message is that the keys to resuscitation are early initiation of each procedure,
limited interruption of compressions and a
pre-planned, systematic approach to everything you do on these critical cardiac resuscitation calls. And remember, success is all
about the effective use of the pump. JEMS
in your words
I work in a dynamic system. Our response times would
be faster, no doubt about it, but only if you have the
correct number of units available to respond. Without a
high level of responders, response times that should take
less than six minutes end up taking 20 minutes.
Also consider the half-life of your employees. Sitting
for 12 hours a day, four days a week in a cramped ambulance isn’t healthy. I’ve seen EMS providers as young as
25 taking blood thinners. Obesity is becoming a real issue,
as well as the ability to pack healthy and efficient meals
for lunch and dinner, which doesn’t help the dynamic
In my opinion, dynamic systems increase response
times by one or two minutes at most. And that system
only works if the provider is staffed correctly. On the
other hand, stations increase the time an employee can
serve his or her community. The question is: Which is
I believe that the trend is to cross-train and diversify. I’m a strong supporter of combo units (a mini
pumper of sorts) staffed with two firefighters, a
police officer and a paramedic personnel. When
this has been tried, it has been very successful, but
only when the system is designed from scratch.
Politics and empires will control change in the traditional departments.
This will allow more units to be used and be capable
of multitasking. It will end aerial ladder trucks responding to sick patient calls. It will deliver 250 gallons of
water with a reel line that can handle most fires if
they’re attacked quickly enough. And it will reduce the
stagnant periods that so many paramedics normally
experience. This means more pay for more skills, more
units for quicker response times and more efficient use
I was so excited to see the front cover of the July issue
of JEMS. I couldn’t wait to read the article. But I was
disappointed to see it was more of an opinion piece that
didn’t tell us anything new.
As far as response times go, they’re never fast
enough. From the information I have, the main response
time is initiating CPR within four minutes of arrest.
Nobody has enough money or the technology to
accomplish this through EMS alone. This is up to the
bystander who calls in. As far as dynamic vs. static
deployment goes, how many people reach the retirement age of 60 with 25–30 years running eight to 12 calls
a day in a 12-hour period?
If a patient can be transported to a hospital within
the same amount of time it takes to do the paperwork
required for a refusal, obtain the two required blood
pressures, call their doctor or go through an on-call nurse
to set up the appropriate treatment plan, the private
ambulance service will choose the transport. Even the
public EMS will choose this because it’s quicker to get
the unit out to handle the call volume of a dynamic
system. You start taking more than an hour on a call
and you don’t transport the patient, and you need more
ambulances on the street to make response times, which
costs more money. Will communities really invest in their
call-takers and call reporting systems?
The catch is that if you don’t dispatch an ambulance right away and the call goes from a low-level
to a high-level response, then you get dinged for not
making the high-level response time because of the
time it takes to go through the entire set of questions. If it takes four to six minutes to go through
the whole questionnaire, then the ambulance is
almost to the scene by the time the call-taker is
finished (at least in the cities). You might as well keep
Bob Farley, EMT-P
Author Jonathan D. Washko, BS-EMSA, NREMT-P, EMD,
responds: Sorry for your disappointment. Unfortunately,
I’m only given so many words and so much space to
express concepts and ideas that quite honestly could
You’re correct in your observation related to the
initiation of CPR and the timeliness associated with
starting effective chest compressions and survival. You
are also correct that few can afford to provide a fourminute response time standard with first response or
You may note in my article I discussed the initiation
of CPR by a variety of methods, the first being dispatch
life-support (DLS). DLS is pre-arrival instructions given
by trained emergency medical dispatchers following
clinical algorithms that provide lay callers the instructions necessary to get care initiated before EMS arrives.
In many communities that embrace this type of system,
Hi Guys. No ambulance needed.
I’m a paramedic and have cleared
my C-spine already.
illustration steve berry
The article featured on the July JEMS cover,
“Rethinking Delivery Models: EMS Industry
May Shift Delivery Methods,” by Jonathan
D. Washko, BS-EMSA, NREMT-P, EMD, garnered a great deal of interest from readers.
What is ‘the new normal’ of EMS, and how do
you embrace it? Also, a JEMS Connect discussion thread about the use of lights and siren
at night generated a conversation among
Facebook fans regarding this hot topic. Do
they do more damage than help?
Watch Steve Berry and JEMS
Editor-in-Chief AJ Heightman tell
you why this book is a must-read!
continued from page 18
pre-arrival instructions save countless lives through the
immediate (within a minute or so of 9-1-1 activation) initiation of lifesaving treatments. My point is that response
times do count in survival and many EMS systems that
have improved response times (although they may not
have published their findings) have also seen correlated
improvements in cardiac arrest return of spontaneous
circulation (ROSC) rates.
The mechanism by which the response time
improves may vary, for example, the use of dispatch
life support or system status management or just adding
more resources into the EMS system or a combination
of these in order to yield improved clinical results. The
point is that systems attempting to achieve this with
traditional deployment methodologies are financially
unsustainable for a variety of reasons.
To your next concern regarding human sustainability,
I agree. Workloads must be balanced in order to provide
not just long-term financial stability but also the stability
of our teams. Unfortunately, dynamic deployment (like
any other tool) can be used for good or bad. It’s how
the tool was used that matters. I know many individuals
in balanced high-performance EMS systems that have
worked their entire careers in the field and love the
work they do.
To your third point, regarding whether private
entities will embrace the concepts associated with
healthcare reform, my answer is that they’ll have no
other choice. As I mentioned in the article, once the
economic conditions change and population-based payments replace fee-for-service payment methodologies,
a shift in how we have to deliver care will take place
driven by market force innovation and the dollars available to provide care. As this shift occurs, our mission in
EMS will also shift toward keeping patients out of the
emergency department and placing them in the proper
locus of care.
Next, you’re correct in your concerns related to
the legal risks associated with triage and care referral
systems versus treating and transporting everyone. It
is evident that the U.S. healthcare system practices risk
avoidance in pretty much everything it does; however, if
we’re to overcome these obstacles, we must shift from
risk avoidance to risk tolerance, and the government will
have to help us accomplish this through reform or some
Finally, your point about performance-based contracting is spot on. Regulators will have to also evolve
and create penalty and reward systems designed around
new goals and objectives. We may also see a shift in the
regulators moving from government-based ones toward
payer-based or provider-based governance models as
their bottom lines.
Lastly, this little known excerpt from Jack L. Stout
addresses many of my critics and is one of the impetuses
that drives me to do what I do every day:
“As EMS providers, we invite the public to literally
trust us with their lives. We advise the public that,
during a medical emergency, they should rely upon our
organization, and not any other. We even suggest that it
is safer to count on us than the resources of one’s own
family and friends. We had better be right. Regardless
of actual performance, EMS organizations do not differ
significantly in their claimed goals and values. Public
and private, nearly all claim dedication to patient care.
Efficient or not, most claim an intent to give the community its money’s worth. And whether the money comes
from user fees or local tax sources, the claim is the same.
Our moral obligation to pursue clinical and response
time improvement is widely accepted. But our related
obligation to pursue economic efficiency is poorly
understood. Many believe these are separate issues.
They are not. Economic efficiency is nothing more than
the ability to convert dollars into service. If we could do
better with the dollars we have available, but we don’t,
the responsibility must be ours. In EMS, that respon-
sibility is enormous—it is impossible to waste dollars
without also wasting lives.”
Use of Lights Siren
Lights for safety on scene ... but if it’s a residence, we
will usually turn them off once we arrive and no sirens
at night in town .... we live in a small rural community
and traffic is generally not an issue.
This issue again ... Sigh. Sadly, we as a profession of caring, are stuck utilizing all emergency signaling devices
to be recognized as an emergency operation. Litigation
against our fellow professionals has consistently found
us at fault when we try to be ‘reasonable’ to the public
and run silent to aid a neighbor. Running silent draws
the criticism that we don’t take the response seriously.
Using the signaling devices wakes everyone up and gets
us tagged as hooligans with no regard for the public. It
is with a wince that I flip the switches and roll using the
signaling devices as the lesser of the evils is not getting
you and your department stuck in a lengthy and costly
litigation should the untoward take place.
David M. Neptune
If the nature of the call merits an emergency response
it gets one. An emergency response means lights AND
sirens, not lights OR sirens. The time of day has nothing
to do with it. JEMS
Do you have questions, comments or concerns
about recent JEMS or JEMS.com articles? We’d love
to hear from you. E-mail your letters to editor.jems@
elsevier.com or send to 525 B St. Suite 1800, San Diego,
CA 92101, Attn: Allison Moen.
interesting FACT ABOUT a photo that ran in our
August 2012 issue
Photographer Kathy Keatley Garvey took this rare photo that won an
international award and has drawn international acclaim on the Internet. It
was named one of the top images of 2012 on Huffington Post and also was
select as “Picture of the Day” on numerous websites. Garvey captured this
image of a bee stinging Cooperative Extension apiculturist Eric Mussen of the
University of California, Davis, Department of Entomology in the apiary of
the Harry H. Laidlaw Jr. Honey Bee Research Facility, UC Davis. What’s unusual
about this photo is that this sting was not a clean break; you can see the
abdominal tissue being pulled out as the bee tries to leave.
Kathy Keatley Garvey is a communications specialist with the UC Davis
Department of Entomology and a former newspaper editor but enjoys taking
macro photos of insects in her leisure time. She also writes a daily educational
Bug Squad blog on the UC Agriculture and Natural Resources website; the
blog, a volunteer blog, has garnered some 3 million hits in three years.
NEWS YOU CAN
Aurora Active shooter
News media prematurely critiques incident
AP Photo/Ed Andrieski
ust after midnight on July 21, moviegoers and responders in Aurora, Colo., were
subjected to real-life horror and chaos
when a heavily armed gunman dressed in full
body armor exited and returned via a rigged
door during a premiere showing of the latest
Batman movie, “The Dark Knight Rises” and
fired on the packed audience. The gunman
killed 12 people and wounded 58 others.
It was a horrific event, complicated by
many factors: the early morning time, a dark
environment both inside and outside the
theater, and the presence of a chemical agent
designed to debilitate the victims and make
easier, less resistive targets. Not to mention
the incident also involved the panicked and
chaotic exodus of hundreds of moviegoers—
many with serious injuries—who fled, in all
directions not only from the fully packed
room, but also into other nearby rooms, hallways and concession areas.
Many horribly injured victims who fled
from a multitude of exits sought help from
the first public safety personnel they could
find. In many cases, the first person of contact
was a police officer. Although EMS and fire
resources were on the scene and still responding, the multitude of factors presented above
didn’t allow for a standard mass casualty
incident (MCI) set up and action plan.
A gag order by the judge overseeing the
legal aspects of this case has limited the
release of information about the incident and
ability of responders to tell their side of the
story. So it’s frustrating to read newspaper
accounts and challenges about the way the
Aurora Fire Department and their contracted
ambulance provider, Rural/Metro Corporation, responded, treated and transported
patients. The local media has been critical of
the seemingly short supply of ambulances
during the first 30 minutes of the incident.
And much has also been written about the
police transporting victims rapidly from the
scene to definitive care.
Any seasoned responder who has arrived
on scene at an MCI knows that even under
Police officers were thrust into a patient transportation role in Aurora.
the best of conditions, a mass exodus of the out to be a key lifesaving effort—as it was
injured and uninjured from an incident can when President Ronald Reagan was shot in
be difficult to manage. Sorting out the injured Washington, D.C. and rapidly transported to
in a dark parking lot and at multiple exit a trauma center in his limousine.
JEMS will report on this major incident
points is a complex task. The rapid transportation of victims from that scene with criti- when appropriate clearances are received.
cal penetrating and exsanguinating gunshot Until then, don’t prejudge our colleagues in
wounds in police vehicles may in fact turn Aurora. —A.J. Heightman, MPA, EMT-P
Defending Their own
The media was critical in initial reports of a slow EMS response of resources to the Aurora shooting,
but JEMS Facebook fans quickly jumped to their defense:
Michael Torchia: We can train for these situations but no two situations are ever the same, and
we’re humans not robots. The press never says, “they did two things wrong but 100 things right.”
Suzi Pierce-Green: I saw where our agencies were on the news saying they practice and prepare
for such an event, and all I could think is NO MATTER how much you prepare it’s a charlie foxtrot and
everyone just does their best. My hat is off to them in the great job they did!
KimiAnn Corey: People need to understand we have a system/protocols we have to follow
for that stuff. There were on scene within minutes, but they had so many patients in the parking lot
bombarding [them] that they couldn’t just bypass.
Bobby Dorrell: You’re not helping anyone if you as a responder get hurt. In a situation like that,
scene safety is the top priority.
Join the conversation at www.facebook.com/jemsfans
Audio from Aurora shooting: www.jems.com/video/news/audio-colorado-theater-shooting
Federal Law Addresses Critical Drug Issues
MS providers are patient
advocates and voices for
the sick, injured, and sometimes, even the deceased.
During such events as the
unfortunate mass shooting at the movie theater in
Aurora, Colo., providers are
often tasked with ensuring
family members and relief
agencies know about the
status of the victims. Thankfully, Health Insurance Portability and Accountability Act (HIPAA) makes the sharing of critical patient information a little easier
during an MCI.
Disaster Relief Entities: HIPAA allows EMS providers to share information about a patient’s location, general condition or death with an agency
that’s authorized to assist in disaster relief
Pro Bono is written by attorefforts. This information can be shared with
neys Doug Wolfberg, Ryan
the disaster relief agency for the purposes
Stark and Steve Wirth of
of notifying a family member, a personal repPage, Wolfberg Wirth LLC,
resentative of the patient or another person
a national EMS-industry law
responsible for the patient’s care. So EMS
firm. Visit the firm’s website
providers can release patient information
at www.pwwemslaw.com for
to such entities as the American Red Cross,
more EMS law information.
a state emergency management agency or
another similar type of entity to enable that organization to contact
someone who’s responsible for the patient’s care.
Family Members and Friends: HIPAA also permits EMS providers to disclose information about a patient’s location, general condition or death
to a patient’s family member, relative, close personal friend or any other
person who might be involved in the patient’s care. Bystanders, however, are a different story. Even if a bystander is truly concerned about
a patient’s welfare, or may have even assisted the patient before you
arrived on the scene, you may not share patient information with them,
unless the patient agrees.
There are two rules that you must follow when providing patient information to relief agencies or family and friends:
1. If the patient is competent and able to make healthcare decisions, you
should first obtain the individual’s agreement to share the information,
or at least give him/her an opportunity to object. The patient’s verbal
agreement is enough. You can also infer from the circumstances that
the patient doesn’t object to you sharing the information. For example, if you ask the patient if there’s anyone you can contact and they
say “my spouse,” you can infer that the patient is OK with giving information to the spouse.
2. If the patient is incapacitated, which is often the case in MCIs,
then providers can disclose patient information if they believe that
disclosure is in the best interests of the patient. HIPAA permits
providers to use their best judgment here in gauging how much
information they should share. Just remember to keep the patient’s
Choose 21 at www.jems.com/rs
continued from page 23
best interests in mind and to not disclose
more than the patient’s location, general
condition or death.
Finally, there’s always the concern about others
overhearing discussions between two crew members or radio transmissions. But these types of inevitable disclosures are called “incidental disclosures”
under HIPAA and generally don’t pose a HIPAA violation. In addition, if it’s necessary to ask a bystander,
police officer, news reporter or other non-medical
person to assist you in treating, moving or transporting a patient in a mass casualty situation, you
may do so.
HIPAA always permits you to share patient information for treatment-related purposes with any
party who’s also involved in the treatment of the
patient. And it isn’t a HIPAA violation to transport
multiple patients in an ambulance or other vehicle.
Sometimes, an emergency simply overwhelms the
available resources, and HIPAA recognizes that incidental disclosures will occur.
