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Choose 13 at www.jems.com/rs
I WAVE OF THE FUTURE I
Monitoring technology has potential
to transform EMS
By Mike McEvoy, PhD, NREMT-P, RN, CCRN
JANUARY 2013 VOL. 38 NO. 1
I PUTTING THE ‘RAP’ IN RAPPORT I
I REVOLUTIONARY MULTI-TOOL I
5 I LOAD & GO I Now on JEMS.com
10 I EMS IN ACTION I Scene of the Month
12 I FROM THE EDITOR I Future Forecast
I TUNNEL VISION I
DEPARTMENTS & COLUMNS
I OCCUPATIONAL MEDICINE ABCS I
By Gary Ludwig, MS, EMT-P
22 I TRICKS OF THE TRADE I Teeter-Totter
By Thom Dick
EMS surveillance program assists with ‘frequent flyers’
By Anne-Marie Jensen, EMT-P; & James Dunford, MD
Tablet devices transform how data is used & accessed in the field
By Richard Huff, NREMT-B
Is your agency receiving the full value?
By Katherine West, RN, BSN, MSEd
I UPDATE ON 360-DEGREE DATA I
I KEEPING IT COOL I
By A.J. Heightman, MPA, EMT-P
14 I LETTERS I In Your Words
16 I PRIORITY TRAFFIC I News You Can Use
20 I LEADERSHIP SECTOR I Whackers
The role of video laryngoscopy in future advanced
By Terence Valenzuela, MD, MPH; Jarrod Mosier, MD; & John Sakles, MD
Creating better healthcare by challenging the call to collect more
data in the field
By John Pringle & Loralee Olejnik
Therapeutic hypothermia for out-of-hospital cardiac arrest
patients produces promising results
By Francis Kim, MD; Brent Myers, MD; & Michael K. Copass, MD
24 I CASE OF THE MONTH I ‘Not Acting Right’
By Dennis Edgerly, EMT-P
26 I RESEARCH REVIEW I What Current Studies Mean to EMS
By David Page, MS, NREMT-P
62 I HANDS ON I Product Reviews from Street Crews
By Dominic Silvestro, EMT-P, EMS-I
64 I LIGHTER SIDE I Can EMS Still Party?
By Steve Berry
70 I EMPLOYMENT & CLASSIFIED ADS
71 I AD INDEX
72 I LAST WORD I The Ups & Downs of EMS
About the Cover for out-of-hospital cardiac arrest patients produces promIn “Keeping it Cool: Therapeutic hypothermia
ising results,” pp. 54–61, Francis Kim, MD, Brent Myers, MD and Michael K. Copass, MD, discuss a case in
which providers from the Wake County (N.C.) EMS system deliver cooled saline to a patient after return of
spontaneous circulation. Wake County utilizes EMS to rendezvous with crews to deliver cooled saline via a
thermostatically controlled cooler. A patient suffering from cardiac arrest who requires treatment with therapeutic hypothermia cooling methods will be among those featured in the 2013 JEMS Games Clinical Skills
competition at EMS Today in March. This clinical education feature, sponsored by Laerdal Medical Corp. and
the Eagles Coalition, is the ﬁnal of three that participating teams will need to study to plan and prepare for
the challenging competition . PHOTO JULIE MACIE
PREMIER MEDIA PARTNER OF THE IAFC, THE IAFC EMS SECTION & FIRE-RESCUE MED
LOAD & GO
LOG IN FOR EXCLUSIVE CONTENT
A BETTER WAY TO LEARN
TOP 2012 LISTS
As we enter a new year, we thought it would
be fun to create lists of the most popular, most
uplifting and most bizarre news articles of 2012.
We had a blast reminding ourselves of the
stories that made our Facebook page, Twitter
feed and e-newsletters unique. And we think
you will, too.
SHOW US YOUR SKILLS!
PHOTO GLEN ELLMAN
This is your last chance to register for the 2013
JEMS Games—an international clinical skills competition that takes place at the EMS Today Conference & Exposition March 5–9 in Washington,
D.C. The first-place team will receive free conference registration for the following year (as well
as bragging rights for eternity). We’ll give you a
hint: Be sure to read the clinical education article
on pp. 54–61, as well as the ones in October and
November, because components of those articles will be used for the JEMS Games final scenario on March 8.
JEMS.com offers you
original content, jobs,
products and resources.
But we’re much more
than that; we keep
you in touch with
> Facebook fan page;
> JEMS Connect site;
> Twitter account;
> LinkedIn profile;
> Product Connect site; and
> Fire EMS Blogs site.
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EMS NEWS ALERTS
NEW YEAR’S RESOLUTIONS
Match your EMS resolution.
If you’re like most readers,
you look for the Case of the
Month in every issue of JEMS
and want to be able to refer to
them later. Now you can get
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EDITOR-IN-CHIEF I A.J. Heightman, MPA, EMT-P I firstname.lastname@example.org
MANAGING EDITOR I Jennifer Berry I email@example.com
ASSOCIATE EDITOR I Allison Moen I firstname.lastname@example.org
ASSOCIATE EDITOR I Ryan Kelley I email@example.com
ASSISTANT EDITOR I Kindra Sclar I firstname.lastname@example.org
ONLINE NEWS/BLOG MANAGER I Bill Carey I email@example.com
MEDICAL EDITOR I Edward T. Dickinson, MD, NREMT-P, FACEP
Travis Kusman, MPH, NREMT-P; Fred W. Wurster III, NREMT-P, AAS
CONTRIBUTING EDITOR I Bryan Bledsoe, DO, FACEP, FAAEM
ART DIRECTOR I Liliana Estep I firstname.lastname@example.org
Steve Berry, NREMT-P; Paul Combs, NREMT-B
Vu Banh, Glen Ellman, Craig Jackson, Kevin Link, Courtney McCain, Tom Page, Rick Roach,
Steve Silverman, Michael Strauss, Chris Swabb
DIRECTOR OF ePRODUCTS/PRODUCTION I Tim Francis I email@example.com
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REPRINTS, ePRINTS & LICENSING I Wright’s Media I 877/652-5295 I email@example.com
eMEDIA STRATEGY I 410/872-9303 I
MANAGING DIRECTOR I Dave J. Iannone I firstname.lastname@example.org
DIRECTOR OF eMEDIA SALES I Paul Andrews I email@example.com
DIRECTOR OF eMEDIA CONTENT I Chris Hebert I firstname.lastname@example.org
SUBSCRIPTION DEPARTMENT I 888/456-5367 I
DIRECTOR, AUDIENCE DEVELOPMENT & SALES SUPPORT I Mike Shear I email@example.com
AUDIENCE DEVELOPMENT COORDINATOR I Marisa Collier I firstname.lastname@example.org
MARKETING DIRECTOR I Debbie Murray I email@example.com
MARKETING & CONFERENCE PROGRAM COORDINATOR I
Vanessa Horne I firstname.lastname@example.org
CHAIRMAN I Frank T. Lauinger
PRESIDENT & CHIEF EXECUTIVE OFFICER I Robert F. Biolchini
CHIEF FINANCIAL OFFICER I Mark C. Wilmoth
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VICE PRESIDENT/PUBLISHER I Jeff Berend I firstname.lastname@example.org
EXECUTIVE DIRECTOR I Jeff Berend
CONFERENCE DIRECTOR I Debbie Murray
EDUCATION DIRECTOR I A.J. Heightman
EVENT OPERATIONS MANAGER I Amanda Wilson
EXHIBIT SERVICES MANAGER I Raymond Ackermann
EXHIBIT SALES REPRESENTATIVE I Sue Ellen Rhine I 918/831-9786 I email@example.com
FOUNDING EDITOR I Keith Griffiths
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Duluth, MN 55802
WILLIAM K. ATKINSON II, PHD, MPH, MPA,
President & Chief Executive Officer,
WakeMed Health & Hospitals
JAMES J. AUGUSTINE, MD, FACEP
Washington Township (Ohio) Fire Department
Associate Medical Director,
North Naples (Fla.) Fire Department
Director of Clinical Operations, EMP Management
Clinical Associate Professor, Department of
Emergency Medicine, Wright State University
STEVE BERRY, NREMT-P
Paramedic & EMS Cartoonist, Woodland Park, Colo.
BRYAN E. BLEDSOE, DO, FACEP, FAAEM
Professor of Emergency Medicine, Director, EMS Fellowship,
University of Nevada School of Medicine
Medical Director, MedicWest Ambulance
CRISS BRAINARD, EMT-P
Deputy Chief of Operations, San Diego Fire-Rescue
CHAD BROCATO, DHS, REMT-P
Assistant Chief of Operations,
Deerfield Beach (Fla.) Fire-Rescue
Adjunct Professor of Anatomy & Physiology,
J. ROBERT (ROB) BROWN JR., EFO
Fire Chief, Stafford County (Va.) Fire & Rescue Department
Executive Board, EMS Section,
International Association of Fire Chiefs
CAROL A. CUNNINGHAM, MD, FACEP, FAAEM
State Medical Director,
Ohio Department of Public Safety, Division of EMS
THOM DICK, EMT-P
Quality Care Coordinator,
Platte Valley (Colo.) Ambulance
BRUCE EVANS, MPA, EMT-P
Deputy Chief, Upper Pine River Bayfield Fire Protection,
JAY FITCH, PHD
President & Founding Partner, Fitch & Associates
RAY FOWLER, MD, FACEP
University of Texas Southwestern School of Medicine
Chief of EMS,
University of Texas Southwestern Medical Center
Chief of Medical Operations,
Dallas Metropolitan Area BioTel (EMS) System
ADAM D. FOX, DPM, DO
Assistant Professor of Surgery,
Division of Trauma Surgery & Critical Care,
University of Medicine & Dentistry of New Jersey
Former Advanced EMT-3 (AEMT-3)
JEFFREY M. GOODLOE, MD, FACEP, NREMT-P
Professor & EMS Section Chief
Emergency Medicine, University of Oklahoma School of
Medical Director, EMS System for Metropolitan
Oklahoma City & Tulsa
President, RedFlash Group
Founding Editor, JEMS
DAVE KESEG, MD, FACEP
Medical Director, Columbus Fire Department
Clinical Instructor, Ohio State University
W. ANN MAGGIORE, JD, NREMT-P
Associate Attorney, Butt, Thornton & Baehr PC
Clinical Instructor, University of New Mexico,
School of Medicine
CONNIE J. MATTERA, MS, RN, EMT-P
EMS Administrative Director & EMS System Coordinator,
Northwest (Ill.) Community Hospital
EDWARD M. RACHT, MD
Chief Medical Officer, American Medical Response
JEFFREY P. SALOMONE, MD, FACS, NREMT-P
Trauma Medical Director, Maricopa Medical Center
Professor of Surgery,
University of Arizona College of Medicine—Phoenix
KATHLEEN S. SCHRANK, MD
Professor of Medicine & Chief,
Division of Emergency Medicine,
University of Miami School of Medicine
Medical Director, City of Miami Fire Rescue
Medical Director, Village of Key Biscayne Fire Rescue
JOHN SINCLAIR, EMT-P
MIKE MCEVOY, PHD, REMT-P, RN, CCRN
International Director, IAFC EMS Section
EMS Coordinator, Saratoga County, N.Y.
