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Choose 13 at www.jems.com/rs
I WAVE OF THE FUTURE I
Monitoring technology has potential
to transform EMS
By Mike McEvoy, PhD, NREMT-P, RN, CCRN
JANUARY 2013 VOL. 38 NO. 1
I PUTTING THE ‘RAP’ IN RAPPORT I
I REVOLUTIONARY MULTI-TOOL I
5 I LOAD & GO I Now on JEMS.com
10 I EMS IN ACTION I Scene of the Month
12 I FROM THE EDITOR I Future Forecast
I TUNNEL VISION I
DEPARTMENTS & COLUMNS
I OCCUPATIONAL MEDICINE ABCS I
By Gary Ludwig, MS, EMT-P
22 I TRICKS OF THE TRADE I Teeter-Totter
By Thom Dick
EMS surveillance program assists with ‘frequent flyers’
By Anne-Marie Jensen, EMT-P; & James Dunford, MD
Tablet devices transform how data is used & accessed in the field
By Richard Huff, NREMT-B
Is your agency receiving the full value?
By Katherine West, RN, BSN, MSEd
I UPDATE ON 360-DEGREE DATA I
I KEEPING IT COOL I
By A.J. Heightman, MPA, EMT-P
14 I LETTERS I In Your Words
16 I PRIORITY TRAFFIC I News You Can Use
20 I LEADERSHIP SECTOR I Whackers
The role of video laryngoscopy in future advanced
By Terence Valenzuela, MD, MPH; Jarrod Mosier, MD; & John Sakles, MD
Creating better healthcare by challenging the call to collect more
data in the field
By John Pringle & Loralee Olejnik
Therapeutic hypothermia for out-of-hospital cardiac arrest
patients produces promising results
By Francis Kim, MD; Brent Myers, MD; & Michael K. Copass, MD
24 I CASE OF THE MONTH I ‘Not Acting Right’
By Dennis Edgerly, EMT-P
26 I RESEARCH REVIEW I What Current Studies Mean to EMS
By David Page, MS, NREMT-P
62 I HANDS ON I Product Reviews from Street Crews
By Dominic Silvestro, EMT-P, EMS-I
64 I LIGHTER SIDE I Can EMS Still Party?
By Steve Berry
70 I EMPLOYMENT & CLASSIFIED ADS
71 I AD INDEX
72 I LAST WORD I The Ups & Downs of EMS
About the Cover for out-of-hospital cardiac arrest patients produces promIn “Keeping it Cool: Therapeutic hypothermia
ising results,” pp. 54–61, Francis Kim, MD, Brent Myers, MD and Michael K. Copass, MD, discuss a case in
which providers from the Wake County (N.C.) EMS system deliver cooled saline to a patient after return of
spontaneous circulation. Wake County utilizes EMS to rendezvous with crews to deliver cooled saline via a
thermostatically controlled cooler. A patient suffering from cardiac arrest who requires treatment with therapeutic hypothermia cooling methods will be among those featured in the 2013 JEMS Games Clinical Skills
competition at EMS Today in March. This clinical education feature, sponsored by Laerdal Medical Corp. and
the Eagles Coalition, is the ﬁnal of three that participating teams will need to study to plan and prepare for
the challenging competition . PHOTO JULIE MACIE
PREMIER MEDIA PARTNER OF THE IAFC, THE IAFC EMS SECTION & FIRE-RESCUE MED
LOAD & GO
LOG IN FOR EXCLUSIVE CONTENT
A BETTER WAY TO LEARN
TOP 2012 LISTS
As we enter a new year, we thought it would
be fun to create lists of the most popular, most
uplifting and most bizarre news articles of 2012.
We had a blast reminding ourselves of the
stories that made our Facebook page, Twitter
feed and e-newsletters unique. And we think
you will, too.
SHOW US YOUR SKILLS!
PHOTO GLEN ELLMAN
This is your last chance to register for the 2013
JEMS Games—an international clinical skills competition that takes place at the EMS Today Conference & Exposition March 5–9 in Washington,
D.C. The first-place team will receive free conference registration for the following year (as well
as bragging rights for eternity). We’ll give you a
hint: Be sure to read the clinical education article
on pp. 54–61, as well as the ones in October and
November, because components of those articles will be used for the JEMS Games final scenario on March 8.
JEMS.com offers you
original content, jobs,
products and resources.
But we’re much more
than that; we keep
you in touch with
> Facebook fan page;
> JEMS Connect site;
> Twitter account;
> LinkedIn profile;
> Product Connect site; and
> Fire EMS Blogs site.
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EMS NEWS ALERTS
NEW YEAR’S RESOLUTIONS
Match your EMS resolution.
If you’re like most readers,
you look for the Case of the
Month in every issue of JEMS
and want to be able to refer to
them later. Now you can get
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CHECK IT OUT
EDITOR-IN-CHIEF I A.J. Heightman, MPA, EMT-P I email@example.com
MANAGING EDITOR I Jennifer Berry I firstname.lastname@example.org
ASSOCIATE EDITOR I Allison Moen I email@example.com
ASSOCIATE EDITOR I Ryan Kelley I firstname.lastname@example.org
ASSISTANT EDITOR I Kindra Sclar I email@example.com
ONLINE NEWS/BLOG MANAGER I Bill Carey I firstname.lastname@example.org
MEDICAL EDITOR I Edward T. Dickinson, MD, NREMT-P, FACEP
Travis Kusman, MPH, NREMT-P; Fred W. Wurster III, NREMT-P, AAS
CONTRIBUTING EDITOR I Bryan Bledsoe, DO, FACEP, FAAEM
ART DIRECTOR I Liliana Estep I email@example.com
Steve Berry, NREMT-P; Paul Combs, NREMT-B
Vu Banh, Glen Ellman, Craig Jackson, Kevin Link, Courtney McCain, Tom Page, Rick Roach,
Steve Silverman, Michael Strauss, Chris Swabb
DIRECTOR OF ePRODUCTS/PRODUCTION I Tim Francis I firstname.lastname@example.org
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eMEDIA STRATEGY I 410/872-9303 I
MANAGING DIRECTOR I Dave J. Iannone I email@example.com
DIRECTOR OF eMEDIA SALES I Paul Andrews I firstname.lastname@example.org
DIRECTOR OF eMEDIA CONTENT I Chris Hebert I email@example.com
SUBSCRIPTION DEPARTMENT I 888/456-5367 I
DIRECTOR, AUDIENCE DEVELOPMENT & SALES SUPPORT I Mike Shear I firstname.lastname@example.org
AUDIENCE DEVELOPMENT COORDINATOR I Marisa Collier I email@example.com
MARKETING DIRECTOR I Debbie Murray I firstname.lastname@example.org
MARKETING & CONFERENCE PROGRAM COORDINATOR I
Vanessa Horne I email@example.com
CHAIRMAN I Frank T. Lauinger
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CHIEF FINANCIAL OFFICER I Mark C. Wilmoth
SENIOR VICE PRESIDENT & GROUP PUBLISHER I Lyle Hoyt I firstname.lastname@example.org
VICE PRESIDENT/PUBLISHER I Jeff Berend I email@example.com
EXECUTIVE DIRECTOR I Jeff Berend
CONFERENCE DIRECTOR I Debbie Murray
EDUCATION DIRECTOR I A.J. Heightman
EVENT OPERATIONS MANAGER I Amanda Wilson
EXHIBIT SERVICES MANAGER I Raymond Ackermann
EXHIBIT SALES REPRESENTATIVE I Sue Ellen Rhine I 918/831-9786 I firstname.lastname@example.org
FOUNDING EDITOR I Keith Griffiths
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Duluth, MN 55802
WILLIAM K. ATKINSON II, PHD, MPH, MPA,
President & Chief Executive Officer,
WakeMed Health & Hospitals
JAMES J. AUGUSTINE, MD, FACEP
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 (Fla.) Fire-Rescue
Adjunct Professor of Anatomy & Physiology,
J. ROBERT (ROB) BROWN JR., EFO
Fire Chief, Stafford County (Va.) Fire & Rescue Department
Executive Board, EMS Section,
International Association of Fire Chiefs
CAROL A. CUNNINGHAM, MD, FACEP, FAAEM
State Medical Director,
Ohio Department of Public Safety, Division of EMS
THOM DICK, EMT-P
Quality Care Coordinator,
Platte Valley (Colo.) Ambulance
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
University of Texas Southwestern School of Medicine
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)
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
President, RedFlash Group
Founding Editor, JEMS
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
EDWARD M. RACHT, MD
Chief Medical Officer, American Medical Response
JEFFREY P. SALOMONE, MD, FACS, NREMT-P
Trauma Medical Director, Maricopa Medical Center
Professor of Surgery,
University of Arizona College of Medicine—Phoenix
KATHLEEN S. SCHRANK, MD
Professor of Medicine & 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
MIKE MCEVOY, PHD, REMT-P, RN, CCRN
International Director, IAFC EMS Section
EMS Coordinator, Saratoga County, N.Y.
