JOURNAL OF EMERGENCY MEDICAL SERVICES ®
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
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
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
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
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
26 I Tricks OF the TRADE I Warm Enough for Ya?
y Thom Dick
28 I case of the month I Naked Unconscious
y Kimberly Doran
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
82 I LAST WORD I The Ups Downs of EMS
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
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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
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OCTOBER 2012 JEMS
JOURNAL OF EMERGENCY MEDICAL SERVICES
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JOURNAL OF EMERGENCY MEDICAL SERVICES
JOURNAL OF EMERGENCY MEDICAL SERVICES ®
William K. Atkinson II, PHD, MPH, MPA, EMT-P
President Chief Executive Officer
WakeMed Health Hospitals
James J. Augustine, MD, FACEP
Medical Director, Washington Township (Ohio) Fire Department
Associate Medical Director, North Naples (Fla.) Fire Department
Director of Clinical Operations, EMP Management
Clinical Associate Professor, Department of
Emergency Medicine, Wright State University
steve berry, NRemt-p
Paramedic EMS Cartoonist, Woodland Park, Colo.
Bryan E. Bledsoe, DO, FACEP, FAAEM
Professor of Emergency Medicine, Director, EMS Fellowship
University of Nevada School of Medicine
Medical Director, MedicWest Ambulance
Criss Brainard, EMT-P
Deputy Chief of Operations, San Diego Fire-Rescue
Chad Brocato, DHS, REMT-P
Assistant Chief of Operations, Deerfield Beach Fire-Rescue
Adjunct Professor of Anatomy Physiology, Kaplan University
J. Robert (Rob) Brown Jr., EFO
Fire Chief, Stafford County, Va., Fire and Rescue Department
Executive Board, EMS Section,
International Association of Fire Chiefs
Jeffrey M. Goodloe, MD, FACEP, NREMT-P
Professor EMS Section Chief
Emergency Medicine, University of Oklahoma School of
Medical Director, EMS System for Metropolitan
Oklahoma City Tulsa
David E. Persse, MD, FACEP
Physician Director, City of Houston Emergency Medical Services
Public Health Authority, City of Houston Department.
of Health Human Services
Associate Professor, Emergency Medicine,
University of Texas Health Science Center—Houston
President, RedFlash Group
Founding Editor, JEMS
John J. Peruggia Jr., BSHuS, EFO, EMT-P
Assistant Chief, Logistics, FDNY Operations
Dave Keseg, MD, FACEP
Medical Director, Columbus Fire Department
Clinical Instructor, Ohio State University
W. Ann Maggiore, JD, NREMT-P
Associate Attorney, Butt, Thornton Baehr PC
Clinical Instructor, University of New Mexico,
School of Medicine
Connie J. Mattera, MS, RN, EMT-P
EMS Administrative Director EMS System Coordinator,
Northwest (Ill.) Community Hospital
Robin B. Mcfee, DO, MPH, FACPM, FAACT
Medical Director, Threat Science
Toxicologist Professional Education Coordinator,
Long Island Regional Poison Information Center
carol a. cunningham, md, FACEP, FAAEM
State Medical Director
Ohio Department of Public Safety, Division of EMS
Mark Meredith, MD
Assistant Professor, Emergency Medicine and Pediatrics,
Vanderbilt Medical Center
Assistant EMS Medical Director for Pediatric Care,
Nashville Fire Department
Thom Dick, EMT-P
Quality Care Coordinator
Platte Valley Ambulance
Geoffrey T. Miller, EMT-P