Fire Chief & Emergency Manager,
EMS Editor, Fire Engineering Magazine
Kittitas Valley (Wash.) Fire & Rescue
Resuscitation Committee Chair, Albany (N.Y.) Medical College
COREY M. SLOVIS, MD, FACP, FACEP, FAAEM
MARK MEREDITH, MD
Professor & Chair, Emergency Medicine,
Assistant Professor, Emergency Medicine and Pediatrics,
Vanderbilt University Medical Center
Vanderbilt Medical Center
Professor, Medicine, Vanderbilt University Medical Center
Assistant EMS Medical Director for Pediatric Care,
Medical Director, Metro Nashville Fire Department
Nashville Fire Department
Medical Director, Nashville International Airport
GEOFFREY T. MILLER, EMT-P
Director of Simulation Eastern Virginia Medical School,
Office of Professional Development
BRENT MYERS, MD, MPH, FACEP
Medical Director, Wake County EMS System
Emergency Physician, Wake Emergency Physicians PA
Medical Director, WakeMed Health & Hospitals
Emergency Services Institute
MARY M. NEWMAN
President, Sudden Cardiac Arrest Foundation
JOSEPH P. ORNATO, MD, FACP, FACC, FACEP
Professor & Chairman, Department of Emergency Medicine,
Virginia Commonwealth University Medical Center
Operational Medical Director,
Richmond Ambulance Authority
JERRY OVERTON, MPA
Chair, International Academies of Emergency Dispatch
DAVID PAGE, MS, NREMT-P
Paramedic Instructor, Inver Hills (Minn.) Community College
Paramedic, Allina Medical Transportation
Member of the Board of Advisors,
Prehospital Care Research Forum
PAUL E. PEPE, MD, MPH, MACP, FACEP, FCCM
Professor, Surgery, University of Texas
GREGORY R. FRAILEY, DO, FACOEP, EMT-P
Southwestern Medical Center
Medical Director, Prehospital Services, Susquehanna Health Head, Emergency Services, Parkland Health & Hospital System
Tactical Physician, Williamsport (Pa.) Bureau of
Head, EMS Medical Direction Team,
Police Special Response Team
Dallas Area Biotel (EMS) System
DAVID E. PERSSE, MD, FACEP
City of Houston Emergency Medical Services
Public Health Authority, City of Houston Department.
of Health & Human Services
Associate Professor, Emergency Medicine,
University of Texas Health Science Center—Houston
WALT A. STOY, PHD, EMT-P, CCEMTP
Professor & Director, Emergency Medicine,
University of Pittsburgh
Director, Office of Education,
Center for Emergency Medicine
RICHARD VANCE, EMT-P
Captain, Carlsbad (Calif.) Fire Department
JONATHAN D. WASHKO, BS-EMSA, NREMT-P,
Assistant Vice President, North Shore-LIJ Center for EMS
Co-Chairman, Professional Standards Committee,
American Ambulance Association
Ad-Hoc Finance Committee Member, NEMSAC
KEITH WESLEY, MD, FACEP
Medical Director, HealthEast Medical Transportation
KATHERINE H. WEST, BSN, MED, CIC
Infection Control Consultant,
Infection Control/Emerging Concepts Inc.
STEPHEN R. WIRTH, ESQ.
Attorney, Page, Wolfberg & Wirth LLC.
Legal Commissioner & Chair, Panel of Commissioners,
Commission on Accreditation of Ambulance Services
DOUGLAS M. WOLFBERG, ESQ.
Attorney, Page, Wolfberg & Wirth LLC
WAYNE M. ZYGOWICZ, BA, EFO, EMT-P
EMS Division Chief, Littleton (Colo.) Fire Rescue
EMS IN ACTION
SCENE OF THE MONTH
>> PHOTOS BRADLEY WILSON
FEELING THE HEAT
MS providers from an American Medical Response (AMR) crew in
Wichita Falls, Texas, arrive at medical tents to transport a patient
who complained of abdominal pain and difficulty breathing after he
fell near mile 26 of the “Hotter ‘N Hell Hundred” bike race, a day-long
100-mile ride. The patient was assessed by a team of paramedics, EMTs
and physicians and transported to the United Regional Health Care System in Wichita Falls. The goal of the medical staff who work the race is
to eliminate the need for hospital care, according to executive director Ben “Chip” Filer. “One of our primary goals is to ensure that everyone
who comes to the race goes home vertical,” he says. But just in case, the
AMR ambulances as well as the Wichita Falls Air Evac Lifeteam are standing by all day. The nearly 1,000 medical volunteers saw some 900 patients
at 15 stops along the route during the 96o F day. Of those patients, only 14
required transport to emergency departments.
FROM THE EDITOR
PUTTING ISSUES INTO PERSPECTIVE
>> BY A.J. HEIGHTMAN, MPA, EMT-P
Forces beyond your control are destined to affect your agency
anuary is the time of year when people make resolutions, try to forget the
problems (personal and financial) they
encountered throughout the previous
year and dive into the New Year with
hope of success, or at least improvements.
Unfortunately, January is also the start of
a new budget year, and the “resolutions”
made by agencies at the start of the year
are often made too late to make an effect
on the changes or improvements that are
needed to have an effect during that year.
Think about it; couples plan their wedding for 12–18 months before the wedding
date, and manufacturers plan and design
new products secretly for years before they
are manufactured and launched. But many
response systems wait until a point when
it’s too late to redesign their administrative
and operational systems to meet budget
goals or participate in new approaches to
Moving from a non-transport first
response system into a system of full-service fire first response and transport is
an example of a project that a fire agency
needs to plan well in advance of introduc-
Many response systems
wait until a point when
it’s too late to redesign
their administrative &
to meet budget goals
or participate in new
approaches to service
tion of a proposal to a mayor and city
council for it to be successful. Then, even
if approved, it can take an agency a year
to get the appropriate ambulances built.
So design and bid specs also have to be
preplanned and approved months before
an order is made. Yet some agencies actually think they can make a major change,
such as movefrom non-transport to full
transport, in a few months.
In the next 12–18 months, you will see
lots of action by agencies that have been
thinking ahead by planning for changes
in EMS reimbursement. These changes
include the new world of healthcare reform
with pay-for-performance; new delivery
models and methodologies, such as the
redirection or transport of patients to nontraditional (non-hospital) destinations;
and use of community practice paramedics
to reduce call load and keep patients from
returning prematurely to hospitals in their
Those agencies that are preplanning will
reap the benefits and those that are not will
begin to realize they’re spinning their fiscal
wheels in the mud.
Those agencies that are
preplanning will reap
the benefits & those that
are not will begin to realize they’re spinning their
fiscal wheels in the mud.
So let’s circle back to January. This first
month of the year is when most agencies
begin to implement their new budgets,
business plans and projects in hopes of
greater success, financial prosperity and
territory fortification. Territory fortification is the ability to maintain contracts
and service area in the face of political or
economic changes and challenges.
Although private, non-profit and hospital-based agencies are familiar with the
development of business plans, service
contracts and territory fortification, many
fire and third service EMS agencies are not.
Although private, nonprofit and hospital-based
agencies are familiar
with the development of
business plans, service
contracts & territory
fortification, many fire
& third service EMS
agencies are not.
What’s the reason some are more familiar and others are not? There’s been little need for municipal services to do so
because they’ve offered what are termed
“traditional services.” Traditional services
include crews waiting in fixed stations for
calls to come in, responding and going
back to quarters to wait for the next run.
Agencies and workforces that fit in
this category have also traditionally participated in standard budget development,
had limited need for contracts or new
business outside their normal operational
parameters and had a reasonably certain
hold on their service area (territory).
However, the economic downturn,
municipal shortfalls in tax revenue and
reduced or eliminated federal grants and
financially supported programs during
the past five years are changing all that.
Municipalities are cutting back staff and
services in hopes of stopping fiscal bleeding: cutting out EMS supervisors, training
and quality assurance staff, holding off on
implementing new projects and forcing
their departments to “do without” rather
than innovate and implement replacement
programs and services.
The resultant cutbacks will have a snowball effect on the quality and quantity of
service and, ultimately, affect the revenue
a service has come to expect from third-
party payers. In the future, if your system
becomes less efficient and the quality of
the patient care and follow-up diminishes,
so too will the reimbursement your system
If your system becomes
less efficient & the quality of the patient care &
so too will the reimbursement your system
receives for the ‘services’
receives for the “services” delivered.
Many agencies, particularly those operating in a traditional municipal environment, also aren’t paying close attention
to the affect of the Patient Protection and
Affordable Care Act (PPACA). They are
ignoring the inevitable—that the waves
of what some politely refer to as “Obama
Care,” and the now famous “fiscal cliff,”
could potentially overtake and suffocate
Many agencies are
ignoring the inevitable—
that the waves of what
some politely refer to as
‘Obama Care,’ & the now
famous ‘fiscal cliff,’ could
& suffocate them
operationally & fiscally.
them operationally and fiscally.
Although I’m not an economist and
don’t claim to be an expert on the PPACA,
my position and access to EMS systems
and industry experts compel me to give
you a few things to think about. The Patient
Protection and Affordable Care Act will
affect the way you operate in the future.
And if you’re not thinking, planning and
preparing for the future, you will be affected,
perhaps negatively, in the future.
It’s important to note that there’s a difference between strategic planning and
innovating. Innovation can occur throughout your normal operational and budget
year. But strategic planning needs to be
performed in advance of target projects
and usually phased in over time.
Strategic planning also involves careful
review by key stakeholders and managers and, to be truly successful, cannot be
just the ideas of the director. Top-down
planning, often referred to as “management in a bubble,” is dangerous because it
often reflects just the ideas of one or two
managers or chiefs. In many cases, these
managers have been “off the streets” for
years—often just driving a desk. These
types of managers can be out of touch with
the real, evolving world of EMS and not in
synch with what’s projected for the future.
A few examples of how many systems
have fallen behind the pack over the past
five years include electronic patient care
report and computer-aided design integration; robust data collection and system
reports; patient compartment re-design;
continuous positive airway pressure use
by EMTs; and the adoption of therapeutic
hypothermia. It’s funny, but the root cause
of an EMS systems decline is often one toplevel manager or medical director who isn’t
keeping up with the times or is resistant to
implement changes or enhancements.
If your agency doesn’t have a strategic
plan for the future, you need to start the
development of one now for implementation in late 2013 and beyond. And if you
don’t believe in strategic planning or preparing for future changes in the delivery
of health care services in America, I can
assure you that other EMS agencies or
organizations are doing so and will benefit
from your inactivity.
I am not calling those agencies “competitors” because, to have a competitor,
you have to be prepared to compete. The
athlete who fails to prepare for and train in
any sport usually ends up in second place
or worse. In EMS, it’s important for you
to realize that anything below first place
makes you the de-facto loser.
