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Conheça um pouco mais de nossos serviços de BOMBEIRO INDUSTRIAL em

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  • JANUARY 2013 Always En Route At
  • Making Precious Minutes Count™ Visit our NEW WEBSITE! Success Within Your Sight The King Vision™ Video Laryngoscope is a lightweight and portable video laryngoscope that can be used for both difficult and routine intubations. The full-color, non-glare and anti-scratch display helps you visualize and secure the airway quickly, minimizing interruptions in patient care. The durable and reusable device is ideal for EMS because it can withstand repeated cleaning and normal wear and tear. maximum control and minimal contact with soft tissue and teeth OLED (Organic Light Emitting Diode) color display standard intubations For more information or a product demonstration, contact your dedicated Account Manager or call 800.533.0523 Choose 11 at 800-533-0523
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  • MASKED LARYNGEAL AIRWAY PREVENTS OVERINFLATION The Only Self-Pressurizing Mask Cuff Available in Six Sizes Recent clinical studies have confirmed that laryngeal mask cuff overinflation is a real problem, potentially causing tissue or nerve damage. It may even impair carotid artery blood flow. Who else but Mercury Medical could deliver another life-saving clinical solution? , with the first and only selfpressuring mask cuff, uses positive pressure ventilation (PPV) to self-inflate the mask—on exhalation, the cuff decompresses to the level of PEEP. It will not overinflate, so you can treat your patients with confidence. Problem solved. SAFE. SIMPLE. SELF-PRESSURIZING. Be sure to stop by the Mercury Medical Booth, 34/35P at the 2013 NAEMSP® Annual Meeting, Hyatt Regency Coconut Point Resort & Spa Bonita Springs, FL, January 10 - 12, 2013 Choose 13 at 2 JEMS JANUARY 2013
  • ® 28 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 Contents I 42 I PUTTING THE ‘RAP’ IN RAPPORT I I REVOLUTIONARY MULTI-TOOL I 46 5 I LOAD & GO I Now on 10 I EMS IN ACTION I Scene of the Month 12 I FROM THE EDITOR I Future Forecast I TUNNEL VISION I 42 DEPARTMENTS & COLUMNS 32 38 I 50 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 50 I UPDATE ON 360-DEGREE DATA I 54 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 airway management 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 WWW.JEMS.COM JANUARY 2013 JEMS 3
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  • LOAD & GO LOG IN FOR EXCLUSIVE CONTENT A BETTER WAY TO LEARN JEMSCE.COM ONLINE CONTINUING EDUCATION PROGRAM S ON LLOW U FO TOP 2012 LISTS PASHAIGNATOVIISTOCK.COM 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. ▲ offers you JEMS com MS original content, jobs, products and resources. But we’re much more than that; we keep you in touch with your colleagues through our: > Facebook fan page; > JEMS Connect site; > Twitter account; > LinkedIn profile; > Product Connect site; and > Fire EMS Blogs site. LIKE US /jemsfans FOLLOW US /jemsconnect Sponsored Product Focus LIFE-STAT® MECHANICAL CPR MEETS 2010 AHA CPR GUIDELINES! Life-Stat® is the only mechanical CPR device that offers uninterrupted hands-free 2010 AHA-compliant CPR with coordinated ATV oxygen ventilation at the patient site and in all modes of transport. It provides the AHA required “at least 2 inches (5 cm),” complete recoil compression up to 3.2 inches (8 cm) for adults or precise 1.5 inches (4 cm) compression if needed. GET CONNECTED about=&gid=113182 ▲ Check out their ad on! EMS NEWS ALERTS NEW YEAR’S RESOLUTIONS 34% 32% Improve More formal education my clinical skills Match your EMS resolution. ▲ Mentor a new employee 9% Learn the business and operations No resolutions 12% 12% WANT MORE CASE REVIEWS? 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 them all in one place. ▲ CHECK IT OUT BEST BLOGGERS WWW.JEMS.COM JANUARY 2013 JEMS 5
  • Choose 16 at HealthEMS® Mobile • Industry–Leading ePCR Secure field data collection using your hardware of choice • HealthEMS® FlexFields Unique functionality creates customized ePCR • HealthEMS® Integrates to CAD and EKG Wireless data exchange eliminates manual entry improving accuracy • HealthEMS® XchangER Two-way wireless communication of ePCR data to/from hospital HealthEMS® EHR • Industry-Leading EHR Advanced QA solution supports CQI • HealthEMS® Xchange NEMSIS Gold compliant, v3 development in process • HealthEMS® is CARES Compliant; Sansio is the IT partner of the CARES network • myPatientEncounters™ Provides patients with secure, online access to their EHR NEW • • • • EMS Web-Based Revenue Cycle Management Solution! Improved efficiency with ePCR system integrated to billing system Accurate/Automatic ICD-9/10 coding, medical necessity, service level, loaded mileage, eligibility checking HIPAA Compliant Transactions 4010/5010 electronic claims and remittances Complete AR Management Workload management/change management and reporting Visit www.HealthEMS.NET or call 877.506.2747 for Demo #1 EMS Software as a Service (SaaS) Solution – Over 25% Top EMS Agencies Use HealthEMS® Sansio 11 East Superior Street, Suite 310 Choose 17 at Duluth, MN 55802
  • ® EDITORIAL BOARD WILLIAM K. ATKINSON II, PHD, MPH, MPA, EMT-P President & Chief Executive Officer, WakeMed Health & Hospitals JAMES J. AUGUSTINE, MD, FACEP Medical Director, Washington Township (Ohio) Fire Department Associate Medical Director, North Naples (Fla.) Fire Department Director of Clinical Operations, EMP Management Clinical Associate Professor, Department of Emergency Medicine, Wright State University STEVE BERRY, NREMT-P Paramedic & EMS Cartoonist, Woodland Park, Colo. BRYAN E. BLEDSOE, DO, FACEP, FAAEM Professor of Emergency Medicine, Director, EMS Fellowship, University of Nevada School of Medicine Medical Director, MedicWest Ambulance CRISS BRAINARD, EMT-P Deputy Chief of Operations, San Diego Fire-Rescue CHAD BROCATO, DHS, REMT-P Assistant Chief of Operations, Deerfield Beach (Fla.) Fire-Rescue Adjunct Professor of Anatomy & Physiology, Kaplan University 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, Colorado District JAY FITCH, PHD President & Founding Partner, Fitch & Associates RAY FOWLER, MD, FACEP Associate Professor, 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 Community Medicine Medical Director, EMS System for Metropolitan Oklahoma City & Tulsa KEITH GRIFFITHS 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 JEMS JANUARY 2013 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 8 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 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, 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 (Colo.) Fire Rescue
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  • FEELING THE HEAT E 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. WWW.JEMS.COM JANUARY 2013 JEMS 11
  • FROM THE EDITOR PUTTING ISSUES INTO PERSPECTIVE >> BY A.J. HEIGHTMAN, MPA, EMT-P FUTURE FORECAST Forces beyond your control are destined to affect your agency J 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 service delivery. 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 & operational systems to meet budget goals or participate in new approaches to service delivery. 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 12 JEMS JANUARY 2013 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 service area. 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 & follow-up diminishes, so too will the reimbursement your system receives for the ‘services’ delivered. 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 potentially overtake & 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 healthcare chain. 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 by it. 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! WWW.JEMS.COM JANUARY 2013 JEMS 13
  • CHALLENGES TO ‘EATING HEALTHY’ HY’ This month, JEMS readers and d 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. Scott H. Via Facebook 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? Derek M. Via Facebook 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 cream scoop. >> 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 computer mouse. >> An appropriately sized bagel is the size of a hockey puck. >> One serving of cheese is the size of a pair of dice. 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 14 JEMS JANUARY 2013 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. Trent S. Via Facebook 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 co the 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 co clean cl contaminated clothing. So you are allowed to carry ca food and eat in the truck, just keep it in the front 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. Melissa M. Via Facebook 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 they feel. Philip B. Via Facebook 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 … Scott M. Via Facebook AP PHOTO/NEWTOWN BEE, SHANNON HICKS PHOTO CYBERNESCO/DREAMSTIME.COM LETTERS 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. Scott W. Via Facebook 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. Cassandra D. Via Facebook 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. Lizelle P. Via Facebook 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. Troy Willrick 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 JANUARY 2013 JEMS 15
  • PRIORITYUSE TRAFFIC NEWS YOU CAN Bringing issues to THE HILL Fourth annual EMS on the Hill Day to be held prior to EMS Today PHOTO ISTOCKPHOTO.COM R 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,” Lane says. 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 EMS issues. 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 the following: 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 and safety. 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 the states. 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 16 JEMS JANUARY 2013
  • The JEMS Family of Products: Helping You Save Lives Website JEMS, Journal of Emergency Medical Services Your online connection to the EMS world, gives you information on: Products Jobs Patient Care Training Technology With content from writers who are EMS professionals in the feld, JEMS provides the information you need on clinical issues, new products and EMS trends. Available in print and digital editions! eNewsletter Product Connect The JEMS eNewsletter gives you breaking news, articles and product information. It’s free to subscribe … stay ahead of the latest news! Giving you the detailed product information you need, when you need it. We collect all the information from manufacturers and put it in one place, so it’s easy for you to fnd and easy for you to read. Go to Archived Webcasts Approaches to Shock Management ® TM Free … Available 24/7! For more information on the JEMS Family of EMS Products:
  • PRIORITY TRAFFIC >> 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 its children. 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 are located. PERSONAL USE OF COMPANY EQUIPMENT W 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 organization. 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 18 JEMS JANUARY 2013 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 website at
  • QUICK TAKE SUNSTAR SUCCESS Agency one of two in U.S. to receive triple accreditation S 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 Emergency Dispatch. 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 jitteriness, 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 nitroglycerin for severe hypertension not respond- ing to benzodiazepineinduced relaxation. Beta blockers are contraindicated because they allow caffeine’s (like cocaine’s) unopposed alpha effects and risk of severe hypertension. 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 PHOTO A.J. HEIGHTMAN Caffeine is omnipresent. It’s found in coffee, tea, most soft drinks, chocolate, dietary supplements, 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 large drink. 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 WWW.JEMS.COM JANUARY 2013 JEMS 19
  • LEADERSHIP SECTOR PRESENTED BY THE IAFC EMS SECTION >> BY GARY LUDWIG, MS, EMT-P WHACKERS Discipline isn’t always the best action 20 JEMS JANUARY 2013 PHOTO A.J. HEIGHTMAN W 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 managers discipline. 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 matically. You could even go one step further naemt-board-adopts-new-position-statemen. 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
  • ANSWERS AS FAST AS OUR VASCULAR ACCESS Download the EZ-IO app and have powerful information at your fingertips. Scan and get your APP. Choose 21 at Choose 22 at Choose 23 at Choose 24 at
  • TRICKSOUR PATIENTS & OURSELVES OF THE TRADE CARING FOR >> BY THOM DICK, EMT-P TEETER-TOTTER EMT poses a different loading strategy T 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 much attention. 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 and loading. 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 22 JEMS JANUARY 2013 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 teeter-totter. 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 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 avoid pending lawsuits EMS Insider provides you with the “inside infor- EMS Research & Technology mation” on EMS. It’s a monthly publication from Elsevier Public Safety and affiliated with JEMS (Journal of Emergency Medical Services) so it has EMS Trend the best network of sources in EMS. That means Analysis AVOID COSTLY FINES revenue generating ideas you get only the highest quality reporting . . . insightful, timely, authoritative. . . not available elsewhere. EMS Insider pays for itself. Every issue contains articles to help you, by bringing you money-saving and revenue-generating ideas. Don’t miss out, order your subscription today! Exclusively for EMS Management Subscribe to EMS Insider WWW.JEMS.COM JANUARY 2013 JEMS 23
  • 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 T 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 acting weird.” 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 nearly full. 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 24 JEMS JANUARY 2013 PHOTO JEFFREY MAYES CASE PRESENTATION 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 lab work. 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. DISCUSSION 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 hyponatremia. 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 TREATMENT 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. REFERENCES 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 242166-overview. 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. Choose 25 at Become the new leaders of EMS by taking your EMS education to the next level. A fully online BS in Emergency Medical Services Administration from Anna Maria College can get you there. Our online EMS Administration Bachelors Degree is perfect for your busy lifestyle. Focusing on leadership training and advanced problem solving, you’ll be one step closer to an executive position in the EMS field. Dennis Edgerly, EMT-P, began his EMS career in 1987 as a volunteer firefighter EMT. He’s the paramedic education coordinator for the paramedic education program at HealthONE EMS. Contact him at Read additional case studies at This online program is offered only by Anna Maria College. Log on to or call 800-344-4586 for more information. 50 Sunset Lane, Paxton, MA 01612 • Choose 26 at WWW.JEMS.COM JANUARY 2013 JEMS 25
  • RESEARCH REVIEW EMS WHAT CURRENT STUDIES MEAN TO >> BY DAVID PAGE, MS, NREMT-P CLINICAL COMPETENCE 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 about glucagon. 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.] W 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 thorough methodology. The group videotaped 81 performances of 61 EMS students and 24 active para- PHOTO DAVID PAGE I 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. 26 JEMS JANUARY 2013 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. BOTTOM LINE 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 Washington, D.C. 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 Take the best in EMS continuing education NAEMT courses provide high quality, evidencebased education to improve patient care: PHTLS, AMLS, EPC, TCCC and EMS Safety. All courses are CECBEMS accredited and meet Learn more at Serving our nation’s EMS practitioners WWW.JEMS.COM JANUARY 2013 JEMS 27
  • MONITORING TECHNOLOGY HAS POTENTIAL TO TRANSFORM EMS A 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 environments. B C Physio-Control offers CODE-STAT data software for post-CPR review. D Sotera Wireless offers the ViSi, a powerful, compact monitoring device. E Oridion’s Integrated Pulmonary Index (IPI) uses waveform capnography and pulse oximetry to monitor respiratory rate, EtCO2, heart rate and SpO2. F ZOLL’s offers CPR Dashboard, a realtime accelerometer-based technology with data transmission capability. A 28 JEMS JANUARY 2013
  • 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 B C >> BY MIKE MCEVOY, PHD, NREMT-P, RN, CCRN M 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. D E CARDIAC MONITORING 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 F WWW.JEMS.COM JANUARY 2013 JEMS 29
  • 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 “alarm fatigue.” PULSE OXIMETRY 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 pleth waveforms. 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 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- 30 JEMS JANUARY 2013 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 waveform analysis. 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. CPR FEEDBACK 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. ULTRASOUND 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 are lacking.14,15 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 sufficient proficiency. LOOKING AHEAD 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 task force. REFERENCES 1. Metzner J, Posner KL, Lam MS, et al. Closed claims analysis. Best Pract Res Clin Anesthesiol. 2011;25(2):263–276. 2. Hu X, Sapo M, Nenov V, et al. Predictive combinations of monitor alarms preceding in-hospital code blue events. J Biomed Inform. 2012;45(5):913–921. 3. Cvach M. Monitor alarm fatigue: An integrative review. Biomed Instrum Technol. 2012;46(4): 268–277. 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. 2011;40(6):640–642. 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. Resuscitation. 2009;80(1):79–82. 11. Hostler D, Rea TD, Stiell IG, et al, and the Resuscitation Outcomes Consortium Investigators. Effect of real-time feedback during cardiopulmonary resuscitation outside hospital: Prospective, cluster-randomised trial. BMJ. 2011 Feb 4;342 [Epub]. 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 of print]. 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 Care. 2010;55(11):1,522. 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. Resuscitation. 2012;83(5):626–632. WWW.JEMS.COM JANUARY 2013 JEMS 31