All of us at Page, Wolfberg Wirth would like
to express our deepest sympathy for the victims
and everyone affected by the tragedy in Aurora.
We also express utmost gratitude to all of the
responders who answered the call on that fateful
morning, and those across the U.S. who continue to
answer that call every day. We’re honored to represent an industry that’s solely committed to the
care of others in need.
The authors are all attorneys with Page, Wolfberg Wirth, a national EMS law firm. Visit the firm’s
website at www.pwwemslaw.com for more information on a variety of EMS law issues.
As emergency medicine evolves, the National Institutes of Health (NIH) recently opened an Office of Emergency
Care Research (OECR) to bridge research from institute to institute and from academia to institute. At this
time it’s composed of an office of two to three people, a working group of 23 and a steering group of five.
Walter Koroshetz, MD, is its acting director.
“This was the recommendation of a steering committee’s strategic plan to create this office. We want
to be sensitive to all of our institutes,” he says.
After five years of discussion with the NIH and the emergency medicine community, the creation of the
office was announced late in July.
The NIH is composed of 27 institutes, such as nursing, neurology and child health. With the new office,
the many disciplines of research that fall under the huge tent of emergency medicine have the potential to
work together better and become greater than the sum of their parts.
“We all do emergency research. The OECR is a convergence point between those institutes,” Koroshetz says.
Although still in its infancy, Koroshetz is excited about the prospects and will recruit a permanent director. “The time is right. Research in an emergency setting is more feasible now working with a good set of
investigators. —Devin Greaney
For more of the latest EMS news, visit JEMS.com/news
Choose 22 at www.jems.com/rs
presented by the iafc ems section
by gary ludwig, ms, emt-p
ob is a newly promoted EMS manager
who has been hired from another
state to lead an EMS agency. On his
first day, things didn’t go well. He came into
the office and greeted only his secretary and
next in command. People who wanted to
meet him never got the chance because the
second-in-command monopolized his time.
The second and subsequent days went the
same way. Bob never got out of the office.
Soon, word trickled to those working in the
field that the new boss was an unfriendly,
aloof jerk. As could be predicted, everything
went downhill from there.
EMTs, paramedics, and people who
worked in the EMS administrative offices
really didn’t like Bob. He could never
get everybody on board with the
changes he wanted to implement.
People within the EMS organization
became resistant to him, didn’t like
his approach and grumbled about
every policy he issued.
Within six months, Bob was looking for
a new job because he wasn’t happy either.
Within a year, the Board of Directors let
Bob go. What did Bob do wrong? He had
a wonderful track record in his other EMS
organization, and he had a fantastic resume.
What Bob failed to recognize is that if
you’re the new leader of an EMS organization, it isn’t business as usual on the first day
you walk through the door.
recognized by the boss on the first day. Make
sure you meet every employee, acknowledge
them and give them a personal greeting—
from the janitor all the way up to your secretary or the next in command.
When you first enter a new organization
as the new boss, you should remain positive.
If you’re critical of the organization’s current operation—especially if you’re coming
in from the outside—it might not go over
well. People will see it as an attack on their
organization. Even though you’re a part of
the organization, you haven’t been accepted
yet. Such statements as, “We did it this way
where I just came from” may polarize you
and your employees.
Next, I recommend not changing any-
A QI officer would show up at your station
and make you sign the form acknowledging
that you missed something. Quite frankly, it
really pissed people off when the situation
was their 12th trip of the day at 4 a.m. and
they failed to check a box on the patient care
report. It was one of the major things I heard,
and it really seemed to set them off. I failed
to see the significance of the form because it
seemed to make the QI process punitive with
having to sign the form acknowledging you
did something wrong.
So looking for the “low-hanging fruit”
and looking for the chance to set the right
positive attitude being the “new guy” coming in from the outside, I immediately got
rid of the QI form. The response was overwhelmingly positive and upbeat.
The crews were elated with my
decision. They felt I was a good
selection for the organization and
I was going to move the EMS part
of the fire department forward. It
helped me consolidate support for some
of the tough decisions I had to make down
the road with changes that were necessary,
while maintaining high morale.
Make sure you meet everyone,
acknowledge them give
them a personal greeting.
Your First Day
I’ve always seen this as a make-or-break
point. I’ve seen some good people get run
out the door because of the way they came in
the door. Everybody’s going to be watching
what a new manager does and says, as well as
observing how they react to different situations. If you’re a new EMS manager and have
come in from the outside, your employees
will really be watching you.
My first suggestion is to say “hello,”
and meet everyone. People want to feel
important, and they certainly want to be
thing until you learn the works and the
dynamics that make it function. It’s especially important not to change anything that
has to do with the culture of the organization. If your first act is to change the patch or
the name of the organization, expect a tremendous amount of resistance and trouble.
People who are already within the organization have created their identity with the
organization. Although some may grumble, they still take pride in the organization
they’re associated with. Taking that away
from them can only bring you headaches.
When I came to Memphis seven years ago,
I got around and talked to most of
the firefighter/paramedics about the
organization and how EMS operated
in the department. One of the biggest
complaints I heard was about a quality improvement (QI) form that was
issued to everyone from a QI officer if you
missed something on the patient care report.
Being new to an EMS organization is a challenge. If you’ve moved a great distance,
there’s added stress with moving and finding
housing. There’s no need to add to that stress
by taking the wrong approach with your
entry into the organization. Stay focused,
observe and start slow. If you’re successful
with your entrance, you will have an easier
time down the road making the changes you
think are necessary. JEMS
Gary Ludwig, MS, EMT-P, has 35 years of
EMS, fire and rescue experience. He currently
serves as a deputy fire chief for the Memphis
Fire Department. He’s also Chair of the EMS
Section for the International Association of
Fire Chiefs. He can be reached through his website at
TRICKSour patients ourselves
OF THE TRADE
by Thom Dick, EMT-P
Is all this noise really necessary?
Photo Chris Swabb
y state has a law that says if your
emergency warning lights are
on during a response, your siren
needs to be on as well. Always. Most laws
here are pretty sensible. But like so many
things that stipulate “always” or “never” in
this business, this one’s goofy.
There are times when the last thing you
want to do is advertise your arrival or your
intentions in advance. That’s true all the
time in some neighborhoods. And it’s fundamental on interstates, where you pretty
much have to expect other drivers to do
Just for a moment, Life-Saver, put yourself in the mind of the motorist I’m about
It’s close to dusk. You’re cruising home
from work at 65 miles per hour, nodding to
your favorite loud music. Suddenly and without warning, you’re overwhelmed by a pair
of siren speakers that somehow got within
20 feet of your rear bumper. (Yep, that’s way
too close.) In addition, your rearview mirror
reveals a big blue, elliptical Ford sign with a
few inches of a shiny grille around it, and its
silver details reflecting the rhythmic flashers
of—ohmigosh—an ambulance. (How’d that
What would you do? Seriously, would
you have a seizure? Wet yourself? Pull over
quickly and switch places with your frontseat passenger? Slam on the brakes? Speed
up and pull to the right without so much as a
glance for traffic in the adjoining lane? Lower
your window and wave for them to pass?
Flip them off? Or turn up the music and
drown out that awful woop-woop noise?
Even a year of experience should tell you
that if those options were actually offered
on a driver’s license renewal test as multiplechoice answers, plenty of licensed drivers
out there would consider at least a few of
them as viable options.
See, I don’t think most drivers are accustomed to making emergency decisions. And
when they try, they sometimes make errors
Ambulances should go into stealth mode
during the night instead of flooding cities with
in judgment. (At 65 miles per hour even the
smallest errors can have big consequences,
I think of emergency warning equipment
as a tool. And I think its applications are
generally different on city streets than on
interstates. On city streets (at lower speeds),
a siren keeps pedestrians on the sidewalk
and helps an ambulance get people’s attention from behind so you can ask for the right
of way. (Remember it’s ask, not demand.) On
interstates, you use it instead to mitigate
traffic flow once you’ve gotten past other
motorists. But either way, you need the flexibility to choose which kinds of warning
equipment to use in any given situation. (That might include no warning
equipment at all, even during highpriority calls.)
On interstates, the California
Highway Patrol (CHP) routinely
employs the use of no forward-facing
lights and no sirens while they’re en route
to interstate calls. The CHP has known for
years that most drivers can’t hear a siren at
higher speeds until you’re right on top of
them. Most drivers also don’t monitor their
rearview mirrors, so they tend to not notice
those forward-facing lights anyway. Officers concentrate on sneaking through traffic
without startling or scaring anybody. They
try to use their rear-facing lights to advise
drivers in their wake that they’re responding to an incident. That helps them explain
their use of the shoulders, lane changes and
As emergency vehicle operators, it’s
incumbent on us to think for other drivers.
We should be doing no harm, not only medically but also in regard to our emergency
driving. And as you know, we can do a lot
of harm by causing just one other driver
It’s time to abandon our outdated practice
of flooding our cities and interstates with
noise every time we respond to an emergency. It’s time for all emergency vehicle
operators to consider some sort of stealthmode option as a matter of routine, especially on busy interstates. I also advocate one
other thing, and I realize not everyone will
agree with it.
You can usually tell when your warning
equipment is confusing people. When that
happens, your safest option is to shut it
down and advise your communications center that you’re cutting your “code” response
due to traffic. That gives dispatchers the
option of selecting a more appropriate unit
for your call, or at least it tells them you’re
going to be delayed. Delay is an acceptable
option to hurting innocent people.
Especially our own. JEMS
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 firstname.lastname@example.org.
CASE OF THE MONTH
DILEMMAS IN DAY-TO-DAY CARE
BY Travis Polk, MD, Carrie Sims, MD
Tourniquet saves man severely injured in vehicle crash
t’s easy for a current and former military
physician working in a busy urban trauma
center to look around and see the countless advances in trauma care that have been
translated from the military to civilian experience. This month’s case highlights just one
of the many lessons learned from caring for
injured service members.
When a 72-year-old male who was driving
unrestrained in his sedan along the highway
was suddenly struck from behind, he lost
control of his vehicle and it rolled. His left
arm, which was resting in the open window,
Philadelphia Fire Rescue medics arrived at
the scene and found the patient in a large pool
of blood with a severely deformed left arm
dangling by what seemed to be a thin connection of soft tissue. There was profound, pulsatile bleeding. Medics applied a tourniquet
to the arm above the injury and tightened it
until the bleeding stopped. They then immobilized the patient on a spine board, obtained
IV access and administered morphine for pain
control, splinted his arm with blankets as
best they could and transported him to the
trauma center at the Hospital of University
of Pennsylvania as a “trauma alert,” the highest level of activation. The patient remained
hemodynamically stable during the transport.
On arrival, the trauma team quickly completed a primary survey, attached the patient
to monitors, exposed and rolled the patient,
and obtained additional IV access. Initial
vital signs were heart rate=126, blood pressure=162/100, respiratory rate=20, temperature of 96.9° F and pulse oximetry of
100%. His Glasgow Coma Scale score was 15.
Secondary survey was notable for some spinal tenderness, abrasions on the back and the
obvious near amputation/de-gloving deformity of the left forearm. The tourniquet was in
place above the elbow, and the bleeding was
Photo Courtesy Travis Polk
This image shows the patient’s arm with a tourniquet shortly after arrival in the emergency department.
stopped. A focused assessment with sonography in trauma (FAST) ultrasound exam
showed no blood in the abdomen, and a chest
X-ray was unremarkable.
The tourniquet was carefully released to
better examine the arm. This resulted in severe
pain for the patient in the area above and
surrounding the wound. Pulsatile bleeding
appeared to emanate from the vicinity of the
radial artery. A limited neurologic exam of the
hand with the tourniquet released revealed no
evidence of motor or sensory function during
this brief interval. Because of the persistent
bleeding, the tourniquet was reapplied.
The patient remained in extreme pain
and became agitated. At this point, since a
neurologic exam had been performed and
the patient would be going to the operating
room (OR), the medical team proceeded with
elective endotracheal intubation to provide
adequate sedation and analgesia. Following
intubation, the patient was brought to the
computed tomography (CT) scanner for
imaging of his head, C-spine, chest, abdomen
and pelvis. No other injuries were identified.
The Operating Room
The patient was brought to the OR and
underwent repair of the radial artery, ligation of the ulnar artery, external fixation of
the radius and ulna, extensive irrigation and
debridement of devitalized tissue, and wound
coverage with cadaveric skin. He was extubated the following morning, and examination of his hand revealed mostly intact
sensation and slight movement in his thumb
Of note, the patient’s medical history was
significant for coronary artery disease and
deep vein thrombosis. On initial evaluation,
he reported taking aspirin, clopidogrel and
warfarin. He was treated with vitamin K via IV
and transfused with fresh frozen plasma and
platelets for presumed drug-induced coagulopathy. His initial hemoglobin was 10.3 gm/
dL with an international normalized ratio
of 1.1. Given his history of significant blood
loss and ongoing hemorrhage, he was transfused three units of packed blood cells in the
OR. His tetanus status was unknown, so he
received a tetanus vaccine. He was treated
with broad spectrum antibiotics for his open,
severely contaminated fracture.
At the time of this article, the patient
had left the intensive care unit, but he
remained in the hospital three weeks. On
the road to salvation of his limb, the patient
had five surgeries, including placement of
antibiotic impregnated beads and free-flap tissue transplantation.
Exsanguinating hemorrhage from isolated
extremity trauma in the civilian setting is
rare. Unfortunately, due to mixed messages
in much of the civilian medical literature and
first aid texts, many providers are hesitant to
place a tourniquet for fear of causing further
injury or committing the patient to an amputation. The military experience during the
past several years, however, has demonstrated
how this simple technology can be both lifeand limb- saving.
Historically, the mortality rate from
exsanguination from extremity trauma on
the battlefield has been approximately 9%.1
A retrospective study of special operations
personnel deaths in the global war on terror found that 13% of the potentially preventable deaths might have been prevented
with a tourniquet.2 Likewise, a large prospective study examining the use of prehospital
and emergency department tourniquet use
in a combat support hospital in Iraq found
that early use of tourniquets not only
provided hemorrhage control but also
In a series of more than 400 applied tourniquets, no amputations were associated with
inappropriate tourniquet use, and few were
associated neurologic complications.3 For
these reasons, in 2005, the U.S. Army adopted
a new standard Tactical Combat Casualty Care
guideline that tourniquets should be first-line
treatment for any life-threatening extremity
trauma while under fire.
Although extremity trauma in the civilian
setting is rare, studies show that it’s deadly. A
similar retrospective study of exsanguinating
extremity trauma in the civilian population
identified 14 patient deaths during a period of
five and a half years at two Level 1 trauma centers in Houston. Of these 14 patients, 57% had
wounds that would have been amenable to
the placement of a tourniquet, and therefore
potentially could have been saved.4
Given this information, civilian EMS providers
should feel confident that placing a tourniquet
for severe extremity hemorrhage that isn’t
controlled by other means is safe, appropriate
Radiograph Courtesy Travis Polk
This plain radiograph shows the severely comminuted fracture of the patient’s forearm.
and life-saving. Studies also show they should
be applied early and before the patient is
A variety of tourniquets are available for
EMS use. EMS units should work with their
medical directors to select and train with the
device that best suits their needs. As this case
illustrates, the use of a tourniquet was lifesaving for this patient and should always be
considered in cases of severe extremity
Travis Polk, MD, is a trauma surgeon on active duty in the
U.S. Navy currently stationed at the Naval Medical Center in
Portsmouth, Va. He is board certified in general surgery and
board eligible in surgical critical care. At the time of this case,
he was an instructor in surgery and fellow in traumatology,
surgical critical care and emergency surgery at the University
of Pennsylvania in Philadelphia. He can be contacted at
Carrie Sims, MD, is an assistant professor of surgery at
the University of Pennsylvania in Philadelphia and is a former U.S. Army Reserve Medical Corps Officer. She is board
certified in surgery and surgical critical care and practices as
a trauma surgeon and surgical intensivist. She can be contacted at Carrie.email@example.com.
