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  1. 1. JANUARY 2013 Always En Route At
  2. 2. Making Precious Minutes Count™ Visit our NEW WEBSITE! Success Within Your Sight The King Vision™ Video Laryngoscope is a lightweight and portable video laryngoscope that can be used for both difficult and routine intubations. The full-color, non-glare and anti-scratch display helps you visualize and secure the airway quickly, minimizing interruptions in patient care. The durable and reusable device is ideal for EMS because it can withstand repeated cleaning and normal wear and tear. maximum control and minimal contact with soft tissue and teeth OLED (Organic Light Emitting Diode) color display standard intubations For more information or a product demonstration, contact your dedicated Account Manager or call 800.533.0523 Choose 11 at 800-533-0523
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  4. 4. MASKED LARYNGEAL AIRWAY PREVENTS OVERINFLATION The Only Self-Pressurizing Mask Cuff Available in Six Sizes Recent clinical studies have confirmed that laryngeal mask cuff overinflation is a real problem, potentially causing tissue or nerve damage. It may even impair carotid artery blood flow. Who else but Mercury Medical could deliver another life-saving clinical solution? , with the first and only selfpressuring mask cuff, uses positive pressure ventilation (PPV) to self-inflate the mask—on exhalation, the cuff decompresses to the level of PEEP. It will not overinflate, so you can treat your patients with confidence. Problem solved. SAFE. SIMPLE. SELF-PRESSURIZING. Be sure to stop by the Mercury Medical Booth, 34/35P at the 2013 NAEMSP® Annual Meeting, Hyatt Regency Coconut Point Resort & Spa Bonita Springs, FL, January 10 - 12, 2013 Choose 13 at 2 JEMS JANUARY 2013
  5. 5. ® 28 I WAVE OF THE FUTURE I Monitoring technology has potential to transform EMS By Mike McEvoy, PhD, NREMT-P, RN, CCRN JANUARY 2013 VOL. 38 NO. 1 Contents I 42 I PUTTING THE ‘RAP’ IN RAPPORT I I REVOLUTIONARY MULTI-TOOL I 46 5 I LOAD & GO I Now on 10 I EMS IN ACTION I Scene of the Month 12 I FROM THE EDITOR I Future Forecast I TUNNEL VISION I 42 DEPARTMENTS & COLUMNS 32 38 I 50 I OCCUPATIONAL MEDICINE ABCS I By Gary Ludwig, MS, EMT-P 22 I TRICKS OF THE TRADE I Teeter-Totter By Thom Dick EMS surveillance program assists with ‘frequent flyers’ By Anne-Marie Jensen, EMT-P; & James Dunford, MD Tablet devices transform how data is used & accessed in the field By Richard Huff, NREMT-B Is your agency receiving the full value? By Katherine West, RN, BSN, MSEd 50 I UPDATE ON 360-DEGREE DATA I 54 I KEEPING IT COOL I By A.J. Heightman, MPA, EMT-P 14 I LETTERS I In Your Words 16 I PRIORITY TRAFFIC I News You Can Use 20 I LEADERSHIP SECTOR I Whackers The role of video laryngoscopy in future advanced airway management By Terence Valenzuela, MD, MPH; Jarrod Mosier, MD; & John Sakles, MD Creating better healthcare by challenging the call to collect more data in the field By John Pringle & Loralee Olejnik Therapeutic hypothermia for out-of-hospital cardiac arrest patients produces promising results By Francis Kim, MD; Brent Myers, MD; & Michael K. Copass, MD 24 I CASE OF THE MONTH I ‘Not Acting Right’ By Dennis Edgerly, EMT-P 26 I RESEARCH REVIEW I What Current Studies Mean to EMS By David Page, MS, NREMT-P 62 I HANDS ON I Product Reviews from Street Crews By Dominic Silvestro, EMT-P, EMS-I 64 I LIGHTER SIDE I Can EMS Still Party? By Steve Berry 70 I EMPLOYMENT & CLASSIFIED ADS 71 I AD INDEX 72 I LAST WORD I The Ups & Downs of EMS About the Cover for out-of-hospital cardiac arrest patients produces promIn “Keeping it Cool: Therapeutic hypothermia ising results,” pp. 54–61, Francis Kim, MD, Brent Myers, MD and Michael K. Copass, MD, discuss a case in which providers from the Wake County (N.C.) EMS system deliver cooled saline to a patient after return of spontaneous circulation. Wake County utilizes EMS to rendezvous with crews to deliver cooled saline via a thermostatically controlled cooler. A patient suffering from cardiac arrest who requires treatment with therapeutic hypothermia cooling methods will be among those featured in the 2013 JEMS Games Clinical Skills competition at EMS Today in March. This clinical education feature, sponsored by Laerdal Medical Corp. and the Eagles Coalition, is the final of three that participating teams will need to study to plan and prepare for the challenging competition . PHOTO JULIE MACIE PREMIER MEDIA PARTNER OF THE IAFC, THE IAFC EMS SECTION & FIRE-RESCUE MED WWW.JEMS.COM JANUARY 2013 JEMS 3
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  7. 7. LOAD & GO LOG IN FOR EXCLUSIVE CONTENT A BETTER WAY TO LEARN JEMSCE.COM ONLINE CONTINUING EDUCATION PROGRAM S ON LLOW U FO TOP 2012 LISTS PASHAIGNATOVIISTOCK.COM As we enter a new year, we thought it would be fun to create lists of the most popular, most uplifting and most bizarre news articles of 2012. We had a blast reminding ourselves of the stories that made our Facebook page, Twitter feed and e-newsletters unique. And we think you will, too. ▲ SHOW US YOUR SKILLS! PHOTO GLEN ELLMAN This is your last chance to register for the 2013 JEMS Games—an international clinical skills competition that takes place at the EMS Today Conference & Exposition March 5–9 in Washington, D.C. The first-place team will receive free conference registration for the following year (as well as bragging rights for eternity). We’ll give you a hint: Be sure to read the clinical education article on pp. 54–61, as well as the ones in October and November, because components of those articles will be used for the JEMS Games final scenario on March 8. ▲ offers you JEMS com MS original content, jobs, products and resources. But we’re much more than that; we keep you in touch with your colleagues through our: > Facebook fan page; > JEMS Connect site; > Twitter account; > LinkedIn profile; > Product Connect site; and > Fire EMS Blogs site. LIKE US /jemsfans FOLLOW US /jemsconnect Sponsored Product Focus LIFE-STAT® MECHANICAL CPR MEETS 2010 AHA CPR GUIDELINES! Life-Stat® is the only mechanical CPR device that offers uninterrupted hands-free 2010 AHA-compliant CPR with coordinated ATV oxygen ventilation at the patient site and in all modes of transport. It provides the AHA required “at least 2 inches (5 cm),” complete recoil compression up to 3.2 inches (8 cm) for adults or precise 1.5 inches (4 cm) compression if needed. GET CONNECTED about=&gid=113182 ▲ Check out their ad on! EMS NEWS ALERTS NEW YEAR’S RESOLUTIONS 34% 32% Improve More formal education my clinical skills Match your EMS resolution. ▲ Mentor a new employee 9% Learn the business and operations No resolutions 12% 12% WANT MORE CASE REVIEWS? If you’re like most readers, you look for the Case of the Month in every issue of JEMS and want to be able to refer to them later. Now you can get them all in one place. ▲ CHECK IT OUT BEST BLOGGERS WWW.JEMS.COM JANUARY 2013 JEMS 5
  9. 9. Choose 16 at HealthEMS® Mobile • Industry–Leading ePCR Secure field data collection using your hardware of choice • HealthEMS® FlexFields Unique functionality creates customized ePCR • HealthEMS® Integrates to CAD and EKG Wireless data exchange eliminates manual entry improving accuracy • HealthEMS® XchangER Two-way wireless communication of ePCR data to/from hospital HealthEMS® EHR • Industry-Leading EHR Advanced QA solution supports CQI • HealthEMS® Xchange NEMSIS Gold compliant, v3 development in process • HealthEMS® is CARES Compliant; Sansio is the IT partner of the CARES network • myPatientEncounters™ Provides patients with secure, online access to their EHR NEW • • • • EMS Web-Based Revenue Cycle Management Solution! Improved efficiency with ePCR system integrated to billing system Accurate/Automatic ICD-9/10 coding, medical necessity, service level, loaded mileage, eligibility checking HIPAA Compliant Transactions 4010/5010 electronic claims and remittances Complete AR Management Workload management/change management and reporting Visit www.HealthEMS.NET or call 877.506.2747 for Demo #1 EMS Software as a Service (SaaS) Solution – Over 25% Top EMS Agencies Use HealthEMS® Sansio 11 East Superior Street, Suite 310 Choose 17 at Duluth, MN 55802
  10. 10. ® EDITORIAL BOARD WILLIAM K. ATKINSON II, PHD, MPH, MPA, EMT-P President & Chief Executive Officer, WakeMed Health & Hospitals JAMES J. AUGUSTINE, MD, FACEP Medical Director, Washington Township (Ohio) Fire Department Associate Medical Director, North Naples (Fla.) Fire Department Director of Clinical Operations, EMP Management Clinical Associate Professor, Department of Emergency Medicine, Wright State University STEVE BERRY, NREMT-P Paramedic & EMS Cartoonist, Woodland Park, Colo. BRYAN E. BLEDSOE, DO, FACEP, FAAEM Professor of Emergency Medicine, Director, EMS Fellowship, University of Nevada School of Medicine Medical Director, MedicWest Ambulance CRISS BRAINARD, EMT-P Deputy Chief of Operations, San Diego Fire-Rescue CHAD BROCATO, DHS, REMT-P Assistant Chief of Operations, Deerfield Beach (Fla.) Fire-Rescue Adjunct Professor of Anatomy & Physiology, Kaplan University J. ROBERT (ROB) BROWN JR., EFO Fire Chief, Stafford County (Va.) Fire & Rescue Department Executive Board, EMS Section, International Association of Fire Chiefs CAROL A. CUNNINGHAM, MD, FACEP, FAAEM State Medical Director, Ohio Department of Public Safety, Division of EMS THOM DICK, EMT-P Quality Care Coordinator, Platte Valley (Colo.) Ambulance BRUCE EVANS, MPA, EMT-P Deputy Chief, Upper Pine River Bayfield Fire Protection, Colorado District JAY FITCH, PHD President & Founding Partner, Fitch & Associates RAY FOWLER, MD, FACEP Associate Professor, University of Texas Southwestern School of Medicine Chief of EMS, University of Texas Southwestern Medical Center Chief of Medical Operations, Dallas Metropolitan Area BioTel (EMS) System ADAM D. FOX, DPM, DO Assistant Professor of Surgery, Division of Trauma Surgery & Critical Care, University of Medicine & Dentistry of New Jersey Former Advanced EMT-3 (AEMT-3) JEFFREY M. GOODLOE, MD, FACEP, NREMT-P Professor & EMS Section Chief Emergency Medicine, University of Oklahoma School of Community Medicine Medical Director, EMS System for Metropolitan Oklahoma City & Tulsa KEITH GRIFFITHS President, RedFlash Group Founding Editor, JEMS DAVE KESEG, MD, FACEP Medical Director, Columbus Fire Department Clinical Instructor, Ohio State University W. ANN MAGGIORE, JD, NREMT-P Associate Attorney, Butt, Thornton & Baehr PC Clinical Instructor, University of New Mexico, School of Medicine CONNIE J. MATTERA, MS, RN, EMT-P EMS Administrative Director & EMS System Coordinator, Northwest (Ill.) Community Hospital JEMS JANUARY 2013 EDWARD M. RACHT, MD Chief Medical Officer, American Medical Response JEFFREY P. SALOMONE, MD, FACS, NREMT-P Trauma Medical Director, Maricopa Medical Center Professor of Surgery, University of Arizona College of Medicine—Phoenix KATHLEEN S. SCHRANK, MD Professor of Medicine & Chief, Division of Emergency Medicine, University of Miami School of Medicine Medical Director, City of Miami Fire Rescue Medical Director, Village of Key Biscayne Fire Rescue JOHN SINCLAIR, EMT-P MIKE MCEVOY, PHD, REMT-P, RN, CCRN International Director, IAFC EMS Section EMS Coordinator, Saratoga County, N.Y. Fire Chief & Emergency Manager, EMS Editor, Fire Engineering Magazine Kittitas Valley (Wash.) Fire & Rescue Resuscitation Committee Chair, Albany (N.Y.) Medical College COREY M. SLOVIS, MD, FACP, FACEP, FAAEM MARK MEREDITH, MD Professor & Chair, Emergency Medicine, Assistant Professor, Emergency Medicine and Pediatrics, Vanderbilt University Medical Center Vanderbilt Medical Center Professor, Medicine, Vanderbilt University Medical Center Assistant EMS Medical Director for Pediatric Care, Medical Director, Metro Nashville Fire Department