  • THE ROLE OF VIDEO LARYNGOSCOPY IN FUTURE ADVANCED AIRWAY MANAGEMENT >> BY TERENCE VALENZUELA, MD, MPH; JARROD MOSIER, MD; & JOHN SAKLES, MD D 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 32 JEMS JANUARY 2013 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 endotracheal intubation. 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 WWW.JEMS.COM JANUARY 2013 JEMS 33
  • TUNNEL VISION >> CONTINUED FROM PAGE 33 bagging exacerbates existing high Figure 1: Oxygen Saturation vs. Time for Types of Patients Made Apneic in the lungs relative to the oropharynx, allowing gas flow into the lungs. intrathoracic pressures and may by RSI A high concentration of oxygen cause pneumothorax or significant delivered via nasal cannula at a flow cardiovascular strain.1 rate of 15 L per minute will provide Proper BVM technique presupa continuous flow of oxygen to the poses proper positioning. Correct alveoli. This is called “apneic oxygenpositioning is achieved when a ation” and has been demonstrated to line from the ear canal to the stermaintain oxygen saturation for lonnal notch is parallel to the floor or ger periods in patients paralyzed in reverse Trendelenburg position, in the operating room and emergency which the patient’s head are placed department (ED) for endotracheal about 15–30 degrees higher than (ET) tube placement.1 The duration their head, for patients immobiof safe apnea after the administration lized on spine boards.1 Proper of sedatives and muscle relaxants is positioning prevents atelectasis prolonged. A nasal cannula is the and improves oxygenation. Effecmost readily available and effective tive BVM use requires a tight seal between face and mask; in practice, Source: Benumof JL, Dagg R & Benumof R. Critical hemoglobin desatura- means of providing apneic oxygenthis requires two operators. With tion will occur before return to an unparalyzed state following 1 mg/kg ation during ET tube attempts. an adequate seal, a bag-valve mask intravenous succinylcholine. Anesth. 1997;87(4):979–982. Caution: Oxygen at a flow rate of 15 L rapidly with an oxygen reservoir and onedessicates the nasal mucosa. The extended way exhalation port will deliver an FIO2 be applied to the bag to create rise and fall duration of normal O2 saturation masks greater than 90%.1 Bag compression rates of the chest wall. More force applied to the absence of adequate ventilation. This may greater than eight to 10 per minute cause BVM bag will be required to expand the lesslead to prolonged intubation attempts and decreased cerebral perfusion and contrib- compliant lungs of patients with COPD. hemodynamic instability as the CO2 in the ute to increased intrathoracic pressure. Field However, a common error is interpretation blood rises. interventions have attempted to control of the back pressure felt from attempting to Given the unique variables involved in BVM ventilation rates. Examples are metro- force gas too quickly through the larynx as nomes and timing lights—standalone and “stiff lungs” and applying even more force each emergency tracheal intubation, it’s attached to BVMs. These provide conve- to the BVM. Try compressing the bag less impossible to predict the exact duration of nient guidance without changing the BVM forcefully to see if airflow improves. Con- safe apnea for any given patient. Those with process. sider also upper airway obstruction and re- high initial saturation levels on room air or Sufficient self-discipline under the high check patient positioning. Don’t administer after adequate oxygenation are at lower risk stress of an actual field response is diffi- a BVM breath while the patient is still exhal- and may maintain adequate saturation for cult. Less important is the duration of each ing. Patients who don’t reach SpO2 of 100% as long as eight minutes of apnea. Critically compression of the bag. Breaths should be saturation with a standard BVM treatment ill patients and those with saturations just administered over two seconds; shorter will benefit from attachment of a dispos- above the steep portion of the oxyhemobreath times result from higher airway able PEEP valve to the exhalation port of globin dissociation curve are at high risk of rapid-onset hypoxemia with prolonged trapressures. The peak airway pressure pos- the BVM. sible from manual compression of a stanNote: CPAP alone should not be used in cheal intubation efforts. dard adult-size BVM easily exceeds 20 cm apneic or intermittently apneic patients of water, the pressure at which air is forced Gastric insufflation isn’t generally created ENDOTRACHEAL INTUBATION past the lower esophageal sphincter into the by overinflation of the lungs but by short Of course, endotracheal intubation (ETI) by stomach. 1 Gastric distention, regurgitation breath times and high inspiratory flows paramedics in the field is controversial— and aspiration result. creating high upper airway pressures. As with or without rapid sequence intubaBVMs with built-in “variable resistance” these high flows are restricted from immedi- tion (RSI) medications, which paralyze the valves are helpful in limiting both venti- ately entering the lungs by the larynx, gas is patient’s airway.2,3 Like any complex psycholation rate and peak airway pressure. The diverted into the stomach. Cricoid pressure motor skill, ETI must be performed freharder one squeezes these bags, the harder produces laryngeal/tracheal compression in quently, or a reasonably accurate simulation they are to compress. The provider controls many patients and doesn’t reduce the risk of repeated frequently, to maintain a high level of skill. Including ETI in the scope of pracboth ventilation rate and peak airway pres- regurgitation and aspiration. tice is a local decision based on frequency sure without conscious thought or calculaof intubations, available alternative airways tion. The potential for hyperinflation of the PREOXYGENATION lungs and dangerously high peak airway In the apneic patient, more oxygen is and training resources. absorbed in the alveoli than carbon dioxide In the field, every airway is a “difficult pressure is thereby reduced. In practice, sufficient pressure needs to is released. This creates a negative pressure airway.” For example, the patient in the 34 JEMS JANUARY 2013
  • Accurate from the First Breath World’s smallest portable self-contained capnometer EMMA™ (Emergency Mainstream Analyzer) is a fully selfcontained mainstream capnometer that requires no routine calibration and virtually no warm up time.1 With rapid measurement of end-tidal CO2 and respiration rate, EMMA can help providers guide ventilation rates and assess the effectiveness of CPR allowing them to make adjustments in the course of treatment, breath by breath. 800-257-3810 | © 2013 Masimo Corporation. All rights reserved. 1 EMMA Users Manual. Choose 28 at
  • TUNNEL VISION scenario is obese with a short neck and pharyngeal anatomy that makes visualizing the glottis—a key step in successful ETI—a challenge. He also verges on respiratory failure with deteriorating oxygenation and hypoventilation. He has been working hard to breathe and will soon tire out. Definite indications for endotracheal intubation are present. And although ETI remains the best method of advanced airway management—providing better (not perfect) airway protection, higher FIO2 and more reliable ventilation of the lungs than other airway management techniques, it remains difficult for many paramedics to maintain an adequate level of skill. That’s where devices that assist the provider in visualizing necessary anatomy to successfully intubate patients can be beneficial. EXTRAGLOTTIC AIRWAYS & RSI Extraglottic airways are alternate airway devices that are inserted blindly into the esophagus and don’t pass through the vocal cords into the trachea. Inflated balloons obstruct the oropharynx and esophagus to create a path for ventilation into the trachea. Because of this, they don’t require visualization of the glottis. They’re designed to support both ventilation and oxygenation in combination with a BVM. A variety of them are in widespread EMS use. The Combitube, King Airway and Laryngeal Mask Airway (LMA) device have proven useful where ALS isn’t available, where the frequency of ET tube placement per paramedic is low, and where local medical direction judges the balance between risk and benefit better than that of endotracheal intubation. There’s a significant history and body of medical literature on their use as a primary airway or rescue device after unsuccessful ETI attempts. Administration of RSI medications in the field, like ETI itself, requires knowledge of patient selection, opportunities for skills maintenance, a preconstructed backup PHOTO GLEN ELLMAN >> CONTINUED FROM PAGE 35 Emergency department and EMS studies have proven video laryngoscopes provide better visualization of the glottis and higher intubation success rates. plan in case of unsuccessful intubation and meticulous review of each event for quality assurance. The use of sedating and paralyzing medications in the ED improves the rate of successful and atraumatic endotracheal intubation. In the field, successful endotracheal intubation in other than unconscious unresponsive patients without RSI is possible but improbable.4 In some awake, conscious patients— notably those with significant airway burns and expanding neck hematomas, the predictable clinical course indicates intubation to prevent imminent total airway occlusion. The probability of successful endotracheal tube placement with less trauma and fewer attempts is increased with the use of RSI medications.5 VIDEO LARYNGOSCOPY Successful ETI with direct laryngoscopy (DL), which includes all the prementioned methods and devices, requires the alignment of the oral cavity, pharynx and tracheal axes to permit a direct line of sight from the operator to the vocal cords. Despite the optimal positioning, (e.g., horizontal line from ear to sternal notch), visualization is often difficult or impossible. Video laryngoscopes improve this view by incorporating a micro video camera on the undersurface of the laryngoscope blade that projects magnified images onto a monitor screen. This allows the operator to indirectly view the glottic inlet.6 During the past 10 years, video laryngoscopes, as well as optical devices using mirrors and prisms, have become common in operating rooms, EDs and critical care units for routine and difficult airways. Multiple studies have shown improved success with video laryngoscope (VL) compared with direct laryngoscopes in a variety of settings, including prehospital and novice trainees.7–9 Optimizing first-attempt success is of paramount importance, especially in critically ill patients with difficult airways. Three or more unsuccessful attempts at ETI are associated with a higher incidence of complications (e.g., unrecognized esophageal intubation, airway trauma, aspiration and hypoxemia).10 Recent research from several EDs and at least one EMS system demonstrates that video laryngoscopes result in better visualization of the glottis, higher proportion of successful ETIs and shorter placement times without an increase in complications (see Table 1, below).3,7,11 Prehospital video laryngoscopes come in a variety of configurations. Several factors will determine the best choice for a particular jurisdiction. The initial capital investment and recurring cost of use differ widely among video laryngoscopes currently available on the market. Some available video laryngoscopes may be reused if properly disinfected. Others are completely disposable. Economically speaking, there’s a point when the number of intubations make reusable laryngoscopes a better economic proposition than disposable ones. Early VLs that were portable enough to be used in the field contained internal rechargeable battery packs. These needed either charging devices or wall plugs. Increasingly available are ones powered by AA or AAA alkaline batteries. Video laryngoscopes vary significantly in the shape of Table 1: Some Available Video Laryngoscopes DEVICE COMPANY POWER SOURCE TECHNIQUE GlideScope Ranger Verathon Rechargeable Both reusable & disposable blades. Best results with rigid stylet C-MAC PM Karl Storz Rechargeable Mac & Miller style blades; pediatric blades available Pentax AWS Pentax Medical AA batteries ET tube guide attached to blade directs tip to “cross hairs” on screen King Vision King Systems AAA batteries Reusable video head attaches to disposable blades (with or without ET tube guide) McGrath Series 5/MAC Aircraft Medical AA battery 36 JEMS JANUARY 2013 Disposable plastic blades; smaller sizes available.
  • blade. Some are comparable to Macintosh and Miller blades and may be used in the same way. Little retraining is necessary, and in some cases these blades may be used to perform conventional direct laryngoscopy. Other video blades differ from standard direct laryngoscope blades incorporating a hyper-angulated curvature. They require additional training and, in some cases, the addition of specialized stylets. VLs also vary in sizes and although not all VLs can be used in children, manufacturers continue to introduce separate pediatric-sized devices or laryngoscope blades for existing devices. Channel guides are another innovation that vary among video laryngoscopes. They are fittings that are attached to the laryngoscope where an endotracheal tube may be placed. After visualization of the glottis, the ET tube is advanced through the guide and the cords. Guides limit the size ET tube that can be used. Acceptable image size and quality is a matter of user preference. VLs suitable for field use generally provide images of sufficient quality for successful endotracheal intubation. In general, an inverse relationship between image quality and cost exists, meaning the higher the device costs, the better the image quality. Finally some VLs can be connected to an external monitor. This permits a trainer or observer to simultaneously view the picture available to the endotracheal tube operator. Terence Valenzuela, MD, MPH, is medical director of Tucson Fire Department. He can be reached at terry@ Jarrod Mosier, MD, is an assistant professor of emergency medicine at the University of Arizona College of Medicine Department of Emergency Medicine. John Sakles, MD, is a professor of emergency medicine at the University of Arizona College of Medicine Department of Emergency Medicine. REFERENCES Video laryngoscopes vary in size. desaturation (see Figure 1, p. 35). Thus, there’s virtually no time of safe apnea for small children because they begin to desaturate immediately on becoming apneic for any reason. Therefore, an approach de-emphasizing ETI in small children is more medically prudent. The majority of children, who are without trauma to the face or facial abnormalities may be adequately oxygenated and ventilated with a bag valve mask and oropharyngeal or nasopharyngeal airway device. This approach, “uninterrupted ventilation,” should be stopped only if there’s no movement of the chest with bagging. “Quick-look” laryngoscopy with pediatric Magill forceps at the ready to remove any possible foreign bodies may then be performed—but then only long enough to visualize the foreign body. SUMMARY For more on quality assurance with video laryngosopy, see the Tucson Fire Department template in the online version of this article at CHALLENGES Note that children aged 4 years or younger are particularly challenging. The epiglottis is at the level of C-1, not C-4 as in adults; there’s a relatively large amount of adenoidal tissue in the airway that’s friable and prone to bleeding with minimal trauma. In addition, small children have a rapid metabolic rate and are therefore prone to rapid Since 2000, many studies of advanced emergency airway management have appeared in the medical literature. Although most described patients in the operating room, intensive care unit or emergency department, studies of video laryngoscopy in the field are in progress and beginning to appear in the literature. Video laryngoscopy provides better views of the glottis, and it permits more successful intubations with fewer attempts. Price reductions as more devices, some specifically intended for EMS, enter the market will lower the entry costs for adoption. It is my prediction that in five years, video laryngoscopy will be the method of choice for endotracheal intubation in the field. 1. Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 2012;59(3):165–175. 2. Wang HE, Szydlo D, Stouffer JA, et al. Endotracheal intubation versus suproglottic airway insertion in out-of-hospital cardiac arrest. Resusciation 2012;83(9):1061–1066. 3. Dunford JV, Davis DP, Ochs M, Incidence of transient hypoxia and pulse rate reactivity during paramedic rapid sequence intubation. Ann Emerg Med. 2003;42(6):721–728. 4. Lawner BJ. RSI without paralytics: Just don’t do it. In: Avoiding Common Prehospital Errors. Lawner BJ, Slovis CM, Fowler R, et al (Eds). Lippincott Williams & Wilkins: Philadelphia, 2013. 5. Nagib M, Samarkandi AH, El-Din ME, et al. The dose of succinylcholine required for excellent endotracheal intubating conditions. Anesth Analg 2006;102(1)151–155. 6. Sakles JC, Brown CA, Bair AE. Video laryngoscopy. In: Manual of Emergency Airway Management. 4th ed. Lippincott Williams & Wilkins: Philadelphia, 2012:140–157. 7. Wayne MA, McDonnell M. Comparison of traditional vs. video laryngoscopy in out-of-hospital tracheal intubation. Prehosp. Emerg Care. 2010;14(2):278–282. 8. Sakles JC, Tolby N, VanderHeyden TC, et al. Ability of emergency medicine residents to use alternative optical airway devices. Presentation at April 2003 Western Society for Academic Emergency Medicine meeting; Phoenix. 9. Kaplan MB, Hagberg CA, Ward DS, et al. Comparison of direct and video-assisted views of the larynx during routine intubations. J Clin Anesth. 2006;18(5):357–362. 10. Hasegawa K, Shigemitsu K, Hagiwara Y, et al. Association between repeated intubation attempts and adverse events in emergency departments: An analysis of a multicenter prospective observational study. Ann Emerg Med. 2012;60(6):749–754.e2. 11. Sakles JC, Mosier J, Chiu S, et al. A comparison of the C-MAC video laryngoscope to the Macintosh direct laryngoscope for intubation in the emergency department. Ann Emerg Med. May 4 2012. [Epub ahead of print]. WWW.JEMS.COM JANUARY 2013 JEMS 37