Disclaimer: The views expressed in this presentation
are those of the author and do not necessarily reflect
the official policy or position of the Department of the
Navy, Department of Defense, or the U.S. government. Dr. Polk is a service member. This work was prepared as part of his official duties. Title 17, USC, §105
provides that “Copyright protection under this title is
not available for any work of the U.S. government.”
Title 17, USC, §101 defines a U.S. government work
as a work prepared by a military service member or
employee of the U.S. government as part of that person’s official duties.
1. Bellamy RF. The causes of death in conventional
land warfare: Implications for combat casualty care
research. Mil Med. 1984;149(2):55–62.
2. Holcomb JB, McMullin NR, Pearse L, et al. Causes of
death in U.S. Special Operations Forces in the global war
on terrorism: 2001–2004. Ann Surg. 2007;245(6):986–991.
3. Kragh JF, Walter TJ, Baer DG, et al. Survival with emergency tourniquet use to stop bleeding in major limb
trauma. Ann Surg. 2009;249(1):1–7.
4. Dorlac WC, Debakey ME, Holcomb JB, et al. Mortality
from isolated civilian penetrating extremity injury.
J Trauma. 2005;59(1):217–222.
When placing the tourniquet, providers should remember the following:
ighten until all bleeding stops. If the wound is still bleeding, you likely have a venous tourniquet, and it
may need to be tightened further or repositioned in order to occlude all arterial inflow.
lace as low on the extremity as possible.
ote the time that the tourniquet is applied. (Paperwork gets lost and people don’t always listen during the
report, so write it on the patient too!)
ourniquets are extremely painful; administer some pain medication.
RESEARCH REVIEW ems
What current studies mean to
by David Page, MS, NREMT-P
Studies measure CO-detection device nausea treatment
I CO-Oximetry Effectiveness I
Weaver L, Churchill S, Deru K, et al. False positive rate of
carbon monoxide saturation by finger probe oximetry
of emergency department patients. Respir Care. 2012 Jul
10. [Epub ahead of print]
hould you trust your pulse CO-oximeter
(SpCO) monitor? During the past few
years, there have been conflicting messages
about the accuracy of these devices. This Salt
Lake City-based emergency department (ED)
group attempted to answer that question by
comparing Masimo RAD-57 SpCO monitor
readings from a finger probe/sensor, to the
carboxyhemoglobin (COHb) readings from a
simultaneous blood draw.
Three lab technicians collected SpCO and
COHb samples on 1,363 ED patients receiving blood draws from April to August 2008.
This was a non-randomized sample of convenience study conducted at a single hospital.
The authors report that 84% of the study’s
population was light-skinned and 45% were
male. Fifty-two of the people studied were
non-smokers. A variety of patient complaints
existed, but the SpCO monitor flagged 122
patients, meeting a false positive criteria. A
false positive was considered if the SpCO
showed a value greater than a 3% point difference than the actual COHb level.
Only four patients were actually diagnosed
with CO poisoning from the entire sample.
In these cases, the SpCO oximetry monitor
reading was 4–14% lower than COHb blood
levels, which led the authors to conclude
that the RAD-57 reports lower numbers than
COHb. So far so good, right?
Well, three other patients with COHb
greater than 10% received a 0% rating on the
SpCO monitor. If the SpCO value of 0% had
been used as a field triage tool, then these
patients may have not received necessary
evaluation and treatment at an ED.
So what should we conclude? First, the
good: Previous studies have followed some
flawed methodologies and didn’t adequately
describe the details of their methodologies.
Photo david page
Researchers analyzed the false positive rate of carbon monoxide saturation on the RAD-57 monitor.
(See a review by Keith Wesley, MD, FACEP,
and Marshall Washick, NREMT-P at www.
The authors of this Salt Lake City hospital
study were careful to describe their methods
and avoid some of the previous pitfalls of
other researchers (e.g., timing of the blood
draw). The authors did not report whether the
sensors were shielded from excessive ambient
light, if patient motion was reduced, or if the
various sensor sizes were used, which are each
important considerations with the Masimo
CO-Oximeter. They did report that the device
performed within the margin of the manufacturer’s specifications.
And, from a purely statistical and research
perspective, the sample of patients with
detectible CO levels is simply too small to
make any meaningful conclusions.
The concern a study like this presents is
that, if we are to use this device for prehospital triage of potential CO exposures, then
it would be preferable that the device would
be sensitive enough to detect any potential
exposure, and perhaps err on the side of
over-triaging. Sending someone home based
on a RAD-57’s “0” or low reading if that
patient was actually sick, could be disastrous.
Regardless of whether this was an operator
or machine error, I worry about the patients
with 0% readings who had elevated blood
I would feel pretty terrible sending someone home only to find out they had a
treatable condition that caused them harm
because of my lack of action. The controversy will continue, but this is an important
reason never to just base your field triage
decisions on any machines. Instead, providers should use these devices in conjunction
with other assessment processes and treatment tools, particularly when patients have
potentially been exposed to CO or have
I Nausea Cure? I
Fullerton L, Weiss S, Forman P, et al. Ondansetron oral
dissolving tablets are superior to normal saline alone
for prehospital nausea. Prehosp Emerg Care. 2012. [Epub
ahead of print.]
his prehospital cohort study compared
the use of normal saline bolus with an
odansetron orally dissolving tablet (ODT)
for the treatment of nausea. Researchers
enrolled 274 consecutive patients to receive
What we know: The RAD-57 is being used by many systems across the country. The
machine has shown great promise and helped identify many CO exposures. Previous
research has raised concerns regarding its accuracy.
What these studies add: This study provides very weak evidence of a possible 9% false
positive rate and confusion about the trustworthiness of a low RAD-57 number based
on only five patients. More rigorous study is needed before any conclusions can be
made. Providers are encouraged to talk to their medical directors and be sure to receive
proper orientation and training before using any medical device.
normal ODT during a four-month period.
As you would have predicted, the ODT
group showed significantly decreased
nausea symptoms. No amount of normal
saline was able to show a significant effect.
No adverse events were reported, and the
two groups of patients were similar in ages
and severity of nausea. This study shows a
clear win for odansetron and for ALS care
making a difference.
Kudos to this group for doing prehospital research. Many of us have seen odansetron work its magic, but having some
science to back up its safe and efficacious
use makes for a more scientific and professional care standard. JEMS
I watch box I
Blanchette C, Dalal A, Mapel D, et al. Changes
in COPD demographics and costs over 20 years.
Journal Med Econ. 2012. [Epub ahead of print.]
This cross-sectional, population-based study
should pique the curiosity of community paramedic advocates. They report rapidly rising inhospital admission costs and more prevalence of
chronic obstructive pulmonary disorder (COPD)
in women. This survey of 416 respondents shows
a 37% increase in the cost of caring for COPD during the past 20 years. The authors conclude that
COPD has become a costly disease, which is now
more prevalent in women than men. The authors
recommend shifting costs to fund prevention and
conducting follow-up efforts to avoid readmission
of patients back into the hospital.
Perhaps the community paramedic model
will play a role in improving this part of the
Choose 26 at www.jems.com/rs
I glossary I
Sample of convenience: A sample of
convenience is a grouping of research
subjects or values collected because
they were easily available. They aren’t
randomized or otherwise scientifically
selected, and generally they’re not representative of or able to be generalized to
an entire population.
Visit www.pcrfpodcast.org for audio
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 firstname.lastname@example.org.
Choose 27 at www.jems.com/rs
Feedback-driven team performance impacts survival
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
Photo David Howerton
EMS providers go back to
the basics in training for
s EMS professionals, we’re routinely challenged to successfully
resuscitate victims of sudden cardiac arrest. Fortunately, our
understanding of cardiac arrest pathophysiology continues to grow.
More fortunate still, our enthusiasm in translating that understanding to effective therapies has never been greater.
In the August 2012 issue of JEMS, we introduced a comprehensive restructuring of the EMS System for Metropolitan Oklahoma
City and Tulsa’s cardiac arrest program using a three-part approach:
chest compression fundamentals, resuscitation team dynamics and
accelerated feedback on resuscitation performance. We discussed
the benefit of going “back to the basics” of chest compression fundamentals training, increasing our rate to 120 chest compressions
per minute and using metronomes to attain and maintain that rate
throughout resuscitations. Now, we share how those fundamentals
were incorporated into a Resuscitation Team Playbook and how we
use directed feedback to further refine resuscitation performance.
For Step 1 and the introduction to this team’s approach to resuscitation, read “Oklahoma EMS System Strives for Higher Cardiac Arrest
Survival Rates” at www.jems.com /magazines/2012/august.
Step 2: Resuscitation Team Dynamics. Have you ever been a part of
an EMS call that was particularly “busy” in activity, yet when the
patient was transferred for further care, you started to think, “What
did we actually get done?” Us too. In fact, it happens to all of us in
cardiac Arrest part II
continued from page 35
the inherently challenging practice of EMS medicine. We believe
what you do with those reflections can make all the difference
in the world for future patients. We therefore chose to turn our
reflections, and those of our colleagues, into a Resuscitation
Team Playbook that channels individual enthusiasms into a carefully orchestrated team performance, often described favorably
as “pit crew resuscitation.”
Figure 1 shows the positions used in our resuscitations, with
roles defined for teams of one to six professionals. In our EMS
system, we often start with resuscitation teams of two, three,
or four, with subsequently arriving responders building that
team to five or six actively contributing members. It’s rare in
our system that one EMT or paramedic would be tasked with
resuscitating a cardiac arrest patient alone, but it could happen
for a brief period if a patient were to collapse at a nearly empty
fire station or ambulance headquarters. We wanted to ensure
we had all the possibilities covered, including the single rescuer
scenario. Let’s review the key contributions provided by each
position, so that you’ll be certain to include the care most likely
to promote neurologically intact survival, regardless of resuscitation team size.
Position 1: Rapidly identifies arrest and initiates continuous
lternates minutes of chest compressions with Position 2
over the course of the resuscitation.
When not compressing, assists with bag-valve-mask ventilations (squeezing the bag).
inimizes pauses in chest compressions for rhythm deterM
mination and/or defibrillation.
Position 2: Applies automated external defibrillator or monitor/
irror image of Position 1.
Position 3: Provides airway management; avoids hyperventilation.
Position 4: Leads scene management.
Interface with family/bystanders for events preceding
arrest and medical history.
upervises positions 1–3 for continuous compressions,
timely defibrillation, and no hyperventilation.
Position 5: Provides ALS support.
hythm determination and manual defibrillation.
Position 6: Provides ALS support.
Patient management leader.
The full playbook can be accessed at
At first, it looks like a lot of instruction—because it is. However, these directives simply expand in detail on the key contributions at each position. You may think this degree of directive
is micromanaging hardworking EMS professionals who already
know the right things to do in time-sensitive situations. You’re
right; it actually is micromanaging, but let’s look at why cardiac
Choose 28 at www.jems.com/rs
arrest calls for no less.
Try this exercise, literally. Do 20 jumping jacks. What do
you feel? Unless you’re in particularly athletic shape, you likely
feel an increase in pulse and in respiratory rate and effort.
Why? You’re compensating for an increased activity demand.
The human body is amazing in its ability to compensate, even
to some degree when severely ill or injured. But spontaneous
circulation reflects an unforgiving light switch. When it’s “on,”
compensation is at work. When it’s “off,” as in cardiac arrest,
there’s complete loss of compensation … except for resuscitative efforts.
Thinking back to our understanding of cardiac arrest pathophysiology, we have to be precise in those efforts for our “compensation on loan” to work. The only way to make that happen
comes when we use a carefully crafted plan (the playbook) and
actively micromanage ourselves in each position (running the
play). So in sum, it’s not micromanaging by others, it’s self-micromanaging, and it’s for all the right reasons.
Figure 1: Resuscitation Positions
We’ve definitely laid out a plan, but how do we know whether
it’s the right plan? One quick answer you’ll say is by looking at neurologically intact survival rates—before and after adoption of this
plan. In fact, that’s a great answer, but we think it comes up short
as the lone answer.
In athletics, if a team loses a game, does that mean they played
badly? Often, the answer is “not at all;” it may mean the team simply played a better team, or depending on how score is kept, the
team may have started with a handicap that’s insurmountable.
Ever start a resuscitation feeling that you were working with such
a handicap? That’s where Step 3 comes into use in our cardiac
Step 3: Feedback on Resuscitation Team Performance. Every highperformance professional values feedback designed to “build up”
future abilities. Our feedback program channels that philosophy
using proprietary software that captures data from the monitor/
Choose 29 at www.jems.com/rs
cardiac Arrest part II
continued from page 37
defibrillator throughout the resuscitation. Many EMS systems are
using this type of capability, but the real value lies in merging data
with a set of skilled clinical eyes, annotating the basic feedback
forms. Credit goes to the Redmond, Wash., Medic One program
for helping us see the full potential already in our grasp.
Only through annotating a case do specific gaps in compresEMS providers in Oklahoma
City and Tulsa maintain a
rate of 120 compressions,
using metronomes in
Photo David Howerton
Choose 30 at www.jems.com/rs
sions, changes in ventilation rates and timings of defibrillation
really become clear. No “real world” resuscitation will ever be
textbook perfect. Thus, only through analysis by an experienced
clinician does variability reliably fall into the “makes sense”
or “opportunity to reflect” categories. Without annotation, a
“report card” gets generated without showing a valid grade …
arguably pointless, right?
Our goal is to have an annotated resuscitation team performance feedback report available to the resuscitation team on its
next shift after working a cardiac arrest. The report is sent with
explanation through annotated comments and without discouraging remarks, even in areas for improvement. Those areas are
self-evident, and we believe the best correction can come through
So how are we doing in achieving our own goal? Currenrtly,
just about 5% of the time. But here’s a key point, and one we’ve
had to learn with hard experience: If you wait until everything
is perfect to start improving, you never start improving. Like
Choose 31 at www.jems.com/rs
most EMS systems, we’re understaffed in comparison with our
goals. However, we’re fortunate in being able to hire a new data
specialist position that’s dedicated full-time in our Office of the
Medical Director. This position will dramatically improve our
feedback abilities, both in volume and timeliness.
Even with feedback 5% of the time, the results are encouraging. We’re routinely seeing chest compression fractions (CCF)
(i.e., time in which chest compressions are actively occurring)
above 90%. In fact, many resuscitations are being performed
with CCFs above 95%. (To be clear, these cases reflect random
analysis, not just review of clear survivors.) These numbers
reflect CCF increases 5–15% above our historical baselines. Not
surprisingly, return of spontaneous circulation (ROSC) rates
have increased since we started resuscitation team dynamics in
February. Although we anticipate cardiac arrest survival rates
in 2012 to be rewarding, it’s still early, and we don’t want to
report on incomplete data.
Conclusion (For Now)
Our EMS system, just like yours, is committed to attacking cardiac arrest and doing everything we can to help the suddenly dead
become alive again. Focusing our energies (with encouragement
from friends throughout EMS) on chest compression fundamentals, resuscitation team dynamics and better timely feedback on
resuscitation team performance—all in support of patients and
the EMS professionals caring for them—makes a lasting influence
on cardiac arrest. JEMS
Jeffrey M. Goodloe, MD, NREMT-P, FACEP, is professor and chief of the EMS section
of the Department of Emergency Medicine at The University of Oklahoma School
of Community Medicine in Tulsa. He serves as medical director for the Medical
Control Board in the EMS System for Metropolitan Oklahoma City and Tulsa,
working with a multitude of agencies, including the Emergency Medical Services
Authority (EMSA), the Oklahoma City Fire Department and the Tulsa Fire Department. He started in EMS in 1988 as an EMT-B and has never quit learning. Contact
him at email@example.com
T.J. Reginald, NREMT-P, is director of research and clinical standards development for the Office of the Medical Director in Oklahoma City and Tulsa. He’s a
driving force behind the success and continuing advancement of cardiac arrest
resuscitation in the major metropolitan areas of Oklahoma. His EMS career spans
three decades and includes a multitude of clinical and administrative leadership
roles. Contact him at firstname.lastname@example.org.