Fire Chief & Emergency Manager,
EMS Editor, Fire Engineering Magazine
Kittitas Valley (Wash.) Fire & Rescue
Resuscitation Committee Chair, Albany (N.Y.) Medical College
COREY M. SLOVIS, MD, FACP, FACEP, FAAEM
MARK MEREDITH, MD
Professor & Chair, Emergency Medicine,
Assistant Professor, Emergency Medicine and Pediatrics,
Vanderbilt University Medical Center
Vanderbilt Medical Center
Professor, Medicine, Vanderbilt University Medical Center
Assistant EMS Medical Director for Pediatric Care,
Medical Director, Metro Nashville Fire Department
Nashville Fire Department
Medical Director, Nashville International Airport
GEOFFREY T. MILLER, EMT-P
Director of Simulation Eastern Virginia Medical School,
Office of Professional Development
BRENT MYERS, MD, MPH, FACEP
Medical Director, Wake County EMS System
Emergency Physician, Wake Emergency Physicians PA
Medical Director, WakeMed Health & Hospitals
Emergency Services Institute
MARY M. NEWMAN
President, Sudden Cardiac Arrest Foundation
JOSEPH P. ORNATO, MD, FACP, FACC, FACEP
Professor & Chairman, Department of Emergency Medicine,
Virginia Commonwealth University Medical Center
Operational Medical Director,
Richmond Ambulance Authority
JERRY OVERTON, MPA
Chair, International Academies of Emergency Dispatch
DAVID PAGE, MS, NREMT-P
Paramedic Instructor, Inver Hills (Minn.) Community College
Paramedic, Allina Medical Transportation
Member of the Board of Advisors,
Prehospital Care Research Forum
PAUL E. PEPE, MD, MPH, MACP, FACEP, FCCM
Professor, Surgery, University of Texas
GREGORY R. FRAILEY, DO, FACOEP, EMT-P
Southwestern Medical Center
Medical Director, Prehospital Services, Susquehanna Health Head, Emergency Services, Parkland Health & Hospital System
Tactical Physician, Williamsport (Pa.) Bureau of
Head, EMS Medical Direction Team,
Police Special Response Team
Dallas Area Biotel (EMS) System
DAVID E. PERSSE, MD, FACEP
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
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 (Calif.) Fire Department
JONATHAN D. WASHKO, BS-EMSA, NREMT-P,
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
DOUGLAS M. WOLFBERG, ESQ.
Attorney, Page, Wolfberg & Wirth LLC
WAYNE M. ZYGOWICZ, BA, EFO, EMT-P
EMS Division Chief, Littleton (Colo.) Fire Rescue
EMS IN ACTION
SCENE OF THE MONTH
>> PHOTOS BRADLEY WILSON
FEELING THE HEAT
MS providers from an American Medical Response (AMR) crew in
Wichita Falls, Texas, arrive at medical tents to transport a patient
who complained of abdominal pain and difficulty breathing after he
fell near mile 26 of the “Hotter ‘N Hell Hundred” bike race, a day-long
100-mile ride. The patient was assessed by a team of paramedics, EMTs
and physicians and transported to the United Regional Health Care System in Wichita Falls. The goal of the medical staff who work the race is
to eliminate the need for hospital care, according to executive director Ben “Chip” Filer. “One of our primary goals is to ensure that everyone
who comes to the race goes home vertical,” he says. But just in case, the
AMR ambulances as well as the Wichita Falls Air Evac Lifeteam are standing by all day. The nearly 1,000 medical volunteers saw some 900 patients
at 15 stops along the route during the 96o F day. Of those patients, only 14
required transport to emergency departments.
FROM THE EDITOR
PUTTING ISSUES INTO PERSPECTIVE
>> BY A.J. HEIGHTMAN, MPA, EMT-P
Forces beyond your control are destined to affect your agency
anuary is the time of year when people make resolutions, try to forget the
problems (personal and financial) they
encountered throughout the previous
year and dive into the New Year with
hope of success, or at least improvements.
Unfortunately, January is also the start of
a new budget year, and the “resolutions”
made by agencies at the start of the year
are often made too late to make an effect
on the changes or improvements that are
needed to have an effect during that year.
Think about it; couples plan their wedding for 12–18 months before the wedding
date, and manufacturers plan and design
new products secretly for years before they
are manufactured and launched. But many
response systems wait until a point when
it’s too late to redesign their administrative
and operational systems to meet budget
goals or participate in new approaches to
Moving from a non-transport first
response system into a system of full-service fire first response and transport is
an example of a project that a fire agency
needs to plan well in advance of introduc-
Many response systems
wait until a point when
it’s too late to redesign
their administrative &
to meet budget goals
or participate in new
approaches to service
tion of a proposal to a mayor and city
council for it to be successful. Then, even
if approved, it can take an agency a year
to get the appropriate ambulances built.
So design and bid specs also have to be
preplanned and approved months before
an order is made. Yet some agencies actually think they can make a major change,
such as movefrom non-transport to full
transport, in a few months.
In the next 12–18 months, you will see
lots of action by agencies that have been
thinking ahead by planning for changes
in EMS reimbursement. These changes
include the new world of healthcare reform
with pay-for-performance; new delivery
models and methodologies, such as the
redirection or transport of patients to nontraditional (non-hospital) destinations;
and use of community practice paramedics
to reduce call load and keep patients from
returning prematurely to hospitals in their
Those agencies that are preplanning will
reap the benefits and those that are not will
begin to realize they’re spinning their fiscal
wheels in the mud.
Those agencies that are
preplanning will reap
the benefits & those that
are not will begin to realize they’re spinning their
fiscal wheels in the mud.
So let’s circle back to January. This first
month of the year is when most agencies
begin to implement their new budgets,
business plans and projects in hopes of
greater success, financial prosperity and
territory fortification. Territory fortification is the ability to maintain contracts
and service area in the face of political or
economic changes and challenges.
Although private, non-profit and hospital-based agencies are familiar with the
development of business plans, service
contracts and territory fortification, many
fire and third service EMS agencies are not.
Although private, nonprofit and hospital-based
agencies are familiar
with the development of
business plans, service
contracts & territory
fortification, many fire
& third service EMS
agencies are not.
What’s the reason some are more familiar and others are not? There’s been little need for municipal services to do so
because they’ve offered what are termed
“traditional services.” Traditional services
include crews waiting in fixed stations for
calls to come in, responding and going
back to quarters to wait for the next run.
Agencies and workforces that fit in
this category have also traditionally participated in standard budget development,
had limited need for contracts or new
business outside their normal operational
parameters and had a reasonably certain
hold on their service area (territory).
However, the economic downturn,
municipal shortfalls in tax revenue and
reduced or eliminated federal grants and
financially supported programs during
the past five years are changing all that.
Municipalities are cutting back staff and
services in hopes of stopping fiscal bleeding: cutting out EMS supervisors, training
and quality assurance staff, holding off on
implementing new projects and forcing
their departments to “do without” rather
than innovate and implement replacement
programs and services.
The resultant cutbacks will have a snowball effect on the quality and quantity of
service and, ultimately, affect the revenue
a service has come to expect from third-
party payers. In the future, if your system
becomes less efficient and the quality of
the patient care and follow-up diminishes,
so too will the reimbursement your system
If your system becomes
less efficient & the quality of the patient care &
so too will the reimbursement your system
receives for the ‘services’
receives for the “services” delivered.
Many agencies, particularly those operating in a traditional municipal environment, also aren’t paying close attention
to the affect of the Patient Protection and
Affordable Care Act (PPACA). They are
ignoring the inevitable—that the waves
of what some politely refer to as “Obama
Care,” and the now famous “fiscal cliff,”
could potentially overtake and suffocate
Many agencies are
ignoring the inevitable—
that the waves of what
some politely refer to as
‘Obama Care,’ & the now
famous ‘fiscal cliff,’ could
& suffocate them
operationally & fiscally.
them operationally and fiscally.
Although I’m not an economist and
don’t claim to be an expert on the PPACA,
my position and access to EMS systems
and industry experts compel me to give
you a few things to think about. The Patient
Protection and Affordable Care Act will
affect the way you operate in the future.
And if you’re not thinking, planning and
preparing for the future, you will be affected,
perhaps negatively, in the future.
It’s important to note that there’s a difference between strategic planning and
innovating. Innovation can occur throughout your normal operational and budget
year. But strategic planning needs to be
performed in advance of target projects
and usually phased in over time.
Strategic planning also involves careful
review by key stakeholders and managers and, to be truly successful, cannot be
just the ideas of the director. Top-down
planning, often referred to as “management in a bubble,” is dangerous because it
often reflects just the ideas of one or two
managers or chiefs. In many cases, these
managers have been “off the streets” for
years—often just driving a desk. These
types of managers can be out of touch with
the real, evolving world of EMS and not in
synch with what’s projected for the future.
A few examples of how many systems
have fallen behind the pack over the past
five years include electronic patient care
report and computer-aided design integration; robust data collection and system
reports; patient compartment re-design;
continuous positive airway pressure use
by EMTs; and the adoption of therapeutic
hypothermia. It’s funny, but the root cause
of an EMS systems decline is often one toplevel manager or medical director who isn’t
keeping up with the times or is resistant to
implement changes or enhancements.
If your agency doesn’t have a strategic
plan for the future, you need to start the
development of one now for implementation in late 2013 and beyond. And if you
don’t believe in strategic planning or preparing for future changes in the delivery
of health care services in America, I can
assure you that other EMS agencies or
organizations are doing so and will benefit
from your inactivity.
I am not calling those agencies “competitors” because, to have a competitor,
you have to be prepared to compete. The
athlete who fails to prepare for and train in
any sport usually ends up in second place
or worse. In EMS, it’s important for you
to realize that anything below first place
makes you the de-facto loser.
Let me get more specific. The 1,000plus pages of the Patient Protection and
Affordable Care Act do not specifically reference or name EMS, emergency responders, fire first responders, rescue services,
mass casualty response, disaster preparedness or hospital surge. That, in itself is a
bad sign because the authors of the legislation appear to have forgotten us or at least
not viewed emergency and out-of-hospital
response resources as a high priority in the
However, rest assured, we are (or can be)
a big part of the future healthcare delivery
system if you read between the lines, plan
for integration and adjust your operations
and workforce to ride the healthcare wave
instead of being pushed aside or drowned
Incentives, and disincentives, that will
result from the new healthcare regulations will hit hospitals where they feel
it the most—in their budget. If a patient
returns to their hospital within 30 days
after discharge, the hospital will be penalized financially. So they now have a financial incentive to work with you or another
agency to deploy community practice
paramedics to check on Aunt Mabel in
her home or have an automated system
The Patient Protection &
Affordable Care Act will
affect the way you operate in the future.
that alerts one whenever there are abnormalities in vital signs of the programmed
device “predicts” that an untoward effect is
on the horizon.
