Jems201303 dl-1
Upcoming SlideShare
Loading in...5
×
 

Jems201303 dl-1

on

  • 1,171 views

Conheça um pouco mais de nossos serviços de BOMBEIRO INDUSTRIAL em www.resgate.com

Conheça um pouco mais de nossos serviços de BOMBEIRO INDUSTRIAL em www.resgate.com

Statistics

Views

Total Views
1,171
Views on SlideShare
1,171
Embed Views
0

Actions

Likes
0
Downloads
6
Comments
0

0 Embeds 0

No embeds

Accessibility

Upload Details

Uploaded via as Adobe PDF

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

Jems201303 dl-1 Jems201303 dl-1 Document Transcript

  • MARCH 2013 ISSUE Always En Route At t
  • Making Precious Minutes Count™ Macro. Mini. All Set. When a patient requires intravenous therapy, EMS providers need to administer care as quickly as possible. The AMSafe-3® IV Administration Set features a 3-in-1 multi-drip chamber that allows providers to select a 10, 15 or 60 drop setting on the spot. The AMSafe-3 drop setting can be adjusted without interrupting patient care. Since the device combines three IV sets into one, it reduces inventory and takes up less room on an ambulance or in an equipment bag. 1712-30204 1712-30304 D38301 AMSafe-3 IV Set, 91”, 1 luer activated AMSafe-3 IV set, 89” with backcheck valve, AMSafe-3 IV Set, 83”, 1 luer activated injection site and 1 pre-pierced injection site, 1 pre-pierced injection site, 1 luer activated injection site and 1 pre-pierced injection site and pre-pierced injection sites, slide For more information or a product demonstration, contact your dedicated Account Manager or call 800.533.0523 Choose 11 at www.jems.com/rs 800-533-0523 www.boundtree.com
  • Choose 12 at www.jems.com/rs
  • Barbara Spoden Thanks to a dedicated EMS team and use of the ResQPOD®, Barbara survived and was able to return to playing with her granddaughter. Choose 13 at www.jems.com/rs
  • ® 28 I SPINAL IMMOBILIZATION I Time for a change By Jim Morrissey, MA, EMT-P MARCH 2013 VOL. 38 NO. 3 Contents I 40 40 50 I IN THE PATH OF DESTRUCTION I New Jersey EMS response to Superstorm Sandy aided by pre-planning & preparedness By Henry P. Cortacans, MAS, CEM, NREMT-P; & Terry Clancy, PhD, NREMT-P I THE PREHOSPITAL CARE RESEARCH FORUM PRESENTS ... I Selected abstracts for presentation at the 31st annual EMS Today Conference & Exposition in Washington, D.C., March 5–9, 2013 58 DEPARTMENTS & COLUMNS I EXPANDING THE MISSION I 60 I PLANNING LIKE AN OLYMPIAN I 5 I LOAD & GO I Now on JEMS.com 10 I EMS IN ACTION I Scene of the Month 12 I FROM THE EDITOR I ‘Special Stretchers’ 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 Impact Ahead 22 I 24 I 80 I 82 I By Gary Ludwig, MS, EMT-P TRICKS OF THE TRADE I Batteries By Thom Dick CASE OF THE MONTH I Forward Fall By Michael Orland, MD HANDS ON I Product Reviews from Street Crews By Dominic Silvestro, EMT-P, EMS-I LIGHTER SIDE I The Slow Farewell By Steve Berry Mission: Lifeline will incorporate EMS recognition in STEMI & cardiac resuscitation systems of care By Chris Bjerke, MBA, BSN; Gary Wingrove, EMT-P; Franklin Pratt, MD; J. Lee Garvey, MD; & A. Gray Ellrodt, MD How London Ambulance Service successfully handled their ‘summer of sport’ By Jason Killens, MStJ, JP 70 I REVIVING FREEDOM HOUSE I 76 I BUILT TO SHARE I How the storied ambulance company has been reborn By Megan Corry, MA, EMT-P; Casey Keyes, BA, NREMT-B; & David Page, MS, NREMT-P The Bay Shore/Brightwaters Rescue Ambulance’s new vehicle will respond to multiple incident types and provide mutual aid By Bob Vaccaro 84 I EMPLOYMENT & CLASSIFIED ADS 87 I AD INDEX 88 I LAST WORD I The Ups & Downs of EMS I 60 Aboutvehicle involved in a multiple vehicle crash in Springfield, Mo., is being the Cover The driver of a assessed prior to extrication by a Springfield Fire Department firefighter. The issue of when to fully immobilize patients and on what devices is explored in-depth in this month’s issue of JEMS. Read more, p. 12 and pp. 28–39. IMAGE JOSEPH THOMAS PREMIER MEDIA PARTNER OF THE IAFC, THE IAFC EMS SECTION & FIRE-RESCUE MED WWW.JEMS.COM MARCH 2013 JEMS 3
  • The responsive emergency team delivers exceptional CPR And they choose Physio-Control to help make it happen. Today’s responsive emergency team is always looking to elevate the level of care they deliver, and they rely on evidence and data to get them there. With the CPR Solution from Physio-Control, they have the science-based, guidelines-consistent tools they need to respond better to patients—and the demands of constant performance improvement. uninterrupted hands-free compressions featuring comprehensive CPR analytics with capnography and CPR Metronome Visit our booth #811 at EMS Today 2013 in Washington D.C. to see CPR innovation in action and receive a T-shirt. physio-control.com/CPR Choose 14 at www.jems.com/rs ©2013 Physio-Control, Inc. Redmond, WA
  • LOAD & GO LOG IN FOR EXCLUSIVE CONTENT A BETTER WAY TO LEARN JEMSCE.COM ONLINE CONTINUING EDUCATION PROGRAM S ON LLOW U FO FEATURED BLOG: Rescuing Providence THE JOURNEY I take for granted the things I do that make up most days; starting IV’s, administering aspirin and nitro, assessing vital signs, stopping blood from leaving peoples bodies et al, but one of those mundane tasks I’ll never think of as business as usual again. Last night, while talking with a group of friends, a meeting if you will, one of the members of the group, who struggles with addiction spoke of his recent overdose, and subsequent revival and spiritual awakening. “I know how much I can do, and how much I can’t,” he explained. “Trust me, people who OD don’t do so by accident.” JEMS.com 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. Sponsored Product Focus MULTI-PATIENT MONITORING SYSTEM The new Multi-Patient Monitoring System (MPMS) from First Line Technology allows emergency personnel to stay connected and provide constant monitoring for up to 20 patients during triage, transport and care. The MPMS includes a roll and carry bag wired to charge both the (included) Wireless Vital Signs Monitor devices and a remote monitoring device. LIKE US facebook.com /jemsfans ▲ Check out their ad on JEMS.com! FOLLOW US twitter.com /jemsconnect DATA WEBCAST Check out our next webcast, which will be at 10 a.m. (Eastern time) March 20. In this webcast, sponsored by ZOLL Data, firefighter/paramedic and EMS 10: Innovator in EMS Awardwinner John Pringle will present, “Update on 360-degree Data: How to collect better data in the field.” He will give you practical steps to successfully integrate new electronic tools into your emergency response systems. ▲ jems.com/webcasts GET CONNECTED linkedin.com/groups? about=&gid=113182 EMS NEWS ALERTS JEMS.com Visit www.ems2020 vision.com to watch the latest 2020 Vision Leadership Series video interviews. Where do you see EMS going in 2020? That was the question put to four EMS visionaries—James J. Augustine, MD, FACEP; Matt Zavadsky, MS-HSA, EMT; David Page, MS, NREMT-P; and moderator A.J. Heightman, MPA, EMT-P. For hours, we flmed them while they created a new future. Join the 2020 EMS Visionaries LinkedIn group to get engaged in the discussion. www.FernoEMS.com Setting our sights on the future of EMS http://linkedin. ems2020vision.com jems.com/enews CHECK IT OUT jems.com/ems-products BEST BLOGGERS FireEMSBlogs.com WWW.JEMS.COM MARCH 2013 JEMS 5
  • ® EDITOR-IN-CHIEF I A.J. Heightman, MPA, EMT-P I aheightman@pennwell.com MANAGING EDITOR I Jennifer Berry I jenniferb@pennwell.com ASSOCIATE EDITOR I Ryan Kelley I rkelley@pennwell.com ASSISTANT EDITOR I Kindra Sclar I kindras@pennwell.com ONLINE NEWS/BLOG MANAGER I Bill Carey I billc@pennwell.com ASSOCIATE WEB EDITOR I Nicole Reino I nicoler@pennwell.com EDITORIAL DIRECTOR I Shannon Pieper I shannonp@pennwell.com MEDICAL EDITOR I Edward T. Dickinson, MD, NREMT-P, FACEP CONTRIBUTING EDITOR I Bryan Bledsoe, DO, FACEP, FAAEM ART DIRECTOR I Liliana Estep I alildesign@me.com CONTRIBUTING ILLUSTRATORS Steve Berry, NREMT-P; Paul Combs, NREMT-B CONTRIBUTING PHOTOGRAPHERS Vu Banh, Glen Ellman, Craig Jackson, Kevin Link, Courtney McCain, Tom Page, Rick Roach, Steve Silverman, Michael Strauss, Chris Swabb DIRECTOR OF ePRODUCTS/PRODUCTION I Tim Francis I timf@pennwell.com PRODUCTION COORDINATOR I Matt Leatherman I matthewl@pennwell.com PUBLICATION OFFICE 800/266-5367 I Fax 858/638-2601 ADVERTISING DEPARTMENT 800/266-5367 I Fax 858/638-2601 ADVERTISING DIRECTOR I Judi Leidiger I 619/795-9040 I j.leidiger@jems.com WESTERN ACCOUNT REPRESENTATIVE I Cindi Richardson I 661/297-4027 I c.richardson@jems.com SENIOR SALES COORDINATOR I Elizabeth Zook I 951/244-1245 I elizabethz@pennwell.com REPRINTS, ePRINTS & LICENSING I Rae Lynn Cooper I 918/831-9143 I raec@pennwell.com VICE PRESIDENT, MARKETING SERVICES I Paul Andrews I 240/595-2352 I marketingservices@pennwell.com SUBSCRIPTION DEPARTMENT I 888/456-5367 DIRECTOR, AUDIENCE DEVELOPMENT & SALES SUPPORT I Mike Shear I mshear@pennwell.com MARKETING & CONFERENCE DIRECTOR I Debbie Murray I debbiem@pennwell.com MARKETING & CONFERENCE COORDINATOR I Vanessa Horne I vhorne@pennwell.com • CHAIRMAN I Frank T. Lauinger PRESIDENT & CHIEF EXECUTIVE OFFICER I Robert F. Biolchini CHIEF FINANCIAL OFFICER I Mark C. Wilmoth SENIOR VICE PRESIDENT & GROUP PUBLISHER I Lyle Hoyt I lyleh@pennwell.com VICE PRESIDENT/PUBLISHER I Jeff Berend I jeffb@pennwell.com • • www.EMSToday.com EXECUTIVE DIRECTOR I Jeff Berend CONFERENCE DIRECTOR I Debbie Murray EDUCATION DIRECTOR I A.J. Heightman EVENT OPERATIONS MANAGER I Amanda Wilson EXHIBIT SERVICES MANAGER I Raymond Ackermann EXHIBIT SALES REPRESENTATIVE I Sue Ellen Rhine I 918/831-9786 I sueellenr@pennwell.com EXHIBIT SALES REPRESENTATIVE I Tracy Thompson I 918/832-9390 I tracyt@pennwell.com • • FOUNDING EDITOR I Keith Griffiths FOUNDING PUBLISHER James O. Page (1936–2004) ® bringing change to life ® Choose 15 at www.jems.com/rs
  • Accurate from the First Breath World’s smallest portable self-contained capnometer EMMA™ (Emergency Mainstream Analyzer) is a fully selfcontained mainstream capnometer that requires no routine calibration and virtually no warm up time.1 With rapid measurement of end-tidal CO2 and respiration rate, EMMA can help providers guide ventilation rates and assess the effectiveness of CPR allowing them to make adjustments in the course of treatment, breath by breath. 800-257-3810 | www.masimo.com © 2013 Masimo Corporation. All rights reserved. 1 EMMA Users Manual. Choose 16 at w ww.jems.com/rs
  • ® 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) GREGORY R. FRAILEY, DO, FACOEP, EMT-P Medical Director, Prehospital Services, Susquehanna Health Tactical Physician, Williamsport (Pa.) Bureau of Police Special Response Team 8 JEMS MARCH 2013 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 MIKE MCEVOY, PHD, REMT-P, RN, CCRN EMS Coordinator, Saratoga County, N.Y. EMS Editor, Fire Engineering Magazine Resuscitation Committee Chair, Albany (N.Y.) Medical College MARK MEREDITH, MD Assistant Professor, Emergency Medicine and Pediatrics, Vanderbilt Medical Center Assistant EMS Medical Director for Pediatric Care, Nashville Fire Department 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 Southwestern Medical Center Head, Emergency Services, Parkland Health & Hospital System Head, EMS Medical Direction Team, Dallas Area Biotel (EMS) System 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 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 International Director, IAFC EMS Section Fire Chief & Emergency Manager, Kittitas Valley (Wash.) Fire & Rescue COREY M. SLOVIS, MD, FACP, FACEP, FAAEM Professor & Chair, Emergency Medicine, Vanderbilt University Medical Center Professor, Medicine, Vanderbilt University Medical Center Medical Director, Metro Nashville Fire Department Medical Director, Nashville International Airport WALT A. STOY, PHD, EMT-P, CCEMTP Professor & Director, Emergency Medicine, University of Pittsburgh Director, Office of Education, Center for Emergency Medicine RICHARD VANCE, EMT-P Captain, Carlsbad (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