David S. Howerton, NREMT-P, is director of Clinical Affairs - Western Division for
the Office of the Medical Director in Oklahoma City. He’s the medical oversight liaison officer for all metropolitan Oklahoma City agencies working with the Medical
Control Board. His EMS career spans nearly three decades and includes a multitude
of clinical and administrative leadership roles. Contact him at email@example.com.
Jim O. Winham, RN, BSN, NREMT-P, is the immediate past director of Clinical
Affairs - Eastern Division for the Office of the Medical Director in Tulsa. He’s enjoying
a new career move as the general manager for Paramedics Plus - Oklahoma. His EMS
career spans more than three decades and includes a multitude of operational, clinical and administrative leadership roles. Contact him at firstname.lastname@example.org.
Tammy Appleby, NREMT-B, is executive assistant to the medical director for the
Office of the Medical Director in Oklahoma City and Tulsa. Retired from the U.S.
Air Force, she has an accomplished career in medical operation administration and
leadership. Contact her at email@example.com.
Choose 32 at www.jems.com/rs
Photo Courtesy Portland Fire Department
Once adenosine is administered,
its effectiveness lasts between
five and 10 seconds.
Expert safe use of adenosine depends
on patient’s cardiac status
By Corey Slovis, MD, FACEP; Jared McKinney,
MD; Jeremy Brywczynski, MD, FAAEM
denosine is the drug of choice for paroxysmal supraventricular tachycardia (PSVT) and is once again
Advanced Cardiac Life Support-approved for differentiating PSVT with aberrancy from ventricular tachycardia (v tach) in patients with monomorphic wide complex tachycardias.1 Adenosine is a
potent and safe antiarrhythmic when used appropriately. However, its use in the wrong patient or
rhythm can prove fatal. This article focuses on how to expertly use adenosine and to know when
this “safe” antiarrhythmic can be dangerous and contraindicated.
Pharmacology Mechanisms of Action
Adenosine’s mechanism of action can be thought of as a “temporary
paralyzing” of supraventricular tissue. Pharmacologically, adenosine
hyperpolarizes the cell by stimulating an inward potassium current
and temporarily inhibiting calcium migration.2 In doing so, the pacemaker activity of the sinoatrial (SA) node, spontaneous atrial activity
and conduction through the atrioventricular (AV) node are dramatically slowed or temporarily stopped.
Adenosine has no effects on accessory pathways, such as those
seen in the Wolf-Parkinson White Syndrome (WPW). Mild side
effects of adenosine are common. They include a transient sinus
pause that usually lasts less than five seconds, chest pressure or tightness, dyspnea, facial flushing and the feeling of impending doom (see
Table 1, below).2–4
Rare, benign side effects reported include anxiety and dizziness.
In one large prehospital trial, 11% of patients had a minor transient
complaint, with chest pain being the most common complaint seen
in 4% of patients.4 Chest tightness was induced by adenosine administration in 83% of patients in one large in-emergency department
to cause prolonged sinus pauses, syncope, seizures and even asystole, although this rare side effect has been described almost solely in
older patients with preexisting conduction disease and/or second- or
third-degree heart block.7–9 Adenosine is the drug of choice for PSVT
in pregnant patients.1
The biggest dangers with adenosine are seen in two groups of
patients: 1) those with atrial fibrillation or atrial flutter, and 2) those in
sinus tachycardia and not PSVT.
Figure 1a, 1b 1c: Regular Wide-Complex Tachycardia
Side effects from adenosine administration that are serious are
extremely rare when used in healthy patients with PSVT (see Table 1,
below). Adenosine may cause mild bronchospasm, which is almost
always short lived. However, adenosine can also cause severe bronchospasm and should
Table 1: Toxicology of Adenosine
be given carefully to
those with a history
of asthma or chronic
pulmoShortness of breath
nary disease (COPD).6
It shouldn’t be given to
patients who are already
has also been reported
To verify true regularity, make marks on a piece of paper that match the
peaks of the QRS then moving the QRS-marked paper a few beats over to
compare it to three to four new beats on the rhythm strip. If they line up,
the rhythm is regular; if they don’t, the rhythm is irregular, and adenosine
shouldn’t be used.
Check the Rhythm
continued from page 41
Numerous studies in the literature report
serious rhythm degeneration and even death
when adenosine has been inadvertently
given to patients with either atrial fibrillation
or atrial flutter. Adenosine can convert relatively stable atrial flutter with 2:1 conduction
and a heart rate of 150 to 1:1 conduction with
a heart rate of 300 and cause rapid clinical
Adenosine slows or blocks antegrade
(atrial to ventricular) conduction through
the AV node but doesn’t affect accessory or
bypass tracts like those seen in WPW syndrome. Because of this, adenosine can be
dangerous when given to patients with atrial
fibrillation, especially if they have a bypass
track. Numerous reports show patients
degenerating into rapid atrial fibrillation
with rates at 250 or greater and becoming
Thus, an absolute contraindication to
adenosine exists in patients who have either
atrial flutter or an irregular rhythm in atrial
fibrillation. Because rapid atrial fibrillation
may seem regular on ECG monitor, paramedics are urged to run a rhythm strip and
verify true regularity.
We find this easiest by making marks on
a piece of paper that match the peaks of the
QRS then moving the QRS-marked paper a
few beats over to compare it to three to four
new beats on the rhythm strip. If they line
up, then the rhythm is regular; if they don’t,
then the rhythm is irregular (and likely atrial
fibrillation), and adenosine shouldn’t be used
(see Figures 1a, 1b, 1c, p. 41).
The other absolute contraindication to
adenosine is in sinus tachycardia. Dehydrated patients, especially the elderly with
fever, failure to thrive and/or an infection
may appear to be in PSVT when in fact they’re
barely compensated with a sinus tachycardia with a rate that may be greater than 150.
These patients are at high risk for morbidity
and mortality if adenosine is administered,
Table 2: When PSVT is not likely PSVT
Reason It Is Not PSVT
Heart rate of 150 or less
At 150 atrial flutter 1:1; 150 or less usually is sinus tach
Atrial fibrillation or multifocal atrial tachycardia
Transiently slows to vagal stimulation
Diagnostic of sinus tachycardia
History of atrial fibrillation, atrial flutter or multifocal atrial tachycardia (MAT)
Marked increased likelihood of previous arrhythmia and not PSVT
History of COPD or CHF
Atrial fibrillation or MAT much more likely
Choose 33 at www.jems.com/rs
Choose 34 at www.jems.com/rs
and they have a prolonged sinus pause (see
Table 2, below).
In cases for which there’s any chance
that sinus tachycardia is the etiology of the
patient’s elevated heart rate, a rapid fluid
bolus of 250 cc should be administered. Any
slowing by just a few beats per minute (rather
than a dramatic conversion to a normal sinus
rhythm) confirms the diagnosis of sinus
tachycardia due to volume depletion.
This is also true in heat stroke victims
with PSVT at rates approaching 180 beats
per minute. EMS providers should rapidly hydrate and cool these patients before
administering adenosine. If the patient’s
pulse begins to fall with therapy, the diagnosis of sinus tachycardia due to heat illness and
dehydration is confirmed, and adenosine is
contraindicated. Table 2 lists the rhythms,
rates and patient types in which the diagnosis of PSVT should be considered unlikely.
Once adenosine is administered, its effectiveness lasts only between five and 10 seconds because it’s rapidly metabolized by
cellular uptake. Because of the ability of
blood vessel endothelium to metabolize
adenosine, it’s imperative for EMS providers
to give adenosine by rapid bolus followed by
Figure 2: Prolonged Pause Status Post Adenosine
Choose 35 at www.jems.com/rs
a 10–20 cc rapid flush.2,3
Larger, more proximal IV lines are preferred because small-bore IVs don’t routinely allow fast flow or rapid transit to the
heart. The dosage of adenosine should be
reduced to 3 mgs if injected into a central
line, and it shouldn’t be used in heart transplant patients.1,14
The standard initial recommended dosage of adenosine is 6 mg, followed by a rapid
saline flush. If this dose isn’t effective, EMS
providers should double the dose to 12 mg,
repeat the bolus and rapidly flush the line.1–
These recommendations come from the
original article that compared adenosine
Check the Rhythm
continued from page 43
Table 3: Dosages Protocol for Adenosine Administration
6–12 mg IV push in large-bore IV
Immediately flush with 10–20 cc normal saline solution
12 mgs IV push if not effective in 60 seconds
If protocol began with 6 mg IV, consider second dose of 12 mgs IV; push and re-flush line.
Contact medical control in the event of refractory cases
with verapamil in PSVT and used a variety of adenosine doses. In this article, the
investigators found that 6 mg of adenosine
converted 62.3% of patients and that 12 mg
converted 91.4% of patients without increase
Because there doesn’t appear to be any
increased toxicity in a 12 mg initial dose
and it’s more effective, others have recommended starting at 12 mg.4,17 Some have recommended doses as high as 18 mg, which
can convert 95% of PSVT patients vs. 65%
with 6 mg and 90% with 12 mg.18
Thus, paramedics and their medical
directors should have pre-established protocols beginning with 6–12 mg. These protocol should conclude that a second 12 mg
dose should be attempted if 12 mg is ineffective,. This is because reports show a second repeat dose of 12 mg may convert up to
10–31% of patients.4,5
Treating Wide Complex
Adenosine was initially considered useful
in helping distinguish wide complex tachycardias due to aberrantly conducted PSVT
vs. true v tach. However, based on cases
of patients deteriorating, many cautioned
against trying this drug in any patient with
wide complex tachycardia.14,16
We now know that adenosine is safe
and can help distinguish supraventricular
arrhythmias from those originating in the
ventricle for monomorphic wide complex
tachycardias that are regular in rate (and
by definition, have the same QRS size and
In the largest recent study of adenosine
in wide complex tachycardias, 197 patients
were studied.16 Of these, 116 had SVT and
81 had v tach. Ninety percent of the SVTs
responded to escalating doses of adenosine
(i.e., administering 6 mg, then 12 mg, then
repeating 12 mg if no response, and even
administering 18 mgs to one patient). Only
one patient with proven v tach responded
to adenosine, and a second patient may have
The authors concluded that adenosine was safe as long as patients had regular monomorphic wide complexes and that
adenosine was useful in helping distinguish
between PSVT and v tach. In fact, they noted
a 36-fold increase in the likelihood of a
adenosine are usually mild and transient,
lasting just a few seconds. They include
chest tightness, shortness of breath and a
short sinus pause. Although more serious
side effects can occur, such as hypotension,
bradycardias and seizures, these side effects
are rare in healthy patients with no underlying heart disease.
Adenosine is contraindicated in patients
who are likely to be harmed by its inappropriate use. Patients with irregular heart rates,
especially atrial fibrillation, patients with
PSVT mimics such as atrial flutter with 2:1
conduction or sinus tachycardia in a dehydrated or stressed patient should never
Adenosine should never be used in wide
irregular tachycardias. Providers who are
going to use adenosine must be experts in
An absolute contraindication
to adenosine is in patients who
have either atrial flutter or an
irregular rhythm as is seen in
supraventricular origin if the wide complex
tachycardia converted to sinus with adenosine and a nine-fold increased likelihood of v
tach if it didn’t respond to escalating doses
Another thing is absolutely clear: Never
give adenosine to a wide irregular tachycardia or a polymorphic (multiple different QRS
configurations) tachycardia, such as Torsades de Pointes. It’s in these patients that adenosine might be lethal.1,16
Read about a real case of a patient
who presented with Torsades
de Pointes at www.jems.com/
Adenosine is a safe and effective agent in
PSVT. It’s currently the EMS drug of choice
for regular tachycardias about 150–160
beats per minute, believed to be PSVT—
whether wide or narrow. The side effects of
cardiac rhythm interpretation. They also
must carefully review a rhythm strip prior to
Our recommended starting dosage is
12 mgs via IV push followed by a 10–20 cc
rapid flush of saline. If the first 12 mg dose
isn’t effective after one minute, we recommend repeating 12 mgs a second time. EMS
services and their medical directors should
decide whether 6 or 12 mgs should be initially used because there’s no national consensus on which is optimal. JEMS
Corey Slovis, MD, FACEP, is professor and chair of emergency medicine at Vanderbilt and serves as the medical
director for Nashville (Tenn.) Fire Department and Nashville International Airport. Slovis is also a member of the
JEMS Editorial Board.
Jared McKinney, MD, is director of event medicine for
Vanderbilt Medical Center, an assistant professor of emergency medicine at Vanderbilt University Medical Center in
Nashville and is an assistant medical director for the Nashville Fire Department.
Jeremy Brywczynski, MD, FAAEM, is medical director of Vanderbilt’s aeromedical LifeFlight Program and an
assistant professor of emergency medicine at Vanderbilt
University Medical Center in Nashville and is an assistant medical director the Nashville Fire Department.
1. Neumar RW, Otto CW, Link MS, et al. Part 8: Adult advanced cardiovascular
life support: 2010 American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 Suppl
2. Sampson K Kass R. Anti-Arrhytmic Drugs: Introduction. 12th. ed. Goodman
Gilman’s the Pharmacological Basis of Therapeutics 2011. McGraw-Hill: New
3. Kowey P Yan G. Antiarrhythmic Drugs. 13th. ed. Hurst’s the Heart 2011.
McGraw-Hill: New York.
4. Gausche M, Persse DE, Sugarman T, et al., Adenosine for the prehospital treatment of paroxysmal supraventricular tachycardia. Ann Emerg Med.
5. Riccardi A, Arboscello E, Ghinatti M, et al. Adenosine in the treatment of supraventricular tachycardia: 5 years of experience (2002-2006). Am J Emerg Med.
6. Burkhart KK. Respiratory failure following adenosine administration. Am J Emerg
7. Christopher M, Key CB, Persse DE. Refractory asystole and death following the
prehospital administration of adenosine. Prehosp Emerg Care. 2000;4(2):196–198.
8. Reed R, Falk JL O’Brien J. Untoward reaction to adenosine therapy for supraventricular tachycardia. Am J Emerg Med. 1991;9(6):566–570.
9. Webster DP Daar AA. Prolonged bradyasystole and seizures following IV adenosine for supraventricular tachycardia. Am J Emerg Med. 1993;11(2):192–4.
10. Mallet ML. Proarrhythmic effects of adenosine: A review of the literature.
Emerg Med J. 2004;21(4): 408–410.
11. Exner DV, Muzyka T, Gillis AM. Proarrhythmia in patients with the Wolff-Parkinson-White syndrome after standard doses of intravenous adenosine. Ann Int
12. Haynes BE. Two deaths after prehospital use of adenosine. J Emerg Med.
13. Shah CP, Gupta AK, Thakur RK, et al. Adenosine-induced ventricular fibrillation.
Indian Heart Journal, 2001;53(2):208–210.
14. Delacretaz E. Clinical practice. Supraventricular tachycardia. New Eng J Med.
15. DiMarco JP, Miles W, Akhtar M, et al. Adenosine for paroxysmal supraventricular
tachycardia: dose ranging and comparison with verapamil. Assessment in placebo-controlled, multicenter trials. The Adenosine for PSVT Study Group. Ann
Int Med. 1990;113(2):104–110.
16. Marill KA, Wolfram S, Desouza IS, et al., Adenosine for wide-complex tachycardia: Efficacy and safety. Crit Care Med. 2009;37(9):2512–2518.