  • EMS SURVEILLANCE PROGRAM ASSISTS WITH ‘FREQUENT FLYERS’ PHOTO LIZETH ROMO >> BY ANNE-MARIE JENSEN, EMT-P, & JAMES DUNFORD, MD The eRAP technology identifies & ranks calls from high-need patients, helping EMS work with community partners by redirecting patients to the appropriate agency. T he San Diego Resource Access Program (RAP) is an EMSbased surveillance and case management system. Conceived in 2008 by the San Diego Fire-Rescue Department (SDFD) and Rural/Metro Ambulance, this paramedic-coordinated project was designed to help individuals who repeatedly accessed 9-1-1. Since its inception, RAP has evolved from a gumshoe case management approach into a health information technology (HIT)-enabled program supported by real-time EMS and computer-aided device surveillance. The features of the electronic component of RAP (eRAP) illustrate an EMS application capable of assisting communities to achieve better care and improved health at lower cost. PROGRAM BACKGROUND Chronic 9-1-1 use is often an indication of a health or social vulnerability. Frequent users typically suffer from combinations of chronic medical diseases, psychiatric disorders, drug and alcohol dependence, in-home difficulties and homelessness. For this population, repetitive 38 JEMS JANUARY 2013 transport to emergency departments (EDs) is a particularly ineffective and wasteful use of 9-1-1 resources. The underlying need often remains unaddressed and EMS dependence persists. RAP identifies such patients, investigates the underlying circumstances and seeks to reduce dependence on acute care services by linking these individuals with resources more appropriate to their situations. RAP primarily focuses on the most dynamic and unstable of frequent users in the system. Many of these vulnerable individuals have a profoundly deleterious impact on multiple branches of the public safety net. Current case management methods for this population are based on San Diego’s experience addressing chronic public inebriates: effective management of these patients require partnerships with key stakeholders including law enforcement, courts, behavioral and homeless outreach teams, social workers, case managers, housing providers, etc.1 During the first two years of using this case management method, RAP demonstrated significant improvements for 51 clients, reducing the number of ambulance
  • What is eRAP Technology? The eRAP technology is best described as an electronic surveillance and case management platform that continuously monitors incoming electronic patient care report (ePCR) and computer-aided dispatch (CAD) data traffic. The user interface was designed specifically for use on an iPad, but because it’s a web-based tool, it’s agnostic to operating systems and can be accessed from any Internet-connected device with appropriate security. (Flip to p. 42 for more on how EMS providers are using iPads and tablets in the field.) The goal of eRAP is to display the realtime, comprehensive status of repeated 9-1-1 activity, including the affects of individual patients on operations and resources over time (e.g., the past week or past year). This tool allows the RAP coordinator to prioritize and strategically deploy resources for more effective interventions. transports (736 to 459), task time (263 hours), miles (1939) and charges ($314,306).2 Given the tendency of many frequent users to access multiple facilities for care, the collective connectedness of EMS with hospitals and other providers affords a unique opportunity to detect abnormal patterns of activity. Additionally, EMS information systems can serve as regional health networks, and when linked with CAD data provide a rich healthcare geo-database that can be mined. This position allows EMS to detect not only frequent 9-1-1 users, but also equally vulnerable yet less noticeable individuals. The eRAP development has leveraged existing technologies to more quickly identify, rank, alert and intervene on individuals with the greatest need. TECHNOLOGY GAP Early RAP efforts attempted to identify and prioritize chronic 9-1-1 users by manual investigation of patient care records. However, it quickly became apparent that accurate analysis of the overall EMS system was impossible; painstaking chart reviews and queries consumed valuable case management time. This left little choice but to prioritize cases based on field responder complaints. Furthermore, existing case management platforms didn’t meet the needs of RAP. Information technology development was necessary to create a software system tailored to RAP goals. Fortunately, in 2010 the San Diego region was the recipient of a $15 million Beacon Community grant from the Office of the National Coordinator.3 San Diego was the only one of the 16 Beacon communities that proposed to demonstrate the value of bidirectional information exchange between EMS and hospitals. Beacon funding enabled software developers, including Infotech Systems Management Inc., ImageTrend Inc. and FirstWatch, to explore the potential of EMS information exchange. Infotech developed the Beacon EMS Hub to serve as the gateway into the health information exchange (HIE) and independently created novel applications with RAP, illustrating the value and potential of EMS data. WWW.JEMS.COM JANUARY 2013 JEMS 39
  • ‘RAP’ IN ‘RAPPORT’ >> CONTINUED FROM PAGE 39 1: Electronic ranking to ID most active callers A major component of eRAP surveillance involves the application of programmatic algorithms to electronically identify frequent users and sort them by impact to the EMS system. By data mining multiple repositories, eRAP recognizes a distinct person across multiple incidents, uses a patient-association technique to collect all records connected to a unique patient and converts them into an auto-populated, patient-centric case management system. The eRAP patient-association mechanism matches patients in spite of errors or missing information. Patients are then electronically ranked according to their number of 9-1-1 encounters and displayed on active dashboards. Remarkably, during the process of developing this technology, eRAP identified three individuals among the city’s 10 most affective patients who had never been referred or previously identified, including the number one EMS user in the city. We attribute the conventional method’s inability to identify this patient to two principal factors: 1) the vast geographical range from which this individual called 9-1-1, and 2) the aggressive rate at which he suddenly began calling the 9-1-1 system without previous frequent use. >> Case 1: RAP Client 1 is an energetic 60-year-old male with underlying schizoaffective disorder. A resident of a neighboring city, he used to use a senior citizen discount to enthusiastically tour San Diego via public transportation. When routes were inconvenient, he called 9-1-1 and strategically requested a hospital close to his desired destination. On arrival at a hospital, he typically eloped and reactivated 9-1-1 several blocks away. By the time this patient’s behavior was identified and referred to RAP, the client had accumulated 96 ambulance transports in three months. The geographical spread of his calling location was so vast (see map above), and his interactions with fire engine and paramedic crews so diverse that he went unrecognized in the system. Based on eRAP’s electronic patient ranking data, RAP was able to intervene and assist in developing a comprehensive case plan. Unfortunately patients with this level of affect frequently have inadequately treated psychiatric disease and require a multitude of resources to be stabilized. When Client 1 began exhibiting violent behavior toward first responders and reached more than 200 calls in a brief period, he was arrested and charged with 9-1-1 abuse, false reporting and assaults on ambulance personnel. Once in custody, RAP advocated for the patient’s redirection into the behavioral health court system, which typically results in supervised medication management and psychiatric care. Unfortunately, the court therapeutic team determined the patient did not have the ability to comply with treatment requirements, and the patient received 90 days of custody plus three years of probation. After serving 90 days, the patient was released from jail. He promptly activated the 9-1-1 system from across the street in less than five minutes of his release. RAP is still currently working to find appropriate resources for Client 1. 40 JEMS JANUARY 2013 2: Electronic discovery of the vulnerable P erhaps the most groundbreaking function of eRAP is its ability to electronically identify vulnerable people in San Diego who have come in contact with EMS. All incoming ePCR and CAD incidents are put through vulnerability filters, where eRAP searches the report for indications of vulnerabilities, such as substance abuse, psychiatric and behavioral emergencies, in-home falls and hoarding behavior Individuals associated with these incident types are identified, aggregated and ranked using custom recognition algorithms. Vulnerability flags are automatically added to the patient’s profile page; other data aggregated within the profile page include patterns in 9-1-1 activity, such as calling location, time of day and hospital destinations, to help subsequent RAP case management strategies. The eRAP “in-home vulnerability” algorithm identifies addresses where residents appear to be experiencing specific difficulties. The search algorithm is IN-HOME DIFFICULTIES 3: Patient associative CAD View T he eRAP program monitors and displays all incoming 9-1-1 calls on its iPad interface via a patient associative live “CAD View” screen. When engine or ambulance crews enter patient information into a handheld ePCR device and click “save,” CAD View creates a link to that current patient data. This allows RAP to identify patients within minutes of a 9-1-1 call, even while crews are still on scene. Additionally, an icon indicates if the patient fulfills vulnerability criteria or is a “top 50” client and tapping it will take the provider to the patient-specific management page. >> Case 3: RAP Client 3 is a 56-year-old homeless male who often called 9-1-1 up to three times per day from the same payphone. His chief complaints were anxiety and shortness of breath after a bad dream; his symptoms typically resolved after being awake for several minutes. All 9-1-1 calls would occur during the daytime, with estimated costs to EMS and first responders of nearly $25,000 per month. RAP provided case management services with its sister program, the San Diego Police Department (SDPD) Homeless Outreach Team (HOT). 4: Alerting T he eRAP program allows responders and assigned case managers to subscribe to time-sensitive 9-1-1 information alerts relevant to current case management workflow. Alerts can be delivered as e-mails, text messages and pages. >> Case 4: RAP Client 4 is a 59-year-old chronically inebriated male who had enrolled in the SDPD San Diego Serial Inebriate Program. In one year, the patient had generated more than 70 alcohol-related ambulance transportsand four admissions to the Level 1 trauma center. Three months after achieving sobriety, the patient relapsed and was encountered again by EMS. The eRAP alerting system sent a text message
  • triggered when a series of calls suggests mobility issues or when responding crews repeatedly determine calls are “not of a medical nature.” The location is electronically flagged; resources, referrals and interventions follow. The following example illustrates the usefulness of this algorithm. >> Case 2 Crews began responding to RAP Client 2, a 76-year-old woman suffering from dementia who lived in a recreational vehicle (RV) with her husband. The RV had been permanently parked at a local campsite facility, and the patient had been recently discharged with the diagnosis of bilateral cellulitis, which affected her already deteriorating mobility. Without the provision of additional resources, the patient adopted the 9-1-1 system (calling up to three times per day) with requests to change diapers, reposition herself in bed, change her urine-soaked clothing and linens, sort her laundry, reach her equipment, and review medical and prescription paperwork. In spite of retirement income with full benefits, the couple refused relocation assistance. In a coordinated on-scene response involving the Adult Protective Services (APS) department, RAP and law enforcement, the couple was removed against their will and placed in an appropriate facility. And although APS officials didn’t have grounds to remove the couple against their will, law enforcement readily determined this need based on scene assessment and the eRAP data displayed on-scene by the RAP coordinator. Prior to eRAP, it was difficult to track calls that were non-medical in nature. The in-home vulnerability algorithm combines dispatch records (without personal health identifiers) with ePCR records to track the entire 9-1-1 effect of any patient. In locations with multiple residents, eRAP can recognize and indicate them separately. Despite efforts to direct the patient into a more stable situation, the patient continued this behavior. One day, after being released from jail after 9-1-1 abuse charges had been dropped by attorneys, the patient walked to his usual payphone and called 9-1-1. HOT and RAP confirmed the incoming call via CAD View, arrived at the scene and cancelled responding units. Since the patient didn’t have what they considered to be a legitimate complaint, the teams escorted the patient to a clinic and introduced him to the clinic staff During the clinic’s offer of assistance the patient discretely slipped outside and called 9-1-1 from the payphone. RAP again identified the incoming 9-1-1 call via CAD View and intervened again. The HOT sergeant immediately requested the city shut down this particular payphone. Remarkably, one day later Client 3 attempted to call 9-1-1 again, but encountered the dead phone. He walked to the clinic to inform staff and inquired if he could use their phone. Instead, the clinic staff instructed the patient to sit until he felt better. The patient took their advice and began watching television. Client 2 has stopped calling 9-1-1, preferring to watch television in the clinic. HOT visits him regularly while arranging for benefits and placement in a care facility. He has had only one EMS encounter in the past four months—a projected EMS and fire savings of $75,000–100,000. immediately to a SIP officer, who responded to the emergency department with a treatment counselor. Within one hour, the patient had been placed back into his treatment program with an admonishment that further behavior would result in re-incarceration. Incidents RAP CLIENT 4 9-1-1 ENCOUNTERS, PAST 12 MONTHS Period BETWEEN THE LINES San Diego’s most dynamic and demanding EMS patients have a profound and complicated effect on the community. Its most chronic 9-1-1 users have frequent encounters with law enforcement, psychiatric services, jail services, homeless services and the court system. In these cases, habitual EMS use is one effect of a severely troubled and afflicted individual. Although EMS can usually identify the vulnerable, EMS doesn’t necessarily have the expertise to provide total case management. These patients need referral to coordinated multi-pronged services because isolated case management focused exclusively on health may offer no benefit. Once RAP navigates an individual out of the EMS system, EMS use can be dramatically reduced. However, elimination of 9-1-1 calls doesn’t necessarily indicate overall success. As a case in point, while Client 4 dramatically reduced his 9-1-1 calls, SIP counselors became taxed as he began exhibiting increasing and extreme attention-seeking behavior. Thus, RAP simply shifted a burden to another provider, as is often the case. EMS is likely to reencounter patients like this during periods of recidivism. Subsequent 9-1-1 encounters require immediate intervention and navigation back into their treatment programs to discourage a return to his or her former 9-1-1 dependence, and reinforce treatment thus far. For this reason, RAP actively supports efforts to keep clients in their respective treatment programs, partly by extension of eRAP technology to case management partners. THE FUTURE OF ERAP San Diego EMS is currently engaged in the expansion of eRAP technology to case management partners. RAP hopes that this extension will help provide the necessary connections for coordinated and responsible community care. Monthly meetings with stakeholders, including the city attorney, are allowing RAP to design appropriate electronic sharing practices. A goal of the RAP is to create a “spoke-and-hub” bidirectional data sharing with all stakeholders and ultimately link to the Beacon HIE. This will require the development of suitable HIPAA-compliant consent protocols similar to those employed by SIP, as well as adaptable programming methods. With such a system in place, EMS sees the role of eRAP extending beyond its most chronic users, soon helping to assist others in the community with disproportionate health burdens. For example, eRAP could facilitate case management of select high-needs beneficiaries (e.g., dual eligibles) who are engaged by managed care programs. In addition, eRAP technology can provide a means to significantly assist in injury and disease prevention. Anne Marie Jensen, EMT-P, is the RAP coordinator for San Diego EMS-Rural/Metro of San Diego and San Diego Fire-Rescue Department. She received a California EMS Authority Award in 2010 for her work in EMS-related technology and was selected as 2012 paramedic of the year by her peers. James Dunford, MD, is the medical director of San Diego EMS and professor emeritus of emergency medicine at the University of California San Diego School of Medicine REFERENCES 1. Dunford JV, Castillo EM, Chan TC, et al. Impact of the San Diego serial inebriate program on use of emergency medical resources. Ann Emerg Med. 2006;47(4):328–336. 2. Tadros AS, Castillo EM, Chan TC, et al. Effects of an emergency medical services-based resource access program (RAP) on frequent users of health services Prehosp Emerg Care. 2012;16(4):541–547. 3. The San Diego Beacon eHealth Community. (2012). In the San Diego Beacon eHealth Community. Accessed Nov. 16, 2012, from WWW.JEMS.COM JANUARY 2013 JEMS 41