Let me get more specific. The 1,000plus pages of the Patient Protection and
Affordable Care Act do not specifically reference or name EMS, emergency responders, fire first responders, rescue services,
mass casualty response, disaster preparedness or hospital surge. That, in itself is a
bad sign because the authors of the legislation appear to have forgotten us or at least
not viewed emergency and out-of-hospital
response resources as a high priority in the
However, rest assured, we are (or can be)
a big part of the future healthcare delivery
system if you read between the lines, plan
for integration and adjust your operations
and workforce to ride the healthcare wave
instead of being pushed aside or drowned
Incentives, and disincentives, that will
result from the new healthcare regulations will hit hospitals where they feel
it the most—in their budget. If a patient
returns to their hospital within 30 days
after discharge, the hospital will be penalized financially. So they now have a financial incentive to work with you or another
agency to deploy community practice
paramedics to check on Aunt Mabel in
her home or have an automated system
The Patient Protection &
Affordable Care Act will
affect the way you operate in the future.
that alerts one whenever there are abnormalities in vital signs of the programmed
device “predicts” that an untoward effect is
on the horizon.
The same type of penalties will be
incurred by hospitals if they don’t have
a 360-degree data exchange and review
system in place with all of their “affiliated partners.” Although satellite facilities, affiliate doctor groups and other heal
centers are named in Patient Protection
and Affordable Care Act and EMS is not,
people in the know tell me that EMS will
be considered an affiliated member of each
hospitals care network.
So I and others think secure linkage to
a hospital’s patient record system is probably in your future. And if you can’t afford
to do it, I’m betting that hospitals will eventually become convinced that it’s cheaper
to pay to have you linked than to receive
reduced reimbursements for not having
you linked to their system.
Best wishes for a safe, happy and wellplanned New Year!
CHALLENGES TO ‘EATING HEALTHY’
This month, JEMS readers and
Facebook fans chime in with
additional suggestions and feedback on a December JEMS article
by nutrition columnist Elizabeth
Smith, MS, RD, LDN, EMT-B, “Eating Healthy on an EMS Budget: 8 tips to stretch your budget, not your
waistline.” Also, our Facebook fans respond to news posts about the tragic
school shooting at Sandy Hook Elementary School in Newtown, Conn., on
Dec. 14, 2012. We were touched by their words of love and support for the
Newtown Volunteer Ambulance Service, Newtown Fire and Rescue, and
the community’s other first responders. We echo their thoughts and sentiments to all who have been touched by this terrible tragedy.
I’m fortunate to have a vacuum sealer. Sunday is a
big cooking day in my house. I make stuff that could
be, but doesn’t necessarily need to be, reheated.
I’ve been around for quite a few decades and still
cannot figure out what a “serving size” is. We deal
with things like ounces, grams, etc. When is someone going to put things in terms we use?
Author Elizabeth Smith, MS, RD, LDN, EMT-B,
responds: You’re right, Derek; serving sizes are often
labeled in ounces and grams, and it is much easier
if you can think of servings in terms of everyday
things. Here are a few for reference:
>> One serving of fruit or vegetables is the size
of your fist.
>> One serving of pasta is the size of an ice
>> Three ounces of meat, fish or poultry is the size
of a deck of cards.
>> One serving size of potato is the size of a
>> An appropriately sized bagel is the size of a
>> One serving of cheese is the size of a pair
There are a lot of great visual aids along these
lines available online as well.
Sounds great in theory, but the bottom line is that
in busy systems it does not work. With turnaround
times less than 10 minutes at the hospital, being
scheduled for 12 hours but working 16 hours and it’s
against Occupational Safety and Health Administration (OSHA) regulations to eat in an ambulance
or even store food in an ambulance, you cannot
prepare your meals for the week. What you are
describing may be the norm in your area but in most
services good luck with being able to do this on a
daily basis. Your intentions are good but the real
factor is that you need time to stop and eat and that
just does not happen.
Author Elizabeth Smith, MS, RD, LDN, EMT-B,
responds: I believe the OSHA regulation you are
referring to is the prohibition of eating and drinking
in the workplace, part of 29 CFR 1910.1030, Occupational Exposure to Bloodborne Pathogens. This regulation has been interpreted in the OSHA Bloodborne
Pathogens Exposure Control Plan for ambulance
companies specifically to define the patient area as
th workplace and the cab section of the ambulance
as permissible for food and drink, provided that the
company has a policy in place for employees to
cl contaminated clothing. So you are allowed to
ca food and eat in the truck, just keep it in the
fr and away from the patients.
TRAGEDY IN NEWTOWN, CONN.
We in EMS who responded will be forever changed
for what we could not do at the scene. There was
nobody to transport, and that was devastating.
Nothing breaks an EMT’s heart more than not being
able to do anything but move the dead. May we find
strength in each other and in our profession. God
bless, from a Newtown resident and AEMT.
I was there at the [Newtown] High School gym
[working with American Red Cross Disaster Mental Health], where I got to talk with the EMS folks.
We don’t have words to express the deep loss
I’ve been in EMS nearing 23 years; I don’t think I’d
be able to work another day for a while after all
that happened there. After all the years, it is the
young’uns that still haunt my dreams and thoughts …
AP PHOTO/NEWTOWN BEE, SHANNON HICKS
IN YOUR WORDS
Paramedics push stretchers toward Sandy Hook Elementary School in Newtown, Conn., where a gunman opened fire, killing 26 people, including 20 children, on Dec. 14, 2012.
As I began my shift today, I was shocked at the tragic
news of this senseless act. I feel sad for those struck
by this devastating situation. Through the sadness
comes pride in my fellow EMS/fire/law enforcement brothers and sisters that ran toward this scene
today. Stay safe and continue with courage and
strength. Hug your family a little tighter when you
get off duty.
In the time to come, may strength, compassion, selflessness and service guide your way. And when it is
your turn to take care of each other and yourselves,
may you have the healing that you need.
This is what makes me so passionate about my job
in the EMS field. All of us have to endure so many
scenes like this. We have to put our feelings aside at
that moment to help the people in need. I take my
hat off to all EMS medics and salute you for what
you do for patients. Thank you to all you guys what
you do for your fellow man. I’m so proud of you
even though I don’t know you. It’s a cruel world out
there. Good luck to all of you.
FEATURED BLOG: A
Day in the Life of an Ambulance Driver
BLOG POST EXCERPT:
‘FOR NEWTOWN VOLUNTEER AMBULANCE CORPS’
And then there are days like Friday, when nothing can prepare you for the horror you faced, and no amount of code
saves, or babies birthed, or little old ladies comforted, no
amount of joy your career as an EMT has brought you
before or since, can erase the scar it leaves on your soul.
You only triaged three from Sandy Hook Elementary School as red. All the rest
were blacks. Only one you transported lived beyond the emergency department. And given that you’re a small volunteer department, odds are you knew
many of the children killed.
People who do not work in EMS do not understand triage. Sure, they may
grasp the concept of it; sickest transported first, stable patients transported
next to last, dead patients transported last of all. They may even know what the
colors red, yellow, black and green signify.
Wow ... thank you for your gift of words, so beautifully written! Heather M. Via Facebook
A very touching look at a day in the life of volunteer EMTs. A sad day indeed for all of us that answer the
call. The crews from Crook County, Wyo., send our deepest sympathies to the families and our thanks to all
the first responders. Sheila H. Via Facebook
For more on the Sandy Hook
Elementary School massacre, please see
JEMS Editor-in-Chief A.J. Heightman’s
note on page 18 of this issue.
MCI MANAGEMENT TIPS
I am assembling some of the items you mentioned in
your great article on MCI planning in the November
issue of JEMS (“Incident Management: 10 tips to help
gear up for MCIs” by A.J. Heightman, MPA, EMT-P).
Do you have any checklists you have used in the past
to assist me in large event planning? Thank you for
the insight on this very important topic.
Daytona Beach, Fla.
Editor’s Note: Thank you, Troy, for the kind words.
We recommend reading the article “MCI Magnifiers: Many factors can complicate an incident of
any size” by Editor-in-Chief A.J. Heightman which
appeared in the September issue of JEMS. This
article, and many more resources for management of major incidents, can be found online at
Choose 19 at www.jems.com/rs
NEWS YOU CAN
Bringing issues to THE HILL
Fourth annual EMS on the Hill Day to be held prior to EMS Today
egistration has begun for the fourth
annual EMS on the Hill Day, hosted by the National Association of
Emergency Medical Technicians (NAEMT).
The 2013 event takes place on March 5–6,
2012, in Washington, D.C. In order for
appointments to be scheduled with congressional leaders, participants must register by February 15, 2013.
EMS on the Hill Day is the nation’s only
national EMS advocacy event, providing
professionals from all sectors of the emergency medical community the opportunity to advocate for specific EMS legislation. According to NAEMT Executive
Director Pamela Lane, EMS on the Hill
Day sends a consistent message to elected
leaders regarding critical issues facing EMS
throughout the nation and builds important relationships with Senate and House
leaders and their staff.
Meeting with Congressional leaders
also has a direct effect on individual EMS
agencies and practitioners. “The more [legislators] in Washington understand the
challenges to providing quality EMS, the
greater the possibility that they will craft
policies that address those challenges,”
This past year, nearly 200 EMS practitioners from 42 states and the District
of Columbia attended 246 meetings with
U.S. Senators, House representatives, and
their congressional staff to advocate for
This year, EMS on the Hill Day will
be held just prior to EMS Today, the
annual JEMS conference and exhibition
that is scheduled for March 5–9, also
in Washington D.C. The schedule for
the 2013 EMS on the Hill Day includes
March 5: Participants will meet with
other participants and attend a preHill visit briefing, followed by a reception.
March 6: Participants will attend scheduled appointments with their Senate and
House leaders and their staff, followed by
an evening reception. Register online at
—Teresa McCallion, EMT-B
From our Facebook Audience
We asked our Facebook fans what issues
they would bring to Washington if they
had the opportunity. Here’s what they said:
Brent D.: Pay, benefits and provider health
Justin S.: Educational standards, evidencebased medicine, community paramedicine.
David C.: Hooray for healthcare reform. I
myself have a full-time job, but most of my coworkers work two or three part-time jobs. This
will finally give EMS providers an actual affordable
option to insure themselves instead of praying they
don’t get sick.
Skip K.: The need to include basic civics and
constitutional law in EMT class, so that folks in EMS
have some idea of the responsibilities of the federal
government versus the things that are reserved to
Jason B.: Make EMS a profession with licensure
not just certification.
Skip K.: Also have to get people to do research.
A piece of paper from the government that lets
you practice a job or profession is a license, even
if they call it something else. Check out the legal
opinion on the subject on the NREMT’s website:
J Mac Q.: Declining Medicare reimbursements.
Garrett H.: All of the above are good things,
most necessitating money and organization. We
can take care of some of that with current draft
legislation like the EMS field bill. Money will
involve the need to have alternate payments other
than being a taxi.
Check out the most interesting, bizarre and unusual cases at jems.com/case-of-the-month
The JEMS Family of Products:
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in the feld, JEMS provides
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products and EMS trends.
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The JEMS eNewsletter
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It’s free to subscribe …
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Giving you the detailed
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For more information on the JEMS Family
of EMS Products: www.JEMS.com
>> CONTINUED FROM PAGE 16
THOUGHTS ON THE SANDY HOOK MASSACRE
A NOTE FROM JEMS EDITOR-IN-CHIEF A.J. HEIGHTMAN, MPA, EMT-P
The shooting and killing of 26 innocent children and staff at Sandy Hook
Elementary School in the peaceful, beautiful town of Newtown, Conn., 45 miles
southwest of Hartford and 60 miles northeast of New York City, causes us all to
take pause and wonder how such a tragedy can happen.