  • When urgency and bravery are essential job requirements, the success of your business depends on a commercial vehicle that won’t back down from a challenge. With an Adaptive Electronic Stability Program® 1 and both Best-In-Class* payload capacity and standing height, only the 2013 Freightliner Sprinter is designed to answer the call as boldly as you do every day. freightlinersprinterusa.com DRIVEN LIKE YOU. ©2013 Daimler Vans USA, LLC *Based on a comparison of the Automotive News classification of full-size commercial vans. 1 No system, regardless of how advanced, can overcome the laws of physics or correct careless driving. Please always wear your seat belt. Performance is limited by available traction, which snow, ice and other conditions can afect. Always drive carefully, consistent with conditions. Best performance in snow is obtained with winter tires. Choose 18 at www.jems.com/rs Choose 17 at www.jems.com/rs
  • EMS IN ACTION SCENE OF THE MONTH 10 JEMS MARCH 2013 >> PHOTOS JOSEPH THOMAS
  • PEDIATRIC IMMOBILIZATION S t. John’s/Mercy (Mo.) EMS Paramedic Christy Biram carries a 3-year-old female pediatric patient on a pediatric backboard to a waiting ambulance at the scene of a crash that involved two vehicles colliding at a stoplight. The vehicle the pediatric patient was in was hit when another vehicle allegedly ran a red light. The girl was secured properly in a child safety seat and had been extricated from the vehicle and car seat by her mother prior to EMS arrival. Her only injuries were abrasions to her thighs and clavicles from the safety seat restraints. She had been placed in spinal mobile restriction by Springfield Fire Department prior to EMS arrival. She was transported to a Level 1 trauma center, where she was treated and released. The driver of the other car collided with one of the stoplight posts, causing the battery to fly out of the vehicle and hit a pedestrian who narrowly missed getting hit by the vehicle. The pedestrian had a minor leg injury but refused care on scene, and the driver of the vehicle that ran the light had to be extricated and was transported to an emergency department. Note the crew’s professionalism, covering the patient’s body surface with a turnout coat after exposing and assessing her lower torso. WWW.JEMS.COM MARCH 2013 JEMS 11
  • FROM THE EDITOR PUTTING ISSUES INTO PERSPECTIVE >> BY A.J. HEIGHTMAN, MPA, EMT-P ‘SPECIAL STRETCHERS’ How two eliminated words impacted immobilization options I t’s amazing how committees, lim- FERNO FULL-BODY VACUUM MATTRESS splinting; and pad the splint carefully to ited research and the omission of prevent pressure points and discomfort to a few words can change protocols the extremity [and the patient].” and affect the delivery of patient care Morrissey’s article gives you the and comfort. Jim Morrissey’s article, science, research and reasons to “Spinal Immobilization,” pp. 28–39, allow your crews to use multiple is an epic piece of work, backed by FERNO’S EASYFIX VACUUM MATTRESS/STRETCHER proven “special stretchers,” in addi36 footnoted references that illustrate COMBINATION tion to the traditional longboard, we over-board patients, waste preto immobilize patients and “splint” cious time at penetrating injury calls their injuries. and make patients uncomfortable by I spent a day with Poway (Calif.) placing them on hard surfaces that do Fire Department Captain Andy Page not fit their anatomy or support their and crews from Engine 3711 and injuries without proper padding and Medic 3791. We applied, secured, weight distribution. moved and transported paramedic/ I’m going to take you back to 1971, firefighter Jon Maxwell up and down when EMS got its “roots” in formalstairways in some of the latest “speized education with the release of the cial stretchers” designed to properly initial EMT textbook, Emergency Care immobilize his spine. and Transportation of FERNO’S MODEL 137 FLEXIBLE STRETCHER WITH BUILT-IN We used: ConvenHARTWELL MEDICAL EVAC-U-SPLINT MATTRESS/STRETCHER USED ALONG the Sick and Injured. RESTRAINTS USED IN TANDEM WITH A VACUUM SPLINT tional scoop-style WITH A HARTWELL COMBICARRIER The first AAOS textstretchers; Full-body book stated: vacuum platforms; “Carefully splint the Vacuum splints and injured spine, avoiding a Ferno Flexible abnormal or excessive Stretcher. We also used motion. Be sure that the Ferno’s EasyFix Vacinjured person is properly uum Mattress/Stretcher splinted and transported that is being used on a long backboard or throughout Europe special stretcher withand was recently introout bending or twisting duced in the U.S. the spine in any direction.” Most of the devices I call your attention to the important words “or special offered more comfort and security than a longboard without extra stretcher” because those words were somehow omitted from padding. The vacuum devices were also durable, easily moldable to subsequent editions of the AAOS and most other textbooks. the patient, and tended to better “cradle” the patient securely. We Those omitted words resulted in decreased use of scoop and used SSCOR and Laerdal suction devices to speed up the process. canvas stretchers with slat supports, and SKED stretchers, in Perhaps the most interesting finding was that vacuum matsome systems, and should be added back into our protocols and tresses used in conjunction with the Ferno flexible stretcher and its textbooks to allow crews to use multiple devices to accomplish six conveniently-located handles, offered the best body mechanics spinal immobilization. and positioning to maneuver our patient down stairways and The “General Principles of Splinting” section in the 1971 around tight corners, proving that some things haven’t changed AAOS textbook presented treatment considerations that still since 1971, when this type of flexible stretcher was first introduced hold true today: to EMS. “All fractures should be ‘splinted where they lie’; Apply the splint or banSee a demo of the EasyFix Mattress at www.youtube.com/watch?v=-WF73wKdfZM dage before moving or transporting the patient; With some very important exceptions, a severely angulated fracture should be straightened prior to 12 JEMS MARCH 2013
  • The Safe Choice Introcan Safety® 3 Closed IV Catheter helps shield against Needlesticks Blood Exposure Catheter Complications From start to finish, Introcan Safety 3 provides: Fully automatic safety shield that protects against needlesticks. Multiple-access septum that helps prevent blood exposure. Advanced stabilization that minimizes catheter movement to help reduce irritation and associated restarts. Lower cost and less waste from insertion through disposal. introcansafety.bbraunusa.com 1-800-227-2862 The following is a list of supporting documents and reference material: 1) Tosini, et al “Needlestick Injury Rates According to Diferent Types of Safety-Engineered Devices: Results of a French Multicenter Study”, Infection Control and Hospital Epidemiology, Vol. 31, No. 4 April 2012 pp. 402-407 2) Bausone-Gazda D, et al, A Randomized Controlled Trial to Compare the Complications of 2 Peripheral Intravenous Catheter-Stabilization Systems, Journal of Infusion Nursing, 2012, Nov-Dec: 33(6):371 84 3) Shears G MD, Comparing an Intravenous Stabilizing Device to Tape, Journal of Infusion Nursing, Vol. 29, No. 4 July/August 2006 4) B. Braun Engineering Data on File 5) B. Braun Introcan Safety 3 Cost Analysis Model 6) McNeill, EE, et al, A Clinical Trial of a New All-in-one Peripheral Short Catheter, JAVA, 2009, Vol. 14, No. 1, pp. 46-50 13-3611_2/13_JEMS_BB 7) Infusion Nurses Society (2011), Infusion Nursing Standards of Practice, Journal of Infusion Nursing Supplement, Vol. 34, No. 15, Std. 22, Std. 36 Choose 18 at www.jems.com/rs
  • LETTERS IN YOUR WORDS ADDING TO THE A D DISCUSSION PHOTO COURTESY PHYSIO-CONTROL This month, we feature some T strong opinions from readers on s two recent articles. The first is a t response to a JEMS.com Street r Science column “Are the BenS efits of Mechanical CPR Worth e the Interruption Time?” by Keith t Wesley, MD, FACEP, and MarW shall J. Washick, BAS, NREMT-P, s that reviewed a study examining t interruption time in mechanii cal CPR. The second comment is c from one of our Facebook fans, f who takes issue with Thom Dick’s w August “Tricks of the Trade” colA umn advising on “Psych Transu fers: Know how to deal with these f types of patients.” t MECHANICAL CPR ADVANTAGES We read the article “Are the Benefits of Mechanical CPR Worth the Interruption Time?” (www.jems.com/article/patient-care/are-benefits-mechanical-cpr-worthinterr) with great interest. We participated in the NALE project and submitted our data as part of the article published in Resuscitation. The authors of the review bring up some important points about the findings, but we fear they do not answer the question posed in the title of their article. We have extensive experience using the mechanical compression device with more than 1,200 uses to date. One of the first things we learned when deploying the device was that crews put it as a priority and the other, time-important interventions were delayed. We had to put it into our protocols and train our people to place it later in the event, after other interventions were completed. Next, we learned that placing the device tended to cause everyone else to pause and help out. This is much like our previous experience with intubation where everyone stopped what they were doing until the “vital” procedure was completed. We changed our protocol again and trained our staff how to place the device with no or minimal interruptions in other tasks. We now have a procedure where the device is placed in stages and the maximum interruption in compressions is 15 seconds. The benefits of the device are many. We can see in our cases that interruptions are minimal and short once the device is placed. That may be the best argument when discussing whether the interruption is worth it. We see it as accepting an early 15 second delay which then prevents multiple delays later in the event. 