  • WWW.JEMS.COM JANUARY 2013 JEMS 43 W hen Hurricane Sandy was bearing down on the East Coast, New Jersey EMS Task Force planner Henry Cortacans was never far from his iPad. Before, during and after the massive storm, Cortacans, one of the key forces in the statewide EMS organization, was plotting the positions of key assets that would be used to render help throughout New Jersey. “This is the best piece of technology to come along since I’ve been an EMT or paramedic,” says Cortacans. “They’re simple, easy to use and provide a great deal of functionality.” Cortacans says the iPad is “critical” to his work during the storm response and has been a useful tool in past deployments as well. Tablet computing devices, including the iPad, have transformed field response by EMS agencies across the nation. PHOTOS MOZCANN/T.KIM URA/ISTOCKPHOTO.COM
  • REVOLUTIONARY MULTI-TOOL The N.J. EMS Task Force is a statewide organization of more than 250 career and volunteer professionals that responds to man-made and natural disasters. Using Intermedix’s Fleeteyes application on his iPad, Cortacans was able to instantly see where each piece of equipment was positioned and where it may be better incorporated into a response plan. Moreover, the application and his iPad were key in assigning additional ambulance strike teams brought in from as far away as Indiana to help with the storm response. “For situational awareness, there’s nothing better,” Cortacans says. Cortacans is not alone. The digital age has transformed the EMS industry in many ways, for sure. At the forefront of that change has been the boom in tablet computing devices, led by the iPad. Apple released the first version of the iPad in 2010, and the device quickly changed the world as everyone knows it. Other large suppliers, such as Samsung and now Microsoft, followed with a tablet device that allows users easy access to applications for tracking data, creating reports and storing information in ways that were unimaginable a decade ago. Although this article focuses on Apple devices and mobile applications, it’s important to note that the pages of JEMS and its associated websites, Product Connect pages and Buyer’s Guides show dozens of other tablet, PC and mobile devices that are enhancing the way EMS documents, researches, reviews, revises, enhances and reports on our work in the field. For more visit ESSENTIAL APPS Tablet penetration is expected to reach 29.1% of the country’s Internet users by the end of 2012, according to eMarketer. com. Moreover, it’s projected that the tablet user base will go from 55 million people in 2012 to 90 million in the next two years. The fire and EMS communities have responded to that growth with a plethora of applications that run on a variety of tablets that are geared toward making emergency operations more efficient. From BLS protocols and guidebooks to incident command system tools, more applications targeted to EMS providers are launching every day. “I think it’s going to be revolutionary,” 44 JEMS JANUARY 2013 PHOTO COURTESY INTERMEDIX >> CONTINUED FROM PAGE 43 The New Jersey EMS Task Force used the Fleeteyes app for iPad to position and monitor assets and other strike teams during Hurricane Sandy storm response. says Bruce Evans, interim fire chief at the Upper Pine River (Colo.) Fire Protection District and a JEMS Editorial Board member. “I’ve seen some things [recently] that tell me even more is on the horizon.” Evans notes seeing a new series of pulse oximetry and cardiac diagnostic tools that work with iPhones and iPads at a recent EMS conference. “That was a seminal event for me,” he says, adding that he thinks these new technologies could have a huge affect on the EMS world. For example, Masimo Corporation has developed an application that allows a special sensor to turn an iPhone into a pulse oximeter. Once it’s approved by the Food and Drug Administration (FDA), it will allow providers to use their iPhones as a primary or backup pulse oximeter and could be especially useful when multiple patients are involved at the same incident or at mass casualty incidents. And, VectraCor has introduced an application that runs advanced 12-lead ECGs (with additional views of the heart added) from an inexpensive tablet or laptop simply by attaching cables to a USB port. Although the VectraplexECG System is currently FDA approved for a specially configured laptop, rapid development of technology in EMS means that it’s only a matter of time until a tablet version is available. Evans is already a fan of tablet technology. In a wildland fire [or other major emergency] scenario, to have all of that mapping is absolutely critical,” he says. ENHANCED SIMULATION Outside of disaster responses, tablets have also found a home in the classroom by helping students access textbooks and take tests. More importantly, the audio and video elements of tablets let students visually experience a learning scenario rather than just read about it. “They are incredibly useful for all sorts of purposes, educational in particular,” says JEMS Editorial Board member David Page, MS, NREMT-P. “We use them in our classroom today. We have eight of them, and people in class are running around checking each other off on skills.” Page has been part of a program within the National Registry of Emergency Medical Technicians to revamp the paramedic program and incorporate tablet testing in the practical portion of the process. “In our case, in education, the use of it seems immediate,” Page says. “We have tons of manikins, but we need to control the manikin and tell it what to do. We can use tablets to do that.” Cortacans has used his iPad in training scenarios as well. Earlier this year when several agencies gathered for a drill around a railroad tunnel, Cortacans was able to use the video function of his tablet to send real-time images back to command, providing a firsthand look at the incident. Had it been real, Cortacans says he would have been able to give the leadership in the emergency operations center (EOC) a view on the scene they wouldn’t normally have—and one he couldn’t have
  • PHOTO BOB KRANE provided as easily with a laptop. software applications. “You’re giving them the best Page believes pricing and durabilpicture possible,” he says. “There’s ity of tablets may be one factor holdnothing like them seeing it with ing up more widespread adaptation their own eyes.” of the tools in field EMS today. “Once The N.J. EMS Task Force planprices decline and they get more rugner also used his iPad to log the ged, laptops used today will fade position of equipment respondaway,” he says. In fact, many of the ing to a recent call at a port, where largest manufacturers of rugged lapthe initial report was that upwards tops have already released tablet verof 50 stowaways were in a consions such as Panasonic’s Toughbook tainer aboard a ship. Within a and GammaTech’s Durabook. short period of time on the scene, he was able to locate each ambuWHAT’S NEXT? Ambulances organized into strike teams at the Northern New Jersey lance that responded and report EMS regional staging area. The position of each team was monitored “Imagine, in an ambulance, you step back to the EOC. in, there’s an iPad on the wall [that] is using the Fleeteyes app for iPad. In addition, the use of Dropaccumulating information via Bluebox, a common cloud storage application, applications. All of this makes the incorpo- tooth and Wi-Fi,” Page says. “Then imagine enables Cortacans to distribute response ration of tablets into field EMS work that being able to hit a button to Skype over to the plans for ports, train lines and other poten- much easier. hospital and talk directly to the doctor.” tial disaster sites to members of the Task To that end, another aspect of tablets to The idea isn’t so far off. Force in an instant, so they can also access be considered is the ease of use and nearAs Evans notes, organizations can buy the plans via their mobile devices. immediate access to the Internet and to three tablets for the cost of one durable lapsocial media. top. So they’re already economical. Likewise, Putting tablets with instant Internet access proven tough cases are already on the marFor more information about cloud security, in the hands of EMS providers in the field ket to protect the sometimes delicate tablets, please see “Secure in the Cloud: The new public vs. private debate is in data security” does create some additional policy work for transforming them into even more powerin the December issue of JEMS or online at EMS managers. Although many agencies ful devices that are dirt, dust and waterproof. already have programs in place to advise “These [devices] can do any number of employees about taking and using photos in things,” says Evans. “It really opens up the In many areas, EMS agencies have tran- the field, the tablets change the game a bit. To whole world of diagnostics in emergency sitioned into doing electronic patient care be successful in this area, they’ll need to have services and gets it down into a small handreports on tablets, rather than paper or lap- solid social media and Internet use policies held device.” tops used in the past. And, using a tablet in place before handing a tablet to a provider “Fact is, the future of tablets in EMS is limdevice, EMS folks in the field can now gain heading out to an EMS post in the field. ited only by the imagination of those using instant access to all kinds of digital informaThe flipside of that, of course, is that them,” says Cortacans. tion, like weather forecasts, TV news and consumers are now relying on social media “All you need is someone with a little even direct video feeds from news helicop- (e.g., Facebook and Twitter) to commu- innovation and creativity, and they’ll find ters—things only achievable via landline or nicate during disasters and expect emer- many ways to use them,” Cortacans says. satellite feeds five years ago. gency responders to do so as well. In fact, “Once you show it to someone, not only are Tablets are being used to transmit real- four in 10 respondents to an American Red they going to be shown the capabilities, but in time images and video of patients to doctors Cross survey said they would use social their minds they can come up with 10 other in hospitals who can make advanced prepa- media to let loved ones know they are safe reasons to use them.” rations on care decisions before the patient during a disaster. Likewise, a third of the arrives in the emergency department. general public would expect emergency REFERENCES There are other factors involved with the help to arrive within an hour after they 1. American Red Cross. (Aug. 31, 2012). More Amerirapid adaption of tablets in EMS, too. Some posted a message on social media, and 76% cans using mobile apps in emergencies. In Ameriof that can be attributed to the changing said they expected help to arrive within can Red Cross. Retrieved Nov. 7, 2012, from demographics of the employee base. three hours after posting on social media, employees tend to come into according to the survey. Also, 70% of the Americans-Using-Mobile-Apps-in-Emergencies. the EMS field already adapted to new tech- general public felt emergency response nologies, rather than having to adapt to organizations should regularly monitor Richard Huff, NREMT-B, is a network television new ways of doing things. Moreover, their websites for emergency requests.1 communications executive, an award-winning journalist, they’re more likely to have already made All of these functions can now be author and former chief of the Atlantic Highlands (N.J.) the transition to smartphones—phones that accomplished easily from the field using First Aid and Safety Squad. Huff can be reached at allow access to the Internet and the use of tablets, Internet access and appropriate WWW.JEMS.COM JANUARY 2013 JEMS 45
  • MANAGEMENT FOCUS >> BY KATHERINE WEST, RN, BSN, MSED IS YOUR AGENCY RECEIVING THE FULL VALUE? M any departments across the country have been signing contacts with occupational medicine groups for a variety of services, including annual physicals, hepatitis B vaccine administration, tuberculosis (TB) testing and post-exposure medical follow-up and counseling. The question: Is this all these occupational medicine groups offer in the way of services? Are they actually offering the practice of occupational medicine, or are they functioning more like a “doc in the box?” In other words, is your department getting the full value of what an occupational medicine practice should or can offer? The definition of the practice of occupational medicine is as follows: “Occupational medicine focuses on the 46 JEMS JANUARY 2013 health of workers, including the ability to perform work; the physical, chemical, biological and social environments of the workplace; and the health outcomes of environmental exposures. Practitioners in this field address the promotion of health in the workplace and the prevention and management of occupational and environmental injury, illness, and disability.”1 This definition suggests that occupational medicine services are actually broad. POST-EXPOSURE ISSUES With regard to post-exposure medical treatment and counseling, the training for occupational medicine providers is generally not present. If the occupational medicine group your department is using offers this service, it would be important to interview and document their specific training in this area of care. This is important, because the Occupational Safety and Health Administration (OSHA) holds the employer responsible for the proper administration of post-exposure care and counseling—not the care provider. The occupational medicine practice is only acting as an agent on behalf of the contracting department and would not be cited by OSHA if proper care wasn’t in place. However, your agency or your government authority—would be. Some occupational medicine groups sub-contract out post-exposure care and counseling to an infectious disease physician, who is best qualified for handling
  • post-exposure events. Infectious disease practices deal with these issues on a day-today basis, so there would be quality of care and consistency of care. This begs the question: Why use the middle man? If this is the case for your department, look at the cost you’re paying on the contract and determine if this is the best routine to follow. Another factor is availability of the service. When assessing the use of an occupational medicine group for post-exposure issues, asking key questions before selection and signing on the dotted line is very important. Is the occupational medicine practice available for coverage for exposure events 24 hours a day, seven days a week? If constant coverage isn’t available and you’re required to use an emergency department (ED) during “off” hours, then the cost of care for your employees increases, and the proper care and counseling may not be delivered. AGENCY AUDIT If you’re currently using an occupational medicine practice, then you might consider conducting an audit. This will assist in protection for your department if an OSHA inspection was to occur, and will identify any areas in need of improvement. The goal is to protect care providers and ensure the department is meeting its needs for compliance. VACCINES/IMMUNIZATIONS On Nov. 25, 2011, the Centers for Disease Control & Prevention (CDC) published new guidelines for vaccination and immunization of healthcare personnel. In this document, the CDC states that these records are to be secure and computerized for easy access. This is to facilitate prompt/proper post-exposure medical treatment. In today’s world, old diseases are back and many individuals are in need of revaccination or vaccination. For example, if you received measles, mumps, rubella vaccine (MMR) between the years of 1963 and 1967, you need to be re-vaccinated with the live measles vaccine. Did your occupational medicine group notify you about this? Was your department notified in 2006 that all healthcare workers were to get boosters for protection from pertussis (whooping cough)? These types of alerts should be included in their role and service. All new hire personnel should be asked to bring copies of their vaccine/immunization records as part of the hiring process. This will assist in the identification of personnel who are in need of vaccines because they haven’t had the diseases or are in need of a booster. In 2006, the CDC published that all healthcare personnel needed a booster for protection from pertussis. This was not well responded to and was published again in 2011. Occupational medicine groups should be tracking this type of information and sharing it with their clients. Previous vaccine/immunization records can be obtained by an individual from their high school, college or past employers. Each individual must request their records, and should be able to obtain them, because those records legally belong to each individual. Current members of your department also need to put forth their records for review of their protective status and childhood disease history. This is all part of health maintenance and prevention from exposure to these diseases. Some of these vaccinations don’t work if given post exposure. This would apply to MMR, for example. Obtaining this information is in your best interest for your protection and also works for the department’s benefit because prevention up front is far less costly than exposure follow-up. Clearly, the need for expanding protection beyond hepatitis B vaccine and TB testing has long passed. Your occupational health practice should be tracking and maintaining records on all administered vaccine and immunizations. The CDC stated in May 2008 that these records need to be “readily available at the work location.” If they aren’t available to the Designated Infection Control Officer WWW.JEMS.COM JANUARY 2013 JEMS 47 SATORI13, CAPIFRUTTA/ISTOCKPHOTO.COM Your agency may not be getting the most it can from its occupational medicine program.