Director of Simulation Eastern Virginia Medical School,
Office of Professional Development
Charlie Eisele, BS, NREMT-P
Flight Paramedic, State Trooper, EMS Instructor
Brent Myers, MD, MPH, FACEP
Medical Director, Wake County EMS System
Emergency Physician, Wake Emergency Physicians PA
Medical Director, WakeMed Health Hospitals
Emergency Services Institute
Bruce Evans, MPA, EMT-P
Deputy Chief, Upper Pine River Bayfield Fire Protection,
Jay Fitch, PhD
President Founding Partner, Fitch Associates
Ray Fowler, MD, FACEP
Associate Professor, University of Texas Southwestern SOM
Chief of EMS, University of Texas Southwestern Medical Center
Chief of Medical Operations,
Dallas Metropolitan Area BioTel (EMS) System
Adam D. Fox, DPM, DO
Assistant Professor of Surgery,
Division of Trauma Surgery Critical Care,
University of Medicine Dentistry of New Jersey
Former Advanced EMT-3 (AEMT-3)
Gregory R. Frailey, DO, FACOEP, EMT-P
Medical Director, Prehospital Services, Susquehanna Health
Tactical Physician, Williamsport Bureau of
Police Special Response Team
Mary M. Newman
President, Sudden Cardiac Arrest Foundation
Joseph P. Ornato, MD, FACP, FACC, FACEP
Professor Chairman, Department of Emergency Medicine, Virginia
Commonwealth University Medical Center
Operational Medical Director,
Richmond Ambulance Authority
Jerry Overton, MPA
Chair, International Academies of Emergency Dispatch
David Page, MS, NREMT-P
Paramedic Instructor, Inver Hills (Minn.) Community College
Paramedic, Allina Medical Transportation
Member of the Board of Advisors,
Prehospital Care Research Forum
Paul E. Pepe, MD, MPH, MACP, FACEP, FCCM
Professor, Surgery, University of Texas
Southwestern Medical Center
Head, Emergency Services, Parkland Health
Head, EMS Medical Direction Team,
Dallas Area Biotel (EMS) System
Edward M. Racht, MD
Chief Medical Officer, American Medical Response
Jeffrey P. Salomone, MD, FACS, NREMT-P
Associate Professor of Surgery,
Emory University School of Medicine
Deputy Chief of Surgery, Grady Memorial Hospital
Assistant Medical Director, Grady EMS
Kathleen S. Schrank, MD
Professor of Medicine and Chief,
Division of Emergency Medicine,
University of Miami School of Medicine
Medical Director, City of Miami Fire Rescue
Medical Director, Village of Key Biscayne Fire Rescue
John Sinclair, EMT-P
International Director, IAFC EMS Section
Fire Chief Emergency Manager,
Kittitas Valley Fire Rescue
Corey M. Slovis, MD, FACP, FACEP, FAAEM
Professor Chair, Emergency Medicine,
Vanderbilt University Medical Center
Professor, Medicine, Vanderbilt University Medical Center
Medical Director, Metro Nashville Fire Department
Medical Director, Nashville International Airport
Walt A. Stoy, PhD, EMT-P, CCEMTP
Professor Director, Emergency Medicine,
University of Pittsburgh
Director, Office of Education,
Center for Emergency Medicine
Richard Vance, EMT-P
Captain, Carlsbad Fire Department
Jonathan D. Washko, BS-EMSA, NREMT-P, AEMD
Assistant Vice President, North Shore-LIJ Center for EMS
Co-Chairman, Professional Standards Committee,
American Ambulance Association
Ad-Hoc Finance Committee Member, NEMSAC
keith wesley, MD, facep
Medical Director, HealthEast Medical Transportation
Katherine H. West, BSN, MED, CIC
Infection Control Consultant,
Infection Control/Emerging Concepts Inc.
Stephen R. Wirth, Esq.
Attorney, Page, Wolfberg Wirth LLC.
Legal Commissioner Chair, Panel of Commissioners,
Commission on Accreditation of Ambulance Services (CAAS)
Douglas M. Wolfberg, Esq.