The same type of penalties will be
incurred by hospitals if they don’t have
a 360-degree data exchange and review
system in place with all of their “affiliated partners.” Although satellite facilities, affiliate doctor groups and other heal
centers are named in Patient Protection
and Affordable Care Act and EMS is not,
people in the know tell me that EMS will
be considered an affiliated member of each
hospitals care network.
So I and others think secure linkage to
a hospital’s patient record system is probably in your future. And if you can’t afford
to do it, I’m betting that hospitals will eventually become convinced that it’s cheaper
to pay to have you linked than to receive
reduced reimbursements for not having
you linked to their system.
Best wishes for a safe, happy and wellplanned New Year!
CHALLENGES TO ‘EATING HEALTHY’
This month, JEMS readers and
Facebook fans chime in with
additional suggestions and feedback on a December JEMS article
by nutrition columnist Elizabeth
Smith, MS, RD, LDN, EMT-B, “Eating Healthy on an EMS Budget: 8 tips to stretch your budget, not your
waistline.” Also, our Facebook fans respond to news posts about the tragic
school shooting at Sandy Hook Elementary School in Newtown, Conn., on
Dec. 14, 2012. We were touched by their words of love and support for the
Newtown Volunteer Ambulance Service, Newtown Fire and Rescue, and
the community’s other first responders. We echo their thoughts and sentiments to all who have been touched by this terrible tragedy.
I’m fortunate to have a vacuum sealer. Sunday is a
big cooking day in my house. I make stuff that could
be, but doesn’t necessarily need to be, reheated.
I’ve been around for quite a few decades and still
cannot figure out what a “serving size” is. We deal
with things like ounces, grams, etc. When is someone going to put things in terms we use?
Author Elizabeth Smith, MS, RD, LDN, EMT-B,
responds: You’re right, Derek; serving sizes are often
labeled in ounces and grams, and it is much easier
if you can think of servings in terms of everyday
things. Here are a few for reference:
>> One serving of fruit or vegetables is the size
of your fist.
>> One serving of pasta is the size of an ice
>> Three ounces of meat, fish or poultry is the size
of a deck of cards.
>> One serving size of potato is the size of a
>> An appropriately sized bagel is the size of a
>> One serving of cheese is the size of a pair
There are a lot of great visual aids along these
lines available online as well.
Sounds great in theory, but the bottom line is that
in busy systems it does not work. With turnaround
times less than 10 minutes at the hospital, being
scheduled for 12 hours but working 16 hours and it’s
against Occupational Safety and Health Administration (OSHA) regulations to eat in an ambulance
or even store food in an ambulance, you cannot
prepare your meals for the week. What you are
describing may be the norm in your area but in most
services good luck with being able to do this on a
daily basis. Your intentions are good but the real
factor is that you need time to stop and eat and that
just does not happen.
Author Elizabeth Smith, MS, RD, LDN, EMT-B,
responds: I believe the OSHA regulation you are
referring to is the prohibition of eating and drinking
in the workplace, part of 29 CFR 1910.1030, Occupational Exposure to Bloodborne Pathogens. This regulation has been interpreted in the OSHA Bloodborne
Pathogens Exposure Control Plan for ambulance
companies specifically to define the patient area as
th workplace and the cab section of the ambulance
as permissible for food and drink, provided that the
company has a policy in place for employees to
cl contaminated clothing. So you are allowed to
ca food and eat in the truck, just keep it in the
fr and away from the patients.
TRAGEDY IN NEWTOWN, CONN.
We in EMS who responded will be forever changed
for what we could not do at the scene. There was
nobody to transport, and that was devastating.
Nothing breaks an EMT’s heart more than not being
able to do anything but move the dead. May we find
strength in each other and in our profession. God
bless, from a Newtown resident and AEMT.
I was there at the [Newtown] High School gym
[working with American Red Cross Disaster Mental Health], where I got to talk with the EMS folks.
We don’t have words to express the deep loss
I’ve been in EMS nearing 23 years; I don’t think I’d
be able to work another day for a while after all
that happened there. After all the years, it is the
young’uns that still haunt my dreams and thoughts …
AP PHOTO/NEWTOWN BEE, SHANNON HICKS
IN YOUR WORDS
Paramedics push stretchers toward Sandy Hook Elementary School in Newtown, Conn., where a gunman opened fire, killing 26 people, including 20 children, on Dec. 14, 2012.
As I began my shift today, I was shocked at the tragic
news of this senseless act. I feel sad for those struck
by this devastating situation. Through the sadness
comes pride in my fellow EMS/fire/law enforcement brothers and sisters that ran toward this scene
today. Stay safe and continue with courage and
strength. Hug your family a little tighter when you
get off duty.
In the time to come, may strength, compassion, selflessness and service guide your way. And when it is
your turn to take care of each other and yourselves,
may you have the healing that you need.
This is what makes me so passionate about my job
in the EMS field. All of us have to endure so many
scenes like this. We have to put our feelings aside at
that moment to help the people in need. I take my
hat off to all EMS medics and salute you for what
you do for patients. Thank you to all you guys what
you do for your fellow man. I’m so proud of you
even though I don’t know you. It’s a cruel world out
there. Good luck to all of you.
FEATURED BLOG: A
Day in the Life of an Ambulance Driver
BLOG POST EXCERPT:
‘FOR NEWTOWN VOLUNTEER AMBULANCE CORPS’
And then there are days like Friday, when nothing can prepare you for the horror you faced, and no amount of code
saves, or babies birthed, or little old ladies comforted, no
amount of joy your career as an EMT has brought you
before or since, can erase the scar it leaves on your soul.
You only triaged three from Sandy Hook Elementary School as red. All the rest
were blacks. Only one you transported lived beyond the emergency department. And given that you’re a small volunteer department, odds are you knew
many of the children killed.
People who do not work in EMS do not understand triage. Sure, they may
grasp the concept of it; sickest transported first, stable patients transported
next to last, dead patients transported last of all. They may even know what the
colors red, yellow, black and green signify.
Wow ... thank you for your gift of words, so beautifully written! Heather M. Via Facebook
A very touching look at a day in the life of volunteer EMTs. A sad day indeed for all of us that answer the
call. The crews from Crook County, Wyo., send our deepest sympathies to the families and our thanks to all
the first responders. Sheila H. Via Facebook
For more on the Sandy Hook
Elementary School massacre, please see
JEMS Editor-in-Chief A.J. Heightman’s
note on page 18 of this issue.
MCI MANAGEMENT TIPS
I am assembling some of the items you mentioned in
your great article on MCI planning in the November
issue of JEMS (“Incident Management: 10 tips to help
gear up for MCIs” by A.J. Heightman, MPA, EMT-P).
Do you have any checklists you have used in the past
to assist me in large event planning? Thank you for
the insight on this very important topic.
Daytona Beach, Fla.
Editor’s Note: Thank you, Troy, for the kind words.
We recommend reading the article “MCI Magnifiers: Many factors can complicate an incident of
any size” by Editor-in-Chief A.J. Heightman which
appeared in the September issue of JEMS. This
article, and many more resources for management of major incidents, can be found online at
Choose 19 at www.jems.com/rs
NEWS YOU CAN
Bringing issues to THE HILL
Fourth annual EMS on the Hill Day to be held prior to EMS Today
egistration has begun for the fourth
annual EMS on the Hill Day, hosted by the National Association of
Emergency Medical Technicians (NAEMT).
The 2013 event takes place on March 5–6,
2012, in Washington, D.C. In order for
appointments to be scheduled with congressional leaders, participants must register by February 15, 2013.
EMS on the Hill Day is the nation’s only
national EMS advocacy event, providing
professionals from all sectors of the emergency medical community the opportunity to advocate for specific EMS legislation. According to NAEMT Executive
Director Pamela Lane, EMS on the Hill
Day sends a consistent message to elected
leaders regarding critical issues facing EMS
throughout the nation and builds important relationships with Senate and House
leaders and their staff.
Meeting with Congressional leaders
also has a direct effect on individual EMS
agencies and practitioners. “The more [legislators] in Washington understand the
challenges to providing quality EMS, the
greater the possibility that they will craft
policies that address those challenges,”
This past year, nearly 200 EMS practitioners from 42 states and the District
of Columbia attended 246 meetings with
U.S. Senators, House representatives, and
their congressional staff to advocate for
This year, EMS on the Hill Day will
be held just prior to EMS Today, the
annual JEMS conference and exhibition
that is scheduled for March 5–9, also
in Washington D.C. The schedule for
the 2013 EMS on the Hill Day includes
March 5: Participants will meet with
other participants and attend a preHill visit briefing, followed by a reception.
March 6: Participants will attend scheduled appointments with their Senate and
House leaders and their staff, followed by
an evening reception. Register online at
—Teresa McCallion, EMT-B
From our Facebook Audience
We asked our Facebook fans what issues
they would bring to Washington if they
had the opportunity. Here’s what they said:
Brent D.: Pay, benefits and provider health
Justin S.: Educational standards, evidencebased medicine, community paramedicine.
David C.: Hooray for healthcare reform. I
myself have a full-time job, but most of my coworkers work two or three part-time jobs. This
will finally give EMS providers an actual affordable
option to insure themselves instead of praying they
don’t get sick.
Skip K.: The need to include basic civics and
constitutional law in EMT class, so that folks in EMS
have some idea of the responsibilities of the federal
government versus the things that are reserved to
Jason B.: Make EMS a profession with licensure
not just certification.
Skip K.: Also have to get people to do research.
A piece of paper from the government that lets
you practice a job or profession is a license, even
if they call it something else. Check out the legal
opinion on the subject on the NREMT’s website:
J Mac Q.: Declining Medicare reimbursements.
Garrett H.: All of the above are good things,
most necessitating money and organization. We
can take care of some of that with current draft
legislation like the EMS field bill. Money will
involve the need to have alternate payments other
than being a taxi.