  • OCCUPATIONAL MEDICINE ABCs >> CONTINUED FROM PAGE 47 (DICO), then treatment may be delayed or unnecessary treatment ordered. Your designated officer needs to be able to access these records at any time in an exposure situation. When should you be at work and when should you stay home due to illness? Work restriction guidelines were originally published by the CDC in 1997 and were updated in November 2011, and should be part of each department’s exposure control plan used by the occupational medicine group. The guidelines offer clear information on when staff is fit for duty or when they should be off duty. Working when ill increases your risk because your immune response is lowered and poses a risk for transmission of your illness to co-workers. Are these guidelines in place in your department? Vaccine declination forms are an OSHA requirement and are also addressed by the CDC and in NFPA 1581. Is your occupational medicine group collecting them? Your department should get a report on the percent of declination forms signed and an evaluation of the reasons for individuals declining. no oversight to ensure compliance and no cost analysis. Is your department being told you need annual TB testing no matter what your risk assessment shows? Similarly, is your department being told that annual hepatitis B titers are needed annually or that hepatitis B titers are to be performed on all new hires? If the answer to any of these questions is “yes,” then there’s a problem. None of these is recommended by the CDC, and an audit for OSHA and CDC compliance is in order. The department’s DICO officer can play an important role in performing this audit, and a relationship should be established between the DICO and occupational medicine service. The DICO serves as a liaison between the department and the treating entity for compliance and quality monitoring. The DICO works to benefit department members, but they also work for administration to ensure compliance and quality of care. Remember, the CDC guidelines set the standard of care, and OSHA enforces most of them, but ultimately, the department is held responsible for compliance. ENSURING COMPLIANCE REFERENCES compliance monitoring. Compliance monitoring is a required component of OSHA’s exposure control plan. WORK RESTRICTION GUIDELINES DATA COLLECTION The CDC and OSHA also have requirements for annual data collection as part of annual education and training and exposure control plan updates. Annual reporting of sharps-related injuries, TB risk assessment and airborne/droplet exposures should occur. There’s also a need to support the TB risk assessment by conducting TB conversion rates. TB conversion rates are new positive TB tests in department personnel since the last testing period. This information should be provided by the occupational medicine practice, especially if they are administering TB testing. Departments should also be provided with information regarding the percent of personnel that do not return in time to have their TB skin tests read at 72 hours and have to have them repeated. This adds to department cost and may enter into a decision to switch over to one of the TB blood test that doesn’t require a return visit or a two-step testing process. A department’s need to perform annual TB testing depends on the number of active untreated TB patients that the department transported in the previous 12 months. Many occupational medicine groups aren’t aware of this and are still advising annual skin testing. Is it better to just do annual testing anyway? No. Continuing annual testing when not needed may lead to false positive test results. More is not always better. The CDC is now asking that compliance rates with annual flu vaccine be reported annually and that this information be incorporated into annual training in an effort to boost participation. This information should also be tracked and provided by the occupational medicine group. Occupational medicine groups should be spearheading the effort to increase participation rates. Exposure data should be reviewed on an annual basis and determination made regarding the number that may have been preventable, and recommendations for prevention and educational needs be offered. This may assist in the identification of purchasing needs and serves as a form of 48 JEMS JANUARY 2013 The practice of occupational medicine is much more than simply the administration of hepatitis B vaccine, flu vaccine and TB testing. It also involves the collection of data important to maintaining health and safety of personnel in a department. Because the occupational medicine practice works for your department on a contract basis, conducting an audit for OSHA compliance and ensuring the CDC guidelines are being followed is important. OSHA is responsible for enforcing many of the CDC guidelines, and if they’re not followed, a citation is given to the department. When contracting with an occupational medicine group, your department should present a list of identified needs, and ask if they can be delivered and at what cost. Using a letter of agreement is also a good idea. The letter should state that the practice will adhere to the CDC guidelines. This offers added legal protection for your department because the CDC guidelines are the medical standard of care. Many departments put these responsibilities and compliance in the hands of the occupational medicine practice with 1. Occupational Health & Safety Administration. CPL 02.-02.069: Enforcement procedures for the occupational exposure to bloodborne pathogens, occupational health & safety administration, Nov. 27, 2001. In U.S. Department of Labor. Retrieved Nov. 1 2012, from www.osha. gov/pls/oshaweb/owadisp.show_document?p_ table=DIRECTIVES&p_id=2570. 2. Advisory Committee on Immunization Practices: Centers for Disease Control and Prevention (CDC). Immunization of health-care personnel, recommendations of the advisory committee on immunization practices (ACIP).MMWR Recomm Rep.2011;11(60):1–3. 3. Jensen P, Lambert L, Iademarco M, et al. Guidelines for preventing the transmission of mycobacterium tuberculosis in health-care settings. Morb Mortal Wkly Re. 2005;12(54):1–141. 4. Center for Disease Control & Prevention. Evaluation of results from occupational tuberculin skin tests: Mississippi, 2006. Morb Mortal Wkly Re. 2007;56(50):1,316–1,318. Katherine West, BSN, MSEd, CIC, is an infections control consultant for Infection Control/Emerging Concepts, Inc. and a member of the JEMS Editorial Board. Contact her at
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  • I s filling in fields making you less effective in the field? San Diego Fire-Rescue Department was an early adopter of electronic patient care reports (ePCRs) when it introduced its own system, called “TapChart,” in 2000. Since then, patient information enter- ing has matured and evolved. Electronic documentation of patient data, now hailed as a feat EMS, has been successfully accomplished, and rightfully so, but with the seemingly infinite possibilities for data analysis and the subsequent ability to make data-driven decisions, there has also been a downside. EMS providers now find themselves asking the question, “Am I a healthcare provider or a data collection technician?” More than a decade into the TapChart project, San Diego Fire-Rescue paramedics might now reluctantly admit that they played a part in creating a problem of excessive data collection. But as health records systems inevitably expand, understanding the complexities and evolution of data systems means their experience allows them to also be part of a solution. Experience suggests that the first step toward a solution is to open dialogue between EMS administrators and field personnel surrounding the question of how to integrate ePCR technology without compromising the quality of patient care. In other words, answering the question, “How do we give proper attention to an ailing patient and an electronic device at the same time?” Though the integration of electronic health record documentation has been studied in the hospital and doctor-patient settings, not much has been done yet to examine its affect in the prehospital setting. The integration of technology has and will continue to revolutionize our job as EMS patient care providers. All of us, from the old paramedic waxing nostalgic for the return of the “bubble form” to the new EMT whose smartphone is almost an appendage, will continue to negotiate the balance between patient care provider and data collector. There are some practical steps administrators and patient care providers can take to successfully integrate these new electronic tools into their emergency response systems. DIGITAL CHARTING Computers and electronic medical records are more widely used today by clinicians in the prehospital setting than ever before. According to the National EMS Information System (NEMSIS), more than 75% of U.S. states have an electronic storage system that houses patient data. These systems are at various levels of sophistication, and many states are in the process of revising data elements, improving data capture and ensuring compliance with the future NEMSIS dataset. Both the U.S. federal government and the National Health Service (NHS) in the U.K. have recently announced new initiatives to increase the use of computers as part of routine prehospital patient care data collection. For example, all 50 U.S. states, Washington D.C. and three territories have signed a memorandum of agreement documenting support for the NEMSIS project, a campaign to create a national EMS database. This will be done in collaboration with the Centers for Disease Control (CDC), National Center for Statistics and Analysis and the National Highway Transportations Safety Administration (NHTSA), which will store the data. So we know data is important. Unfortunately, there’s little information on how EMS provider use of computers to obtain this data in the prehospital setting affects patient care and transmission of critical information (in the form of data) as the patient moves from EMS to the emergency department and perhaps to hospital admittance. This absence of knowledge is particularly concerning given that communication arguably is one of the most influential, encompassing and versatile aspects of EMS. Studies in the hospital setting suggest that good communication can improve healthcare outcomes ranging from better treatment adherence to fewer interactions, even reducing medical malpractice lawsuits. But what about in EMS? Published protocols or evidence on how, and under what conditions, EMS use of ePCRs can or should affect the processes and dynamics of care is not as readily available. Every day, EMS is focused on creating better healthcare. So why do we continue to inject complicated technology into the prehospital healthcare environment without considering the dangers along the way, such as creating distraction from high-quality clinically attentive care? Well for one, we’ve got to pay the rent. And for that, we need data. DATA COLLECTION IN EMS Private insurance and government coverage providers are making documentation requirements for reimbursement increasingly stringent. A missing data field great or small may mean the difference between whether your organization gets paid for transport. Billions of dollars in lost revenue for EMS organizations are at stake. The need for thorough patient documentation has never been greater. Undeniably, electronic documentation indeed has been beneficial in this regard. Making data-driven decisions based on numbers rather than anecdotes can result Clockwise: The ambulance crew gets information via a computer-aided display. Fire first responders enter initial patient data on scene. The paramedic finishes patient data entry and sends data to the hospital from the scene. The hospital can retrieve the data via the system. WWW.JEMS.COM JANUARY 2013 JEMS 51
  • 360-DEGREE DATA >> CONTINUED FROM PAGE 51 outcomes or patient satisfaction across their different patient populations. Less than one in five hospitals that collected this data used it for any of these purposes.2 San Diego has been forward-thinking in using statistical data to improve patient care. For example, John Serra, MD, James Dunford, MD, and their team has extrapolated data collected from electronic patient care reports, using that data identify three neighborhoods with higher rates of sudden cardiac arrest and lower rates of bystander CPR. They announced this at the 2012 National Association of EMS Physicians conference. As a result, they’re starting to target community outreach efforts in these neighborhoods and take interventions to teach CPR and cardiac health. Eventually, they will be able to analyze the data to see whether these efforts affected save rates. The point is that if you’re going to have paramedics collect data, you should use it. CHANGE FOR THE BETTER? Collecting, transferring and retrieving patient data shouldn’t be complicated. in better patient care and fiscal policy, saving millions of dollars. This is imperative for private-sector EMS and public agencies with unpredictable municipal budgets. Data also helps us do a better job at showing our community what we do and how we are of value. But we have to do it with accurate and reports are rife with inaccuracies of all types. With that kind of disparate data, what’s the use of collecting it unless we can do it with more reliability? Medical data collection is only the first step in defining and designing prehospital EMS healthcare. Collected data doesn’t mean much unless it can be quantified and If you’re going to have paramedics collect data, you should use it. relevant information. For instance, a 2008 study published in Prehospital Emergency Care showed that collecting social security numbers of 360 patients in the field resulted in an error rate of 73.9% (266).1 You might say that is an extreme example, but have you ever tried spelling a complicated last name in the emergency department at 3 a.m. and then tried to find that patient report through a query later on? Let’s be frank; patient care 52 JEMS JANUARY 2013 analyzed, and unless it takes form as sound clinical direction or quantitative business decisions. Most agencies are not doing this. Massive amounts of unused data sits stored in their “electronic garages.” A 2006 National Public Health and Hospitals Institute survey asked hospitals that collected race and ethnicity data whether they used the data to assess and compare quality of care, use of health services, health You may be asking, did EMS intend to turn clinicians into something other than patient caretakers? To avoid these unintended consequences, EMS administrators should change the way their agency collects data. The following are seven recommendations that administrators and field personnel can use to more easily integrate electronic devices into their EMS system. Insist on intuitive software design. Few software solutions put the patient’s needs first, are organized with the information in the way a patient encounter happens and use intelligent intuitive principles to collect data. Instead, many provide complicated pages and layers, creating a labyrinth that inhibits user buy-in and engagement. This is because the programmer creating your software may never have even talked to a paramedic before and isn’t aware of the needs of your EMS personnel on scene. Work with your vendors to communicate what you really need. Or better yet, if you’re lucky enough to have personnel in your organization who are savvy at programming, use them on special assignment to assist with creating software.
  • Streamline patient data. At a regulatory level, insist the data collection process be made efficient. Increasingly stringent insurance and medical reimbursement requirements for documentation make it cumbersome for paramedics to create patient records. Keep in mind providers shouldn’t be burdened with collecting demographic or other data that isn’t critical for the emergency call. Look at hardware as a short-term investment. There will be a better platform next year. We’re conditioned to look at capital investment as getting the most use of our precious funds through a long lifespan of hardware. However, the opposite is actually best when it comes to technology. Once an item comes down from the shelf, it’s virtually obsolete. Look at the devices you purchase for electronic documentation as a more disposable item, something meant to be used for a time and replaced. Keep it simple. It’s tempting to want to add all the bells and whistles, questions and reference guides, and apps we can to our electronic device, but we must resist the urge. If your current vendor can’t or won’t make the changes you need to simplify your software, then find someone who will. Market hunger is an incredible incentive. EMS administrators should change the way their agency collects data. to insist on bridging the disparity of data silos from healthcare devices with a common, universal standard. There’s a need for better integration and sharing data sources within and across healthcare entities, such as between EMS, EDs and area hospital systems as a whole. Be supportive of your EMS crews with the adoption of technology. Some people are going to naturally adopt new technologies more easily than others, and you will always have a contingent that resists. Provide appropriate, hands-on training about electronic charting to improve their performance and quell concerns. Watching a PowerPoint presentation about the 47 simple steps to complete a patient report on a new device isn’t going to help someone who just learned to program his microwave. Work closely with those providers who are hesitant, and assign people among the ranks on duty who can troubleshoot when necessary. If you have the means, give your field providers adequate time to chart. If you don’t have the time, make it. Some systems are so busy that paramedics must respond to call after call from the hospital without time to document their calls properly. A paramedic at the end of their shift trying to document a cardiac arrest call that happened eight hours and five calls ago is going to be challenged, regardless of the features on the device they’re using. Solicit and accept Build standardized data feedback. bridges to our healthcare devices and to the hospital systems we This is probably an “easier said than done” work with every day. It’s time to insist on standardization and universal standards of healthcare data exchange. Currently, each medical device manufacturer has its own system, most of which are incompatible with others. Users need item, but try asking trusted co-workers how you can improve ease of use of electronic devices. Or ask them to note specific times when you could have done better in this regard. And periodically self-reflect about how you did well or could have done better. CONCLUSION Evaluating electronic patient care information systems isn’t much different than clinical quality improvement steps your agency has instituted. How about evaluating your crews’ performance with integrating electronic devices and the effects of those devices on the crews’ ability to effectively communicate with a patient the way you test them on how to put a patient in C-spine and cardiac pace? You probably got into EMS because you wanted to help people, not fill out boxes and collect data. But the integration of technology in EMS, as in life, is the inevitable way of the future. By keeping pace with your ePCR technology the same way you keep yourself up to date on the newest monitor or intubation gadget, you can be great both in the field and in filling out the field. John Pringle is a firefighter paramedic and the electronic documentation coordinator for San Diego Fire-Rescue Department. He is also a California CEMSIS EMS systems Division Data committee member, a 2008 ComputerWorld Honor program laureate and an EMS 10: Innovators in EMS award winner. Loralee Olejnik coordinates community outreach and education for Rural/Metro of San Diego, San Diego’s 9-1-1 ambulance provider. REFERENCES 1. Brice JH, Friend KD, Delbridge TR. Accuracy of EMS-recorded patient demographic data. Prehosp Emerg Care. 2008;12(2):187–191. 2. Regenstein M, Sickler D. (2006). Race, ethnicity, and language of patients: Hospital practices regarding collection of information to address disparities in health care. In National Public Health and Hospital Institute. Retrieved from www.naph. org/Main-Menu-Category/Our-Work/HealthCare-Disparities/raceethnicityandlanguageof patients.aspx. Check out article/technology/san-diegobeacon-project-delivers-real-t for more about the San Diego Beacon Project. WWW.JEMS.COM JANUARY 2013 JEMS 53
  • 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. THERAPEUTIC HYPOTHERMIA FOR OUT-OF-HOSPITAL CARDIAC ARREST PATIENTS PRODUCES PROMISING RESULTS >> BY FRANCIS KIM, MD; BRENT MYERS, MD; & MICHAEL K. COPASS, MD 2013 JEMS GAMES I n March 2013, a patient suffering from cardiac arrest treated with therapeutic cooling methods 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 one 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 who register using promo code JEMSJanCE (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. FOR MORE, VISIT JEMS.COM/DISCOVER-SIMULATION 54 JEMS JANUARY 2013
