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  • 1. OCTOber 2012 Always En Route At
  • 2. Choose 11 at www.jems.com/rs
  • 3. Choose 12 at www.jems.com/rs
  • 4. Choose 13 at www.jems.com/rs
  • 5. The Conscience of EMS JOURNAL OF EMERGENCY MEDICAL SERVICES ® 30 I JEMS 2012 Salary & Workplace Survey I The future looks bright—but how bright? By Michael Greene, MBA/MSHA OctoBER 2012 Vol. 37 No. 10 Contents I 46 42 I Healthcare Reform I Changes present an unparalleled opportunity for EMS By Teresa McCallion, EMT-B 46 I Mobile Warming I Lessons learned in hypothermia prevention under difficult field conditions By 2LT Collin Hu, EMT-E, James Spotila, PhD, EMT-B 52 I A Study on Safety I Highlights from workshop on ambulance patient compartments By Jennifer Marshall Y. Tina Lee 60 I Innovative Design I Departments columns 7 I Load go I Now on JEMS.com 12 I EMS in Action I Scene of the Month 14 I From the Editor I Patches, Pride Patients Pumper/ambulance model takes service to a new level By Bob Vaccaro 64 I Vital Pathways I Detect treat symptoms related to hemorrhagic shock By Peter Taillac, MD, FACEP, Chad Brocato, DHSC, CFO, JD y A.J. Heightman, MPA, EMT-P B 16 I Letters I In Your Words 18 I Priority Traffic I News You Can Use 24 I lEADERSHIP sECTOR I Closed Door Policy y Gary Ludwig, MS, EMT-P B 26 I Tricks OF the TRADE I Warm Enough for Ya? y Thom Dick B 28 I case of the month I Naked Unconscious y Kimberly Doran B 74 77 78 80 I employment Classified Ads I Ad Index I Hands On I Product Reviews from Street Crews I Lighter Side I Clenched Teeth Verbiage y Steve Berry B 82 I LAST WORD I The Ups Downs of EMS I 60 I 64 About Salary Survey, we revisit Flowing Springs EMS from this past year’s survey in an effort to anathe Cover In this year’s JEMS lyze how the economy and the overall structure of U.S. healthcare is affecting typical EMS agencies across the country. And as the subtitle “The future is bright—but how bright?,” hints, we found the data to be (cautiously) optimistic. pp. 30–41. Photo Chris Swabb Premier Media Partner of the IAFC, the IAFC EMS Section Fire-Rescue Med www.jems.com OctobER 2012 JEMS 5
  • 6. Choose 14 at www.jems.com/rs
  • 7. LOAD GO  log in for EXCLUSIVE CONTENT A Better Way to Learn JEMSCE.com online continuing education program n us o follow Have you ever considered serving on the board of directors for an EMS agency in your area? Before you consider it, you should be aware of what a director is—and isn’t. Unlike an operations position, which manages the dayto-day workings of an organization, the board of directors is all about leadership and governance. In “View from the Top,” Allison J. Bloom, Esq., discusses what serving on a board of directors involves, including how to set the tone and direction for an organization by engaging in strategic thinking and planning, and providing oversight of corporation management. s jems.com/article/view-from-the-top Photo Pilin_Petunyia/istockphoto.com View From the Top JEMS.com offers you original content, jobs, products and resources. But we’re much more than that; we keep you in touch with your colleagues through our: Facebook fan page; JEMS Connect site; Twitter account; LinkedIn profile; Product Connect site; and Fire EMS Blogs site. EverydayHeroes photo and video contest is your chance to nomiHeroes The Laerdal Everyday nate an individual within your organization to be recognized for exemplary service toward helping save lives. Check out their ad on JEMS.com or visit their Everyday Heroes contest for submissions guidelines. All entries will receive an Everyday Heroes t-shirt and pin. s laerdal.com/EverdayHeroes Sponsored Product Focus EMS ALS App like us facebook.com /jemsfans follow us The EMS Advanced Life Support (ALS) interactive application puts critical information at your fingertips with rich content, detailed illustrations, and pioneering features. It provides fast, easy access to vital assessment information, medications, and drug doses; quick interpretation of 12-lead ECGs; and the latest CPR and ACLS algorithms from the American Heart Association (AHA). This app is now available on the iPhone and Droid platforms. For more information call 888/624-8014 or visit informedguides.com. s Check out their ad on JEMS.com! Seeking EMS Innovators We’re looking for the EMS industry’s newest innovators, and we need your help identifying them. The 2012 EMS 10: Innovators in EMS award program, sponsored by JEMS and Physio-Control, Inc., seeks to recognize 10 people who have stepped outside the box, identified a need and taken steps to advance the art and science of prehospital emergency care. If that sounds like someone you know, nominate them before the Dec. 14 deadline. s jems.com/ems10 twitter.com /jemsconnect get connected linkedin.com/groups? about=gid=113182 ems news alerts jems.com/enews Check it out jems.com/ems-products best bloggers FireEMSBlogs.com www.jems.com OCTOBER 2012 JEMS 7
  • 8. Conscience of EMS JOURNAL OF EMERGENCY MEDICAL SERVICES The Conscience of EMS JOURNAL OF EMERGENCY MEDICAL SERVICES ® Editor-In-Chief I A.J. Heightman, MPA, EMT-P I aheightman@pennwell.com MANAGING Editor I Jennifer Berry I jenniferb@pennwell.com assistant eDITOR I Allison Moen I allisonm@pennwell.com assistant eDITOR I Kindra Sclar I kindras@pennwell.com online news/blog manager I Bill Carey I bill@goforwardmedia.com Medical Editor I Edward T. Dickinson, MD, NREMT-P, FACEP Technical Editors Travis Kusman, MPH, NREMT-P; Fred W. Wurster III, NREMT-P, AAS Contributing Editor I Bryan Bledsoe, DO, FACEP, FAAEM art director I Liliana Estep I alildesign@me.com Contributing illustrators Steve Berry, NREMT-P; Paul Combs, NREMT-B Contributing Photographers Vu Banh, Glen Ellman, Craig Jackson, Kevin Link, Courtney McCain, Tom Page, Rick Roach, Steve Silverman, Michael Strauss, Chris Swabb Director of eProducts/Production I Tim Francis I timf@pennwell.com Production Coordinator I Matt Leatherman I matthewl@pennwell.com PUBLICATION OFFICE 800/266-5367 I Fax 619/699-6396 ADVERTISING DEPARTMENT 800/266-5367 I Fax 619/699-6722 advertising director I Judi Leidiger I 619/795-9040 I j.leidiger@jems.com Western Account Representative I Cindi Richardson I 661-297-4027 I c.richardson@jems.com senior Sales coordinator I Elizabeth Zook I elizabethz@pennwell.com REprints, eprints Licensing I Wright’s Media I 877/652-5295 I reprints@jems.com eMedia Strategy I 410/872-9303 I Managing Director I Dave J. Iannone I dave@goforwardmedia.com Director of eMedia Sales I Paul Andrews I paul@goforwardmedia.com Director of eMedia Content I Chris Hebert I chris@goforwardmedia.com SUBSCRIPTION DEPARTMENT I 888/456-5367I Director, Audience Development Sales Support I Mike Shear I mshear@pennwell.com Audience development coordinator I Marisa Collier I marisac@pennwell.com marketing director I Debbie Murray I debbiem@pennwell.com Marketing Conference Program Coordinator I Vanessa Horne I vhorne@pennwell.com chairman I Frank T. Lauinger President Chief Executive Officer I Robert F. Biolchini Chief Financial Officer I Mark C. Wilmoth Senior Vice President Group Publisher I Lyle Hoyt I lyleh@pennwell.com Vice President/Publisher I Jeff Berend I jeffb@pennwell.com founding editor I Keith Griffiths founding publisher James O. Page (1936–2004) Choose 15 at www.jems.com/rs Choose 16 at www.jems.com/rs
  • 9. Choose 16 at www.jems.com/rs
  • 10. JOURNAL OF EMERGENCY MEDICAL SERVICES The Conscience of EMS JOURNAL OF EMERGENCY MEDICAL SERVICES ® EDITORIAL board William K. Atkinson II, PHD, MPH, MPA, EMT-P President Chief Executive Officer WakeMed Health Hospitals James J. Augustine, MD, 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 Community Medicine Medical Director, EMS System for Metropolitan Oklahoma City Tulsa David E. Persse, MD, FACEP Physician Director, City of Houston Emergency Medical Services Public Health Authority, City of Houston Department. of Health Human Services Associate Professor, Emergency Medicine, University of Texas Health Science Center—Houston Keith Griffiths President, RedFlash Group Founding Editor, JEMS John J. Peruggia Jr., BSHuS, EFO, EMT-P Assistant Chief, Logistics, FDNY Operations Dave Keseg, MD, FACEP Medical Director, Columbus Fire Department Clinical Instructor, Ohio State University W. Ann Maggiore, JD, NREMT-P Associate Attorney, Butt, Thornton Baehr PC Clinical Instructor, University of New Mexico, School of Medicine Connie J. Mattera, MS, RN, EMT-P EMS Administrative Director EMS System Coordinator, Northwest (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, Colorado District Jay Fitch, PhD President Founding Partner, Fitch Associates Ray Fowler, MD, FACEP Associate Professor, University of Texas Southwestern SOM Chief of EMS, University of Texas Southwestern Medical Center Chief of Medical Operations, Dallas Metropolitan Area BioTel (EMS) System Adam D. Fox, DPM, DO Assistant Professor of Surgery, Division of Trauma Surgery Critical Care, University of Medicine Dentistry of New Jersey Former Advanced EMT-3 (AEMT-3) Gregory R. Frailey, DO, FACOEP, EMT-P Medical Director, Prehospital Services, Susquehanna Health Tactical Physician, Williamsport Bureau of Police Special Response Team 10 JEMS OCTOBER 2012 Mary M. Newman President, Sudden Cardiac Arrest Foundation Joseph P. Ornato, MD, FACP, FACC, FACEP Professor Chairman, Department of Emergency Medicine, Virginia Commonwealth University Medical Center Operational Medical Director, Richmond Ambulance Authority Jerry Overton, MPA Chair, International Academies of Emergency Dispatch David Page, MS, NREMT-P Paramedic Instructor, Inver Hills (Minn.) Community College Paramedic, Allina Medical Transportation Member of the Board of Advisors, Prehospital Care Research Forum Paul E. Pepe, MD, MPH, MACP, FACEP, FCCM Professor, Surgery, University of Texas Southwestern Medical Center Head, Emergency Services, Parkland Health Hospital System Head, EMS Medical Direction Team, Dallas Area Biotel (EMS) System Edward M. Racht, MD Chief Medical Officer, American Medical Response Jeffrey P. Salomone, MD, FACS, NREMT-P Associate Professor of Surgery, Emory University School of Medicine Deputy Chief of Surgery, Grady Memorial Hospital Assistant Medical Director, Grady EMS Kathleen S. Schrank, MD Professor of Medicine and Chief, Division of Emergency Medicine, University of Miami School of Medicine Medical Director, City of Miami Fire Rescue Medical Director, Village of Key Biscayne Fire Rescue John Sinclair, EMT-P International Director, IAFC EMS Section Fire Chief Emergency Manager, Kittitas Valley Fire Rescue Corey M. Slovis, MD, FACP, FACEP, FAAEM Professor Chair, Emergency Medicine, Vanderbilt University Medical Center Professor, Medicine, Vanderbilt University Medical Center Medical Director, Metro Nashville Fire Department Medical Director, Nashville International Airport Walt A. Stoy, PhD, EMT-P, CCEMTP Professor Director, Emergency Medicine, University of Pittsburgh Director, Office of Education, Center for Emergency Medicine Richard Vance, EMT-P Captain, Carlsbad Fire Department Jonathan D. Washko, BS-EMSA, NREMT-P, AEMD Assistant Vice President, North Shore-LIJ Center for EMS Co-Chairman, Professional Standards Committee, American Ambulance Association Ad-Hoc Finance Committee Member, NEMSAC keith wesley, MD, facep Medical Director, HealthEast Medical Transportation Katherine H. West, BSN, MED, CIC Infection Control Consultant, Infection Control/Emerging Concepts Inc. Stephen R. Wirth, Esq. Attorney, Page, Wolfberg Wirth LLC. Legal Commissioner Chair, Panel of Commissioners, Commission on Accreditation of Ambulance Services (CAAS) Douglas M. Wolfberg, Esq. Attorney, Page, Wolfberg Wirth LLC Wayne M. Zygowicz, BA, EFO, EMT-P EMS Division Chief, Littleton Fire Rescue
  • 11. Choose 17 at www.jems.com/rs
  • 12. EMS IN ACTION Scene of the month Photos Roland Webb Off-Road Care R iders collide during the start of day six of the seven-day BC Bikerace, a rugged mountain bike course stretching from Vancouver to Whistler, British Columbia, Canada. According to Roland Webb, course medical manager, the EMS team of approximately 20 paid and volunteer paramedics and nurses treat nearly all of the approximately 520 participants at some point during the seven days, whether for minor or complex injuries. (Top right) A basecamp nurse cleans foreign bodies from a man’s eye after a day racing in heavy rainfall and mud. Performing effective care at the race presents many challenges for EMS, including re-locating daily and dealing with remote locations and potentially challenging extrications, Webb says. “In some places, access is a nightmare, and in others it’s easy, so you have to be flexible and get a clinic staff together for one week a year that can handle it.” 12 JEMS OCTOBER 2012
  • 13. www.jems.com OCTOBER 2012 JEMS 13
  • 14. from the editor putting issUes into perspective by A.J. HEIGHTMAN, MPA, EMT-P Patches, Pride Patients Consistent cooperation should be the goal H ave you noticed how well personnel from different agencies—and those wearing different uniforms and shoulder patches—get along and work together during a cardiac arrest or mass casualty incident? Know why that is? It’s because they’re all focused on a common goal: the mitigation of a complex incident or resuscitation of a person whose life will slip away if they don’t focus on the most appropriate care, set aside personal biases about who’s in charge and follow the command system regardless of who’s “in charge.” I’ve found this to be the case during most “big” calls. But when you get public, private, third service and hospital-based EMS system administrators together for a planning meeting or at a city council hearing on the best way to offer EMS in a region, their protective attitudes, operational and staffing biases, and agency loyalties, will often surface like the teeth on a shark that smells blood in the water. It shouldn’t be that way. We should check our egos and biases at the door whenever we leave home to head to work. We should simply focus on the patient and delivering optimal service to the community. Wars have taught us invaluable lessons about strategy development, command and control, and the use of innovative tactics. They have also taught us many hidden lessons about group interaction, the use of limited resources and, most importantly, “blind” faith and cooperation between forces from different service branches without bias or prejudice—particularly when it comes to combat casualty care. The importance of this unbiased attitude and approach to patient care was never more evident to me than in the sad, but powerful, story of the life and tragic death of Sgt. Eric E. Williams, an Army flight medic from Southern California who was killed on July 23 in Afghanistan. At Williams’ funeral, Army Staff Sgt. Michael Constantine told of being on the receiving end of Williams’ care in 2008, and vividly recalled the battle that almost took his life. A bullet tore through Constantine’s ribs and collapsed his lung during a fierce battle in Afghanistan. Sgt. Williams was the flight medic who rapidly arrived on an Army helicopter to attend to him as he gasped for breath, watch High School and later became an EMT for American Medical Response. He did his job then based on what was in the best interest of his community and his patients. Later, while serving as a medic in the Army, he provided care indiscriminately to those in need whether they wore a patch from the Army, Marines, Air Force, Navy or Afghanistan military—or no patch at all. During his memorial service, the last entry in Williams’ Internet blog entry titled “Coming Home” was read. In his short blog message, the dedicated, humble Army medic noted having witnessed “the atrocities of war” and wrote words that sum up why we all work in the field of EMS: “We have thrust ourselves into the midst of chaos in order to do something so important, so visceral, that few will ever understand what it means. We collectively have risked it all and put everything on the line to save our fellow man, regardless of nationality, race, religion or sex.” Remember Sgt. Eric Williams’ ultimate sacrifice and never let personal bias or your agency affiliation stand in the way of patient care or decisions that are the best interest of your patient or the community you serve. We all have to accept and embrace the fact that we will always wear different shoulder patches and have different employer-driven philosophies and service objectives. But we must work cooperatively together, particularly in the years ahead as new approaches to healthcare delivery require a more comprehensive, integrated EMS delivery model. JEMS He never made it home, but the stories of his heroic acts did. 14 JEMS OCTOBER 2012 his vision begin to fade and “tunnel,” and had a significant amount of blood filling his airway. Constantine says, “I had started to give up and let the inevitable rush over me until, in a calm voice, I heard Williams’ voice say ‘Just breathe out.’ So I did.”1 He then felt Williams’ hands repairing his massive, open wound. Constantine says he looked up and searched the medic’s face for some indication of how bad the wound was. He told those in attendance at his funeral that he was met with a reassuring smile and words of promise from Williams, who told him he would do all that he could to save him. Williams and his flight crew members did, in fact, save Constantine, and he never saw Williams again. In July, four years after Williams saved Constantine’s life, he learned that Williams was killed as his second deployment ended. Williams was in transit from his duty station in Ghazni Province, Afghanistan back to the U.S., and his forward operating base came under enemy fire. He never made it home, but the stories of his heroic acts did. The most important part of this story is that Williams grew up in civilian life serving with public and private emergency response agencies. He had served as president of the fire explorers while at Murrieta (Calif.) Valley Reference 1. Kabbany J. (Aug. 4, 2012). WILDOMAR: Region remembers slain Murrieta soldier. In North County Times. Retrieved Aug. 4, 2012, from www.nctimes.com/ news/local/wildomar. Read Sgt. Eric E. Williams’ last blog entry, “Coming Home,” at http://myfriendthemedic. blogspot.com/2012/07/coming-home.html.