Check out the most interesting, bizarre and unusual cases at jems.com/case-of-the-month
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in the feld, JEMS provides
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products and EMS trends.
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It’s free to subscribe …
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of EMS Products: www.JEMS.com
>> CONTINUED FROM PAGE 16
THOUGHTS ON THE SANDY HOOK MASSACRE
A NOTE FROM JEMS EDITOR-IN-CHIEF A.J. HEIGHTMAN, MPA, EMT-P
The shooting and killing of 26 innocent children and staff at Sandy Hook
Elementary School in the peaceful, beautiful town of Newtown, Conn., 45 miles
southwest of Hartford and 60 miles northeast of New York City, causes us all to
take pause and wonder how such a tragedy can happen.
Those of us in the emergency community think of the responders—the tragic
and grisly scene they were forced to endure—and we feel the desire to reach out,
pat them on the back and let them know our thoughts and prayers are with them.
It appears that the shooter was shooting randomly and had a purposeful
attack plan. Many are trying to make sense of this tragedy and wonder what
they would do if an attack of this nature took place in their community.
This type of attack has occurred before and will be replicated again. School
shootings have become commonplace for myriad reasons: Revenge on bullying,
retribution on teachers and administrators, and by individuals who are out to
make a strong statement.
But what few people know is that terrorism and mass casualty experts have
predicted this type of mass killing spree (and scores larger) for years—and for
a reason we all dread hearing—that terror organizations have been espousing
that, if you want to make a statement and bring a country to its knees, kill
In my MCI classes, I discuss the little-known incident that occurred in
Beslan School Number One (SNO) in the town of Beslan, North Ossetia (an
autonomous republic in the North Caucasus region of the Russian Federation)
on Sept. 1, 2004. It was a premeditated terrorist assault planned for the first
day of school, when it was customary for parents, siblings and grandparents
to accompany their school-aged children back to school for the start of the
new school year.
The terrorists were deployed by a Chechen separatist warlord who
demanded recognition of the independence of Chechnya at the U.N. and
Russian withdrawal from Chechnya.
To make a strong statement, the assault was targeted for a vulnerable and
easy target—an elementary school where the students and faculty aren’t physically able to repel an attack.
The terrorists easily entered an open access, unsecured school that they had
scouted and took 1,100 people (including 777 children) hostage. They used the
strongest male hostages to fortify the school and then killed them to eliminate
them as future threats. They herded the youngest children into the school’s
gymnasium and chained several to basketball hoop assemblies rigged with
explosives that would detonate if any of them tried to escape.
Townspeople soon learned of the terrorists’ takeover of the school, alerted
the authorities and began to shoot at the school in an attempt to mitigate the
incident. This created a vicious crossfire that impeded rescue operations. The
hostage situation lasted more than three days and ended tragically when, during
an assault by Russian security forces, one of the booby-trapped children detonated the explosives and 334 hostages, of which 186 were children, were killed.
The tragedy in Newtown, Conn., at an elementary school occupied by 700
children, should cause all responding agencies to take the time to obtain a
copy of John Giduck’s book, Terror at Beslan, read it carefully and work with
their school systems to improve school security, practice active shooter and
MCI scenarios and be properly prepared if such an event happens in their
community, particularly one involving places where a high volume of children
PERSONAL USE OF COMPANY EQUIPMENT
here does the line get drawn with regard to the personal use of company equipment and supplies? A certain amount of personal use of an
employer’s “stuff” seems to be common and accepted practice these days.
For instance, the use of a workplace computer to check sports scores or order
from an online merchant is a regular occurrence in American workplaces. But
what about some of the relatively expensive equipment found in the EMS
workplace? For instance, what are the rules when it comes to using one of
your employer’s ambulances to stop at the store for a few personal items, or
to swing by your child’s soccer game?
The first rule is that there are no hard and fast rules—those are set by each
employer. No state laws of which we are aware would regulate what can and
cannot be done with an ambulance or other EMS equipment when it’s not
engaged in active EMS operations.
There may be laws, regulations or policies that require on-duty ambulances
to remain in a specified coverage zone or operating area. Certainly there could
be consequences for violating these requirements. Otherwise, so long as the
agency is not violating any rules regarding vehicle deployment, this would not
pose a legal barrier to occasional personal use of a company vehicle.
Where the bigger issue comes into play, however, is whether the employee
is violating the employer’s policies with regard to the personal use of company equipment. If an employer permits employees to use ambulances or
other company vehicles for occasional, minor personal errands, then that is
up to the employer. On the other hand, if the employer has a “zero tolerance”
policy, prohibiting the use of company vehicles for any personal use, then
the employer would likely be within its rights to discipline or terminate an
employee for such conduct.
If the workplace is unionized, discipline
for violating any such rules would have to
be resolved with reference to the collective
bargaining agreement in place between the
union and the employer.
Extra caution should be taken when the
vehicles, equipment or other supplies belong to a nonprofit, tax-exempt organization. State and federal laws generally prohibit “private inurement”—that
is—using tax-exempt assets to benefit specific individuals.
Although an occasional trip to the store would likely not catch the attention of the IRS, regular use of nonprofit assets for private benefit could very
well become an issue that could even jeopardize the tax-exempt status of an
Although occasional use of an ambulance or other vehicle is one thing,
the “pilfering” of supplies for personal use is another issue altogether. Taking
one band-aid out of the jump kit is commonplace, and probably would be
OK with most employers, but helping yourself to supplies needed to stock
your personal jump kit would be something else entirely. Again, the rules are
ultimately up to the employer, but few employers would tolerate the theft of
company supplies in this fashion.
The bottom line is that employers should take the time to write clear and
workable policies on this issue—and then employees would be well-served to
follow those policies. If no written policy is in place, but employers knowingly
permit or tolerate the use of vehicles or equipment, then that might create
a de facto policy permitting it. A clear written policy removes the guesswork
for both parties.
For more of the latest EMS news, go to jems.com/news
Pro Bono is written by
attorneys Doug Wolfberg
and Steve Wirth, founding
partners of Page, Wolfberg &
Wirth, a national EMS industry law firm. Visit the firm’s
Agency one of two in U.S. to receive triple accreditation
unstar Paramedics, the EMS transport provider for Pinellas County (Fla.), remains one of
two EMS providers in the U.S. to be accredited
by the following three respected industry organizations:
>> The Commission on Accreditation of Medical
Transport Systems (CAMTS),
>> The Commission on Accreditation of
Ambulance Services (CAAS), and
>> The Accredited Center of Excellence (ACE)
by the National/International Academies of
The only other two programs in the world
to hold all three accreditations are Regional
Emergency Medical Services Authority (REMSA)
in Reno, Nev., and Emergency Medical Care Inc.
in Nova Scotia.
The CAMTS, CAAS and ACE programs ensure
quality care and transportation service safety. To
become accredited, EMS programs are evaluated
on a range of criteria, from general operations
(such as safety procedures and equipment management), to staff wellness policies and public
education programs (such as free CPR classes and
child passenger safety assistance).
“These accreditations are important to us;
we’re pleased to hold them and to take part in
the processes,” said Mark Postma, COO with
Sunstar Paramedics, in a press release. “Along
with frequent awards and a 96% customer satisfaction rate, our people take great pride in our
work, and we appreciate being told we’re doing
a good job.”
The accreditation processes take at least four
months, and each accreditation lasts three years.
In Florida, there are 17 organizations accredited
by ACE, nine with CAAS, and five with CAMTS.
Sunstar employs 500-plus local residents and
responds to approximately 500 calls a day.
CAFFEINE: THE GOOD & BAD
WHAT EMS PROVIDERS NEED TO KNOW
with beta effects from
stimulating epinephrine release. As some of
us know too well, too
much coffee can cause
palpitations, tremors and even
sweating. Other relatively benign side effects
of increased amounts
of caffeine include nausea, vomiting and
anxiety. Serious and potential fatal effects of
caffeine include ventricular arrhythmia, seizures, altered mental status, excited delirium,
status seizures, hypertensive emergencies
and stroke syndromes because of intercerebral hemorrhage.
The treatment of potential caffeine overdoses focuses on securing the patient’s airway, breathing and
circulation via IV
fluids and temperature control, calming the patients
with a benzodiazepine like valium
or Versed, using
an antiemetic for
nausea or vomiting and using
severe hypertension not respond-
ing to benzodiazepineinduced relaxation. Beta
blockers are contraindicated because they allow
caffeine’s (like cocaine’s)
effects and risk of severe
In summary, caffeine ingestion is usually
benign, but it may have neurologic, cardiac
and gastrointestinal side effects. Caffeine
intoxication should be considered in previously healthy patients who deny cocaine and
amphetamine use but who appear hyperadrenergic. Acute caffeine intoxication can
mimic many conditions including mania,
excited delirium, cocaine intoxication and
thyroid storm. —Corey M. Slovis, MD
Choose 20 at www.jems.com/rs
PHOTO A.J. HEIGHTMAN
Caffeine is omnipresent. It’s found in
coffee, tea, most soft
prescription medications and energy
drinks. Brewed coffee usually averages
about 80–100 mg of
caffeine per 8 oz. cup,
and coffee drinks at
places like McDonald’s and Starbucks range
in caffeine from 50–200 mg. Some specialty
coffee drinks have as much as 330 mg in a
Similarly, great variability exists in
“energy” pills and drinks that can have as
little as 50 mgs to as much as 200 mgs in
just 2 oz. of liquid. Recently, some deaths
attributed to the ingestion of energy drinks
with high amounts of caffeine have gained
media attention. Caffeine can be toxic with
an estimated lethal dose in the range of 5–10
grams in normal subjects. Lower amounts
could potentially be toxic in patients with
pre-existing heart disease and those who are
taking other stimulants or intoxicants, especially if they were dehydrated.