Attorney, Page, Wolfberg Wirth LLC
Wayne M. Zygowicz, BA, EFO, EMT-P
EMS Division Chief, Littleton Fire Rescue
EMS IN ACTION
Scene of the month
Photos Roland Webb
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.”
from the editor
putting issUes into perspective
by A.J. HEIGHTMAN, MPA, EMT-P
Patches, Pride Patients
Consistent cooperation should be the goal
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
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
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
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
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
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.
his vision begin to fade and “tunnel,” and
had a significant amount of blood filling his
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
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
1. Kabbany J. (Aug. 4, 2012). WILDOMAR: Region remembers slain Murrieta soldier. In North County Times.
Retrieved Aug. 4, 2012, from www.nctimes.com/
Read Sgt. Eric E. Williams’ last blog entry,
“Coming Home,” at http://myfriendthemedic.
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
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,
I’m going to have to play devil’s advocate a little here.
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?
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.
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.
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
illustration steve berry
in your words
NEWS YOU CAN
Hurricane Isaac HITS
Crews Activate Response Plans
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.
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
“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
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
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• 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
• 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
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
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.
“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
on or about the same day seems more than just
Typically, EMS operations experience a
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
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
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
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
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
continued from page 20
When Patients Don’t Stay Put
e’ve seen some tragic headlines recently that should be a cause
Aug. 19, 2012: “Woman Dies After Jumping from Ambulance” (Calif.)
March 12, 2012: “Patient Jumps from Ambulance Only to be Struck by
Dec. 23, 2011: “Naked Man Jumps from Ambulance, Dies on Freeway”
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
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
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
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/
For more of the latest EMS news, visit jems.com/news
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.
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
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
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.
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
TRICKSour patients ourselves
OF THE TRADE
by Thom Dick, EMT-P
Warm Enough for Ya?
Preventing failures to start
Photo Thom Dick
’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@
CASE OF THE MONTH
DILEMMAS IN DAY-TO-DAY CARE
BY Kimberly Doran
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-
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.
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
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 email@example.com.
For more information about this condition,
go to www.AIUnited.org.
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
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
By Michael Greene, MBA/MSHA
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.
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
The survey represents
all federal regions. But
the individual states
not responding were
Delaware, District of
In total, 221 survey
participants resulted in a
10% response rate.
The median population of
respondents is 50,000.
Median annual call volume
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
Fourteen of 19 job
wage gains in 2012.
Of 25 employee benefit
categories, 15 were reported
as being “reduced” and 14
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.
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
this past year’s survey, Duke is
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%
ily and friends. “I save lives, and
City/county third-service governmental
get paid for doing it. I can’t imagPrivate, not-for-profit organization
ine doing anything else!” (Doing
something else was exactly what
Duke was pondering a year ago,
Private, for profit company
but more on that later.)
Fire department, single-role
“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
Fire department, multi-role
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
Public utility model
Total Population Served
Less than 5,000
More than 1,000,000
Call Requests vs. Transports
n=199 Transports n=199
Less than 1,000
50,001 - 70,000
Greater than 90,000
“Turn and burn,” quips Duke. “Those
newbies are in and out of orientation quickly; they’re in the field at
“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.
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
at 16% and on-demand at 13%.
Duke asks Lyndy.
“I guess I don’t know,” she
Less than 1,000 (999)
responds. “He’s been a bit overDoing More
committed to the new commuDuke’s former partner and field
nity paramedic (CP) training.
trainee Dave stops as he’s walk15,001–30,000 (29,999)
“Between that and trips to the
ing by. He leans in the door,
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
adds, looking at a closed office
and they shake hands and
door marked with “Mark Manexchange backslaps.
Greater than 90,000 (99,999)
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
“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
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
(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.
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
for Salary Data
Choose 27 at www.jems.com/rs
Choose 28 at www.jems.com/rs
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
Emergency Medical Technician-Intermediate (EMT-I): A full-time
emergency medical technician–intermediate based on the current National
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
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.