Those of us in the emergency community think of the responders—the tragic
and grisly scene they were forced to endure—and we feel the desire to reach out,
pat them on the back and let them know our thoughts and prayers are with them.
It appears that the shooter was shooting randomly and had a purposeful
attack plan. Many are trying to make sense of this tragedy and wonder what
they would do if an attack of this nature took place in their community.
This type of attack has occurred before and will be replicated again. School
shootings have become commonplace for myriad reasons: Revenge on bullying,
retribution on teachers and administrators, and by individuals who are out to
make a strong statement.
But what few people know is that terrorism and mass casualty experts have
predicted this type of mass killing spree (and scores larger) for years—and for
a reason we all dread hearing—that terror organizations have been espousing
that, if you want to make a statement and bring a country to its knees, kill
In my MCI classes, I discuss the little-known incident that occurred in
Beslan School Number One (SNO) in the town of Beslan, North Ossetia (an
autonomous republic in the North Caucasus region of the Russian Federation)
on Sept. 1, 2004. It was a premeditated terrorist assault planned for the first
day of school, when it was customary for parents, siblings and grandparents
to accompany their school-aged children back to school for the start of the
new school year.
The terrorists were deployed by a Chechen separatist warlord who
demanded recognition of the independence of Chechnya at the U.N. and
Russian withdrawal from Chechnya.
To make a strong statement, the assault was targeted for a vulnerable and
easy target—an elementary school where the students and faculty aren’t physically able to repel an attack.
The terrorists easily entered an open access, unsecured school that they had
scouted and took 1,100 people (including 777 children) hostage. They used the
strongest male hostages to fortify the school and then killed them to eliminate
them as future threats. They herded the youngest children into the school’s
gymnasium and chained several to basketball hoop assemblies rigged with
explosives that would detonate if any of them tried to escape.
Townspeople soon learned of the terrorists’ takeover of the school, alerted
the authorities and began to shoot at the school in an attempt to mitigate the
incident. This created a vicious crossfire that impeded rescue operations. The
hostage situation lasted more than three days and ended tragically when, during
an assault by Russian security forces, one of the booby-trapped children detonated the explosives and 334 hostages, of which 186 were children, were killed.
The tragedy in Newtown, Conn., at an elementary school occupied by 700
children, should cause all responding agencies to take the time to obtain a
copy of John Giduck’s book, Terror at Beslan, read it carefully and work with
their school systems to improve school security, practice active shooter and
MCI scenarios and be properly prepared if such an event happens in their
community, particularly one involving places where a high volume of children
PERSONAL USE OF COMPANY EQUIPMENT
here does the line get drawn with regard to the personal use of company equipment and supplies? A certain amount of personal use of an
employer’s “stuff” seems to be common and accepted practice these days.
For instance, the use of a workplace computer to check sports scores or order
from an online merchant is a regular occurrence in American workplaces. But
what about some of the relatively expensive equipment found in the EMS
workplace? For instance, what are the rules when it comes to using one of
your employer’s ambulances to stop at the store for a few personal items, or
to swing by your child’s soccer game?
The first rule is that there are no hard and fast rules—those are set by each
employer. No state laws of which we are aware would regulate what can and
cannot be done with an ambulance or other EMS equipment when it’s not
engaged in active EMS operations.
There may be laws, regulations or policies that require on-duty ambulances
to remain in a specified coverage zone or operating area. Certainly there could
be consequences for violating these requirements. Otherwise, so long as the
agency is not violating any rules regarding vehicle deployment, this would not
pose a legal barrier to occasional personal use of a company vehicle.
Where the bigger issue comes into play, however, is whether the employee
is violating the employer’s policies with regard to the personal use of company equipment. If an employer permits employees to use ambulances or
other company vehicles for occasional, minor personal errands, then that is
up to the employer. On the other hand, if the employer has a “zero tolerance”
policy, prohibiting the use of company vehicles for any personal use, then
the employer would likely be within its rights to discipline or terminate an
employee for such conduct.
If the workplace is unionized, discipline
for violating any such rules would have to
be resolved with reference to the collective
bargaining agreement in place between the
union and the employer.
Extra caution should be taken when the
vehicles, equipment or other supplies belong to a nonprofit, tax-exempt organization. State and federal laws generally prohibit “private inurement”—that
is—using tax-exempt assets to benefit specific individuals.
Although an occasional trip to the store would likely not catch the attention of the IRS, regular use of nonprofit assets for private benefit could very
well become an issue that could even jeopardize the tax-exempt status of an
Although occasional use of an ambulance or other vehicle is one thing,
the “pilfering” of supplies for personal use is another issue altogether. Taking
one band-aid out of the jump kit is commonplace, and probably would be
OK with most employers, but helping yourself to supplies needed to stock
your personal jump kit would be something else entirely. Again, the rules are
ultimately up to the employer, but few employers would tolerate the theft of
company supplies in this fashion.
The bottom line is that employers should take the time to write clear and
workable policies on this issue—and then employees would be well-served to
follow those policies. If no written policy is in place, but employers knowingly
permit or tolerate the use of vehicles or equipment, then that might create
a de facto policy permitting it. A clear written policy removes the guesswork
for both parties.
For more of the latest EMS news, go to jems.com/news
Pro Bono is written by
attorneys Doug Wolfberg
and Steve Wirth, founding
partners of Page, Wolfberg &
Wirth, a national EMS industry law firm. Visit the firm’s
Agency one of two in U.S. to receive triple accreditation
unstar Paramedics, the EMS transport provider for Pinellas County (Fla.), remains one of
two EMS providers in the U.S. to be accredited
by the following three respected industry organizations:
>> The Commission on Accreditation of Medical
Transport Systems (CAMTS),
>> The Commission on Accreditation of
Ambulance Services (CAAS), and
>> The Accredited Center of Excellence (ACE)
by the National/International Academies of
The only other two programs in the world
to hold all three accreditations are Regional
Emergency Medical Services Authority (REMSA)
in Reno, Nev., and Emergency Medical Care Inc.
in Nova Scotia.
The CAMTS, CAAS and ACE programs ensure
quality care and transportation service safety. To
become accredited, EMS programs are evaluated
on a range of criteria, from general operations
(such as safety procedures and equipment management), to staff wellness policies and public
education programs (such as free CPR classes and
child passenger safety assistance).
“These accreditations are important to us;
we’re pleased to hold them and to take part in
the processes,” said Mark Postma, COO with
Sunstar Paramedics, in a press release. “Along
with frequent awards and a 96% customer satisfaction rate, our people take great pride in our
work, and we appreciate being told we’re doing
a good job.”
The accreditation processes take at least four
months, and each accreditation lasts three years.
In Florida, there are 17 organizations accredited
by ACE, nine with CAAS, and five with CAMTS.
Sunstar employs 500-plus local residents and
responds to approximately 500 calls a day.
CAFFEINE: THE GOOD & BAD
WHAT EMS PROVIDERS NEED TO KNOW
with beta effects from
stimulating epinephrine release. As some of
us know too well, too
much coffee can cause
palpitations, tremors and even
sweating. Other relatively benign side effects
of increased amounts
of caffeine include nausea, vomiting and
anxiety. Serious and potential fatal effects of
caffeine include ventricular arrhythmia, seizures, altered mental status, excited delirium,
status seizures, hypertensive emergencies
and stroke syndromes because of intercerebral hemorrhage.
The treatment of potential caffeine overdoses focuses on securing the patient’s airway, breathing and
circulation via IV
fluids and temperature control, calming the patients
with a benzodiazepine like valium
or Versed, using
an antiemetic for
nausea or vomiting and using
severe hypertension not respond-
ing to benzodiazepineinduced relaxation. Beta
blockers are contraindicated because they allow
caffeine’s (like cocaine’s)
effects and risk of severe
In summary, caffeine ingestion is usually
benign, but it may have neurologic, cardiac
and gastrointestinal side effects. Caffeine
intoxication should be considered in previously healthy patients who deny cocaine and
amphetamine use but who appear hyperadrenergic. Acute caffeine intoxication can
mimic many conditions including mania,
excited delirium, cocaine intoxication and
thyroid storm. —Corey M. Slovis, MD
Choose 20 at www.jems.com/rs
PHOTO A.J. HEIGHTMAN
Caffeine is omnipresent. It’s found in
coffee, tea, most soft
prescription medications and energy
drinks. Brewed coffee usually averages
about 80–100 mg of
caffeine per 8 oz. cup,
and coffee drinks at
places like McDonald’s and Starbucks range
in caffeine from 50–200 mg. Some specialty
coffee drinks have as much as 330 mg in a
Similarly, great variability exists in
“energy” pills and drinks that can have as
little as 50 mgs to as much as 200 mgs in
just 2 oz. of liquid. Recently, some deaths
attributed to the ingestion of energy drinks
with high amounts of caffeine have gained
media attention. Caffeine can be toxic with
an estimated lethal dose in the range of 5–10
grams in normal subjects. Lower amounts
could potentially be toxic in patients with
pre-existing heart disease and those who are
taking other stimulants or intoxicants, especially if they were dehydrated.
Caffeine’s effects are almost always
benign; it usually increases alertness and
may mildly raise pulse and respirations due
to its alpha vaso-constricting effects along
PRESENTED BY THE IAFC EMS SECTION
>> BY GARY LUDWIG, MS, EMT-P
Discipline isn’t always the best action
PHOTO A.J. HEIGHTMAN
hen my kids were little, one of
our favorite things was to go to
Chuck E. Cheese’s, where they
could burn up some energy eating pizza,
playing arcade games and running around
on the playthings.
One of the arcade games was called
“Whack-a-Mole.” Out of five holes, a mole
pops up at random, and you “whack” it in the
head using a soft hammer to knock it back
down. If you don’t hit it fast or hard enough,
it disappears back down its hole. The more
you hit and the faster you hit them, the
higher your score.
This classic arcade game spurred a book
on a managerial style that I find is reminiscent of how some EMS organizations manage their employees. It seems some managers
think they’re playing Whack-a-Mole. They
discipline employees on a routine basis and
without regard for the circumstances, knocking the employees in the head as fast and as
hard as they can.
In these types of EMS organizations,
you’re disciplined any time a complaint is
received from a nurse, physician, citizen,
patient or bystander. It doesn’t matter who
complains, and the circumstances of the
complaint aren’t investigated. The bottom
line is that management feels the employee
must have done something wrong. Basically,
they only follow one fundamental principle:
“the customer is always right.”
The resulting morale and turnover in these
EMS organizations is deplorable. Nobody
goes out of their way to deliver exceptional
service. They instead go about their jobs in
pure fear of doing something wrong and
receiving a complaint.
I contend that employees do things wrong
for three reasons: They’re unaware, unable or
unwilling. Many EMS managers discipline
employees for all three reasons. Instead,
we should be looking at the circumstances
by which the infraction happened. If an
employee is unaware of a policy or procedure, this is an opportunity to mentor rather
Stop playing Whack-a-Mole with your employees.
the number of accidents. Why do we think
changing people through disciplinary action
is an effective solution to a problem, especially when changing the system will ensure
the problem will go away?