  • 15. Choose 18 at www.jems.com/rs
  • 16. Just Words? Perhaps it’s not surprising that JEMS readers had a lot to say about the August feature article by Rollin J. Fairbanks, MD, MS, that discussed how to combat the longstanding issue EMS providers have with being referred to as “ambulance drivers” in the media and elsewhere (“More than Words: how we can influence the ‘ambulance driver’ media epidemic.”) Is there a solution, or will this continue to be a problem for the profession? If you want to advance and improve our profession (and help make it a profession) then you will understand that a single, simple collective term of identity is necessary for the media to describe us and what we do. We have to make it easy for THEM to get it right. When I’ve had this conversation with media representatives (and I have), they say, “Oh, OK.” The Canadians and Australians have figured this out. Those who work on ambulances are all paramedics, just like those who work on fire trucks are firefighters, and those who work in police cars are police officers. It has worked well enough that they have a public identity in those countries that is substantial. How about we “real” paramedics get over it and share our “elite” (cough, cough) title with the others who work with us. We should all be paramedics. I don’t care; we can be called “BLS paramedic,” “ILS paramedic,” “ALS paramedic,” “critical care paramedic,” “tactical paramedic” or “flight paramedic,” etc., etc., ad nauseam infinitum amen. The bottom line: They’re all paramedics. Skip Kirkwood Via jems.com New Zealand still uses the generic term “ambulance officer” to describe those at all clinical levels, be they a technician, a paramedic or an intensive care paramedic. Technician level officers are overwhelmingly volunteers; they complete a six-month block course, perform a limited number of procedures and dispense a limited number of drugs (about 10). It’s not appropriate to call them a “paramedic,” and it’s certainly not appropriate to call an American EMT who, under the EMS Agenda for the Future, completes a course of less than 200 hours and has oxygen, aspirin and glucose, a “paramedic.” Elsewhere in the world, a paramedic must go to college for three years to earn the right to use the title. As much as I applaud Canada for its use of the titles, primary and advanced care paramedic, 16 JEMS OCTOBER 2012 I’m going to have to play devil’s advocate a little here. Sorry folks. Ben Hoffman Via jems.com We are ambulance drivers. We work with fire truck drivers and police car drivers to provide first aid and a ride to the hospital. Once we arrive there, the vital sign takers, bed makers and report takers help the prescription writers and test orderers take care of the medical services consumer. After all, it’s all about the words, isn’t it? Christopher Black Via jems.com I am an ambulance driver. I’m probably a decent EMT as well. I teach the Emergency Vehicle Operator Course (EVOC) after spending years of white knuckle driving. My primary focus when teaching a class is to impart the enormous responsibility involved in driving an emer- gency vehicle. In addition to being an emergency room on wheels, that truck is a billboard for your service, and potentially an instrument of destruction. If I haven’t scared the crap (spark) out of my students before the road test, I haven’t done my job. When I stand in front of or behind the ambulance during the road practical, I make it clear that my life and that of those in the truck as well as on the road is in their hands. They are proud of that accomplishment when they receive their EVOC certificate. Yet some consider being called “ambulance driver” the equivalent of a racial slur? Get over yourself. Nancy Magee Via jems.com Thank you for a great article. The term also leads to a misconception about what the ambulance is used for. I can’t tell you how many times nurses or unit secretaries have asked us as we’re leaving to take someone home because we happen to be going “his way.” When I politely decline, they usually become irritated and say things to the effect of “what good is driving an ambulance if you don’t drive people places?” We in EMS have a long way to go, but I think we all collectively appreciate your effort and your article. Thanks again. Geoffrey Horning Via jems.com Nice article. After almost 30 years at this, I still don’t like being called an “ambulance driver.” However, I also wish the media would use a thesaurus: The only verb they have for us is “rush.” It doesn’t matter what we do, the standard line is, “And EMS rushed the victim to the hospital.” As long as all we do is “rush,” then I guess our primary job is driving. JEMS Sam Benson Via jems.com illustration steve berry monkeybusinessimages/ istockphoto.com LETTERS in your words
  • 17. Choose 19 at www.jems.com/rs
  • 18. PRIORITYUSE TRAFFIC NEWS YOU CAN Hurricane Isaac HITS Crews Activate Response Plans A Photo Associated Press/Gerald Herbert s Hurricane Isaac headed toward the Gulf Coast region in the end of August, residents were figuring out to ways evacuate, and EMS operations were swinging into full gear in their efforts to receive for back-up assistance. With the potential of a major storm hitting a wide swath of land, officials initiated emergency plans and waited out the weather early on. Acadian Ambulance An uprooted tree lies across Poydras St. in New Orleans as Hurricane Isaac made landfall with 80 mph winds, making it a Category 1 storm. Photo Associated Press/Eric Gay On Aug. 26, with the storm just two days away, Acadian Ambulance in Lafayette, La., activated its Evacuation Response Operations Center (EROC), a system borne out of responses to previous storms, to specifically handle the evacuations of healthcare facilities. “Compared to other storms of the past 10 to 15 years, it was not one of the most challenging we’ve had,” says Jerry Romero, senior vice president of operations at Acadian. “But, we had to execute our disaster plan.” Part of this plan included having 40 additional ambulances in service. The EROC system was created after hurricanes Gustav, Katrina and Ike struck the regions Acadian serves. Evacuating healthcare facilities and nursing homes is a major part in the storm preparation process. To meet that need, Acadian activates a separate communications center to handle only those types of evacuations, rather than have those calls bog down the normal 9-1-1 system. For instance, during Hurricane Katrina, Acadian evacuated more than 2,000 patients. During the first day of the EROC operation for Hurricane Isaac, the company transported 150 people. Hurricanes are challenging for EMS organizations. Officials are faced with calling in extra staff at a time where the staffers’ families and homes may be in danger. This happens at the same time that government officials are asking residents to evacuate the area where first responders are being sent to wait. The result, however, can sometimes be a shortage Trevelle Bivalacqua, 12, at right, helps firefighters and other volunteers evacuate residents from the Riverbend Nursing Center as Hurricane Isaac makes landfall in Jesuit Bend, La. of employees physically unable or unwilling to return to work. “Our employees are pretty hurricane savvy,” says Romero. “At the beginning of hurricane season, we put out our employee update to remind them of the points to have a family plan prepared, to know what you’re going to do, and have a three-day supply of clothes and food in case you don’t get home. We get a lot of people who call in and volunteer.” SunStar EMS Officials at SunStar EMS in Pinellas County, Fla., like others, began altering their hurricane response plans in 2004 and have upgraded NIH creates Office of Emergency Care Research: www.jems.com/article/nih-creates-office-emergency-care-resear 18 JEMS OCTOBER 2012
  • 19. Comprehensive, Credible, Educational... JEMS Products Help You Save Lives. Jems, Journal of Emergency Medical Services jems.com Website With content from writers who are EMS professionals in the field, JEMS provides the information you need on clinical issues, products and trends. Your online connection to the EMS world, JEMS.com gives you information on: • Products • Jobs • Patient Care • Training • Technology Available in print or digital editions! Product Connect jems.com eNewsletter Sign up now for the weekly JEMS.com eNewsletter. Get breaking news, articles and product information sent right to your computer. Read it on your time and stay ahead of the latest news! Giving you the detailed product information you need, when you need it. We collect all the information from manufacturers and put it in one place, so it’s easy for you to find and easy for you to read. Go to www.jems.com/ems-products FREE WEBCASTS did you Miss a live webcast? Check out the archives at www.JEMS.com/webcasts. • Securing the Airway: The expanding role of extraglottic devices • Maximizing Your Revenue • May the G-Force Be With You • ‘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 Patient Care • CPR Quality Improves Survival • Breathe Deeply: How CPAP and Ventilation Can Help Your Patients • Simulating Work: How to Effectively Incorporate Simulation into Prehospital Care • CPAP: Filling The Sails to Respiratory Relief Go to www.JEMS.com
  • 20. continued from page 18 Photo courtesy Mark Postma Two must be on duty at all times, which gives the other providers a chance to check on their families. Another 250 go to the company headquarters. Bringing everyone in inevitably involves logistical challenges for managers, such as the feeding and housing of staff. And once a storm begins, there will ultimately come a point where the crews can’t go out. SunStar EMS hurricane deployment units prepare and debrief “We’ve kind of learned from during the Republican National Convention at Tropicana Field other hurricanes that have hapas they mobilize for Hurricane Isaac response. pened,” says SunStar Vice President Mark Postma. “We’ve tried to be as them after every storm since then. SunStar’s current plan includes a man- flexible as we can.” Early on, it appeared the region covered datory callback for all employees, and it also includes provisions to make sure by SunStar might get hit by Hurricane Isaac. employees’ family concerns are taken into However, the storm track went further west. consideration. For instance, six responders The plan has been tested several times, though and an ambulance are placed in 20 hotels it’s been activated only once since its implethroughout SunStar’s response area—and mentation, Postma says. SunStar was prepared, however, says geographically near the responders’ homes Richard Schomp, director of operations. to assist families if needed. The company had already activated special EMS coverage for an event staged for the A Word of Encouragement Republican National Convention on the SunEditor’s note: Jullette M. Saussy, MD, served day before the storm. That coverage, says with NOEMS during hurricanes Katrina and Schomp, included 14 additional ambulances, Gustav. She provided this message to EMS extra management and a mass casualty supcrews responding to Hurricane Issac. ply vehicle. “I’d already staffed up the system to handle It’s incredibly difficult to be so far away and yet an extreme amount of volume,” Schomp says. to still feel the deep longing to be right beside “With the storm coming, we maintained that each of you as this hurricane approaches. Katrina high amount. It had very little impact, but we in 2005, Gustav in 2008, and now Isaac in 2012—all were ready.” on or about the same day seems more than just Typically, EMS operations experience a statistically impossible. large influx of 9-1-1 calls after a storm when For those of you who have been through this residents have no power. Romero says there’s drill, I know it brings up all kinds of emotions. It often a jump in heat-related calls, chainsaw has for me, and I’m not even there. For the newcuts and falls from roofs as homeowners est members of the team, take a few lessons work to rebuild. from the seasoned men and women of New Getting crews time to rest, especially when Orleans EMS (NOEMS.) If they seem on edge, it’s they’re stationed over a wide geographical for a reason. Be patient. If they seem emotional, location, is one of the largest challenges, it’s for a reason. Be patient. If they tell you to do Romero says. However, each storm, Romero something, it’s for a reason. Do it. says, helps the company prepare for the next You have capable leaders, and they need the one. Hurricane Isaac was no different. team to pull together and perform at their high“Katrina, Rita, Gustav and Ike taught us a est capacity. We have one mission and that is to lot,” says Romero. “We’ve gotten better every stay safe and to keep our citizens and visitors time. We can always improve and will consafe. Stay focused on that, and you will succeed. tinue to improve after this one.” Thank you for the work you do each day. —Richard Huff, EMT-P —Jullette M. Saussy, MD Remembering an EMS Pioneer Robert Forbuss was an EMS advocate, speaker, author, leader and pioneer known for promoting EMS, EMS careers and high-quality private and public ambulance services. He died in August after a long battle with amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease. He was 64. Janet Smith, a former Mercy Ambulance employee and colleague of Forbuss’ says, “The Bob Forbuss story is about how a man in an emerging new healthcare service in the 1970s, leveraged his company’s position in a growing Nevada metropolis to open political and strategic access to the power structure of the city and county his company served.” Co-founder and subsequent president of the American Ambulance Association (AAA), Forbuss presided over the National Showcase for EMS in Washington, D.C. He served on the AAA committee to institute the process for ambulance accreditation from which the Commission on Accreditation of Ambulance Services (CAAS) was formed. Jay Fitch, PhD, founding partner of Fitch and Associates, LLC, reflects, “He was my second private client, the best thing that could happen to a young consultant. Energetic and passionate, I came to admire his leadership.” Forbuss served as the industry’s spokesperson during the national Ford ambulance crisis and was named EMS administrator of the year at the EMS Today Conference Exposition in 1988 for his work during that crisis. Forbuss coordinated the ambulance and walking wounded components at the 1980 MGM Grand and 1981 Hilton high-rise hotel fires, an effort JEMS founder James O. Page described as a “command performance.” Smith reflects, “Who knows how many have lived to see another birthday, a graduation or a grandchild’s first steps because of him, his influence, his care in countless cities and towns throughout America and especially in those communities where CAAS Accreditation is the benchmark. He will be missed.” —Mike Ward, EMT-P Halloween safety tips: www.jems.com/article/don-t-get-spooked 20 JEMS OCTOBER 2012
  • 21. Choose 20 at www.jems.com/rs
  • 22. continued from page 20 When Patients Don’t Stay Put W e’ve seen some tragic headlines recently that should be a cause for concern: Aug. 19, 2012: “Woman Dies After Jumping from Ambulance” (Calif.) March 12, 2012: “Patient Jumps from Ambulance Only to be Struck by Truck” (Nev.) Dec. 23, 2011: “Naked Man Jumps from Ambulance, Dies on Freeway” (Calif.) Oct. 13, 2011: “Patient Jumps Out of Ambulance and Into River” (Okla.) Is this a trend? How can these incidents happen in the first place? We don’t know the statistics, but we do know that patients who unexpectedly leap from your ambulance—while you’re with them in the patient compartment—not only can get injured or killed, but can also present huge liability issues for you and your EMS agency. Dealing with patients with psychological issues is a big challenge. They may appear “fine” and “calm” one moment and then they snap into another person the next second. They often don’t have any outward physical injury, so they almost appear “normal.” This is when we may let our guard down ever so slightly, and bang: The next thing you see is the rear door flapping open and no patient in your vehicle. Not a good scenario. We need to always remember to strive to never let something bad happen to a patient while they’re under our care. We don’t want them to be worse off than when we first found them, because if they are, then the obvious question from a “fact-finder” will be: “Did the EMS crew do enough to prevent this unfortunate incident?” And if the answer is no, then you may be looking at a negligence or wrongful death action against your agency. Follow these tips for reducing your risk when transporting patients who have a “questionable” mental state: Always be attentive: Keep your eye on the patient at all times in a faceto-face position. The first sign that the patient is about to escape may be a change in their facial expression. You can’t see that sitting in the captain’s chair texting a friend, staring out the side window, or chatting with the driver. We must be totally attentive to the patient every second they’re with us. Being complacent or distracted leads to dead patients in these situations. Follow your protocols: Most systems have a protocol for dealing with a patient who may have psychological issues or has exhibited signs they may hurt QUICK TAKE PennWell Acquires Elsevier Public Safety; JBL Acquires EMS Product Line On Sept. 14, PennWell Corporation announced the acquisition of Elsevier Public Safety, the publisher of JEMS, from Elsevier, Inc. The deal also includes JEMS.com, the EMS Today Conference Exposition (the JEMS Conference), EMS Insider, FireRescue magazine, FirefighterNation.com, FireEMSblogs.com, Law Officer magazine, LawOfficer.com and the publishing contract for APCO’s Public Safety Communications magazine. Elsevier Public Safety, a division of Elsevier, Inc., was founded in 1980 as JEMS Communications, with JEMS, one of the most iconic brands in the EMS market. During the past 32 years, Elsevier Public Safety expanded to become the themselves. Make sure you review that protocol and follow it. Your protocol will usually be the patient care standard by which you will be judged in a negligence lawsuit. Get good Information at the scene: Ask lots of questions of the facility staff or family members concerning mental stability, suicidal ideations, and so forth. Document exactly what the patient, nursing staff and bystanders tell you. Never accept a patient who looks “fine” without a good explanation as to why you’re taking them. Don’t hesitate to call law enforcement: True, police officers are not always helpful, but it’s best to err on the side of calling them, and then keep them there for the remainder of the transport or ask an officer to ride in the back if possible. Always consider the option of an involuntary mental health commitment in accordance with your state law, if you’re concerned. Use two people in the back: If you question the mental stability of a patient, it’s always best to have two providers in the patient compartment— positioned strategically so that the patient can’t escape easily. Someone should definitely be between the patient and the rear door of the ambulance. Don’t make it easy for them to escape. Use restraints when needed: We’re not talking about the cot straps, which by the way, should always be in your complete view so that you can see them if a patient is trying to get unbuckled; never cover buckles under a blanket. Chemical restraints may be the safer way to go and can reduce patient anxiety. Don’t hesitate to use them or ask your medical command physician. Keep in mind from a risk management standpoint, it’s far better to get sued for false imprisonment for excessively restraining a patient, than to get sued for wrongful death if the patient jumps from your ambulance as you look up and it’s too late. There are only a few lawsuits where EMS providers were sued for taking a patient involuntarily, but there have been hundreds of lawsuits against EMS for negligence when the patient is left worse off than when you found them — regardless of your defense. 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. only media company serving all four key public safety segments—EMS, fire/rescue, law enforcement and communications. The management and staff will join PennWell, a diversified global media and information company, and will remain based in San Diego. PennWell conducts more than 50 conferences and exhibitions, including the Fire Department Instructors Conference (FDIC), and has an extensive line of trade publications, including Fire Engineering and Fire Apparatus magazines. PennWell will bring its trade show management knowhow to the EMS Today Conference Expo, held annually each spring. EMS Today celebrated its 30th anniversary this year and in 2013 will be held March 5–9 at the Washington Convention Center in Washington, D.C. For more information, visit www.jems.com/article/ news/pennwell-acquires-elsevier-public-safety. For more of the latest EMS news, visit jems.com/news 22 JEMS OCTOBER 2012 Pro Bono is written by attorneys Doug Wolfberg and Steve Wirth of Page, Wolfberg Wirth LLC, a national EMS-industry law firm. Visit the firm’s website at www.pwwemslaw.com for more EMS law information. In other acquisition news, Jones Bartlett Learning (JBL), a division of Ascend Learning, acquired the EMS product line from Elsevier, Inc., closing the deal in July, according to JBL Executive Publisher Kimberly Brophy. EMS education resources previously published under the Elsevier brand are now part of the JBL EMS product line, including those marketed under the Mosby, Saunders and Churchill Livingstone imprint. The added value, Brophy notes, is that customers can now order a large variety of titles from one publisher. JBL is a provider of instructional, assessment and learning-performance management solutions for the secondary, post-secondary and professional markets. JBL will continue to support and enhance EMS products, domestically and internationally. Customers should note that Elsevier will be responsible for accepting returns on any products purchased directly from Elsevier through April 30, 2013.
  • 23. Choose 21 at www.jems.com/rs
  • 24. LEADERSHIP SECTOR presented by the iafc ems section by gary ludwig, ms, emt-p Closed Door Policy Keeping lines of communication open can help you your staff I recently received an e-mail that told me of an innovative new management principle that most major business schools, such as Wharton, Harvard and Yale, would soon be scampering to teach. The e-mail added that management books would need to be rewritten and this new management practice would set teaching of leadership and management back 200 years. Intrigued, I couldn’t resist reading further into the e-mail about this earth-shattering management principle. I was curious about what was so tremendous and incredible. Could I possibly be on the brink of some utterly fantastic discovery that maybe somehow I could share with fellow EMS managers? Closing the Door As I read further, I discovered that the writer was being facetious. He was being tonguein-cheek and not really writing about an earth-shaking innovative or unfounded management application. What the author wanted to share with me was what the management at his EMS service had distributed to its employees; a memorandum appropriately called the “Closed Door Policy.” The memorandum basically said that managers were too busy to deal with employees when they had an issue that needed addressing. Here is what the memo said (with the names deleted). To All Employees, During business hours (9–17), [name deleted] and [name deleted] are being bombarded with operational issues every five minutes. This makes it impossible to complete our tasks and work assignments. We are tired of answering the locked door that specifically says, “AUTHORIZED PERSONNEL ONLY” to find out that you need to talk about scheduling, supplies, etc. Although we appreciate all your concerns, unless it’s on fire, please e-mail us. We will get back to you in a timely manner. You cooperation is much appreciated and no exceptions will be made nor tolerated. Please take this seriously. We have a larger work load and get seriously behind due to constant visitors. 24 JEMS OCTOBER 2012 Surprisingly, this wasn’t a large service where 1,000-plus employees would keep the head of an EMS organization from doing their job because they were inundated with employees knocking on the door. So when I read the memo, I was baffled. Leading with Your Feet Management does need to prioritize tasks. And, as I have always preached, management shouldn’t be bogged down in minutia and should focus on strategic issues. However, I have also advocated they can’t sit in their offices behind closed doors and not interact with their employees. They need to find a balance between staying focused on strategic issues and getting out of the ivory tower to find out what’s happening in the operation. When you get out and talk with employees, you find out what’s working and what’s not. As I’ve often said, you don’t want to wake up in the morning and read in the paper what’s happening in your operation. A label for this practice is “Management by Walking Around,” or MBWA. I have always felt this concept was misnamed and would be better termed “Leadership by Walking Around.” After all, we manage budgets and inventories; we should be leading people. Nonetheless, this spontaneous practice in an unstructured manner allows managers to randomly check with employees or equipment to find out what is happening in the operation. My favorite method to do MBWA is to stop by one of our busier hospitals in Memphis where I know I’m going to find three or more Memphis Fire Department ambulances dropping off patients. It gives me the opportunity to randomly and spontaneously meet with personnel. It allows me to talk with them, and it allows them to ask me questions, let me know about any issues that need addressing, and, my favorite—deny or confirm rumors they’ve heard. This is probably one of the best tools I have to discover what’s wrong and needs to be fixed, build rapport with employees and receive feedback. I may hear things I don’t want to hear, but that comes with the job and I would prefer employees to be honest. Sometimes it seems like it’s a small problem. But I’ve discovered if you don’t deal with the small problems, they can become big problems. A Balancing Act It’s important to point out that, if you’re going to use MBWA, you have to do it the proper way. You can’t just walk around to say “Good morning.” Don’t criticize. Don’t create an atmosphere of fear that causes your employees to get scared and “clam up” when they see you coming. And, most importantly, EMS managers can’t just sit in locked offices and shelter themselves from what’s happening outside the confines of their office. Maintaining that careful balance between becoming a recluse and interacting with your employees can allow you to truly find out what’s happening within (and around) your operation. 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 GaryLudwig.com.
  • 25. Choose 22 at www.jems.com/rs
  • 26. TRICKSour patients ourselves OF THE TRADE caring for by Thom Dick, EMT-P Warm Enough for Ya? Preventing failures to start 26 JEMS OCTOBER 2012 Photo Thom Dick “I ’m melting, I’m melting!” So said the Wicked Witch of the West just before she magically shriveled her way into history. I’m beginning to sympathize with that cranky lady. At the time of this article’s writing, my state has had a record-breaking summer of wildfires after more than a month of temperatures in excess of 90° F and multiple strings of 100-plus days in the mix. And the calendar says our summer is still ahead. We need rain. One of my duties is to oversee the maintenance of a small fleet of six Type III Ford ambulances. They’re all 7.3-Liter PowerStroke Diesel chassies with LifeLine boxes. We’ve hung onto the 7.3s because we don’t generate a lot of miles, and those engines and their TorqShift transmissions have been bulletproof. Just as importantly, the quality of the boxes has supported our continued investments in chassis maintenance. In fact, so far we’ve sent two units back to the factory in Sumner, Iowa, to refurbish and return them to service. When I was originally assigned to take care of this fleet, we were having two kinds of starting failures. One was an easy fix: We began replacing the batteries annually. The other, which had plagued us for years, was alternator failures—especially of the upper alternators. Of course, the easiest way to correct that would be to switch to Type I ambulances. One of the disadvantages of a cutawaybased Type III chassis is its teeny engine compartment. There’s not enough room in there for an alternator big enough to supply the needs of an ambulance (or a leprechaun to service it). So Ford resorted to a pair of alternators: one mounted high and the other one low. A Type I chassis has a longer hood, like a pickup truck, that offers much more space. But our garage bays aren’t physicially deep enough to accommodate Type I ambulances. And Colorado’s range of temperatures can Maintaining proper vehicle temperature isn’t rocket science, but it does require proper training. reach 110 degrees winter to summer. So you pretty much have to keep an ambulance garaged. Neither of those alternators is just a spare; if one fails (usually the upper one because of heat), the other will follow soon enough. You can minimize the load on them by switching your emergency lighting from incandescent to high-intensity LEDs. LEDs produce a lot of light with a little energy. Decreasing the load on an alternator should lower its operating temperature, minimize the wear on its drive belt and improve its reliability. But LEDs require a lot of rewiring, and that’s pricey. You can’t just replace bulbs. You can idle a diesel all day long, even on a hot summer day with a heavy electrical load (including both air conditionings on full-blast). But when you turn the motor off, the radiant heat of all that metal has nowhere to go. So your underhood tem- peratures will rise. If the cooling system is in good shape and your coolant is mixed at the proper concentration, it should be OK up to a temperature of almost 300° F. But the underhood temperature won’t be constant. It’ll be hottest up high (like where the upper alternator is) and not so hot down low. We talked to our friend Cap Unrein at Rocky Mountain Emergency Vehicles (EVMARS) of Denver, who does our maintenance. Cap recommended the basis of the following hot-weather procedure. We leave an ambulance running when we park it outdoors for just a few minutes. Nobody wants to climb into a 120° F ambulance, right? EVMARS installed externally accessible security switches that either lock or unlock all of our doors simultaneously. So we can leave a locked vehicle idling, yet we can access it quickly for a call. Then, when we return to quarters, we turn off the engines and leave the hoods open. Looks funny. Makes sense. Obviously, we try not to leave the hoods open in public. Our crews don’t post on street corners, and they’re mindful of the temperaturesensitive contents of their compartments, so they normally return to quarters between calls. And we don’t know yet if this will even work. But it makes sense for any vehicle, whatever its design. And in this heat, we’ve gotta do something. I have to tell you, there’s one more component to this plan. The crews have to understand their instruments—and the mechanics of their vehicles—well enough to make it work. To my way of thinking, that requires training and experience. Neither of which happens by magic. 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 boxcar414@ comcast.net.
  • 27. Choose 23 at www.jems.com/rs
  • 28. CASE OF THE MONTH DILEMMAS IN DAY-TO-DAY CARE BY Kimberly Doran Naked Unconscious Crew’s misdiagnosis could have cost patient her life Arrival at the ED On arrival to the ED, the medic hands over the loaded syringe containing 2mL of unidentified solution, as well as the empty vial of Solu-Cortef and the bottles of dexa- 28 JEMS OCTOBER 2012 Photo BigshotD3/istockphoto.com A call comes in to 9-1-1 dispatch. “Help” is all that’s spoken before the operator hears the phone hit the floor. The 9-1-1 dispatcher calls back only to get a busy signal. Police and EMS are dispatched for a well-being call. On arrival, the front door is found to be slightly ajar. The crew knocks, but there’s no reply. Entering the home, the crew sees a young woman lying on the floor in a pool of vomit. A syringe with an unknown substance is on the ground nearby. Suspecting a drug overdose, the EMS crew begins treatment. The patient is unconscious with emesis about her head and face. Her vital signs are blood pressure 60/45, heart rate of 130 bpm and respiratory rate of 10. The patient shows no signs of waking. The crew clears the airway and administers oxygen. An IV is established and the patient is readied for transport. As the crew leaves the scene, one of the medics turns to shut the door and sees a vial under a chair. He retrieves it and notes that the label says Solu-Cortef (a glucocorticoid). He bags it for the emergency department (ED). Following his instinct, he looks around the area for medications and finds two bottles. One is labeled dexamethosone and the other is labeled fludrocortisone. He takes his findings and rushes out the door into the awaiting ambulance. During transport the patient continues to deteriorate. The medic administers 0.5 mg of narcan and a 500mL bolus of normal saline with no response. He radios ahead to let the hospital know that they’re en route. Now questioning the original diagnosis of drug overdose, he reports the medications he found on the scene in hopes it will help the receiving physician determine the cause of the patient’s condition. Symptoms of adrenal insufficiency can mirror a drug overdose, so providers need to be wary. methosone and fludrocortisones. As they arrive at the hospital, the ED physician meets the crew and informs them that he’s familiar with the medications and they’re all used for people who have various forms of adrenal insufficiency (AI). The symptoms seen in this patient coincide with life-threatening adrenal crisis. The physician administers 100mg of Solu-Cortef via IV and within minutes, the patient rouses. In 30 minutes, she can explain what happened in the desperate moments before her crisis. Adrenal Insufficiency The adrenal medulla (inside of the adrenal gland) secretes epinephrine and norepinephrine. The adrenal cortex (outer layer of the adrenal gland) secretes cortisol and aldosterone. Cortisol, a glucocorticoid, is often called the “stress” hormone. One of the things cortisol in the body is responsible for is elevating blood glucose levels in times of stress. It also functions as a mediator for several inflammatory pathways. Absence of cortisol can result in hypotension, hypoglycemia and death. Aldosterone, a mineralocorticoid, is responsible for the regulation of sodium and water. Absence of aldosterone can result in hypotension and electrolyte imbalance. AI is a life-threatening condition in which the body is unable to produce enough cortisol to sustain life. In other words, their adrenal cortex is “asleep.” People suffering from AI take daily cortisol/glucocorticoid steroid replacement because whatever adrenal function they have is depleted. These patients are glucocorticoid dependent. In times of injury, dehydration, illness or surgery, they require an injection of Solu-Cortef. Solu-Cortef contains both glucocorticoid and mineralocorticoid properties, helping the body to compensate during a stress event. AI in the prehospital setting may be difficult to recognize in the absence of a good history, including medications, to point providers to the cause of the problem. Two conditions associated with AI include hypotension and hypoglycemia. If not managed, these two conditions are life threatening. Prehospital treatment should include management of the patient’s airway, vascular access and fluid resuscitation. If blood glucose levels are low, the patient should receive dextrose per local protocol. It’s important to complete a thorough physical assessment and obtain a complete patient history. Providers may confuse patients having an adrenal crisis with drug overdose patients because of their similar symptoms. Although the condition is rare, it should still be considered as a potential diagnosis. Authors’ note: Parts of the above case are taken from a true story. However, the difference is that there was no syringe on the floor, no vial under the chair and no one found the medications. The patient was diagnosed as a drug-overdose patient and treated with charcoal. She likely would have died, but her mother charged into the ED and expressed the need for Solu-Cortef. Security was called, but luckily someone listened, researched and called the patient’s treating physician. The patient was treated and released. JEMS Kimberly Doran is medical liaison for Adrenal Insufficiency United. She is committed to bringing about awareness and proper medical care and treatment for all who suffer from various forms of adrenal insufficiency. She can be contacted at docs4aiu@gmail.com. For more information about this condition, go to www.AIUnited.org.