  • KEEPING IT COOL >> CONTINUED FROM PAGE 55 CASE REPORT A 56-year-old male was walking into his place of work when he suddenly collapsed in the parking lot. He was found by a coworker who happened to be a registered nurse. She initiated bystander compressions while the public access automatic external defibrillator (AED) was obtained from the place of business. Prior to the arrival of the AED at the patient’s side, firefighter BLS first response and a paramedic level ambulance were on the scene (with a 9-1-1 phone ring to arrival interval of five minutes and 11 seconds). An advanced practice paramedic arrived two minutes later, carrying normal saline IV fluids chilled at 2° C. The airway was managed with a bagvalve mask (BVM). Bilateral tibial intraosseous (IO) needles were placed via an EZ-IO device and infused with chilled saline, and the defibrillator applied during continuous chest compressions (see Figure 1, below). The patient had return of spontaneous circulation (ROSC) after the first defibrillation with a total estimated down time of less than 10 minutes. Airway management was continued with the BVM, and the postresuscitation 12-lead ECG demonstrated an obvious ST-elevation myocardial infarction (STEMI) (See Figure 2, p. 58). The patient was emergently transported to a post-resuscitation center 30 minutes from the scene. While en route, LEARNING Objectives >> Provide a rationale for the use of early hypothermia >> Describe effective prehospital cooling methods and procedures >> Describe the benefits and harm associated with prehospital induction of therapeutic hypothermia he became combative but non-purposeful in his movements. He received 10 mg of midazolam and 1,700 mL of chilled saline, and was discovered to have thermal burns on his back and posterior arms from the hot asphalt of the parking lot where he collapsed. INTRODUCTION Cardiac arrest occurs commonly and causes substantial morbidity and mortality. The incidence of out-of-hospital cardiac arrest ranges from 0.04–0.13% of the total population per year.1–3 Despite advances in prevention and treatments, including external chest compression with ventilation, defibrillation and advanced life support, most patients whom paramedics resuscitate in the field remain unconscious. Survival with good neurologic recovery has been reported achieved in 11–48% of resuscitated patients; the remaining number either die during their hospital stay or remain alive with severe neurologic IMAGE COURTESY WAKE COUNTY EMS Figure 1: Pre-Resuscitation ECG 56 JEMS JANUARY 2013 deficits.1,2 Brain-specific strategies that go beyond cardiac arrest prevention and limitation of brain insult with effective CPR are needed. Many cooling methods have been proposed for use in the field by paramedics: The use of cold 4o C IV fluid, cold metal cooling plates, and a cooling helmet. The development of new cooling methods and technology to augment or improve cooling are currently under way and are an area of commercial interest. This article will focus primarily on the use of cold fluid and briefly discuss the use of other surface cooling methods. RATIONALE FOR EARLY HYPOTHERMIA Prior to implementing any new therapy, medical providers first seek to do no harm. Both animal and human studies have consistently demonstrated that early implementation of hypothermia—either during resuscitation or after ROSC—does not cause harm and may even improve effectiveness of such traditional therapies as defibrillation.4–7 In considering the optimal timing of mild hypothermia as it relates to neurological outcome, several animal studies suggest that cooling earlier rather than cooling later results in more protection. In a recent study of cardiac arrest in mice, application of hypothermia (using cooling blankets) during CPR was shown to enhance outcomes compared with application after ROSC.8 In a dog model of ventricular fibrillation (v fib) arrest, early application of mild hypothermia with cold normal saline infusion during CPR enables intact survival; however, delay in the induction of mild hypothermia reduces its efficacy, which suggests that mild hypothermia should be applied as early as possible.9 In another study, researchers demonstrated that mild hypothermia induced immediately after cardiac arrest improves cerebral function and morphologic outcome, whereas delays of 15 minutes in the initiation of cooling after reperfusion doesn’t improve outcomes.10 Thus, these animal studies suggest that intra-arrest cooling or cooling within 15 minutes after ROSC offers the best chance for neurologic recovery. However, these animal studies must be
  • evaluated in the context of clinical studies, which have demonstrated that even delayed cooling started four to eight hours after resuscitation is associated with improved survival and neurologic outcomes.11,12 Additionally, another recent study from Bernard and co-authors evaluated the effect of prehospital vs. in-hospital induction of mild hypothermia and found no difference in patient outcomes in the two groups.4 This study deserves particular attention for two reasons. First, it must be noted that patients in KEY Terms Endovascular: Inside the vascular space Morphologic: The form and structure of an organism or one of its parts Reperfusion: Re-established coronary artery blood flow, particularly during cardiac arrest resuscitation Tympanic route: The ear; a common site for temperature monitoring. The tympanic membrane, also referred to as the eardrum, carries sound vibrations to the inner ear by means of the bones of the middle ear. achieving goal temperature; however, they’re impractical for field application because they are placed into the inferior vena cava. External cooling techniques have the advantage of being less invasive; however, most of them, including cooling blankets or fluid pads, depend on an external energy supply or external cooling unit and aren’t practical for out-of-hospital use. Ice packs have also been used. However, wide application is limited because of slow induction time to temperatures less than 34o C or 120 minutes.11 The Wake County (N.C.) EMS system uses EMS district chiefs and advanced practice paramedics to rendezvous with crews to deliver cooled saline. the in-hospital cooling group and patients in the prehospital cooling group all achieved identical temperatures within 30 minutes of hospital arrival. In other words, the study didn’t evaluate prehospital vs. in-hospital cooling as much as it evaluated the relative importance of reaching the target temperature 30 minutes faster in one group vs. the other group. Second, this study didn’t evaluate the potential benefits of intra-arrest cooling because no patients received this therapy. It’s important to note that no harm was attributed to the prehospital induction of hypothermia. Thus, in this study, which contained relatively short transport times and very rapid cooling in the emergency department (ED), no benefit and no harm could be attributed to the prehospital induction of hypothermia. Yet, the optimal timing of the initiation of mild hypothermia still needs to be determined. One of the challenges of testing such a hypothesis in humans rests on finding a simple and safe method for rapidly inducing hypothermia that paramedics can apply in the field. Several invasive and non-invasive cooling strategies have been investigated for use in hospitalized outof-hospital cardiac arrest; however, these methods may not be applicable in the field. Field cooling needs to be safe, portable, and easy to administer. Invasive strategies using cooling catheters are rapid in INFUSION OF COLD FLUID The use of IV infusion of ice-cold fluids is appealing because they are portable and easy to administer in the field. It was initially proposed by Stephen Bernard’s group in 2003.9 Another researcher studied the use of 40 mL/kg of normal 4o C saline solution for times greater than 30 minutes in nine anesthetized volunteers who received vecuronium and demonstrated a mean temperature decrease of 2.5o C.10 Similar results have been demonstrated in elective surgical volunteer patients; however healthy surgical or young volunteers may not be applicable to patients with out-of-hospital cardiac arrest. In all of these studies, neuromuscular blockade WWW.JEMS.COM JANUARY 2013 JEMS 57
  • KEEPING IT COOL >> CONTINUED FROM PAGE 57 was used to augment the effects of infusing cold fluid. Before administering cold fluid in the field, the use of cold fluid was initially tested in patients who had bee resuscitated after suffering cardiac arrest. Results from three studies, including one from Seattle, have been remarkably consistent.9,11,12 Patients have low temperatures on admission after resuscitation from out-of-hospital cardiac arrest (35.5º C, 35.4º C, and 35.6º C in these three studies) and drop them drop substantially after the infusion of ice-cold IV fluids (1.7º C, 1.7º C, 1.8º C). In two studies, the fluids were administered with a pressure bag during a 20–30 minute time frame.9,11 In two studies, 4º C lactated ringers solution was infused while in the other, 4º C normal saline was infused.9,11,12 In two studies, the amount infused was 2 L, while in the other it was 30 ml/kg.9, 11, 12 All protocols included paralytic agents and sedatives. The infusions were well tolerated without deterioration noted on clinical examination, blood tests and echocardiograms. In these patients, hypothermia in the target range of 32–34º C was maintained for 12–24 hours using cooling blankets or more complicated devices that allow for easy control of temperature.11,12 One study employed an endovascular device, and one used an external cooling device. Although these studies demonstrate the feasibility and safety of lowering temperatures rapidly with the IV infusion of ice-cold fluids initiated in the hospital, the feasibility and safety An EMS supervisor brings an extra monitor/ defibrillator and cooled saline to his personnel. of paramedics initiating such treatments in the field, their effect on neurologic outcome, and differences between those whose initial rhythm is v fib and those whose initial rhythm is not v fib remain unclear. RECENT STUDIES In a recent pilot study, the Seattle system examined the safety, efficacy and feasibility of using a rapid infusion of 4o C normal saline by paramedics in the field following ROSC in 125 patients who suffered cardiac arrest from v fib, asystole or pulseless electrical activity.13 Sixty-three patients received a rapid infusion of up to 2 L of cold normal saline, resulting in a mean temperature decrease of 1.24 plus or minus 1o C with a hospital arrival temperature of 34.7o C, while the 62 patients not randomized to cooling experienced a mean temperature increase of 0.10 plus or minus 0.94o C (p less than 0.0001) with a hospital arrival temperature of 35.7o C. In-field cooling wasn’t associated with adverse consequences in terms of blood pressure, heart rate, arterial oxygenation, evidence for pulmonary edema on initial chest X-ray, or re-arrest. Secondary endpoints of awakening and being discharged alive from hospital trended toward improvement in v fib patients randomized to in-field cooling, suggesting a potential benefit for early cooling in v fib patients. Early field cooling in non-v fib patients, however, wasn’t associated with improved outcomes. A 2010 study from Wake County, N.C., demonstrated improved outcomes after the field cooling in conjunction with other treatment modalities to care for cardiac arrest patients. The study wasn’t designed to evaluate the impact of field cooling as an isolated therapeutic intervention, however. Thus, the relative impact of field cooling can’t be stated.14 An analysis of patients who achieved ROSC demonstrated a statistically significant increase in survivability for all victims of out-of-hospital cardiac arrest, with trends toward improvement not just for patients with v fib, but also for patients with pulseless electrical activity and asystole.15 IMAGE COURTESY WAKE COUNTY EMS Figure 2: Post-Resuscitation ECG 58 JEMS JANUARY 2013
  • ADDITIONAL CONSIDERATIONS The use of cold IV fluid for prehospital cooling requires additional training and equipment, such as portable refrigeration for cooling the IV fluid and ability to measure central body temperature in the field. In Wake County (N.C.), a district chief or advanced practice paramedic is dispatched to all cardiac arrests. Their vehicles are equipped with portable refrigeration units that maintain the normal saline at 2–4° C. Temperatures are obtained via the tympanic route and infusion of chilled saline is initiated during resuscitation for all patients with an initial temperature greater than 34°. Paralysis with vecuronium and sedation with etomidate is available for use at the discretion of the paramedics, should shivering ensue. In Seattle, each of the paramedic units is equipped with portable refrigerators capable of storing several 1 L bags of normal saline at 4o C. Paramedics are placing esophageal temperature probes after tracheal intubation in all resuscitated out-of-hospital cardiac arrest patients. Paramedics record temperatures using a portable temperature recorder and other temperature recorders, which are directly integrated into the ALS monitors. During a Seattle/King County pilot field study, paramedics administered up to 2 L of 4o C normal saline, pancuronium (0.1 mg/kg), and diazepam (1–2 mg) via IV. Similar to the previously mentioned pilot study of patients treated in hospital, the use of pancuronium appears to augment the cooling effect of the infusion of cold fluid. Seattle Medic One paramedics were already using IV pancuronium and diazepam in the field but not for this indication. Not all EMS systems use these drugs routinely, and this could limit the applicability of this cooling protocol to other systems. The use of cold fluid alone is enough to lower patients’ temperatures in the field. However, in these patients, skeletal muscle relaxation needs to be administered on arrival at the ED. In the Seattle pilot study, the saline was infused through a peripheral IV line, 18-gauge or larger, using a pressure bag inflated to 300 mmHg. The Seattle research protocol didn’t adjust the amount of 4o C normal saline to body weight. Many systems use adult intraosseous infusion in at least one body location to administer cooled saline during therapeutic hypothermia treatment of patient’s in cardiac arrest. EXTERNAL COOLING DEVICES External cooling devices, such as cooling helmets and cooling plates, have also been proposed for use in the prehospital setting. Cooling helmets are an attractive alternative and have been used in an in-hospital cardiac arrest pilot study.14 The investigators used a helmet device containing a solution of aqueous glycerol and placed it around the head and neck in order to induce cooling. Before its application, the helmet device was kept in the refrigerator to maintain a temperature at -4o C. Using this device, cooling to 34o C took a median time of 180 minutes as measured by bladder thermometer and 60 minutes as measured by tympanic thermometer. Another external cooling device developed in Vienna, Austria, known as Emcools, consists of multiple metal cooling plates. The plates are pre-cooled to 20o C until shortly before use. The efficacy of these cooling plates has been demonstrated in a swine model of cardiac arrest. The main advantage is the very rapid cooling rates compared with infusion of cold fluid. The cooling plates are also less invasive because an infusion of fluid isn’t needed. In this animal model, no evidence of skin trauma was detected after the application of the cooling plates. CASE REPORT CONTINUED On arrival at the post-resuscitation center, the patient was paralyzed, sedated and intubated. He was taken emergently to the cardiac catheterization lab, where he was found to have 100% occlusion of his right coronary artery. He then received successful percutaneous intervention with a door-to-balloon time of 46 minutes. The patient was continued on the hypothermia protocol for 24 hours, rewarmed, and transferred to the regional burn center for continued care of his third-degree burns. On hospital day number 13, the patient was successfully weaned from the ventilator. On day 20, he was moved from the intensive care unit and was subsequently discharged with good neurological function. CONCLUSIONS Experimental animal work demonstrates that early cooling or even intra-arrest cooling offers the best chance or neurologic recovery following cardiac arrest. Because the majority of cardiac arrests occur outside the hospital, the application of therapeutic hypothermia presents numerous challenges. The use of cold 4o C IV fluid has been shown to be effective and safe for use in the field by paramedics, while the use of other techniques, such as cold metal plates and helmets, awaits further testing. Whether field cooling improves neurologic outcomes and survival in resuscitated cardiac arrest patients needs to be tested in a large clinical trial before final conclusions can be made. WWW.JEMS.COM JANUARY 2013 JEMS 59
  • KEEPING IT COOL >> CONTINUED FROM PAGE 59 A Wake County EMS crew works in a coordinated fashion to continue cooling of a patient after ROSC. ACKNOWLEDGEMENT We wish to thank the outstanding efforts of the Seattle Fire Department paramedics and the emergency physicians at Harborview Medical Center, the providers in the Wake County EMS System, and the medical care teams of Rex Healthcare and WakeMed Health and Hospitals. Francis Kim, MD, is an associate professor of medicine/neurology at the University of Washington (UW) Harborview Medical Center. Contact him at Michael K. Copass, MD, is medical director of the Seattle Fire Department Medic One Program, medical director of the UW Paramedic Training Program and professor of medicine/neurology at UW School of Medicine. Brent Myers, MD, is director and medical director of the Wake County EMS System in Raleigh, N.C. He also serves as adjunct assistant professor of emergency medicine at the University of North Carolina School of Medicine in Chapel Hill, N.C. Contact him at REFERENCES 1. Becker LB, Smith DW, Rhodes KV. Incidence of cardiac arrest: a neglected factor in evaluating survival rates. Ann Emerg Med. 1993;22(1):86–91. 2. de Vreede-Swagemakers J, Gorgels AP, DuboisArbouw WI, et al. Out-of-hospital cardiac arrest in the 1990s: A population-based study in the Maastricht area on incidence, characteristics and survival. J Am Coll Cardiol. 1997;30(6):1,500–1,505. 3. Cobb LA, Fahrenbruch CE, Copass MK, et 60 JEMS JANUARY 2013 al. Changing incidence of out-of-hospital ventricular fibrillation, 1980–2000. JAMA. 2002;288(23):3,008–3,013. 4. Bernard SA, Smith K, Cameron P, et al. Induction of therapeutic hypothermia by paramedics after resuscitation from out of hospital ventricular fibrillation cardiac arrest: A randomised controlled trial. Circulation. 2010;122(7):737–742. 5. Rhee BJ, Zhang Y, Boddicker SA, et al. Effect of hypothermia on transthoracic defibrillation in a swine model. Resuscitaiton. 2005;65:79–85. 6. Boddicker SA, Zhang Y, Zimmerman MB, et al. Hypothermia improves defibrillation success and resuscitation outcomes from ventricular fibrillation. Circulation. 2005;111(3):195–201. 7. Wira C, Martin G, Stoner J, et al. Application of normothermic cardiac arrest algorithms to hypothermic cardiac arrest in a canine model. Resuscitaiton. 2006;69:509–516. 8. Abella BS, Zhao D, Alvarado J, et al. Intra-arrest cooling improves outcomes in a murine cardiac arrest model. Circulation. 2004;109(22):2786–2791. 9. Nozari A, Safar P, Stezoski SW, et al. Critical time window for intra-arrest cooling with cold saline flush in a dog model of cardiopulmonary resuscitation. Circulation. 2006;113(23):2,690–2,696. 10. Kuboyama K, Safar P, Radovsky A, et al. Delay in cooling negates the beneficial effect of mild resuscitative cerebral hypothermia after cardiac arrest in dogs: A prospective, randomized study. Crit Care Med. 1993;21(9):1,348–1,358. 11. Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med. 2002;346(8):557–563. 12. Hypothermia after cardiac arrest study group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med. 2002;346(8):549–556. 13. Bernard S, Buist M, Monteiro O, et al. Induced hypothermia using large volume, ice-cold intravenous fluid in comatose survivors of out-ofhospital cardiac arrest: A preliminary report. Resuscitation. 2003;56(1):9–13. 14. Hinchey PR, Myers JB, Lewis RS, et al. Improved out-of-hospital cardiac arrest survival after the sequential implementation of the 2005 AHA guidelines for compressions, ventilations, and induced hypothermia: The Wake County experience. Ann Emerg Med. 2010;56(4):348–357. 15. Cabanas JG, Lewis RS, DeMaio VJ, et al. Out-ofhospital initiation of therapeutic hypothermia with cold saline improves survival in patients with return of the spontaneous circulation in the field. Ann Emerg Med. 2010;56(3)S5 [abstract]. 16. Rajek A, Greif R, Sessler DI, et al. Core cooling by central venous infusion of ice-cold (4 degrees C and 20 degrees C) fluid: Isolation of core and peripheral thermal compartments. Anesthesiology. 2000;93(3):629–637. 17. Kim F, Olsufka M, Carlbom D, et al. Pilot study of rapid infusion of 2 L of 4 degrees C normal saline for induction of mild hypothermia in hospitalized, comatose survivors of outof-hospital cardiac arrest. Circulation. 2005; 112(5):715–719. 18. Kliegel A, Losert H, Sterz F, et al. Cold simple intravenous infusions preceding special endovascular cooling for faster induction of mild hypothermia after cardiac arrest: A feasibility study. Resuscitation. 2005;64(3):347–351. 19. Kim F, Olsufka M, Longstreth WT, Jr., et al. Pilot randomized clinical trial of prehospital induction of mild hypothermia in out-of-hospital cardiac arrest patients with a rapid infusion of 4 degrees C normal saline. Circulation. 2007; 115(24):3,064–3,070. 20. Hachimi-Idrissi S, Corne L, Ebinger G, et al. Mild hypothermia induced by a helmet device: A clinical feasibility study. Resuscitation. 2001;51(3):275–281. 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.