One management philosophy emerging
in the healthcare industry, which is supported by the National Association of Emergency Medical Technicians (NAEMT), is
“just culture.”1 In a just culture—a concept
invented by “Whack-a-Mole” author David
Marx—the goal is to look at an error and
classify the action into one of three categories: human error, at-risk behavior or reckless behavior. The need for and extent of any
punishment is based on this classification.
Once the error is assessed and classified,
the just culture concept suggests a course of
action. Managing human errors is done by
looking at processes, procedures, training
and design. People who make at-risk decisions are usually managed by coaching and
increasing situational awareness. It’s only
those employees who demonstrate reckless
behavior that just culture recommends that
Developing a just culture and taking this
new approach to managing mistakes in your
organization is a large-scale change. But the
Whack-a-Mole mentality certainly has demonstrated it doesn’t work and can actually
cause harm to an organization.
than discipline. Wouldn’t the employee
prefer to receive coaching rather than be
whacked in the head like a mole?
Sometimes the problem occurs because of
a systemic problem. For example, consider a
service that keeps disciplining employees for
hitting the door frame on either side when
they back an ambulance into the station. This
keeps happening over and over. An EMS
manager should question why an employee
would intentionally back an ambulance into
the door frame of an ambulance station.
They might come to the conclusion that the
mistake isn’t intentional and perhaps suggest
a policy where spotters have to be in place REFERENCES
1. National Association of EMTs. (July 19, 2012).
any time an ambulance backed into the staNAEMT Board Adopts New Position Statement
tion. I bet accidents involving ambulances
on ‘Just Culture’ System. In JEMS. Retrieved
backing into a door frame would drop draNov. 5, 2012, from www.jems.com/article/news/
matically. You could even go one step further
and add back-up cameras and an alarm system to further assist the drivers.
Gary Ludwig, MS, EMT-P, has 35 years of
In the above scenario, a systemic
EMS, fire and rescue experience. He currently
problem existed because the employserves as a deputy fire chief for the Memphis
ees were unable to do their job withFire Department. He’s also Chair of the EMS
out a tool they needed (a spotter or a
Section for the International Association of
camera and alarm system). A change
to the policy and procedure supported by Fire Chiefs. He can be reached through his website at
additional technology drastically reduced GaryLudwig.com.
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TRICKSOUR PATIENTS & OURSELVES
OF THE TRADE
>> BY THOM DICK, EMT-P
EMT poses a different loading strategy
his is a story about an EMS device
that arose from a situation no
ordinary person would appreciate. But as an EMS provider, trust me, you
will. When you read what happened, you’ll
understand its significance immediately. In
fact, you’ll want to stop reading and salute
the EMT who invented it.
Imagine you’re a volunteer at a small
rural EMS agency. You and your partner,
both munchkins, respond alone for a rollover motor vehicle collision. On arrival, you
encounter an inverted vehicle containing
two small children in the back seat and two
generously proportioned adults up front.
The front passenger weighs about 350 lbs.,
and the driver at least 500. Somehow, you’ll
have to extricate all four patients and get
them into one ambulance.
Let’s salute Doris Van Ness. Doris and
her partner did something rural EMTs do
every day, Life-Saver—something that transcends all of the spreadsheets, databases and
journal articles to which we devote so
They adapted to their situation and overcame. They enlisted the help of enough
passing motorists to stabilize, extricate,
carry and load all four patients into the
ambulance for transport.
People like Doris do what they do for free
because there simply are no other resources.
Sick people are getting heavier. And Doris’
agency, is struggling financially—as are
most small agencies. In the future, they
may or may not be able to come up with
even the 50% matching funds for a grant to
obtain a self-lifting cot and a loading system
that would at least help them during lifting
Self-lifting cots are wonderful tools, but
their extra weight is nothing to sneeze at.
Anyway, back to Doris. After the call, she
patented a completely different loading idea,
using something she did have: her vehicle’s
electrical system, a three-quarter-ton bumper winch, some extruded aluminum and a
The front passenger weighs about 350 lbs.,
& the driver at least 500. Somehow, you’ll
have to extricate all four patients & get
them into one ambulance.
EMT/inventor Doris Van Ness operates her
cot-loading device. Its forward end is attached
to a three-quarter-ton winch bolted to the supports beneath the deck of this demo ambulance.
basic understanding of physics.
Her design is nothing like the loading
systems you’ve seen so far. It certainly
doesn’t look strong enough to do
the job of loading a 500-lb. patient.
But Doris isn’t fooling around;
her lift is based on a parallel double boom, almost like you’d see
on a tow truck—only the boom is
hinged at the aft end of the deck in
an ambulance’s patient compartment. At
the forward end of the boom is a winch
attached to the frame under the vehicle’s
deck. When it lifts, it works kind of like a
The boom incorporates a pair of telescoping beams attached to channels intended
to integrate with the upper frame of any
ambulance cot. When engaged and fully
extended, the whole assembly is designed
to lift a combined patient-and-cot weight of
1,200 lbs. (It’s been tested at 1,800 lbs.)
Called the Bedrock Lift, Doris’ invention
can be installed initially in three hours.
It weighs 350 lbs., and it can be removed
or reinstalled in minutes. It can be pressurewashed, and it’s designed to lift any kind of
cot. Doris demo’ed her beta unit for us at the
fifth annual Colorado EMS Safety Summit
in Loveland, Colo., in early October. It
wasn’t fancy, and it was mounted in a small
second-hand ambulance she had purchased
just for demonstrations. But fancy or not,
it’s a horse.
The production model will come powder-coated. It’s designed to be mounted
without modifying an ambulance’s existing
frame. Doris said she plans to install her lifts
on-site and provide instructions in their use.
They say that necessity is the mother of all
invention. I’d like to congratulate Doris for
being the mother of this back-saving, practical invention.
For more information, contact
her at firstname.lastname@example.org.
Thom Dick has been involved in EMS
for 42 years, 23 of them as a full-time
EMT and paramedic in San Diego County.
He’s currently the quality care coordinator for Platte Valley Ambulance, a hospital-based
9-1-1 system in Brighton, Colo. Contact him at
POWERFUL SOLUTIONS FROM SMART THINKERS
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CASE OF THE MONTH
DILEMMAS IN DAY-TO-DAY CARE
>> BY DENNIS EDGERLY, EMT-P
‘NOT ACTING RIGHT’
Providers treat patient with hyponatremia due to a brain tumor
he patient’s wife called 9-1-1
because her husband was acting
drunk. When you arrive on scene, a
middle-aged woman meets you at the door
and tells you she’s concerned about her husband. She came home from a weekend business trip and found him “not acting right.”
You ask for clarification, and she tells you
he is confused and having difficulty walking. She doesn’t think he’s drunk because
he’s only had one beer, but says, “He is sure
After assuring the wife you will take care
of her husband, you and your partner walk
into the living room where he’s sitting.
You find a 46-year-old male sitting on the
couch. He looks at you and nods his head
when you say, “hello,” but doesn’t speak.
A quick physical exam reveals no signs
of trauma. He appears to be moving all
extremities but is unable to follow commands when you attempt to perform a Cincinnati Stroke Scale assessment.
You note no facial droop or drooping
of the eyelid, which is called ptosis. The
patient’s skin is pink, warm and dry, and his
pupils are equal and reactive at 4 mm. He
doesn’t appear to be in pain or respiratory
distress. His pulse is 72 and regular. Blood
pressure is 146/82 and respirations are 18
and uncompromised. A finger-stick blood
glucose level reads 106 mg/dL. There’s a
can of beer sitting next to him, but it’s
The patient’s wife tells you her husband seemed normal when she spoke with
him this past evening but he was tired
and going to bed early. She tells you he is
healthy and takes no medications on a regular basis. A little bewildered, you and your
partner place the patient on a stretcher and
into the ambulance.
During transport, you establish an IV
and begin a reassessment when the patient
develops a tonic-clonic seizure. The seizure
PHOTO JEFFREY MAYES
Hyponatremia is commonly found at endurance events where patients sweat excessively.
lasts about 45 seconds. The patient now
responds only to noxious stimuli with
moaning and withdrawal. You suction his
airway, apply oxygen and ask you partner
to step it up to an emergent transport.
As you transfer the patient, you ask the
emergency physician what she thinks is the
cause. She tells you she needs to wait for
When you follow up later, she tells you
the patient’s sodium level was 118 mEq/L.
The patient was hyponatremic because he
has a tumor on his posterior pituitary gland
that’s causing an increased production of
antidiuretic hormone (ADH), resulting in a
dilution of his sodium levels. This is called
syndrome of inappropriate anti-diuretic
hormone (SIADH), which has many underlying causes in addition to hyponatremia.
The brain tumor that caused hyponatremia
in this case may not be commonplace, but
hyponatremia is one of the most common
electrolyte imbalances seen in the field.1
Sodium is the primary extracellular
ion. Normal values are 135–145 mEq/dL.
Hyponatremia is defined as sodium levels
less than 135 mEq/dL, with levels less than
125 mEq/dL being considered severe.2
When sodium levels drop, there’s a change
in osmolarity that causes fluid to move into
cells. This causes cellular swelling, which
is most concerning in the brain and is the
cause of many of the symptoms. If hyponatremia develops slowly, the body may have
the ability to compensate, and patients may
be asymptomatic even with sodium levels as
low as 115 mEq/dL.1 However, patients with
acute hyponatremia can be critical.
Sodium concentration can be depleted
in a couple of ways. In hypovolemic hyponatremia, a body has lost too much sodium
in relation to water loss. This can occur with
excessive sweating as seen with endurance
sports like marathons, use of such diuretics as thiazide diuretics, and third spacing of
fluid, as is seen with burns.
The other way is to dilute the body’s
sodium concentration with too much
water. Dilution of sodium can occur with
excessive fluid intake or secondary to the
body’s ability to eliminate fluid, which is the
case with heart and renal failure. There have
also been cases of hyponatremia seen in
infants when their formula has been diluted
with water or the child has been fed tap
water.3 This is referred to as hypervolemic
In this case, the patient developed hyponatremia secondary to the body’s inability
to eliminate fluid because of the alteration in
ADH levels. Common signs and symptoms
of hyponatremia include lethargy, apathy,
confusion, disorientation and seizures.
Other non-specific symptoms include muscle cramps, nausea and weakness.4
Identification of hyponatremia in the prehospital setting may be difficult. A thorough history is a good start, and agencies
using bedside lab devices, such as i-STAT,
will be able to obtain a sodium value. However, treatment should be based on the
underlying cause, type of hyponatremia and
whether the onset was acute of chronic.
EMS providers should keep hyponatremia
in mind as a possible cause of patient’s
symptoms rather than attempting to fix the
patient’s electrolyte imbalance.
1. Vaidya C, Ho W, Freda BJ. Management of hyponatremia: Providing treatment and avoiding harm.
Cleve Clin J Med. 2010;77(10):715–726.
2. Simon EE. (March 6, 2012). Hyponatremia. In
Medscape. Retrieved Oct. 12, 2012, from
3. Keating JP, Schears GJ, Dodge PR. Oral water
intoxication in infants: An American epidemic.
Am J Dis Child. 1991;145(9):985–990.