Nashville Fire Department Medical Director, Nashville International Airport GEOFFREY T. MILLER, EMT-P Director of Simulation Eastern Virginia Medical School, Office of Professional Development BRENT MYERS, MD, MPH, FACEP Medical Director, Wake County EMS System Emergency Physician, Wake Emergency Physicians PA Medical Director, WakeMed Health & Hospitals Emergency Services Institute MARY M. NEWMAN President, Sudden Cardiac Arrest Foundation JOSEPH P. ORNATO, MD, FACP, FACC, FACEP Professor & Chairman, Department of Emergency Medicine, Virginia Commonwealth University Medical Center Operational Medical Director, Richmond Ambulance Authority JERRY OVERTON, MPA Chair, International Academies of Emergency Dispatch DAVID PAGE, MS, NREMT-P Paramedic Instructor, Inver Hills (Minn.) Community College Paramedic, Allina Medical Transportation Member of the Board of Advisors, Prehospital Care Research Forum PAUL E. PEPE, MD, MPH, MACP, FACEP, FCCM Professor, Surgery, University of Texas GREGORY R. FRAILEY, DO, FACOEP, EMT-P Southwestern Medical Center Medical Director, Prehospital Services, Susquehanna Health Head, Emergency Services, Parkland Health & Hospital System Tactical Physician, Williamsport (Pa.) Bureau of Head, EMS Medical Direction Team, Police Special Response Team Dallas Area Biotel (EMS) System 8 DAVID E. PERSSE, MD, FACEP Physician Director, City of Houston Emergency Medical Services Public Health Authority, City of Houston Department. of Health & Human Services Associate Professor, Emergency Medicine, University of Texas Health Science Center—Houston WALT A. STOY, PHD, EMT-P, CCEMTP Professor & Director, Emergency Medicine, University of Pittsburgh Director, Office of Education, Center for Emergency Medicine RICHARD VANCE, EMT-P Captain, Carlsbad (Calif.) Fire Department JONATHAN D. WASHKO, BS-EMSA, NREMT-P, AEMD Assistant Vice President, North Shore-LIJ Center for EMS Co-Chairman, Professional Standards Committee, American Ambulance Association Ad-Hoc Finance Committee Member, NEMSAC KEITH WESLEY, MD, FACEP Medical Director, HealthEast Medical Transportation KATHERINE H. WEST, BSN, MED, CIC Infection Control Consultant, Infection Control/Emerging Concepts Inc. STEPHEN R. WIRTH, ESQ. Attorney, Page, Wolfberg & Wirth LLC. Legal Commissioner & Chair, Panel of Commissioners, Commission on Accreditation of Ambulance Services (CAAS) DOUGLAS M. WOLFBERG, ESQ. Attorney, Page, Wolfberg & Wirth LLC WAYNE M. ZYGOWICZ, BA, EFO, EMT-P EMS Division Chief, Littleton (Colo.) Fire Rescue
  11. 11. Choose 18 at
  13. 13. FEELING THE HEAT E MS providers from an American Medical Response (AMR) crew in Wichita Falls, Texas, arrive at medical tents to transport a patient who complained of abdominal pain and difficulty breathing after he fell near mile 26 of the “Hotter ‘N Hell Hundred” bike race, a day-long 100-mile ride. The patient was assessed by a team of paramedics, EMTs and physicians and transported to the United Regional Health Care System in Wichita Falls. The goal of the medical staff who work the race is to eliminate the need for hospital care, according to executive director Ben “Chip” Filer. “One of our primary goals is to ensure that everyone who comes to the race goes home vertical,” he says. But just in case, the AMR ambulances as well as the Wichita Falls Air Evac Lifeteam are standing by all day. The nearly 1,000 medical volunteers saw some 900 patients at 15 stops along the route during the 96o F day. Of those patients, only 14 required transport to emergency departments. WWW.JEMS.COM JANUARY 2013 JEMS 11
  14. 14. FROM THE EDITOR PUTTING ISSUES INTO PERSPECTIVE >> BY A.J. HEIGHTMAN, MPA, EMT-P FUTURE FORECAST Forces beyond your control are destined to affect your agency J anuary is the time of year when people make resolutions, try to forget the problems (personal and financial) they encountered throughout the previous year and dive into the New Year with hope of success, or at least improvements. Unfortunately, January is also the start of a new budget year, and the “resolutions” made by agencies at the start of the year are often made too late to make an effect on the changes or improvements that are needed to have an effect during that year. Think about it; couples plan their wedding for 12–18 months before the wedding date, and manufacturers plan and design new products secretly for years before they are manufactured and launched. But many response systems wait until a point when it’s too late to redesign their administrative and operational systems to meet budget goals or participate in new approaches to service delivery. Moving from a non-transport first response system into a system of full-service fire first response and transport is an example of a project that a fire agency needs to plan well in advance of introduc- Many response systems wait until a point when it’s too late to redesign their administrative & operational systems to meet budget goals or participate in new approaches to service delivery. tion of a proposal to a mayor and city council for it to be successful. Then, even if approved, it can take an agency a year to get the appropriate ambulances built. So design and bid specs also have to be 12 JEMS JANUARY 2013 preplanned and approved months before an order is made. Yet some agencies actually think they can make a major change, such as movefrom non-transport to full transport, in a few months. In the next 12–18 months, you will see lots of action by agencies that have been thinking ahead by planning for changes in EMS reimbursement. These changes include the new world of healthcare reform with pay-for-performance; new delivery models and methodologies, such as the redirection or transport of patients to nontraditional (non-hospital) destinations; and use of community practice paramedics to reduce call load and keep patients from returning prematurely to hospitals in their service area. Those agencies that are preplanning will reap the benefits and those that are not will begin to realize they’re spinning their fiscal wheels in the mud. Those agencies that are preplanning will reap the benefits & those that are not will begin to realize they’re spinning their fiscal wheels in the mud. So let’s circle back to January. This first month of the year is when most agencies begin to implement their new budgets, business plans and projects in hopes of greater success, financial prosperity and territory fortification. Territory fortification is the ability to maintain contracts and service area in the face of political or economic changes and challenges. Although private, non-profit and hospital-based agencies are familiar with the development of business plans, service contracts and territory fortification, many fire and third service EMS agencies are not. Although private, nonprofit and hospital-based agencies are familiar with the development of business plans, service contracts & territory fortification, many fire & third service EMS agencies are not. What’s the reason some are more familiar and others are not? There’s been little need for municipal services to do so because they’ve offered what are termed “traditional services.” Traditional services include crews waiting in fixed stations for calls to come in, responding and going back to quarters to wait for the next run. Agencies and workforces that fit in this category have also traditionally participated in standard budget development, had limited need for contracts or new business outside their normal operational parameters and had a reasonably certain hold on their service area (territory). However, the economic downturn, municipal shortfalls in tax revenue and reduced or eliminated federal grants and financially supported programs during the past five years are changing all that. Municipalities are cutting back staff and services in hopes of stopping fiscal bleeding: cutting out EMS supervisors, training and quality assurance staff, holding off on implementing new projects and forcing their departments to “do without” rather than innovate and implement replacement programs and services. The resultant cutbacks will have a snowball effect on the quality and quantity of service and, ultimately, affect the revenue a service has come to expect from third-
  15. 15. party payers. In the future, if your system becomes less efficient and the quality of the patient care and follow-up diminishes, so too will the reimbursement your system If your system becomes less efficient & the quality of the patient care & follow-up diminishes, so too will the reimbursement your system receives for the ‘services’ delivered. receives for the “services” delivered. Many agencies, particularly those operating in a traditional municipal environment, also aren’t paying close attention to the affect of the Patient Protection and Affordable Care Act (PPACA). They are ignoring the inevitable—that the waves of what some politely refer to as “Obama Care,” and the now famous “fiscal cliff,” could potentially overtake and suffocate Many agencies are ignoring the inevitable— that the waves of what some politely refer to as ‘Obama Care,’ & the now famous ‘fiscal cliff,’ could potentially overtake & suffocate them operationally & fiscally. them operationally and fiscally. Although I’m not an economist and don’t claim to be an expert on the PPACA, my position and access to EMS systems and industry experts compel me to give you a few things to think about. The Patient Protection and Affordable Care Act will affect the way you operate in the future. And if you’re not thinking, planning and preparing for the future, you will be affected, perhaps negatively, in the future. It’s important to note that there’s a difference between strategic planning and innovating. Innovation can occur throughout your normal operational and budget year. But strategic planning needs to be performed in advance of target projects and usually phased in over time. Strategic planning also involves careful review by key stakeholders and managers and, to be truly successful, cannot be just the ideas of the director. Top-down planning, often referred to as “management in a bubble,” is dangerous because it often reflects just the ideas of one or two managers or chiefs. In many cases, these managers have been “off the streets” for years—often just driving a desk. These types of managers can be out of touch with the real, evolving world of EMS and not in synch with what’s projected for the future. A few examples of how many systems have fallen behind the pack over the past five years include electronic patient care report and computer-aided design integration; robust data collection and system reports; patient compartment re-design; continuous positive airway pressure use by EMTs; and the adoption of therapeutic hypothermia. It’s funny, but the root cause of an EMS systems decline is often one toplevel manager or medical director who isn’t keeping up with the times or is resistant to implement changes or enhancements. If your agency doesn’t have a strategic plan for the future, you need to start the development of one now for implementation in late 2013 and beyond. And if you don’t believe in strategic planning or preparing for future changes in the delivery of health care services in America, I can assure you that other EMS agencies or organizations are doing so and will benefit from your inactivity. I am not calling those agencies “competitors” because, to have a competitor, you have to be prepared to compete. The athlete who fails to prepare for and train in any sport usually ends up in second place or worse. In EMS, it’s important for you to realize that anything below first place makes you the de-facto loser. Let me get more specific. The 1,000plus pages of the Patient Protection and Affordable Care Act do not