Caffeine’s effects are almost always
benign; it usually increases alertness and
may mildly raise pulse and respirations due
to its alpha vaso-constricting effects along
PRESENTED BY THE IAFC EMS SECTION
>> BY GARY LUDWIG, MS, EMT-P
Discipline isn’t always the best action
PHOTO A.J. HEIGHTMAN
hen my kids were little, one of
our favorite things was to go to
Chuck E. Cheese’s, where they
could burn up some energy eating pizza,
playing arcade games and running around
on the playthings.
One of the arcade games was called
“Whack-a-Mole.” Out of five holes, a mole
pops up at random, and you “whack” it in the
head using a soft hammer to knock it back
down. If you don’t hit it fast or hard enough,
it disappears back down its hole. The more
you hit and the faster you hit them, the
higher your score.
This classic arcade game spurred a book
on a managerial style that I find is reminiscent of how some EMS organizations manage their employees. It seems some managers
think they’re playing Whack-a-Mole. They
discipline employees on a routine basis and
without regard for the circumstances, knocking the employees in the head as fast and as
hard as they can.
In these types of EMS organizations,
you’re disciplined any time a complaint is
received from a nurse, physician, citizen,
patient or bystander. It doesn’t matter who
complains, and the circumstances of the
complaint aren’t investigated. The bottom
line is that management feels the employee
must have done something wrong. Basically,
they only follow one fundamental principle:
“the customer is always right.”
The resulting morale and turnover in these
EMS organizations is deplorable. Nobody
goes out of their way to deliver exceptional
service. They instead go about their jobs in
pure fear of doing something wrong and
receiving a complaint.
I contend that employees do things wrong
for three reasons: They’re unaware, unable or
unwilling. Many EMS managers discipline
employees for all three reasons. Instead,
we should be looking at the circumstances
by which the infraction happened. If an
employee is unaware of a policy or procedure, this is an opportunity to mentor rather
Stop playing Whack-a-Mole with your employees.
the number of accidents. Why do we think
changing people through disciplinary action
is an effective solution to a problem, especially when changing the system will ensure
the problem will go away?
One management philosophy emerging
in the healthcare industry, which is supported by the National Association of Emergency Medical Technicians (NAEMT), is
“just culture.”1 In a just culture—a concept
invented by “Whack-a-Mole” author David
Marx—the goal is to look at an error and
classify the action into one of three categories: human error, at-risk behavior or reckless behavior. The need for and extent of any
punishment is based on this classification.
Once the error is assessed and classified,
the just culture concept suggests a course of
action. Managing human errors is done by
looking at processes, procedures, training
and design. People who make at-risk decisions are usually managed by coaching and
increasing situational awareness. It’s only
those employees who demonstrate reckless
behavior that just culture recommends that
Developing a just culture and taking this
new approach to managing mistakes in your
organization is a large-scale change. But the
Whack-a-Mole mentality certainly has demonstrated it doesn’t work and can actually
cause harm to an organization.
than discipline. Wouldn’t the employee
prefer to receive coaching rather than be
whacked in the head like a mole?
Sometimes the problem occurs because of
a systemic problem. For example, consider a
service that keeps disciplining employees for
hitting the door frame on either side when
they back an ambulance into the station. This
keeps happening over and over. An EMS
manager should question why an employee
would intentionally back an ambulance into
the door frame of an ambulance station.
They might come to the conclusion that the
mistake isn’t intentional and perhaps suggest
a policy where spotters have to be in place REFERENCES
1. National Association of EMTs. (July 19, 2012).
any time an ambulance backed into the staNAEMT Board Adopts New Position Statement
tion. I bet accidents involving ambulances
on ‘Just Culture’ System. In JEMS. Retrieved
backing into a door frame would drop draNov. 5, 2012, from www.jems.com/article/news/
matically. You could even go one step further
and add back-up cameras and an alarm system to further assist the drivers.
Gary Ludwig, MS, EMT-P, has 35 years of
In the above scenario, a systemic
EMS, fire and rescue experience. He currently
problem existed because the employserves as a deputy fire chief for the Memphis
ees were unable to do their job withFire Department. He’s also Chair of the EMS
out a tool they needed (a spotter or a
Section for the International Association of
camera and alarm system). A change
to the policy and procedure supported by Fire Chiefs. He can be reached through his website at
additional technology drastically reduced GaryLudwig.com.
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TRICKSOUR PATIENTS & OURSELVES
OF THE TRADE
>> BY THOM DICK, EMT-P
EMT poses a different loading strategy
his is a story about an EMS device
that arose from a situation no
ordinary person would appreciate. But as an EMS provider, trust me, you
will. When you read what happened, you’ll
understand its significance immediately. In
fact, you’ll want to stop reading and salute
the EMT who invented it.
Imagine you’re a volunteer at a small
rural EMS agency. You and your partner,
both munchkins, respond alone for a rollover motor vehicle collision. On arrival, you
encounter an inverted vehicle containing
two small children in the back seat and two
generously proportioned adults up front.
The front passenger weighs about 350 lbs.,
and the driver at least 500. Somehow, you’ll
have to extricate all four patients and get
them into one ambulance.
Let’s salute Doris Van Ness. Doris and
her partner did something rural EMTs do
every day, Life-Saver—something that transcends all of the spreadsheets, databases and
journal articles to which we devote so
They adapted to their situation and overcame. They enlisted the help of enough
passing motorists to stabilize, extricate,
carry and load all four patients into the
ambulance for transport.
People like Doris do what they do for free
because there simply are no other resources.
Sick people are getting heavier. And Doris’
agency, is struggling financially—as are
most small agencies. In the future, they
may or may not be able to come up with
even the 50% matching funds for a grant to
obtain a self-lifting cot and a loading system
that would at least help them during lifting
Self-lifting cots are wonderful tools, but
their extra weight is nothing to sneeze at.
Anyway, back to Doris. After the call, she
patented a completely different loading idea,
using something she did have: her vehicle’s
electrical system, a three-quarter-ton bumper winch, some extruded aluminum and a
The front passenger weighs about 350 lbs.,
& the driver at least 500. Somehow, you’ll
have to extricate all four patients & get
them into one ambulance.
EMT/inventor Doris Van Ness operates her
cot-loading device. Its forward end is attached
to a three-quarter-ton winch bolted to the supports beneath the deck of this demo ambulance.
basic understanding of physics.
Her design is nothing like the loading
systems you’ve seen so far. It certainly
doesn’t look strong enough to do
the job of loading a 500-lb. patient.
But Doris isn’t fooling around;
her lift is based on a parallel double boom, almost like you’d see
on a tow truck—only the boom is
hinged at the aft end of the deck in
an ambulance’s patient compartment. At
the forward end of the boom is a winch
attached to the frame under the vehicle’s
deck. When it lifts, it works kind of like a
The boom incorporates a pair of telescoping beams attached to channels intended
to integrate with the upper frame of any
ambulance cot. When engaged and fully
extended, the whole assembly is designed
to lift a combined patient-and-cot weight of
1,200 lbs. (It’s been tested at 1,800 lbs.)
Called the Bedrock Lift, Doris’ invention
can be installed initially in three hours.
It weighs 350 lbs., and it can be removed
or reinstalled in minutes. It can be pressurewashed, and it’s designed to lift any kind of
cot. Doris demo’ed her beta unit for us at the
fifth annual Colorado EMS Safety Summit
in Loveland, Colo., in early October. It
wasn’t fancy, and it was mounted in a small
second-hand ambulance she had purchased
just for demonstrations. But fancy or not,
it’s a horse.
The production model will come powder-coated. It’s designed to be mounted
without modifying an ambulance’s existing
frame. Doris said she plans to install her lifts
on-site and provide instructions in their use.
They say that necessity is the mother of all
invention. I’d like to congratulate Doris for
being the mother of this back-saving, practical invention.
For more information, contact
her at email@example.com.
Thom Dick has been involved in EMS
for 42 years, 23 of them as a full-time
EMT and paramedic in San Diego County.
He’s currently the quality care coordinator for Platte Valley Ambulance, a hospital-based
9-1-1 system in Brighton, Colo. Contact him at
POWERFUL SOLUTIONS FROM SMART THINKERS
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CASE OF THE MONTH
DILEMMAS IN DAY-TO-DAY CARE
>> BY DENNIS EDGERLY, EMT-P
‘NOT ACTING RIGHT’
Providers treat patient with hyponatremia due to a brain tumor
he patient’s wife called 9-1-1
because her husband was acting
drunk. When you arrive on scene, a
middle-aged woman meets you at the door
and tells you she’s concerned about her husband. She came home from a weekend business trip and found him “not acting right.”
You ask for clarification, and she tells you
he is confused and having difficulty walking. She doesn’t think he’s drunk because
he’s only had one beer, but says, “He is sure
After assuring the wife you will take care
of her husband, you and your partner walk
into the living room where he’s sitting.
You find a 46-year-old male sitting on the
couch. He looks at you and nods his head
when you say, “hello,” but doesn’t speak.
A quick physical exam reveals no signs
of trauma. He appears to be moving all
extremities but is unable to follow commands when you attempt to perform a Cincinnati Stroke Scale assessment.
You note no facial droop or drooping
of the eyelid, which is called ptosis. The
patient’s skin is pink, warm and dry, and his
pupils are equal and reactive at 4 mm. He
doesn’t appear to be in pain or respiratory
distress. His pulse is 72 and regular. Blood
pressure is 146/82 and respirations are 18
and uncompromised. A finger-stick blood
glucose level reads 106 mg/dL. There’s a
can of beer sitting next to him, but it’s
The patient’s wife tells you her husband seemed normal when she spoke with
him this past evening but he was tired
and going to bed early. She tells you he is
healthy and takes no medications on a regular basis. A little bewildered, you and your
partner place the patient on a stretcher and
into the ambulance.