4. Marx JM, Hockberger R, Walls R. Rosen’s emergency medicine concepts and clinical practice,
6th ed., vol. 2. Mosby: St. Louis, p. 1934, 2002.
Choose 25 at www.jems.com/rs
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RESEARCH REVIEW EMS
WHAT CURRENT STUDIES MEAN TO
>> BY DAVID PAGE, MS, NREMT-P
Study rates global skill levels of students & medics
n the hierarchy of research, a case report
often serves only as an FYI or a good war
story. In the case of the below study, we’re
lucky the authors had research on administration of intranasal (IN) glucose published for
the first time in a peer-review journal. I recommend you read it more for the review of the
literature on IN medication administration than for any earth-shattering news
I did find it interesting, however, that
2 mg of IN glucagon was just as speedy at
raising blood sugar as 1 mg of intramuscular (IM) glucagon, according to a 1992
study by Rosenfalck published in Diabetes
Research and Clinical Practice, and that
few studies have successfully compared IV
dextrose to IM glucagon. With a single dose
of IN glucagon being around $1.50 vs. $8
for dextrose, I doubt we’ll see IN glucagon
replace IV dextrose as a first-line drug. But
this write-up gives us some ammunition
for medical directors to approve the IN glucagon route as well as intramuscular. I’ve
already fired off the e-mail to my medical
directors. Will you?
I PARAMEDIC COMPETENCE I
Tavares W, Boet S, Theriault R, et al. Global rating scale for the assessment of paramedic clinical
competence. Prehosp Emerg Care. 2012; Jul 26 [Epub
ahead of print.]
e seldom see educational research
in EMS, and even less frequently a
study dealing with clinical competency.
Kudos to this Canadian all-star group for
tackling such a difficult subject with such a
The group videotaped 81 performances
of 61 EMS students and 24 active para-
PHOTO DAVID PAGE
Researchers measured intranasal glucagon for
the first time in a peer-reviewed journal.
medics responding to a simulated scenario.
Two trained evaluators reviewed each video
using a prototype global rating scale (GRS).
The objective was to see if the GRS would
correctly identify a competent performance. The candidates were lone paramedics responding to a simulated unstable
cardiac patient in the back of a transfer
ambulance on the side of the road, which
deteriorates into cardiac arrest. The two
EMTs were allowed to assist the paramedic
being tested, and the scenario lasted nine
minutes. A high-fidelity manikin was used.
The rating scale included eight dimensions, or rubrics. These were distilled by
a national expert panel using a modified
Delphi process from 257 observable paramedic clinical behaviors. The final rubrics
were situation awareness, history gathering (i.e., interviewing), patient assessment
(i.e., physical exam), decision making
(i.e., differential diagnosis), resource use
(i.e., leadership and delegation of tasks),
communication and procedural skills.
I GLOSSARY I
Adjectival rating scale refers to a numeric appraisal (similar to a pain scale rating) based on
descriptions (adjectives) that best fit their assessment.
Finally, an overall clinical performance
score was assigned.
It’s particularly encouraging that these
dimensions match the recently released
National Registry paramedic psychomotor competency package evaluations.
Although the NREMT followed a different
methodology, the categories are identical,
giving these rubrics more validity.
Interestingly, the individual categories
didn’t seem to be as reliable as the overall rating. The authors note that raters
had difficulty differentiating between the
dimensions, and suggest that a “Gestalt”
categorical judgment or “halo effect” may
be at work. Still, they noted, the GRS accurately identified who should pass and who
should fail. Without a doubt, every EMS
educator should read this study and start
using these rubrics.
An adjectival rating scale from 1–7 similar
to a Likert scale was used, with 1 being
unsafe, then unsatisfactory, poor/weak,
marginal, competent, highly competent
and 7 being exceptional. Although these
authors didn’t comment on their 1–7 scale,
previous studies have shown poor results
using similar rating scales.
From the descriptive statistics in this
study it would appear the scale could be
simplified without affecting the accuracy
of the pass/fail ratings, similar to those
recently proposed by the NREMT.
Although it appears we’re getting closer
to having defensible tools to measure
clinical competency, the reproducibility of
these methods would be challenging, such
as what would be required for large programs or even state and national exams.
Not everyone has access to high-fidelity manikins, quality video recording,
archiving and raters with 22 and 11 years
of experience. Both were trained over
a 60-minute period and viewed all the
videos, presumably gaining quite a bit of
experience along the way.
I WATCH BOX I
I RATE MATTERS I
Idris A, Guffey D, Pepe P, et al. The ROC investigators. The interaction
of chest compression rates with the impedance threshold device and
association with survival following out-of-hospital cardiac arrest.
In the December 2011 Research Review column, I reviewed the
National Institutes of Health Resuscitation Outcomes Consortium
(ROC) study that evaluated the impedance threshold device (ITD) in
a large multi-center clinical trial called the PRIMED trial (published in
the New England Journal of Medicine in September 2011). It reported
no difference between use of an active ITD and a placebo (or sham)
ITD. This has always puzzled me because I have used an ITD for years
and have seen it work.
In November 2012, Ahamed Idris, MD, presented an abstract
at the American Heart Association (AHA) Resuscitation Science
Symposium (ReSS), reporting that chest compressions for patients
in the ROC database weren’t necessarily performed at the 100 per
minute rate recommended in the study protocol or by the AHA; in
fact, more than half of the more than 10,000 patients received chest
compression rates that were too slow (less than 90 per minute) or
too fast (greater than 110 per minute). The data showed that the
faster the chest compression rate, the worse the outcomes.
This is reminiscent of the findings of Thomas Aufderheide, MD,
that hyperventilation is deadly in cardiac arrest. The ROC study confirmed that for chest compression rates, like ventilation, more is not
better, and in fact, more can be harmful. Idris presented additional
ROC data that shed new light on my confusion about the ITD’s previously reported efficacy. He reported that there was a significant
interaction between chest compression rate and ITD efficacy. Their
adjusted model predicted greater survival to discharge when the
ITD was used at AHA-recommended compression rates of around
100 per minute, compared with conventional CPR without an active
ITD at similar rates. Clearly, CPR needs to be performed correctly in
order to fairly assess new technologies like the ITD.
Idris and colleagues are planning to follow up the paper
soon. If the paper mirrors the abstract, we will see the first randomized, controlled, double-blinded clinical trial to demonstrate
that the ITD improves survival to hospital discharge with favorable
neurologic outcome with properly performed chest compressions.
What we know: Compression rates affect survival rates. The faster the compression rates, the worse the outcomes.
What this study adds: When an ITD is used as intended (at AHA-recommended
chest compression rates), observed survival-to-hospital discharge is considerably increased compared to CPR without an ITD.
Learn more from David Page at the EMS Today Conference & Expo, March 5–9 in
David Page, MS, NREMT-P, is an educator at Inver Hills Community
College and a paramedic at Allina EMS in Minneapolis/St. Paul.
He’s a member of the Board of Advisors of the Prehospital Care
Research Forum and the JEMS Editorial Board. Send him feedback at
Choose 27 at www.jems.com/rs
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Serving our nation’s EMS practitioners
Philips offers Q-CPR, a real-time
accelerometer-based technology that
incorporates a downloadable resuscitation review.
Masimo’s EMMATM is a miniaturized
capnometer useful for space-limited
Physio-Control offers CODE-STAT
data software for post-CPR review.
Sotera Wireless offers the ViSi, a
powerful, compact monitoring device.
Oridion’s Integrated Pulmonary
Index (IPI) uses waveform capnography
and pulse oximetry to monitor respiratory rate, EtCO2, heart rate and SpO2.
ZOLL’s offers CPR Dashboard, a realtime accelerometer-based technology
with data transmission capability.
IMAGE ALENGO/ISTOCKPHOTO.COM, A) PHOTO COURTESY A.J. HEIGHTMAN, B) PHOTO COURTESY MASIMO, C) PHOTO COURTESY PHYSIO-CONTROL, INC. , D) PHOTO COURTESY SOTERA WIRELESS, E) PHOTO COURTESY A.J. HEIGHTMAN, F) PHOTO CHRIS SWABB
>> BY MIKE MCEVOY, PHD, NREMT-P, RN, CCRN
onitoring technology has tremendous potential to improve
patient outcomes—when it’s designed and used properly. Routine
use of pulse oximetry and waveform capnography virtually eliminated esophageal intubations and inadequate oxygenation claims
against anesthesia providers, transforming their profession from
frequent and costly malpractice targets in the 1970s to 1980s into
one of the safer fields of practice today.1 The value of technology lies in collecting meaningful data that a provider can’t easily obtain with their own assessment skills. Lives are saved
in hospitals every day through the use of monitoring technology: The more sophisticated
the level of care, the more advanced the monitoring technology tends to be.2
Technology enhances prehospital patient care as well, enhancing provider assessment abilities and detecting changes in patient condition. This article will review current
prehospital technology and discuss current and future evolutions.
The first technology adapted for EMS use was cardiac monitoring. Portable cardiac
monitors have evolved since their introduction in the 1970s to include defibrillators,
pulse oximeters, non-invasive blood pressure (NIBP) modules, waveform capnography,
temperature and, most recently, CPR feedback technologies. Perhaps the most important
recent prehospital development has been monitor alarms, intended to alert providers of
potential problems.3 Early prehospital monitors didn’t include alarms, probably under
the mistaken notion that an EMS provider caring for a patient would immediately notice
significant changes. It’s no secret that EMS providers have many things to do besides continuously watch a monitor screen.
The addition of alarms is a welcome improvement in prehospital monitors. A typical intensive care unit (ICU) patient generates some 700 monitoring alarms per day
WAVE OF THE FUTURE
>> CONTINUED FROM PAGE 29
of which only 15% are clinically significant.4 This year, the hospital issue known
as “alarm fatigue” has been considered the
top hospital technology hazard.3 EMS currently has a unique opportunity to customize monitoring alarms, with the option
not to allow silencing such critical alerts as
apnea, asystole and lethal rhythms, to avoid
desensitization and falling into the trap of
Now a standard of care included in the EMT
curriculum, pulse oximetry was one of the
earliest devices to appear in ambulances.
Originally introduced in 1974 for use on
anesthetized patients during surgery, oximetry has matured tremendously in recent
years.4 Arguably one of the most important
patient safety devices ever invented, pulse
oximetry has reduced anesthesia deaths by
90%, now promising to protect patients from
the damaging effects of hyperoxia seen with
routine use of oxygen in patient care.5 In
addition to guiding selection of appropriate oxygen delivery devices, pulse oximetry
technology utilizing additional wavelengths
of light can now screen for carbon monoxide
poisoning, methemoglobin, and even assess
fluid volume status from analysis of the pleth
waveform.6 In the future, manufacturers will
introduce respiratory rate and blood pressure
measurements obtained from pulse oximetry
Non-invasive or electronic blood pressure
measurement followed pulse oximetry into
the prehospital market. Current devices are
oscillometric, meaning that they sense arterial oscillations, typically measuring a heart
rate and mean arterial pressure then working
backwards to calculate a systolic and diastolic
pressure. Algorithms vary by manufacturer,
making it virtually impossible to validate
accuracy, but for the majority of NIBP devices
used in EMS the mean arterial pressure is the
most accurate value displayed.7 Like auscultatory measurements, proper cuff size and
meticulous attention to keeping the extremity being measured at mid-heart level are key
to obtaining good measurements.8
Capnography has made major inroads into
EMS and, in many systems, is more frequently
utilized in prehospital patients than hospitalized patients. The driving force for capnogra-
phy is patient safety during intubation and,
like pulse oximetry, the anesthesia standard
of care dictates monitoring every intubated
patient with waveform capnography. Many
EMS systems mandate continuous waveform capnography for all intubated patients,
a common sense standard that virtually
eliminates the possibility of not detecting a
misplaced endotracheal tube or supraglottic
airway.1,9 Today, there is no excuse for not
using continuous waveform capnography on
every intubated patient, in my opinion.