14 JEMS MARCH 2013 During our quality assurance reviews, we see interruptions as providers tire and switch users, or as the patient’s location is changed. There is a real challenge in any research pertaining to cardiac arrest right now. That challenge is trying to associate one treatment with a definitive improvement in outcome. This is a rapidly changing body of knowledge and there is no agreed-upon protocol. So the question of whether the delay in compressions when placing the device is worth it is a difficult question to answer and maybe should not be asked. A better question might be “What are the advantages of using a mechanical compression device, and how does it fit into a system approach to care of the cardiac arrest victim?” Our extensive experience is a resounding “yes,” it is a vital part of our overall approach to improving the community’s and emergency care system’s response to cardiac arrest. Charles Lick, MD Paul Satterlee, MD Allina Health EMS PSYCH ISSUES I am sorry Thom … while I’m sure you are a great medic and all, I just feel much of this is bad advice. The main reason being, why would/ should EMS be transporting patients that are currently off their meds and/or known to be diagnosed at the hospital as psychotic, are potentially suicidal and/or homicidal, when we have very little to no education in handling this? Isn’t it enough that we have to occasionally deal with potentially psychotic, suicidal or homicidal patients? I read a story from a provider just last night who described a situation where a psych patient, who went nuts during an inter-facility transport, was able to free themselves, threaten the provider and then proceed to jump out of the ambulance and run away. The truth is, as long as these patients don’t require some sort of medical intervention en route to the receiving medical/psychological treatment facility, there is absolutely no reason whatsoever that they should not be transported by law enforcement. Law enforcement officers have the training and authority to safely handle these patients, not EMS providers. Jason M. Via Facebook Author Thom Dick, EMT-P, responds: Thanks, Jason, for highlighting these issues. I think no matter who we are or how great our skill, we don’t “know” very much about most of the sick people we meet—certainly not during the brief span of an ED visit. But even if we could be sure somebody’s etiology is psychological, does that somehow transform them into something less than a sick person? I don’t think it does. I agree with you that we all need and deserve to understand more about behavioral disorders. The Western medicine to which we all subscribe endorses a pathetic approach to people with mental illness. Your health insurance company will typically pay for a 60-minute first visit with an internist. Care to guess what they’ll allow for a first visit with a psychiatrist, for a much more complex problem? On average, they’ll pay a psychiatrist for 15 minutes. What we call caring for mental patients basically amounts to throwing drugs at them. It’s no wonder. The standard Diagnostic and Statistical Manual (DSM) you’ll find on the desk of every ED physician is republished every few years as a means of classifying people with psychiatric illnesses. The current edition, the DSM-IV, lists six technical editors—all with published direct financial ties to pharmaceutical companies. Five of those six are linked to the same pharmaceutical company (Eli Lilly). As for bad advice, every one of the suggestions in this article would have helped the crew you describe to sense, predict and prevent the incident they experienced, as well as protect the patient and the public who were also endangered. It’s sad that, after all these years, the EMS texts we trust either ignore this important part of field medicine or recommend procedures that are sure to get us injured along with the sick people we care for. In my opinion, this is medicine we’re doing here. Medicine is supposed to help people. We’re supposed to help people. And a cage car is just not part of that process.
  • Your patient requires urgent pain medication. How can you administer this less invasively? ® Answer. LMA MAD Nasal ™ No shot. No needle. No risk of needle stick injury. The LMA MAD Nasal™ atomization device is the safe and painless way to deliver medication into your patient’s blood * stream without an intravenous line. ATOMIZATION SPRAY SOFT CONICAL PLUG The spray atomizes drugs into a fine mist of particles 30 - 100 microns in size. The plug forms a seal with the nostril preventing expulsion of fluid. FLEXIBLE STYLET The flexible stylet allows 180° positioning of the nasal plug. *For use with drugs approved for intranasal delivery For more information contact your LMA representative or visit LMANA.com. LMA FAMILY LMA Atomization® | LMA EMS™ | LMA Airway Management™ | LMA Visualization™ | LMA Pain Management™ 4660 La Jolla Village Drive, Suite 900 | San Diego, CA 92122 | 800-788-7999 | Fax 858-622-4130 | www.LMANA.com Teleflex, LMA, LMA Airway Management, LMA Atomization, LMA Better by Design, LMA EMS, LMA MAD Nasal, LMA Pain Management, LMA Visualization and MAD are trademarks or registered trademarks of Teleflex Incorporated or its affiliates. ©2013 Teleflex Incorporated. All rights reserved. 2013-1644. Choose 19 at www.jems.com/rs
  • PRIORITYUSE TRAFFIC NEWS YOU CAN NFFF Response to Violent Incidents Nine questions first responders should ask T IMAGE COURTESY NATIONAL FALLEN FIRE FIGHTERS he Newtown (Conn.) school shooting and Webster (N.Y.) ambush of firefighters provide increased awareness of violence against emergency responders. East Hartford (Conn.) Fire Chief John Oates, writing for the National Fallen Fire Fighters (NFFF), has provided nine questions responders should ask: 1. Do you use risk/benefit analysis for every call? 2. Do you have an effective relationship at all levels with the law enforcement agencies in your community? 3. How good is the information you get from your dispatcher? 4. Do you allow members to “first respond” directly to the scene? 5. Does your law enforcement agency use an incident management system? 6. When responding to a potentially violent incident, do you Cover of the NFFF report “Firefighter Life Safety Initiative 12.” seek out a law enforcement PREVENTING LINE-OF-DUTY INJURY officer when you arrive? 7. Have you told your fire officers/per- Everyone Goes Home is a national prosonnel that it’s OK to leave the scene gram by the National Fallen Firefighters Foundation to prevent line-of-duty deaths if things start to turn bad? 8. Is there a point at which you don’t and injuries. In March 2004, a Firefighter respond or limit your response to vio- Life Safety Summit was held in Tampa, Fla., to address the cultural, philosophilent incidents? 9. Is your uniform easily mistaken for cal, technical and procedural problems that affected safety within the fire service. law enforcement? These questions came from a March 2012 The most important domains were identifocus group of 35 participants representing fied, resulting in 16 Firefighter Life Safety 29 organizations. The NFFF-commissioned Initiatives. Everyone Goes Home started report from this group, “Firefighter Life as a way of implementing initiatives at the Safety Initiative 12 Final Report: National local level. NFFF asked subject matter experts to protocols for response to violent incidents should be developed and championed,” is develop a white paper for each initiapart of a resource package covering 16 Fire- tive. Chief Oates provided the Initiative fighter Life Safety Initiatives of the Everyone 12 report. The Novato, Calif., 2007 summit developed actionable objectives to Goes Home program. support each of the Firefighter Life Safety Initiatives. Noting that there was, “an absence of response protocols for violent incidents in many fire departments” a focus group met in Anne Arundel County, Md., in 2012 to develop an expanded report for Initiative 12, including the nine questions. There’s no enforcement authority or funding to implement the Firefighter Life Safety Initiatives. Some feel that more effort should be directed against those who assault responders. ‘PARAMEDICS ARE NOT PUNCHING BAGS’ New South Wales, Australia, ambulance service acting Commissioner Mike Willis announced a zero-tolerance policy toward violence against EMS personnel, noting on the agency’s website that there were six assaults against paramedics in early December. There’s a perception that sanctions against those who assault EMS personnel are inadequate. In Illinois it’s a felony to assault a first responder; however, Chicago paramedics claimed, in a WLS-TV ABC News 7 report, that those who assault them get trivial punishment. One technique that has been used is to fill a courtroom with emergency responders in uniform. In January, the New York Post reported that two dozen EMS workers filled a Manhattan courtroom to support their colleague who was allegedly choked by a drunken assistant district attorney. — Michael J. Ward, MGA Reports referenced in this article are available at: www.everyonegoeshome. com/news/2013/initiative12_012913.html For more of the latest EMS news, go to jems.com/news 16 JEMS MARCH 2013
  • The JEMS Family of Products: Helping You Save Lives JEMS, Journal of Emergency Medical Services 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! JEMS.com eNewsletter JEMS.com Website Your online connection to the EMS world, JEMS.com gives you information on: • Products • Jobs • Patient Care • Training • Technology 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 www.jems.com/ems-products Archived Webcasts • PEARS: Helping You Help Kids • Lessons From Our Battlefelds: New Approaches to Shock Management • Securing the Airway: The Expanding Role of Extraglottic Devices • Maximizing Your Revenue • Advances in Assisted Ventilation: Where have we come from & where are we going? ® TM Free … Available 24/7! For more information on the JEMS Family of EMS Products: www.JEMS.com
  • PRIORITY TRAFFIC >> CONTINUED FROM PAGE 16 SERVING THOSE WHO SERVE Effectively treating military personnel & veterans F irst responders are a critical first contact point for members of the armed forces and veterans in crisis. Many EMS and other emergency response agencies aren’t effectively prepared to effectively serve those who serve. For example, first responders often don’t have sufficient knowledge of military culture and few know how to de-escalate calls involving military members and veterans. Special programming at this year’s 2013 EMS Today Conference & Exposition will focus on serving this special population. The conference will feature presentations by a team from Arizona’s Military/Veteran First Responder Initiative. This effort, facilitated by the Arizona Coalition for Military Families (ACMF), brings together public and private sector partners from the military, government and community to focus on strengthening crisis response for military members and veterans, including those experiencing post-traumatic stress and traumatic brain injury. The training, which has been developed by the ACMF over the past four years, is nationally recognized as a best-practice approach to improve the coordination of care through training and networking personnel. In the past year, through this partnership, more than 2,200 first responders in Arizona have received training, with plans for several hundred more this spring. This initiative fits into a larger state effort to build community capacity to care for and support service members, veterans and their families, including initiatives around behavioral health, higher education, employment and faith-based communities. The Arizona Coalition for Military Families and partners are currently exploring how to expand this training effort to reach first responders across the country. The presentation team at EMS Today Conference & Exposition will include Captain Dean Pedrotti of the Phoenix Fire Department, SSG (Ret.) Patrick Ziegert of the Office of the Arizona Attorney General and Colleen Day Mach of the Arizona Coalition for Military Families. The main presentation is Friday, March 8, from 8–10 a.m. with a presentation on post-traumatic stress on Saturday, March 9, from 10–10:30 a.m. — Thomas Winkel, MA, LPC, NCC DUTY TO ACT ARE YOU ALWAYS ON CALL? S cenario: A medic stops at the grocery store after her shift. She’s still in her company uniform and witnesses an older man drop to the floor, apparently unconscious. Does the medic have a legal duty to act? Probably not. If she chooses to walk on by, can she be held legally liable? Again, probably not. Why? Because she doesn’t have a legal duty to act. Tort law requires four elements for a plaintiff to hold a defendant legally responsible for a personal