17. Slovis CM, Kundencheck PJ, Wayne MA, et al., Prehospital management of
acute tachyarrhythmias. Prehosp Emerg Care. 2003;7(1):2–12.
18. Weismuller P, Kattenbeck K, Heinroth KM, et al. [Terminating supraventricular
tachycardia with adenosine--comparing the effectiveness of 12 mg and 18 mg].
Dtsch Med Wochenschr. 2000;125(33):961–969.
Read a clinical education article about heart
rhythms at www.jems.com/article/monitorsrecorders-vital-signs/rhythm-clues
Choose 36 at www.jems.com/rs
EMS provider becomes patient
he smoky plume had relentlessly
grown with vehemence during the
previous five days—culminating in
a 65 mile-per-hour-wind-driven fire storm
that had consumed 346 homes and taken
two lives in less than just an hour one day
earlier. My mountain community lies just
10 miles west of the Colorado Springs devastation, and although we shared with our
front-range neighbors the collective loss of
property, life and scenic beauty, I admit I
felt a sense of selfish relief and guilt that the
winds had chosen an easterly path away
from my domesticated habitat.
Still, the fire was 0% contained while
by steve berry
being sporadically fanned by wind patterns
the likes no one had ever seen before. And
there was still a psychopathic pyromaniac
on the loose in our county. Add to that an
unprecedented 100-plus degree temperature, single-digit humidity and no precipitation in the foreseeable future. Many of us
believed, in spite of the awe-inspiring quantity of firefighting resources being brought
to bear, these merciless flames might very
well circumvent their way back up the canyon and valley to consume the foundation
of Pikes Peak’s purple mountain majesties.
I believed our pre-evacuation orders would
no longer include the prefix “pre.”
Now I’m not one to say, “I told you so”
(ha!), but for years our highland region
had been suffering from a brutal drought.
“It’s just a matter of time,” I would incessantly preach to any ears that were open
to my dire warning (of which receptive
auricles belonged only to my dog).
Seeing what medics see in EMS affords
us the opportunity to integrate the belief
system of, “Of course things can always
get worse, and, by God, I want to be there
when it happens!” The advantage of this
seemingly moronic perspective is that it
forces EMS providers to believe there’s a
solution to any problem regardless of the
probability of a successful outcome. Why
else would we want to be there? Simply
put, we believe in being hopelessly hopeful.
It is this form of logic that enabled me
to endure my neighbor’s ridicule (during
the past 20 years) of my efforts to create
a fire-free zone around my property. He
would watch me diligently work my land
as I cleared the forest floor of its dead
wood and needles while thinning the pine
trees, thus allowing them more personal
space to branch out. “What’s the point?”
my neighbor would stoically ask. “If a fire
rages through here, all will be lost, you
Obviously my neighbor never heard of
fire TRIAGE (Trees Readily Ignite Architecturally Grown Entanglements). Just as
in EMS, wildland firefighters
have triage tags. The black tag
for them symbolizes death of a
structure by blackened charred
embers, and without adequate
fire mitigation around one’s
home, an owner might as well
TRIAGE (Try Running Immediately Away Grudgingly
East). Firefighters will not take
a stand to save such acreage,
especially if there’s fuel lying
near or above the residence.
This is why just one day
after so many homes were
lost in Colorado Springs, I
was determined to eliminate
the last remaining low-lying
branch menacingly clawing
its way toward my house. But
when I say low-lying branch,
this particular abominable limb hovered
well over 20 feet above the ground. Her tentacle branchioles (capillary branches) spread
ominously toward the gutters of my second
story. She had to come down, and it was to
be my last act of fire mitigation should the
final order to evacuate come down.
For the record, I will arrogantly admit
that I wasn’t too concerned about the task
at hand. I considered myself quite handy
with a chain saw and axe after having
resided in these thar woods all these years.
When December clouds annually shroud
our home’s passive solar heating system—
no problem. We had wood. The fragrant
smoke from the chimney billowed in carcinogenic testimony to my ability to cut,
haul and split wood. “I am a lumberjack!
Arrrrgh!” (OK, so I’m a pirate lumberjack.)
With the surface area now secured, the
metal clips began to clatter their way up past
each step with each pull of the rope. Each
subsequent clank would represent an additional foot of separation of me from the
earth’s surface. By the sixth clank, I realized
I would be lucky if the extension ladder
could even reach the base of the tree limb.
No matter. My fully extended body and
20 chain saw guide bar would more than
make up for the gap in distance. Cumbersome? Yes. But I’d done it thousand times
before without incident. No harm, no foul,
Copious amounts of sawdust rained
down on my head as the guide bar sliced
easily through the tree limb like a hot knife
through butter. I applauded myself for my
foresight in replacing the dull chain with a
new one to reduce arm fatigue from having to hold a 35-pound chain saw above
my head. Take a
back seat Paul Bunyan, for I am the
master. Blinded by the showering confetti
of wood particles, I suddenly heard a crack.
Not a little crack, mind you, but a loud,
whopping pre-emptive, oh-crap crack!
It’s wise to constantly monitor one’s
progress while cutting down timber. The
tree will talk to you as the grain is objectively being weakened. It’s considered standard practice to give pause and reassess the
act of cutting before the wood is completely
severed from its rooted ties to itself. But
I had cut too deep, too rapidly, and the
goggles I had negligently left on the ground
wouldn’t provide me the visual acuity necessary to foresee the misdirection this gigantic sap-laden pendulum was about to take
toward my delicate frame.
It’s kind of funny what goes
through one’s mind when something irrevocably bad is about to
unhinge your gravitational homeostasis. For me, I was thinking of
Looney Toons, the Road Runner’s
nemesis—Wile E. Coyote. He was,
after all, the master of the whistling
astrophysical plummet routine,
and I’m pretty sure I had his exact
same resigned, deadpan expression
as the reality of the situation sank
into me … literally.
But unlike Wile E., whose
scripted character is supposed to be
more humiliated than harmed by
his failures, I began to contemplate
all the potential prospects in store
for my fragile anatomical parts as
the partially avulsed limb vengefully eradicated me like an annoying tick
from its main body. For I knew it wasn’t the
falling that was going to hurt, but the landing that was going to be a bitch.
It’s true what they say: Time stands still
at moments like these (sans bladder). Here
are just a few of my thoughts as I began my
reentry into the atmosphere:
1. This is going to hurt.
2. When was my last BM (breath mint)?
3. Is that squirrel laughing at me?
GOING OUT ON A LIMB
continued from page 47
4. This is going to hurt.
5. hat EMS shift is on today, and did
I piss off any of the crew members
This is embarrassing. I hope no one is
watching this. No. Wait. I’m unaided. I
hope somebody is watching this.
7. Where is the chain saw?
8. This is going to hurt.
Think like a cat. Land like a cat. Think
like a cat. Land like a cat.
10. ook! A butterfly! (ADD still intact).
11. his is going to … Arrrrrrrrrrrrgh!
Hmmmmmm. Interesting. No loss of
consciousness, I think, but (gasp) I can’t catch
my breath. Take in a lungful. Yah, nope!
That ain’t happening. How am I lying? Left
lateral recumbent, which explains the leftsided thoracic pain. I note lateral
neck tightness as I attempt to
survey myself for external bleeding. Sweet! No blood anywhere.
What did I land on? Phew! Just
missed that severed aspen tree
spike. No ground, roots-only,
soft needle-laden soil. The chain
saw is still running, but where
is it? Still no signs of mid-line
C-spine point tenderness to
palp. Feeling for a strong radial
pulse. Ouch! Left wrist slightly
deformed. At least I’m right
handed. Where did that butterfly go? Why am I tachycardic?
Am I hemorrhaging internally?
Could be a spleen from landing
on my left side. No, wait. Of
course you’re tachycardic you
epi-rush-dumb-ass. Why else would your
hands be trembling? Besides, the peripheral
skin is pink, warm and dry with good capillary refill. No abdominal pain. How are the
legs? WTF? That doesn’t feel right. Hip fracture possibly, but on the right side? Coup
contrecoup maybe? Please don’t let it be the
pelvis. Cell phone! Where’s my cell phone?
“9-1-1. What is your emergency?”
“I fell out of a tree.”
“Who fell out of a tree?”
“I fell out of a tree.”
“You fell out of your tree?”
“Yes, my tree!”
“Which tree is it?”
“The tree I am under!”
I’m sure there was a lot more pertinent
dialogue to the conversation with the 9-1-1
operator, but I don’t recall a lot of the details,
except for a few shining moments—especially when the dispatcher asked me to please
hold. Please hold? Seriously?
Time may have stood still for me during
my nosedive into the abyss, but for the Ute
Pass Regional Ambulance District (UPRAD)
EMS providers who would respond to me
on this day, my timing couldn’t have been
worse. During the exact moment of my
reckless act, an already taxed UPRAD was
preparing for the immediate fire evacuation
of the town’s chronically sick and immobile
citizens by either recruited buses or ambulances. On top of that, a rollover accident
with multiple patients being ejected was
concurrently being dispatched, along with
my call. Thus, through no fault of her own,
the 9-1-1 dispatcher had to put me on hold
while she valiantly attempted to bring all the
available resources to bear amid the chaos.
Still on hold, and having already completed my initial primary survey, I began to
contemplate a more thorough self-exam,
upon which I discovered not only my health
insurance card, but also a Subway sandwich
gift card that still had five dollars worth of
credit on it. Suddenly, I saw my loyal dog
Koosko sitting just above me on the slope.
“Lassie,” I bemoaned through my aching
thorax. “Go get help girl! Find help.” I was
delighted and surprised to see Koosko, sensing my situation, take off like a bolt of lightning toward the road. I closed my eyes in
quiet satisfaction, knowing help was on the
way. Minutes later, I felt a light, hollow thud
hit my chest, followed by heavy panting. My
dog had returned to his master. Not with
help mind you, but with his saliva-soaked
Resigned to the fact that it is what it is and
that it may take a while before 9-1-1 gets
back with me, I feebly lobbed the ball maybe
five feet down the hill. Like a good dog, he
fetched and returned the ball each time I
threw it, despite his obvious air of discontent
with my less-than-stellar effort.
As I lay quietly under the tree, despite
the continuous, soothing idling rumble of
the chain saw’s engine, my mind was far
from quiet. I was now scared. Any thread of
arrogance that embodied my earlier interpretation of myself was now gone.
I knew my body was not that of
a young man anymore and that
my brain could only mobilize just
so many neurons when it came to
interpreting any damage. I knew
there could possibly be more underlying issues my endorphins were
masking at the moment, despite my
stable vital signs. Still, I was hopeful
my injuries were limited to musculoskeletal in nature as my faithful
dog continued to drop his slimy orb
on my contused chest.
I didn’t hear the sirens while I
continued to reassess my C-spine in
a half sit-up position, but I did hear
a voice yelling, “EMS.” Moments
later, the feel of gloved latex firmly
fixating itself bi-laterally along my
temporal lobes was simultaneously met by
an upside down, sun-blinded view of paramedic Chris Erickson saying, “Don’t move,
Steve!” His voice was both commanding and
compassionate; his facial expression read
“What the hell were you thinking?”
“I’ve cleared my C-spine,” I began but was
quickly cut off.
“You know the drill,” Chris said.
“But I …”
I heard, “Shut up, Berry!” as the nonrebreather mask was instantaneously placed
over my nose and mouth as if to emphasize
the point. And with that, I can honestly say I
let go. I let go of the control and put all my
trust into my prehospital care providers—
my comrades, my brothers, my stupid dog.
Chris is one of the best paramedics I’ve ever
had the pleasure of knowing, and his EMT
partner Travis Daniels, although new to the
field of EMS, has more street sense than most
medics I’ve known.
“Launch the bird,” Chris tersely ordered.
“Damn! Really?” I contested.
Again, I was cut off, not by his voice, but
by his charismatic furrowed eyebrows.
“He’s one of ours,” Chris emphatically
told the Northeast Teller County firefighters
arriving on scene. He wanted a helicopter,
and he wanted it now.
Once the C-collar was applied, my view of
the world became stiflingly one dimensional
,with occasional faces, arms, hands, splints,
stethoscopes, a blood pressure cuff, straps
and tennis ball making brief and sporadic
appearances across my 20 by 20 transversal
I knew the pinch (ouch!) on my forearm
indicated pain management was forthcoming, but instead a second pinch in the same
general vicinity soon followed.
“Chris? Oh, Chriiiis? Did you just happen to miss the line on your first attempt?” I
satirically inquired in a falsetto voice.
“You moved,” he voiced meekly. I couldn’t
help but laugh, despite my unsolicited situation, for three reasons. One: I had ropes for
veins without a tourniquet. Two: Chris is a
master at venous access. Three: He used the
ole pathetic, “You moved” line.
“This was almost all worth it just to witness this implausible moment,” I continued
in my attempt to rib him just as my ribs were
“No matter,” he grinned. “You won’t
remember this short-term memory moment
anyway.” And with that, I was given a fluid
challenge of 100 mcg of fentanyl, soon followed by 2 mg of Versed.
Chris was right about my inability to recall
much of what transpired following my IV
inoculation of happy meds. Brief moments
of EMS procedural applications, well wishes,
sounds of sirens and rotor blades, along
with loading and unloading from ground
to ambulance, ambulance to helicopter and
helicopter to hospital helipad felt like only
minutes rather than the hour it probably
required to transport me from scene to ED.
Nonetheless, there were some moments of
clarity that I know can only enhance my
patient care and compassion in the future:
Pay attention to the mechanics of trauma triage. Chris quickly understood the risk for
injury from such a vertical deceleration scenario, including the assessment of height,
impact surface area, body orientation, age
of patient, circumstances of fall, secondary
collisions and anticipated weight distribution. I was very lucky to still be among the
living, and Chris stayed the course despite my
paramedic-induced martyred invincibility.
Introduce your face often to spinal immobilized
patients and explain all procedures that are about to
or are being performed outside their visual periphery. And keep patients posted often as to their
current geographic locality during transport.
Provide your patient updates often as to what
you suspect isn’t anatomically correct, but also tell
them what’s functioning correctly.
A reassuring touch speaks volumes. Although
my EMS peers joked with me often during
my ordeal, Chris and Travis made it clear they
2013 CALL FOR NOMINATIONS
The James O. Page/ JEMS Leadership Award, sponsored
by Elsevier Public Safety, encourages EMS personnel and EMS
agencies to deliver quality service, gain the respect of their
colleagues in the ﬁeld of EMS, and ﬁght to do what’s in the
best interest of patient care and EMS in their community.
It recognizes an individual (or organization) who exhibits the
drive and tenacious effort to resolve important EMS issues or
bring about positive change in an EMS system, often at great
personal or professional sacriﬁce.
Eligibility: This award is open to an individual OR an agency
who has championed a cause or righted an EMS wrong.
Past winners are not eligible to participate.
DEADLINE FOR SUBMISSION: DEC. 30, 2012
For detailed award submission information, go to:
GOING OUT ON A LIMB
continued from page 49
cared deeply about my well-being by simply
gripping my hand occasionally.
Be polite. Repeatedly incorporate the words
please, thank you and I’m sorry as part of your
Never throw the tennis ball farther than that of
the disabled pet’s owner current ability, lest the dog
turn traitor to a different master.
I also took a lesson on humility that I hope
to incorporate into my line of work. I broke
many safety rules the day of my fall from
sapling grace. I knew better, and yet I cut corners and made a conscious decision to take
on a substantial and unjustifiable risk. Did
my years of experience carving up wooded
landscapes allow me more latitude to drift,
simply because nothing bad had happened
years earlier? Maybe there’s a tendency to
ignore or miss the warnings that don’t conform to what’s actually familiar. It’s easy to
draw the line after the accident, but you don’t
have to be in one to become a victim.