specifically reference or name EMS, emergency responders, fire first responders, rescue services, mass casualty response, disaster preparedness or hospital surge. That, in itself is a bad sign because the authors of the legislation appear to have forgotten us or at least not viewed emergency and out-of-hospital response resources as a high priority in the healthcare chain. However, rest assured, we are (or can be) a big part of the future healthcare delivery system if you read between the lines, plan for integration and adjust your operations and workforce to ride the healthcare wave instead of being pushed aside or drowned by it. Incentives, and disincentives, that will result from the new healthcare regulations will hit hospitals where they feel it the most—in their budget. If a patient returns to their hospital within 30 days after discharge, the hospital will be penalized financially. So they now have a financial incentive to work with you or another agency to deploy community practice paramedics to check on Aunt Mabel in her home or have an automated system The Patient Protection & Affordable Care Act will affect the way you operate in the future. that alerts one whenever there are abnormalities in vital signs of the programmed device “predicts” that an untoward effect is on the horizon. The same type of penalties will be incurred by hospitals if they don’t have a 360-degree data exchange and review system in place with all of their “affiliated partners.” Although satellite facilities, affiliate doctor groups and other heal centers are named in Patient Protection and Affordable Care Act and EMS is not, people in the know tell me that EMS will be considered an affiliated member of each hospitals care network. So I and others think secure linkage to a hospital’s patient record system is probably in your future. And if you can’t afford to do it, I’m betting that hospitals will eventually become convinced that it’s cheaper to pay to have you linked than to receive reduced reimbursements for not having you linked to their system. Best wishes for a safe, happy and wellplanned New Year! WWW.JEMS.COM JANUARY 2013 JEMS 13
  16. 16. CHALLENGES TO ‘EATING HEALTHY’ HY’ This month, JEMS readers and d Facebook fans chime in with additional suggestions and feedback on a December JEMS article by nutrition columnist Elizabeth Smith, MS, RD, LDN, EMT-B, “Eating Healthy on an EMS Budget: 8 tips to stretch your budget, not your waistline.” Also, our Facebook fans respond to news posts about the tragic school shooting at Sandy Hook Elementary School in Newtown, Conn., on Dec. 14, 2012. We were touched by their words of love and support for the Newtown Volunteer Ambulance Service, Newtown Fire and Rescue, and the community’s other first responders. We echo their thoughts and sentiments to all who have been touched by this terrible tragedy. I’m fortunate to have a vacuum sealer. Sunday is a big cooking day in my house. I make stuff that could be, but doesn’t necessarily need to be, reheated. Scott H. Via Facebook I’ve been around for quite a few decades and still cannot figure out what a “serving size” is. We deal with things like ounces, grams, etc. When is someone going to put things in terms we use? Derek M. Via Facebook Author Elizabeth Smith, MS, RD, LDN, EMT-B, responds: You’re right, Derek; serving sizes are often labeled in ounces and grams, and it is much easier if you can think of servings in terms of everyday things. Here are a few for reference: >> One serving of fruit or vegetables is the size of your fist. >> One serving of pasta is the size of an ice cream scoop. >> Three ounces of meat, fish or poultry is the size of a deck of cards. >> One serving size of potato is the size of a computer mouse. >> An appropriately sized bagel is the size of a hockey puck. >> One serving of cheese is the size of a pair of dice. There are a lot of great visual aids along these lines available online as well. Sounds great in theory, but the bottom line is that in busy systems it does not work. With turnaround times less than 10 minutes at the hospital, being scheduled for 12 hours but working 16 hours and it’s against Occupational Safety and Health Administration (OSHA) regulations to eat in an ambulance or even store food in an ambulance, you cannot 14 JEMS JANUARY 2013 prepare your meals for the week. What you are describing may be the norm in your area but in most services good luck with being able to do this on a daily basis. Your intentions are good but the real factor is that you need time to stop and eat and that just does not happen. Trent S. Via Facebook Author Elizabeth Smith, MS, RD, LDN, EMT-B, responds: I believe the OSHA regulation you are referring to is the prohibition of eating and drinking in the workplace, part of 29 CFR 1910.1030, Occupational Exposure to Bloodborne Pathogens. This regulation has been interpreted in the OSHA Bloodborne Pathogens Exposure Control Plan for ambulance companies specifically to define the patient area as co the th workplace and the cab section of the ambulance as permissible for food and drink, provided that the company has a policy in place for employees to co clean cl contaminated clothing. So you are allowed to carry ca food and eat in the truck, just keep it in the front fr and away from the patients. TRAGEDY IN NEWTOWN, CONN. We in EMS who responded will be forever changed for what we could not do at the scene. There was nobody to transport, and that was devastating. Nothing breaks an EMT’s heart more than not being able to do anything but move the dead. May we find strength in each other and in our profession. God bless, from a Newtown resident and AEMT. Melissa M. Via Facebook I was there at the [Newtown] High School gym [working with American Red Cross Disaster Mental Health], where I got to talk with the EMS folks. We don’t have words to express the deep loss they feel. Philip B. Via Facebook I’ve been in EMS nearing 23 years; I don’t think I’d be able to work another day for a while after all that happened there. After all the years, it is the young’uns that still haunt my dreams and thoughts … Scott M. Via Facebook AP PHOTO/NEWTOWN BEE, SHANNON HICKS PHOTO CYBERNESCO/DREAMSTIME.COM LETTERS IN YOUR WORDS Paramedics push stretchers toward Sandy Hook Elementary School in Newtown, Conn., where a gunman opened fire, killing 26 people, including 20 children, on Dec. 14, 2012.
  17. 17. As I began my shift today, I was shocked at the tragic news of this senseless act. I feel sad for those struck by this devastating situation. Through the sadness comes pride in my fellow EMS/fire/law enforcement brothers and sisters that ran toward this scene today. Stay safe and continue with courage and strength. Hug your family a little tighter when you get off duty. Scott W. Via Facebook In the time to come, may strength, compassion, selflessness and service guide your way. And when it is your turn to take care of each other and yourselves, may you have the healing that you need. Cassandra D. Via Facebook This is what makes me so passionate about my job in the EMS field. All of us have to endure so many scenes like this. We have to put our feelings aside at that moment to help the people in need. I take my hat off to all EMS medics and salute you for what you do for patients. Thank you to all you guys what you do for your fellow man. I’m so proud of you even though I don’t know you. It’s a cruel world out there. Good luck to all of you. Lizelle P. Via Facebook FEATURED BLOG: A Day in the Life of an Ambulance Driver BLOG POST EXCERPT: ‘FOR NEWTOWN VOLUNTEER AMBULANCE CORPS’ And then there are days like Friday, when nothing can prepare you for the horror you faced, and no amount of code saves, or babies birthed, or little old ladies comforted, no amount of joy your career as an EMT has brought you before or since, can erase the scar it leaves on your soul. You only triaged three from Sandy Hook Elementary School as red. All the rest were blacks. Only one you transported lived beyond the emergency department. And given that you’re a small volunteer department, odds are you knew many of the children killed. People who do not work in EMS do not understand triage. Sure, they may grasp the concept of it; sickest transported first, stable patients transported next to last, dead patients transported last of all. They may even know what the colors red, yellow, black and green signify. Wow ... thank you for your gift of words, so beautifully written! Heather M. Via Facebook A very touching look at a day in the life of volunteer EMTs. A sad day indeed for all of us that answer the call. The crews from Crook County, Wyo., send our deepest sympathies to the families and our thanks to all the first responders. Sheila H. Via Facebook For more on the Sandy Hook Elementary School massacre, please see JEMS Editor-in-Chief A.J. Heightman’s note on page 18 of this issue. MCI MANAGEMENT TIPS I am assembling some of the items you mentioned in your great article on MCI planning in the November issue of JEMS (“Incident Management: 10 tips to help gear up for MCIs” by A.J. Heightman, MPA, EMT-P). Do you have any checklists you have used in the past to assist me in large event planning? Thank you for the insight on this very important topic. Troy Willrick Daytona Beach, Fla. Editor’s Note: Thank you, Troy, for the kind words. We recommend reading the article “MCI Magnifiers: Many factors can complicate an incident of any size” by Editor-in-Chief A.J. Heightman which appeared in the September issue of JEMS. This article, and many more resources for management of major incidents, can be found online at Choose 19 at WWW.JEMS.COM JANUARY 2013 JEMS 15
  18. 18. PRIORITYUSE TRAFFIC NEWS YOU CAN Bringing issues to THE HILL Fourth annual EMS on the Hill Day to be held prior to EMS Today PHOTO ISTOCKPHOTO.COM R egistration has begun for the fourth annual EMS on the Hill Day, hosted by the National Association of Emergency Medical Technicians (NAEMT). The 2013 event takes place on March 5–6, 2012, in Washington, D.C. In order for appointments to be scheduled with congressional leaders, participants must register by February 15, 2013. EMS on the Hill Day is the nation’s only national EMS advocacy event, providing professionals from all sectors of the emergency medical community the opportunity to advocate for specific EMS legislation. According to NAEMT Executive Director Pamela Lane, EMS on the Hill Day sends a consistent message to elected leaders regarding critical issues facing EMS throughout the nation and builds important relationships with Senate and House leaders and their staff. Meeting with Congressional leaders also has a direct effect on individual EMS agencies and practitioners. “The more [legislators] in Washington understand the challenges to providing quality EMS, the greater the possibility that they will craft policies that address those challenges,” Lane says. This past year, nearly 200 EMS practitioners from 42 states and the District of Columbia attended 246 meetings with U.S. Senators, House representatives, and their congressional staff to advocate for EMS issues. This year, EMS on the Hill Day will be held just prior to EMS Today, the annual JEMS conference and exhibition that is scheduled for March 5–9, also in Washington D.C. The schedule for the 2013 EMS on the Hill Day includes the following: March 5: Participants will meet with other participants and attend a preHill visit briefing, followed by a reception. March 6: Participants will attend scheduled appointments with their Senate and House leaders and their staff, followed by an evening reception. Register online at —Teresa McCallion, EMT-B From our Facebook Audience We asked our Facebook fans what issues they would bring to Washington if they had the opportunity. Here’s what they said: Brent D.: Pay, benefits and provider health and safety. Justin S.: Educational standards, evidencebased medicine, community paramedicine. David C.: Hooray for healthcare reform. I myself have a full-time job, but most of my coworkers work two or three part-time jobs. This will finally give EMS providers an actual affordable option to insure themselves instead of praying they don’t get sick. Skip K.: The need to include basic civics and constitutional law in EMT class, so that folks in EMS have some idea of the responsibilities of the federal government versus the things that are reserved to the states. Jason B.: Make EMS a profession with licensure not just certification. Skip K.: Also have to get people to do research. A piece of paper from the government that lets you practice a job or profession is a license, even if they call it something else. Check out the legal opinion on the subject on the NREMT’s website: J Mac Q.: Declining Medicare reimbursements. Garrett H.: All of the above are good things, most necessitating money and organization. We can take care of some of that with current draft legislation like the EMS field bill. Money will involve the need to have alternate payments other than being a taxi. Check out the most interesting, bizarre and unusual cases at 16 JEMS JANUARY 2013