During transport, you establish an IV
and begin a reassessment when the patient
develops a tonic-clonic seizure. The seizure
PHOTO JEFFREY MAYES
Hyponatremia is commonly found at endurance events where patients sweat excessively.
lasts about 45 seconds. The patient now
responds only to noxious stimuli with
moaning and withdrawal. You suction his
airway, apply oxygen and ask you partner
to step it up to an emergent transport.
As you transfer the patient, you ask the
emergency physician what she thinks is the
cause. She tells you she needs to wait for
When you follow up later, she tells you
the patient’s sodium level was 118 mEq/L.
The patient was hyponatremic because he
has a tumor on his posterior pituitary gland
that’s causing an increased production of
antidiuretic hormone (ADH), resulting in a
dilution of his sodium levels. This is called
syndrome of inappropriate anti-diuretic
hormone (SIADH), which has many underlying causes in addition to hyponatremia.
The brain tumor that caused hyponatremia
in this case may not be commonplace, but
hyponatremia is one of the most common
electrolyte imbalances seen in the field.1
Sodium is the primary extracellular
ion. Normal values are 135–145 mEq/dL.
Hyponatremia is defined as sodium levels
less than 135 mEq/dL, with levels less than
125 mEq/dL being considered severe.2
When sodium levels drop, there’s a change
in osmolarity that causes fluid to move into
cells. This causes cellular swelling, which
is most concerning in the brain and is the
cause of many of the symptoms. If hyponatremia develops slowly, the body may have
the ability to compensate, and patients may
be asymptomatic even with sodium levels as
low as 115 mEq/dL.1 However, patients with
acute hyponatremia can be critical.
Sodium concentration can be depleted
in a couple of ways. In hypovolemic hyponatremia, a body has lost too much sodium
in relation to water loss. This can occur with
excessive sweating as seen with endurance
sports like marathons, use of such diuretics as thiazide diuretics, and third spacing of
fluid, as is seen with burns.
The other way is to dilute the body’s
sodium concentration with too much
water. Dilution of sodium can occur with
excessive fluid intake or secondary to the
body’s ability to eliminate fluid, which is the
case with heart and renal failure. There have
also been cases of hyponatremia seen in
infants when their formula has been diluted
with water or the child has been fed tap
water.3 This is referred to as hypervolemic
In this case, the patient developed hyponatremia secondary to the body’s inability
to eliminate fluid because of the alteration in
ADH levels. Common signs and symptoms
of hyponatremia include lethargy, apathy,
confusion, disorientation and seizures.
Other non-specific symptoms include muscle cramps, nausea and weakness.4
Identification of hyponatremia in the prehospital setting may be difficult. A thorough history is a good start, and agencies
using bedside lab devices, such as i-STAT,
will be able to obtain a sodium value. However, treatment should be based on the
underlying cause, type of hyponatremia and
whether the onset was acute of chronic.
EMS providers should keep hyponatremia
in mind as a possible cause of patient’s
symptoms rather than attempting to fix the
patient’s electrolyte imbalance.
1. Vaidya C, Ho W, Freda BJ. Management of hyponatremia: Providing treatment and avoiding harm.
Cleve Clin J Med. 2010;77(10):715–726.
2. Simon EE. (March 6, 2012). Hyponatremia. In
Medscape. Retrieved Oct. 12, 2012, from
3. Keating JP, Schears GJ, Dodge PR. Oral water
intoxication in infants: An American epidemic.
Am J Dis Child. 1991;145(9):985–990.
4. Marx JM, Hockberger R, Walls R. Rosen’s emergency medicine concepts and clinical practice,
6th ed., vol. 2. Mosby: St. Louis, p. 1934, 2002.
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RESEARCH REVIEW EMS
WHAT CURRENT STUDIES MEAN TO
>> BY DAVID PAGE, MS, NREMT-P
Study rates global skill levels of students & medics
n the hierarchy of research, a case report
often serves only as an FYI or a good war
story. In the case of the below study, we’re
lucky the authors had research on administration of intranasal (IN) glucose published for
the first time in a peer-review journal. I recommend you read it more for the review of the
literature on IN medication administration than for any earth-shattering news
I did find it interesting, however, that
2 mg of IN glucagon was just as speedy at
raising blood sugar as 1 mg of intramuscular (IM) glucagon, according to a 1992
study by Rosenfalck published in Diabetes
Research and Clinical Practice, and that
few studies have successfully compared IV
dextrose to IM glucagon. With a single dose
of IN glucagon being around $1.50 vs. $8
for dextrose, I doubt we’ll see IN glucagon
replace IV dextrose as a first-line drug. But
this write-up gives us some ammunition
for medical directors to approve the IN glucagon route as well as intramuscular. I’ve
already fired off the e-mail to my medical
directors. Will you?
I PARAMEDIC COMPETENCE I
Tavares W, Boet S, Theriault R, et al. Global rating scale for the assessment of paramedic clinical
competence. Prehosp Emerg Care. 2012; Jul 26 [Epub
ahead of print.]
e seldom see educational research
in EMS, and even less frequently a
study dealing with clinical competency.
Kudos to this Canadian all-star group for
tackling such a difficult subject with such a
The group videotaped 81 performances
of 61 EMS students and 24 active para-
PHOTO DAVID PAGE
Researchers measured intranasal glucagon for
the first time in a peer-reviewed journal.
medics responding to a simulated scenario.
Two trained evaluators reviewed each video
using a prototype global rating scale (GRS).
The objective was to see if the GRS would
correctly identify a competent performance. The candidates were lone paramedics responding to a simulated unstable
cardiac patient in the back of a transfer
ambulance on the side of the road, which
deteriorates into cardiac arrest. The two
EMTs were allowed to assist the paramedic
being tested, and the scenario lasted nine
minutes. A high-fidelity manikin was used.
The rating scale included eight dimensions, or rubrics. These were distilled by
a national expert panel using a modified
Delphi process from 257 observable paramedic clinical behaviors. The final rubrics
were situation awareness, history gathering (i.e., interviewing), patient assessment
(i.e., physical exam), decision making
(i.e., differential diagnosis), resource use
(i.e., leadership and delegation of tasks),
communication and procedural skills.
I GLOSSARY I
Adjectival rating scale refers to a numeric appraisal (similar to a pain scale rating) based on
descriptions (adjectives) that best fit their assessment.
Finally, an overall clinical performance
score was assigned.
It’s particularly encouraging that these
dimensions match the recently released
National Registry paramedic psychomotor competency package evaluations.
Although the NREMT followed a different
methodology, the categories are identical,
giving these rubrics more validity.
Interestingly, the individual categories
didn’t seem to be as reliable as the overall rating. The authors note that raters
had difficulty differentiating between the
dimensions, and suggest that a “Gestalt”
categorical judgment or “halo effect” may
be at work. Still, they noted, the GRS accurately identified who should pass and who
should fail. Without a doubt, every EMS
educator should read this study and start
using these rubrics.
An adjectival rating scale from 1–7 similar
to a Likert scale was used, with 1 being
unsafe, then unsatisfactory, poor/weak,
marginal, competent, highly competent
and 7 being exceptional. Although these
authors didn’t comment on their 1–7 scale,
previous studies have shown poor results
using similar rating scales.
From the descriptive statistics in this
study it would appear the scale could be
simplified without affecting the accuracy
of the pass/fail ratings, similar to those
recently proposed by the NREMT.
Although it appears we’re getting closer
to having defensible tools to measure
clinical competency, the reproducibility of
these methods would be challenging, such
as what would be required for large programs or even state and national exams.
Not everyone has access to high-fidelity manikins, quality video recording,
archiving and raters with 22 and 11 years
of experience. Both were trained over
a 60-minute period and viewed all the
videos, presumably gaining quite a bit of
experience along the way.
I WATCH BOX I
I RATE MATTERS I
Idris A, Guffey D, Pepe P, et al. The ROC investigators. The interaction
of chest compression rates with the impedance threshold device and
association with survival following out-of-hospital cardiac arrest.
In the December 2011 Research Review column, I reviewed the
National Institutes of Health Resuscitation Outcomes Consortium
(ROC) study that evaluated the impedance threshold device (ITD) in
a large multi-center clinical trial called the PRIMED trial (published in
the New England Journal of Medicine in September 2011). It reported
no difference between use of an active ITD and a placebo (or sham)
ITD. This has always puzzled me because I have used an ITD for years
and have seen it work.
In November 2012, Ahamed Idris, MD, presented an abstract
at the American Heart Association (AHA) Resuscitation Science
Symposium (ReSS), reporting that chest compressions for patients
in the ROC database weren’t necessarily performed at the 100 per
minute rate recommended in the study protocol or by the AHA; in
fact, more than half of the more than 10,000 patients received chest
compression rates that were too slow (less than 90 per minute) or
too fast (greater than 110 per minute). The data showed that the
faster the chest compression rate, the worse the outcomes.
This is reminiscent of the findings of Thomas Aufderheide, MD,
that hyperventilation is deadly in cardiac arrest. The ROC study confirmed that for chest compression rates, like ventilation, more is not
better, and in fact, more can be harmful. Idris presented additional
ROC data that shed new light on my confusion about the ITD’s previously reported efficacy. He reported that there was a significant
interaction between chest compression rate and ITD efficacy. Their
adjusted model predicted greater survival to discharge when the
ITD was used at AHA-recommended compression rates of around
100 per minute, compared with conventional CPR without an active
ITD at similar rates. Clearly, CPR needs to be performed correctly in
order to fairly assess new technologies like the ITD.
Idris and colleagues are planning to follow up the paper
soon. If the paper mirrors the abstract, we will see the first randomized, controlled, double-blinded clinical trial to demonstrate
that the ITD improves survival to hospital discharge with favorable
neurologic outcome with properly performed chest compressions.
What we know: Compression rates affect survival rates. The faster the compression rates, the worse the outcomes.
What this study adds: When an ITD is used as intended (at AHA-recommended
chest compression rates), observed survival-to-hospital discharge is considerably increased compared to CPR without an ITD.