There’s a reason airline pilots follow a
detailed, by-the-numbers transcript of preflight safety procedures that they check off
each time they climb into the cockpit, regardless of their years of winged experience. I
plan on being more diligent in regard to the
check-off list of EMS preventable foreseeables. Events will line up a certain way despite
the best intentions to prevent a problem, but
eventually something will go wrong. Let’s
not add to that probability by drifting simply
because we’re currently in a safe place.
Shortly after my (insistent) discharge
from the hospital (sorry floor nurses,
but your venous access technique really
sucked), I had the opportunity to attend the
Woodland Park community post-Fourth of
July Symphony in the Park celebration—an
annual event our family has never missed
since the birth of our children. The community had a special reason to celebrate
this year as our town was just days earlier spared the ravages of the Waldo Canyon fire. Although the annual fireworks
were obviously prohibited, the symphonic
orchestra instead introduced our local firefighters to the stage. A well-deserved, fiveminute standing ovation ensued.
As I struggled to stand with my acutely
recuperating fractured forearm, wrist, ribs,
sacrum, pelvis and various other leaking
appendages, I noted the UPRAD ambulance
and its crew standing by for the event far off
stage, just up the ridge. My applause made
no sound as I attempted to clap with my
casted forearm in their direction—a fitting
silent tribute that I suppose EMS has always
unfairly had to shoulder since its true beginnings. Standing in the shadows, these crews
provided fire rehabilitation and evacuated
the local hospital of its residents along with
countless other sick and bedridden patients.
Through all this, they still had to be there
for the 9-1-1 call I needed on that day.
Thank you EMS, from a grateful patient and
his golden retriever. Oh, look! A butterfly!
Until next time, be safe … and this time I
really do mean it. JEMS
Steve Berry is an active paramedic with Southwest
Teller County EMS in Colorado. He’s the author of the
cartoon book series I’m Not An Ambulance Driver. Visit
his website at www.iamnotanambulancedriver.com to
purchase his books or CDs.
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• Securing the Airway:
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• ‘Posting’ Is Not a Dirty Word
• When You Leave a Patient Behind: Refusals, Non-Transports Best
Practices for Documentation
• The Mobile Transformation
• EMS Strategies for Improving Cardiac Arrest Survival
• Are You Bagging the Life Out of Your Patients?
• Drug Shortage Action Plans for EMS
• Statewide Trauma System Enables Multi-Agency Coordination
with Trauma Centers to Improve Patient Outcomes
• CPAP in EMS: The Standard of Care Argument
• Top 5 Ways an In-Vehicle Router Improves EMS Operations
• CPR Quality Improves Survival
• Breathe Deeply: How CPAP and Ventilation Can Help Your Patients
• Simulating Work: How to Effectively Incorporate Simulation
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• CPAP: Filling The Sails to Respiratory Relief
Go to www.JEMS.com
by Skip Kirkwood, MS, JD,
NREMT-P, EFO, CEMSO
Enhance EMS preparation using the field
training evaluation program model
n the government sector, there’s a concept known as “the plenary police power of
the state.” This means that the state has the
authority to do things to generally protect the
well-being, and health and safety, of its citizens.
One of the ways states use this is through the
enactment of laws and regulations. The “police
power standard,” as seen in licensing statutes
and rules, is “the minimum level of knowledge
and skill needed so that the regulated profession
doesn’t constitute a threat to public health and
safety.” It’s a floor. It’s a minimum standard. In
the academic sense, it’s a grade C- (or 1.7 on a
Unfortunately, in the world of EMS, these
minimum standards often turn into a maximum,
or a ceiling, once they leave the state capitol. If
the minimum number of hours for a paramedic
course is set at 1,000 hours, then paramedic
programs at educational institutions often get a
budget for 1,000 hours and not a minute more.*
Therefore, the floor becomes the ceiling. So take
a 1.7 standard, graduate a 1.7 student, you’ve got
a 1.0 new licensee. Is that person really ready to
staff your ambulance? Do you want that person
showing up at your house when a loved one is
critically sick or injured? Probably not. If you’re
a responsible EMS agency leader, you’re aware of
this gap and understand that your agency must
do something about it.
*Author’s Note: Throughout this article, we use
the term “paramedic” to mean any level of EMS
provider who responds to emergency calls and
provides medical care and/or ambulance transportation. This use is consistent throughout National
EMS Management Association (NEMSMA)
publications, with our colleagues in Canada and
with the International Paramedic movement.
formance and progress, using valid
and reliable tools; and
Formally trained field training officers,
supervised by a hierarchy that is properly trained and understands and supports FTEP within the agency.
Is there anything in this list of requirements that isn’t applicable to an EMS agency?
Filling the Gap
Approaching the ‘Gap’
So what should we do to fill the gap between
the knowledge, skills and effective traits that
EMS providers have when they first arrive,
and those we’d want them to have when they
staff a unit in service on their first shift?
Does your organization approach this
question in a manner that will help the new
employee? Do you teach the needed (and
missing) knowledge, skills and behaviors
necessary to protect the provider and your
organization, and help to ensure compassionate, clinically excellent care for the
patients being served?
This problem is not new or unique to
EMS. The law enforcement community,
which is driven much more by litigation,
began to confront this same issue in the
mid-1960s, when societal demands on law
enforcement began to change, workforce
challenges surfaced and community expectations increased.
What had been a casual, mostly on-the-job
training environment needed to change. The
law enforcement community took a close
look at their training and operational practices and made the following observations:
1. you don’t adequately train new
employees, bad things happen.
2. f bad things happen, you get sued.
3. f you fire people who want their jobs,
you get sued.
They adopted a system: the Field Training and Evaluation Program (FTEP), which
originated in 1976 in San Jose, Calif., and
spread throughout the U.S. It’s now required
for police officer certification in many states
The “Bible” of the FTEP program is the
book The Field Training Concept in Criminal
Justice Agencies, by Glen Kaminsky, which
states that an FTEP requires the following:
An identified set of competencies that
a new police officer must be able to
perform before being released for independent duties;
reliable and valid process by which
the new police officer is coached,
taught and evaluated;
tandardized documentation of perS
EMS agencies have several approaches to
training new employees. One way of thinking, often expounded by EMS managers, is ,
“They have a state license, so they have been
taught what they need to know.” Agencies
with this attitude give them the keys to an
ambulance, or just a small orientation, and
send them out on a rig.
Another line often heard is, “We’re not
sure what they know, so we assign them
with an experienced medic to teach them
the ropes.” The problem with this approach
is that most of those folks have not received
any formal training in how to teach, evaluate or perform employee development.
Finally, the last common way of thinking
is, “We need to be sure that they know certain things, so we’ll give them an orientation
manual and let their preceptor work through
it with them.” This approach assumes that
what new employees are lacking is psychomotor skills, which may be part—but only
part—of the problem.
None of these approaches is sufficient. If
you use an “on the job training” process for
making employment determinations, that
is a “test” pursuant to EEOC guidelines. So it
must be a valid and reliable test. If not, it has
an “adverse impact” on anyone, substantial
liability could result.
Some agencies have what they call a field
training officer (FTO) program, although
many of those programs lack the essential
elements of a valid, reliable program. If you
ask the medics, “Can you identify the hard
FTOs and the easy FTOs?” If even one says
“yes”, your system isn’t reliable because it
doesn’t have a universal, identifiable standard for passing or failing the process.
In the mid-1990s, a number of EMS leaders
discovered the law enforcement FTEP program During the intervening years, several
EMS agencies built an EMS version of FTEP.
Discussion among NEMSMA members
revealed a perception that “the gap” was not
only a real issue, but also an issue that was
widening. So in 2009, multiple agencies came
together to take the fledgling EMS-FTEP program and make it standardized and available
throughout the EMS community.
EMS-FTEP consists of two educational
programs, the first of which is “Developing and Managing the Emergency Medical
Services Field Training and Evaluation Program.” This program is directed at senior
EMS executives and chief officers, training
chiefs and other middle managers.
This 24-hour management program
requires 2–2.5 days of instruction and educates participants on the need and basis
for quality, essential elements (standardized
evaluation guidelines, daily observation
reports and the recruit training manual)
and how to develop them. It outlines how
to select, train and supervise EMS FTOs;
the legal aspects of EMS-FTEP; and the role
of supervisors, managers and executives in
ensuring the success of the program.
The second program is the “Basic EMS
FTO Course.” This course is designed for
EMS personnel who are destined to serve as
FTOs in their EMS agencies and for first-line
supervisors who will have daily oversight of
FTOs and their medics-in-training.
It lasts 3.5 days and
includes the essentials
For more information,
of teaching, coaching
and remedial training strategies, how to
work with employees from different generations, use of EMS-FTEP tools, paramedic/
trainee/patient safety, provision of feedback,
documentation of performance, and ethical
and legal issues involved in field training.
The third FTO component, currently in
development, is an FTO program accreditation process. EMS agencies that develop and
operate field training programs meeting
NEMSMA’s EMS-FTEP program standards
will be recognized as meeting EMS-FTEP
Wrapping It Up
Responsible EMS agencies must identify
what’s missing in the gap and take steps
to fill in that gap. NEMSMA’s EMS-FTEP
program will help agencies develop, implement and evaluate a sound, legally defensible program that will make sure employees
are ready when they “hit the street” to provide service to their community. JEMS
Skip Kirkwood, MS, JD, EMT-P, EFO, CMO, is the chief
of the Wake County (N.C.) EMS Division and the current
president of the National EMS Management Association.
Contact him via e-mail at firstname.lastname@example.org.
Many factors can
incident of any size
By A.J. Heightman, MPA, EMT-P
hen you think of a mass casualty incident (MCI), you often
think of a plane crash, bus accident or other incident that
thrusts a large number of victims on responders and tests the
resources of an EMS system. However, multiple-patient incidents
that have complicating factors occur throughout the world every
day. These “MCI multipliers” tax the resources of an EMS system or
inhibit the response, access or egress to a scene.
When MCI multipliers exist or occur during an incident, a
small MCI can be just as challenging to manage as a large one,
so it’s important that incident managers—and EMS, fire and law
enforcement personnel—recognize these factors and take them
into account when developing their action plans and managing a
scene that involves one or more multipliers (see Table 1, p. 56).
But if you plan ahead and recognize MCI multipliers when you
encounter them, you can request any necessary additional or specialized resources. You can also engage in important communications with supervisors, communications centers, hospitals and
regional medical resource centers to stay ahead of the chaos.
This article profiles an incident that occurred in the Los Angeles
County Fire Department’s (LACoFD) service area. On Tuesday, June
The scene of a mass
casualty incident can
be compounded by
LACoFD USAR team
and crib an unstable
pickup truck involved
in a 19-vehicle
A patient is extricated
in a coordinated
operation by LACoFD,
AMR and Bowers
photography Rick McClure
continued from page 55
26, 2012, this well-drilled, high-call-volume
EMS system with numerous resources and
personnel was presented with a small MCI
that involved several MCI multipliers.
The first multiplier was the location of
the incident: a heavily traveled section of the
Antelope Valley (14) Freeway that traverses
a mountainous, remote area in northeastern Los Angeles County near Agua Dulce
south of Lancaster. It’s a section of the highway that’s notorious to responders for frequent accidents.
The incident involved just 17 people,
two of whom were triaged as critical, but
it presented situations and obstacles that
made the incident commander’s work just
as hard as an MCI involving 100 patients.
The Incident Unfolds
The incident started around 9:40 a.m. on
the southbound side of the “14” freeway,
in an area where there’s a steep, downhill, right-hand bend on the highway.
Debris that fell from an unidentified vehicle caused traffic to strike it, which led to
a sudden backup on the freeway. A tractor
trailer rig full of stone and dirt then rounded
the bend at normal speed and collided with
In an instant, a chain reaction began,
causing the tractor trailer and 18 other vehicles to pile up in what a Los Angeles Times
reporter described as “bizarre roadside
sculptures.” Another multiplier was traffic halted on the southbound side of the
freeway and subsequent lane closures that
caused a backup for miles. The LACoFD
dispatch center initially dispatched crews
on a “traffic collision, person trapped”
That assignment sent ALS Squad 131,
Engine 107, paramedic assessment Engine
81, Quint 104 and Battalion Chief (BC) 22
and an American Medical Response (AMR)
ambulance. But subsequent reports and
MCI multipliers soon escalated the incident
to a higher-level response.
In a stroke of good luck, a Bowers Ambulance Service ambulance, not a normal
response unit for the area, was on another
assignment and happened on the crash
scene within two minutes of the pileup.
They reported to LACoFD dispatch that
there were at least six vehicles involved and
two patients trapped, one underneath a pile
of vehicles (another multiplier). Another
ambulance from MedResponse Ambulance Inc., also traveling on the freeway, also
stopped at the scene and was integrated into
Early Command Decisions
When BC 22 Greg Hisel arrived on scene,
he immediately established formal incident
command (IC) from a position in the northbound lane/center divider, where he could
be easily identified and located, and had a
maximum view of the incident.
Hisel says that his first observation after
assessing the scene was that the big rig
wasn’t able to stop in time and “ran through
the stopped vehicles like a ping pong ball.”
California Highway Patrol (CHP) officers
were already on scene and had shut down
the No. 1 northbound lane and all southbound lanes. The IC confirmed with the
Table 1: Multipliers that Affect MCIs
1. Physical location access/egress complications.
2. Number of access points distance between exits on a highway.
3. Location, speed density of traffic.
4. Weather or roadway conditions.
5. Time of day.
6. Staffing levels.
7. Massive debris field.
8. Other simultaneous incidents that drain available resources.
9. Location of specialty teams resources.
10. Ambulances unfamiliar with a district’s MCI operational procedures.
11. Ambulances from another system arriving on scene, or self-dispatching.
12. Hospital backlogs, closures or lack of resources or capabilities.
13. Communication coverage gaps or inability to communicate with mutual response resources.
14. Failure to establish incident command, divisions or groups early enough.
15. Lack of scene vests or identification of triage, treatment or transportation areas.
16. Late or improper access directions or staging instruction to incoming units.
17. Complicating factors, such as ongoing crashes, gunfire or explosions.
Bowers crew and CHP officers that there
were eight patients, two of whom were
entrapped in a vehicle under the pile.
Hisel knew he shouldn’t delay requesting additional resources. So he requested
that two additional ambulances be sent to
the scene by AMR, the contracted LACoFD
Because of the tractor trailer involvement and the fact that multiple vehicles
were mangled on top of each other, with
the potential for fuel leaks and other hazardous materials involved (more multipliers), the IC requested a hazardous materials
(hazmat) response. That request resulted in
the dispatch of Hazmat Task Force 129 that
brought Hazmat Engine 129 and a specialized hazmat vehicle to the scene.
Initial Search Assessment
For a more complete search and tally
of involved people and patients, the IC
assigned Paramedic Assessment Engine
81, commanded by Captain Frank McCarthy, to perform a search of the scene and all
involved vehicles. He also assigned Engine
81 to start triage operations and requested
the closet LACoFD air squad be placed
As a standard procedure, Hisel ordered
one engine to position protector hose lines
and dry chemical extinguishers on both
sides of the incident. Engine 107’s crew,
commanded by Captain Steve Bartram, was
assigned to establish a medical group.
A duty safety officer, Captain Doug
LaCount, ensured that proper safety gear
was in use and all safety aspects were considered and managed. LaCount also doubled
as the scene public information officer and
briefed the media.
When advised by Engine 81 that 17 patients
were involved, with two of them entrapped,
Hisel asked dispatchers to upgrade the call
to a “major” incident. This escalated the
unit response to three engines, two trucks,
two paramedic squads, urban search and
rescue (USAR) Task Force 130 (seven personnel who respond in a special tractor
trailer) and Squad 130, a two-person USAR
Rescue Tender. He also requested the dispatch of a heavy rescue vehicle equipped
with a crane.