  • 29. Choose 24 at www.jems.com/rs
  • 30. The future looks bright—but how bright? photo vu bahn About the Data The Web-based survey consisted of approximately 150 questions. It allowed participants to voluntarily “skip” sections they considered “not applicable.” Two hundred twenty-one organizations (N=221) initiated the survey - a return rate of 10% from a distribution of 2,411 invitations. Survey participation was open for a five-week period during May and June 2012. Figure 1, p. 32, shows the breakdown of provider types and their call volumes. The median of respondents serves populations of 50,000 and responds to 5,000 calls annually. Total respondents are noted as “n =” for each dataset where possible. In some instances, data was limited, not available or not applicable for all respondents. For example, respondents may answer call volume but not provider type, which means that “n” can change from dataset to dataset. A representative sample of participation from provider organizations in each region of the U.S. and across all system model designs (see Figure 2, p. 34) was achieved. All 10 federal regions are represented in this year’s data national salary rollup, however several job classes and regions did not reach required participation for reporting. Salary reporting follows Department of Justice and Federal Trade Commission issued Statements of Antitrust Enforcement Policy in Health Care.1 The text of the guidelines as they relate to salary surveys can be accessed online; the following are the most relevant extracts: The agencies will not challenge, absent extraordinary circumstances, provider participation in written surveys of a) prices for health care services, or b) wages, salaries or benefits of health care personnel, if the following conditions are satisfied: The survey is managed by a third party (e.g., a purchaser, government agency, health care consultant, academic institution or trade association). Information provided by survey participants is based on data more than three months old. There are at least five providers reporting data on which each disseminated statistic is based, no individual provider’s data represents more than 25% on a weighted basis of that statistic, and any information disseminated is sufficiently aggregated such that it would not allow recipients to identify the prices charged or compensation paid by any particular provider. 1 30 jems | october 2011
  • 31. short course By Michael Greene, MBA/MSHA I n the JEMS 2011 Salary Workplace Survey, we followed a long day in the life of fictional character Duke Gracie, a field training officer and veteran paramedic at Flowing Springs EMS (FSEMS). For 28 years, running the JEMS Salary and Workplace Survey, conducted in cooperation with EMS consulting firm Fitch Associates, provides insight and understanding on key human resource topics. Continuing on the narrative from a year ago, we’ll check in not only on the fictional Duke Gracie, but also his boss Margaret Taylor and FSEMS. Potential bias/limitations This year, participating EMS organizations were given the option to complete the survey anonymously. Thirty-six respondents selected this option. With this selection the author and research staff are “blinded” to the e-mail or IP address of the respondents. Regardless of how information is submitted, raw data is only available to the research staff and author, and only aggregate data is published. Data accuracy is a primary objective. Survey results may be limited by the accuracy of respondent submitted data, organizational selective participation and an inconsistent pool of respondents year-toyear. Ambiguous, unclear or incomplete answers were unilaterally excluded from the dataset, rather than interpreted by the author, thus creating a potential additional bias. The survey represents all federal regions. But the individual states not responding were Massachusetts, New Hampshire, Vermont, Delaware, District of Columbia, Nevada and Wyoming. In total, 221 survey participants resulted in a 10% response rate. The median population of respondents is 50,000. Median annual call volume is 5,000. Nearly one-third (27.5%) of responses were from multirole fire services. In a 2011–2012 comparison, some salaries have declined. However, wage growth between 2006 and 2012, including the recession years of 2008–2009, ranks high among U.S. jobs (8%). Word of mouth and electronic media were the top tools used to find potential job candidates. New employees spend less time in orientation, 160 hours vs. 240 in 2011 and less time in field training, seven weeks down from 10 in 2011. One-third of employees are cleared to work after training without ever meeting with a medical director, with more than 20% “never” meeting with a medical director. Fourteen of 19 job categories experienced wage gains in 2012. Of 25 employee benefit categories, 15 were reported as being “reduced” and 14 were “eliminated.” The “JEMS Salary Workplace Survey” is a joint research project in collaboration with Fitch Associates, LLC (www. fitchassoc.com). For 28 years, Fitch Associates is the leading international emergency services consulting firm and serves a diverse range of clients. www.jems.com | october 2011 | jems 31
  • 32. JEMS 2012 Salary Workplace Survey continued from page 31 This year, we find Duke as a newly minted Director Maggie Taylor leverages the same community paramedic, looking like a new technology in her recruitment strategy as man who is refreshed and self-assured. In a her industry colleagues. Recruitment via an freshly pressed uniform, Duke steps out of a “agency website” (31%) takes a narrow secFlowing Springs EMS Community Paramedic ond to “employee referral” (32%) in this year’s rig and pulls his sunglasses down over eyes in survey results. Other job websites, such as the bright early morning sunlight. “Another Monster.com and CareerBuilder.com (10%), day in paradise, saving lives and stomping as well as electronic mailing/list-servs (7%), out disease,” he thinks as he smiles to himself. round out the technological approach to In EMS, the human element—be it patient recruiting. Trade journal ads (4%) and conferor provider—is the driving force in the sys- ence booth recruiting (6%) are the least-used tem. As Michael F. Staley wrote in Igniting tools to find new employees, while local EMS the Leader Within, “Knowing how to motivate training programs (23%) continue to be fertile a person in emergency medical services ground to fill job openings. requires that you understand the person, the passion and the pay- Figure 1: Participant Distribution Survey Respondent Mix check—in that order.”2 After his internal struggle in Survey Responses n= 221 this past year’s survey, Duke is Regional Distribution now passionate about his work. See Regional Map (Figure 2), p. 34 “It’s not like building widgets Provider Model Distribution in some factory,” he tells fam% NUM ily and friends. “I save lives, and City/county third-service governmental 21.7 49 get paid for doing it. I can’t imagPrivate, not-for-profit organization 15.9 36 ine doing anything else!” (Doing Hospital-based 11.9 27 something else was exactly what Duke was pondering a year ago, Private, for profit company 8.8 20 but more on that later.) Fire department, single-role 0.9 2 Recruitment, Hiring Retention “I haven’t been ‘texted’ about open shifts in months now,” Duke comments as he walks into the FSEMS Communications Center. “Maggie must have gotten my replacement hired.” “Yup, you’ve been replaced,” replies Lyndy Grayson, the communications supervisor. “We got hundreds of hits on Monster and our Facebook page, tens of qualified candidates from Maggie’s Tweet and a huge response from the buzz on the streets. Your job was as hot as a software IPO [initial public offering].” “Tweet, Monster, Facebook, IPO … this sounds like ‘Maggie speak’ to me,” Duke responds with a snort. “Kids these days don’t use the same language as they used to.” Although these terms might sound unfamiliar to Duke, Flowing Springs EMS Executive 32 JEMS OCTOBER 2012 Fire department, multi-role 26.5 Seventy-six of 221 agencies reported vacancies within their organizations. They reported an average of three vacancies in 2012, down from five in 2011.3 Additionally, agencies continue to use part-time EMS personnel (67%) with nearly 30% reporting an increased interest from applicants in parttime employment. Of key frontline EMS positions, organizations continue to report a shortage of paramedic staff (39% vs. 40% in 2011) with an increase in a shortage of emergency medical dispatchers (28%), which is up 10% from 2011. The EMT-Basic category continues to exhibit a low percentage of reported shortages (18%). When positions are available, Flowing Springs EMS is able to hire qualified candidates that they recruit. Similarly, 83% of survey respondents report “hiring as usual” with a single-digit minority saying “hiring is on hold or frozen” (greater than 6%). Training, Education Medical Control 60 Public utility model 1.8 4 Other 12.4 23 Total Population Served n=201 % Less than 5,000 NUM 7.5 15 5,001-10,000 5.5 11 10,0001-25,000 21.9 44 25,001-50,000 15.4 31 50,001-100,000 12.9 26 100,001-250,000 15.4 31 250,001-500,000 10.0 20 500,001-1,000,000 9.0 18 More than 1,000,000 2.5 5 Call Requests vs. Transports Responses n=199 Transports n=199 % NUM % NUM Less than 1,000 15.1 30 22.6 45 1,001-5,000 37.2 74 36.7 73 5,001-15,000 17.6 35 17.6 35 15,001-30,000 12.6 25 9.5 19 30,001-50,000 7.0 14 8.5 17 50,001 - 70,000 5.5 11 2.0 4 70,001-90,000 2.5 5 2.0 4 Greater than 90,000 2.5 5 1.0 2 “Turn and burn,” quips Duke. “Those newbies are in and out of orientation quickly; they’re in the field at breakneck speed.” “It’s like a well-oiled machine,” Lyndy comments. “We’ve got the orientation process dialed in.” Little has changed this year over last in the subject matter covered in new employee orientation (e.g., policies, patient care guidelines and customer service). What has changed are the average hours the employee spends in orientation. In 2011, respondents indicated that 240 was the average number of hours of orientation training required for new EMS employees. The average number of hours in orientation has dropped to 160 hours for 2012. A concurrent drop in the “average length of time (weeks) an employee new  to your organization spends in the clearance/probation process before they are considered a fully functional and independent member of field staff” is noted in 2012 data. This is down from 10 weeks in 2011 to seven in 2012.
  • 33. Choose 25 at www.jems.com/rs
  • 34. JEMS 2012 Salary Workplace Survey continued from page 32 illustration amane kaneko Figure 2: Participant by Region Note: The number in parentheses is the number of respondents from that region. Standard Federal Regions established in 1974 by the Office of Emergency Management and Budget. The same regions are used by the federal Emergency Management Agency and the Centers for Medicare Medicaid Services. organizations, more frequently “What’s Dr. Mark’s stance on Figure 3: Participant Unit Hour Utilization than monthly at 27%, quarterly this ‘speed training’ process?” Avg Unit Hours/ Avg Call Volume/ Avg Unit Hour Response Volume at 16% and on-demand at 13%. Duke asks Lyndy. Week (A) Week (A) Utilization (B/A) “I guess I don’t know,” she Less than 1,000 (999) 310 19 0.06 responds. “He’s been a bit overDoing More 1,001–5,000 (4,999) 755 96 0.13 committed to the new commuDuke’s former partner and field 5,001–15,000 (14,999) 892 288 0.32 nity paramedic (CP) training. trainee Dave stops as he’s walk15,001–30,000 (29,999) 1,338 576 0.43 “Between that and trips to the ing by. He leans in the door, 30,001–50,000 (49,999) 2,002 960 0.48 rural health clinic, he hasn’t been “Hey old man, how’s it going as hands-on as in the past,” she with the new job?” Duke stands 50,001–70,000 (69,999) 3,278 1,344 0.41 adds, looking at a closed office and they shake hands and 70,001–90,000 (89,999) 4,258 1,728 0.41 door marked with “Mark Manexchange backslaps. Greater than 90,000 (99,999) 4,541 1,920 0.42 gus, MD—Medical Director.” “Good,” Duke responds. Duke thinks about how unusual that is, that it “believes that all aspects of the orga- “We’re always doing more; it’s job security, remembering the days when he and Mangus nization and provision of basic (including you know.” first responder) and advanced life support ran calls together. “It’s not enough to be a paramedic and field “Maggie needs to talk to him,” Duke tells emergency medical services (EMS) require the training officer. No, Duke’s got to be a comLyndy. “Now that the CP program is up and active involvement and participation of phy- munity paramedic too,” mocks Dave. “Looksicians.”4 How much time does your medical ing to the future’s not a bad thing,” responds running, he needs to get back in here.” Only 30% of “new employees who have director spend one-on-one with field staff? Duke, “Do more, or someone else gives you completed their probationary credentialing Few organizations report that continu- more to do. Besides, if I can make the system process must complete an interview with a ing education (CE) content is developed and work even better, then I’ve made a difference.” medical control physician as the final step delivered solely “in-house” (9%) or entirely “It’s all about productivity,” Lyndy chimes to clearance.” “outsourced” (15%); in fact, most use “both” in. “I’d rather be in Duke’s shoes than handing Worse yet, following the probationary (76%). CE occurs in a “traditional classroom” out parking tickets.” credentialing process, some field employees at 40% of the agencies responding. Less than City managers in a Tennessee commu(22%) “never” meet one-on-one with the med- 2% use “distributive methods” (e.g., video and nity may have found a win/win on producical control physician. Furthermore, in 2012 the Internet) exclusively; most, or 58%, use tivity and budget. Firefighters in Oak Ridge organizations reported field staff only met both methods. Monthly CE occurs at 49% of will be issuing parking tickets according to with the medical director “when one online publication.5 Whether it’s needed” (67%). to generate revenue or boost proFigure 4: Unit Hour Utilization Calculator Although the American Colductivity, doing more with less is the Total Unit Hours per Week = (A) lege of Emergency Physicians new norm. (Total number of staffed hours per week) (ACEP) doesn’t specify how As director of Flowing Springs EMS, Average Call Volume per Week = (B) much face-to-face time a mediMaggie knows it’s imperative that the (Total number of responses per week including transports, refusals, no transports, etc.) cal director needs to spend with service operates in an economically Unit Hour Utilization = (B/A) EMS caregivers, ACEP has stated sustainable and accountable model. 34 JEMS OCTOBER 2012
  • 35. Choose 26 at www.jems.com/rs
  • 36. JEMS 2012 Salary Survey continued from page 34 Mention productivity to staff, and you can see a visible shudder. If she mentions unit hour utilization (UHU), she can almost hear the chorus of moans. As a visionary leader, she sees great potential for a win/win in her new community paramedicine program. As uncertainty over the financial impact of the Patient Protection and Affordable Care Act (PPACA) leads the media headlines and political campaigns, some EMS systems are looking to expand their role in healthcare. PPACA places increased priority on prevention, wellness and improved outcomes within a healthcare system. According to Wikipedia.com, “An accountable care organization [ACO] is a Job Descriptions for Salary Data ChristopherBernard/istockphoto.com Choose 27 at www.jems.com/rs Choose 28 at www.jems.com/rs 36 JEMS OCTOBER 2012 Emergency Medical Technician (EMT-B): This section inquires about your full-time emergency medical technicians with basic EMS skill levels that may include additional skills, such as defibrillation, assisting patients with medications, and first aid based on the current National Standard Curriculum. Emergency Medical Technician-Intermediate (EMT-I): A full-time emergency medical technician–intermediate based on the current National Standard Curriculum. Emergency Medical Technician-Paramedic (EMT-P): A full-time emergency medical technician at the paramedic level based on the current National Standard Curriculum. Emergency Medical Dispatcher (EMD): A full-time emergency medical dispatcher that includes frontline communications positions. Duties include call taking, dispatch, or both. This person may also be certified as an EMT or paramedic. Communications/Dispatch Supervisor: A first-line supervisor of emergency medical dispatcher(s). Duties may include shift supervision, scheduling, performance evaluation as well as call taking, dispatch or both. This person may also be certified as an EMT or paramedic. Communications Manager: A senior management position of the EMS communication center. This position may oversee all operations, budgeting, hiring, quality and strategic planning. Field Training Officer: A full-time field training officer whose duties include field training of new employees or EMT students at all levels. This may be a full-time position or performed as part of regular shift work. Education Coordinator: An entry-level management position. This position may be charged with providing or coordinating continuing medical education, overseeing field training and supporting recertification of staff. In some organizations, duties may be blended with the quality management functions. Quality Coordinator/Manager: Traditionally, an entry-level management position that may be charged with coordinating and managing key clinical performance indicators (e.g., cardiac arrest survival) and quality assurance (e.g., run form review and complaint investigation). In some organizations, duties may be blended with the quality management functions.
  • 37. healthcare organization characterized by a payment and care delivery model that seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients.” Can EMS do more? For a UHU calculator, see Figure 3, p 34. Using this year’s respondent data, participant UHU is presented in Figure 4, p. 34. Reported annual response volume and average unit hours were distributed by 52 weeks per year to determine an average UHU. Comparing that UHU to several published benchmarks the conclusion is clear.6–8 There’s capacity to do more within many EMS Financial Officer/Manager: A full-time management position focused on budget and finance that may also have blended duties related to the oversight of billing operations. Billing/Reimbursement Clerk: A frontline position responsible for processing patient care records, billing payers and collecting reimbursement for services. Billing/Reimbursement Manager: Traditionally a middle management position responsible for supervising the processing of patient care records, billing payers and collecting reimbursement for services. Fleet Mechanic: A frontline mechanic in fleet services whose duties may include preventative maintenance, scheduled/unscheduled maintenance, vehicle remounting/replacement and purchase specifications. Fleet Manager: A middle management position charged with leading fleet services. Duties may include supervising mechanics, coordinating preventative maintenance, vehicle remounting/replacement and purchase specifications. Information Technology/Systems Manager: This position may or may not be a management position. Responsibilities may include maintaining technological infrastructure (e.g., e-mail, servers, networks, etc.) for the organization. Logistics/Supply Manager: May be management position or not. Responsibilities may include supply purchasing, storage, distribution and tracking. This position may also manage restocking of stations or ambulances. EMS Operations Manager/EMS Chief: A middle- to upper-management position responsible for managing day-to-day operations. This position may have field supervisors and other frontline leadership positions reporting directly to them. Administrative Director/EMS Administrative Chief: A senior-level management position that traditionally includes oversight of all nonoperations functions and may include finance, billing/reimbursement and human resources. Executive Director/Highest-Ranking EMS Chief: A senior leader of all EMS functions whose duties include strategic planning, constituent relations and leading senior management team. Choose 29 at www.jems.com/rs www.jems.com OCTOBER 2012 JEMS 37
  • 38. JEMS 2012 Salary Workplace Survey continued from page 37 to healthcare, personal care and social assistance … are projected to have Quality the fastest job growth between 2010 Education EMT EMT-I EMT-P EM Dispatcher Assurance and 2020.”14 Coordinator Manager Listed as one of the “top five industries for salary growth,” health2006 Average (Max.) $39,143 $37,485 $51,537 $40,845 $63,444 $65,073 care workers have gained the biggest 2012 Average (Max.) $45,179 $40,059 $55,696 $46,777 $58,342 $69,017 changes in wages, 9.4%, since 2006.15 Loss/Gain (+/-) 15% 7% 8% 15% -8% 6% What does that mean to EMS workers? There’s reason for some optimism Note: Survey results for the following are available at jems.com: Communications supervisor, communications manager, chief financial officer, billing manger, fleet mechanic, information technology manager, operations manager, administrative director, executive director. in EMS wages. Twelve job categories from the 2006 JEMS Salary and Workplace Survey were compared to 2012 data organizations, whether it be writing parking of Labor Statistics (BLS) reported that the tickets or becoming more accountable for unemployment rate ticked up a tenth of (See Figure 5, at left).16 Despite losses in two the health of your community. If you had to percent to 8.2.13 Yet a February 2012 BLS individual categories, EMS salaries increased choose between the two, it doesn’t seem to be report on employment projections opened 8% over that timeframe. This increase places a difficult decision; EMS is at its best when it’s with, “Industries and occupations related EMS with general healthcare as one of the caring for patients. Can CP programs make a dif- Figure 6: Existing Employee Benefits ference? According to the Agency Partially Not Paid by Reduced Eliminated for Healthcare Research and QualPaid by N this Year this Year Applicable Employer ity (AHRQ), they do.9 MedStar Employer Health’s Community Health ProNew Employee Relocation Expenses 98% 1% 6% 0% 4% 112 gram in Fort Worth, Texas, has Life Insurance 17% 58% 26% 0% 0% 113 saved millions in emergency room Line-of-Duty-Death Insurance 41% 46% 13% 0% 0% 113 charges and reduced 9-1-1 use.10 The Centers for Medicare and MedMajor Medical (Employee) 5% 26% 68% 1% 0% 112 icaid Services (CMS) must think Major Medical (Employee’s Family) 14% 11% 73% 2% 1% 114 so as well. In July, the CMS Health Short-term Disability 28% 42% 28% 1% 1% 111 Care Innovations Grant program Long-term Disability 31% 38% 29% 2% 0% 109 awarded Prosser Memorial Hospital in Washington almost $1.5 Employee Assistance Program 18% 72% 11% 0% 0% 113 million to develop and provide a Dental 17% 18% 65% 1% 0% 113 community paramedic program.11 Optical/Vision 25% 15% 55% 3% 1% 110 Which model for community paramedicine should you Liability Insurance 36% 53% 9% 1% 1% 110 choose? It could be a “new niche EMS Tuition Reimbursement 19% 40% 33% 3% 5% 113 for EMS,” according to the August College Tuition Reimbursement 43% 13% 35% 3% 6% 111 JEMS article “It Takes a Village.”12 Scholarship Fund for Employee’s Children 97% 0% 2% 1% 0% 111 The article identifies the key component of the multiple CP modRetirement or Pension Plan 8% 13% 74% 3% 2% 115 els as the needs of and resources Retirement or Pension Plan 86% 5% 5% 1% 1% 111 in the community. “They all feaProfit Sharing 96% 1% 2% 0% 1% 113 ture aspects of home assessment, Stock Purchase Program 74% 26% 0% 0% 0% 112 home care and patient followup. They all focus resources on Shift Differential Pay 12% 73% 14% 0% 2% 113 target population, follow-up care Uniform Allowance 64% 16% 18% 1% 1% 110 and prevention,” the article states. Health Club Membership Reimbursement 27% 69% 4% 1% 0% 113 The take-home message: “Community need” should drive model Paid Time Off (PTO) Combined Benefit 97% 0% 2% 0% 1% 110 Leave development and implementation, creating a partnership in the Daycare Reimbursement 94% 6% 0% 0% 1% 111 healthcare of the community. Dry-cleaning of Uniforms 95% 2% 3% 1% 0% 112 Figure 5: Annual Salary Growth Index from 2006 to 2012 With Less? Meal Service 99% 1% 0% 0% 0% 110 In May 2012, the U.S. Bureau Concierge Service 98% 1% 6% 0% 4% 112 38 JEMS OCTOBER 2012