  19. 19. The JEMS Family of Products: Helping You Save Lives Website JEMS, Journal of Emergency Medical Services Your online connection to the EMS world, gives you information on: Products Jobs Patient Care Training Technology With content from writers who are EMS professionals in the feld, JEMS provides the information you need on clinical issues, new products and EMS trends. Available in print and digital editions! eNewsletter Product Connect The JEMS eNewsletter gives you breaking news, articles and product information. It’s free to subscribe … stay ahead of the latest news! Giving you the detailed product information you need, when you need it. We collect all the information from manufacturers and put it in one place, so it’s easy for you to fnd and easy for you to read. Go to Archived Webcasts Approaches to Shock Management ® TM Free … Available 24/7! For more information on the JEMS Family of EMS Products:
  20. 20. PRIORITY TRAFFIC >> CONTINUED FROM PAGE 16 THOUGHTS ON THE SANDY HOOK MASSACRE A NOTE FROM JEMS EDITOR-IN-CHIEF A.J. HEIGHTMAN, MPA, EMT-P The shooting and killing of 26 innocent children and staff at Sandy Hook Elementary School in the peaceful, beautiful town of Newtown, Conn., 45 miles southwest of Hartford and 60 miles northeast of New York City, causes us all to take pause and wonder how such a tragedy can happen. Those of us in the emergency community think of the responders—the tragic and grisly scene they were forced to endure—and we feel the desire to reach out, pat them on the back and let them know our thoughts and prayers are with them. It appears that the shooter was shooting randomly and had a purposeful attack plan. Many are trying to make sense of this tragedy and wonder what they would do if an attack of this nature took place in their community. This type of attack has occurred before and will be replicated again. School shootings have become commonplace for myriad reasons: Revenge on bullying, retribution on teachers and administrators, and by individuals who are out to make a strong statement. But what few people know is that terrorism and mass casualty experts have predicted this type of mass killing spree (and scores larger) for years—and for a reason we all dread hearing—that terror organizations have been espousing that, if you want to make a statement and bring a country to its knees, kill its children. In my MCI classes, I discuss the little-known incident that occurred in Beslan School Number One (SNO) in the town of Beslan, North Ossetia (an autonomous republic in the North Caucasus region of the Russian Federation) on Sept. 1, 2004. It was a premeditated terrorist assault planned for the first day of school, when it was customary for parents, siblings and grandparents to accompany their school-aged children back to school for the start of the new school year. The terrorists were deployed by a Chechen separatist warlord who demanded recognition of the independence of Chechnya at the U.N. and Russian withdrawal from Chechnya. To make a strong statement, the assault was targeted for a vulnerable and easy target—an elementary school where the students and faculty aren’t physically able to repel an attack. The terrorists easily entered an open access, unsecured school that they had scouted and took 1,100 people (including 777 children) hostage. They used the strongest male hostages to fortify the school and then killed them to eliminate them as future threats. They herded the youngest children into the school’s gymnasium and chained several to basketball hoop assemblies rigged with explosives that would detonate if any of them tried to escape. Townspeople soon learned of the terrorists’ takeover of the school, alerted the authorities and began to shoot at the school in an attempt to mitigate the incident. This created a vicious crossfire that impeded rescue operations. The hostage situation lasted more than three days and ended tragically when, during an assault by Russian security forces, one of the booby-trapped children detonated the explosives and 334 hostages, of which 186 were children, were killed. The tragedy in Newtown, Conn., at an elementary school occupied by 700 children, should cause all responding agencies to take the time to obtain a copy of John Giduck’s book, Terror at Beslan, read it carefully and work with their school systems to improve school security, practice active shooter and MCI scenarios and be properly prepared if such an event happens in their community, particularly one involving places where a high volume of children are located. PERSONAL USE OF COMPANY EQUIPMENT W here does the line get drawn with regard to the personal use of company equipment and supplies? A certain amount of personal use of an employer’s “stuff” seems to be common and accepted practice these days. For instance, the use of a workplace computer to check sports scores or order from an online merchant is a regular occurrence in American workplaces. But what about some of the relatively expensive equipment found in the EMS workplace? For instance, what are the rules when it comes to using one of your employer’s ambulances to stop at the store for a few personal items, or to swing by your child’s soccer game? The first rule is that there are no hard and fast rules—those are set by each employer. No state laws of which we are aware would regulate what can and cannot be done with an ambulance or other EMS equipment when it’s not engaged in active EMS operations. There may be laws, regulations or policies that require on-duty ambulances to remain in a specified coverage zone or operating area. Certainly there could be consequences for violating these requirements. Otherwise, so long as the agency is not violating any rules regarding vehicle deployment, this would not pose a legal barrier to occasional personal use of a company vehicle. Where the bigger issue comes into play, however, is whether the employee is violating the employer’s policies with regard to the personal use of company equipment. If an employer permits employees to use ambulances or other company vehicles for occasional, minor personal errands, then that is up to the employer. On the other hand, if the employer has a “zero tolerance” policy, prohibiting the use of company vehicles for any personal use, then the employer would likely be within its rights to discipline or terminate an employee for such conduct. If the workplace is unionized, discipline for violating any such rules would have to be resolved with reference to the collective bargaining agreement in place between the union and the employer. Extra caution should be taken when the vehicles, equipment or other supplies belong to a nonprofit, tax-exempt organization. State and federal laws generally prohibit “private inurement”—that is—using tax-exempt assets to benefit specific individuals. Although an occasional trip to the store would likely not catch the attention of the IRS, regular use of nonprofit assets for private benefit could very well become an issue that could even jeopardize the tax-exempt status of an organization. Although occasional use of an ambulance or other vehicle is one thing, the “pilfering” of supplies for personal use is another issue altogether. Taking one band-aid out of the jump kit is commonplace, and probably would be OK with most employers, but helping yourself to supplies needed to stock your personal jump kit would be something else entirely. Again, the rules are ultimately up to the employer, but few employers would tolerate the theft of company supplies in this fashion. The bottom line is that employers should take the time to write clear and workable policies on this issue—and then employees would be well-served to follow those policies. If no written policy is in place, but employers knowingly permit or tolerate the use of vehicles or equipment, then that might create a de facto policy permitting it. A clear written policy removes the guesswork for both parties. For more of the latest EMS news, go to 18 JEMS JANUARY 2013 Pro Bono is written by attorneys Doug Wolfberg and Steve Wirth, founding partners of Page, Wolfberg & Wirth, a national EMS industry law firm. Visit the firm’s website at
  21. 21. QUICK TAKE SUNSTAR SUCCESS Agency one of two in U.S. to receive triple accreditation S unstar Paramedics, the EMS transport provider for Pinellas County (Fla.), remains one of two EMS providers in the U.S. to be accredited by the following three respected industry organizations: >> The Commission on Accreditation of Medical Transport Systems (CAMTS), >> The Commission on Accreditation of Ambulance Services (CAAS), and >> The Accredited Center of Excellence (ACE) by the National/International Academies of Emergency Dispatch. The only other two programs in the world to hold all three accreditations are Regional Emergency Medical Services Authority (REMSA) in Reno, Nev., and Emergency Medical Care Inc. in Nova Scotia. The CAMTS, CAAS and ACE programs ensure quality care and transportation service safety. To become accredited, EMS programs are evaluated on a range of criteria, from general operations (such as safety procedures and equipment management), to staff wellness policies and public education programs (such as free CPR classes and child passenger safety assistance). “These accreditations are important to us; we’re pleased to hold them and to take part in the processes,” said Mark Postma, COO with Sunstar Paramedics, in a press release. “Along with frequent awards and a 96% customer satisfaction rate, our people take great pride in our work, and we appreciate being told we’re doing a good job.” The accreditation processes take at least four months, and each accreditation lasts three years. In Florida, there are 17 organizations accredited by ACE, nine with CAAS, and five with CAMTS. Sunstar employs 500-plus local residents and responds to approximately 500 calls a day. CAFFEINE: THE GOOD & BAD WHAT EMS PROVIDERS NEED TO KNOW with beta effects from stimulating epinephrine release. As some of us know too well, too much coffee can cause jitteriness, palpitations, tremors and even sweating. Other relatively benign side effects of increased amounts of caffeine include nausea, vomiting and anxiety. Serious and potential fatal effects of caffeine include ventricular arrhythmia, seizures, altered mental status, excited delirium, status seizures, hypertensive emergencies and stroke syndromes because of intercerebral hemorrhage. The treatment of