As another stroke of luck, LACoFD USAR
130, en route to a training exercise, happened to be on the southbound 14 freeway
and arrived on the scene rapidly. They went
to work immediately, cribbing and shoring
vehicles with air shores and other stabilization equipment not normally carried on
ladder companies, quints or engines. Quint
104, led by Captain Chad Hunter, was designated as the extrication group, and oversaw
the extrication of both patients in conjunction with the USAR team.
When AMR supervisor David Ellis
arrived on scene, he was assigned the role
of transportation coordinator and immediately requested five additional ambulances.
With the southbound side of the freeway
completely shut down, the IC and CHP command officer approved several northbound
units to have access the scene via the southbound lanes (another multiplier).
Access was difficult because of the road
closure, so Ellis requested five additional
ambulances from the Santa Clarita area
because he knew access from that direction
would be more efficient.
Ellis had to have incoming units,
approaching from both directions, stage in
separate areas, with non-transport LACoFD
ALS and USAR squad units positioned in a
separate area. The first-arriving ALS squad
(131) was assigned to established contact
with the LA County Medical Alert Center to
provide a scene report, alert local hospitals
of the incident and request bed availability.
Most of the injured were walking wounded
victims who extricated themselves and
walked up to the established triage area
located along the shade side of the highway along the face of a cliff. This can be
another multiplier: EMT/firefighters were
initially confronted with five to seven walking wounded and Priority 3 patients complaining of neck and back pain. In the initial
stages of triage, the EMTs applied C-collars
and positioned patients in a safe patient collection area on the shady side of the highway
until triage was completed and additional
treatment personnel arrived on scene.
Once assessed, the patients deemed to
be in need of complete immobilization
were fully immobilized and moved in priority order to ambulances by the transportation coordinator. The Medical Alert
Center assisted the transportation group
supervisor via his assigned radio officer (from ALS Squad 131) in assigning patient to the most appropriate
hospital and ensuring an even distribution of patients. Because the size
of the incident was within the scope
of normal operations for the crews
on the scene, triage tags weren’t used.
Instead, the crews used their regular
EMS reports, which feature a special
section on the back of each report for
The patients at this incident were all
triaged, treated and transported from
the scene in less than an hour despite
the geographic and physical obstacles
presented by the remote area of the
highway. They were evenly distributed to four area hospitals: Antelope
Valley Hospital in Lancaster, Palmdale
Regional Medical Center in Palmdale,
Henry Mayo Newhall Memorial Hospital in Newhall and Providence Holy
Cross Medical Center in Mission Hills.
The truck driver,
initially reported as
a period of unconsciousness, was
extricated from the
cab of his vehicle
by LACoFD and
It’s beneficial to have
areas for transport
at the scene of a
As with any incident of this nature,
crews debriefed and conducted an
“after action” review. Some of the key
lessons learned include the following:
The benefits of joint training
with contracted and mutual
aid ambulance services and
their familiarity of critical MCI
operational and command
2. The importance of early search
and rescue process and designation/
use of a safety officer;
The benefits of joint command and
use of frequent, concise scene reports;
The need to request extra resources
and specialized teams early;
The importance of knowing the distance to nearby exits/access points;
P resentation of vehicle access,
approach and staging information
to units, particularly when major
traffic backups or blocked roadways
The need to use tarps or flags to identify the location of the triage and treatment areas for walking wounded and
rescuers bringing supplies or patients
The potential need to dispatch a
Providers place C-collars and prevent unnecessary movement for walking wounded.
tanker or water tender in the event a
significant water supply is needed in
a remote area;
The benefit of dispatching heavy rescue and/or USAR resources early
into an incident to capitalize on their
technical skills, specialized tools and
shoring supplies; and
10. he need to deploy scene ID vests
whenever a scene escalates or mutual
aid resources are involved, so command responsibilities are clearly
visible and crews can identify key
personnel and their locations. JEMS
A.J. Heightman, MPA, EMT-P, is the JEMS editor-in-chief
and has a background as an EMS director and EMS operations director. He specializes in MCI management. Contact
him at email@example.com.
Current goals obstacles in cardiac arrest By Brandon Oto
randon Oto, BA, NREMT-B, is editor of emsbasics.com and a field EMT and clinical educator who
works with rescuers in numerous settings to promote best practices for resuscitation and streamline
systems of care. He discussed sudden cardiac arrest (SCA) outcomes with JEMS in advance of September’s
biannual Emergency Cardiovascular Care Update Conference. In this question-and-answer session, Brandon
offers his perspective on the current challenges of SCA and how folks in the trenches are confronting them.
Q: Why should we change the
way we do things?
A: Sudden cardiac arrest (SCA) continues to
needlessly kill too many people. If you collapse tomorrow without a pulse in downtown Seattle, you have about a 50/50 chance
of walking out of the hospital with a functioning brain. But if you were to collapse in
Detroit instead, your chances of survival
would be less than 1%. That’s a difference of
over 40 times, and we’d never accept such a
survival disparity for other diseases. In fact,
if anything else caused that many preventable deaths in our community, there would
be an uproar.
Granted, some people simply aren’t going
to survive after sudden out-of-hospital cardiac arrest. But when we compare numbers, we’re usually looking at witnessed
arrests with a primarily cardiac etiology and
a shockable initial rhythm. In other words,
these are patients who could survive if we
give them a fighting chance.
It is possible to fix the gap? Consider that
Wake County, N.C., which saw around 14%
of its shockable arrests survive in 2004,
improved its survival to more than 40%
after an aggressive initiative to strengthen
their resuscitation infrastructure. That
could be you.
Q: I want numbers like that in my
community. What’s the secret?
A: Unfortunately, if we’ve learned anything yet after 60-plus years of resuscitation
research, it’s that there’s no secret. The old
model of a “cardiac chain of survival” keeps
proving true. Good outcomes depend on
an interlocking sequence of events happening rapidly and effectively. If even one link
is weak or missing, you can’t make up for
it elsewhere. There are no silver bullets or
quick fixes; a comprehensive system built on
a solid foundation is essential.
Q: This doesn’t sound new at all.
What has changed?
A: It’s not new. If anything is new, it’s our
understanding of what’s truly necessary
and what can be deemphasized. It’s clear
that early and high-quality chest compressions save lives, as does early defibrillation,
and post-arrest hypothermia. Beyond those
three interventions, anything else is experimental at best and a distraction at worst,
so the goal is now to create systems that
streamline delivery of the basics.
In most cases, the weakest link in the
chain—and hence the lowest-hanging
fruit—is layperson intervention. Many
arrests still don’t get bystander compressions; even fewer get pre-EMS defibrillation.
The consequences are grim. Thus, the challenges of resuscitation have shifted from
the clinical, such as finding the ideal antiarrhythmic medication, and toward the
psychological: determining how to market
CPR so people will learn it, teach it so they’ll
remember it, and contextualize it so they’ll
be willing to do it.
That’s why the American Heart Association (AHA) CPR recommendations have
been getting simpler every five years. If
streamlining the methodology means that
more patients get compressions instead of
nothing, that’s a definite win.
We’re realizing that when EMS providers walk in and nobody’s doing CPR—even
bystanders who have been certified—it’s
because they were afraid of doing it wrong
and being liable, concerned about catching
a disease, or not confident they could correctly recognize the need. We can fix those
problems with smart and pointed public
education, such as public safety announcements and simplified 20-minute CPR Anytime courses. In short, we need to mobilize
On the other hand, we’re also learning
that chest compressions and defibrillation
aren’t “all or nothing.” You can execute them
well or poorly, and the quality of that execution makes a difference.
As a result, today’s ideal resuscitation
is much closer to a golf swing than a math
test. It’s become a physical rather than a
cognitive skill. But it’s still not an easy skill,
and practice is needed to succeed. EMS systems that are yielding the best survival are
taking the time to drill through the fundamentals until all responders are performing compressions deep and fast, with full
recoil, minimal interruptions, no hyperventilation and seamless integration with
That’s the reason for the “pit crew” model
many successful services have adopted,
where the role of every provider is explicitly
assigned and choreographed ahead of time.
It’s all just another way to ensure the fundamentals are done right.
Q: This sounds like a big undertaking. Where do I start?
A: To address any problem with so many
different facets, numerous parties must be
involved. This includes government, public
safety, EMS and healthcare agencies, as well
as the public itself. Rarely will a system be
successful without widespread buy-in.
These parties won’t come together without an active effort to recruit them. Since
most victims of SCA don’t survive, it isn’t a
high-visibility problem and public awareness is poor. Motivation for change requires
champions to advocate for it. EMS is well
positioned to shoulder that burden, along
with other public safety and healthcare services. We can also benefit from the testimony of successfully resuscitated victims,
whose good outcomes and compelling stories help bring the message to life.
Most of all, it’s clear lip service isn’t
enough. Everyone believes in these ideas
and wants survival. But you need to put
in real work and make real changes. And
although it’s often difficult to get traction
when most people don’t realize the problem exists, things can snowball once they
For example, one of the great achievements in Seattle wasn’t just developing
strong tools for resuscitation, it was creating
a culture of survival. Now, the community is
proud of what they have. They believe in it.
And if someone collapses, there’s an expectation that someone else will intervene.
You don’t need to reinvent the wheel.
Some great templates already exist, such as
Medtronic Foundation’s HeartRescue program and the AHA’s HEARTSafe Communities. In the HEARTSafe model, a region
(usually a state) establishes criteria supporting the chain of survival. When a community in that region meets the requirements,
they can apply to their home office and
receive “HEARTSafe” designation, earning
the right to post a sign proclaiming that status. It’s an odd motivator and a grass-roots
approach. Although the AHA supports the
concept, nobody owns it, no central administration exists, and it costs nothing to
implement. But it’s proven internationally
successful, and if your state doesn’t already
have a program, many good criteria exist
that can be readily adopted.
Q: That covers bystanders. what
should EMS agencies be doing?
A: The first step is data collection. You
need a reliable scorecard. If you don’t know
how well you’re doing, you can’t do much to
improve. (Nor would you even realize if you
had.) The more data, the better.
With hospital input, basic figures can be
compiled directly from electronic patient
care report systems. Or you can use a purpose-built, Utstein-type registry, such as the
Cardiac Arrest Registry to Enhance Survival
To drill down further, all major manufacturers offer software suites allowing review
of data, such as compression fraction (i.e.,
the total time spent on vs. off the chest), depth
and ventilatory rate. This is invaluable for
pinpointing where you need to focus your
efforts, both as a system and as individual
providers. As you implement changes, you
can track the results and watch your numbers climb.
Ironically, one of the challenges can come
from the veterans in your system. Many
paramedics with 10–20 years’ experience
have visited so many arrests and seen so few
positive outcomes that they’ve come to view
working a code as mere ritual, an opportunity to go through the motions and perhaps
practice some little-used skills, rather than
a fight for survival. Highlighting the statistics and offering testimonies from survivors
can help convince them that out-of-hospital
SCA is now a treatable, survivable condition.
Once they’re believers, they can become
your best advocates.
Work with your fellow rescuers to establish a standard flow of care, if not an actual
“pit crew” model, for every arrest. This will
not only ensure that everybody understands
their role and what the goals are on scene,
it also gets all parties on-board so that the
police officer who shows up first is just as
passionate about compressions and defibrillation as the paramedics who arrive later.
In addition, remember that your receiving hospitals are a key part of the puzzle.
Post-arrest hypothermia is truly lifesaving,
yet has still not been consistently adopted in
EMS may help move this forward by
working directly with hospital administrators. However, if financial constraints or
general institutional inertia stand in the way,
we can also apply friendly but effective pressure by instituting field hypothermia protocols (most EDs are more likely to continue
ongoing cooling measures than to initiate
them), or even modifying destination plans
to prohibit post-arrest patients from being
transported to hospitals that won’t provide
Another conversation worth having
involves hospital willingness to perform
percutaneous coronary intervention (PCI)
on post-arrest patients, or even intra-arrest
patients (perhaps using a mechanical compression device) who have not achieved
return of spontaneous circulation (ROSC).
Although potentially lifesaving, many
centers are reluctant to catheterize these
patients due to their risk—treating such a
high-mortality cohort can bring down outcome figures. Try to work out indications
and contraindications with the interventionalists ahead of time.
Q: What’s on the horizon?
A: Intriguing possibilities for future interventions include the administration of such
IV female sex hormones as estrogen, which
has shown promise for mitigating tissue
damage. “Ischemic conditioning,” possibly
using low-tech devices like blood pressure
cuffs, may also prove to be beneficial.
Double defibrillation for refractory ventricular fibrillation (v fib), lipid infusions for
overdoses and high-dose nitrates all might
have a role for specific patient groups. And
more studies are needed to refine best practices for hypothermia, including the role of
field induction and specific endpoints for
duration, temperature and supportive care.
We may even eventually find that effective hypothermia helps “bridge the gap” to
neurologically intact discharge for the many
therapies, such as epinephrine, that have
shown early improvements in ROSC but no
Better still are innovations that improve
our ability to deliver BLS, such as realtime CPR feedback and metronome tools,
active decompression devices or smartphone apps that direct bystanders to available AEDs.
And there’s some evidence that “handson CPR,” or defibrillation without taking
gloved hands off the chest, may be safe and
allow us to remove yet another interruption to continuous compressions. (Some
clinicians are already practicing this routinely, with no negative incidents reported
In the end, however, the basic picture
remains the same. Improving survival
from out-of-hospital cardiac arrest requires
widespread improvements to the entire
chain of survival. And that means making
a commitment and doing the work. We can
have it everywhere, but it won’t happen on
its own. JEMS
Dealing with the 12 types of
By Mark Cipolle, MD, PhD; Michael Rhodes, MD; Glen Tinkoff, MD
Case Study 1: You’re dispatched to a scene in which a young male has been stabbed. On
arrival, you hear him screaming in pain and find him diaphoretic and dyspneic. He tells you he
was stabbed with a pocket knife. The wound is in the right chest, slightly lateral and just above the
nipple. He has distended neck veins, decreased breath sounds on the right chest, a systolic blood
pressure of 60 and a heart rate of 130. You provide supplemental oxygen, and then you would do
which of the following?
a. Perform drug-facilitated intubation;
b. Place an IV;
c. Perform a needle decompression of the right chest; or
d. Place a chest seal over the wound.
Of course, we know you selected “c” because there are few things more gratifying in trauma care
than saving a life with a needle decompression for a tension pneumothorax! You recognized that the
patient was maintaining his own airway and the shock was due to inadequate venous return from
the elevated pressure in his right chest. Just like other life-threatening problems after injury, putting
more volume in a closed space will soon lead to disastrous consequences (e.g., tension pneumothorax, cardiac tamponade, brain hemorrhage and brain edema).
Photo adam fox
Hospital staff performs a thoractomy on a patient
where the heart is visible through the wound.
continued from page 61
Case Study 2: Shortly after completing your paperwork from the stab wound
patient, you’re summoned to care for an
intoxicated middle-aged man who drove his
car off the road, rolled over a few times and
smashed into a tree. He was unrestrained.
He’s complaining of severe left chest pain,
and you observe abrasions, crepitus and poor
chest rise with inspiration of the left chest.
His BP is 120/80, HR is 110 and oxygen saturation (SpO2) is 85%. Which of the following
would be your next step?
a. Place an IV;
b. Place the patient on high-flow oxygen;
c. Perform a needle decompression of the
left chest; or
d. Perform rapid sequence intubation.
When we answer this question, our
thought process goes something like this:
The airway is intact, and circulation appears
reasonable. However, there’s a problem with
breathing, so the answer is “b.” The patient
likely has a flail chest and may very well have
a hemothorax and/or pneumothorax on that
side, but vital signs are reasonable so needle
decompression is not indicated. This patient
will be best served by supplemental oxygen,
followed by placing an IV line (“b” is before
“c”) while rapidly transporting your patient
to the trauma center for definitive care.