Like their anesthesia and critical care
counterparts, EMS providers have become
quite skilled with analysis of capnography
waveforms. In both spontaneously breathing
and intubated patients, waveforms demonstrate changes in airway resistance revealing
conditions like bronchospasm, airway cuff
leaks, ventilator asynchrony and more. In the
future, manufacturers will introduce software
to quantify capnography waveforms to allow
clinicians to measure severity and effects of
treatment on conditions detected through
Miniturization of capnography technology has improved portability and battery life.
It also promises in the very near future to further revolutionize the industry with enhancements to a capnometer known as EMMA. The
manufacturer of this second generation endtidal device was recently acquired by Masimo
and will very likely transform into a much
more robust and usable miniaturized device,
perfect for space-limited environments, such
as air medical, combat and intrafacility transports. Keep an eye on EMMA.
One of the more recent monitoring technologies to make its way into ALS monitors
is CPR feedback. The three major monitoring manufactures have feedback devices to
provide both real-time and retrospective
analysis of CPR. Philips offers Q-CPR, a realtime accelerometer-based technology that
incorporates a downloadable resuscitation
review. ZOLL offers CPR Dashboard, a realtime accelerometer-based technology with
data transmission capability for post-event
review. Physio-Control offers CODE-STAT
data review software for post CPR review
and will very shortly introduce its TrueCPR
coaching device in the U.S., a standalone
triaxial field induction (TFI) based unit. TFI,
once it becomes available, promises to elimi-
nate overestimations of compression depth
reported by accelerometer-based devices
when CPR is administered on a mattress
(regardless of whether a board is in place).10
CPR feedback helps rescuers deliver nearperfect compressions and ventilations to
victims of sudden cardiac arrest. For anyone
who has ever performed CPR using a feedback device, they seem to deliver quite nicely
in that regard. Use of post-resuscitation analysis software has led to consistent and sustained improvements in the quality of CPR.
Yet a recent study by Hostler and coauthors
(and the largest study of real-time feedback
yet conducted) suggests that these changes
in performance don’t seem to improve outcomes.11 This is troubling, and it strongly
suggests problems not with the feedback
devices or rescuers, but with the guidelines
themselves. Indeed, anecdotal reports from
CPR feedback users show significantly
improved markers of better perfusion, such
as end-tidal CO2, throughout the peri-arrest
period, yet few have seen improved results. If
anything, CPR feedback devices are showing
us that our “one size fits all” approach to CPR
using the same compression depth and rate
isn’t appropriate for every patient. Hopefully,
the guidelines will change.
POINT OF CARE TESTING
Point of care (POC) testing has slowly
invaded the prehospital world. Use of glucometers is widespread and is now included
in the EMT scope of practice. One promising
technology with a broad range of potential
uses is saliva osmolality to assess dehydration. Several recent studies have found close
correlation between measurement of saliva
osmolality, or concentration, and hydration
status.12-13 Firefighters, athletes, and nursing home patients frequently suffer from
dehydration, and EMS providers lack good
tools to easily determine hydration status.
A Menlo Park (Calif.) company, Cantimer
Corporation is refining a device similar to
a glucometer that will allow field testing of
saliva to detect dehydration.
Another technology currently making prehospital inroads is ultrasound. In the emergency department (ED) and ICU, ultrasound
has for years been used to quickly detect
presence of blood or fluid in the abdomen
of trauma patients, place lines, confirm
endotracheal tube (ET) placement, assess
for pnuemothorax, check cardiac function
and volume status in the heart and vascular
system, find fractures and examine unborn
children. Numerous studies have demonstrated that prehospital providers can accurately use ultrasound, but outcome studies
There is little doubt in the hospital setting that ultrasound has and will continue
to replace more invasive testing. A nurse
using ultrasound can avoid placing a foley
catheter, saving much discomfort and risk of
infection for the patient. A clinician performing a comprehensive ultrasound exam in an
unstable patient can very rapidly assess heart
function, fluid volume status and visualize
the lungs. These exams, however, take considerable practice and require continued use
to maintain proficiency. Like ETI, the opportunity to perform ultrasound may not occur
often enough to allow prehospital providers
in many systems to develop and maintain
Increasing concerns are arising that clinicians
may become overwhelmed with the vast
amount of data to determine an appropriate
plan of care. To that end, monitoring manufacturers are beginning to develop algorithms
or fuzzy logic systems that analyze multiple
parameters to provide the clinician with an
overall wellness score on their patient. One of
the first entrants in this market was Integrated
Pulmonary Index (IPI) by Oridion.16 IPI uses
waveform capnography combined with
pulse oximetry to monitor respiratory rate,
EtCO2, heart rate and SpO2, combining these
values into an algorithm that produces a
score from 1 to 10.
This overall pulmonary score doesn’t
replace the need for a clinician to look at each
one of the parameters, but it does provide
early warning about deterioration so the provider can determine which of the measured
parameters is in need of treatment. Although
IPI isn’t yet available on prehospital monitors,
expect to see it soon along with algorithms
from other manufacturers that will help you
more effectively analyze and manage large
quantities of monitored data.
WEARABLE DEVICES & SENSORS
Lastly, pay close attention to the field of wearable devices and sensors. As our population
ages, patients are discharged from hospitals
earlier, and healthcare providers look for
ways to more closely monitor their patients
at home, the need for wearable sensors
will explode. Remote monitoring systems,
such as the ViSi mobile monitor by Sotera
Wireless, are rapidly benefiting from miniaturization, faster and more robust internet
access, more sophisticated Bluetooth technology and developments in microelectronics and sensor technology.
Fully functional ECG monitors the size of
a wristwatch, fabric integrated sensors and
electrodes, ambient sensors mounted in the
home to monitor patient vitals and activity,
and very sophisticated implantable sensors
are all in various stages of development.17
The same technology that allows closer
monitoring of patients outside healthcare
settings promises to improve your ability
to communicate and consult with medical
experts. Researchers using real-time high
speed audiovisual connections between
prehospital providers and experienced physicians are finding potential to improve outcomes.18 If you can use your cell phone to
video chat with family or friends across the
country, then it makes perfect sense that EMS
could utilize the same technology.
Medicine is a constantly evolving art and
science. It’s highly unlikely that a patient will
thank you for using a state-of-the art monitor or the latest in CPR feedback. They will,
however, thank you for competently and
respectfully integrating the equipment you
carry into a care plan that makes them feel
better for having met you.
Mike McEvoy, PhD, NREMT-P, RN, CCRN, is the EMS coordinator for Saratoga County, N.Y., and teaches pulmonary
and critical care medicine at Albany Medical College. He’s
a paramedic, firefighter and member of the International
Association of Fire Chiefs Emerging Infectious Diseases
1. Metzner J, Posner KL, Lam MS, et al. Closed
claims analysis. Best Pract Res Clin Anesthesiol.
2. Hu X, Sapo M, Nenov V, et al. Predictive
combinations of monitor alarms preceding
in-hospital code blue events. J Biomed Inform.
3. Cvach M. Monitor alarm fatigue: An integrative review. Biomed Instrum Technol. 2012;46(4):
4. Severinghaus JW. Takuo Aoyagi: Discovery of pulse
oximetry. Anesth Analg. 2007;105(6 Suppl):S1–4.
5. Severinghaus JW. Monitoring oxygenation. J Clin
Monit Comput. 2011;25(3):155–161.
6. Roth D, Hubmann N, Havel C, et al. Victim
of carbon monoxide poisoning identified
by carbon monoxide oximetry. J Emerg Med.
7. Smulyan H, Safar ME. Blood pressure measurement: Retrospective and prospective views. Amer
J Hypertens. 2011;24(6):628–634.
8. Brett SE, Guilcher A, Clapp B, et al. Estimating
central systolic blood pressure during oscillometric determination of blood pressure: Proof of
concept and validation by comparison with intraaortic pressure recording and arterial tonometry.
Blood Press Monit. 2012;17(3):132–136.
9. Westhorpe RN, Ball C. The history of capnography. Anesth Intensive Care. 2010;38(4):611.
10. Perkins GD, Kocierz L, Smith SC, et al. Compression
feedback devices over estimate chest compression depth when performed on a bed.
11. Hostler D, Rea TD, Stiell IG, et al, and the
Investigators. Effect of real-time feedback during
cardiopulmonary resuscitation outside hospital:
Prospective, cluster-randomised trial. BMJ. 2011 Feb
12. Smith DL, Shalmiyeva I, DeBlois J, et al. Use of
salivary osmolality to assess dehydration. Prehosp
Emerg Care. 2012;16(1):128–135.
13. Taylor N, van den Heuvel A, Kerry P, et al.
Observations on saliva osmolality during progressive dehydration and partial rehydration. Eur J
Appl Physiol. 2012;112(9):3,227–3,237.
14. Chin EJ, Chan CH, Mortazavi R, et al. A pilot study
examining the viability of a prehospital assessment with ultrasound for emergencies (PAUSE)
protocol. J Emerg Med. 2012 May 15 [Epub ahead
15. Hasler RM, Kehl C, Exadaktylos AK, et al. Accuracy
of prehospital diagnosis and triage of a Swiss
helicopter emergency medical service. J Trauma
Acute Care Surg. 2012;73(3):709–715.
16. Waugh JB. Integrated Pulmonary Index stability in
healthy adults under changing conditions. Resp
17. Patel S, Park H, Bonato P, et al. A review of wearable sensors and systems with application in
rehabilitation. J Neuroeng Rehabil. 2012;4(20)9:21.
18. Skorning M, Bergrath S, Rortgen D, et al.
Teleconsultation in prehospital emergency medical services: Real-time telemedical support in
a prospective controlled simulation study.
THE ROLE OF VIDEO LARYNGOSCOPY IN FUTURE
ADVANCED AIRWAY MANAGEMENT
>> BY TERENCE VALENZUELA, MD, MPH; JARROD MOSIER, MD; & JOHN SAKLES, MD
ispatch sends you to the home of a
79-year-old male with chronic obstructive pulmonary disease (COPD) who
is complaining of “shortness of breath.” He sits
upright, leaning forward and supporting his weight
with both arms. His head seems to be attached
directly to his shoulders. He appears drowsy, and
replies to your questions about medical history with
single-word answers only. His wife relates that he
has grown increasingly short of breath during the
past three days. After he refused to see his doctor, his
wife called 9-1-1.
You palpate a pulse of 98 beats per minute
(bpm) and measure his blood pressure at 180/90.