potential caffeine overdoses focuses on securing the patient’s airway, breathing and circulation via IV fluids and temperature control, calming the patients with a benzodiazepine like valium or Versed, using an antiemetic for nausea or vomiting and using nitroglycerin for severe hypertension not respond- ing to benzodiazepineinduced relaxation. Beta blockers are contraindicated because they allow caffeine’s (like cocaine’s) unopposed alpha effects and risk of severe hypertension. In summary, caffeine ingestion is usually benign, but it may have neurologic, cardiac and gastrointestinal side effects. Caffeine intoxication should be considered in previously healthy patients who deny cocaine and amphetamine use but who appear hyperadrenergic. Acute caffeine intoxication can mimic many conditions including mania, excited delirium, cocaine intoxication and thyroid storm. —Corey M. Slovis, MD Choose 20 at PHOTO A.J. HEIGHTMAN Caffeine is omnipresent. It’s found in coffee, tea, most soft drinks, chocolate, dietary supplements, prescription medications and energy drinks. Brewed coffee usually averages about 80–100 mg of caffeine per 8 oz. cup, and coffee drinks at places like McDonald’s and Starbucks range in caffeine from 50–200 mg. Some specialty coffee drinks have as much as 330 mg in a large drink. Similarly, great variability exists in “energy” pills and drinks that can have as little as 50 mgs to as much as 200 mgs in just 2 oz. of liquid. Recently, some deaths attributed to the ingestion of energy drinks with high amounts of caffeine have gained media attention. Caffeine can be toxic with an estimated lethal dose in the range of 5–10 grams in normal subjects. Lower amounts could potentially be toxic in patients with pre-existing heart disease and those who are taking other stimulants or intoxicants, especially if they were dehydrated. Caffeine’s effects are almost always benign; it usually increases alertness and may mildly raise pulse and respirations due to its alpha vaso-constricting effects along WWW.JEMS.COM JANUARY 2013 JEMS 19
  22. 22. LEADERSHIP SECTOR PRESENTED BY THE IAFC EMS SECTION >> BY GARY LUDWIG, MS, EMT-P WHACKERS Discipline isn’t always the best action 20 JEMS JANUARY 2013 PHOTO A.J. HEIGHTMAN W hen my kids were little, one of our favorite things was to go to Chuck E. Cheese’s, where they could burn up some energy eating pizza, playing arcade games and running around on the playthings. One of the arcade games was called “Whack-a-Mole.” Out of five holes, a mole pops up at random, and you “whack” it in the head using a soft hammer to knock it back down. If you don’t hit it fast or hard enough, it disappears back down its hole. The more you hit and the faster you hit them, the higher your score. This classic arcade game spurred a book on a managerial style that I find is reminiscent of how some EMS organizations manage their employees. It seems some managers think they’re playing Whack-a-Mole. They discipline employees on a routine basis and without regard for the circumstances, knocking the employees in the head as fast and as hard as they can. In these types of EMS organizations, you’re disciplined any time a complaint is received from a nurse, physician, citizen, patient or bystander. It doesn’t matter who complains, and the circumstances of the complaint aren’t investigated. The bottom line is that management feels the employee must have done something wrong. Basically, they only follow one fundamental principle: “the customer is always right.” The resulting morale and turnover in these EMS organizations is deplorable. Nobody goes out of their way to deliver exceptional service. They instead go about their jobs in pure fear of doing something wrong and receiving a complaint. I contend that employees do things wrong for three reasons: They’re unaware, unable or unwilling. Many EMS managers discipline employees for all three reasons. Instead, we should be looking at the circumstances by which the infraction happened. If an employee is unaware of a policy or procedure, this is an opportunity to mentor rather Stop playing Whack-a-Mole with your employees. the number of accidents. Why do we think changing people through disciplinary action is an effective solution to a problem, especially when changing the system will ensure the problem will go away? One management philosophy emerging in the healthcare industry, which is supported by the National Association of Emergency Medical Technicians (NAEMT), is “just culture.”1 In a just culture—a concept invented by “Whack-a-Mole” author David Marx—the goal is to look at an error and classify the action into one of three categories: human error, at-risk behavior or reckless behavior. The need for and extent of any punishment is based on this classification. Once the error is assessed and classified, the just culture concept suggests a course of action. Managing human errors is done by looking at processes, procedures, training and design. People who make at-risk decisions are usually managed by coaching and increasing situational awareness. It’s only those employees who demonstrate reckless behavior that just culture recommends that managers discipline. Developing a just culture and taking this new approach to managing mistakes in your organization is a large-scale change. But the Whack-a-Mole mentality certainly has demonstrated it doesn’t work and can actually cause harm to an organization. than discipline. Wouldn’t the employee prefer to receive coaching rather than be whacked in the head like a mole? Sometimes the problem occurs because of a systemic problem. For example, consider a service that keeps disciplining employees for hitting the door frame on either side when they back an ambulance into the station. This keeps happening over and over. An EMS manager should question why an employee would intentionally back an ambulance into the door frame of an ambulance station. They might come to the conclusion that the mistake isn’t intentional and perhaps suggest a policy where spotters have to be in place REFERENCES 1. National Association of EMTs. (July 19, 2012). any time an ambulance backed into the staNAEMT Board Adopts New Position Statement tion. I bet accidents involving ambulances on ‘Just Culture’ System. In JEMS. Retrieved backing into a door frame would drop draNov. 5, 2012, from matically. You could even go one step further naemt-board-adopts-new-position-statemen. and add back-up cameras and an alarm system to further assist the drivers. Gary Ludwig, MS, EMT-P, has 35 years of In the above scenario, a systemic EMS, fire and rescue experience. He currently problem existed because the employserves as a deputy fire chief for the Memphis ees were unable to do their job withFire Department. He’s also Chair of the EMS out a tool they needed (a spotter or a Section for the International Association of camera and alarm system). A change to the policy and procedure supported by Fire Chiefs. He can be reached through his website at additional technology drastically reduced
  23. 23. ANSWERS AS FAST AS OUR VASCULAR ACCESS Download the EZ-IO app and have powerful information at your fingertips. Scan and get your APP. Choose 21 at Choose 22 at Choose 23 at Choose 24 at
  24. 24. TRICKSOUR PATIENTS & OURSELVES OF THE TRADE CARING FOR >> BY THOM DICK, EMT-P TEETER-TOTTER EMT poses a different loading strategy T his is a story about an EMS device that arose from a situation no ordinary person would appreciate. But as an EMS provider, trust me, you will. When you read what happened, you’ll understand its significance immediately. In fact, you’ll want to stop reading and salute the EMT who invented it. Imagine you’re a volunteer at a small rural EMS agency. You and your partner, both munchkins, respond alone for a rollover motor vehicle collision. On arrival, you encounter an inverted vehicle containing two small children in the back seat and two generously proportioned adults up front. The front passenger weighs about 350 lbs., and the driver at least 500. Somehow, you’ll have to extricate all four patients and get them into one ambulance. Let’s salute Doris Van Ness. Doris and her partner did something rural EMTs do every day, Life-Saver—something that transcends all of the spreadsheets, databases and journal articles to which we devote so much attention. They adapted to their situation and overcame. They enlisted the help of enough passing motorists to stabilize, extricate, carry and load all four patients into the ambulance for transport. People like Doris do what they do for free because there simply are no other resources. Sick people are getting heavier. And Doris’ agency, is struggling financially—as are most small agencies. In the future, they may or may not be able to come up with even the 50% matching funds for a grant to obtain a self-lifting cot and a loading system that would at least help them during lifting and loading. Self-lifting cots are wonderful tools, but their extra weight is nothing to sneeze at. Anyway, back to Doris. After the call, she patented a completely different loading idea, using something she did have: her vehicle’s electrical system, a three-quarter-ton bumper winch, some extruded aluminum and a 22 JEMS JANUARY 2013 The front passenger weighs about 350 lbs., & the driver at least 500. Somehow, you’ll have to extricate all four patients & get them into one ambulance. EMT/inventor Doris Van Ness operates her cot-loading device. Its forward end is attached to a three-quarter-ton winch bolted to the supports beneath the deck of this demo ambulance. basic understanding of physics. Her design is nothing like the loading systems you’ve seen so far. It certainly doesn’t look strong enough to do the job of loading a 500-lb. patient. But Doris isn’t fooling around; her lift is based on a parallel double boom, almost like you’d see on a tow truck—only the boom is hinged at the aft end of the deck in an ambulance’s patient compartment. At the forward end of the boom is a winch attached to the frame under the vehicle’s deck. When it lifts, it works kind of like a teeter-totter. The boom incorporates a pair of telescoping beams attached to channels intended to integrate with the upper frame of any ambulance cot. When engaged and fully extended, the whole assembly is designed to lift a combined patient-and-cot weight of 1,200 lbs. (It’s been tested at 1,800 lbs.) Called the Bedrock Lift, Doris’ invention can be installed initially in three hours. It weighs 350 lbs., and it can be removed or reinstalled in minutes. It can be pressurewashed, and it’s designed to lift any kind of cot. Doris demo’ed her beta unit for us at the fifth annual Colorado EMS Safety Summit in Loveland, Colo., in early October. It wasn’t fancy, and it was mounted in a small second-hand ambulance she had purchased just for demonstrations. But fancy or not, it’s a horse. The production model will come powder-coated. It’s designed to be mounted without modifying an ambulance’s existing frame. Doris said she plans to install her lifts on-site and provide instructions in their use. They say that necessity is the mother of all invention. I’d like to congratulate Doris for being the mother of this back-saving, practical invention. For more information, contact her at Thom Dick has been involved in EMS for 42 years, 23 of them as a full-time EMT and paramedic in San Diego County. He’s currently the quality care coordinator for Platte Valley Ambulance, a hospital-based 9-1-1 system in Brighton, Colo. Contact him at