  • 39. National Region X Region IX Region VIII Region VII Region VI Region V Region IV Region III Region II Show Me the Money “Daylight is burning,” declares Duke as he ends the conversation and heads toward the Communications Center for a schedule of today’s community visits. During his workday Duke will visit a number of “frequent flyers” that have been identified within the healthcare community as needing screening and help with chronic care. One of Duke’s congestive heart failure patients wrote in recent thank-you card to FSEMS that Duke saved him from an ambulance trip to the hospital. “He listened to me breathe, took a blood pressure and made a complete assessment. Then he called my doctor, who adjusted my pills. He did all of this before I was really sick,” Mr. Write wrote, adding that Duke even stopped by later to check on him again that day, concluding with a thank you to both Duke and FSEMS for good community service. National salaries for 2012 are broken down into several categories and stratified by region (see Figure 7, at right) and call volume (see Figure 8, p. 40). The job descriptions used in the survey are also presented in “Job Descriptions for Salary Data,” p. 36–37. Regional data is reported where antitrust guidelines were achieved. All wages are adjusted to reflect a 40-hour workweek for comparison. See Figure 9, p. 40, for instructions on calculating wages for comparison to different shift lengths. Author’s note: Comparing 2012 salary data to 2011 appears unreliable due to a qualitative participation bias. Data reported for 2011 national average salaries was significantly higher than data EMT   n= Average 10th 25th 50th 75th 90th Max Hourly Average n= Average 10th 25th 50th 75th 90th n= Average 10th 25th 50th 75th 90th n= Average 10th 25th 50th 75th 90th n= Average 10th 25th 50th 75th 90th n= Average 10th 25th 50th 75th 90th n= Average 10th 25th 50th 75th 90th n= Average 10th 25th 50th 75th 90th n= Average 10th 25th 50th 75th 90th n= Average 10th 25th 50th 75th 90th n= Average 10th 25th 50th 75th 90th EMT-I EMT-P 105 $27,747 $10,400 $18,342 $20,800 $26,398 $32,885 $66,789 $13.34 3 N/A N/A N/A N/A N/A N/A 6 $25,441 $17,520 $20,300 $29,443 $33,181 $33,852 11 $28,115 $19,635 $21,226 $25,230 $33,134 $41,021 11 $25,402 $17,977 $19,559 $22,763 $26,731 $35,547 23 $27,685 $21,062 $24,357 $26,499 $28,850 $38,759 7 $35.254 $18,698 $23,000 $31,434 $42,127 $55,220 17 $25,824 $19,215 $20,800 $25,938 $28,787 $32,349 9 $28,929 $19,479 $22,693 $29,203 $33,301 $40,652 12 $27,723 $17,385 $20,592 $23,017 $31,808 $46,475 5 $28,418 $20,202 $23,504 $26,578 $34,008 $37,603 39 $29,542 $16,672 $19,366 $23,050 $27,040 $32,051 $66,480 $14.20 1 N/A N/A N/A N/A N/A N/A 0 N/A N/A N/A N/A N/A N/A 3 N/A N/A N/A N/A N/A N/A 8 $23,965 $18,273 $21,458 $23,837 $26,287 $28,792 7 $31,501 $26,333 $27,872 $29,869 $36,090 $37,440 1 N/A N/A N/A N/A N/A N/A 5 $33,132 $21,919 $22,880 $31,117 $35,657 $47,101 5 $28,615 $22,010 $23,024 $23,400 $28,600 $39,470 3 N/A N/A N/A N/A N/A N/A 6 $35,057 $24,835 $26,559 $29,947 $34,887 $50,388 109 $37,909 $21,174 $26,000 $29,000 $35,818 $43,867 $79,040 $18.23 4 N/A N/A N/A N/A N/A N/A 4 N/A N/A N/A N/A N/A N/A 13 $37,258 $26,789 $27,851 $34,299 $44,286 $51,027 14 $34,328 $24,425 $26,242 $31,986 $41,776 $53,400 22 $37,185 $28,291 $29,796 $33,966 $40,082 $46,413 8 $39,857 $27,331 $33,704 $37,183 $48,607 $52,134 15 $38,950 $26,525 $27,602 $33,342 $42,949 $61,113 10 $39,388 $28,596 $31,767 $37,835 $47,060 $54,199 11 $37,189 $22,384 $33,280 $38,251 $43,212 $47,445 7 $41,438 $29,993 $35,981 $39,000 $42,026 $54,134 Field Training Officer 35 $45,055 $21,840 $25,552 $30,319 $40,128 $55,959 $95,000 $21.66 0 N/A N/A N/A N/A N/A N/A 2 N/A N/A N/A N/A N/A N/A 5 $35,784 $28,392 $30,888 $39,175 $40,128 $41,251 2 N/A N/A N/A N/A N/A N/A 9 $42,521 $23,587 $25,520 $30,992 $58,032 $64,856 3 N/A N/A N/A N/A N/A N/A 2 N/A N/A N/A N/A N/A N/A 2 N/A N/A N/A N/A N/A N/A 7 $45,424 $24,111 $31,338 $37,272 $56,145 $71,633 3 N/A N/A N/A N/A N/A N/A EM Dispatcher Education Coordinator 44 $36,327 $20,096 $23,036 $29,900 $35,770 $42,583 $61,714 $17.47 2 N/A N/A N/A N/A N/A N/A 3 N/A N/A N/A N/A N/A N/A 7 $33,585 $24,369 $27,872 $32,531 $34,029 $44,040 6 $38,294 $29,204 $36,006 $38,480 $41,922 $47,199 10 $32,662 $25,228 $28,642 $31,934 $36,494 $41,292 2 N/A N/A N/A N/A N/A N/A 5 $37,325 $28,445 $36,011 $40,000 $42,213 $43,885 4 N/A N/A N/A N/A N/A N/A 5 $38,420 $26,170 $35,280 $43,750 $45,136 $46,758 0 N/A N/A N/A N/A N/A N/A 45 $55,570 $30,160 $39,092 $43,867 $52,894 $63,128 $89,837 $26.72 1 N/A N/A N/A N/A N/A N/A 1 N/A N/A N/A N/A N/A N/A 5 $52,537 $47,520 $52,998 $60,008 $76,460 $79,718 8 $58,405 $39,822 $48,203 $57,662 $67,345 $80,334 7 $50,337 $41,191 $46,500 $52,000 $53,040 $56,431 4 N/A N/A N/A N/A N/A N/A 6 $47,981 $31,080 $34,497 $46,693 $57,849 $66,171 5 $66,083 $55,371 $60,000 $66,560 $72,800 $76,382 6 $51,549 $37,482 $42,115 $50,397 $56,684 $66,768 2 N/A N/A N/A N/A N/A N/A www.jems.com Quality Assurance Manager 28 $60,502 $29,719 $45,608 $52,894 $58,016 $66,919 $91,243 $29.09 1 N/A N/A N/A N/A N/A N/A 1 N/A N/A N/A N/A N/A N/A 5 $53,150 $48,639 $52,582 $52,998 $56,160 $57,264 3 N/A N/A N/A N/A N/A N/A 5 $51,134 $36,177 $45,864 $53,227 $60,300 $64,056 3 N/A N/A N/A N/A N/A N/A 2 N/A N/A N/A N/A N/A N/A 5 $65,358 $59,779 $62,400 $65,562 $67,995 $70,878 3 N/A N/A N/A N/A N/A N/A 0 N/A N/A N/A N/A N/A N/A Billing Clerk Supply Clerk 47 $33,397 $20,509 $25,651 $27,040 $31,200 $37,380 $62,387 $16.06 3 N/A N/A N/A N/A N/A N/A 1 N/A N/A N/A N/A N/A N/A 10 $31,801 $25,097 $27,238 $31,325 $34,679 $37,502 8 $29,463 $26,824 $27,028 $29,040 $30,679 $32,475 9 $33,532 $26,000 $26,624 $34,195 $38,813 $40,718 0 N/A N/A N/A N/A N/A N/A 4 N/A N/A N/A N/A N/A N/A 5 $37,417 $30,716 $36,712 $40,685 $41,371 $41,508 4 N/A N/A N/A N/A N/A N/A 0 N/A N/A N/A N/A N/A N/A 22 $48,511 $18,720 $25,272 $35,261 $44,023 $64,067 $97,850 $23.32 1 N/A N/A N/A N/A N/A N/A 0 N/A N/A N/A N/A N/A N/A 3 N/A N/A N/A N/A N/A N/A 6 $58,423 $32,001 $41,241 $61,845 $64,592 $81,425 3 N/A N/A N/A N/A N/A N/A 3 N/A N/A N/A N/A N/A N/A 3 N/A N/A N/A N/A N/A N/A 4 N/A N/A N/A N/A N/A N/A 2 N/A N/A N/A N/A N/A N/A 0 N/A N/A N/A N/A N/A N/A Note: Survey results for the following are available at jems.com: Communications supervisor, communications manager, chief financial officer, billing manger, fleet mechanic, information technology, operations manager, administrative director executive director. Figure 7: Salaries by Region Region I best jobs for wage growth. Not all the news is good. Organizational “belt tightening” is reflected in the 2012 Employee Benefits data (See Figure 6, below left.). Twenty of 25 benefits categories were reduced or eliminated this year. Taking the biggest hits, the categories of EMS reimbursement (5%) and college tuition reimbursement (6%) and new employee relocation expenses (4%) were eliminated by organizations reporting. JEMS 39 OCTOBER 2012
  • 40. JEMS 2012 Salary Workplace Survey continued from page 39 Figure 8: Salaries by Call Volume Less than 1,000 1,001 - 5,000 5,001 - 15,000 15,001 - 50,000 Greater than 50,000 n= Average 10th 25th 50th 75th 90th n= Average 10th 25th 50th 75th 90th n= Average 10th 25th 50th 75th 90th n= Average 10th 25th 50th 75th 90th n= Average 10th 25th 50th 75th 90th EMT-I EMT-P Field Training Officer EM Dispatcher Education Coordinator Quality Assurance Manger Billing Clerk Supply Clerk 14 5 17 5 6 5 5 6 5 $19,917 $23,858 $30,674 $35,957 $44,993 31 $20,851 $24,003 $30,659 $34,739 $35,673 11 $25,578 $31,846 $38,195 $40,976 $46,883 30 $26,707 $30,888 $40,128 $52,000 $69,934 7 $31,429 $33,119 $36,161 $42,173 $43,846 16 $44,450 $52,998 $60,000 $81,120 $81,582 13 $48,805 $52,998 $58,000 $62,400 $79,706 9 $26,671 $26,996 $28,915 $33,755 $40,092 14 $34,212 43,410 $60,320 $69,000 $72,112 6 $18,699 $19,864 $23,754 $28,694 $34,545 27 $17,160 $22,151 $23,442 $30,670 $46,717 8 $26,169 27,945 $34,320 $41,481 $54,199 25 $37,183 $37,734 $39,175 $45,594 $56,584 7 $21,934 $29,250 $35,646 $41,259 $42,401 9 $36,858 $51,144 $52,285 $61,300 $71,552 15 $52,308 $55,994 $60,300 $65,000 $67,009 6 $24,923 $26,109 $31,325 $36,778 $40,348 15 $32,760 $37,700 $43,118 $59,384 $66,387 5 $19,386 $23,601 $27,642 $31,317 $35,260 13 $21,996 $25,350 $29,132 $31,558 $33,540 7 $27,144 $29,709 $34,112 $42,308 $46,263 17 $24,048 $28,256 $45,302 $54,713 $61,318 9 $28,417 $35,528 $41,600 $45,000 $45,294 7 $40,782 $42,934 $52,894 $59,266 $76,935 5 $50,148 $54,573 $66,770 $85,868 $89,655 5 $27,040 $27,581 $31,200 $37,877 $54,898 5 $19,402 $20,426 $63,369 $65,000 $84,710 2 $24,011 $27,579 $35,755 $41,856 $46,432 6 $22,233 $23,335 $25,506 $28,808 $36,660 3 $27,275 $28,148 $42,389 $49,140 $62,519 5 $34,924 $37,088 $44,822 $51,019 $60,872 1 $31,889 $35,262 $37,844 $41,427 $43,704 1 $40,230 $40,455 $41,126 $44,871 $50,627 3 $49,559 $50,612 $52,368 $57,659 $60,834 1 $32,292 $32,967 $34,592 $36,242 $36,961 2 N/A N/A N/A N/A N/A 1 $17,091 $17,328 $17,723 $19,822 $21,081 N/A N/A N/A N/A N/A $22,425 $22,823 $23,486 $24,149 $24,547 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Note: Survey results for the following are available at jems.com: Communications supervisor, communications manager, chief financial officer, billing manger, fleet mechanic, information technologymanager, operations manager, administrative director executive director. EMT   reported in 2010 and 2012. Figure 9: Calculating Alternative Shift Schedule Wages As previously noted, selective See bonus salary All wages are calculated based on 2,080 hours annually (40-hour work week). participation and a different figure online at jems. To calculate alternative shift schedules, divide an annual wage for a position by 2,080 hours to pool of respondents year-tocom/journal. find the hourly rate and then multiply the result by the annual number of straight hours for the shift type of interest. Below are examples for the three most common average weekly hours. year creates this situation outA just-released Pew side of survey and researcher Research Center survey Average Work Week Straight Hours x 52 weeks/year Annual Straight Hours control. Visit jems.com/jourreports that a $70,000 annual 40 hours 40 straight hours x 52 weeks 2,080 hours nal and click on the salary surincome is needed for a fam48 hours 52 straight hours x 52 weeks 2,704 hours vey for an extended figure with ily of four to lead a middle56 hours 64 straight hours x 52 weeks 3,328 hours additional job categories not class lifestyle in the U.S. Using shown here as well as a comthe Pew study definition of EMTs and education coordinators demon- middle-class lifestyle, only three of the EMS plete comparison of 2011–2012 data. Out of 19 job categories, 14 reported sal- strated a moderate loss in wages, minus two job categories—operations manager, adminary growth in comparison to 2010 wages. The and minus four percent respectively. Chief istrative director and executive director— billing manager position showed no growth financial officers (CFO) and supply coordina- would allow a single-income family of four in wages between 2010 and 2012 (see bonus tors took the greatest wage losses at -9% and to live middle-class lifestyle .17 In comparison, -14%, respectively. salary figure online at jems.com/journal). a registered nurse receives an annual salary 40 JEMS OCTOBER 2012
  • 41. of approximately $70,000.18,19 It’s no wonder that EMS often experiences a migration of EMS personnel to nursing professions. Conclusion Duke considers the opportunity that the community paramedicine program has provided him to be a good one. “It’s not just a paycheck. I get to help people before they need an ambulance. I get to spend some time helping them stay out of the ambulance and hospital,” he thinks. “And it saves the system money. How great is that?” Considering the current state of jobs and employment in the U.S. today, EMS is looking pretty good. Although the profession’s future might not quite be bright enough for “dark sunglasses,” wage growth has been a bright spot in an otherwise depressed U.S. job market. EMS innovation, aimed at serving the population and cutting costs, has demonstrated benefit and value to healthcare. Community paramedicine is a key component in future ACO success. Based on the quantitative reductions in education, training and tuition reimbursement, EMS leaders and providers in all sectors of the industry are cautioned that short-term economic gains may hinder future EMS capacity and capability. Further, a family-oriented EMS employer must consider that many EMS workers households are supported by two working adults in order to maintain a middle-class lifestyle. Flexible staffing, scheduling, childcare and sick childcare may be a key component of workforce recruitment, retention, employee satisfaction and loyalty. Circling back to Staley’s motivational theory in EMS, it’s the person who brings the passion that gives the “heart” to EMS. A paycheck is meaningless if you lack the understanding of those human components. Takeaway Points: 2012 Data Michael Greene, MBA/MSHA, is a senior associate at Fitch Associates. He has served in frontline and leadership positions, including volunteer and paid search and rescue, as a paramedic, a county EMS director and an air medical/critical care transport director. He’s the author of numerous articles and chapters on EMS, air medical transport and safety. Contact him at mgreene@fitchassoc.com or 816/431-2600. Acknowledgment: The author acknowledges the support and contributions of Fitch project team members Sharon Conroy, Melissa Addison and Cindy Jackson. Disclosure: The author is an external, expert consultant with the consulting firm Fitch Associates, LLC, which provides emergency service organizational and system audits for communities and individual organizations. Note: If you’re an EMS service with paid staff that did not participate in this year’s survey but would like to include your agency data next year, please e-mail the author. References 1. Department of Justice and Federal Trade Commission. (August 1996). Statements of Antitrust Enforcement Policy in Health Care Statement 6: Enforcement policy on provider participation in exchanges of price and cost information. In Federal Trade Commission. Retrieved July 13, 2012, from www.ftc.gov/bc/ healthcare/industryguide/policy/statement6.pdf. 2. Staley MF. Igniting the Leader Within: The leadership legacy of Ben Franklin, father of the American fire service. Fire Engineering Books: Saddle Brook, N.J., 120, 1998. 3. Greene M Wright D. JEMS 2011 Salary and Workplace Survey. JEMS. 2011;36(10):42–49. 4. ACEP Board of Directors. (April 2012). Medical Direction of EMS. In American College of Emergency Physicians. Retrieved Aug. 10, 2012, from www.acep.org. 5. Fowler B. (July 12, 2012). Car parked near hydrant? OR firefighters might write you up. In Knoxville News Sentinel. Retrieved July 16, 2012. from http://www.knoxnews.com/news/2012/jul/12/ car-parked-near-hydrant-or-firefighters-might-up/. 6. Andreson D. Overton J. High Performance and EMS: Market study 2006–2009. Coalition of Advanced Emergency Medical Systems. 2007. 7. Kuehl AE, editor. Prehospital Systems and Medical Oversight. Kendall/Hunt Publishing Company: Dubuque, Iowa. 2002. Innovative EMS leaders and staff are looking at new ways to increase productivity, efficiency and economics within the industry. The future may be inherited by those agencies with a vision of healthcare over a population ‘without walls.’ Early results of community paramedicine programs demonstrate favorable outcomes especially in light of healthcare reforms. Motivation is more than a paycheck in EMS. EMS leaders and medical directors must leverage individual’s passions and talents through personal interactions and understanding that goes beyond policy and workplace compliance. EMS has provided excellent wage growth during 8. Schaltberger HA. (n.d.). Emergency Medical Services: A guidebook for fire based systems. 4th edition. In International Association of Fire Fighters. Retrieved from www.iaff.org/tech/PDF/EMSGuideBk.pdf. 9. Agency for Healthcare Research and Quality. (Jan. 18, 2012). Trained Paramedics Provide Ongoing Support to Frequent 911 Callers, Reducing Use of Ambulance and Emergency Department Services Agency for Healthcare Research. In U.S. Department of Health and Human Services. Retrieved Aug. 11 2012 from www. innovations.ahrq.gov/content.aspx?id=3343. 10. MedStar EMS. (2012). Community Health Program. Retrieved Aug. 14, 2012, from www.medstar911.org/ community-health-program. 11. PMH Medical Center. (2010). PMH Awarded Community Paramedic Grant. In PMH Medical Center. Retrieved Aug. 14, 2012 from http://pmhmedicalcenter. com/index.php/resources-for-you/latest-news/ item/119-pmh-awarded-community-paramedic-grant. 12. Berry J. It Takes a Village. JEMS. 2012;37(8):42–47. 13. U.S. Department of Labor. (n.d.). Databases, Tables Calculators by Subject. In Bureau of Labor Statistics. Retrieved July 12, 2012 from http://data.bls.gov. 14. U.S. Department of Labor. (n.d.). Databases, Tables Calculators by Subject: Employment. In Bureau of Labor Statistics. Retrieved July 12, 2012 from http://data.bls.gov. 15. Ritter T. (July 16, 2012). Best and Worst Jobs for Wage Growth [infographic]. In Payscale. Retrieved Aug.2, 2012, from http://blogs.payscale.com/ compensation/2012/07/prevailing-wage-rates.html. 16. Williams DM. 2006 JEMS Salary and Workplace Survey. JEMS. 2006;31(10):38–49. 17. Pew Social Demographic Trends. (Aug. 22, 2012). Fewer, Poorer, Gloomier: The lost decade of the middle class. In Pew Research Center. Retrieved Aug. 22, 2012, from www.pewsocialtrends.org/files/2012/08/pewsocial-trends-lost-decade-of-the-middle-class.pdf. 18. Bacon D. Results of the 2011 AORN Salary and Compensation Survey. AORN J. 2011;94(6):536–553. 19. U.S. Department of Labor. (May 2011). Occupational Employment and Wages: 2011;29-1111 registered nurses. In Bureau of Labor Statistics. Retrieved Aug. 5, 2012, from www.bls.gov/oes/current/oes291111.htm. tough times. This fact is important as a recruitment tool and incentive to those in, and those considering, a career in EMS. Cutbacks in orientation, field training and education benefits may serve a short-term staffing and economic purpose but continued cuts may affect long-term work force performance, knowledge acquisition, succession and satisfaction. A middle-class lifestyle can’t be achieved by most EMS job categories on a single income. Family-oriented organizations must be innovative in employee programs designed for two working adult families. www.jems.com OCTOBER 2012 JEMS 41
  • 42. tfoxfoto/istock.com Management Focus Changes present an unparalleled opportunity for EMS By Teresa McCallion, EMT-B The following article is part one of two in an EMS Insider exclusive series on healthcare changes. The Insider, the premier publication for EMS managers, supervisors, chiefs and medical directors, is a must-have resource for the critical, accurate information EMS leaders need. The monthly publication offers quality investigative reporting, exclusive articles, management tips and the very latest news on legislative issues, grants, current trends and controversies. For more about how to become an Insider, go to www.jems.com/ems-insider. T he landmark decision by the U.S. Supreme Court to uphold the constitutionality of the Patient Protection and Affordable Care Act (PPACA) could become a watershed moment for EMS, according to number of EMS leaders. The fiveto-four decision by the justices may open the door for the kind of opportunities to deliver patient care outside the narrow confines of the traditional prehospital emergency system. The question now is: “How will we step up and define how our organizations move forward?” The Supreme Court decision upheld the individual mandate with a twist. Although 42 JEMS OCTOBER 2012 the federal government doesn’t have the power to force citizens to purchase health insurance, it can impose a tax on those who choose to go without coverage. All other provisions of the healthcare law, often referred to as “Obamacare,” including the Medicaid provision (with modifications) and the section establishing accountable care organizations (ACOs), were upheld. Although the legislation has passed a major judicial hurdle, it still faces political challenges. Even before the ruling was made public, Speaker of the House John Boehner pledged his party would launch an immediate effort to repeal the law. Still, EMS leaders warn against taking a “wait-and-see” approach. “This is not the time to sit at home. This is the time to be engaged,” says Scott Bourn, PhD, EMT-P, vice president of clinical practices and research at American Medical Response, Inc. (AMR). He and others believe that the opportunity exists for EMS to evolve beyond the conventional “load-and-go” model into a more sophisticated concept of caring for patients outside of a hospital, including transport to alternative facilities and the expansion of the scope and practice of paramedics. He describes integration into the healthcare system as a “therapeutic win-win” for the