These cases are examples of two patients
with life threatening thoracic trauma who
have different mechanisms of injury. The patient
in the first case required a rapid assessment
and a decision, as well as a maneuver in the
field that saved his life. The second patient
required BLS intervention only.
bout 25% of trauma deaths in the U.S.
result from major thoracic injury.
Although most thoracic trauma is ultimately
managed without an operation (up to 85%),
proper prehospital management is vital in
achieving a good outcome. Early recognition
of severe or potentially severe thoracic injuries followed by rapid treatment in the field
may make the difference between life and
death for these patients. Several prehospital
interventions are currently available—and
some on the horizon—that providers may
employ with the potential to reduce the mortality and morbidity of chest injury.
To properly treat these patients, providers
should be able to recognize the “deadly dozen”
thoracic injuries, understand the importance
of the mechanism and location of injury and
Recognize the “deadly dozen” thoracic
Understand the importance of the
mechanism and location of injury.
Be able to identify the key features of a
good assessment of chest injury.
Mechanisms of injury: The method or force that
causes a victim’s injuries.
Tension pneumothorax: Positive-pressure air
or gas accumulation within the pleural cavity,
compressing the lungs and limiting the ability of the
heart to function.
Thoracotomy: An incision into the chest cavity.
Pericardial tamponade: Compression of the heart
due to increased pressure within the pericardial sac
due to accumulated fluid or blood.
identify the key features of a good assessment
of chest injury. In addition, current monitoring and therapeutic options, and new monitoring technologies are also important in the
prehospital management of thoracic trauma.
The ‘Deadly Dozen’
With such vital structures as the heart, lungs
and major vascular structures residing in the
thoracic cavity, it isn’t surprising that chest
injuries can be or become fatal immediately
or within hours. The foundation of good
trauma care, as taught in Advanced Trauma
Life Support and Prehospital Trauma Life
Support, is to identify and treat life-threatening injuries in the “golden hour.”
Other than provision of a definitive airway and/or needle decompression of a tension pneumothorax in the field, the vast
majority of patients with thoracic injury will
be best served by “load and go” with highflow oxygen and placement of an IV line.
Mechanism of Injury
It’s important to consider that the thoracic
cavity not only contains the heart and lungs
but also the origination of major vascular
structures (e.g., the aorta, subclavian and
carotid arteries). Also, running through the
mediastinum along with the heart are the
major aerodigestive structures, the esophagus, trachea and bronchi. The bottom half of
the rib cage protects such major structures of
the upper abdomen as the liver, spleen, stomach and kidneys.
In fact, the diaphragm may rise as high
as the fourth intercostal space, so penetrating injury in this thoracoabdominal area can
injure vital organs both above and below the
diaphragm. The thoracoabdominal region
Table 1: The ‘Deadly Dozen’ Killers of Thoracic Trauma
Injuries identified in the primary survey often encountered by prehospital personnel
Airway obstruction: The airway originates in the thorax constituting the tracheo-bronchial tree, which may
obstruct with blood or secretions that need to be addressed despite the presence of an endotracheal tube or
Flail chest: Two fractures on at least two adjacent ribs, causing instability in part of the chest wall and paradoxical
breathing with the lung underlying the injured area contracting on inspiration and bulging on expiration. This
results in respiratory insufficiency.
Open pneumothorax: A pneumothorax associated with a chest wall defect greater than 0.75 times the size of
the trachea in which air enters preferentially through the thoracic cavity (“sucking” chest wound) and results in
inadequate oxygenation and ventilation.
Massive hemothorax: Greater than 1,500 mL of blood within the pleural space of a hemothorax, causing significant
compression of the lung and hemorrhagic shock.
Tension pneumothorax: Progressive build-up of air within the pleural space that pushes the mediastinum to the
opposite hemithorax and obstructs venous return to the heart, leading to circulatory instability and arrest.
Cardiac tamponade: Compression of the heart that occurs when blood builds up in the pericardial sac impeding
heart contractions and leading to circulatory instability and arrest.
Injuries identified in the secondary survey or during hospital evaluation
Traumatic aortic rupture
Tracheal or bronchial tree injury
Photo adam fox
Photo edward dickinson
is defined as nipples to costal margins in the
front and inferior border of scapula to costal
margins in the back. The location of penetrating injury is critical to provision of proper
prehospital care and hospital evaluation.
It’s important to separate stab wounds
from gunshot wounds. In addition, gunshot wounds should be categorized by type,
velocity, number of wounds and trajectory.
For a categorization of gunshot wounds, go
Stab wounds should be characterized
when possible by number, location, and the
width and length of the blade. It’s critical to Gunshot wound to the “box.”
identify and accurately describe the anatomic penetrating injuries or blunt injury at 1–2%). 64 for these mechanisms and the potential
location of stab wounds. It’s not only impor- Given this, most trauma surgeons will per- deadly injuries associated with them.
tant to guide the work-up once the patient form a resuscitative thoracotomy on a patient
arrives at the trauma center, but it may deter- with penetrating chest trauma that had signs Assessment
mine what you do in the field if a patient sud- of life in the field and up to 15 minutes of A good history and physical examination
CPR. Therefore, effective CPR and commu- is essential. PHTLS recommends a SAMdenly deteriorates.
For example, a patient who becomes nication with the trauma center would be PLE history (symptoms, age and allergies,
pulseless in your ambulance with a single what’s best in this scenario.
medications, past history, last meal and the
stab wound to “the box” (a rectangle outlined
events surrounding the injury). The physical
by the clavicles, nipple line and costal mar- Blunt Injury
examination, challenging in the field, should
gins) will be treated differently from a patient In many ways, blunt injury is more chal- include observation, auscultation, palpation
with a chest stab wound lateral to the box. In lenging to care for than penetrating injury, and percussion accompanied by pulse oximthe latter case, our working diagnosis would because it’s generally less obvious which etry. A great deal can be learned by taking
be a tension pneumothorax, which will be organs are injured, and it’s often accompa- a minute to perform an adequate thoracic
treated with a needle decompression. The nied by more tissue injury and inflammatory exam with special attention to the findings
first patient who has a stab wound in the box response. This is especially true in civilian described in Table 4, p. 64.
is likely dying of pericardial tamponade from trauma. Other than an open pneumothorax
A good assessment may be challenging
a cardiac injury. This patient will be best and cardiac tamponade, the remainder of the in the field. For instance, the classic signs of
served by “load and go” and communication “deadly dozen” are more common after blunt a tension pneumothorax may be difficult to
of this scenario to the trauma center so they injury than penetrating injury.
identify at a chaotic scene. Cyanosis may be
may prepare for direct operating room (OR)
Blunt injury should be described by mech- difficult to identify in low-light conditions,
transport and sternotomy.
anism so the trauma team can identify key especially with blood and dirt present. DisTable 2, below, describes important ana- injuries as quickly as possible. See Table 3, p. tended neck veins is a classic sign but a late
tomic descriptors for penetrating trauma that may Table 2: Anatomic
Descriptors of Penetrating
assist in facilitating diagnosis
An important aspect of
penetrating thoracic trauma
Right vs. left
is that it has the highest surSupraclavicular
vivability after resuscitative
thoracotomy. Patients with a
Precordial (or “the box”)
single penetrating injury to
the chest are more likely to
survive a resuscitative thoLateral chest
racotomy than any other
type of patient. Survivability in this scenario has been
reported to be 15–35%. No
Above or below nipple
other type of injury comes
anywhere close to this surSubsternal
vivability (e.g., multiple
A patient with a knife wound to the chest that’s partially in “the box.”
finding and won’t be present in a patient who
has had substantial blood loss.
Determining whether breath sounds are
diminished on one side may be difficult in
a noisy environment. Practicing listening
to breath sounds as much as possible will
help providers to become more proficient.
Percussion of the chest to detect hyperresonance may be challenging enough in a quiet
environment and nearly impossible at a
noisy scene. Tracheal deviation due to a tension pneumothorax is more pronounced in
the chest and is usually identified by a chest
radiograph, a tool obviously not available
in the field. Tracheal deviation in the neck is
rarely apparent and is truly a very late sign.
Photo adm fox
continued from page 63
Seatbelt sign of the chest can be an important indicator of hidden thoracic injuries.
and percussion. All providers should become
adept at these techniques and practice them
as much as possible.
The utility of these new monitoring
options in the prehospital environment is
Although prehospital monitoring is becom- still under investigation. The focused abdoming more sophisticated all the time, EMS pro- inal ultrasound for trauma (FAST) is now an
viders shouldn’t lose sight of the basics, which accepted and routine part of the secondary
include observation, palpation, auscultation survey during hospital evaluation.
Many reports on the
Table 3: Blunt Thoracic Trauma Mechanisms Associated Injuries
role of ultrasound in the
prehospital setting note it
Mechanism of Injury
can be useful in detecting
Blunt cardiac injury
pneumothoraces, hemoRuptured aorta
Blunt cardiac injury
Ruptured thoracic aorta
Hollow viscus retroperitoneal injuries
hemorrhage and cardiac
arrest, as well as being
helpful in cases of diffiLateral impact
cult IV access. It has been
demonstrated that paraFall (with height when available)
Ruptured thoracic aorta
medics can become adept
at using this technology
Roll over and/or ejection
Tracheal or bronchial injury
Primary (i.e., initial overpressure)
Direct lung injury
Secondary (i.e., struck by shrapnel)
Tertiary (i.e., patient is throw or crushed)
Quaternary (e.g., thermal or radiation
Direct lung injury
relatively quickly. Considering this and the
portability and relatively low cost of ultrasound, we anticipate it becoming more
commonplace in prehospital trauma care.
Currently, it’s far more commonly employed
in Europe than in the U.S.
Another technology, near-infrared spectrometry (NIRS), is being used more commonly in trauma and emergency medicine
care to detect tissue oxygen saturation. The
currently available monitor, InSpectra StO2
from Hutchinson Technology, measures the
oxygen saturation in the thenar eminence,
which is the fleshy part of palm below the
thumb. The InSpectra StO2 measures oxygen saturation in the capillary beds of these
hand muscles giving the provider an estimate of overall tissue perfusion. Initial studies in trauma patients demonstrate that levels
less than 75% correlate with other measures
of hemorrhagic shock, such as acidosis and
the development of organ failure. This device
is now available as a portable unit about the
size of a small shoe.
Table 4: Important Findings in the Assessment of Thoracic Trauma
BP, Pulse, RR, loss of consciousness
Lip and ear lobe color (hypoxia)
Scleral hemorrhage (crush injury)
Quality of voice
Subcutaneous crepitance (rib fracture vs. air)
Tracheal deviation (late finding)
Distended Neck veins (late finding and will not be present with significant hemorrhage)
• Tension pneumothorax if decreased breath sounds
• Pericardial tamponade if decreased heart sounds
Decreased breath sounds
Air vs. blood vs. abdominal organs in chest
Image adam fox
Telemedicine is becoming more commonplace worldwide. The ability to transport
real-time data and images from the patient’s
bedside to a command center manned by
physicians and nurses has been available for
about 10 years. It’s only a matter of time until
this technology will be made routinely available to prehospital providers. EMS providers
can transmit not only patient data, such as
vital signs, ECG and pulse oximetry, and also
images that will be instantly made available
to the medical control center. It stands to reason that the ability to share this vital information in real time with medical command will
enhance care and decision making.
Although these new technologies may not
drastically change care in the field, they may
dramatically help the patient by ramping up
the response at the hospital. For instance, if
medical command is viewing ultrasound
images of a pericardium full of blood in a
penetrating trauma patient with a NIRS tissue perfusion of 50% and a systolic pressure
of 90, it’s likely that patient will be directly
transported to the OR for sternotomy, rather
than spending precious time in the trauma
bay only to have the tamponade worsen.
A CT scan of two rib fractures on the patient’s
left (right side of the image).
Although monitoring options have
expanded in recent years, our therapeutic
options have, for the most part, stayed “tried
and true.” These therapeutic options serve a
single purpose: to correct problems identified in the primary and secondary survey.
Some of the therapeutic options that may be
employed in the prehospital care of patients
with thoracic injury include:
A suction or oral airway device;
Bag-valve mask ventilation;
Table 5 Survey for Thoracic Killers
Needle decompression of the chest;
Positive-end expiratory pressure (PEEP);
Direct pressure of the hemorrhage;
Placement of an IV;
Splinting the chest wall;
A lidocaine patch over a rib fracture for
prolonged transport; and
A three-sided occulsive dressing for
Case Study 3: A young man shot in
the left lateral chest has an open “sucking”
chest wound. He appears to be in shock with
some respiratory distress with a BP of 100/60,
HR 120, 90% oxygen saturation (SpO2) and
diminished breath sounds on the left. It’s a
long transport time, so you receive medical
direction to perform drug-facilitated intubation. Intubation is successful, and you then
place a three-sided occlusive dressing over
the “sucking” wound and establish an IV.
You place a bag-valve mask with 5 cm PEEP,
which improves SpO2. However, he loses his
pulse while being loaded into the ambulance.
What would you do next?
a. Bolus a liter of fluid;
b. Increase the frequency of bagging;
c. Remove the occlusive dressing; or
d. Perform a pericardiocentesis.
The correct answer is “c.” Importantly, one
must always remember that PEEP, either via
a continuous positive airway pressure mask
or via an endotracheal tube, can worsen any
kind of pneumothorax, converting it to a
tension pneumothorax. Although the positive pressure may be helping the patient’s
oxygenation, it may cause more air to enter
the pleural space. Also, if a three-sided occlusive dressing is used on an open pneumothorax and the patient deteriorates, remove the
dressing. In this scenario, it would be equivalent to a needle decompression.
Although most thoracic trauma may be
treated non-operatively, major thoracic
trauma accounts for 25% of trauma deaths.
Except for provision of a definitive airway and/or relief of a tension pneumothorax with a needle decompression, the vast
majority of thoracic trauma is best served
with “load and go,” high-flow oxygen, placement of an IV line and administration of
crystalloid solutions as the clinical scenario
Understanding the mechanism of injury is
helpful in establishing both prehospital and
in-hospital management priorities. Patients
who sustain a single penetrating wound to
the chest have the best survivability after a
Practicing chest assessment skills is
vital to being a good prehospital provider.
Ultrasound, NIRS tissue oxygenation and
telemedicine will likely become more commonly employed as prehospital monitoring
options. PEEP, or “over bagging,” may exacerbate a simple or open pneumothorax, converting it to a tension pneumothorax. JEMS
Mark Cipolle, MD, PhD, is the medical director of the
Trauma Program at Christiana Care Health System in Wilmington, Del.
Michael Rhodes, MD, is the chairman of the Department of Surgery at Christiana Care Health System.
Glen Tinkoff, MD, is the vice chairman of the Department of Surgery and The Medical Director of the Simulation
Center at Christiana Care Health System.
1. Salomone JP, Pons PT, eds. Thoracic Trauma. Pre Hospital Trauma Life Support, Seventh Edition. 2010;291–316.
2. Asensio JA, Mazzini F, Vu T. Thoracic Injuries. Trauma
Manual, Fourth Edition. 2012; Chapter 28.
3. Bowman J. Visible Improvement: Ultrasound provides
diagnostic images in prehospital medicine. JEMS.
4. Cothren CC Moore EE. Emergency department thoracotomy for the critically injured patient: Objectives,
indications and outcomes. World J Emerg Surgery.
5. Bauza GM Peitzman AB. Thoracic Trauma. International Trauma Life Support, Seventh Edition.
6. Cohn S, Nathens A, Moore F, et al. Tissue Oxygenation saturation predicts the development of organ
dysfunction during traumatic shock resuscitation. The
Journal of Trauma injury, Infection, and Critical Care.
March 5 - March 9
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