injury. These elements are 1) a legal duty to act; 2) a breach of that duty; 3) proximate causation (i.e., the defendant’s breach of duty was the legal cause of the plaintiff’s harm); and 4) damages (i.e., losses or harm that merits financial compensation). Unless an EMS provider has a legal duty to the patient, they cannot be held liable in tort law. In our scenario above, the medic was off duty, having completed her shift. The fact that she was in uniform doesn’t change the analysis; your legal duty to act isn’t dependent on your wardrobe. To use the reverse of this example, if the medic was on duty, spilled grape juice on her uniform at work and changed into a non-uniform shirt, she still has a duty to respond when called. Certainly, the fact that the medic was in uniform while off duty at the grocery store, probably with a patch or some insignia that identified her employer, still doesn’t create a legal duty to act when she witnessed the man fall to the floor. Of course, it could raise a public relations issue if the medic elects not to provide assistance to the patient, but it doesn’t give rise to a legal duty. As this scenario makes clear, there’s a difference between a legal duty and a moral duty. Certainly, many EMS providers feel they may have a moral duty to act in this scenario, though that is a personal decision that the law permits each of us to make based on our own values and beliefs. In fact, this is why most states have Good Samaritan laws: to incentivize people to act on behalf of a fellow human being in peril even though they may have no legal duty to do so. Can the medic’s employer be held liable for the medic’s failure to act? They possibly can in the court of public opinion, but not in tort law. If the agency is dispatched to respond, of course, that’s a different story. But her employer cannot be held liable simply because an offduty employee decided not to render aid as a bystander. What are the liability ramifications in this case if the medic does choose to act and provides care to the patient? Can the medic be held liable? Can her employer? Let’s start with the medic herself. When she decided to act voluntarily, most states’ laws would hold her liable only for harm that resulted from gross negligence, recklessness or intentional misconduct—not for acts of ordinary negligence. (Gross negligence vs. ordinary negligence is a threshold issue that is typically decided by the judge before the case goes to trial.) Some individual EMS providers choose to carry personal liability insurance to address concerns about personal liability, though in truth it’s quite rare for an EMS provider to have to pay out of their own pocket in a tort case. (In fact, we haven’t encountered it in our nearly 20 years in the practice of law.) Lastly, what is the liability of the medic’s employer if the medic chooses to act, in her uniform, while off duty? That is a bit more complex. If the employer has a policy (or even an unwritten expectation communicated to employees) making it a job requirement to provide off-duty care as a bystander, then it can possibly be held liable, because any errors or omissions committed by the medic would then likely be found to have occurred in the course and scope of her employment. However, in our experience, it’s unlikely (and inadvisable) for an EMS agency to have such a policy, which means the agency itself could most likely not be held liable for any acts or omissions committed by one of its employees off duty. The concept of a legal duty to act is a basic principle of tort law, and is the threshold issue in determining whether an EMS provider can face liability for their acts or omissions. Check out the most interesting and bizarre cases at jems.com/case 18 JEMS MARCH 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 www.pwwemslaw.com.
  • QUICK TAKE AWARD WINNERS FireEMS blogger, JEMS sister sites gain recognition Fire/EMSBlogs blogger Michael Morse, who pens the Rescuing Providence blog, was one of three Rhode Island writers who received the prestigious MacColl Johnson Fellowships from the Rhode Island Foundation. Morse, who was one of three writers to receive $25,000, writes about his work as an EMT/firefighter with the Providence Fire Department at http://rescuingprovidence.com. Two JEMS sister publications were named Jesse H. Neal Awards competition finalists. The Law Officer Facebook page is up for Best Use of Social Media, and FirefighterNation. com is being considered for Best Website. The American Business Media considers the Neal Awards the industry’s most prestigious and sought-after editorial honors. BOOK REVIEW Alright, Let’s Call it a Draw: The Life of John Pryor By Richard (and John) Pryor, based on the life and death of John Pryor, MD John P. Pryor, MD, FACS, former trauma program director for the Hospital of the University of Pennsylvania in Philadelphia, JEMS author and JEMS Editorial Board member, was killed by an enemy mortar round in Mosul, Iraq on Christmas morning of 2008. This posthumous biography, penned by John’s younger brother, Richard, is a moving and in-depth look into the life of an EMT turned trauma surgeon. It provides a rarely written view of the motivation and dedication behind heroic behavior. John Pryor’s journey began as a humble EMT in upstate New York. Like many JEMS readers, an inner voice compelled John to serve his fellow man. Ultimately, he decided that he wanted to be a surgeon. This seemingly impossible dream led him to Grenada in the Caribbean, Buffalo, N.Y., and Philadelphia as well as onto the pile at the World Trade Center on Sept. 11, 2001. Reading this book helps one realize that anything can be accomplished once you set your mind to doing so. It’s also a powerful and sometimes painful insight into the costs involved in achieving these dreams. Alright, Let’s Call it a Draw is an eloquently detailed compilation of stories and incidents that became the pivotal moments in the life of Dr. John Pryor. It details the life events that made him a man of conviction, a man of integrity, and a family man. This book reveals the unique characteristics of John’s life that resulted in an exceptional individual whose family, colleagues, friends and all who knew him would ultimately be proud of. Every EMS provider will see a little bit of themselves in the life of John Pryor. Anyone who ever wondered what medical school is like will gain an inside perspective. This book is a must read for every emergency services provider. You won’t be able to put it down. To obtain a copy, go to www.drjohnpryor.com. —Mike McEvoy, PhD, REMT-P, RN, EMT-P & A.J. Heightman, MPA, EMT-P Choose 20 at www.jems.com/rs
  • LEADERSHIP SECTOR PRESENTED BY THE IAFC EMS SECTION >> BY GARY LUDWIG, MS, EMT-P IMPACT AHEAD I t’s final! In June 2011, the U.S. Supreme Court upheld the Patient Protection and Affordable Care Act (PPACA), commonly known as Obamacare. This past November, President Barack Obama won reelection and Democrats maintained a majority control of the Senate. Any hopes Republicans had of repealing the law went away with those two opportunities. By the end of Obama’s second term, many of the PPACA’s core components will have been in effect for three years or more. There’s really no turning back; healthcare as we know it is going to change. The healthcare bill was 2,733 pages long and EMS is only referenced a few times in the document. But the effect on EMS will be dramatic. I suspect that many EMS systems will look totally different in 10 years. I know; you’ve heard this rhetoric before. About 15 years ago, we heard that managed care organizations would be the “gatekeepers” that would keep people from unnecessarily calling 9-1-1 to go to an emergency department (ED). We heard that call centers for insurance providers would properly evaluate the caller and route them to the appropriate level of care instead of calling 9-1-1. Those changes largely failed to materialize. CHANGES TO MANAGED CARE The problem with managed care is that it was mainly an effort by some insurance providers to control costs and profits, and it was voluntary. The PPACA will be legally required. Besides the 2,733 pages of the bill itself, more than 14,000 pages of federal regulations have already been written. In addition, the PPACA is partially funded through tax reforms (e.g., a 2.3% tax on medical devices costing more than $100). Expect those manufacturers to pass that cost on to you when you purchase devices costing more than $100. Although nobody truly knows how these changes will affect healthcare, there’s one thing we can be sure of: People are still 20 JEMS MARCH 2013 PHOTO ALLKINDZA/ISTOCKPHOTO.COM Obamacare will transform future EMS systems readmittals and other quality of care issues, hospitals may partner with the local EMS system to perform a variety of services. These can include checking on the patient with home visits for the first three days, or if complications arise, transporting the patient to another level of care. START PREPARING NOW EMS managers should prepare now for the changes that are coming. As patients with insurance are moved to management systems and existing Medicare patients are moved to ACOs, prepare for initial call load increases. This should be followed by a leveling-off period. Start meeting with your local hospital administrators to discuss partnerships that can come about with the implementation of the PPACA. As the saying goes, “Chance favors the prepared mind.” EMS systems that start preparing for the long-term impacts of the PPACA will no doubt reap the benefits. going to get shot, have heart attacks at the ball game and get into auto accidents going home from work. Our 9-1-1-based EMS systems will still be needed to address such medical emergencies. What’s most likely to change for EMS is how we deal with chronically ill patients who call 9-1-1 because they have waited too long to address their medical problem or because they lack health insurance and use the ED as an entry into the healthcare system to address their problem. For Medicare patients, these needs will most likely be met through accountable care organizations GLOSSARY (ACOs), which are just starting to form. The main function of an Accountable The main function of an ACO is to moniCare Organization (ACO) is to monitor tor and control reimbursements for healthand control reimbursements for healthcare providers while also monitoring the care providers while also monitoring the quality of the care being provided. The quality of the care being provided. The PPACA allowed for the establishment of a PPACA allowed for the establishment Medicare Shared Savings Program (MSSP), of a Medicare Shared Savings Program which allows for ACOs to contract with (MSSP), which allows for ACOs to conMedicare. Under this type of scenario, the tract with Medicare. Under this type of ACO would need to be totally responsible scenario, the ACO would need to be for the quality, cost, care and management of totally responsible for the quality, cost, at least 5,000 Medicare recipients. care and management of at least 5,000 An ACO can deny or reduce payment if Medicare recipients. the provider isn’t meeting quality standards. For example, reimbursement can be denied when a patient is readmitted to a hospital within three days for the Gary Ludwig, MS, EMT-P, is a deputy same problem. It’s therefore in that fire chief with the Memphis (Tenn.) Fire hospital’s interest to make sure the Department. He has 30 years of fire and patient doesn’t get readmitted for the rescue experience. He’s chair of the EMS same problem. Section for the International Association of Fire How does this affect EMS? To avoid such Chiefs and can be reached at www.garyludwig.com.