Learn more from David Page at the EMS Today Conference & Expo, March 5–9 in
David Page, MS, NREMT-P, is an educator at Inver Hills Community
College and a paramedic at Allina EMS in Minneapolis/St. Paul.
He’s a member of the Board of Advisors of the Prehospital Care
Research Forum and the JEMS Editorial Board. Send him feedback at
Choose 27 at www.jems.com/rs
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Serving our nation’s EMS practitioners
Philips offers Q-CPR, a real-time
accelerometer-based technology that
incorporates a downloadable resuscitation review.
Masimo’s EMMATM is a miniaturized
capnometer useful for space-limited
Physio-Control offers CODE-STAT
data software for post-CPR review.
Sotera Wireless offers the ViSi, a
powerful, compact monitoring device.
Oridion’s Integrated Pulmonary
Index (IPI) uses waveform capnography
and pulse oximetry to monitor respiratory rate, EtCO2, heart rate and SpO2.
ZOLL’s offers CPR Dashboard, a realtime accelerometer-based technology
with data transmission capability.
IMAGE ALENGO/ISTOCKPHOTO.COM, A) PHOTO COURTESY A.J. HEIGHTMAN, B) PHOTO COURTESY MASIMO, C) PHOTO COURTESY PHYSIO-CONTROL, INC. , D) PHOTO COURTESY SOTERA WIRELESS, E) PHOTO COURTESY A.J. HEIGHTMAN, F) PHOTO CHRIS SWABB
>> BY MIKE MCEVOY, PHD, NREMT-P, RN, CCRN
onitoring technology has tremendous potential to improve
patient outcomes—when it’s designed and used properly. Routine
use of pulse oximetry and waveform capnography virtually eliminated esophageal intubations and inadequate oxygenation claims
against anesthesia providers, transforming their profession from
frequent and costly malpractice targets in the 1970s to 1980s into
one of the safer fields of practice today.1 The value of technology lies in collecting meaningful data that a provider can’t easily obtain with their own assessment skills. Lives are saved
in hospitals every day through the use of monitoring technology: The more sophisticated
the level of care, the more advanced the monitoring technology tends to be.2
Technology enhances prehospital patient care as well, enhancing provider assessment abilities and detecting changes in patient condition. This article will review current
prehospital technology and discuss current and future evolutions.
The first technology adapted for EMS use was cardiac monitoring. Portable cardiac
monitors have evolved since their introduction in the 1970s to include defibrillators,
pulse oximeters, non-invasive blood pressure (NIBP) modules, waveform capnography,
temperature and, most recently, CPR feedback technologies. Perhaps the most important
recent prehospital development has been monitor alarms, intended to alert providers of
potential problems.3 Early prehospital monitors didn’t include alarms, probably under
the mistaken notion that an EMS provider caring for a patient would immediately notice
significant changes. It’s no secret that EMS providers have many things to do besides continuously watch a monitor screen.
The addition of alarms is a welcome improvement in prehospital monitors. A typical intensive care unit (ICU) patient generates some 700 monitoring alarms per day
WAVE OF THE FUTURE
>> CONTINUED FROM PAGE 29
of which only 15% are clinically significant.4 This year, the hospital issue known
as “alarm fatigue” has been considered the
top hospital technology hazard.3 EMS currently has a unique opportunity to customize monitoring alarms, with the option
not to allow silencing such critical alerts as
apnea, asystole and lethal rhythms, to avoid
desensitization and falling into the trap of
Now a standard of care included in the EMT
curriculum, pulse oximetry was one of the
earliest devices to appear in ambulances.
Originally introduced in 1974 for use on
anesthetized patients during surgery, oximetry has matured tremendously in recent
years.4 Arguably one of the most important
patient safety devices ever invented, pulse
oximetry has reduced anesthesia deaths by
90%, now promising to protect patients from
the damaging effects of hyperoxia seen with
routine use of oxygen in patient care.5 In
addition to guiding selection of appropriate oxygen delivery devices, pulse oximetry
technology utilizing additional wavelengths
of light can now screen for carbon monoxide
poisoning, methemoglobin, and even assess
fluid volume status from analysis of the pleth
waveform.6 In the future, manufacturers will
introduce respiratory rate and blood pressure
measurements obtained from pulse oximetry
Non-invasive or electronic blood pressure
measurement followed pulse oximetry into
the prehospital market. Current devices are
oscillometric, meaning that they sense arterial oscillations, typically measuring a heart
rate and mean arterial pressure then working
backwards to calculate a systolic and diastolic
pressure. Algorithms vary by manufacturer,
making it virtually impossible to validate
accuracy, but for the majority of NIBP devices
used in EMS the mean arterial pressure is the
most accurate value displayed.7 Like auscultatory measurements, proper cuff size and
meticulous attention to keeping the extremity being measured at mid-heart level are key
to obtaining good measurements.8
Capnography has made major inroads into
EMS and, in many systems, is more frequently
utilized in prehospital patients than hospitalized patients. The driving force for capnogra-
phy is patient safety during intubation and,
like pulse oximetry, the anesthesia standard
of care dictates monitoring every intubated
patient with waveform capnography. Many
EMS systems mandate continuous waveform capnography for all intubated patients,
a common sense standard that virtually
eliminates the possibility of not detecting a
misplaced endotracheal tube or supraglottic
airway.1,9 Today, there is no excuse for not
using continuous waveform capnography on
every intubated patient, in my opinion.
Like their anesthesia and critical care
counterparts, EMS providers have become
quite skilled with analysis of capnography
waveforms. In both spontaneously breathing
and intubated patients, waveforms demonstrate changes in airway resistance revealing
conditions like bronchospasm, airway cuff
leaks, ventilator asynchrony and more. In the
future, manufacturers will introduce software
to quantify capnography waveforms to allow
clinicians to measure severity and effects of
treatment on conditions detected through
Miniturization of capnography technology has improved portability and battery life.
It also promises in the very near future to further revolutionize the industry with enhancements to a capnometer known as EMMA. The
manufacturer of this second generation endtidal device was recently acquired by Masimo
and will very likely transform into a much
more robust and usable miniaturized device,
perfect for space-limited environments, such
as air medical, combat and intrafacility transports. Keep an eye on EMMA.
One of the more recent monitoring technologies to make its way into ALS monitors
is CPR feedback. The three major monitoring manufactures have feedback devices to
provide both real-time and retrospective
analysis of CPR. Philips offers Q-CPR, a realtime accelerometer-based technology that
incorporates a downloadable resuscitation
review. ZOLL offers CPR Dashboard, a realtime accelerometer-based technology with
data transmission capability for post-event
review. Physio-Control offers CODE-STAT
data review software for post CPR review
and will very shortly introduce its TrueCPR
coaching device in the U.S., a standalone
triaxial field induction (TFI) based unit. TFI,
once it becomes available, promises to elimi-
nate overestimations of compression depth
reported by accelerometer-based devices
when CPR is administered on a mattress
(regardless of whether a board is in place).10
CPR feedback helps rescuers deliver nearperfect compressions and ventilations to
victims of sudden cardiac arrest. For anyone
who has ever performed CPR using a feedback device, they seem to deliver quite nicely
in that regard. Use of post-resuscitation analysis software has led to consistent and sustained improvements in the quality of CPR.
Yet a recent study by Hostler and coauthors
(and the largest study of real-time feedback
yet conducted) suggests that these changes
in performance don’t seem to improve outcomes.11 This is troubling, and it strongly
suggests problems not with the feedback
devices or rescuers, but with the guidelines
themselves. Indeed, anecdotal reports from
CPR feedback users show significantly
improved markers of better perfusion, such
as end-tidal CO2, throughout the peri-arrest
period, yet few have seen improved results. If
anything, CPR feedback devices are showing
us that our “one size fits all” approach to CPR
using the same compression depth and rate
isn’t appropriate for every patient. Hopefully,
the guidelines will change.
POINT OF CARE TESTING
Point of care (POC) testing has slowly
invaded the prehospital world. Use of glucometers is widespread and is now included
in the EMT scope of practice. One promising
technology with a broad range of potential
uses is saliva osmolality to assess dehydration. Several recent studies have found close
correlation between measurement of saliva
osmolality, or concentration, and hydration
status.12-13 Firefighters, athletes, and nursing home patients frequently suffer from
dehydration, and EMS providers lack good
tools to easily determine hydration status.
A Menlo Park (Calif.) company, Cantimer
Corporation is refining a device similar to
a glucometer that will allow field testing of
saliva to detect dehydration.
Another technology currently making prehospital inroads is ultrasound. In the emergency department (ED) and ICU, ultrasound
has for years been used to quickly detect
presence of blood or fluid in the abdomen
of trauma patients, place lines, confirm
endotracheal tube (ET) placement, assess
for pnuemothorax, check cardiac function
and volume status in the heart and vascular
system, find fractures and examine unborn
children. Numerous studies have demonstrated that prehospital providers can accurately use ultrasound, but outcome studies
There is little doubt in the hospital setting that ultrasound has and will continue
to replace more invasive testing. A nurse
using ultrasound can avoid placing a foley
catheter, saving much discomfort and risk of
infection for the patient. A clinician performing a comprehensive ultrasound exam in an
unstable patient can very rapidly assess heart
function, fluid volume status and visualize
the lungs. These exams, however, take considerable practice and require continued use
to maintain proficiency. Like ETI, the opportunity to perform ultrasound may not occur
often enough to allow prehospital providers
in many systems to develop and maintain
Increasing concerns are arising that clinicians
may become overwhelmed with the vast
amount of data to determine an appropriate
plan of care. To that end, monitoring manufacturers are beginning to develop algorithms
or fuzzy logic systems that analyze multiple
parameters to provide the clinician with an
overall wellness score on their patient. One of
the first entrants in this market was Integrated
Pulmonary Index (IPI) by Oridion.16 IPI uses
waveform capnography combined with
pulse oximetry to monitor respiratory rate,
EtCO2, heart rate and SpO2, combining these
values into an algorithm that produces a
score from 1 to 10.