  25. 25. POWERFUL SOLUTIONS FROM SMART THINKERS avoid pending lawsuits EMS Insider provides you with the “inside infor- EMS Research & Technology mation” on EMS. It’s a monthly publication from Elsevier Public Safety and affiliated with JEMS (Journal of Emergency Medical Services) so it has EMS Trend the best network of sources in EMS. That means Analysis AVOID COSTLY FINES revenue generating ideas you get only the highest quality reporting . . . insightful, timely, authoritative. . . not available elsewhere. EMS Insider pays for itself. Every issue contains articles to help you, by bringing you money-saving and revenue-generating ideas. Don’t miss out, order your subscription today! Exclusively for EMS Management Subscribe to EMS Insider WWW.JEMS.COM JANUARY 2013 JEMS 23
  26. 26. CASE OF THE MONTH DILEMMAS IN DAY-TO-DAY CARE >> BY DENNIS EDGERLY, EMT-P ‘NOT ACTING RIGHT’ Providers treat patient with hyponatremia due to a brain tumor T he patient’s wife called 9-1-1 because her husband was acting drunk. When you arrive on scene, a middle-aged woman meets you at the door and tells you she’s concerned about her husband. She came home from a weekend business trip and found him “not acting right.” You ask for clarification, and she tells you he is confused and having difficulty walking. She doesn’t think he’s drunk because he’s only had one beer, but says, “He is sure acting weird.” After assuring the wife you will take care of her husband, you and your partner walk into the living room where he’s sitting. You find a 46-year-old male sitting on the couch. He looks at you and nods his head when you say, “hello,” but doesn’t speak. A quick physical exam reveals no signs of trauma. He appears to be moving all extremities but is unable to follow commands when you attempt to perform a Cincinnati Stroke Scale assessment. You note no facial droop or drooping of the eyelid, which is called ptosis. The patient’s skin is pink, warm and dry, and his pupils are equal and reactive at 4 mm. He doesn’t appear to be in pain or respiratory distress. His pulse is 72 and regular. Blood pressure is 146/82 and respirations are 18 and uncompromised. A finger-stick blood glucose level reads 106 mg/dL. There’s a can of beer sitting next to him, but it’s nearly full. The patient’s wife tells you her husband seemed normal when she spoke with him this past evening but he was tired and going to bed early. She tells you he is healthy and takes no medications on a regular basis. A little bewildered, you and your partner place the patient on a stretcher and into the ambulance. During transport, you establish an IV and begin a reassessment when the patient develops a tonic-clonic seizure. The seizure 24 JEMS JANUARY 2013 PHOTO JEFFREY MAYES CASE PRESENTATION Hyponatremia is commonly found at endurance events where patients sweat excessively. lasts about 45 seconds. The patient now responds only to noxious stimuli with moaning and withdrawal. You suction his airway, apply oxygen and ask you partner to step it up to an emergent transport. As you transfer the patient, you ask the emergency physician what she thinks is the cause. She tells you she needs to wait for lab work. When you follow up later, she tells you the patient’s sodium level was 118 mEq/L. The patient was hyponatremic because he has a tumor on his posterior pituitary gland that’s causing an increased production of antidiuretic hormone (ADH), resulting in a dilution of his sodium levels. This is called syndrome of inappropriate anti-diuretic hormone (SIADH), which has many underlying causes in addition to hyponatremia. DISCUSSION The brain tumor that caused hyponatremia in this case may not be commonplace, but hyponatremia is one of the most common electrolyte imbalances seen in the field.1 Sodium is the primary extracellular ion. Normal values are 135–145 mEq/dL. Hyponatremia is defined as sodium levels less than 135 mEq/dL, with levels less than 125 mEq/dL being considered severe.2 When sodium levels drop, there’s a change in osmolarity that causes fluid to move into cells. This causes cellular swelling, which is most concerning in the brain and is the cause of many of the symptoms. If hyponatremia develops slowly, the body may have the ability to compensate, and patients may be asymptomatic even with sodium levels as low as 115 mEq/dL.1 However, patients with acute hyponatremia can be critical. Sodium concentration can be depleted in a couple of ways. In hypovolemic hyponatremia, a body has lost too much sodium in relation to water loss. This can occur with excessive sweating as seen with endurance sports like marathons, use of such diuretics as thiazide diuretics, and third spacing of fluid, as is seen with burns. The other way is to dilute the body’s sodium concentration with too much
  27. 27. water. Dilution of sodium can occur with excessive fluid intake or secondary to the body’s ability to eliminate fluid, which is the case with heart and renal failure. There have also been cases of hyponatremia seen in infants when their formula has been diluted with water or the child has been fed tap water.3 This is referred to as hypervolemic hyponatremia. In this case, the patient developed hyponatremia secondary to the body’s inability to eliminate fluid because of the alteration in ADH levels. Common signs and symptoms of hyponatremia include lethargy, apathy, confusion, disorientation and seizures. Other non-specific symptoms include muscle cramps, nausea and weakness.4 TREATMENT Identification of hyponatremia in the prehospital setting may be difficult. A thorough history is a good start, and agencies using bedside lab devices, such as i-STAT, will be able to obtain a sodium value. However, treatment should be based on the underlying cause, type of hyponatremia and whether the onset was acute of chronic. EMS providers should keep hyponatremia in mind as a possible cause of patient’s symptoms rather than attempting to fix the patient’s electrolyte imbalance. REFERENCES 1. Vaidya C, Ho W, Freda BJ. Management of hyponatremia: Providing treatment and avoiding harm. Cleve Clin J Med. 2010;77(10):715–726. 2. Simon EE. (March 6, 2012). Hyponatremia. In Medscape. Retrieved Oct. 12, 2012, from 242166-overview. 3. Keating JP, Schears GJ, Dodge PR. Oral water intoxication in infants: An American epidemic. Am J Dis Child. 1991;145(9):985–990. 4. Marx JM, Hockberger R, Walls R. Rosen’s emergency medicine concepts and clinical practice, 6th ed., vol. 2. Mosby: St. Louis, p. 1934, 2002. Choose 25 at Become the new leaders of EMS by taking your EMS education to the next level. A fully online BS in Emergency Medical Services Administration from Anna Maria College can get you there. Our online EMS Administration Bachelors Degree is perfect for your busy lifestyle. Focusing on leadership training and advanced problem solving, you’ll be one step closer to an executive position in the EMS field. Dennis Edgerly, EMT-P, began his EMS career in 1987 as a volunteer firefighter EMT. He’s the paramedic education coordinator for the paramedic education program at HealthONE EMS. Contact him at Read additional case studies at This online program is offered only by Anna Maria College. Log on to or call 800-344-4586 for more information. 50 Sunset Lane, Paxton, MA 01612 • Choose 26 at WWW.JEMS.COM JANUARY 2013 JEMS 25
  28. 28. RESEARCH REVIEW EMS WHAT CURRENT STUDIES MEAN TO >> BY DAVID PAGE, MS, NREMT-P CLINICAL COMPETENCE Study rates global skill levels of students & medics n the hierarchy of research, a case report often serves only as an FYI or a good war story. In the case of the below study, we’re lucky the authors had research on administration of intranasal (IN) glucose published for the first time in a peer-review journal. I recommend you read it more for the review of the literature on IN medication administration than for any earth-shattering news about glucagon. I did find it interesting, however, that 2 mg of IN glucagon was just as speedy at raising blood sugar as 1 mg of intramuscular (IM) glucagon, according to a 1992 study by Rosenfalck published in Diabetes Research and Clinical Practice, and that few studies have successfully compared IV dextrose to IM glucagon. With a single dose of IN glucagon being around $1.50 vs. $8 for dextrose, I doubt we’ll see IN glucagon replace IV dextrose as a first-line drug. But this write-up gives us some ammunition for medical directors to approve the IN glucagon route as well as intramuscular. I’ve already fired off the e-mail to my medical directors. Will you? I PARAMEDIC COMPETENCE I Tavares W, Boet S, Theriault R, et al. Global rating scale for the assessment of paramedic clinical competence. Prehosp Emerg Care. 2012; Jul 26 [Epub ahead of print.] W e seldom see educational research in EMS, and even less frequently a study dealing with clinical competency. Kudos to this Canadian all-star group for tackling such a difficult subject with such a thorough methodology. The group videotaped 81 performances of 61 EMS students and 24 active para- PHOTO DAVID PAGE I Researchers measured intranasal glucagon for the first time in a peer-reviewed journal. medics responding to a simulated scenario. Two trained evaluators reviewed each video using a prototype global rating scale (GRS). The objective was to see if the GRS would correctly identify a competent performance. The candidates were lone paramedics responding to a simulated unstable cardiac patient in the back of a transfer ambulance on the side of the road, which deteriorates into cardiac arrest. The two EMTs were allowed to assist the paramedic being tested, and the scenario lasted nine minutes. A high-fidelity manikin was used. The rating scale included eight dimensions, or rubrics. These were distilled by a national expert panel using a modified Delphi process from 257 observable paramedic clinical behaviors. The final rubrics were situation awareness, history gathering (i.e., interviewing), patient assessment (i.e., physical exam), decision making (i.e., differential diagnosis), resource use (i.e., leadership and delegation of tasks), communication and procedural skills. I GLOSSARY I Adjectival rating scale refers to a numeric appraisal (similar to a pain scale rating) based on descriptions (adjectives) that best fit their assessment. 26 JEMS JANUARY 2013 Finally, an overall clinical performance score was assigned. It’s particularly encouraging that these dimensions match the recently released National Registry paramedic psychomotor competency package evaluations. Although the NREMT followed a different methodology, the categories are identical, giving these rubrics more validity. Interestingly, the individual categories didn’t seem to be as reliable as the overall rating. The authors note that raters had difficulty differentiating between the dimensions, and suggest that a “Gestalt” categorical judgment or “halo effect” may be at work. Still, they noted, the GRS accurately identified who should pass and who should fail. Without a doubt, every EMS educator should read this study and start using these rubrics. An adjectival rating scale from 1–7 similar to a Likert scale was used, with 1 being unsafe, then unsatisfactory, poor/weak, marginal, competent, highly competent and 7 being exceptional. Although these authors didn’t comment on their 1–7 scale, previous studies have shown poor results using similar rating scales. From the descriptive statistics in this study it would appear the scale could be simplified without affecting the accuracy of the pass/fail ratings, similar to those recently proposed by the NREMT. Although it appears we’re getting closer to having defensible tools to measure clinical competency, the reproducibility of these methods would be challenging, such as what would be required for large programs or even state and national exams. Not everyone has access to high-fidelity manikins, quality video recording, archiving and raters with 22 and 11 years of experience. Both were trained over a 60-minute period and viewed all the videos, presumably gaining quite a bit of experience along the way.