  • Choose 21 at www.jems.com/rs
  • TRICKSOUR PATIENTS & OURSELVES OF THE TRADE CARING FOR >> BY THOM DICK, EMT-P BATTERIES Preventing failures we can’t afford I PHOTO THOM DICK survived a grade-school envilate-model diesel depends on a supronment where academic failure ply of urea (and why). And that if meant physical pain. My teacher you’re having steering issues, the first would command me to put my hands thing you should wonder about is on my desk, and she would play rap the air pressure in your tires. Think music on them with a maple pointer. of it the way you think about anatAnd that was nothing, compared to omy and physiology. what awaited me at home when my By far, the most common kinds of dad returned from work. critical failures I’ve seen are failures My crime: not “applying” myself. to start. It turns out, they’re also the Nothing less than a B would do, easiest to prevent—partly by crews because in Pop’s view, non-achievewho understand their instruments, ment meant lack of effort. and partly by proactive agencies Looking back, I don’t recall my that adhere to scheduled preventive slightly neurotic teachers enjoying Batteries eventually fail, no matter what we do. Preventing replacement of their batteries. their work any more than I did mine. failures to start is the key to making sure those failures The thing about batteries is they don’t harm a patient. And not surprisingly, they sucked at it. all eventually fail. A good commerI loved auto shop, though; got straight As you know, an ambulance can either cial ambulance-sized battery should cost As in auto shop. Auto shop, music and writ- earn you a living or kill you on any day of about $200, and the average ambulance ing. Grew up with Rochester QuadraJets, your career. It can kill other people, too. To has two of those. They should be replaced 235 and 327 Chevy engines, and VW bugs. operate, it needs to be able to start, steer, about once a year (even if they work just Listened to the Wolf Man every night, play- stop and stay running. It also needs to pro- fine), they should be protected from rapiding Patsy Cline, Gene Pitney, The Righteous vide a stable interior environment, and its charging, and their connections should be Brothers, Motown, and later The Beach safety restraints need to work. You don’t kept tight and squeaky-clean. You know Boys and Beatles. Idolized Walter Cronkite need a mechanic or a supervisor to tell you what they’ll cost, so you can budget for and dreamed of being him someday. Then when any of those systems fails; and when their replacement. in 1970, as a young journalism student, I they do, you’re like a pilot. Nobody gets to Now let’s think about the consequences found a job as an ambulance attendant. I argue with your decision to put yourself of a failure. When a battery fails, it’ll typiinstantly recognized my calling in life. Of out of service. cally do so when you least expect it to. course, if you worked for an ambulance serI’ve learned to see critical failures not You can’t project what it’ll cost. A pair of vice in those days, it was probably a small just as events that prevent you from run- dead ones is too big to jump-start, they one. And in small organizations, everybody ning calls, but as events that could pre- place unacceptable stress on alternators, does more than one job. vent you from running calls. So, an engine they generate towing bills and they’re surOne of my jobs between calls was man- that cranks hard or leaks fluids needs to rounded by three-sided billboards that aging a fleet: tracking the licenses, buying be taken out of service. So does a tire that say “we screwed up.” And worst of all, the batteries, checking the tires and log- reveals excessive or unusual wear. they interrupt our basic mission of helpging the maintenance. I was untaught, so I In fact, your ambulance will almost ing sick people. made a lot of mistakes. But I loved ambu- always warn you before it fails. So you Don’t think this is important? OK, Lifelances, and I learned a ton about what probably deserve to understand how Saver. Put your hands on the table makes them safe and reliable. I take care of it works and what it’s telling you. in front of you. ... a fleet to this day. Mechanical education is partly Thom Dick has been involved in EMS There are two kinds of vehicle failures, your agency’s responsibility and for 41 years, 23 of them as a full-time Life-Saver. One is the kind that takes you partly yours. Given your access to EMT and paramedic in San Diego County. out of service immediately. Most agencies the Internet, there’s no reason why He’s currently the quality care coordinacall those critical failures. The other kind, a you shouldn’t know some of the non-critical failure, needs to be fixed none- same stuff your vehicle tech knows. For tor for Platte Valley Ambulance, a hospital-based theless. But it won’t keep you from run- instance, that a cracked windshield can 9-1-1 system in Brighton, Colo. Contact him at ning a call. defeat your airbag restraints. That your boxcar414@comcast.net. 22 JEMS MARCH 2013
  • A REVOLUTION IN EMERGENCY CARE NEW DESIGN Clinicians can deliver aerosol & CPAP therapy with Only One oxygen source. EZ ADVANTAGE: INTEGRATED NEBULIZER Offers the capability of an in-line nebulizer. ∙ Uses only one oxygen supply source ∙ Easy Set-Up, Less Parts. ADVANTAGE: CPAP SYSTEM CONSUMES 50% LESS OXYGEN Neb Off Neb On CPAP conserves oxygen while maintaining high FiO2 delivery Increasing flow may be necessary when activating the nebulizer. ADVANTAGE: BUILT-IN MANOMETER & PRESSURE RELIEF VALVE SAFE, SURE, SUPERIOR CPAP. ADVANTAGE: ADVANCED MASK DESIGN ∙ Quick Disconnect Clips ∙ Straight Rotating Port ∙ Soft Forehead Padding to reduce pressure on nose. ∙ CPAP & Nebulizer in One System ∙ Less Parts, Easy Set-Up ∙ Only One O2 Source With so many advantages, it clearly puts you at an advantage. Choose 22 at www.jems.com/rs www.mercurymed.com Visit Mercury Medicalʼs Booths #1431 & #1432 at the 2013 EMS Today Conference & Expo Walter E. Washington Convention Center Washington, D.C. March 7 - 9, 2013
  • CASE OF THE MONTH DILEMMAS IN DAY-TO-DAY CARE >> BY MICHAEL ORLAND, MD FORWARD FALL Get a handle on handlebar injuries I t’s 2 a.m. on a Friday night and a medic unit responds to a call of a “pedestrian struck.” On arrival, city law enforcement declares the scene to be safe and directs the unit to the opposite shoulder of the highway. EMS providers find a 35-year-old male lying in the prone position with a moderately damaged mountain bike beside him. The patient says he was riding home from his friend’s house when he got “bumped” by a passing car, hit a pothole and fell forward off his bike. Although his breath indicates recent alcohol intake, he’s able to answer questions in a moderately slurred voice. Initially the patient refuses medical evaluation and transport to the hospital, but the medics are able to convince him otherwise. The airway is intact with no debris or blood, and breath sounds are equal bilaterally. His respiratory rate is 22 and pulse oximetry 96% on room air. A cervical collar is placed on the patient, and he is log-rolled and secured onto a backboard. The heart rate is found to be 110 mmHg with a blood pressure of 136/92. His helmet has an abrasion to the front but is otherwise intact. Your trauma exam is notable for a 2x3 cm round-shaped wound to the midline epigastric region, just inferior to the xiphoid process, with moderate non-pulsatile bleeding. You note that when the patient exhales following a deep inspiration, there’s a small bulge in the wound that subsequently resolves with the following inspiration. No air movement or bubbling from the wound is detected. The abdomen is mildly distended with moderate diffuse tenderness and there are multiple partial thickness abrasions to the bilateral elbows, hands and lower extremities. Although he’s clinically intoxicated, his Glasgow Coma Scale (GCS) is determined to be 15. 24 JEMS MARCH 2013 PHOTOS COURTESY EDWARD T. DICKINSON ASSESSMENT & TREATMENT A deep breath by the patient produces a small bulge in the ring-shaped wound, indicating traumatic abdominal hernia. Once in the mobile unit, you place the patient on 4 lpm oxygen via nasal cannula and a cardiac monitor. You secure a sterile abdominal gauze pad over the open abdominal wound. The total scene time is 12 minutes, and transport time to the local trauma center is 20 minutes. You place an 18-gauge IV in the patient’s right antecubital fossa and administer 500 ccs of normal saline en route. The dressing controls the bleeding from the abdominal wound, and there’s no significant clinical change in the patient during transport. TRAUMA CENTER CARE On arrival to the trauma center, the trauma team repeats the primary and secondary surveys. Vital signs arenít significantly changed: Heart rate is 112, respiratory rate is 18, blood pressure is 132/88, and pulse oximetry is 100% on room air. The trauma team also performs a focused assessment with sonography for trauma (FAST) exam, which demonstrates a small amount of free fluid in the right upper quadrant, specifically Morrisonís pouch. A FAST exam, which is regularly performed during a trauma survey, uses four different locations to place the ultrasound and screen for free fluid in 10 distinct potential spaces. Free fluid, often blood in the traumatic patient, is a strong indicator of significant abdominal or thoracic injury, and the FAST exam allows early identification of these patients in order to expedite surgical intervention. Morrison’s pouch is a potential space between the inferior aspect of the liver and superior aspect of the right kidney. It is recognized as the most likely location to identify free fluid associated with a serious intra-abdominal injury. Given the stable vital signs, a CT scan of the head, cervical spine, chest, abdomen and pelvis is performed to fully evaluate the injuries. The CT scans demonstrate
  • Choose 23 at www.jems.com/rs