His respiratory rate is 30. Breath sounds are
diminished and wheezy bilaterally, but there’s little
chest movement with each breath. The pulse oximeter reveals an oxygen saturation (SpO2) level of 93%
and an end-tidal carbon dioxide (EtCO2) level of 35.
He grows more somnolent. Narcan doesn’t improve
his level of arousal.
This patient is on the verge of acute respiratory
failure. Level of arousal (wakefulness) is a sensitive and reliable indicator of brain function. The
patient is drowsy and growing more so because of
the buildup of CO2 from a lack of effective ventilation. An easily reversible cause (opiate effect) for his
lethargy isn’t present. The pulse oximeter indicates
borderline hypercapneic respiratory failure. It can
often be misleading, as in this case, with the EtCO2
number indicating adequate ventilation; however, it
likely represents an increase of expired partial pressure of carbon dioxide (PCO2) with ineffective ventilation. Noninvasive positive pressure ventilation,
such as continuous positive airway pressure (CPAP),
may be considered to decrease the work of breathing
in hypercapneic respiratory failure. But this patient
is unlikely to be cooperative because of his somnolence, and his respiratory drive is failing rapidly. The
likeliest clinical course is continued deterioration.
You and your partner attempt to augment the
patient’s ventilation with a bag-valve mask (BVM).
You maintain a tight seal with two hands on
the mask while your partner squeezes the bag.
The patient becomes apneic. His SpO2 drops to
PHOTO IOSEPH/ISTOCKPHOTO.COM; PHOTOS ART VANDALAY
Video laryngoscopes help improve
the view of the epiglottis during
80%. Your partner places an oropharyngeal airway
(OPA) device, which allows ventilation with continued high fraction of inspired oxygen (FIO2) rate via
the BVM. Maintaining a rate of eight to 10 to avoid
hyperventilation, you see the SpO2 climb to 95%
over the next three minutes. Addition of a disposable
positive end-expiratory pressure (PEEP) valve to the
exhalation port of the BVM results in improvement
of the SpO2 to 100%.
Just prior to becoming apneic, his SpO2
was the brink of the steep portion of the
hemoglobin desaturation curve (see Figure
1, p. 35). Further desaturation, even if brief,
indicates a precipitous fall in arterial oxygen content and will place the brain and
other vital organs at risk for anoxic damage.
A further rise in CO2 diminishes the affinity of hemoglobin for oxygen further worsening oxygen delivery to organs. Note that
there’s a lag time between the SpO2 registered by the pulse oximeter and the real-time
arterial saturation. This delay can range from
a few to 30 seconds depending on the etiology (e.g., heart failure vs. septic shock) and
severity of illness. Unfamiliarity with this
characteristic of the pulse oximeter may
cause mistaken concern that the patient isn’t
improving with BVM therapy. Conversely,
false confidence may result when the patient
is “desaturating,” yet the pulse oximeter continues to read 100%.
The urban myth persists that providing high-flow oxygen to COPD patients
will cause respiratory arrest and should be
avoided. This phenomenon is much talked
about but seldom seen. The greater danger to this patient is persistent hypoxemia
untreated. Deterioration in oxygen saturation with apnea occurs at a rate determined
by factors including age, severity of illness
and the presence of obesity. Figure 1, shows
the rate of SpO2 decline in patients initially
100% saturated who are paralyzed prior to
elective intubation. This is a “best case” scenario, and the times to desaturation should
not be generalized to EMS patients. However, one does see how rapidly ill or pediatric apneic patients will become hypoxemic.
For types of patients made apneic by RSI,
see Figure 1.
BVM VENTILATION & OXYGENATION
EMS providers are overconfident in their
skills and knowledge in how to use BVMs.
Multiple studies of prehospital resuscitations
have documented compression rates that
are too rapid, inspiratory pressures generated by bag compression that’s too great and
volumes of air per compression that are too
large for optimal outcomes. These factors
strongly predict patient harm in the patients
with severe obstructive lung disease, such
as COPD or asthma. Rapid large-volume
>> 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
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
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
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
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
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
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
Both reusable & disposable blades. Best results with rigid stylet
Mac & Miller style blades; pediatric blades available
ET tube guide attached to blade directs tip to “cross hairs” on screen
Reusable video head attaches to disposable blades (with or without ET tube guide)
McGrath Series 5/MAC
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
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.
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
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.
For more on quality assurance with video
laryngosopy, see the Tucson Fire Department
template in the online version of this article at
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
3. Dunford JV, Davis DP, Ochs M, et.al. Incidence of transient hypoxia and pulse rate reactivity during paramedic rapid sequence intubation. Ann Emerg Med.
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
6. Sakles JC, Brown CA, Bair AE. Video laryngoscopy.
In: Manual of Emergency Airway Management.
4th ed. Lippincott Williams & Wilkins: Philadelphia,
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.
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].
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.
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.
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
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
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
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.
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.
‘RAP’ IN ‘RAPPORT’
>> CONTINUED FROM PAGE 39
1: Electronic ranking to ID
most active callers
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
calling the 9-1-1
previous frequent use.
>> Case 1: RAP
Client 1 is an energetic 60-year-old
male with underlying schizoaffective disorder.
A resident of a
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.
2: Electronic discovery of
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
3: Patient associative CAD View
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).
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
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
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.
RAP CLIENT 4 9-1-1 ENCOUNTERS, PAST 12 MONTHS
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
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
3. The San Diego Beacon eHealth Community. (2012). In the San Diego Beacon eHealth
Community. Accessed Nov. 16, 2012, from www.sandiegobeacon.org.
TABLET DEVICES TRANSFORM
HOW DATA IS USED & ACCESSED
IN THE FIELD >> BY RICHARD HUFF, NREMT-B
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.
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 jems.com/ems-products
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
“I think it’s going to be revolutionary,”
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
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.
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.
“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,
www.redcross.org/news/press-release/MoreYounger employees tend to come into according to the survey. Also, 70% of the
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 Richardmhuff@gmail.com.
>> BY KATHERINE WEST, RN, BSN, MSED
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
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.
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.
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
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
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
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
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
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
compliance monitoring. Compliance monitoring is a required component of OSHA’s
exposure control plan.
WORK RESTRICTION GUIDELINES
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
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.
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
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
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 Kwest8388@earthlink.net.
THE CALL TO
IN THE FIELD
PHOTOS A.J. HEIGHTMAN
>> BY JOHN PRINGLE & LORALEE OLEJNIK
JANUARY 20 3
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
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
There are some practical steps administrators and patient care providers can take
to successfully integrate these new electronic
tools into their emergency response systems.
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
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.
>> 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
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
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.
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
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
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
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
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.
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.
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.
Check out www.jems.com/
for more about the San Diego
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
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
JEMS.com/Discover-Simulation 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
PHOTOS JULIE MACIE
KEEPING IT COOL
>> CONTINUED FROM PAGE 55
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,
>> Provide a rationale for the use of
>> 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
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
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
RATIONALE FOR EARLY
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
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
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
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
KEEPING IT COOL
>> CONTINUED FROM PAGE 57
was used to augment the effects of infusing
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
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
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
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
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
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.
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.
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.
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
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
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al. Changing incidence of out-of-hospital
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7. Wira C, Martin G, Stoner J, et al. Application
of normothermic cardiac arrest algorithms to
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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.
14. Hinchey PR, Myers JB, Lewis RS, et al. Improved
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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
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.
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;
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;
20. Hachimi-Idrissi S, Corne L, Ebinger G, et al.
Mild hypothermia induced by a helmet device:
A clinical feasibility study. Resuscitation.
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
Test your comprehension with this
post-article quiz. This article has been
accredited by the Continuing Education
Coordinating Board for EMS (CECBEMS)
for 1 hour of continuing education
credit. For a limited time only, readers of this article may obtain CE credit
courtesy of Laerdal Medical Corp. The
first 500 visitors to JEMS.com/DiscoverSimulation who register using promo
code 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
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
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
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
8. What was the reported harm associated with
prehospital induction of hypothermia in the
2003 study by Bernard and co-authors?
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?
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
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
b. Fentanyl and sedation with lidocaine
c. Calcium chloride and etonidate
d. Vecuronium and sedation with
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.
13. The incidence of out-of-hospital cardiac
arrest ranges from what percentage of the
total population per year?
14. Survival with good neurologic recovery has
been reported achieved in what percentage
of resuscitated patients?
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 jems.com
Deadline to enter is Feb. 1.
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Long term Cooling
It’s a challenge to keep cold therapy items cool in an ambulance, especially
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Call for pricing
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
Size: Small, standard and large
Payload capacity: 385 cubic inches (small);
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Colors: Black, desert tan, olive drab, orange, yellow
>> IN THE NEXT ISSUE:
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
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process is a combination of Energized
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using either the remote eHP™ head or
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your vehicles and facilities are clear of
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Simulaids Intraosseous Leg Adult STAT Simulator >> Streamlight ProTac HL
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Rapid Tourniquet Deployment
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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
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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
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Dimensions: 72" x 16" x 1.75"
Weight: 16 lbs.
Capacity: 500 lbs.
Cases that Fit Our Environment
Most EMS providers consider their mobile phone to be an
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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
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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
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The LifeProof iPad case protects iPad 2 and iPad generation 3 and
Fits: iPhone 5 (fre);
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MedixSafe M2 Narcotics Cabinet >> Medline BioMask Antiviral Isolation Mask >> MERET Omni Pro ICB Infection Control BLS/ALS Total System
THETHEY DIDN’T TELL YOU IN MEDIC SCHOOL
>> 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.’
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.)
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
That was one
hell of a party
last night, Joe.
Just look at
how my hands
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
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.
INTER R & TER
WA S CH 7-9
HIN , 2
G T O 01
International Conference on Disaster
& Terrorism Preparedness
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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
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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
5 Tips for Pediatric Assessment
Jason McMullan, MD
10:00 am – 10:30 am
Veteran PTS: What you need to know
Dean R. Pedrotti
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
Top 5 Things Learned from the Battlefeld
Peter P. Taillac, MD, FACEP
1:15 pm – 1:45 pm
What Lies Ahead in the Second Decade of
Therapeutic Hypothermia Treatment?
Brent Myers, MD, MPH
2:00 pm – 2:30 pm
Trapped: When Time is Ticking
Christina Martinka, NREMT-P, FP-C, CCEMT-P, PNCCT
3:00 pm – 3:30 pm
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
Bagging Basics: One Second, One Handed
David Page, MS, NREMT-P
12:15 pm – 12:45 pm
Challenging EMS Case Presentation
David Page, MS, NREMT-P
Interested in Exhibiting?
Sue Ellen Rhine
Exhibit & Sponsorship Sales Representative
March 5-9, 2013 Washington, D.C.
E O ED
CON M PR
INTER R & TE
WA S CH 7-9
HIN , 2
G T O 01
The JEMS Games ofers
a unique experience to
learn from some of the
best EMS providers!
2nd Annual International
Conference on Disaster &
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 NAEMT.org.
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.
Add on to your registration to obtain CEH on a
• 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:
Register at www.EMSToday.com
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 EMSToday.com for the list of ingredients you must
use and the entry application.
12:15 PM – 1:30 PM — Networking Lunch for Seasoned
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
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
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
Gaining and Keeping the Public’s Trust
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
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.
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