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
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
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
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
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
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
Salary Workplace Survey
continued from page 37
to healthcare, personal care and social
assistance … are projected to have
the fastest job growth between 2010
Listed as one of the “top five industries for salary growth,” health2006 Average (Max.)
care workers have gained the biggest
2012 Average (Max.)
changes in wages, 9.4%, since 2006.15
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
for Healthcare Research and QualPaid by
ity (AHRQ), they do.9 MedStar
Health’s Community Health ProNew Employee Relocation Expenses
gram in Fort Worth, Texas, has
saved millions in emergency room
charges and reduced 9-1-1 use.10
The Centers for Medicare and MedMajor Medical (Employee)
icaid Services (CMS) must think
Major Medical (Employee’s Family)
so as well. In July, the CMS Health
Care Innovations Grant program
awarded Prosser Memorial Hospital in Washington almost $1.5
Employee Assistance Program
million to develop and provide a
community paramedic program.11
Which model for community paramedicine should you
choose? It could be a “new niche
EMS Tuition Reimbursement
for EMS,” according to the August
College Tuition Reimbursement
JEMS article “It Takes a Village.”12
Scholarship Fund for Employee’s Children
The article identifies the key component of the multiple CP modRetirement or Pension Plan
els as the needs of and resources
Retirement or Pension Plan
in the community. “They all feaProfit Sharing
ture aspects of home assessment,
Stock Purchase Program
home care and patient followup. They all focus resources on
Shift Differential Pay
target population, follow-up care
and prevention,” the article states.
Health Club Membership Reimbursement
The take-home message: “Community need” should drive model
Paid Time Off (PTO) Combined Benefit
development and implementation, creating a partnership in the
healthcare of the community.
Dry-cleaning of Uniforms
Figure 5: Annual Salary Growth Index from 2006 to 2012
In May 2012, the U.S. Bureau
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
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
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
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.
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
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.
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 straight hours x 52 weeks
nal and click on the salary surincome is needed for a fam48 hours
52 straight hours x 52 weeks
vey for an extended figure with
ily of four to lead a middle56 hours
64 straight hours x 52 weeks
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,
salary figure online at jems.com/journal).
a registered nurse receives an annual salary
of approximately $70,000.18,19 It’s no wonder
that EMS often experiences a migration of
EMS personnel to nursing professions.
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.
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 firstname.lastname@example.org 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.
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/
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
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
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.
10. MedStar EMS. (2012). Community Health Program.
Retrieved Aug. 14, 2012, from www.medstar911.org/
11. PMH Medical Center. (2010). PMH Awarded
Community Paramedic Grant. In PMH Medical Center.
Retrieved Aug. 14, 2012 from http://pmhmedicalcenter.
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/
16. Williams DM. 2006 JEMS Salary and Workplace Survey.
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,
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,
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
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.
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.
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
The Supreme Court decision upheld the
individual mandate with a twist. Although
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
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
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.
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
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.
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
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
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
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,”
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
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 email@example.com.
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
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
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.
By 2LT Collin Hu, EMT-E,
James Spotila, PhD, EMT-B
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
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.
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
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
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
Keeping this nearly inaccessible
patient warm during an extended
rescue demanded creativity.
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.
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
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.
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
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.
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.
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.
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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
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
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 firstname.lastname@example.org.
Mayme Roettig, RN, MSN, is the Assistant Director of
the Center for Educational Excellence (CEE), Duke Clinical Research Institute/Duke University. Contact her at
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–
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.
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.
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
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.
| jems 51
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
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
Participants in a
at the EMS Today
Exposition Conference noted
safe from crashes
like this one is
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.
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
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
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
Patient Compartment Design,” will
develop new crash-safety design stan- Would significantly improve patient care if implemented.
dards and improved user-interface Conditional
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
The project includes the following
for the design requirements of patient
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.)
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
Choose 33 at www.jems.com/rs
Choose 34 at www.jems.com/rs
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.
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
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.