  • CASE OF THE MONTH >> CONTINUED FROM PAGE 24 IMAGE COURTESY EDWARD T. DICKINSON hernia will appear as a discrete bulge on abdominal exam that may expand and reduce with a change in abdominal pressure or remain constant. It’s important to recognize this clinical sign and its association with significant traumatic injuries, but no other specific care should be performed except for a sterile dressing application to any open wounds. Application of manual pressure or compression of any kind to the mass isn’t advised because it may exacerbate other injuries. CONCLUSION This CT scan demonstrates a 2 cm anterior fascial defect and associated abdominal wall hernia at the site of the open wound. a 2 cm anterior abdominal wall hernia at the site of the open wound, injury to two areas of the small bowel with likely perforation given the surrounding small foci of free air and a grade 2 liver laceration. The patient is immediately taken to the operating room, where he undergoes an exploratory laporatomy with resection of two portions of the small bowel, suture repair of the liver laceration and primary repair of the abdominal hernia with mesh. His post-operative course is uneventful, and the patient is discharged to home one week later. DISCUSSION At first glance, a fall from a bicycle can often be mistaken as a non-significant mechanism. As is often the case with lateral falls, a low level of energy is being distributed to a large area of the body or to an extremity. However, forward falls from a bicycle are frequently higher energy, which is distributed to a smaller area of the body. More specifically, the body can be struck in the chest or abdomen by the handlebars or the head by the ground or stationary object. This focused impact in combination with increased abdominal pressure as a result of the initial impact of the bicycle places the patient at significant risk of injury to the abdominal wall and anterior abdominal organs, including the liver, spleen, stomach, bladder, colon and 26 JEMS MARCH 2013 small bowel. Therefore, any patient who falls at a high rate of speed or falls forward off of a bicycle should be considered to have suffered a significant mechanism of injury and treated as such. Blunt traumatic injuries from a bicycle handlebar are more common in the pediatric population. A two-year retrospective chart review at a major children’s hospital found an average age of 8.8 years for this injury, with 79% of patients in this population being boys. Of the 14 patients who presented for evaluation to the ED, 11 had a ring-shaped ecchymotic area noted in the abdomen with a variety of lacerations and abrasions. After evaluation, it was found that 21% had an intestinal perforation and 21% had an abdominal wall hernia, as large as 5 cm.1 In the multiple case reports published, traumatic abdominal wall hernias due to a handlebar injury more often occur in the lower abdomen and appear as a ring- or circular-shaped ecchymosis, abrasion or open wound. In the pediatric population, a handlebar injury is the most common cause of a traumatic abdominal hernia and isn’t a reliable indicator for more significant traumatic injuries. In contrast, seatbelt trauma in a motor vehicle collision is the more frequent mechanism for abdominal hernias in adults and is almost always associated with other significant injuries.2 Clinically, a traumatic abdominal wall In this case, the ALS unit provided prompt and efficient care for their trauma patient; starting with airway, breathing and circulation (ABCs), and proceeding through spinal immobilization and secondary examination. They recognized the significant mechanism and were able to persuade the patient to receive the care he required. Large-bore IV access was obtained, fluid resuscitation was initiated and appropriate wound care was provided—all while expediting transport to a trauma facility. In summary, falling forward onto a bicycle places a patient at risk of a handlebar injury and should be considered a significant traumatic mechanism that may cause serious abdominal injuries with no major outward signs of trauma on exam. A traumatic abdominal wall hernia will appear as an area of ecchymosis or small wound with an underlying bulge. Although this doesn’t require specific care, it should be recognized as a significant injury. In adults, it may indicate additional serious abdominal injuries. As such, these patients should be transported expeditiously to the closest trauma center. Michael Orland, MD, is a resident physician in emergency medicine at the Hospital of the University of Pennsylvania and a former EMT with the Pennington First Aid Squad. He can be reached at Michael.Orland@ uphs.upenn.edu. REFERENCES 1. Karaman I, Karaman A, Aslan M, et al. A hidden danger of childhood trauma: Bicycle handlebar injuries. Surg Today. 2009;39(7):572–574 2. Haimovici L, Papafragkou S, Kessler E, et al. Handlebar hernia: Traumatic abdominal wall hernia with multiple enterotomies. A case report and review of the literature. J Pediatr Surg. 2007;42(3):567-569.
  • Choose 24 at www.jems.com/rs
  • 28 JEMS MARCH 2013 PHOTO BY CHRIS SWABB
  • TIME FOR A CHANGE >> BY JIM MORRISSEY, MA, EMT-P rehospital spinal immobilization has long been r held as the standard of care for victims of blunt h or penetrating trauma who have experienced a o mechanism of injury (MOI) forceful enough to m possibly damage the spinal column. The majority p of EMS textbooks stress that any significant MOI, regardless of f b signs and symptoms of spine injury, requires full-body immobilization, which is typically defined as a cervical collar being applied and the patient being secured to a backboard with head stabilizers in place. This approach to patient immobilization has been accepted and implemented as the standard of care for decades with little scientific evidence justifying the practice.1–3 In addition, scant data shows that immobilization in the field has a positive effect on neurological outcomes in patients with blunt or penetrating trauma.1,4–6 In fact, several studies and articles show that spine immobilization may cause more harm than good in a select sub-set of trauma patients.5–7 Many experts question the current practice of prehospital spinal immobilization.1,2,4–15 There are now some guidelines, textbooks and an increasing number of EMS agencies that support a progressive, evidence-based approach in an effort to lessen unnecessary spinal immobilizations in the field. It’s problematic to use MOI alone as the key indicator for prehospital spinal immobilization. In addition, the harmful sequelae and potential dangers of spine immobilization need to be considered in any field protocol. We need to examine appropriate spine injury assessment guidelines and algorithms that allow for the selective immobilization of injured patients. We also should review immobilization devices and techniques that are more appropriate for patients who do require immobilization, or better termed, spinal motion restriction (SMR), by EMS providers. OUTDATED INDICATORS? It typically takes several years for EMS textbooks to catch up with new evidence and then additional time for the EMS instructional community to modify curricula and change current practice. For example, definitions of mechanisms that require spinal immobilization found in most EMS textbooks are outdated and problematic. Such indicators for potential spine injury as fall, damage to the vehicle, injury above the clavicle and mechanism of injury involving motion, are not particularly helpful when determining the best course of action in the field. Especially troubling has been the lack of emphasis on the assessment of the patient before making a decision about immobilization. Historically, more emphasis has been placed on what happened to the vehicle or the best guess on how far someone may have fallen, instead of what actually happened to the person. It isn’t the fall that causes injury; it’s the sudden stop at the end. The more sudden the stop, the more likely an injury results, especially if the kinetic energy was transmitted to the head and/or neck. The physical condition of the patient must also be considered. A young, athletic person is able to withstand more forces than an elderly patient. So the spectrum of potential injuries is best determined through a detailed history and physical exam. Vehicle damage has long been considered a strong indicator of potential spine injury, yet improvements in vehicular design and construction should change the way we look at vehicle damage. Vehicle technology and passenger protection is far superior to what it has been, particularly since the 70’s when EMS textbooks began advocating back boarding of patients in vehicles with significant damage. Vehicle damage zones are now inherently built into newer WWW.JEMS.COM MARCH 2013 JEMS 29
  • SPINAL IMMOBILIZATION >> CONTINUED FROM PAGE 29 PRECAUTIONARY IMMOBILIZATION PHOTO COURTESY JIM MORRISSEY/JOSH KENNEDY It isn’t surprising that the term and practice of “precautionary immobilization” has developed. It’s estimated that at least five million patients are immobilized in the prehospital environment in the U.S. each year. Most have no complaints of neck or back pain or other evidence of spine injury.3,11,12 (See Photo 2.) EMS personnel historically have neither been given the tools nor the authority to make informed decisions about objectively determining the need for prehospital spinal immobilization. This may be because the emergency medical community thought immobilization was always safe, conservative and always in the best interest of the patient. However, evidence now shows that, in some cases, spinal immobilization may not be in the patient’s best interest.1–3,7,8,10–13 Some prehospital care providers will admit that they often immobilize patients without evidence of spine injury because they want to avoid being questioned on arrival at the emergency department (ED). This dynamic can (and must) change with education and outreach. BACKBOARD-BASED IMMOBILIZATION There are many situations (hostile environment, life threatening injuries) where spinal immobilization may be detrimental to good patient care. This training scenario emphasizes rapid extrication. 30 JEMS MARCH 2013 victims of penetrating trauma without neurologic deficits.20 In the setting of drowning, the 2010 evidence-based guidelines from the American Heart Association state that “Routine c-spine immobilization is a Class III (potentially harmful) unless clear trauma is evident in the history or exam, because it may unnecessarily delay or impede ventilations. ”21 PHOTO A.J. HEIGHTMAN vehicles, designed to absorb and dissipate the kinetic energy of a collision, and keep the passenger cabin relatively isolated and protected.16 An experienced paramedic once said, “The cake box might be crumpled, but the cake can be fine.” Some textbooks accurately address this issue. Even as far back as 1990, the American Academy of Orthopaedic Surgeons addressed emergency medical responders in an extended-care environment, stating, “Patients with a positive mechanism of injury, without signs and symptoms, and with a normal pain response may be treated without full spine immobilization, if approved by your medical control physician.” 17 Emergency medical personnel who work in extended-care, tactical, combat and wilderness environments have long realized the need to safely and accurately assess and clear patients regarding spinal injuries.18,19 New guidelines from Prehospital Trauma Life Support and the National Association of EMS Physicians have diminished the emphasis on immobilizing Assessment is still the key to determining the need for spinal immobilization. In addition to patient discomfort and anxiety associated with backboard-based immobilization, there are several potentially significant consequences. Standard immobilization requires the patient’s body to conform to a flat, hard surface. In addition, EMS secures a cervical collar around the patient’s neck and uses tape to secure the patient’s head to the board. This practice often increases patient anxiety and has the potential to aggravate underlying injuries. Standard spinal immobilization techniques can also take away the patient’s ability to effectively protect their own airway thus significantly increasing the risk of aspiration.3–6,11,13 Patient vomiting, bleeding, airway drainage and swelling are common problems associated with trauma patients. Even with one EMS provider dedicated to the management of the airway and patient suction, it cannot be assumed that a suction catheter can handle the job when significant bleeding and/or vomiting is presented. The continued spinal stability of a patient who is turned on their side to facilitate airway drainage and control is also questionable. Patients typically experience a significant
  • Choose 25 at www.jems.com/rs Choose 26 at www.jems.com/rs