  • 43. patient, the hospital and EMS. James J. Augustine, MD, FACEP, director of clinical operations at Emergency Medicine Physicians (EMP) in Canton, Ohio, says this is a chance for EMS to help design a better system of emergency care outside the traditional role of transporting patients from site to site. “EMS has a very important role as a provider of unscheduled care,” he says. “This really is our opportunity to identify the issues and parts of our practice that need to be reformed.” He notes that healthcare can benefit from the experience of both fire and EMS in the area of prevention measures. “Preventing premature deaths has been the mark of the prehospital emergency system for the past 40 years,” he says. He believes that EMS should promulgate its successes in prevention and allow those lessons learned to be used in the design of new healthcare prevention efforts, improving the overall delivery of healthcare. “I’m a big supporter of our emergency system, and there are opportunities ahead to demonstrate our expertise,” he says. Insurance Coverage One thing is certain: The number of people with healthcare insurance will dramatically increase. The U.S. Census Bureau estimates that currently, nearly 50 million Americans—including nearly one in four working-age adults—are without insurance. Many lost their healthcare coverage when they lost their jobs. Those who kept their insurance have been faced with rising premiums that put a strain on employers and employees alike. According to the Kaiser Family Foundation, a nonprofit organization that focuses on healthcare policy and issues, the average health insurance premium for family coverage has more than doubled during the past decade to $13,770 a year. To provide health insurance for those who can’t afford it, the PPACA calls for the expansion of the Medicaid program. After 2013, individuals who earn up to 133% of the Federal Poverty Level (approximately $14,856 annually) will become eligible for Medicaid, a state-run program that uses matching funds from the federal government. Currently, the federal government pays 57% of the cost of Medicaid to the states. Under the new law, the federal government will fully fund Medicaid for the first three years, decreasing its support to 95% by 2017, then 90% by 2020. Twenty-six states have publicly balked at the idea of taking on that kind of debt. In the ruling, the Supreme Court said that the portion of PPACA allowing Congress to penalize states that opt out by withholding all or part of the state’s Medicaid funds was unconstitutional. It’s nearly certain that some states won’t add these additional Medicaid recipients to their rolls, although it’s unclear at this time which ones will participate and which ones will not—a factor that will certainly affect EMS. Providers operating in these states will face higher uncompensated care due to a larger uninsured population. “For EMS leaders who are politically active, this is the time to start asking what your state plans to do,” says Bourn. As stakeholders, EMS has a say in whether the state accepts those funds. Individuals not covered by the Medicaid expansion will be required by law to maintain “minimum essential” healthcare coverage beginning in January 2014, or they will pay a penalty when filing their income taxes in 2015. Because the penalty is expected to be lower than the cost of insurance, some people may simply choose to pay the penalty. For those who aren’t covered by employer policies, the PPACA provides for health insurance exchanges. These exchanges, set to go into effect no later than Jan. 1, 2013, should drive down the cost of healthcare policies by allowing individuals, who previously had to purchase policies at a higher rate, to buy into a cheaper “group rate” policy. However, many states have held off on implementing of these exchanges in anticipation of the Supreme Court ruling and may not meet the deadline. The U.S. General Accounting Office has estimated that the net result of PPACA could be that approximately 30 million Americans currently without health insurance will be insured under the new law. Revenues The EMS leaders interviewed for this article all agreed that although Medicaid reimburses below the cost of providing the service—6% below according to a 2007 report by the American Ambulance Association, based on 2004 data—some reimbursement is better than nothing. In Minnesota, Aaron Reinert, executive director of Lakes Region EMS, says the added revenue could mean an additional $2 billion in healthcare coverage to his state. He sees this as a huge advantage to begin to receive reimbursement for services his agency already provides. Increasing the number of patients whose service is paid for by a third party offers an added benefit of providing a certain level of fiscal stability for an organization. Agencies that can now count on a stable reimbursement rate in the 80–90% range can think about long-term fiscal planning and investments in innovation, although a couple of bumpy years may be ahead until the new payor mix settles. Although no one believes ambulance services will get rich transporting these potentially insured patients, EMS administrators aren’t the only ones who see a promising opportunity. During the past year, private equity firms have been buying ambulance providers, including the two largest ambulance companies in the U.S., Rural/Metro Corporation and AMR. They see potential revenues created by the confluence of the baby boomers and the expanding market of those covered by Medicaid under healthcare reform. They aren’t the only ones eyeing Medicaid money. Analysts say that Medicaid represents a growth opportunity for U.S. insurers. In July, the nation’s second-largest health insurer, WellPoint Inc., acquired Amerigroup Corp., which runs Medicaid coverage in 13 states, for a reported purchase price of $4.46 billion. Heathcare Integration EMS was hardly mentioned in the more than 2,600 pages of the healthcare reform act; however, the ability to test new payment and care delivery models through demonstration projects funded by the Center for Medicare and Medicaid Innovation does exist. Enterprising providers ought to be seeking demonstration projects to authorize system changes that allow for treat-and-release, alternate destinations and in-home care. “It isn’t the bill I would’ve written … but it provides needed access to insurance, especially for chronically ill patients,” says Bourn. That, he says, will change the dynamics of patient care for EMS. With increased primary care, these patients’ conditions will be less likely to deteriorate to the point where they need EMS. The bill also creates an opportunity for EMS to become integrated into the healthcare system in a way it never has been. “Right www.jems.com OCTOBER 2012 JEMS 43
  • 44. Healthcare Reform continued from page 43 now, we operate on an island,” Bourn says. “We can’t be an island anymore.” Using the core competencies of EMS, there are numerous opportunities to care for patients outside the traditional emergency room setting. “Sometimes the patient needs to be monitored at home,” Bourn says. He doesn’t advocate replacing home healthcare workers, but rather augmenting their responsibilities by using interventions within the paramedic’s skill set and expert assessment on who’s sick and not sick to make an informed decision on whether to go to the hospital or stay home. “We are the experts in remote care in EMS,” he says. O.J. Doyle, a consultant for the Minnesota Ambulance Association and the American College of Emergency Physicians and the only full-time state EMS lobbyist, couldn’t agree more. “Healthcare reform creates a very fertile environment for the community paramedic,” he says. Doyle, a former paramedic, has been both an operations director and the owner of an ambulance service. “As we move forward, innovation and creativity is going to be rewarded,” he says. The goal will be to keep people who don’t need to be in the hospital out of the emergency department. Doyle warns EMS administrators to be aware of possible state statutes that prohibit EMTs and paramedics from providing this type of care. That will require becoming active on the state level and educating lawmakers. “You are all ambulance drivers to your state-elected officials,” he says. However, the path to passing EMS legislation has been blazed by leaders, including Doyle, who know how to avoid opposition from other medical professionals who may feel threatened. “It’s all about the packaging,” Doyle hints. offer full-time workers affordable insurance options or incur annual penalties of $2,000–3,000 per employee. The rules are slightly different for public employers. Every agency should consult a competent counselor to ensure compliance. If you provide health insurance to your employees, research what constitutes a “Cadillac” plan. Most immediately think of the firefighters—who were given a moratorium on their plans, with a sunset clause— but this can also affect some “Mom and Pop” agencies that provide a certain level of coverage for employees, but a much higher level for themselves. The new law applies a 40% surcharge for these types of plans. The surcharge must be paid for by the employer. None of it can come out of the pockets of the employees. JEMS Employer Responsibilities From an employer perspective, beginning in 2014, employers with 50 or more fulltime equivalent employees will need to Teresa McCallion, EMT-B, is the editor of EMS Insider and a freelance public safety writer living in Bonney Lake, Wash. Contact her at teresa@mccallion.biz. How EMS Managers Can Prepare From a billing, employee and systems perspective, EMS administrators should be prepared in the following ways: Expect increased volume: People who previously did not call 9-1-1 because they feared they couldn’t pay for the cost of transport and hospital bill will now be able to call for service. At least initially, expect an increase in the number of transports. “I see this as a short-term step of a few years,” Bourn says. As patients begin receiving appropriate primary care, those numbers should level out. Expect changes in flow patterns: Now that people have insurance, they may want to be transported to a hospital they perceive provides a higher quality of care than the one they previously frequented. Meet a hospital administrator: Your local hospital administrator may be your new best friend. They’re probably already looking at pay-forperformance issues. Ask them how you can help. For most administrators, EMS is just hospital ride, and they don’t realize EMS’ competencies and capacity. It’s up to you to educate them. Prepare your workforce: This is a cultural change in clinical practice unmatched since EMS was introduced. There are a million ways to be a nurse, but only one way to be a paramedic. That will change. As an EMS leader, you must prepare your workforce for these changes. Some people have no desire to do anything but 9-1-1 calls. However, some, maybe toward the end of their career, prefer something that looks more like a healthcare generalist with a tremendous emergency care capacity. What this means for the workforce is an opportunity for expanded career paths in EMS. For EMS administrators, paramedics will no longer be interchangeable, and administrators will have to be responsible for 44 JEMS OCTOBER 2012 more human resource management than they ever have before. Join an EMS organization: If you haven’t already, join national EMS organizations or associations that support the industry. Many are already hard at work providing recommendations for their members. Several provided executive summaries within days of the Supreme Court ruling and have already scheduled webinars to assist members with understanding the possibilities and challenges presented by healthcare reform. These will be particularly helpful with compliance issues. “By paying dues, we are supporting people to be our voice at the regional, state and national level,” says Reinert, who chairs the National EMS Advisory Council (NEMSAC), an organization that provides critical advice to the National Highway Traffic Safety Administration (NHTSA) Office of EMS and the Department of Transportation and the Federal Interagency Committee on EMS (FICEMS). Conduct a cost analysis: The PPACA will require a cost-analysis on a regular basis to justify billing. Check third-party agreements: The new law strengthens antikickback standards. Check all agreements with third-party vendors to ensure compliance. Validate certifications: By 2015, all EMS agencies will be required to conduct a re-validation of service. Make sure every provider’s certification is up to date. Do research: Research opportunities will continue to exist for documenting the value of excellent emergency care. All EMS agencies need to contribute to research efforts that verify how EMS contributes to the overall healthcare system.
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  • 46. Lessons learned in hypothermia prevention under difficult field conditions By 2LT Collin Hu, EMT-E, James Spotila, PhD, EMT-B P reventing the onset of hypothermia is difficult when ambient conditions can’t be controlled. This is illustrated by a 2011 cave rescue in rural southwest Virginia. A man wedged in a fissure at the entrance of a cave was exposed to sub-freezing air temperatures for 12 hours until extricated. The rescue effort included up to 50 first responders from Carilion Clinic LifeGuard, which was in charge of patient care; Blacksburg Volunteer Rescue Squad; the Virginia Tech Cave Club; the Newport Volunteer Rescue Squad; the Giles County Volunteer Rescue Squad; the Newport Volunteer Fire Department and the Virginia Tech Rescue Squad. EMTs succeeded in keeping the patient warm by using chemical heat packs, an electric blanket and hair dryer, and by keeping the patient physically active. This article summarizes this event. It also presents the physiological aspects of hypothermia, and the importance of a creative, flexible approach to complex rescue scenes in challenging environments. Photo Courtesy John Bowling Saved from the Cold On a late winter afternoon in 2011, multiple fire, rescue and EMS units were dispatched to the edge of a farm in rural Virginia for a patient reportedly trapped at the entrance to a natural limestone cave. The 26-year-old patient had been wedged in an irregular rock fissure in a semi-standing position for more than two hours prior to 9-1-1 being called. 46 JEMS OCTOBER 2012 Initial concerns of a crush injury or related trauma were quickly replaced by fear of exposure-induced hypothermia. Though dry, the patient was clad in only a t-shirt and pants, and much of his body was in full contact with bedrock. The air temperature dropped below freezing with the onset of nightfall. The challenge posed to the EMTs was not one of assessment, but how to keep a nearly inaccessible patient warm for a scene time that would last almost 12 hours. After initial efforts to pull the patient free failed, rescue specialists were called in. Extricating the patient was a long process that required the removal of small protruding rock edges from the walls of the fissure using handheld percussion hammers and then extricating the patient in an upward direction. Members of a cave rescue team worked from within the cave, below the fissure, chiseling away rock and pushing the patient upward, while a heavy tactical rescue (HTR) team above the cave entrance removed rock from around the patient’s upper torso and pulled him upwards using ropes secured to his waist. Progress was measured in inches per hour. The patient’s body was initially pinned in several places, confining his left leg in a bent position beneath him. But as he was lifted, he became snagged by additional rock ledges that had to be removed, resulting in a repetitive cycle of chiseling and lifting that went on for hours. The patient remained alert and oriented throughout the ordeal. EMS initially found his skin was cold and pale. He was uncomfortable, but was not showing signs of significant hypothermia. However, his condition slowly worsened, reaching a low point seven hours after becoming stuck. At his worst, still four hours before being extricated, the patient was lethargic, shivering moderately, and without radial or pedal pulses. He exhibited a Glasgow Coma Scale (GCS) score of 14, a heart rate of 90 beats per minute, respirations of 20 on ambient air, and blood pressure of 76/54. Through creative efforts undertaken to actively warm him (see below) and after his body was steadily shifted to a more comfortable position by the rescue efforts, the patient’s condition gradually improved over the course of an hour. His color improved, he became more vibrant, and vital signs improved to GCS of 15, heart rate of 64 beats per minute and blood pressure of 115/85. The patient was ultimately freed in stable condition after almost 11 hours stuck in the cave. His vital signs after he was placed on a backboard and in the ambulance were: heart rate 118, respirations 18, blood pressure 175/121, and skin still pale and cold. Despite an air temperature of 14° F when he was extricated at 3 a.m., his core temperature had only dropped to 96.8° F. Active warming efforts by EMTs had been successful at preventing systemic hypothermia. The
  • 47. Keeping this nearly inaccessible patient warm during an extended rescue demanded creativity. www.jems.com OCTOBER 2012 JEMS 47
  • 48. Mobile Warming continued from page 47 patient was further assessed in the ambulance and then flown by Carilion Clinic LifeGuard to Carilion Roanoke Memorial Hospital, from which he was released the next day. Systemic Hypothermia Hypothermia is separated into three phases: mild, moderate and severe.1 Mild hypothermia begins when the core body temperature, which normally varies among individuals from 98–100° F, drops below 95° F. 2 As core temperature drops, several physiologic changes occur as the body begins to conserve and attempt to generate heat. This process occurs through activation of the sympathetic nervous system and includes shivering, hyperglycemia, tachycardia, vascular constriction and hypertension.3 When core body temperature drops below 89.6° F, moderate hypothermia sets in.2 It results in significant altered mental status including hallucinations, agitation, somnolence and possible loss of pupillary reflex. Other findings include bradycardia, decreased cardiac output and hypoventilation.3 ECG abnormalities are also common, specifically a J or Osborn wave, which is specifically a distortion of early membrane repolarization and indicative of moderate hypothermia.4 In severe hypothermia (when body temperature drops below 82.4° F), a patient will exhibit marked stupor and all shivering will cease.2 The patient will experience progressively worsening bradycardia, hypotension and hypoapnea, progressing to shock and multi-organ system failure.3 This patient exhibited signs of mild hypothermia throughout the incident. During the time when he had his lowest blood pressure readings and became increasingly lethargic, EMTs on scene were concerned about potential onset of moderate hypothermia. Although it was not possible to quantify the patient’s temperature by direct measurement due to his confined position, his rapid recovery suggests his condition never advanced beyond the mildest stage of hypothermia. The rates at which a patient’s core temperature drops and stages of hypothermia are experienced are highly dependent on ambient conditions. The timescale can vary from minutes (i.e., when submersed in cold water) to days (i.e., when exposed to freezing air temperatures with inadequate clothing). During this cave rescue, onset of hypothermia was slow because the patient was dry and 48 JEMS OCTOBER 2012 winds were calm, particularly due to shielding by rock formations. The bedrock he was in direct contact with initially lowered his temperature by conductive heat loss more rapidly than heat lost directly to the atmosphere. This is because the rock was colder than the afternoon air temperature. However, the rock walls eventually worked to insulate him, because the cooling of the rock surface lagged behind the plummeting temperature of the air. (Note: Had the patient been trapped inside the cave, as opposed to its entrance, the ambient temperature would have been a constant 54° F, the mean annual temperature for this location.) The patient’s large body mass of around 220 lbs. also contributed to relatively slow conductive heat loss. patient’s upper body, while an electric blanket draped over the patient’s head and shoulders helped as well. Perhaps the most important warming was from the patient himself. During the course of the extrication, particularly the final few hours after his spirit was buoyed by the steady gains main by removing rock, the patient was very active, almost frantic, in his efforts to wiggle free and pull himself up and out with the rescuers’ assistance. Although this autowarming helped keep hypothermia at bay, the fear was that the patient would exhaust himself or suffer further injuries and then quickly succumb to the cold. Fortunately, he was extricated in time. Conclusion Discussion This rescue illustrates the challenges when key factors that are normally taken for granted on calls are absent, namely patient access, a stable environment and limited scene time. Unlike most situations, it wasn’t possible to remove this patient to a safe ambient setting. Because of his confinement, it was difficult to even obtain vital signs. It wasn’t possible to establish an IV or intraosseous access, given the limited access to his extremities and because of the rigorous motions involved in the rescue. EMTs couldn’t have placed defibrillator pads on the patient had they been needed, and even oxygen by mask wasn’t feasible because of the amount of hammering around the patient’s head and the motion required of him during the effort. Keeping the patient warm, which was the primary goal of the EMTs during the rescue effort, also required flexibility and creativity. The orientation and confinement of the patient prevented wrapping him in blankets or additional clothing. The primary effort to warm him consisted of applying 20-minute duration chemical heat packs wherever accessible, including his hips, arms and neck. The responding units quickly depleted all of their heat packs and eventually drained the storerooms of several neighboring EMS agencies, ultimately consuming about 175 packs. Other means of warming included a propane space heater, but this couldn’t be brought close enough to be effective and posed a risk of fumes and fire to the rescuers inside the cave. An electric hair dryer borrowed from a local farmer was moderately successful at warming the air around the The lesson to take away is that some calls require creative, even ingenious efforts to keep patients alive and bring them to safety. In this case, first responder thinking had to evolve quickly and then continuously adjust and seek out alternatives as the rescue effort stretched on. When hypothermia from exposure is a risk, anything that warms without harming should be considered. Prolonged wintertime rescues like this also require special attention to scene safety to avoid cold-related injury and exhaustion of the first responders themselves. This rescue illustrates that in addition to standard qualities of first responders, particularly diligence, selflessness, calmness and professionalism, some complex rescue scenes demand creativity and flexibility as well. JEMS Collin Hu, EMT-E, is second lieutenant in the U.S. Army, and a fourth-year medical student at the Edward Via College of Osteopathic Medicine. He is a member of the Blacksburg (Va.) Volunteer Rescue Squad. James A. Spotila, PhD, EMT-B, is associate professor of geology at Virginia Polytechnic Institute and State University and a member of the Blacksburg Volunteer Rescue Squad. References 1. McSwain NE. “Environmental Trauma I: Heat and Cold” in PHTLS Prehospital Trauma Life Support, 6th Edition. Mosby Jems/Elsevier: St. Louis. 424–437, 2007. 2. Stephen RL. “Hypothermia and Frostbite.” Emergency Medicine. Saunders/Elsevier: Philadelphia. 1445–1450, 2008. 3. Hanania N Zimmerman JL. Accidental hypothermia. Crit Care Clin. 1999;15(2):235–249. 4. Nolan J Soar J. The ECG in hypothermia. Resuscitation 2005;64(2):133–134.