This overall pulmonary score doesn’t
replace the need for a clinician to look at each
one of the parameters, but it does provide
early warning about deterioration so the provider can determine which of the measured
parameters is in need of treatment. Although
IPI isn’t yet available on prehospital monitors,
expect to see it soon along with algorithms
from other manufacturers that will help you
more effectively analyze and manage large
quantities of monitored data.
WEARABLE DEVICES & SENSORS
Lastly, pay close attention to the field of wearable devices and sensors. As our population
ages, patients are discharged from hospitals
earlier, and healthcare providers look for
ways to more closely monitor their patients
at home, the need for wearable sensors
will explode. Remote monitoring systems,
such as the ViSi mobile monitor by Sotera
Wireless, are rapidly benefiting from miniaturization, faster and more robust internet
access, more sophisticated Bluetooth technology and developments in microelectronics and sensor technology.
Fully functional ECG monitors the size of
a wristwatch, fabric integrated sensors and
electrodes, ambient sensors mounted in the
home to monitor patient vitals and activity,
and very sophisticated implantable sensors
are all in various stages of development.17
The same technology that allows closer
monitoring of patients outside healthcare
settings promises to improve your ability
to communicate and consult with medical
experts. Researchers using real-time high
speed audiovisual connections between
prehospital providers and experienced physicians are finding potential to improve outcomes.18 If you can use your cell phone to
video chat with family or friends across the
country, then it makes perfect sense that EMS
could utilize the same technology.
Medicine is a constantly evolving art and
science. It’s highly unlikely that a patient will
thank you for using a state-of-the art monitor or the latest in CPR feedback. They will,
however, thank you for competently and
respectfully integrating the equipment you
carry into a care plan that makes them feel
better for having met you.
Mike McEvoy, PhD, NREMT-P, RN, CCRN, is the EMS coordinator for Saratoga County, N.Y., and teaches pulmonary
and critical care medicine at Albany Medical College. He’s
a paramedic, firefighter and member of the International
Association of Fire Chiefs Emerging Infectious Diseases
1. Metzner J, Posner KL, Lam MS, et al. Closed
claims analysis. Best Pract Res Clin Anesthesiol.
2. Hu X, Sapo M, Nenov V, et al. Predictive
combinations of monitor alarms preceding
in-hospital code blue events. J Biomed Inform.
3. Cvach M. Monitor alarm fatigue: An integrative review. Biomed Instrum Technol. 2012;46(4):
4. Severinghaus JW. Takuo Aoyagi: Discovery of pulse
oximetry. Anesth Analg. 2007;105(6 Suppl):S1–4.
5. Severinghaus JW. Monitoring oxygenation. J Clin
Monit Comput. 2011;25(3):155–161.
6. Roth D, Hubmann N, Havel C, et al. Victim
of carbon monoxide poisoning identified
by carbon monoxide oximetry. J Emerg Med.
7. Smulyan H, Safar ME. Blood pressure measurement: Retrospective and prospective views. Amer
J Hypertens. 2011;24(6):628–634.
8. Brett SE, Guilcher A, Clapp B, et al. Estimating
central systolic blood pressure during oscillometric determination of blood pressure: Proof of
concept and validation by comparison with intraaortic pressure recording and arterial tonometry.
Blood Press Monit. 2012;17(3):132–136.
9. Westhorpe RN, Ball C. The history of capnography. Anesth Intensive Care. 2010;38(4):611.
10. Perkins GD, Kocierz L, Smith SC, et al. Compression
feedback devices over estimate chest compression depth when performed on a bed.
11. Hostler D, Rea TD, Stiell IG, et al, and the
Investigators. Effect of real-time feedback during
cardiopulmonary resuscitation outside hospital:
Prospective, cluster-randomised trial. BMJ. 2011 Feb
12. Smith DL, Shalmiyeva I, DeBlois J, et al. Use of
salivary osmolality to assess dehydration. Prehosp
Emerg Care. 2012;16(1):128–135.
13. Taylor N, van den Heuvel A, Kerry P, et al.
Observations on saliva osmolality during progressive dehydration and partial rehydration. Eur J
Appl Physiol. 2012;112(9):3,227–3,237.
14. Chin EJ, Chan CH, Mortazavi R, et al. A pilot study
examining the viability of a prehospital assessment with ultrasound for emergencies (PAUSE)
protocol. J Emerg Med. 2012 May 15 [Epub ahead
15. Hasler RM, Kehl C, Exadaktylos AK, et al. Accuracy
of prehospital diagnosis and triage of a Swiss
helicopter emergency medical service. J Trauma
Acute Care Surg. 2012;73(3):709–715.
16. Waugh JB. Integrated Pulmonary Index stability in
healthy adults under changing conditions. Resp
17. Patel S, Park H, Bonato P, et al. A review of wearable sensors and systems with application in
rehabilitation. J Neuroeng Rehabil. 2012;4(20)9:21.
18. Skorning M, Bergrath S, Rortgen D, et al.
Teleconsultation in prehospital emergency medical services: Real-time telemedical support in
a prospective controlled simulation study.
THE ROLE OF VIDEO LARYNGOSCOPY IN FUTURE
ADVANCED AIRWAY MANAGEMENT
>> BY TERENCE VALENZUELA, MD, MPH; JARROD MOSIER, MD; & JOHN SAKLES, MD
ispatch sends you to the home of a
79-year-old male with chronic obstructive pulmonary disease (COPD) who
is complaining of “shortness of breath.” He sits
upright, leaning forward and supporting his weight
with both arms. His head seems to be attached
directly to his shoulders. He appears drowsy, and
replies to your questions about medical history with
single-word answers only. His wife relates that he
has grown increasingly short of breath during the
past three days. After he refused to see his doctor, his
wife called 9-1-1.
You palpate a pulse of 98 beats per minute
(bpm) and measure his blood pressure at 180/90.
His respiratory rate is 30. Breath sounds are
diminished and wheezy bilaterally, but there’s little
chest movement with each breath. The pulse oximeter reveals an oxygen saturation (SpO2) level of 93%
and an end-tidal carbon dioxide (EtCO2) level of 35.
He grows more somnolent. Narcan doesn’t improve
his level of arousal.
This patient is on the verge of acute respiratory
failure. Level of arousal (wakefulness) is a sensitive and reliable indicator of brain function. The
patient is drowsy and growing more so because of
the buildup of CO2 from a lack of effective ventilation. An easily reversible cause (opiate effect) for his
lethargy isn’t present. The pulse oximeter indicates
borderline hypercapneic respiratory failure. It can
often be misleading, as in this case, with the EtCO2
number indicating adequate ventilation; however, it
likely represents an increase of expired partial pressure of carbon dioxide (PCO2) with ineffective ventilation. Noninvasive positive pressure ventilation,
such as continuous positive airway pressure (CPAP),
may be considered to decrease the work of breathing
in hypercapneic respiratory failure. But this patient
is unlikely to be cooperative because of his somnolence, and his respiratory drive is failing rapidly. The
likeliest clinical course is continued deterioration.
You and your partner attempt to augment the
patient’s ventilation with a bag-valve mask (BVM).
You maintain a tight seal with two hands on
the mask while your partner squeezes the bag.
The patient becomes apneic. His SpO2 drops to
PHOTO IOSEPH/ISTOCKPHOTO.COM; PHOTOS ART VANDALAY
Video laryngoscopes help improve
the view of the epiglottis during
80%. Your partner places an oropharyngeal airway
(OPA) device, which allows ventilation with continued high fraction of inspired oxygen (FIO2) rate via
the BVM. Maintaining a rate of eight to 10 to avoid
hyperventilation, you see the SpO2 climb to 95%
over the next three minutes. Addition of a disposable
positive end-expiratory pressure (PEEP) valve to the
exhalation port of the BVM results in improvement
of the SpO2 to 100%.
Just prior to becoming apneic, his SpO2
was the brink of the steep portion of the
hemoglobin desaturation curve (see Figure
1, p. 35). Further desaturation, even if brief,
indicates a precipitous fall in arterial oxygen content and will place the brain and
other vital organs at risk for anoxic damage.
A further rise in CO2 diminishes the affinity of hemoglobin for oxygen further worsening oxygen delivery to organs. Note that
there’s a lag time between the SpO2 registered by the pulse oximeter and the real-time
arterial saturation. This delay can range from
a few to 30 seconds depending on the etiology (e.g., heart failure vs. septic shock) and
severity of illness. Unfamiliarity with this
characteristic of the pulse oximeter may
cause mistaken concern that the patient isn’t
improving with BVM therapy. Conversely,
false confidence may result when the patient
is “desaturating,” yet the pulse oximeter continues to read 100%.
The urban myth persists that providing high-flow oxygen to COPD patients
will cause respiratory arrest and should be
avoided. This phenomenon is much talked
about but seldom seen. The greater danger to this patient is persistent hypoxemia
untreated. Deterioration in oxygen saturation with apnea occurs at a rate determined
by factors including age, severity of illness
and the presence of obesity. Figure 1, shows
the rate of SpO2 decline in patients initially
100% saturated who are paralyzed prior to
elective intubation. This is a “best case” scenario, and the times to desaturation should
not be generalized to EMS patients. However, one does see how rapidly ill or pediatric apneic patients will become hypoxemic.
For types of patients made apneic by RSI,
see Figure 1.
BVM VENTILATION & OXYGENATION
EMS providers are overconfident in their
skills and knowledge in how to use BVMs.
Multiple studies of prehospital resuscitations
have documented compression rates that
are too rapid, inspiratory pressures generated by bag compression that’s too great and
volumes of air per compression that are too
large for optimal outcomes. These factors
strongly predict patient harm in the patients
with severe obstructive lung disease, such
as COPD or asthma. Rapid large-volume