  • SPINAL IMMOBILIZATION PHOTO COURTESY JIM MORRISEY/JOSH KENNEDY >> CONTINUED FROM PAGE 30 Patients with penetrating trauma (ex., gunshots and stabbings) to the head and torso usually do not benefit from spine immobilization. shift in body weight and distribution, causing more movement to the spine than the immobilization process was intended to prevent. In a comprehensive review published in Prehospital and Disaster Medicine, healthy volunteers who were immobilized on a backboard were found to be “significantly more likely to complain of pain when compared with immobilization on a vacuum mattress.” Adverse effects of backboard-based immobilization documented in this study include increased ventilatory effort, pain and discomfort. In addition to pressure injury, the backboard may also be the cause of pain—even in otherwise healthy volunteers. The resultant posterior surface/back pain of immobilized patients has been documented to result in unnecessary radiographs and potential clinical ambiguity regarding the cause of the pain.3,22 There’s an increased cost associated with some of these complications. It has been documented that supine patient immobilization results in a 15–20% reduction in respiratory capacity, and that respiratory effectiveness is markedly reduced by the strapping systems typically used.3,9,13 Patients are often either strapped securely, thus having diminished respiratory capacity, or loosely secured, facilitating easier breathing. Neither scenario is ideal. The challenge is exacerbated in obese patients, the elderly and patients with such underlying diseases as congestive heart failure, COPD, asthma and pneumonia. Done properly, immobilization in the field takes time and multiple personnel. Time delay to the ED or trauma center arrival has been cited as a significant problem for critical trauma victims. Several studies have looked at the risk vs. benefit of prehospital immobilization, with several authors and researchers questioning the value of current practices.1,2,7,8,11,15 Choose 27 at www.jems.com/rs 32 JEMS MARCH 2013
  • Studies have also shown limited or no benefit of prehospital immobilization of penetrating trauma patients. (See photos on pages 32 and 33.) Unnecessary immobilization of this subset of trauma patients can result in prolonged on-scene time and delayed transport to definitive care, which may increase morbidity and mortality.4–6,14,18,23–25 Several studies show that cervical collars by themselves aren’t without risk or significant consequences.4,26–28 One study concludes that cervical collars frequently increase intracranial pressure and may be particularly harmful if used on head-injured patients.26 Another researcher observed that cervical collars “can result in abnormal distraction within the upper cervical spine in the presence of severe injury.”28 In addition, cervical collars hide areas of the head and neck, resulting in the increased possibility of missing injuries or evolving problems, such as swelling, hematoma and tracheal deviation.27,28 In addition, the longer a patient is immobilized, the more likely that cutaneous pressure ulcers will develop, most notably in the occipital, sacral or heel areas.9,12,22,29,30 This is especially true in elderly, unconscious and neurologically impaired patients. This problem may be significantly reduced with padding or use of a vacuum mattress. Unfortunately, the vast majority of the patients who are immobilized don’t get padding in voids or areas of significant body weight/pressure or a vacuum mattress that distributes beads/padding in voids and uneven body surface areas. THE PENETRATING TRAUMA PATIENT As referenced earlier, there is a growing body of evidence that suggests penetrating trauma victims shouldn’t be routinely immobilized. Immobilization has been associated with higher mortality in patients with penetrating trauma.4–6,14,23–25 Independent studies show that whether the penetrating trauma is to the head, neck or torso, immobilization is unnecessary, interferes BEGIN THE CHALLENGE AT: PHOTO COURTESY JIM MORRISSEY/JOSH KENNEDY heart.org/acls-ep Tactical teams often use compact, flexible extraction devices. Choose 28 at www.jems.com/rs WWW.JEMS.COM MARCH 2013 JEMS 33
  • SPINAL IMMOBILIZATION >> CONTINUED FROM PAGE 33 with and delays emergent care, and should be seriously reconsidered as the standard of care.4–6,14,23 A Journal of Trauma article concluded, “Indirect spinal injury does not occur in patients with gunshot wounds to the head.” The authors state, “Protocols mandating cervical spine immobilization after a gunshot wound to the head are unnecessary and may complicate airway management.”14 Another retrospective study showed similar concerns about the use of a cervical collar with patients who have penetrating injuries to the neck. This study suggests that avoiding the collar should be the rule, and that a provider who chooses to apply a cervical collar should have good justification. The authors also suggest that frequent examination of the underlying structures and tissue is warranted if a cervical collar is used.4 A comprehensive retrospective analysis of gunshot injuries to the torso found that immobilization was of little or no benefit, even if an unstable spine fracture was present. The authors argue that airway management, including intubation, is far more complicated and problematic with prehospital spinal immobilization in place.5,6 In fact, failed airway management was reported to be the secondleading error preceding death of trauma patients, accounting for 16% of mortality in one study. This study also highlights the potential delay to definitive surgical treatment and the lack of neurologic improvement after gunshot injury to the spinal cord, suggesting that prehospital spinal immobilization is unjustified.5,6 PROPER SPINE INJURY ASSESSMENT AIRPOWER® R8 Lower profile zipper Station/EMS boot > Built in Arch Support > Steel toe protection > Chemical/bloodborne pathogen protection > Waterproof & breathable Quality shoes for law enforcement, fire and rescue services, hunting, work wear, and leisure time HAIX® North America Inc. 2320 Fortune Drive, Suite 120, Lexington KY 40509 Phone 859-281-0111, Fax 859-281-0113, Toll free 866-344-HAIX (4249) Visit us at DAY EMS TO 49 0 Booth 1 www.haix.com Choose 29 at www.jems.com/rs 34 JEMS MARCH 2013 For many trauma patients, a vetted field assessment criterion that focuses on the assessment of the patient rather than the mechanism of injury would obviate unwarranted immobilization.3,11,31 Many emergency medicine specialists believe an accurate, reliable, simple-to-perform spinal injury assessment could reduce spine immobilizations drastically. Thankfully, there is a trend in this direction across the nation. The idea of “clearing” a patient of spinal injury in the field has been, and continues to be debated. However, there are prehospital spine assessment protocols that safely and accurately allow EMTs and paramedics to omit prehospital spinal immobilization in certain patients. Some EMS experts prefer the term “selective immobilization” to “clearing” the c-spine, but the end result is the same. The end result is the reduction of the incidence of unwarranted spinal immobilizations. For example, the Maine spine injury assessment guidelines, developed by Peter Goth, MD, in the 1990s, have been shown to be accurate and safe.10,31,32 Several states and EMS systems around the nation use this, or a similar protocol, to help decrease the number of trauma patients being subjected to prehospital spinal immobilization. The origin of this type of spinal assessment was initially intended to help ED physicians clinically decide if they can safely clear patients from prehospital spinal immobilization and reduce or eliminate unnecessary radiographic studies. It has been shown that the proper clinical exam and history is more accurate at predicting spine injuries than X-ray review.10,32–35 The spine injury assessment guidelines that have been adopted
  • PHOTO COURTESY JIM MORRISEY/JOSH KENNEDY by multiple prehospital systems are based on the Canadian C-spine rule and the National Emergency X-Radiography Utilization Study (NEXUS) low-risk criteria. Each has similar parameters, requiring that the patient be awake, alert, conversant and without significant distracting injury or intoxication. In addition, the guidelines further state that the physical exam should reveal no pain or tenderness to the posterior neck and back and the neurologic exam must find normal motor and sensory function in the extremities.10,18,31,33–35 Studies show that prehospital care providers can safely apply spine injury assessment criteria and not miss any clinically significant spine injuries.10,31,32 Although these guidelines are PHOTO CHRIS SWABB Some patients, such as pediatric patients, require special spinal immobilization consideration. Children have been immobilized acceptably in specialized spinal devices for decades. Choose 30 at www.jems.com/rs WWW.JEMS.COM MARCH 2013 JEMS 35
  • SPINAL IMMOBILIZATION Patients can be immobilized safely and comfortably via a combination of a backboard or other flexible or scoop-type stretcher, such as shown here with a Hartwell Combi-Carrier/vacuum mattress combination. However, long-established norms are hard to break, and extensive training was required to make this new policy successful. EMS schools, fire departments and other EMS providers, as well as emergency department staff, needed to be exposed to the literature and trained in the new protocol. Initial training and outreach has been well received and the early indicators have shown a significant reduction in spine immobilizations. The end result is: >> A better understanding of the need for expeditious care under specific circumstances, in particular, the need to move rapidly when penetrating trauma is present; >> All involved are empowered to break the paradigm of “board them all” as a result of understanding the importance of proper spinal/neurological assessment and assessment parameters that allow crews to assess for serious spinal indications and perform selective immobilization. We did the same process decades ago when we adopted rapid removal techniques for 36 JEMS MARCH 2013 PHOTO A.J. HEIGHTMAN A vacuum splint can be used as a highly moldable and comfortable cervical immobilization device. of patients. Many of these devices are better suited to patient movement in tight spaces and crew body mechanics when carrying and transferring patients down stairways and other difficult environments. Of course, crews have to take special caution when dealing with and managing high-risk patients, including pediatric patients, the elderly and those with such degenerative bone disorders as osteoporosis. Field personnel need to be conservative while evaluating these patients and should provide spinal motion restriction when in doubt.33,34 UNCONVENTIONAL OPTIONS Even with appropriate application of spine injury assessment guidelines, some patients still require some degree of prehospital spinal motion restriction. Vacuum mattresses and other break-away and flexible stretchers have been used successfully throughout Europe for years. They score well in several critical areas, including patient comfort, secure immobilization, insulation, lack of pressure PHOTO A.J. HEIGHTMAN patients in lieu of spending precious minutes placing splints and half backboards on critical patients. Little or no untoward results occurred with that change in procedure; >> More attention to patient comfort and pain instead of routine placement of trauma patients on a hard, uncomfortable platform that often put them in anatomically-incorrect positions for extended time periods, made patients unnecessarily claustrophobic lying supine and immobile and exacerbation of respiratory distress in patients due to the supine position, strap placement, and existing conditions such as CHF, COPD or morbid obesity; and >> The ability to deploy and maximize the usage of alternative immobilization and transfer devices and stretchers such as vacuum mattresses, scoop or CombiCarriers and flexible stretchers such as Ferno and SKED stretchers and others that feature lateral patient support slats and multiple handles for convenient movement and transfer PHOTO A.J. HEIGHTMAN available, training and practice is needed to become proficient at using these criteria. Alameda County (Calif.) EMS has revised its spine injury assessment protocol to accurately reflect the current literature and research. (See Figure 1, p. 38). Its goals in 2012 were to reduce unnecessary immobilization, and use treatment modalities in the best interest of and provide the most comfort to the patient. In some cases, this meant forgoing prehospital spinal immobilization to expedite transport to a trauma center. PHOTO ED DOERR >> CONTINUED FROM PAGE 35 This patient is securely immobilized in a FERNO Germa Easyfix vacumm mattress – stretcher. Vacuum mattresses and stretchers pad voids and distribute a patient’s weight evenly.