  • 49. Choose 31 at www.jems.com/rs Choose 32 at www.jems.com/rs
  • 50. powerful solutions from smart thinkers avoid pending lawsuits research grant funding EMS Research Technology EMS Trend Analysis avoid costly fines revenue generating ideas TM Exclusively for ems Management EMS Insider provides you with the “inside information” on EMS. It’s a monthly publication from PennWell and affiliated with Jems (Journal of Emergency Medical Services) so it has the best network of sources in EMS. That means you get only the highest quality reporting . . . insightful, timely, authoritative. . . not available elsewhere. EMS Insider pays for itself. Every issue contains articles to help you, by bringing you money-saving and revenue-generating ideas. Don’t miss out, order your subscription today! Subscribe to EMS Insider www.jems.com or call (888) 456-5367
  • 51. Sponsored clinical feature BY JAMES JOLLIS, MD MAYME ROETTIG, RN, MSN imely diagnosis and restoration of coronary artery flow remains the cornerstone of treatment for patients with ST-elevation myocardial infarction (STEMI). During the past six years, enormous efforts by hospitals and medical professionals have focused on a specific phase of coronary reperfusion, namely the “door-to-balloon” process. As a result of this work, more than 90% of patients presenting to hospitals with percutaneous coronary intervention (PCI) facilities are now treated within 90 minutes of hospital arrival.1 However, despite the improvements in door-to-balloon time, the current emergency cardiac care system often performs well below its potential. In 2012, more than half of the STEMI patients who called 9-1-1, and those transferred from outside emergency departments (EDs), haven’t met the new guideline goals for reperfusion: EMS arrival to device deployment within 90 minutes for EMStransported patients, and first hospital door-to-device within 120 minutes for transferred patients.2,3 Paramedics should play a pivotal role in coronary reperfusion. Pre-notification and laboratory activation can reduce door-to-balloon times below 30 minutes. These time goals can only be achieved with the expansion of STEMI protocols beyond the 1,400 hospitals with PCI facilities to the 3,600 hospitals lacking such capability and to the more than 15,000 EMS agencies in the U.S. Emergency cardiac care systems must evolve beyond the PCI hospital door with implementation on a regional basis. Following the examples of such models as Los Angeles County and North Carolina, every hospital and EMS agency within a region should have a prespecified and coordinated plan in which healthcare professionals know their role in the identification, diagnosis and expediting treatment of patients experiencing acute myocardial infarction.4-7 In order to meet the full potential of emergency cardiac care, the Regional Systems of Care Demonstration Project: Mission: Lifeline STEMI System Accelerator Program, funded in part by two-year grants from Philips Healthcare, The MEDICINES Company and Abiomed, has selected 20 regions across the U.S. for sustained efforts to regionalize coronary reperfusion plans. These 20 sites were selected based on leadership, organization and facilities, and their likelihood of developing coordinated diagnosis and treatment plans in every hospital and EMS agency in their region. The STEMI Accelerator Program is designed to build on the experience of successfully implemented regional systems. According to a national survey of 381 STEMI systems conducted by the American Heart Association (AHA), the single most commonly cited barriers to system implementation were hospital and physician competition.8 The program’s interventions are led by national faculty and local AHA staff who will serve as neutral intermediaries between EMS agencies, hospitals and physicians within a region. A number of tenets are central to this accelerator intervention. It’s designed to build or advance systems that are ultimately self-sustaining and use existing regional and national resources whenever possible, such as the ACTION Registry®-GWTGTM data and regional system reports. The program focuses on supporting leaders within each region to design, implement and sustain the system. The ultimate goal is to establish rapid diagnosis and treatment of STEMI as a uniformed standard of care across every EMS agency and hospital within a region. When it comes to building emergency cardiac systems, a number of key features are shared across regions, including implementing national guidelines, similar ECG equipment and protocols, and having hospital systems to support rapid PCI. Many issues are unique to specific regions, largely based on the interplay of geography, government and market forces. Thus, the project will be guided by EMS providers in each region regarding challenges and barriers. The project’s intervention will follow an approach that was developed a number of regional STEMI systems. The initial focus will be on the establishment of leadership, common data and funding. Funding is primarily required to support data collection and analysis, and to provide a neutral “feet on the ground” regional system coordinator/implementer. Next, all PCI hospitals in the region will be organized to provide rapid intervention on a systematic basis that includes single call catheterization laboratory activation by paramedics and emergency physicians on a 24/7 basis, accepting all patients regardless of bed availability, participation in the regional data registry, and adoption of regional reperfusion protocols. In developing these protocols, the focus has been directed toward three patient scenarios that have the most potential to save time and lives: patients presenting by EMS, patients transferred from hospitals lacking PCI facilities, and patients with early signs of cardiogenic shock. With pre-specified and uniform protocols, paramedics, nurses and emergency physicians who first come into contact with patients can rapidly implement treatment plans without delay for consultation or need to identify the accepting facility. Once PCI hospitals have adopted the above processes to rapidly provide coronary reperfusion, coordinators and leaders will work with EMS agencies and non-PCI hospitals to adopt a STEMI diagnosis and treatment plan consistent with regional protocols and local resources. A final step involves ongoing measurement and feedback through Mission: Lifeline™ regional system reports, targeting opportunities for continued improvement. The Accelerator Program has a two-year time horizon from conception to implementation. In order to measure the effects of the intervention, data will be examined from all participating regions relative to changes in treatment times and outcomes. Involving EMS on a regional basis will result in improved treatment times and lower in-hospital mortality. This clinical feature is sponsored by Philips. James Jollis, MD, is a cardiologist at Duke University Medical Center. He is co-medical director of the North Carolina RACE program. Contact him at james.jollis@duke.edu. Mayme Roettig, RN, MSN, is the Assistant Director of the Center for Educational Excellence (CEE), Duke Clinical Research Institute/Duke University. Contact her at mayme.roettig@duke.edu. References 1. Krumholz HM, Herrin J, Miller LE, et al. Improvements in door-to-balloon time in the United States, 2005 to 2010. Circulation. 2011;124(9):1,038– 1,045. 2. American College of Cardiology National Cardiovascular Data Registry (ACCNCDR). The ACTION Registry-GWTG National slide set Quarter 3 2010-Quarter 2 2012. ACCNCDR. December, 2011. 3. Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Catheter Cardiovasc Interv. 2012;79(3):453–495. 4. Rokos IC, Larson DM, Henry TD, et al. Rational for establishing regional ST-elevation myocardial infarction receiving center (SRS) networks. Am Heart J. 2006;152(4):661–667. 5. okos IC, French WJ, Koenig WJ, et al. Integration of pre-hospital electroR cardiograms and ST-elevation myocardial infarction receiving centers (SRC) networks: Impact on door-to-balloon time across 10 independent regions. JACC Cardiovasc Interv. 2009;2(4):339–346. 6. ollis JG, Roettig ML, Aluko AO, et al. Implementation of a Statewide SysJ tem for Coronary Reperfusion for ST-Segment Elevation Myocardial Infarction. JAMA. 2007;298(20):2,371–2,380. 7. ollis JG, Al-Khalidi HR, Monk L, et al.; on behalf of the Regional J Approach to Cardiovascular Emergencies (RACE) Investigators. Expansion of a Regional ST-Segment-Elevation Myocardial Infarction System to an Entire State. Circulation. 2012;126(2):189-195. Epub 2012 Jun 4. 8. ollis JG, Granger CB, Henry TD, et al. Systems of care for STJ segment-elevation myocardial infarction: A report from the American Heart Association’s Mission: Lifeline. Circ Cardiovasc Qual Outcomes. 2012;5(4):423–428. www.jems.com | october 2012 Bibigon /istockphoto.com T | jems 51
  • 52. I n 2010, more than 250 U.S. ambulance crashes were reported in the news media.1 During such crashes, EMS providers riding in the ambulance patient compartment while caring for patients are at high risk of suffering injuries. An ideal internal patient compartment layout would facilitate efficient clinical care 52 JEMS OCTOBER 2012 and ensure the safety of both patients and EMTs. Such patient compartment layout should be based on needs and requirements addressed by the EMS community and ambulance manufacturing community. This article describes the workshop, Design Requirements for Ambulance Patient Compartments, held on Feb. 29, 2012, during the EMS Today Conference Exposition. The workshop was sponsored by the U.S. Department of Homeland Security Science and Technology (DHS ST) Directorate and conducted by the National Institute of Standards Technology (NIST). The purpose of the workshop was to identify gaps in current practice, establish
  • 53. Participants in a workshop held at the EMS Today Exposition Conference noted that keeping their employees safe from crashes like this one is important. Photo Associated Press/Indiana State Patrol Highlights from workshop on ambulance patient compartments By Jennifer Marshall Y. Tina Lee consensus on technical issues related to ambulance design, and review and prioritize design needs and requirements. The workshop results will eventually help identify key requirements to recommend for the next release of the National Fire Protection Association (NFPA) 1917 Standard for Automotive Ambulances. Project Tasks Achieving a balance between EMS crew safety and patient care in the ambulance is a significant challenge for the EMS community. There are approximately 50,000 ambulances on the road every day.1 But there are currently no standards that address performance, ergonomics or safety in ambulance patient compartments that can be used by EMS organizations when procuring ambulances. The DHS ST Human Factors/Behavioral Sciences Division and the First Responder Resource Group have teamed with NIST, the National Institute for Occupational Safety and Health (NIOSH), and the BMT designers www.jems.com OCTOBER 2012 JEMS 53
  • 54. A Study on Safety continued from page 53 prioritize design requirements. The and planners, to aid in the development Figure 1: Likert Scale workshop participants included pracof standards for the design of ambuEssential titioners, practitioner organization replance patient compartments. resentatives and federal government The project, titled “Ambulance Would significantly improve patient and EMS crew safety if implemented. agency representatives. Patient Compartment Design,” will develop new crash-safety design stan- Would significantly improve patient care if implemented. dards and improved user-interface Conditional Requirements Assessment guidance that will result in patient comThe workshop was structured to proWould improve patient and EMS crew safety if implemented, partments that are safer for EMS permote dialogue and knowledge sharing but not to a significant degree. sonnel and patients, and that enable the among a diverse group of practitioWould improve patient care if implemented, but not to a effective delivery of patient care. ners and assess the collective priorities significant degree. The project includes the following for the design requirements of patient Low five major tasks: compartments in ambulances. It used Needs and requirements analysis: To iden- Could improve patient and EMS crew safety to some degree if breakout sessions to initiate focused tify needs and requirements of future implemented, but not an important requirement at this time. discussions. A set of needs and requirepatient compartment design through Could make patient care somewhat easier if implemented, ments, which was developed by the structured and systematic approaches. project team based on the results of prebut not an important requirement at this time. Design concepts evaluation: To validate vious project tasks, was provided to the requirements using a set of alternative throughout the country at a variety of volparticipants of each breakout session. design concepts and criteria. unteer, state, local, private and hospital-affili- They were instructed to assess the requireFinal requirements identification: To iden- ated EMS organizations. ments from the safety, functionality, and the tify critical and important requirements The goal of conducting focus group meet- combined safety and functionality points of that would improve patient care and ings was to gain a broader understanding of view. The assessment used a three-point Liksafety based on the results of the design the issues involved in ambulance safety, from ert scale. (See Figure 1, above left.) concepts evaluation. a variety of stakeholder viewpoints. Three Industry review: To ensure that the selected focus groups, including one manufacturers Topics Design Needs requirements satisfy community needs. group and two groups of EMTs, were con- Participants were grouped into four breakStandard recommendation: To present the ducted in August 2011 in Las Vegas in con- out sessions in order to facilitate the disrequirements document to the NFPA for junction with the 2011 EMS World EXPO. cussion of technical design issues, current incorporation into the next draft (2013) of These groups identified several design chal- practices, and needs and requirements in the NFPA 1917 standard. lenges and suggestions for the improve- different topical domains. The topics of To understand ambulance design and cur- ment of working the environment within the these sessions included: rent practices issues, the project team stud- patient compartments. Seating, restraints and communication systems: ied documents that included the NFPA 1917 The findings from these focus group meet- This covered two domains. The seating and standard, the General Services Administra- ings were used as the basis for developing a restraints domain concerns the extent to tion (GSA) KKK-A-1822F standard, ASTM nationwide ambulance survey that was con- which the patient compartment will enable International Standard Guide for Training ducted in December 2011. The purpose of the EMTs and paramedics to provide safe and Emergency Medical Services Ambulance survey was to aid in soliciting requirements effective patient care from a seated and/or Operations, Alberta Ambulance Vehicle for design standards for ambulance patient restrained position in the ambulance patient Standards Code, Australian/New Zealand compartments and to measure customer sat- compartment. The participants focused on Standard 4535 and British Standards Institu- isfaction with current design standards. This the needs/requirements that will help achieve tion BS EN 1789.2–8 Web-based survey received more than 2,500 a critical balance between safety and effecThe project team then performed needs responses from EMS personnel across the tiveness—restraints vs. seating, adjustabiland requirements analysis of patient com- country. As the result of these efforts, a draft ity of seating for better access to patient and partment design. Their approaches included version of needs and requirements for patient equipment, being able to interact with the practitioner interviews, ridealongs, patient compartment design was generated. The patient while seated, and ergonomic seating. The communication systems domain care walkthroughs, focus group meetings, a aforementioned efforts culminated in the Web-based survey, and a workshop. These EMS Today workshop to review, add to and concerns the extent to which the patient compartment shall 1) enable efficient and approaches allowed the project team to gain prioritize the needs/requirements gathered. effective communications between the firsthand experience with practicing EMTs patient compartment, the driver, and othand paramedics to better understand their Why the Workshop work environment, constraints, and con- The purpose of the workshop was to work ers; 2) facilitate driver awareness of activity in cerns and hence, understand the needs of with practitioners and federal stakeholders the patient compartment; and 3) facilitate the those in the EMS community. to identify gaps in current practice, estab- EMS provider’s awareness of driver actions. The interviews, ridealongs and patient lish consensus on technical issues related The participants focused on ways to comcare walkthroughs were carried out to ambulance design, and review and municate effectively within the patient 54 JEMS OCTOBER 2012
  • 55. Choose 33 at www.jems.com/rs Choose 34 at www.jems.com/rs
  • 56. A Study on Safety continued from page 54 compartment with patients and others in the back, the driver, dispatch and hospitals. Work environment: This domain concerns the extent to which the patient compartment will 1) enable the provider to safely and effectively perform patient care; 2) enables easy cleaning and restocking after each trip; 3) enable quick and safe ingress/egress; 4) include safety mechanisms (e.g., padding and nets) to reduce hazard risks; and 5) provide space and accessibility for storage of disposal containers. The participants focused on overall space design, accessibility of power and lighting control, as well as flooring and the height of the patient compartment. General equipment and storage: This domain concerns the extent to which the patient compartment will 1) provide space and accessibility of storage for equipment and controls; 2) allow safe and effective use of patient care items; 3) facilitate the ability of providers to perform inventory management; and 4) allow safe and secure storage of the patient care items including equipment, supplies and medicines. The participants focused on the needs/requirements for accessibility and location of equipment/supplies. Special equipment and storage: This topic covers the special equipment (e.g., cots and jump bags) and storage. This domain concerns the extent to which the patient compartment will 1) allow cots to safely and effectively be secured/released or loaded/ unloaded; 2) allow the prehospital professional to securely restrain the patient in the cot and safely and effectively treat the patient; 3) facilitate the ability of the EMS provider to safely and effectively perform CPR; 4) provide safe and secure storage and accessibility of jump bags; and 5) allow safe and secure storage of patient’s equipment/ belongings. The participants focused on space around the cot, cot loading systems and jump bag locations. Workshop Results At the end of each breakout session, the group identified the essential design requirements that are most important across both safety and functionality. The groups also identified a small number of items that should not be included in the requirement list for a variety of reasons, such as measurability, policy/ regulatory or out of scope. The participants recommended that some requirements be merged. The following list includes essential design issues/requirements: Participant Comments The workshop participants identified a number of concerns/issues during all four sessions. Several examples are listed here. Seating requirements: Participants expressed concerns about the possibility that new seat designs could infringe on space for equipment and storage. Participants did not perceive that forward-facing or rear-facing seating arrangements were functional enough to address the patient’s needs. The group suggested investigating best practices and designs used in other countries. The group also suggested that the community needs to move away from legacy designs behind and be more innovative in patient compartment design. Restraint systems: The ability to reach the patient is just as important as the ability to reach equipment. Comfort was identified as an important requirement for restraint systems, because the lack of comfort could hinder widespread use of new systems by practitioners. The group identified that existing retractable restraints do not work efficiently, and that there is a need to clarify the difference between restraint systems and seat belts. It was noted that restraint systems could differ according to specific needs; for example, an advanced restraint system would not be needed for “walking wounded,” but such patients would still need to be subjected to some form of restraint. Communication requirements: Participants expressed concern about the use of non-verbal communication systems, which could cause distractions. Hands-free verbal devices were perceived as safer options. The group noted that new technologies could be readily available before the next release of NFPA 1917. Participants also perceived that means of communicating between the EMS provider, the driver and third parties (e.g., hospitals) do not need to be provided in and accessible from all EMS provider workstations. Air ambulance design: A useful model for ambulance design would be air ambulance design (i.e., helicopter and fixed wing). Participants noted that ambulance design is often viewed from the perspective of designing the inside of a large automobile. They suggested that the patient compartment be viewed more as a cockpit. 56 JEMS OCTOBER 2012 Prioritization: The NIOSH accident trend data and no-strike zones would help prioritize implementation (i.e., procurements). Transport capabilities: The ability to transport more than one patient should be considered as a possible requirement. Ergonomic storage: Equipment storage locations should take into account ergonomic issues such as weight and lifting height. Protecting our own: Participants indicated that they care about their employees, and that protecting them from injury is the primary concern. Lift injuries: The leading cause of EMS injury is lifting/loading injuries. Lifting heavy equipment is also a major cause of back and muscle strain. Aggressive/unpredictable patients: Patients who are aggressive or move unpredictably represent a safety consideration. A space of our own: There should be a space provided to accommodate EMS providers’ belongings. Child safety seating: Participants recommended not using the adult cot equipped with child restraints, noting that a child safety seat is a better option. Loading of patients: Hospitals are increasingly prohibiting EMS providers from lifting patients, due to the rate of back injury claims and patient injuries. Reducing back injury to EMS providers should be emphasized. Lack of data: Participants expressed concern that there’s no available data on EMS provider injuries, or the causes, severity, etc. of those injuries. Protect the head: Participants recommended EMS providers wear helmets. Individual equipment standards: There’s a need to address the items carried by EMS providers, and there is a need to address requirements for individual equipment items. Training: Participants suggested there is a need to address training in the standard.
  • 57. Choose 35 at www.jems.com/rs
  • 58. A Study on Safety continued from page 56 Choose 36 at www.jems.com/rs Seating/restraint and communications systems 1. he provider is able to reach common and critical equipment/supplies from a restrained T and/or seated position. 2. The provider is able to operate equipment controls from a seated and/or restrained position. 3. he provider is able to reach and treat the patient from a restrained position. T 4. ommunication systems support the provider’s ability to continue providing safe and C effective patient care. Means for communicating between the EMS provider, the driver and third parties are provided and accessible from all EMS provider workstations. 5. MS providers in the patient compartment are able to establish communications quickly E with the driver or other third party. Work environment 1. orkspace has appropriate space for secure and safe placement and use of equipment, W papers and supplies. 2. roviders are able to exit the patient compartment with a patient loaded on a P transport device from the main patient loading and unloading doors and one other door. 3. afety mechanisms (e.g., padding, nets and airbags) are included in the patient compartS ment to reduce the likelihood of injury to EMS providers and patients during crashes or evasive maneuvers. This priority was seen as also subsuming three additional items: o head strike obstacles; N athways clear of obstacles (no portable patient care equipment); and P oors do not intrude into workspace or provide strike risk. D General equipment and storage 1. The location of the equipment while in use in the patient compartment minimizes the likelihood of introducing additional risks to EMS provider and patient safety. 2. lacement of equipment that requires EMS provider interacP tion, including the monitor, allows EMS providers to complete this interaction from a restrained and/or seated position. 3. quipment stored outside of a cabinet is secured such that it E does not become a hazard to the EMS provider or patient. Special equipment and storage 1. The cot guidance and securing mechanism allows for the cot to be secured in a safe and efficient manner. 2. he cot loading system allows for the patient to be loaded T or unloaded safely with minimal risk of injury to patient or EMS provider. 3. When being used for patient care, the placement of secured jump bags allows EMS providers to quickly and safely access them. 4. ecure storage is available for patient and staff belongings. S 5. Cot allows for the patient (including aggressive/violent ones) to be securely restrained without hindering the ability of the EMS provider to provide safe and effective patient care. Conclusions Future Work Choose 37 at www.jems.com/rs 58 JEMS OCTOBER 2012 The results of the ambulance patient compartment workshop confirmed and prioritized the needs and requirements the project team gathered from other research efforts. These results will be further reviewed, enhanced and evaluated. The workshop participants were asked to continue sending any further needs, requirements and suggestions about future ambulance patient compartment design. The next step is to focus on modeling potential designs for the patient compartment.9 These designs will be based on the prioritized requirements. The selected requirements will be used to develop a set of design concepts that represent threedimensional graphical models. Clinical-care experiments with
  • 59. different designs, placement of equipment and supplies and providers will be simulated using a human modeling tool. The purpose of these simulation experiments is to validate the requirements. With the experimental results, a final set of design requirements will be identified. The final set of requirements and the validated crash safety standards from NIOSH will be input to the next open comment period for NFPA 1917, which is tentatively scheduled for spring. JEMS aspx?ProductID=384875 7. British Standards Institute. (June 29, 2007). BS EN 1789:2007, Medical Vehicles and their equipment: Road ambulances. European Committee for Standardization (CEN), Management Centre: rue Stassart, 36 B-1050 Brussels. http://shop.bsigroup.com/ProductDetail/? pid=000000000030209683. 8. Dadfarnia M, Lee YT Kibira D. A Bibliography of Ambulance Patient Compartments and Related Issues, NISTIR 7835. National Institute of Standards and Technology: Gaithersburg, Md., 2011. 9. Kibira D, Lee YT Dadfarnia M. “Modeling for Optimal Ambulance Patient Compartment Layout,” Proceedings of the 2012 Spring Simulation Multiconference: Orlando, March 26–29, 2012. Acknowledgements: The U.S. Department of Homeland Security Science and Technology Directorate (DHS ST) Human Factors/Behavioral Sciences Division sponsored the production of this material under Interagency Agreement HSHQDC-11-X-00049 with the National Institute of Standards and Technology (NIST). The work described was funded by the United States Government and is not subject to copyright. Disclaimer: The findings expressed or implied in this report do not necessarily reflect the official view or policy of the U.S. government. Jennifer Marshall is the homeland security program manager with the Law Enforcement Standards Office of the National Institute of Standards and Technology and manages the standards development efforts that support DHS and first responders. She has more than 10 years of experience in technology and standards development for the homeland security community— including EMS, fire service and law enforcement. She can be contacted at jennifer.marshall@nist.gov. Y. Tina Lee is a computer scientist with the Engineering Laboratory at the National Institute of Standards and Technology. She has participated in research and authored more than 50 technical papers relating to homeland security modeling and simulation and manufacturing systems integration. She’s the co-editor of the Core Manufacturing Simulation Data Standard (SISO-STD-008-2010). She can be contacted at leet@nist.gov. References 1. Ballam E. (Feb. 9, 2011). Ambulance Crash Roundup. In EMS World. Retrieved from www.emsworld.com/ article/10225399/ambulance-crash-roundup. 2. National Fire Protection Association. (2012). NFPA 1917: Standard for automotive ambulances. In National Fire Protection Association. Retrieved from www.nfpa.org/aboutthecodes/AboutTheCodes. asp?DocNum=1917. 3. U.S. General Services Administration (2007). Federal Specification for the Star-of-Life Ambulance, KKK-A1822F. In FedBizOpps. www.fbo.gov/index?s=opportu nitymode=formtab=coreid=086075b28f43af8197 f412423a1be230_cview=1. 4. ASTM International. Standard Guide for Training Emergency Medical Services Ambulance Operations. F1705-96, 2007. 5. Emergency Health Services, Health Policy and Service Standards Development Branch. (2010). Ambulance Vehicle Standards Code January 2010. In Government of Alberta. Retrieved from www.health.alberta.ca/ documents/ehs-ambulance-standards-code.pdf. 6. Standards Australia, Standards New Zealand. 1999. Australian/New Zealand Standard: Ambulance Restraint Systems, AS/NZS 4535:1999. http://infostore.saiglobal.com/store/Details. Choose 38 at www.jems.com/rs www.jems.com OCTOBER 2012 JEMS 59
  • 60. Pumper/ambulance model takes service to a new level By Bob VacCaro 60 JEMS OCTOBER 2012
  • 61. W hen Joe Pozzo was hired as the new chief of the Volusia County (Fla.) Department of Public Protection (VCDPP) in June 2010, he was given a mandate: Build and create a new model of service for Volusia County.  “We had no funding to keep going with a model that used traditional engines, trucks and squads,” Pozzo says. “We had to come up with innovative technology and vehicles to get the job done.” Like many other departments around the country, the VCDPP needed to identify cost savings to make up for falling revenues. And that meant changes to the department’s fleet. “We had to come up with a way to reduce our fleet and cut costs and still provide the same services to our population,” Pozzo says. After a lot of brainstorming, the VCDPP came up with the idea for a pumper/ambulance that could provide more efficient firefighting capabilities and EMS transport in the rural areas of the county. “Some people in the organization doubted the idea, but we thought the concept was thinking outside of the box,” Pozzo says. “When we began the design process, we decided that for it to work, it had to be as close to a traditional fire engine body as possible, with a traditional ambulance body added.” It took a while to work through the exact specs that would allow the vehicle to serve both firefighting and EMS needs efficiently. To start, the VCDPP contacted Ten-8 Fire Equipment, the local dealer for Braun, which manufactures the Patriot line of vehicles. “We looked at a Patriot that was recently delivered to the West Palm Beach Airport,” Pozzo says. “However, the airport unit had limited fire-suppression capabilities. We wanted a custom fire truck cab with an ambulance body.” Photos courtesy Volusia County Department of Public Protection Pumper/Ambulance Model The Volusia County (Fla.) Department of Public Protection recently took delivery of four Braun Patriot pumper/ambulances built on Spartan MetroStar chassis. www.jems.com OCTOBER 2012 JEMS 61
  • 62. Innovative Design continued from page 61 The ambulance module features custom allaluminum interior cabinets with Meganite countertops and rounded edge corners. The units also feature Braun’s VitalMax lighting system for shadowless light to aid in patient care, the EZ Glide sliding side-entry door for enhanced crew safety, the MasterTech IV electrical system, and the SolidBody construction. After working with the salespeople and engineers at Ten-8 and Braun, the department settled on a limited water tank with a compressed air foam system (CAFS). “We needed to expand the water capability as much as possible since the vehicle would be first-out in some areas, providing firefighting capabilities as well as EMS,” Pozzo says. The VCDPP contracted with Waterous to design and build the pump module, which was connected to a 300-gallon water tank and a 30-gallon foam tank. In addition, Braun raised the height of the ambulance box. The units are set up with two crosslays of 1¾” hose and a dead load of 2½” hose for a supply line if needed and they carry the new Hurst E-Draulic cutters and rams. For future units, the department will engineer a rear compartment with stronger shelving to hold 300–400 feet of 3” supply line. “Braun and Ten-8 were great to work with,” Pozzo says. “They listened to our ideas and worked together with us to make this new concept work for us and the residents of the county.” The four pumper/ambulances are rotated in the high-volume rural areas of the county; they don’t have permanent stations. Pozzo stresses that the set-up is working well. “We would like to order an additional unit this year,” he says. JEMS Bob Vaccaro has more than 30 years of fire-service experience. He is a former chief of the Deer Park (N.Y.) Fire Department. Vaccaro has also worked for the Insurance Services Office, the New York Fire Patrol and several major commercial insurance companies as a senior loss-control consultant. He is a life member of the International Association of Fire Chiefs. Broward Sheriff’s (Fla.) Office Department of Fire Rescue M ost U.S. EMS and fire service leaders are familiar with the various target hazards that they have in their respective jurisdictions. Some have adapted various standard operating procedures (SOPs) and purchased firefighting apparatus that gets the job done for their communities. The Broward County Sheriff’s Office Department of Fire Rescue, located in south Florida, is no exception. When you hear the name Broward Sheriff’s Office Department of Fire Rescue (BSO DFR), you may get the impression that this department operates as a public safety organization with police officers operating in dual roles as firefighters—but that’s a misconception. The BSO DFR originated in October 2003 when all operational and administrative responsibilities were transferred from the Broward County Board of County Commissioners to the Broward Sheriff’s Office. The department’s more than 700 personnel provide fire suppression, fire protection, EMS and educational programs for most unincorporated areas of Broward County and to the municipalities of Weston, Pembroke Park, Cooper City, Lauderdale Lakes, Dania Beach and Deerfield Beach through contract agreements. Additionally, the department serves Ft. Lauderdale-Hollywood International Airport and Port Everglades. A Unique Rig Photos courtesy MIke JACHLES, BROWARD Sheriff PIO Recently, the department purchased a vehicle designed for an area of the county with diverse operational needs: an engine stationed in an area that regionally services the Florida Everglades, a main thoroughfare known as Alligator Alley. “We have one station located midway on this thoroughfare that services the eastern portion of this heavily traveled main highway,” says BSO DFR Chief Neal de Jesus. “Since this is pretty much a rural area and EMS response from the 62 JEMS OCTOBER 2012 next station is a great distance away, we decided to design an engine that could be used for fire suppression as well as EMS response—if we can’t get another ambulance in a timely manner or launch Air Rescue, we can use this engine to transport.” The majority of the calls in this area are singlevehicle rollovers with multiple victims, so the vehicle is designed with a longer wheelbase than a standard engine. Although it probably couldn’t be used easily in another urban setting, on a long stretch of highway, the turning radius isn’t a problem. “The local dealer, Ten-8 Fire Equipment, and the Pierce engineers who helped us design this vehicle, were great to deal with,” de Jesus says. “The rear of the cab is used for EMS transport. It is roomy and has a climate-controlled area for patient treatment. We chose the Velocity chassis because of the added room in the cab, front and rear, as well as having a greater amount of compartment space. It has really worked out well for us so far.” Chief de Jesus and his apparatus committee painstakingly worked out every detail on both vehicles to make them work for the department— something you should be doing when you design any new vehicle. Although your budget might not be as large as some departments’ budgets, you can take this into consideration when you spec out your next ambulance. If you need to work on a commercial chassis instead of a custom unit, then design around that concept. Just make sure the dealer and manufacturer you choose are on the same page.