  • REVIEW QUESTIONS Test your comprehension with this post-article quiz. This article has been accredited by the Continuing Education Coordinating Board for EMS (CECBEMS) for 1 hour of continuing education credit. For a limited time only, readers of this article may obtain CE credit courtesy of Laerdal Medical Corp. The first 500 visitors to who register using promo code JEMSJanCE (not case sensitive) will receive CE credit free. Objective 1: Provide a rationale for the use of early hypothermia 1. When did the researchers induce therapeutic hypothermia with cooling blankets in the 2004 study by Abella and co authors of cardiac arrest in mice? a. Before initiating cardiac arrest b. While providing CPR c. Within 15 minutes of achieving ROSC d. Two hours after achieving ROSC 2. How did a delay in the induction of mild hypothermia in the 2006 dog model of v fib arrest affect the efficacy of cooling? a. Increases the efficacy b. Decreases the efficacy c. Did not affect the efficacy 3. Kuboyama and co-authors (1993) couldn’t demonstrate improved outcome in a dog model of cardiac arrest when cooling was delayed. How long after reperfusion was cooling delayed? a. Five minutes b. 10 minutes c. 15 minutes d. 20 minutes 4. When is the optimal timing for initiation of mild hypothermia following out-of-hospital cardiac arrest? a. Remains undetermined b. While performing CPR c. In the ED d. After ROSC but before transport Objective 2: Describe effective prehospital cooling methods and procedures 5. What cooling strategy is the MOST practical and effective for the prehospital environment? a. Invasive cooling catheters b. External cooling blankets c. Application of ice packs d. Infusion of cold IV fluid 6. What was the mean temperature decrease in human volunteers found in 2000 by Rajek and co-authors after infusion of 40 ml/kg of 4o C normal saline solution? a. 1.0o C b. 2.5 o C c. 5.0 o C d. 8.0 o C 7. What is the target temperature range when inducing therapeutic hypothermia? a. 26o C–28o C b. 29o C–31o C c. 32o C–34o C d. 35o C–37o C Objective 3: Describe the benefits and harm associated with prehospital induction of therapeutic hypothermia 8. What was the reported harm associated with prehospital induction of hypothermia in the 2003 study by Bernard and co-authors? a. Coagulopathy b. Higher mortality rate c. No reported harm d. Increased pulmonary edema 9. What was the reported harm associated with the rapid infusion of cold saline in the 2007 study by Kim and co-authors from Seattle? a. Re-arrest b. Hypotension c. No reported harm d. Oxygen desaturation 10. Which patient presentation trended toward improvement following prehospital induction of therapeutic hypothermia in the Kim and co-authors study from 2007 from Seattle? a. V fib b. Pulseless electrical activity c. Asystole d. Bradycardia 11. Two drugs commonly used in the prehospital setting for paralysis of patients to minimize heat lost from shivering during therapeutic hypothermia therapy are: a. Vecuronium and sedation with etomidate b. Fentanyl and sedation with lidocaine c. Calcium chloride and etonidate sedation d. Vecuronium and sedation with lidocaine 12. Studies have shown no adverse consequences associated with in-field cooling in terms of blood pressure, heart rate, arterial oxygenation, evidence for pulmonary edema on initial chest X-ray, or re-arrest. True False 13. The incidence of out-of-hospital cardiac arrest ranges from what percentage of the total population per year? a. 0.01–0.04% b. 0.01–0.10% c. 0.04–0.10% d. 0.04–0.13% 14. Survival with good neurologic recovery has been reported achieved in what percentage of resuscitated patients? a. 11–48% b. 3–10% c. 15–40% d. 8–22% 15. IV fluids used in the field for therapeutic hypothermia during cardiac arrest resuscitations are generally cooled to: a. 4o C b. 5o C c. 6o C d. 7o C There’s still time to sign up your team for the 2013 JEMS Games Clinical Skills Competition. Go to /discover-simulation. Deadline to enter is Feb. 1. WWW.JEMS.COM JANUARY 2013 JEMS 61
  • HANDS ON PRODUCT REVIEWS FROM STREET CREWS Multifunction Rescue Tool When you combine the foldable pocket knife concept with a rescue tool, the feature combinations are endless. StatGear’s T3 Tactical Triage and Auto Rescue Tool has many of the key tools you may need in a rescue situation folded into one compact, easy-to-use tool. The outside of the tool features an LED light for illuminating a dark area or assessing pupils. There’s also a spring-loaded steel tip window punch for rapid entry into a vehicle. Folded away inside the tool is a half-serrated 440C stainless steel blade for a variety of cutting needs. You will also find a 440C stainless steel hook blade for cutting clothes and seatbelts. It also comes complete with a stainless steel belt clip and heavy duty nylon belt sheath for easy carrying. VITALS Tool length: 5" Blade length: 3 ¼" Weight: 6.4 oz. Color: Black Price: $39.99 718/551-1815 Long term Cooling It’s a challenge to keep cold therapy items cool in an ambulance, especially when vehicle power supplies are already being pushed to their limits. The LifeBox50 from Faretec is the next generation of EMS cold transport containers. Whether your emergency service is responding to a cardiac arrest or transporting units of blood, the LifeBox50 will keep your saline, medications or blood units at the appropriate temperature without the restriction of relying on a tethered power supply. The carbon vacuum insulated panels produce insulation values of R50. This insulation technology combined with the Pelican case can maintain core temperatures for 30–50 hours. It also contains also a digital thermometer (both battery and solar powered) that allows you to monitor the core temperature. The LifeBox50 comes in several sizes and colors, and custom units can also be designed to fit your needs. Complete Decontamination VITALS Dimensions: 19.7" x 12" x 18" Weight: 44.4 lbs. Voltage: 110V AC Call for pricing 800/788-9119 Dominic Silvestro, EMT-P, EMS-I, is a firefighter/paramedic for the Richmond Heights (Ohio) Fire Department. He is also an EMS coordinator and EMS educator for the University Hospitals EMS Training and Disaster Preparedness Institute and an adjunct faculty member at Cuyahoga Community College. He can be reached at VITALS Size: Small, standard and large Payload capacity: 385 cubic inches (small); 684 cubic inches (standard); 950 cubic inches (large) Exterior dimensions: 16.9" x 10.9" x 13" (small); 19.2" x 15.2" x 9" (standard); and 21.2" x 16" x 10.6" (large) Weight: 8.52–19.04 lbs. Colors: Black, desert tan, olive drab, orange, yellow Price: $390.00–590.00 800/322-3273 >> IN THE NEXT ISSUE: 62 JEMS JANUARY 2013 One of 2012 JEMS Hot Products identified from the EMS Today Conference & Exposition, the RDS 1110-P Room Decontamination System from AeroClave LLC is a safe and cost-effective solution to the question, “Is it really clean?” The process is a combination of Energized Hydrogen Peroxide (eHP) and Destroyer technologies. The result is a full-spectrum, 6-log sterilization that leaves rooms, vehicles and equipment germ free. The process takes approximately one hour to complete. It’s safe for electronic equipment. It can be operated by using either the remote eHP™ head or the AeroClave Portable Applicator. The unit is portable, lightweight and easy to transport, giving you the ability to disinfect your entire fleet and base station facilities. The RDS 1110-P takes the guesswork out of the disinfecting and sterilization process. Management tracking software is also included. You can work with the confidence of knowing that your vehicles and facilities are clear of bacteria and viruses after completing the cleaning process. Simulaids Intraosseous Leg Adult STAT Simulator >> Streamlight ProTac HL
  • For more product reviews: VITALS Dimensions: 2" x 6" x 2" Weight: 1.6 oz. Color: Army combat uniform, black, coyote brown, MultiCam, olive drab Price: $11.67 800/766-1365 Rapid Tourniquet Deployment Seconds count when a tactical medic, police or military unit encounters someone with severe bleeding. Rapid deployment of a tourniquet can mean the difference between life and death. The Universal Tourniquet Pouch TMK-UTQ from Chinook Medical Gear Inc. is a heavy duty, easy-to-use pouch that keeps your tourniquet on your belt for easy access. The TMK-UTQ fits most tourniquets on the market today, including the CAT, SOFT, SOFT Wide, RMT, SWAT-T, Ratchet, and TK-4. The dual attachment system on the back makes it both MOLLE and duty belt compatible. Other features include a Velcro closure flap with a red pull tab for easy one-handed access, elastic sides for a universal fit and a Velcro loop for patch attachment. Constructed of 1000 Denier Cordura nylon, it’s rugged and durable. Refining the Backboard If you’ve been in the field of EMS long enough, you probably remember someone in your station cutting plywood into the shape of a backboard and coating it with layer upon layer of polyurethane. Through trial and error, the backboard has gone through many improvements. The features of the new Base Board Spine Board 35850 from Iron Duck will add to the list of evolutionary changes to the backboard. This backboard is made from a tough, completely impervious rotational molded high-density polyethylene shell over non-toxic polyurethane foam and weighs only 16 pounds. Recent tests show this backboard provides the lowest deflection in the 400–500 lbs. weight class. The 14 oversized handholds measuring 6" x 2" will accommodate gloved hands. Ten optional composite pins can be placed in the lower third of the handhold so they’re out of the way when lifting a patient. A convex bottom helps facilitate extrication, logrolling and lifting. The board is also 100% X-ray translucent. VITALS Dimensions: 72" x 16" x 1.75" Weight: 16 lbs. Capacity: 500 lbs. Price: $124.95 800/669-6900 Cases that Fit Our Environment Most EMS providers consider their mobile phone to be an essential part of their uniform and turnout gear, so it has to be tough enough to take the same beating in the field—particularly in harsh weather and “dirty” environments. LifeProof has introduced cases for iPhones and iPads that can not only take a beating and be submerged underwater, but are also easy to clean after a messy call. The LifeProof fre case for the iPhone 5 is a sleek and thin case that gives you complete freedom to use your iPhone in any wet, dirty or rough situation. It’s the only true protective iPhone 5 case that’s waterproof to a depth of 6.6 feet and tested to military specifications (MIL-STD-810F-516.5) for its drop protection up to a height of 6.6 feet onto concrete. The LifeProof nüüd case for the iPad is water, dirt and shock proof, and features a totally naked screen that provides a perfect tactile response and visual clarity. The LifeProof iPad case protects iPad 2 and iPad generation 3 and 4 devices. VITALS Fits: iPhone 5 (fre); iPad 2 and iPad gen. 3/4 (nüüd) Colors: Black, white Dimensions: 2.64" x 5.41" x 0.48" (fre); 10.4" x 8.2" x 0.8" (nüüd) Weight: 1.05 oz. (fre); 0.7 oz. (nüüd) Price: $79.99 (fre); $99.99 (nüüd) 888/533-0735 MedixSafe M2 Narcotics Cabinet >> Medline BioMask Antiviral Isolation Mask >> MERET Omni Pro ICB Infection Control BLS/ALS Total System WWW.JEMS.COM JANUARY 2013 JEMS 63
  • THETHEY DIDN’T TELL YOU IN MEDIC SCHOOL LIGHTER SIDE WHAT >> BY STEVE BERRY CAN EMS STILL PARTY? The evolution of prehospital social gatherings ‘Life may not be the party we hoped for, but while we’re here we should dance.’ —Proverbs I remember when I decided to leave what I thought was my preordained and highly respected career of teaching the deaf for prehospital care. I had been waffling between a profession that offered stability, great health insurance, summers off and an excuse to talk with only my hands and a job that could only guarantee me PTSD, minimum wage, insomnia, stained clothing and (ironically) hearing loss secondary to siren overload. I was struggling as a rookie, part-time EMT to fit into this closely knit family of providers when a seasoned and highly respected paramedic named Dave sympathetically invited me to attend an EMS party. It was deep within a secluded wooded compound. As Dave navigated the narrow, winding road, a partially clad and painted human form leaped on the hood of Dave’s car, laughing hysterically while howling at the moon— even though there was no moon. As I began to assess myself for incontinence, Dave said, “We must be getting close.” What followed can only be described as surreal. I saw paramedics, EMTs, firefighters, police officers, nurses and ER docs running amuck in a self-contained world of mayhem and pine needles—oh, the horror, the horror! I loved it. I knew then that I had to be a part of this dysfunctional family regardless of the consequences. God help me! Now I’m not implying my fellow lifesavers lack moral fiber whilst expressing their zest for life. But society cuts us little slack, and rightfully so, when it comes to letting off steam regarding the 9-1-1 stresses we confront on a constant basis. (Even though that steam often makes the geysers at Yellowstone National Park pale in comparison.) 64 JEMS JANUARY 2013 Partying is an essential part of the EMS social support system, creating urban legends to be retold for centuries. Such social gatherings allow one to loosen the stethoscope around their neck and provide an opportunity to show the fun side of their personality—assuming that personality isn’t that of an #@$%! That was one hell of a party last night, Joe. Just look at how my hands won’t stop shaking. I am, however, beginning to wonder if this tradition of degrading ourselves among our peers is going by the wayside. Is it because we’re more stressed or preoccupied with our lives outside of EMS? Do we have less loyalty to our employer, or have we simply grown up and become more responsible and mature? For me, I must admit age and degenerating organ faculties may be a factor. Indeed, conversations at EMS parties I’ve attended certainly have changed over the years. 1984: “Who’s dating who?” 1988: “Who’s getting married?” 1992: “Who’s getting a divorce?” 1993: “Who’s getting married again?” 1994: “Who’s on light duty from injury?” 2003: “Who died?” I know I cannot party all night and proceed directly to a 24-hour shift anymore. I remember a time when employees (not me, of course) would start a line on themselves and administer a cocktail of vitamin B, dextrose 50%, 4 mg of Zofran and 2 L of normal saline at the beginning of a shift following an EMS party. One thing for sure is that the best parties are the informal parties not sanctioned by the company. Let’s be honest here. An office party is still an office function requiring a professional demeanor. Whatever happens at these parties doesn’t stay at the party, especially when digital cameras, cell phones and managerial associates are present. But if you’ve made a New Year’s resolution to change your career path, I suggest the following conversation with your supervisor at your next office party: “Yo, boss. Thanks for finally throwing a party with an open bar. Time for some serious pounding of brewskies and tequila shots. I guess we know who’s gonna call in sick tomorrow though, eh? Ha! Ha! Still, I’d rather get a bonus than be here eating this antiquated food. Speaking of antiquated, when are we going to get some new ambulances? I have some suggestions on improving your bottom line—assuming I get a raise, of course. Ha! Ha! Boy this music is lame! Kinda like the door prizes! Did you know the competing ambulance service is giving away weekend getaways to Vail? Speaking of prizes, do these award presentations have to drag on so long? We already know who the suck-ups in this company are. Ha! Ha! Whoa! Your wife looks hot. Where’d all these security dudes come from?” Until next time remember, as Kelly Cutrone once said, “When you’re the most happening person at the party, it’s time to leave.” 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 Web site at www.iamnotanambulancedriver. com to purchase his books or CDs.