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
Lift injuries: The leading cause of EMS injury is lifting/loading
injuries. Lifting heavy equipment is also a major cause of back and
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
Lack of data: Participants expressed concern that there’s no
available data on EMS provider injuries, or the causes, severity, etc. of
Protect the head: Participants recommended EMS providers
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.
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
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.
4. ommunication systems support the provider’s ability to continue providing safe and
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
with the driver or other third party.
1. orkspace has appropriate space for secure and safe placement and use of equipment,
papers and supplies.
2. roviders are able to exit the patient compartment with a patient loaded on a
transport device from the main patient loading and unloading doors and one
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;
athways clear of obstacles (no portable patient care equipment); and
oors do not intrude into workspace or provide strike risk.
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
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
or unloaded safely with minimal risk of injury to patient or
3. When being used for patient care, the placement of secured
jump bags allows EMS providers to quickly and safely
4. ecure storage is available for patient and staff belongings.
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
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
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
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
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 email@example.com.
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 firstname.lastname@example.org.
1. Ballam E. (Feb. 9, 2011). Ambulance Crash Roundup. In
EMS World. Retrieved from www.emsworld.com/
2. National Fire Protection Association. (2012). NFPA
1917: Standard for automotive ambulances. In
National Fire Protection Association. Retrieved from
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
4. ASTM International. Standard Guide for Training
Emergency Medical Services Ambulance Operations.
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/
6. Standards Australia, Standards New Zealand.
1999. Australian/New Zealand Standard:
Ambulance Restraint Systems, AS/NZS 4535:1999.
Choose 38 at www.jems.com/rs
takes service to a new level
By Bob VacCaro
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
“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,”
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
The Volusia County (Fla.) Department of Public Protection
recently took delivery of four Braun Patriot pumper/ambulances built on Spartan MetroStar chassis.
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,”
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
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
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.
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
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.
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
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
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
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.
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
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.
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
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
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
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.
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
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
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
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
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
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
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).
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
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.
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
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
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
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Choose 39 at www.jems.com/rs
For more information,
please go to
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
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
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 email@example.com.
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
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
Choose 41 at www.jems.com/rs
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
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
b. Left atrium
d. Left ventricle
2. Which valve separates the right atrium from the right
3. Which valve separates the right ventricle from the pulmonary artery?
4. Which valve separates the left atrium from the left
5. Which valve separates the left ventricle from the
6. What is the name of the innermost layer of an artery?
patients with penetrating torso injuries. N Eng J
3. Taillac P, Doyle G. Tourniquet first! Safe and rational protocols for prehospital tourniquet use.
4. Butler F, Holcomb J, Giebner S. Tactical combat
7. What is another name for the red blood cells?
Objective 2: Describe the physiological components
of blood pressure.
8. Blood pressure is the product of stroke volume,
peripheral vascular resistance, and _________?
c. Cardiac output
9. What term describes the amount of blood ejected
from the ventricles with each contraction?
b. Stroke volume
10. ithout any homeostatic corrections, which event
would lower the patient’s blood pressure?
b. Slight tachycardia
c. Increased stroke volume
d. Bolus of normal saline
Objective 3: Differentiate between compensated,
uncompensated and irreversible shock.
Which sign would you expect to see in a patient with
d. Warm, dry skin
12. What is the hallmark sign of uncompensated shock?
d. Cool, pale skin
13. Which type of shock will result in the patient’s death
regardless of any prehospital intervention?
14. our young male patient has a gunshot wound near
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)
and the respiratory rate is 30 breaths per minute. How
would you classify his hemodynamic status?
c. Compensated shock
Objective 4: Use a comprehensive assessment to
formulate a treatment plan for a patient suffering
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
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
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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:
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While teaching the chapter on lifting and moving
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thethey didn’t tell you in medic school
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.
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
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—
Now totally engaged in the patient, I
Horrid Elections Instigate
Merciless Laryngeal Induced
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
an idealist, but everything in politics has
“But these are exceptionally hard times,” I
“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
“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