  • 63. Detect treat symptoms related to hemorrhagic shock By Peter Taillac, MD, FACEP; Chad Brocato, DHSC, CFO, JD 2 0 1 3 JEMS G a m e s I n March 2013, a patient suffering from hemorrhagic shock will be among the victims managed at the JEMS Games clinical competition at the EMS Today Conference Exposition. This comprehensive clinical article will assist participating teams, attendees and readers in understanding this complex medical event and has been accredited by the Continuing Education Coordinating Board for EMS (CECBEMS) for 1 hour of continuing education credit. For a limited time only, readers of this article may obtain CE credit courtesy of Laerdal Medical Corp. The first 500 visitors to JEMS.com/Discover-Simulation who register using promo code JEMSOctCE (not case sensitive) will receive CE credit free. In addition, JEMS Games founding sponsor, Laerdal will provide a special “Discover Simulation” tool kit to each person attending the JEMS Games finals on March 8, 2013. The tool kit offers a turn-key solution to rolling out the simulations featured at the JEMS Games complete with facilitation guide, checklists and other valuable resources to help make simulation training easier. F o r M o r e , V I s i t j e m s . c o m / D i s c o v e r - Sim u l at i o n Case Presentation On a cold, rainy evening, the crew of Rescue 4 is jolted to attention by a dispatcher announcing, “Respond to a shooting at 7th Street and Main.” The lead paramedic recognizes the address as a location within a community with a long-standing history of violent crimes. Local police have already secured 64 jems OCTOBER 2012 the scene. The EMS crew arrives to note a young male lying in a pool of blood with a visible gunshot wound (GSW) to his right abdomen. He’s conscious but slow to respond to questioning. The crew quickly assesses his initial airway, breathing and circulation status. Although his skin is cool to the touch, he has a palpable radial pulse.
  • 64. Photo Edward Dickinson This clinical education feature appears as part of the JEMS Integrated Clinical Training Simulation (ICTS) project sponsored by Laerdal Medical Corp.’s Discover Simulation program, with support from JEMS and the Eagles Coalition. Photo Courtesy Peter Taillac Serious hemorrhage from truncal wounds is internal and uncontrollable, and requires EMS providers to assist the body’s natural ability to form a clot. Patients with internal or external bleeding are at risk for developing shock, so EMS providers need to be able to identify the hallmark signs. www.jems.com OCTOBER 2012 JEMS 65
  • 65. Vital Pathways continued from page 65 High-flow oxygen is applied while additional assessment is conducted. One crew member quickly performs a rapid head-to-toe exam to discover a second GSW to the left anterior thigh, which is actively hemorrhaging bright red blood. The EMS provider immediately places a tourniquet proximal to the wound and quickly stops the hemorrhage. When the crew rolls the patient to assess his posterior surfaces and place him on a backboard, they note an exit wound just lateral to the spine at approximately the level of the eighth rib on the right posterior thorax. The exit wound is approximately the size of a quarter. Vital signs include a blood pressure of 108/74, respiration rate of 30 and a pulse rate of 128 beats per minute (bpm) His Glasgow Coma Scale score is 14, and he’s confused about the time and place. Once inside the ambulance, the patient is quickly reassessed. The lead medic quickly places two peripheral IV lines while the unit is en route to the hospital. During the 15-minute ride, the patient rapidly deteriorates. His blood pressure drops to 74/50; his heart rate increases to 144 and respirations are 38. Suspecting a possible tension pneumothorax, the medic inserts a 14-gauge catheter into the patient’s chest, and a rush of air ensues. The lead medic then administers a 500 cc bolus of normal saline. The patient’s respiratory rate and pulse immediately decrease, and his blood pressure improves to 95/50. The lead medic provides a concise radio report to the hospital and arrives shortly thereafter, having stabilized this critical patient. Patients with internal or external bleeding are at risk for developing shock. In some cases, such as the one illustrated above, the onset of shock will be rapid. EMS providers need to be able to predict that shock will occur prior to discovering the hallmark signs. This article will address key considerations related to determining the risk of developing shock, detecting shock when it’s present, and providing rapid assessments and interventions to improve patient outcomes. Anatomy Physiology The body meets its metabolic demands through a series of anatomical features and physiological mechanisms. In the context of bleeding and shock, the EMS provider must have a keen awareness of the anatomy and physiology of the cardiovascular system. It’s 66 JEMS OCTOBER 2012 Learning Objectives Identify major anatomical components of the cardiovascular system. ejected from the left ventricle past the aortic valve into the aorta. It’s then distributed throughout the body. Describe the physiological components Blood Distribution Composition Differentiate between compensated, The body’s distribution system for blood includes all of the vessels. Arteries, with the exception of the pulmonary artery, deliver highly oxygenated blood throughout the body. These vessels are relatively thick and are composed of three layers: the tunic intima (innermost layer), the tunic media (middle layer), and the tunic adventitia (outermost layer). The arteries branch off to become smaller vessels, known as arterioles. These smaller vessels bring blood to the capillaries, which are tiny, thin-walled vessels that allow the diffusion of oxygen and nutrients for the benefit of the body’s cells. Waste products are then diffused from the cells into the venous side of the capillaries. Smaller vessels, known as venules, carry this blood to the veins. The venous blood is lower in oxygen but not devoid of it. The veins eventually connect to the vena cava to return the blood to the heart for its next loop in the cycle. The blood is composed of both fluid and formed elements. The fluid is known as plasma, which contains important proteins, including critical clotting factors. The formed elements include the red blood cells (erythrocytes), white blood cells (leukocytes) and platelets. The leukocytes work to fight off infections. However, more important to learn about in the context of bleeding and shock are the erythrocytes and platelets. When the system works properly, the body’s cells, tissues and organs are properly perfused. Perfusion is a complicated process that can be simplified down to this critical point: in order for the cells to function properly, they need an adequate flow of oxygen and nutrients coupled with the need to eliminate harmful waste products. Perfusion is accomplished when the heart, blood vessels and blood are working in harmony. Thus, the heart must be functioning, the blood vessels must have proper tone (resistance), and an adequate amount of blood must be present. EMS providers roughly measure perfusion by assessing blood pressure. Mathematically, blood pressure is a product of heart rate multiplied by stroke volume multiplied by peripheral vascular resistance. of blood pressure. uncompensated, and irreversible shock. Use a comprehensive assessment to formulate a treatment plan for a patient suffering from shock. KEY Terms Hemorrhagic shock: Shock associated with the sudden and rapid loss of significant amounts of blood often caused by severe traumatic injuries. This results in inadequate perfusion to meet the metabolic demands of cellular function. Compensated shock: Category of shock that occurs early, while the body is still able to compensate for a shortfall in one or more of the three areas of perfusion. Uncompensated shock: Category of shock that occurs when the compensatory mechanisms fail and the patient’s condition deteriorates. Irreversible shock: The terminal category of shock that will lead to the patient’s demise because it can’t be reversed. Truncal injury: Injuries pertaining to the chest, abdomen, or pelvis, where hemorrhage can be difficult to detect and control for prehospital providers. equally important to understand how the system attempts to compensate during times of injury. The Heart The heart is at the core of the cardiovascular system. It’s a four-chambered organ that must constantly pump blood to the lungs and the body as a whole. Blood is received in the two superior chambers, known as the atria. The lower chambers are known as the ventricles. The right atrium gets its blood from the inferior and superior vena cava. The blood is then pumped past the tricuspid valve into the right ventricle, which then ejects blood through the pulmonary valve, into the pulmonary artery, where it’s delivered to the lungs to be oxygenated. The “fresh” blood will return to the left atrium via the pulmonary veins. It will then pass through the mitral valve into the left ventricle, which is considered the high-pressure side of the heart. Blood is
  • 66. The heart rate must be adequate to ensure proper blood flow. The average adult heart rate is between 60–100 bpm while at rest. Significant decreases or increases in the heart rate have a direct impact on perfusion. Stroke volume is the volume of blood pumped from each ventricle with each beat and is typically 70 mL for the average adult male. Stroke volume can be decreased by such factors as increased resistance, improper functioning of the heart or valves, and inadequate blood volume. Peripheral vascular resistance is the tone in the blood vessels. Because our bodies must constantly fight the forces of gravity and pump the blood throughout the body, the vessels need to have some pressure or “squeeze.” If all of your vessels were to dilate, your blood pressure would plummet as the blood would pool to the areas where gravity pulled it. So the peripheral vessels maintain this tone in order to equalize the effects of position changes (gravity) and to “fine tune” the blood pressure second to second. Under normal conditions, the entire system works in concert to ensure that the blood flows to all organs, tissues, and cells. When the body has been compromised, such as when hemorrhage from a gunshot wound occurs, it will attempt to compensate for any reductions. For example, if the blood pressure falls, the heart will respond by pumping faster and with more force, and the vessels will constrict and reroute blood from peripheral areas to the core in an effort to preserve the vital organs. Thus, prehospital caregivers should consider any factors that would reduce the overall flow of blood as they relate to heart rate, stroke volume and peripheral vascular resistance. If external or internal bleeding is present, the stroke volume will obviously be affected because of the lost blood. If the patient has a rapid heart rate, then the volume and resistance will need to increase to “compensate” for the change. If the blood vessels lack adequate tone, the heart rate will need to increase as will the force of contractions. It’s important to understand the interconnectedness of the heart rate (HR), stroke volume (SV) and peripheral vascular resistance (PVR). Pathophysiology Simply stated, shock is a state of inadequate perfusion. Hemorrhagic shock occurs when, as a result of acute blood loss, cells are negatively impacted because they are inadequately perfused. Therefore, they don’t receive an adequate supply of oxygen or removal of wastes. Three types of shock exist: compensated, uncompensated, and irreversible. The prehospital provider can have the greatest effect if shock can be prevented, by preventing blood loss. If this isn’t possible because of factors beyond the provider’s control, then caregivers should act quickly to keep compensated shock from becoming uncompensated shock. All efforts should be undertaken to avoid irreversible shock. Compensated shock occurs early while the body is still able to compensate for a shortfall in one or more of the three areas of perfusion (HR, SV, and/or PVR). The signs and symptoms of this stage of shock include tachycardia and tachypnea, as well as cool pale, and diaphoretic skin. The patient’s blood pressure may be within normal ranges during compensatory shock. Mental status may also be normal during this early stage. Uncompensated shock occurs when the compensatory mechanisms fail, and the patient’s condition deteriorates. The hallmark sign of uncompensated shock is a reduction in blood pressure. Other signs include decreased mental status, tachycardia, tachypnea, thirst, reduced body temperature and skin that is cool, sweaty and pale. If untreated or inadequately treated, the patient may lapse into irreversible shock. As its name implies, this latter category of shock will lead to the patient’s demise because it can’t be reversed. New Concepts Now back to our gunshot victim. How do we prevent the cascade of physiologic events that leads to the irreversible shock state? The key is prevention of shock in the first place. EMS providers are in a critical position because their actions in the first hour after injury, often called the “Golden Hour” (or “Platinum 10 Minutes”) can mean the difference between a stable patient and one who rapidly develops an uncompensated and then irreversible shock state, resulting in death. Research from trauma centers and experience from the battlefields of Iraq and Afghan- istan have suggested new approaches to both the avoidance and the management of shock in the prehospital environment. Extremity injuries are addressed with immediate control of hemorrhage, with a pressure dressing or a tourniquet. For patients with a truncal injury (wound to chest, abdomen or pelvis) careful and judicious fluid administration in the field can help minimize hemorrhage and preserve critical blood volume, thus giving the patient a better chance to make it to the operating room where such internal bleeding can be directly controlled. Aggressive and lifesaving EMS care for this shooting victim begins with a rapid but thorough assessment of his wounds. This requires visualization and palpation of the entire torso and extremities for wounds. This patient in this example demonstrates a penetrating wound to abdomen with an exit wound posteriorly at approximately the eighth rib level, which raises the possibility of a chest injury, such as a tension pneumothorax. Rolling the patient to evaluate posterior wounds is a critical step that can be easily missed in the evaluation of a shooting victim. In this case, this revealed a wound that may compromise pulmonary and cardiac function. In addition, an actively bleeding thigh wound is noted as part of the head-totoe exam. The management of these wounds (extremity and torso) requires prompt action on the part of the medic to avoid the onset of shock, to minimize internal bleeding, and to address the rapid deterioration of the patient. The two torso wounds aren’t visibly bleeding; however, it’s assumed there may be significant internal hemorrhage. First, the EMS provider immediately stops the rapid blood loss from the thigh wound by the prompt application of a tourniquet proximal to the wound. This rapid and simple intervention may be lifesaving by preventing the onset of shock. Research from battlefield injuries in Iraq demonstrates a nearly 25-fold (96% vs. 4%) improvement in survival when hemorrhage was controlled by tourniquets prior to the onset of shock. Depending on the status of the patient and the transport time, this tourniquet can either be left in place until arrival at the emergency department (ED) or, if possible, replaced by an effective pressure dressing. If a tourniquet is left in place, the EMS prowww.jems.com OCTOBER 2012 JEMS 67
  • 67. Vital Pathways continued from page 67 is “don’t pop the clot” by the use of excessive IV fluid in the field. For patients with internal bleeding who aren’t in uncompensated shock (their systolic BP is greater than 80–90 mm/ Hg, or a radial pulse is present and mentation is normal), IV fluids should be withheld until the patient can receive definitive control of this internal hemorrhage in the operating room. Resuscitation studies demonstrate that this strategy minimizes hemorrhage and subsequent transfusion requirements. However, in the case of a patient who is demonstrating signs of uncompensated shock (systolic BP is less than 80–90, or the patient has a loss of radial pulse or decreasing mentation), administration of judicious boluses of crystalloid to support the blood pressure may be required to get the patient to the ED alive. Administration of boluses of 500–1,000 cc at a time, with reassessment after each bolus to keep the systolic BP above 80–90 mm/Hg is recommended. This strategy of minimizing IV fluid by such calibrated boluses is contrasted with Photo Courtesy Peter Taillac vider must alert the ED personnel that a tourniquet is in place, so it isn’t overlooked while the other, more obvious, wounds are managed. If a pressure dressing is placed, then the tourniquet should be left loosely in place and the thigh wound frequently re-evaluated by the EMS provider for continued bleeding. Then, if bleeding recurs, the tourniquet can then be simply re-tightened. Once the thigh hemorrhage is stopped, the medics placed two large bore IVs. This has been a recommended practice in early trauma management for decades. However, although the placement of such “lifelines” is still recommended to provide access for medications and fluids, newer research indicates that less IV fluid may be better for truncal wounds. Serious hemorrhage from truncal wounds is internal and uncontrollable by the medic in contrast to extremity wounds, which present with external hemorrhage and are controllable, with direct pressure or a tourniquet. For internal hemorrhage, the medic must assist the body’s natural ability to form a clot. Tourniquets can be an effective treatment for hemorrhage control for extremity wounds, such as this one, which required amputation. Research indicates that this clot formation is disrupted by rapidly increasing the BP with crystalloid IV fluids, such as normal saline. In addition, crystalloid dilutes the clotting factors that are critical to formation and strengthening of these fragile clots. Based on this research, the new recommendation EMS Recruiting Just Got a Lot Easier. JEMS.com EMS Jobs can help you fill your open positions faster and more cost-effectively than other recruiting methods. Post your job opportunity to thousands of qualified EMS professionals and begin finding the qualified candidates you need … immediately! Interested in making your job listing stand out? Upgrade your Basic Job Listing to a Featured Job Listing where it will be posted at the top of the EMS Jobs page as well as highlighted in rotation throughout JEMS.com. In addition, your listing will be featured in the JEMS.com eNewsletter (sent to over 49,000* EMS professionals). *June 2012: Publisher’s Data ® Choose 39 at www.jems.com/rs 68 JEMS OCTOBER 2012 For more information, please go to www.jems.com/ems-jobs/post-job
  • 68. our former practice of indiscriminately administering large volumes of IV fluid to all trauma patients. Lastly, the patient initially had a systolic BP of 108, but then rapidly decompensated, demonstrated by worsening hypotension and increasing tachycardia and tachypnea. The astute medic realized that, with a possible chest wound, this patient may be manifesting a tension pneumothorax. In this condition, the pneumothorax enlarges progressively, increasing pressure in the chest to the point that the return of blood to the heart is compromised, resulting in decreased SV, and a shock state ensues. The immediate and lifesaving treatment is to decompress the tension pneumothorax by placing a largebore IV catheter in the second intercostal space in the mid-clavicular line. This results in an immediate decrease in the intrathoracic pressure and improvement in venous blood refilling the heart, restoring SV and cardiac output. Our medics recognized and treated this patient with chest decompression followed by a calibrated 500 Choose 40 at www.jems.com/rs cc bolus of crytalloid, with improved vital signs found on reassessment. These medics prevented the onset of irreversible shock and saved this patient’s life with their prompt and expert interventions. Last, remember that a penetrating chest injury in the face of shock may represent a tension pneumothorax and require immediate needle thoracostomy to restore cardiac output. JEMS Conclusion Peter P. Taillac, MD, FACEP, is an associate clinical professor in the University of Utah Division of Emergency Medicine. He serves as the medical director for the Utah Bureau of EMS, the Utah Department of Health, and West Valley City Fire and EMS. Contact him at peter.taillac@hsc.utah.edu. Chad Brocato, DHSC, CFO, JD, is the Deerfield Beach (Fla.) district fire chief for the Broward Sheriff’s Office Department of Fire Rescue Emergency Services in South Florida. He’s also an adjunct professor at Kaplan University as well as the coordinator for the JEMS Games. Contact him at medicteach@aol.com. New concepts in trauma management differentiate between controllable hemorrhage from extremities and uncontrollable internal hemorrhage from truncal injuries. The goal of trauma management is the prevention of uncompensated and irreversible shock. Prompt control of blood loss from extremities with a pressure dressing or a tourniquet is an immediate priority and should be implemented during the primary survey of the trauma patient. Internal bleeding control from truncal injuries is facilitated by “not popping the clot.” These patients may be managed in their compensated shock state (BP above 80–90 mm/Hg) by avoiding excess prehospital IV fluids. Judicious and calibrated IV boluses are used to support the BP below this level. This clinical education feature appears as part of the JEMS Integrated Clinical Training Simulation (ICTS) project sponsored by Laerdal Medical Corp.’s Discover Simulation program, with support from JEMS and the Eagles Coalition. Choose 41 at www.jems.com/rs www.jems.com OCTOBER 2012 JEMS 69
  • 69. Vital Pathways continued from page 69 1. Kragh J, Littrel M, Jones J, et al. Battle casualty survival with emergency tourniquet use to stop limb bleeding. J Emerg Med. 2011;41(6):590. 2. Bickell W, Wall M, Pepe P, et al. Immediate versus delayed fluid resuscitation for hypotensive REVIEW QUESTIONS Test your comprehension with this post-article quiz. This article has been accredited by the Continuing Education Coordinating Board for EMS (CECBEMS) for 1 hour of continuing education credit. For a limited time only, readers of this article may obtain CE credit courtesy of Laerdal Medical Corp. The first 500 visitors to JEMS.com/DiscoverSimulation who register using promo code JEMSOctCE (not case sensitive) will receive CE credit free. Objective 1: Identify major anatomical components of the cardiovascular system. 1. Which heart chamber receives blood from the vena cavae? a. atrium Right b. Left atrium c. ventricle Right d. Left ventricle 2. Which valve separates the right atrium from the right ventricle? a. Mitral valve b. Aortic valve c. Tricuspid valve d. Pulmonary valve 3. Which valve separates the right ventricle from the pulmonary artery? a. Mitral valve b. Aortic valve c. Tricuspid valve d. Pulmonary valve 4. Which valve separates the left atrium from the left ventricle? a. Mitral valve b. Aortic valve c. Tricuspid valve d. Pulmonary valve 5. Which valve separates the left ventricle from the aorta? a. Mitral valve b. Aortic valve c. Tricuspid valve d. Pulmonary valve 6. What is the name of the innermost layer of an artery? a. Tunica media 70 JEMS OCTOBER 2012 patients with penetrating torso injuries. N Eng J Med.1994;331(17):1,105. 3. Taillac P, Doyle G. Tourniquet first! Safe and rational protocols for prehospital tourniquet use. JEMS.2008(Oct Suppl);24. 4. Butler F, Holcomb J, Giebner S. Tactical combat b. Tunica intima c. Tunica externa d. Tunica adventitia 7. What is another name for the red blood cells? a. Luekocytes b. Hemocyctes c. Erythrocytes d. Thrombocytes Objective 2: Describe the physiological components of blood pressure. 8. Blood pressure is the product of stroke volume, peripheral vascular resistance, and _________? a. rate Heart b. volume Tidal c. Cardiac output d. Functional reserve 9. What term describes the amount of blood ejected from the ventricles with each contraction? a. volume Tidal b. Stroke volume c. End-systolic volume d. End-diastolic volume 10. ithout any homeostatic corrections, which event W would lower the patient’s blood pressure? a. Vasodilation b. Slight tachycardia c. Increased stroke volume d. Bolus of normal saline Objective 3: Differentiate between compensated, uncompensated and irreversible shock. 11. Which sign would you expect to see in a patient with compensated shock? a. Bradypnea b. Tachycardia c. Hypotension d. Warm, dry skin 12. What is the hallmark sign of uncompensated shock? a. Tachypnea b. Tachycardia c. Hypotension d. Cool, pale skin 13. Which type of shock will result in the patient’s death regardless of any prehospital intervention? a. Neurogenic shock b. Irreversible shock c. Hypovolemic shock d. Uncompensated shock 14. our young male patient has a gunshot wound near Y the spine at the level of the eighth thoracic vertebra. The patient is pale and diaphoretic. The blood pressure is 90/50 mmHg, the heart rate is 128 beats per minute, casualty care 2007: Evolving concepts and battlefield experience. Mil Med. 2007:172(suppl 1):1. 5. McSwain N, Champion H, Fabian T, et al. State of the art fluid resuscitation 2010: Prehospital and immediate transition to the hospital. J Trauma 2011;70(5) (supplement):S2. and the respiratory rate is 30 breaths per minute. How would you classify his hemodynamic status? a. volume Tidal b. Irreversible shock c. Compensated shock d. Uncompensated shock Objective 4: Use a comprehensive assessment to formulate a treatment plan for a patient suffering from shock. 15. You arrive on scene to find a young male lying in a pool of blood with a visible bullet wound to the right abdomen. The patient is trying to speak, but his words do not make any sense. What should you do first? a. Control the bleeding b. Rapidly assess his airway c. Administer high flow oxygen d. Attempt to establish IV access 16. ou’re treating a 20-year-old male with an entrance Y wound to the left anterior thigh. The wound is actively hemorrhaging bright red blood. The bleeding stops with the application of a tourniquet proximal to the wound. After applying pressure dressings, you loosen the tourniquet and note no further bleeding. On the way to the hospital, you notice a sudden soaking of the dressing with bright red blood. What’s the quickest and most reliable way to immediately halt the rebleeding? a. Elevate the leg b. Retighten the tourniquet c. Apply additional pressure dressings d. Compress the femoral pressure point 17. Your young male patient has a GSW to the right lower quadrant of the abdomen. There is little bleeding visible and the abdomen is slightly distended. The patient is pale and diaphoretic. His blood pressure is 91/62 mmHg, his heart rate is 134 beats per minute, and his respiratory rate is 32 breaths per minute. What is the most appropriate crystalloid administration rate during transport? a. Two liters at time b. Judicious fluid boluses c. Wide open through large bore IVs d. Minimal or no fluid administration 18. You’re treating a female patient with a single entrance GSW to the right anterior chest. No air is leaking from the wound although the patient is having some respiratory distress. The patient is pale and diaphoretic. The blood pressure is 66/42 mmHg, the heart rate is 140 beats per minute, and the respiratory rate is 34 breaths per minute. What is the most appropriate initial treatment for this patient? a. Needle thoracostomy for possible tension pneumothorax b. Judicious fluid boluses (500–1,000 cc at a time) c. No fluid administration d. Wide open fluids through large bore IVs 1. A; 2. C; 3. D; 4. A; 5. B; 6. B; 7. C; 8. A; 9. B; 10. A; 11. B; 12. C; 13. B; 14. C; 15. B; 16. B; 17. D; 18. A References
  • 70. special rates for your team! Take advantage of a multiple copy subscription discount offer for JEMS, the Journal of Emergency Medical Services. JEMS provides you and your personnel with crucial information: u reakthrough Clinical Concepts B Fundamental Assessment Tips u Compelling Case Studies u nspiring Advice on Leadership, I Professionalism Higher Learning u Cutting-Edge Gear Technology Call today about our special rates on multiple copy subscriptions: (888) 456-5367 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: www.jems.com/JOP2013
  • 71. A supplement to JEMS (Journal of Emergency Medical Services) Get More Information at
  • 72. Advance Your Career at EMS Today … Where People, Products and Ideas Connect EMS Today provides EMS professionals with progressive education. Here are some of the sessions on the 2013 program: • Lessons Learned: EMS Use of Ketamine for Excited Delirium • TBI: Prehospital Controversies and Management Update • Bath Salts and other Internet-Promoted Substances • 10 Trauma Cases You’d Better Know When You See Them • Extraordinary Threats from Ordinary IEDs • Operational Medicine: Providing care in unconventional settings • What EMS Has Learned From the Iraq and Afghanistan Battlefield PLUS: • ETWORK and make new contacts with EMS professionals from N around the world • See the newest PRODUCTS in the exhibit hall • ARN CEH in conference sessions, workshops and the Exhibit Hall E Learning Center • EXPERIENCE Washington, D.C. and all the city has to offer REGISTRATION WILL BE OPEN SOON! www.EMSToday.com
  • 73. Employment Sussex County EMS Caring People, Quality Service Are you up tothe challenge? Are you ready to join a clinically progressive team with a tradition of excellence? Immediate openings for Nationally Registered Paramedics Contact us at: (302) 854-5050 / www.sussexcountyems.com 74 JEMS OCTOBER 2012 To Place a Classified ad, please email: classifieds@elsevier.com
  • 74. To Place a Classified ad, please email: classifieds@elsevier.com Equipment HAVE OPEN POSITIONS? LIFE SUPPORT EQUIPMENT Get them filled with a JEMS recruitment classified. CERTIFICATION AND DEPOT REPAIR Reach our audience with your message! www.advancedbiomedical.com Email: classifieds@elsevier.com ADVANCED BIO-MEDICAL CALL 1.800.383.8962 greatservice@advancedbiomedical.com Save 25% - All Services www.jems.com OCTOBER 2012 JEMS 75
  • 75. On The Market Choose 48 at www.jems.com/rs Choose 49 at www.jems.com/rs Choose 50 at www.jems.com/rs Emergency Medical Services Edition of MONOPOLY Presented by JEMS This special edition of Monopoly features all the things you love about this classic board game…with an EMS twist. • okens: A stretcher and an ambulance T are just 2 of your options • otels /Buildings: They’re now EMS H Stations and Hospitals • riage Vitals Cards replace the T Chance and Community Chest Cards • lace names are now EMS-related, and P include Cardiac Court, Flatline Freeway and Paramedic Place. Buy your game today at www.EMSPlay.com! The MONOPOLY name and logo, the distinctive design of the game board, the four corner squares, the MR. MONOPOLY name and character, as well as each of the distinctive elements of the board and playing pieces are trademarks of Hasbro for its property trading game and game equip¬ment. © 1935, 2010 Hasbro. All rights reserved. ®/TM denotes U.S. trademarks.