  • ES S Co-located with: N N EO D NC RE ERE PA ONF PRE AL C M TION RORIS NA INTER R & TER TE DISAS MAR WA S CH 7-9 HIN , 2 G T O 01 N, 3 D C International Conference on Disaster & Terrorism Preparedness Presented in partnership with Advance Your Career at EMS Today… Where People, Products and Ideas Connect
  • REGISTER SMART AND SAVE MONEY WITH OUR DISCOUNTS We realize budgets are tight, we’ve got a variety of options to help you save money and maximize your budget. All it takes is a little planning… • Register by February 1 and save $80 on a 3-day conference pass • Register with a group of 5 or 10 and save $500 or $1,000 respectively • Military Discount: save 33% on a 2 or 3-day conference pass • Scholarship Fund for New Attendees: apply online to be considered for a free conference registration (excluding travel costs) • Restaurant Discounts: just show your badge and save! • Book your hotel through the EMS Housing Bureau for discounted rates • Like us on Facebook for up-to-the-minute discount ofers Go to to get the details and even more ways you can save! A ONE-YEAR SUBSCRIPTION TO JEMS IS INCLUDED IN YOUR CONFERENCE REGISTRATION! JEMS is the most authoritative source of EMS information worldwide, dedicated to the improvement of patient care in the prehospital setting. Each month you’ll fnd everything you need to advance your career: news, clinical articles, industry surveys, product reviews and more. If you are a new subscriber, please wait 6-8 weeks after the conference for your frst issue. If you are already a subscriber, 12 issues will be added on to your current subscription ($44 value). (Note: $1 of your registration fee is allocated for this purpose.) “ EMS TODAY IS THE SINGLE BEST OPPORTUNITY TO OBTAIN WORLD CLASS PROFESSIONAL EDUCATION IN A SHORT TIME PERIOD. Register at ”
  • REGISTER BY FEBRUARY 1 TO SAVE! THE EXHIBIT HALL WILL FEATURE HUNDREDS OF MANUFACTURERS WITH THE LATEST TECHNOLOGY, PRODUCTS AND SERVICES TO MAKE YOUR JOB SAFER & MORE EFFICIENT. EXHIBIT HALL HIGHLIGHTS: • See the newest products launched for 2013 EXHIBIT HALL HOURS: • Visit the Learning Center with expanded FREE CEH Thursday, March 7, 5:00 p.m. - 7:30 p.m. Friday, March 8, 10:00 a.m. - 4:00 p.m. Saturday, March 9, 9:30 a.m. – 1:30 p.m. • Watch the Cooking Competition, Friday, March 8: get inspired to cook a new dish! • FREE Continental Breakfast on Saturday, March 9 at 10 AM Exhibit Hall Learning Center Friday, March 8, 2013 Saturday, March 9, 2013 11:00 am – 11:30 am M-PEDS 5 Tips for Pediatric Assessment Jason McMullan, MD 10:00 am – 10:30 am Veteran PTS: What you need to know Dean R. Pedrotti Patrick Ziegert 11:45 am – 12:15 pm Top 10 Things Legal Counsel Wants You to Know Allison J. Bloom, Esq. 12:30 pm – 1:00 pm M-TRAUMA Top 5 Things Learned from the Battlefeld Peter P. Taillac, MD, FACEP 1:15 pm – 1:45 pm F-MEDICAL What Lies Ahead in the Second Decade of Therapeutic Hypothermia Treatment? Brent Myers, MD, MPH 2:00 pm – 2:30 pm M-TRAUMA Trapped: When Time is Ticking Christina Martinka, NREMT-P, FP-C, CCEMT-P, PNCCT 3:00 pm – 3:30 pm M-MEDICAL PSST!? Needle Decompression Secrets David Page, MS, NREMT-P 10:45 am – 11:15 am Top Tips for Instructors Keith Widmeier, NREMT-P, CCEMT-P, EMS-I, BA 11:30 am – 12:00 pm M-ABC Bagging Basics: One Second, One Handed David Page, MS, NREMT-P 12:15 pm – 12:45 pm F-MEDICAL Challenging EMS Case Presentation David Page, MS, NREMT-P Interested in Exhibiting? Sue Ellen Rhine Exhibit & Sponsorship Sales Representative Ofce: 918-831-9786 Mobile: 918-510-6230 Email: March 5-9, 2013 Washington, D.C.
  • S ES N N E O ED ENC R FER EPA CON M PR S NAL ATIO RRORI N INTER R & TE TE DISAS MAR WA S CH 7-9 HIN , 2 G T O 01 N, 3 D The JEMS Games ofers a unique experience to learn from some of the best EMS providers! C 2nd Annual International Conference on Disaster & Terrorism Preparedness Held in conjunction with EMS Today, the International Conference on Disaster & Terrorism Preparedness ofers sessions on planning, resources, and response needs for responders to natural and man-made disasters. Your conference registration to EMS Today gives you access to all of these sessions. Watch the teams compete to see how they react during the live scenario. You’ll get new ideas on how to treat your patients and earn CEH. Preliminaries: Thursday, 8:00 a.m. - 4:30 p.m. Finals: Friday, 6:30 p.m. - 9:30 p.m. EMS on the Hill Day Join EMS professionals from acrosss the nation for EMS on the Hill Day, March 5-6, 2013, immediately prior to EMS Today. This is your opportunity to tell your members of Congress about the challenges you face in providing emergency medical care. For more information, please visit After the competetion, you can attend “Lessons Learned from the JEMS Games,” Saturday at 1:00 p.m. to learn even more about the cases presented during the competition. Founding Sponsor Preconference Workshops Add on to your registration to obtain CEH on a focused topic: TM • NAEMSE Instructor Course Part I • Developing and Managing the Emergency Medical Services Field Training and Evaluation Program • TraCER – Critical Care Transport Certifcation Review Course • Advanced Airway: Lecture and Cadaver Lab • Discover Simulation: A Model for Success • Mini Med School for Paramedics • Federal Town Hall Meeting • Media Relations Bootcamp • NAEMT EMS Safety Course • Managing Fire-Based EMS Systems • Secrets for EMS Leadership Success • From the Chart to the Classroom: An EMS Documentation Clinic • Who is in Charge of What? The National Response Framework and ESF8 • Tactical Emergency Casualty Care • Certifed Critical Care Paramedic (CCP-C®) and Certifed Flight Paramedic (FP-C®) Examinations Workshops presented in partnership with: TM Register at
  • SPECIAL EVENTS: DON’T MISS THEM! THURSDAY, MARCH 7, 2013 FRIDAY, MARCH 8, 2013 12:15 PM – 1:30 PM — Networking Lunch for Supervisors 10:00 AM — Cooking Competition This networking lunch is for supervisors, administrators, chiefs, company ofcers … anyone in a leadership position. This is a great opportunity to build your personal network as you discuss hot topics with your peers, all while enjoying a delicious boxed lunch. Visit the exhibit hall to see your EMS colleagues – and rising culinary stars – compete in a cooking competition. Winners will be announced later that day. EMS teams can apply to compete in the competition by submitting an application by February 1, 2013; teams will be chosen on a frst come, frst accepted basis. Teams may include 2-4 individuals. Visit for the list of ingredients you must use and the entry application. 12:15 PM – 1:30 PM — Networking Lunch for Seasoned EMS Personnel This networking lunch is for all those who’ve been in EMS for 15+ years. We know you’ve got great stories and successes to share, here’s your chance to meet up with others who have been in EMS as long as you have! Limited to 50 people at an additional cost of $35 per person for a boxed lunch. 6:30 PM – 9:30 PM — JEMS Games Final TM Competition See the top three teams compete in this fast-paced simulation of an EMS call and earn 1.5 CEH! 12:30 PM – 1:30 PM — Lunch & Learns Enjoy a boxed lunch while you network with a small group of your peers and our distinguished speakers. Discuss the issues, share success stories and get the experienced input of the speaker. Each Lunch & Learn is placed in a session track to indicate the level of discussion. Please select accordingly. BLS/ALS Clinical: T. Ryan Mayfeld, MS ALS Clinical: Christopher P. Holstege, MD ALS Clinical: Peter P. Taillac, MD, FACEP 3:30 PM - 5:00 PM — Opening Ceremonies • Street Medicine Society/John Pryor Award • EMS10: Innovators in EMS Awards Opening Keynote EMS Through the Ages Dan Swayze, DrPH, MBA, MEMS The history of EMS has never been told like this before! After a year of research and reviewing original literature from the past two centuries, Dr. Swayze brings to life the stories of how the ambulance, the stethoscope, intravenous saline, oxygen therapy and other devices we take for granted today were invented. Dr Swayze portrays the stories of some remarkable but unsung heroes in the history of EMS … while dressed in the ambulance uniform of the age. SATURDAY, MARCH 9, 2013 8:30 AM - 10:00 AM — Closing Ceremonies • Prehospital Care Research Forum Awards • 11th Annual Nicholas Rosecrans Awards • James O. Page/JEMS Award • 10th Annual JEMS Games Medals Ceremony Closing Keynote Gaining and Keeping the Public’s Trust Gordon Graham We now live in a transparent society with expanded resources and exposure to the public. As a result, public safety agencies must be mindful of their image and efects of the internet, blogs, social media, Public Records Requests, distrust of government at all levels, inappropriate release of information by employees. Gordon Graham, recognized internationally for his in-depth public safety and risk management expertise, as well as his powerful and insightful presentations, will explain the approach public safety agencies should take to these important issues. 8:00 PM – 11:00 PM — Pub Crawl “ EMS TODAY IS THE SINGLE BEST OPPORTUNITY TO OBTAIN WORLD CLASS PROFESSIONAL EDUCATION IN A SHORT TIME PERIOD. REGISTER BY FEBRUARY 1 to SAVE! BOOK YOUR HOTEL BY FEBRUARY 11 to SAVE! ” ONLINE: (please use priority code JEMS3) FAX: Send your registration form to 972-620-3099 PHONE: Call 888-299-8016 or 918-831-9160 March 5-9, 2013 Washington, D.C.
  • Employment 70 JEMS JANUARY 2013 Equipment To Place a Classiˇed ad, please email: classiˇ
  • To Place a Classified ad, please email: Equipment HAVE OPEN POSITIONS? Get them filled with a JEMS recruitment classified. Reach our audience with your message! Email: ad direct Your source for immediate information on advertisers’ products and services Advertiser RS# Page Airspace 20 19 Anna Maria College 26 Bound Tree Medical Advertiser RS# Page Lighthouse Innovations, LLC 25 25 25 Masimo 28 35 11 C2 Mercury Medical 13 2 Cindy Elbert Insurance Services 23 21 Columbia Southern University 27 27 Ecolab 16 7 Emergency Medical Products/L.A. Rescue 21 21 Ferno-Washington, Inc. 12 1 Fitch & Associates 18 9 Junkin Safety Appliance Co. 24 Knox Co. Laerdal Medical Corporation NAEMT 23,27 PennWell Corporation 17, 23, 65-69 Pulmodyne 15 6 Sansio 17 7 Stryker EMS 30 C3 (73) 21 Vidacare Corp. 22 21 19 15 Zoll Data 29 49 31 C4 (74) Zoll Medical 14 4 FREE advertiser and product information IT’S FAST, IT’S EASY AND JUST A CLICK AWAY! WWW.JEMS.COM JANUARY 2013 JEMS 71
  • LAST&WORD EMS THE UPS DOWNS OF AUTISM AWARENESS common sense and respect for an ambulance crew and patient. We understand Quicky’s needs to provide their customers with adequate parking. But we give their management a thumbs down for not equipping employees with the knowledge needed to properly enforce such a policy. Thankfully, the patient’s outcome wasn’t compromised by the delay Aleywa’s poor judgment caused. PHOTO COURTESY JEB TATE/PIO/HOMELAND SECURITY LIAISON KEEPING THE BEAT GOING We applaud Howard County Fire and Rescue for taking note of a need in the community and doing its part to form this innovative partnership to meet the needs of this patient population. BOOT FROM THE BAYOU Ahmed Maloum Sidi Aleywa, a 33-year-old Mauritian national in the U.S. on an expired tourist visa,was working at Quicky’s convenience store in downtown New Orleans when a 9-1-1 call came in for a chest pain patient at the store. A New Orleans EMS crew arrived, parked and left the emergency lights active. They went inside and took quick action, transporting the patient to the back of the ambulance and treating him while parked in the lot. Apparently, Aleywa took his duties of “booting” cars parked in the lot without paying so seriously that he ignored the flashing lights and crew occupying the emergency vehicle and placed a boot on the ambulance. Unaware the boot had been placed on the ambulance, the prehospital crew attempted to start the vehicle to transport the patient to a local hospital when they discovered the front tire was locked. They then had to call for backup and wait until another crew arrived to transport the man. We chide Aleywa, who was later fired, for his lack of situational awareness. Doing one’s professional duties is indeed important. However, in this case, it went against The Memphis Fire Department (MFD) purchased 17 LUCAS chest compression systems, manufactured by PhysioControl, Inc., thanks to a $240,000 grant from the Assisi Foundation of Memphis. “We believe this technology will allow us to provide even better care for our patients,” said Fire Director Alvin Benson in a news release. “Providing manual CPR can be difficult, inconsistent, and tiring. The LUCAS system will give the patient high-quality, PHOTO COURTESY PHYSIO-CONTROL, INC. Nationwide, one in 88 public school students have been diagnosed with some form of autism. In Howard County, Md., that number is one in 73. That translates to 700 students in the county with an autism spectrum disorder. Past president and current board member of the Howard County Autism Society Beth Benevides Hill said the county has higher-than-average numbers not because of more children with autism being born in the county but because people move to the county because of the services offered to those who need them, according to a news report in the Baltimore Sun. Capt. Tony Concha of Howard County’s Department of Fire and Rescue Services agreed, and now his department provides online autism awareness training for its personnel. “When developing our continuing education program for Howard County, we needed to consider the demographic needs of our community. Howard County exceeds the statewide percentage of autistic persons by more than twice the state average,” Concha says. “Working with the Autism Society of Howard County, we were able to put together a training program that enables our providers to recognize autistic persons and apply specific techniques to provide appropriate care as needed.” This online training program will include a pre-course knowledge check with critical thinking questions about autism facts and emergency response challenges. After firefighters and paramedics complete the training, a post-course quiz will be given to reinforce content comprehension. This expands county-wide efforts to train first responders in autism awareness. Another joint program gives residents the option to voluntarily flag their addresses with dispatchers so first responders can know prior to arrival that a resident may be nonverbal, oversensitive to sirens, unaware of danger, or prone to elope or exhibit other noteworthy behaviors. continuous and consistent compressions without interruption.” The electrically powered devices are hoped to increase Memphis’ 16% survival rate from out-of-hospital cardiac arrests. The Assisi Foundation of Memphis serves nonprofit organizations that work to improve Memphis and the mid-South. It addresses pressing challenges while also searching for root causes with the goal of creating community-wide transformation. We give a thumbs up to the partnership between MFD and the Assisi foundation in awarding this grant. Hopefully, placing more devices in ambulances can help increase CPR survival rates in the area. JEMS (Journal of Emergency Medical Services), ISSN 0197-2510, is published monthly by Elsevier Public Safety, 525 B Street, Suite 1800, San Diego, CA 92101-4495; 800/266-5367 (fed. ID #13-1958712). SUBSCRIPTIONS: Send $44 for one year (12 issues) or $74 for two years (24 issues) to P.O. Box 3425, Northbrook, IL 60065-9912, or call 888/456-5367. Canada: Please add $25 per year for postage. All other foreign subscriptions: Please add $35 per year for surface and $75 per year for airmail postage. Send $32 for one year (12 issues) or $62 for two years (24 issues) of digital edition. Single copy: $10.00. POSTMASTER: Send address changes to JEMS (Journal of Emergency Medical Services), P.O. Box 17049, North Hollywood, CA 91615-9248. Claims of nonreceipt or damaged issues must be filed within three months of cover date. Periodicals postage paid at San Diego, Calif., and at additional mailing offices. Canada Post International Publications Mail Product (CanadianDistribution) Sales Agreement No. 1247948. ADVERTISING INFORMATION: Rates are available at by request from JEMS Advertising Department at 525 B Street, Suite 1800, San Diego, CA 92101-4495; 800/266-5367. COPYRIGHT © 2012 Elsevier Inc. No material may be reproduced or uploaded on computer network services without the expressed permission of the publisher. JEMS is indexed in the Cumulative Index to Nursing & Allied Health Literature and included in the Medline/PubMed database. JEMS is printed in the United States. 72 JEMS JANUARY 2013
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