  29. 29. I WATCH BOX I I RATE MATTERS I Idris A, Guffey D, Pepe P, et al. The ROC investigators. The interaction of chest compression rates with the impedance threshold device and association with survival following out-of-hospital cardiac arrest. In the December 2011 Research Review column, I reviewed the National Institutes of Health Resuscitation Outcomes Consortium (ROC) study that evaluated the impedance threshold device (ITD) in a large multi-center clinical trial called the PRIMED trial (published in the New England Journal of Medicine in September 2011). It reported no difference between use of an active ITD and a placebo (or sham) ITD. This has always puzzled me because I have used an ITD for years and have seen it work. In November 2012, Ahamed Idris, MD, presented an abstract at the American Heart Association (AHA) Resuscitation Science Symposium (ReSS), reporting that chest compressions for patients in the ROC database weren’t necessarily performed at the 100 per minute rate recommended in the study protocol or by the AHA; in fact, more than half of the more than 10,000 patients received chest compression rates that were too slow (less than 90 per minute) or too fast (greater than 110 per minute). The data showed that the faster the chest compression rate, the worse the outcomes. This is reminiscent of the findings of Thomas Aufderheide, MD, that hyperventilation is deadly in cardiac arrest. The ROC study confirmed that for chest compression rates, like ventilation, more is not better, and in fact, more can be harmful. Idris presented additional ROC data that shed new light on my confusion about the ITD’s previously reported efficacy. He reported that there was a significant interaction between chest compression rate and ITD efficacy. Their adjusted model predicted greater survival to discharge when the ITD was used at AHA-recommended compression rates of around 100 per minute, compared with conventional CPR without an active ITD at similar rates. Clearly, CPR needs to be performed correctly in order to fairly assess new technologies like the ITD. Idris and colleagues are planning to follow up the paper soon. If the paper mirrors the abstract, we will see the first randomized, controlled, double-blinded clinical trial to demonstrate that the ITD improves survival to hospital discharge with favorable neurologic outcome with properly performed chest compressions. BOTTOM LINE What we know: Compression rates affect survival rates. The faster the compression rates, the worse the outcomes. What this study adds: When an ITD is used as intended (at AHA-recommended chest compression rates), observed survival-to-hospital discharge is considerably increased compared to CPR without an ITD. Learn more from David Page at the EMS Today Conference & Expo, March 5–9 in Washington, D.C. David Page, MS, NREMT-P, is an educator at Inver Hills Community College and a paramedic at Allina EMS in Minneapolis/St. Paul. He’s a member of the Board of Advisors of the Prehospital Care Research Forum and the JEMS Editorial Board. Send him feedback at Choose 27 at Take the best in EMS continuing education NAEMT courses provide high quality, evidencebased education to improve patient care: PHTLS, AMLS, EPC, TCCC and EMS Safety. All courses are CECBEMS accredited and meet Learn more at Serving our nation’s EMS practitioners WWW.JEMS.COM JANUARY 2013 JEMS 27
  30. 30. MONITORING TECHNOLOGY HAS POTENTIAL TO TRANSFORM EMS A Philips offers Q-CPR, a real-time accelerometer-based technology that incorporates a downloadable resuscitation review. Masimo’s EMMATM is a miniaturized capnometer useful for space-limited environments. B C Physio-Control offers CODE-STAT data software for post-CPR review. D Sotera Wireless offers the ViSi, a powerful, compact monitoring device. E Oridion’s Integrated Pulmonary Index (IPI) uses waveform capnography and pulse oximetry to monitor respiratory rate, EtCO2, heart rate and SpO2. F ZOLL’s offers CPR Dashboard, a realtime accelerometer-based technology with data transmission capability. A 28 JEMS JANUARY 2013
  31. 31. IMAGE ALENGO/ISTOCKPHOTO.COM, A) PHOTO COURTESY A.J. HEIGHTMAN, B) PHOTO COURTESY MASIMO, C) PHOTO COURTESY PHYSIO-CONTROL, INC. , D) PHOTO COURTESY SOTERA WIRELESS, E) PHOTO COURTESY A.J. HEIGHTMAN, F) PHOTO CHRIS SWABB B C >> BY MIKE MCEVOY, PHD, NREMT-P, RN, CCRN M onitoring technology has tremendous potential to improve patient outcomes—when it’s designed and used properly. Routine use of pulse oximetry and waveform capnography virtually eliminated esophageal intubations and inadequate oxygenation claims against anesthesia providers, transforming their profession from frequent and costly malpractice targets in the 1970s to 1980s into one of the safer fields of practice today.1 The value of technology lies in collecting meaningful data that a provider can’t easily obtain with their own assessment skills. Lives are saved in hospitals every day through the use of monitoring technology: The more sophisticated the level of care, the more advanced the monitoring technology tends to be.2 Technology enhances prehospital patient care as well, enhancing provider assessment abilities and detecting changes in patient condition. This article will review current prehospital technology and discuss current and future evolutions. D E CARDIAC MONITORING The first technology adapted for EMS use was cardiac monitoring. Portable cardiac monitors have evolved since their introduction in the 1970s to include defibrillators, pulse oximeters, non-invasive blood pressure (NIBP) modules, waveform capnography, temperature and, most recently, CPR feedback technologies. Perhaps the most important recent prehospital development has been monitor alarms, intended to alert providers of potential problems.3 Early prehospital monitors didn’t include alarms, probably under the mistaken notion that an EMS provider caring for a patient would immediately notice significant changes. It’s no secret that EMS providers have many things to do besides continuously watch a monitor screen. The addition of alarms is a welcome improvement in prehospital monitors. A typical intensive care unit (ICU) patient generates some 700 monitoring alarms per day F WWW.JEMS.COM JANUARY 2013 JEMS 29
  32. 32. WAVE OF THE FUTURE >> CONTINUED FROM PAGE 29 of which only 15% are clinically significant.4 This year, the hospital issue known as “alarm fatigue” has been considered the top hospital technology hazard.3 EMS currently has a unique opportunity to customize monitoring alarms, with the option not to allow silencing such critical alerts as apnea, asystole and lethal rhythms, to avoid desensitization and falling into the trap of “alarm fatigue.” PULSE OXIMETRY Now a standard of care included in the EMT curriculum, pulse oximetry was one of the earliest devices to appear in ambulances. Originally introduced in 1974 for use on anesthetized patients during surgery, oximetry has matured tremendously in recent years.4 Arguably one of the most important patient safety devices ever invented, pulse oximetry has reduced anesthesia deaths by 90%, now promising to protect patients from the damaging effects of hyperoxia seen with routine use of oxygen in patient care.5 In addition to guiding selection of appropriate oxygen delivery devices, pulse oximetry technology utilizing additional wavelengths of light can now screen for carbon monoxide poisoning, methemoglobin, and even assess fluid volume status from analysis of the pleth waveform.6 In the future, manufacturers will introduce respiratory rate and blood pressure measurements obtained from pulse oximetry pleth waveforms. Non-invasive or electronic blood pressure measurement followed pulse oximetry into the prehospital market. Current devices are oscillometric, meaning that they sense arterial oscillations, typically measuring a heart rate and mean arterial pressure then working backwards to calculate a systolic and diastolic pressure. Algorithms vary by manufacturer, making it virtually impossible to validate accuracy, but for the majority of NIBP devices used in EMS the mean arterial pressure is the most accurate value displayed.7 Like auscultatory measurements, proper cuff size and meticulous attention to keeping the extremity being measured at mid-heart level are key to obtaining good measurements.8 CAPNOGRAPHY Capnography has made major inroads into EMS and, in many systems, is more frequently utilized in prehospital patients than hospitalized patients. The driving force for capnogra- 30 JEMS JANUARY 2013 phy is patient safety during intubation and, like pulse oximetry, the anesthesia standard of care dictates monitoring every intubated patient with waveform capnography. Many EMS systems mandate continuous waveform capnography for all intubated patients, a common sense standard that virtually eliminates the possibility of not detecting a misplaced endotracheal tube or supraglottic airway.1,9 Today, there is no excuse for not using continuous waveform capnography on every intubated patient, in my opinion. Like their anesthesia and critical care counterparts, EMS providers have become quite skilled with analysis of capnography waveforms. In both spontaneously breathing and intubated patients, waveforms demonstrate changes in airway resistance revealing conditions like bronchospasm, airway cuff leaks, ventilator asynchrony and more. In the future, manufacturers will introduce software to quantify capnography waveforms to allow clinicians to measure severity and effects of treatment on conditions detected through waveform analysis. Miniturization of capnography technology has improved portability and battery life. It also promises in the very near future to further revolutionize the industry with enhancements to a capnometer known as EMMA. The manufacturer of this second generation endtidal device was recently acquired by Masimo and will very likely transform into a much more robust and usable miniaturized device, perfect for space-limited environments, such as air medical, combat and intrafacility transports. Keep an eye on EMMA. CPR FEEDBACK One of the more recent monitoring technologies to make its way into ALS monitors is CPR feedback. The three major monitoring manufactures have feedback devices to provide both real-time and retrospective analysis of CPR. Philips offers Q-CPR, a realtime accelerometer-based technology that incorporates a downloadable resuscitation review. ZOLL offers CPR Dashboard, a realtime accelerometer-based technology with data transmission capability for post-event review. Physio-Control offers CODE-STAT data review software for post CPR review and will very shortly introduce its TrueCPR coaching device in the U.S., a standalone triaxial field induction (TFI) based unit. TFI, once it becomes available, promises to elimi- nate overestimations of compression depth reported by accelerometer-based devices when CPR is administered on a mattress (regardless of whether a board is in place).10 CPR feedback helps rescuers deliver nearperfect compressions and ventilations to victims of sudden cardiac arrest. For anyone who has ever performed CPR using a feedback device, they seem to deliver quite nicely in that regard. Use of post-resuscitation analysis software has led to consistent and sustained improvements in the quality of CPR. Yet a recent study by Hostler and coauthors (and the largest study of real-time feedback yet conducted) suggests that these changes in performance don’t seem to improve outcomes.11 This is troubling, and it strongly suggests problems not with the feedback devices or rescuers, but with the guidelines themselves. Indeed, anecdotal reports from CPR feedback users show significantly improved markers of better perfusion, such as end-tidal CO2, throughout the peri-arrest period, yet few have seen improved results. If anything, CPR feedback devices are showing us that our “one size fits all” approach to CPR using the same compression depth and rate isn’t appropriate for every patient. Hopefully, the guidelines will change. POINT OF CARE TESTING Point of care (POC) testing has slowly invaded the prehospital world. Use of glucometers is widespread and is now included in the EMT scope of practice. One promising technology with a broad range of potential uses is saliva osmolality to assess dehydration. Several recent studies have found close correlation between measurement of saliva osmolality, or concentration, and hydration status.12-13 Firefighters, athletes, and nursing home patients frequently suffer from dehydration, and EMS providers lack good tools to easily determine hydration status. A Menlo Park (Calif.) company, Cantimer Corporation is refining a device similar to a glucometer that will allow field testing of saliva to detect dehydration. ULTRASOUND Another technology currently making prehospital inroads is ultrasound. In the emergency department (ED) and ICU, ultrasound has for years been used to quickly detect presence of blood or fluid in the abdomen of trauma patients, place lines, confirm