  • 76. ad direct Your source for immediate information on advertisers’ products and services Advertiser RS# Page Advertiser RS# Page 5.11 Tactical Series 18, 19 15, 17 Junkin Safety Appliance Co. 27 36 Airspace Monitoring Systems 50 76 Knox Co. 43 81 Alternative Support Apparatus 31 49 Laerdal Medical Corporation 45, 49 76, 84 American College of Surgeons 37 58 m2 Inc. 36 58 American Heart Association 29 37 Mercedes 13 4 B Braun Medical Inc. 48 76 Mercury Medical 22 25 Micro Direct 39 68 Blauer Manufacturing Co. Inc. 26 35 NAEMT 40 69 Bound Tree Medical 11 2 North American Rescue Products 38 59 Braun Industries 32 49 O-Two Systems International Inc. 25 33 CAE Healthcare 21 23 Oxygen Generating Systems Intl. 42 81 Panasonic 17 11 CentreLearn 63 Columbia Southern University 28 36 Philips Healthcare 21 50 Physio Control 35 57 Pulmodyne 15 8 Stryker EMS 45 84 Crestline Coach 20 Ecolab 34 55 Emergency Medical Products/L.A. Rescue 41 69 Ferno-Washington Inc. 12 3 Vidacare Corp. 23 27 Fitch Associates 30 45 Witmer Public Safety Group, Inc. (theEMSstore.com) 33 55 I-TEC Mfg 24 29 Zoll Medical Corporation 14, 16 6, 9 FREE advertiser and product information www.jems.com/rs IT’S FAST, IT’S EASY AND JUST A CLICK AWAY! www.jems.com OCTOBER 2012 JEMS 77
  • 77. HANDS ON PRODUCT REVIEWS FROM STREET CREWS Floating on Air While teaching the chapter on lifting and moving to EMT classes, I routinely joke with the students, saying “If you don't have any back problems yet, you will.” Out-of-position lifting, over reaching and just plain large patients account for countless provider back injuries every year. The Hovertech International HoverMatt Single-Patient Use Transfer Mattress could virtually eliminate caregiver injuries related to lateral transfers and repositioning. The inflatable air mattress and the patient float on a cushion of air. The patient can remain on the HoverMatt mattress during the entire transport as well as their entire hospital stay. There are integrated handles for ease of use, and straps to help secure the patient to the matt during moves. There’s also a limited chance for cross contamination because the mattress is disposable. VITALS Sizes: 34, 39 50 wide Power Supply: 100V AC www.Hovermatt.com 800/471-2776 Safety First VITALS Call for pricing www.bbraunusa.com 800/227-2862 The BBraun Introcan Safety 3 Closed IV Catheter has a passive safety needle shield that deploys automatically and cannot be bypassed, which aids in the prevention of needlestick injuries. The multiple-access blood control septum helps prevent blood exposure each time the catheter hub is accessed. Introcan Safety 3’s integrated stabilization platform improves catheter stability and minimizes movement within the vessel, reducing a number of catheter-related complications such as phlebitis, infiltration/extravasation, site infection, dislodgement and catheter kinking. In addition, the advanced hub design allows for easier connections and less touch contamination, and the catheter’s smooth ergonomic surface optimizes patient comfort. Introcan Safety 3’s innovative design features are designed to protect EMS professionals from needlesticks and blood exposure, as well as help maintain site access during patient transport. Harness the Sun The Streamlight SolarStream supplemental solar charging panel helps offset battery drain from computer systems and other rechargeable electronics when an emergency responder vehicle is off. It extends battery life and limits battery-related vehicle maintenance. Using a thin-film amorphous silicon charging panel, the Streamlight SolarStream adheres to a variety of contoured surfaces. The panel allows for 14 watts of maximum power in full sunlight, but it maintains a trickle charge to the vehicle battery even in low sun and cloudy conditions, and is both heat and shade tolerant. It has encapsulated amorphous silicon technology, which offers exceptional durability and weather resistance. And it’s tested for wind resistance up to 120 miles per hour. Dominic Silvestro, EMT-P, EMS-I, is a firefighter/paramedic and public information officer for the Richmond Heights (Ohio) Fire Department. He is also an EMS coordinator and EMS educator for the University Hospitals EMS Training and Disaster Preparedness Institute and an adjunct faculty member at Cuyahoga Community College. He can be reached at d.silvestro@jems.com. VITALS Dimensions: 40.88 long by 13.07 wide Weight: 1.3 pounds Warranty: 5-year limited Price: $400 www.streamlight.com 800/523-7488 IN THE NEXT ISSUE: Rip Shears SAM Medical Products SAM Chest Seal 78 JEMS OCTOBER 2012
  • 78. For more product reviews: www.jems.com/products Stubs Ashes Close to 30% of all needle stick injuries occur when healthcare workers attempt to dispose of needles using a sharps container. Research has also shown that more than 80% of sharps injuries are preventable. The Sharps Terminator, one of the Hot Products selected at the 2012 EMS Today Conference Exhibition, is an effective way to help eliminate sharps-related injuries; it renders syringes and needles harmless and turns needles into stubs and inert ashes in three seconds. Here’s how it works: The needle body completes a circuit between two angled copper electrodes. The resistance from the needle creates heat that destroys the metal portion of the needle. The plastic hub is then cut above the metal needle. The debris then falls into a cleanout tube at the bottom of the unit where it is exposed to UV light to eliminate contaminants. The remaining syringe is now harmless and can be disposed of in a regular medical waste container. This entire process can be accomplished with one hand while you're at the patient’s side, so you no longer have to reach across your ambulance or walk to another area of the room to dispose of your needles. VITALS Height: 7 Weight: Less than 5 lbs. Power: Rechargeable battery Price: $899 www.sharpsterminator.us.com 877/855-1319 Exhaled CO Monitor Headache, fatigue, weakness, flu-like symptoms—one of the most overlooked causes of these signs and symptoms is carbon monoxide poisoning (CO poisoning). It’s also important that firefighters are checked and monitored for CO poisoning after exiting a hazardous environment. The Micro Direct Micro CO is a non-invasive monitor that accurately tests exhaled end-tidal CO levels in less than one minute. The measurements are obtained from a single expiration and instantly displayed on a liquid crystal display. Disposable cardboard mouth pieces are used for each person tested. This product also meets NFPA 1584 Standard on the Rehabilitation Process for Members During Emergency Operations and Training Exercises. VITALS Size: 6.5 x 2.5 x 1 Weight: 5.6 oz. Power: 9V battery Price: $1,150 www.breathCOtest.com 207/786-7808 All-in-One C-Spine System How many times have your head blocks, towel rolls, tape or Velcro slipped, slid or failed to keep your patient fully immobilized? Also, reflect back on how often you’ve attempted to apply C-Collars that just wouldn’t fit your patients properly. The Emergear X-Collar Plus is a splinting system that utilizes bi-lateral and vertical adjustment that create a customized fit for patients with body types ranging from pediatric to extra large adults. The inexpensive X-Collar Plus also has an oversized trachea opening to allow for carotid pulse checks and advanced airway procedures. The most unique feature of this product is the integrated Head Restraint System, which replaces the use of head blocks or towel rolls. The system includes a height adjustable Occipital Support Pad, which ensures proper spinal alignment, and the integrated Velcro straps secure the patient to the backboard. VITALS Key Features: Latex-free, radiolucent, MRI and CT scan compatible Colors: Clear, high-visibility orange military green Price: $11.95 www.xcollar.com 805/684-6568 Laerdal Medical Simpad System EMS Charts Mobile v3 King Systems King Vision www.jems.com OCTOBER 2012 JEMS 79
  • 79. thethey didn’t tell you in medic school LIGHTER SIDE what by steve berry Clenched Teeth Verbiage Why labels should be left out of politics Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly applying the wrong remedies. —Groucho Marx I s it me or does everyone seem a lot more uptight and over-sensitive lately? Fine! Don’t answer the question. See if I give a flying duck! Thank God there are monthly lighthearted articles like mine that allow the reader to kick back and take a break from the unrelenting drama of day-to-day life, which is why I have chosen the topic of politics to help you relax and free your mind of stress. A co-worker recently asked me if I was a democrat or republican to which my response was, “That’s a question I will refer to my lawyer.” Not that I don’t stand by my convictions mind you, but if there’s one thing I’ve learned as an EMS provider, it’s to never buy a suction unit with a reverse switch on it. The other thing I learned was to duck (as in flying) while discussing politics in the workplace. Every quadrennial year it seems, intelligence, integrity and selflessness are thrown out the window as divisive labeling and animosity rules the day. My job is stressful enough when it comes to dealing with confrontational patients without having a colleague considering me vermin simply because he views my political pick as vermin. I’m all for meaningful dialogue that honors political diversity, but more often than not. I’ve seen these civil discussions turn dicey with a resulting exchange of unsportsmanlike angiocath stab wounds rather than that of ideas. Unlike most work environments, a 9–5 hour workday is considered part-time in the fire and EMS profession. We are therefore likely to engage in these types of political discussions whether we want to or not simply because we literally sleep, eat and lounge in the same vicinity. It’s estimated that more 80 JEMS OCTOBER 2012 than $6 billion will be spent by both candidates on mean-spirited, exaggerated and intimidating catchphrase advertising. Thus, voices from the lounge chairs are bound to give rise to political affiliation during these unceasing, polarizing TV political ads— whether you want to hear them or not. So how can one avoid discoursing on one’s political association while at the same time chloroform a co-worker’s blowhard campaign rant that provokes political ideology without thought? Non-confrontational attempt #1: “I am here and salaried to execute a set of commissioned duties—not campaign for your party.” Non-confrontational attempt #2: “I’m not comfortable discussing politics and prefer not to participate in this discussion.” Looks like another choking call during the presidential debates. … Can’t swallow what they’re hearing. smile, “Hoover, Roosevelt, Truman, Eisenhower, Kennedy, Johnson, Nixon, Ford, Carter, Regan, Bush, Clinton and Bush.” “Excuse me?” I asked, smiling back as I ripped the Velcro blood pressure cuff free from his bicep. “I voted in all them elections,” he clarified. “Yeah? A true patriot to the voting process, obviously,” I endorsed. “I suppose,” he said without conviction. “All I know is diapers and politicians should be changed often and for the same reason.” As he said this, he pointed to his underlying Depends. Pausing only to readjust himself on the cot, he continued, “Of course, my two cents worth is worth only just that— two cents.” Now totally engaged in the patient, I Heimlich: Horrid Elections Instigate Merciless Laryngeal Induced Constrictive Hypoxia Vote for me! Confrontational attempt: “%#@ off, you narrow minded, delusional, sanctimonious, rhetorical narcissistic baboon advocate of unsubstantiated generalizations and intolerable dogmatic babble.” Some eight years earlier in my career, while transporting a centurion-plus patient on November fourth to a hospital, the patient pointed to the “I voted” sticker on my uniform and softly said with a introspective ignored the cardiac monitor batteries telling me it was time for a change. “So what do you think of the candidates of today?” Happy to know someone was actually listening to him, the patient pulled himself up even higher on the cot. “It’s all bad comedy really,” he said. “‘Too many clowns and not enough circuses,’ my father would tell me when I was a boy, and he voted as far back as Theodore Roosevelt. Call me
  • 80. an idealist, but everything in politics has always sucked.” “But these are exceptionally hard times,” I interjected ignorantly. “Are they now?” he smirked. “Well young fella,” (I cannot recall the last time anyone called me “young fella.”) “Every electoral proponent of their party touts that this is the most critical time in our history with each partisan group trying to scare the bejesus out of everyone, lest the horrific prospect of the other guy becoming president actually comes true. “Really? Well, guess what?” he continued with more impassioned fervor. “The world is still spinning. No matter who the president is, this country will continue to endure. Our democracy still governs the person in charge of it.” As we approached downtown, we saw a crowd of people with signs on a street corner loudly advocating their candidate with the opposing view standing on the other side of the street. “See those people out there,” my patient grinned. “I laugh at folks who idiotically go crazy when their party member doesn’t get elected. One thing I can say after all these years is that I have mastered the genteel art of letting others rant on and on while sitting back and basking in the knowledge he or she is full of diaper dung. Speaking of, are we at the hospital yet?” EMS is a profession that demands its providers have a high degree of broad-mindedness while working in an environment rich in cultural, ethnic, religious and political diversity. Regardless of a patient’s personal belief systems or social and economic standing, all of us cast our vote each day by what we do or don’t do in relation to patient care. When I see a medic quick to use incendiary words or labels toward a group of people simply because they do not agree with their own political standing, I cannot help but question their overall tolerance and ability to compromise or provide bipartisan patient care. Or as Soren Kierkegaard once said, “Once you label me, you negate me.” Until next time, remember labels are for diseases—not people. JEMS Choose 42 at www.jems.com/rs 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. Choose 43 at www.jems.com/rs www.jems.com OCTOBER 2012 JEMS 81
  • 81. Photos courtesy the Office of the Secretary of Public Safety, Commonwealth of Virginia LAST WORD EMS The Ups downs of ‘Simulance’ on the road A new and innovative “Simulance” recently went into service in western Virginia. The Blue Ridge Volunteer Rescue Squad (BRVRS) and Botetourt County EMS refurbished an ambulance and added a highfidelity patient simulator. The rescue squad submitted a request through the state Rescue Squad Assistance Fund (RSAF) for $100,455.72 at the 80/20 state/agency funding level. The primary goal of RSAF is to financially assist governmental, volunteer and nonprofit EMS agencies to purchase EMS equipment and vehicles and provide needed EMS programs and projects. BRVRS was awarded a grant on Jan. 1, 2012, which covered the patient simulator, HD camera, video recording tether-less and ruggedized automaton needed to create this ground-up approach to EMS training. “It’s like real medicine. There’s the 99% of patients that act a particular way, but then there’s the 1% that’s going to act a little different,” BRVRS member Colt Hagmaier said in a news report. We applaud BRVRS for enacting this effective and innovative approach to regional training—and making good use of a retired ambulance. AED Access Hennepin (Minn.) EMS has announced the addition of a new information system that will assist 9-1-1 dispatchers in helping callers locate lifesaving automated external defibrillators (AEDs) available near sudden cardiac arrest victims. “The problem is that until now, publicly available AEDs are rarely used in an emergency because people don’t know where they are, they can’t see them, and 9-1-1 dispatchers are unaware of the location,” said Chris Kummer, manager with Hennepin EMS, in a news report. The new system from Atrus, Inc., known as AED Link, shows the location of registered AEDs on 9-1-1 agency consoles. “AED Link lets us instantly see the location of all registered AEDs near a sudden cardiac arrest victim so we can send someone to get it in time to help save a life,” Kummer said. Both Hennepin EMS and Atrus officials anticipate the system to be available by this month, which is fittingly, National Sudden Cardiac Arrest Awareness Month. In 2011, Hennepin EMS managed seven cardiac arrest cases in which a bystander used an AED. In six of those cases, the patient was resuscitated and walked out of the hospital neurologically intact. “While there are many factors to survival, bystander intervention with CPR and an AED is clearly a key link,” said Brian Mahoney, MD, Hennepin EMS medical director, in a news release. We tip our hat to Hennepin EMS for working to improve the availability of AEDs and aiding in ongoing efforts to increase cardiac arrest survival rates. Equine Therapy Equine-assisted psychotherapy (EAP) is a specialized form of psychotherapy using horses as a therapeutic tool. This modality is designed to address self-esteem and personal confidence, communication and interpersonal effectiveness, trust, boundaries and limit-setting, and group cohesion. It has been effective in the recovery of our wounded warriors. MONOC Mobile Health Services in New Jersey has announced a partnership with the Chariot Riders Equestrian Academy and Horses for Heroes program to support New Jersey veterans and active mil- itary personnel with disabilities. Chariot Riders Academy is a non-profit organization accredited by the Professional Association of Therapeutic Horsemanship International. In addition to the services they offer to the public, they also operate the Horses for Heroes program in Ocean and Monmouth Counties. The Horses for Heroes therapeutic riding program includes mounted and nonmounted equestrian activities in either group or private settings at no cost to participants. Activities are tailored to the individual’s needs and have been proven to improve the physical balance, gait and morale of both active military personnel and veterans with a wide range of both physical and psychological special needs. We give MONOC Mobile Health Services a thumbs up for supporting such a great service for our veterans. For more information on the Horses for Heroes Program, visit www.chariotriders.org. More Accountability The National Association of EMTs (NAEMT) announced a position paper that encourages the establishment of a “just culture” environment within all EMS agencies. The term “just culture” refers to a valuessupportive system of shared responsibility in which healthcare organizations are accountable for responding to the behaviors of their staff in a fair and just manner. Staff, in turn, are accountable for the quality of their choices and for reporting both their errors and system vulnerabilities. In the just culture program, employees’ behaviors are separated into three categories: 1. “human error”; 2. “at-risk behavior”; and 3. “reckless behavior.” This helps create a formula for consistency for the evaluation of human behaviors, and instills a sense of confidence in the individuals involved. Because mistakes don’t always result in an adverse event, acknowledgement of a mistake allows agencies to take action before an event occurs. We give a thumbs up to the NAEMT for helping foster an environment of accountability and consistency across all EMS agencies. JEMS JEMS (Journal of Emergency Medical Services), ISSN 0197-2510, USPS 858-060, is published 12 times a year (monthly) by PennWell Corporation, 1421 S. Sheridan Road, Tulsa, OK 74112; phone 918/835-3161. Copyright © 2012 PennWell Corporation. subscriptions: Send $44 for one year (12 issues) or $74 for two years (24 issues) to JEMS, P.O. Box 17049, North Hollywood, CA 91615-9247, or call 888/456-5367. Canada: Please add $25 per year for postage. All other foreign subscriptions: Please add $35 per year for surface and $75 per year for airmail postage. Send $20 for one year (12 issues) or $35 for two years (24 issues) of digital edition. Single copy: $10.00. Postmaster: Send address changes to JEMS (Journal of Emergency Medical Services), P.O. Box 17049, North Hollywood, CA 91615-9248. Claims of non-receipt or damaged issues must be filed within three months of cover date. Periodicals postage paid at Tulsa, Oklahoma and at additional mailing offices. Advertising information: Rates are available at www.jems.com/about/advertise or by request from JEMS Advertising Department at 525 B Street, Suite 1800, San Diego, CA 92101-4495; 800/266-5367. EDITORIAL information: Direct manuscripts and queries to JEMS Editor, 525 B Street, Suite 1800, San Diego, CA 92101. No material may be reproduced or uploaded on computer network services without the expressed permission of the publisher. JEMS is printed in the United States. GST No. 1268113153. 82 JEMS OCTOBER 2012
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