  33. 33. endotracheal tube (ET) placement, assess for pnuemothorax, check cardiac function and volume status in the heart and vascular system, find fractures and examine unborn children. Numerous studies have demonstrated that prehospital providers can accurately use ultrasound, but outcome studies are lacking.14,15 There is little doubt in the hospital setting that ultrasound has and will continue to replace more invasive testing. A nurse using ultrasound can avoid placing a foley catheter, saving much discomfort and risk of infection for the patient. A clinician performing a comprehensive ultrasound exam in an unstable patient can very rapidly assess heart function, fluid volume status and visualize the lungs. These exams, however, take considerable practice and require continued use to maintain proficiency. Like ETI, the opportunity to perform ultrasound may not occur often enough to allow prehospital providers in many systems to develop and maintain sufficient proficiency. LOOKING AHEAD Increasing concerns are arising that clinicians may become overwhelmed with the vast amount of data to determine an appropriate plan of care. To that end, monitoring manufacturers are beginning to develop algorithms or fuzzy logic systems that analyze multiple parameters to provide the clinician with an overall wellness score on their patient. One of the first entrants in this market was Integrated Pulmonary Index (IPI) by Oridion.16 IPI uses waveform capnography combined with pulse oximetry to monitor respiratory rate, EtCO2, heart rate and SpO2, combining these values into an algorithm that produces a score from 1 to 10. This overall pulmonary score doesn’t replace the need for a clinician to look at each one of the parameters, but it does provide early warning about deterioration so the provider can determine which of the measured parameters is in need of treatment. Although IPI isn’t yet available on prehospital monitors, expect to see it soon along with algorithms from other manufacturers that will help you more effectively analyze and manage large quantities of monitored data. WEARABLE DEVICES & SENSORS Lastly, pay close attention to the field of wearable devices and sensors. As our population ages, patients are discharged from hospitals earlier, and healthcare providers look for ways to more closely monitor their patients at home, the need for wearable sensors will explode. Remote monitoring systems, such as the ViSi mobile monitor by Sotera Wireless, are rapidly benefiting from miniaturization, faster and more robust internet access, more sophisticated Bluetooth technology and developments in microelectronics and sensor technology. Fully functional ECG monitors the size of a wristwatch, fabric integrated sensors and electrodes, ambient sensors mounted in the home to monitor patient vitals and activity, and very sophisticated implantable sensors are all in various stages of development.17 The same technology that allows closer monitoring of patients outside healthcare settings promises to improve your ability to communicate and consult with medical experts. Researchers using real-time high speed audiovisual connections between prehospital providers and experienced physicians are finding potential to improve outcomes.18 If you can use your cell phone to video chat with family or friends across the country, then it makes perfect sense that EMS could utilize the same technology. Medicine is a constantly evolving art and science. It’s highly unlikely that a patient will thank you for using a state-of-the art monitor or the latest in CPR feedback. They will, however, thank you for competently and respectfully integrating the equipment you carry into a care plan that makes them feel better for having met you. Mike McEvoy, PhD, NREMT-P, RN, CCRN, is the EMS coordinator for Saratoga County, N.Y., and teaches pulmonary and critical care medicine at Albany Medical College. He’s a paramedic, firefighter and member of the International Association of Fire Chiefs Emerging Infectious Diseases task force. REFERENCES 1. Metzner J, Posner KL, Lam MS, et al. Closed claims analysis. Best Pract Res Clin Anesthesiol. 2011;25(2):263–276. 2. Hu X, Sapo M, Nenov V, et al. Predictive combinations of monitor alarms preceding in-hospital code blue events. J Biomed Inform. 2012;45(5):913–921. 3. Cvach M. Monitor alarm fatigue: An integrative review. Biomed Instrum Technol. 2012;46(4): 268–277. 4. Severinghaus JW. Takuo Aoyagi: Discovery of pulse oximetry. Anesth Analg. 2007;105(6 Suppl):S1–4. 5. Severinghaus JW. Monitoring oxygenation. J Clin Monit Comput. 2011;25(3):155–161. 6. Roth D, Hubmann N, Havel C, et al. Victim of carbon monoxide poisoning identified by carbon monoxide oximetry. J Emerg Med. 2011;40(6):640–642. 7. Smulyan H, Safar ME. Blood pressure measurement: Retrospective and prospective views. Amer J Hypertens. 2011;24(6):628–634. 8. Brett SE, Guilcher A, Clapp B, et al. Estimating central systolic blood pressure during oscillometric determination of blood pressure: Proof of concept and validation by comparison with intraaortic pressure recording and arterial tonometry. Blood Press Monit. 2012;17(3):132–136. 9. Westhorpe RN, Ball C. The history of capnography. Anesth Intensive Care. 2010;38(4):611. 10. Perkins GD, Kocierz L, Smith SC, et al. Compression feedback devices over estimate chest compression depth when performed on a bed. Resuscitation. 2009;80(1):79–82. 11. Hostler D, Rea TD, Stiell IG, et al, and the Resuscitation Outcomes Consortium Investigators. Effect of real-time feedback during cardiopulmonary resuscitation outside hospital: Prospective, cluster-randomised trial. BMJ. 2011 Feb 4;342 [Epub]. 12. Smith DL, Shalmiyeva I, DeBlois J, et al. Use of salivary osmolality to assess dehydration. Prehosp Emerg Care. 2012;16(1):128–135. 13. Taylor N, van den Heuvel A, Kerry P, et al. Observations on saliva osmolality during progressive dehydration and partial rehydration. Eur J Appl Physiol. 2012;112(9):3,227–3,237. 14. Chin EJ, Chan CH, Mortazavi R, et al. A pilot study examining the viability of a prehospital assessment with ultrasound for emergencies (PAUSE) protocol. J Emerg Med. 2012 May 15 [Epub ahead of print]. 15. Hasler RM, Kehl C, Exadaktylos AK, et al. Accuracy of prehospital diagnosis and triage of a Swiss helicopter emergency medical service. J Trauma Acute Care Surg. 2012;73(3):709–715. 16. Waugh JB. Integrated Pulmonary Index stability in healthy adults under changing conditions. Resp Care. 2010;55(11):1,522. 17. Patel S, Park H, Bonato P, et al. A review of wearable sensors and systems with application in rehabilitation. J Neuroeng Rehabil. 2012;4(20)9:21. 18. Skorning M, Bergrath S, Rortgen D, et al. Teleconsultation in prehospital emergency medical services: Real-time telemedical support in a prospective controlled simulation study. Resuscitation. 2012;83(5):626–632. WWW.JEMS.COM JANUARY 2013 JEMS 31
  34. 34. THE ROLE OF VIDEO LARYNGOSCOPY IN FUTURE ADVANCED AIRWAY MANAGEMENT >> BY TERENCE VALENZUELA, MD, MPH; JARROD MOSIER, MD; & JOHN SAKLES, MD D ispatch sends you to the home of a 79-year-old male with chronic obstructive pulmonary disease (COPD) who is complaining of “shortness of breath.” He sits upright, leaning forward and supporting his weight with both arms. His head seems to be attached directly to his shoulders. He appears drowsy, and replies to your questions about medical history with single-word answers only. His wife relates that he has grown increasingly short of breath during the past three days. After he refused to see his doctor, his wife called 9-1-1. You palpate a pulse of 98 beats per minute (bpm) and measure his blood pressure at 180/90. His respiratory rate is 30. Breath sounds are 32 JEMS JANUARY 2013 diminished and wheezy bilaterally, but there’s little chest movement with each breath. The pulse oximeter reveals an oxygen saturation (SpO2) level of 93% and an end-tidal carbon dioxide (EtCO2) level of 35. He grows more somnolent. Narcan doesn’t improve his level of arousal. This patient is on the verge of acute respiratory failure. Level of arousal (wakefulness) is a sensitive and reliable indicator of brain function. The patient is drowsy and growing more so because of the buildup of CO2 from a lack of effective ventilation. An easily reversible cause (opiate effect) for his lethargy isn’t present. The pulse oximeter indicates borderline hypercapneic respiratory failure. It can often be misleading, as in this case, with the EtCO2 number indicating adequate ventilation; however, it likely represents an increase of expired partial pressure of carbon dioxide (PCO2) with ineffective ventilation. Noninvasive positive pressure ventilation, such as continuous positive airway pressure (CPAP), may be considered to decrease the work of breathing in hypercapneic respiratory failure. But this patient is unlikely to be cooperative because of his somnolence, and his respiratory drive is failing rapidly. The likeliest clinical course is continued deterioration. You and your partner attempt to augment the patient’s ventilation with a bag-valve mask (BVM). You maintain a tight seal with two hands on the mask while your partner squeezes the bag. The patient becomes apneic. His SpO2 drops to
  35. 35. PHOTO IOSEPH/ISTOCKPHOTO.COM; PHOTOS ART VANDALAY Video laryngoscopes help improve the view of the epiglottis during endotracheal intubation. 80%. Your partner places an oropharyngeal airway (OPA) device, which allows ventilation with continued high fraction of inspired oxygen (FIO2) rate via the BVM. Maintaining a rate of eight to 10 to avoid hyperventilation, you see the SpO2 climb to 95% over the next three minutes. Addition of a disposable positive end-expiratory pressure (PEEP) valve to the exhalation port of the BVM results in improvement of the SpO2 to 100%. Just prior to becoming apneic, his SpO2 was the brink of the steep portion of the hemoglobin desaturation curve (see Figure 1, p. 35). Further desaturation, even if brief, indicates a precipitous fall in arterial oxygen content and will place the brain and other vital organs at risk for anoxic damage. A further rise in CO2 diminishes the affinity of hemoglobin for oxygen further worsening oxygen delivery to organs. Note that there’s a lag time between the SpO2 registered by the pulse oximeter and the real-time arterial saturation. This delay can range from a few to 30 seconds depending on the etiology (e.g., heart failure vs. septic shock) and severity of illness. Unfamiliarity with this characteristic of the pulse oximeter may cause mistaken concern that the patient isn’t improving with BVM therapy. Conversely, false confidence may result when the patient is “desaturating,” yet the pulse oximeter continues to read 100%. The urban myth persists that providing high-flow oxygen to COPD patients will cause respiratory arrest and should be avoided. This phenomenon is much talked about but seldom seen. The greater danger to this patient is persistent hypoxemia untreated. Deterioration in oxygen saturation with apnea occurs at a rate determined by factors including age, severity of illness and the presence of obesity. Figure 1, shows the rate of SpO2 decline in patients initially 100% saturated who are paralyzed prior to elective intubation. This is a “best case” scenario, and the times to desaturation should not be generalized to EMS patients. However, one does see how rapidly ill or pediatric apneic patients will become hypoxemic. For types of patients made apneic by RSI, see Figure 1. BVM VENTILATION & OXYGENATION EMS providers are overconfident in their skills and knowledge in how to use BVMs. Multiple studies of prehospital resuscitations have documented compression rates that are too rapid, inspiratory pressures generated by bag compression that’s too great and volumes of air per compression that are too large for optimal outcomes. These factors strongly predict patient harm in the patients with severe obstructive lung disease, such as COPD or asthma. Rapid large-volume WWW.JEMS.COM JANUARY 2013 JEMS 33