  • Choose 31 at www.jems.com/rs 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 32 at www.jems.com/rs Duluth, MN 55802
  • SPINAL IMMOBILIZATION >> CONTINUED FROM PAGE 36 Figure 1: Alameda County (Calif.) 2012 Spinal Immobilization Procedure POTENTIAL FOR UNSTABLE SPINAL INJURY? YES > Age > 65 > Meet Trauma Patient Criteria for Mechanism of Injury (Section 3) > Axial load to the head (e.g. diving injury) > Numbness or tingling in extremities If any one of the high-risk factors above are present, strongly consider spinal motion restriction (SMR). A reliable patient is cooperative, sober and alert without: Significant Distracting Injuries Language Barrier YES RELIABLE PATIENT? NORMAL SPINE EXAM? NORMAL MOTOR/SENSORY? OMIT SMR NO Low-risk factors: > Simple rear-end MVC > Ambulatory at any time on scene > No neck pain at scene > Absence of midline cervical spine tenderness The low-risk factors above allow safe omission of SMR. sore development and, in the case of some vacuum device configurations, allow crews to utilize them without a cervical collar.12,29,30 When considering adding vacuum mattresses, vacuum stretchers or other immobilization devices to your arsenal, keep in mind that they don’t require more effort or training than using backboards. Vacuum mattresses can also effectively pad voids, distribute weight evenly and immobilize patients on their side because the device can be “molded” around the patient to best package them safely. (See photos on page 36.) However, keep in mind that backboards 38 JEMS MARCH 2013 POSSIBLE SPINE INJURY APPLY SMR SPINAL PAIN/TENDERNESS Palpate vertebral column thoroughly MOTOR/SENSORY EXAM Wrist or finger extension (both hands) Plantarflexion (both feet) Dorsiflexion (both feet) Check gross sensation in all extremities Check for abnormal sensations to extremities (e.g. parathesias) To obtain a copy of the complete Alameda County Spinal Injury Assessment Procedure, go to the web version of this article at jems.com/journal still have a place, especially to restrain or slide a patient out of an extrication mess. There is also nothing that precludes you from utilizing a combination of devices such as a backboard or scoop-type stretcher to remove a patient and transfer them to a more moldable or comfortable secure surface such as a vacuum mattresses. Many systems use this combination or deploy vacuum mattresses in conjunction with flexible stretchers. (See photo, top of page 36.) Another emerging school of thought questions the need for traditional prehospital spinal immobilization at all—even for patients who have positive evidence of a spinal column or spinal cord injury. One group of researchers who compared various extrication tools and methods found that allowing a patient to self-extricate from a vehicle with a cervical collar alone caused less movement of the spine than the use of cervical collar, KED extrication device and standard extrication techniques.36 This triggers a series of questions that are beyond the scope of this article. Groups such as the National Association of EMS Physicians and the U.S. Metropolitan Municipalities Medical Directors and Global Affiliates Consortium
  • are carefully discussing these options and revisions to our traditional approaches to neck and spine immobilization 5. CONCLUSION It’s appropriate for emergency personnel to immobilize certain trauma patients. However, many other trauma patients are unnecessarily immobilized by EMS. Spinal immobilization isn’t always a benign intervention. It can result in increased scene time, delay of delivery to definitive care, problematic airway management, increased patient pain or dyspnea, and unnecessary radiographic testing. Many trauma patients can be safely and accurately assessed and treated without immobilization if they meet all criteria in prehospital spinal assessment guidelines. Extensive initial training and ongoing review is necessary for an effective selective immobilization protocol. Science, research and multiple validated articles have changed the way EMS practices. If good patient care is the goal, it’s time that prehospital spinal immobilization be critically examined. A special note of thanks to Karl Sporer, MD, Alameda County medical director, and Edward Dickinson, MD, JEMS medical editor, for their critical and helpful review of this article, and to Peter Goth, MD, for insight, fortitude and groundbreaking efforts to shift the paradigm. Jim Morrissey, MA, EMT-P, is the terrorism preparedness coordinator for Alameda County (Calif.) EMS. He is a tactical paramedic for the San Francisco FBI SWAT team, and a medical intelligence officer for the Northern California Regional Intelligence Center. He holds a master’s degree in homeland security from the Naval Postgraduate School. He can be reached at jim.morrissey@acgov.org. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. REFERENCES 1. Hauswald M, Ong G, Tandberg D, et al. Out-of-hospital spinal immobilization: Its effect on neurologic injury. Acad Emerg Med. 1998;5(3):214–219. 2. Baez AA, Schiebel N. Evidence-based emergency medicine/systematic review abstract. Is routine spinal immobilization an effective intervention for trauma patients? Ann Emerg Med. 2006;47(1):110–112. 3. Kwan I, Bunn F. Effects of prehospital spinal immobilization: a systematic review of randomized trials on healthy subjects. Prehosp Disaster Med. 2005;20(1):47–53. 4. Barkana Y, Stein M, Scope A, et al. Prehospital 17. 18. 19. 20. stabilization of the cervical spine for penetrating injuries of the neck: Is it necessary? Injury. 2000;31(5):305–309. Haut ER, Kalish BT, Efron DT, et al. Spine immobilization in penetrating trauma: More harm than good? J Trauma. 2010;68(1):115–120; discussion 120–121. Brown JB, Bankey PE, Sangosanya AT, et al. Prehospital spinal immobilization does not appear to be beneficial and may complicate care following gunshot injury to the torso. J Trauma. 2009;67(4):774–778. Smith JP, Bodai BI, Hill AS, et al. Prehospital stabilization of critically injured patients: A failed concept. J Trauma. 1985;25(1):65–70. Seamon MJ, Fisher CA, Gaughan J, et al. Prehospital procedures before emergency department thoracotomy: ‘Scoop and run’ saves lives. J Trauma. 2007;63(1):113–120. Chan D, Goldberg R, Tascone A, et al. The effect of spinal immobilization on healthy volunteers. Ann Emerg Med. 1994;23(1):48–51. Domeier RM, Frederiksen SM, Welch K. Prospective performance assessment of an out-of-hospital protocol for selective spine immobilization using clinical spine clearance criteria. Ann Emerg Med. 2005;46(2):123–131. Kwan I, Burns F. Spinal immobilization for trauma patients (Cochrane Review). Cochrane Review; 2009;11http://summaries.cochrane.org/CD002803/ spinal-immobilisation-for-trauma-patients. McHugh TP, Taylor JP. Unnecessary out-of-hospital use of full spinal immobilization. Acad Emerg Med. 1998;5(3):278–280. Totten VY, Sugarman DB. Respiratory effects of spinal immobilization. Prehosp Emerg Care. 1999;3(4):347–352. Kaups KL, Davis JW. Patients with gunshot wounds to the head do not require cervical spine immobilization and evaluation. J Trauma. 1998;44(5):865–867. Hauswald M. A re-conceptualisation of acute spinal care. Emerg Med J. Sept. 8, 2012. [Epub ahead of print]. Centers for Disease Control and Prevention (Sept. 6, 2012). Guidelines for Field Triage of Injured Patients. 2011; Retrieved from www.cdc.gov/Fieldtriage. Accessed Sept. 24, 2012, 2012. Worsing R. Basic Rescue and Emergency Care. First Edition. Ed: American Academy of Orthopaedic Surgeons, Park Ridge, IL; 1990; 253 . Goth P. Spine Injury, Clinical Criteria for Assessment and Management. Augusta, ME: Medical Care Development Publishing; 1994. Morrissey J. Field Guide of Wilderness Medicine and Rescue. Third Edition Ed: Wilderness Medical Associates, Portland, ME; 2000; 30-33. Stuke LE, Pons PT, Guy JS, et al. Prehospital spine immobilization for penetrating trauma: Review and recommendations from the Prehospital Trauma 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. Life Support Executive Committee. J Trauma. 2011;71(3):763–769; discussion 769–770. Berg RA, Hemphill R, Abella BS, et al. Part 5: Adult basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 Suppl 3):S685–S705. March JA, Ausband SC, Brown LH. Changes in physical examination caused by use of spinal immobilization. Prehosp Emerg Care. 2002;6(4):421–424. Kennedy FR, Gonzalez P, Beitler A, et al. Incidence of cervical spine injury in patients with gunshot wounds to the head. South Med J. 1994;87(6):621–623. Chong CL, Ware DN, Harris JH, Jr. Is cervical spine imaging indicated in gunshot wounds to the cranium? J Trauma. 1998;44(3):501–502. Arishita GI, Vayer JS, Bellamy RF. Cervical spine immobilization of penetrating neck wounds in a hostile environment. J Trauma. 1989;29(3):332–337. Davies G, Deakin C, Wilson A. The effect of a rigid collar on intracranial pressure. Injury. 1996;27(9):647–649. Kolb JC, Summers RL, Galli RL. Cervical collar-induced changes in intracranial pressure. Am J Emerg Med. 1999;17(2):135–137. Ben-Galim P, Dreiangel N, Mattox KL, et al. Extrication collars can result in abnormal separation between vertebrae in the presence of a dissociative injury. J Trauma. 2010;69(2):447–450. Cordell WH, Hollingsworth JC, Olinger ML, et al. Pain and tissue-interface pressures during spine-board immobilization. Ann Emerg Med. 1995;26(1):31–36. Luscombe MD, Williams JL. Comparison of a long spinal board and vacuum mattress for spinal immobilisation. Emerg Med J. 2003;20(5):476–478. Muhr MD, Seabrook DL, Wittwer LK. Paramedic use of a spinal injury clearance algorithm reduces spinal immobilization in the out-of-hospital setting. Prehosp Emerg Care. 1999;3(1):1–6. Domeier RM, Evans RW, Swor RA, et al. The reliability of prehospital clinical evaluation for potential spinal injury is not affected by the mechanism of injury. Prehosp Emerg Care. 1999;3(4):332–337. Stroh G, Braude D. Can an out-of-hospital cervical spine clearance protocol identify all patients with injuries? An argument for selective immobilization. Ann Emerg Med. 2001;37(6):609–615. Barry TB, McNamara RM. Clinical decision rules and cervical spine injury in an elderly patient: a word of caution. J Emerg Med. 2005;29(4):433–436. Burton JH, Dunn MG, Harmon NR, et al. A statewide, prehospital emergency medical service selective patient spine immobilization protocol. J Trauma. 2006;61(1):161–167. Shafer JS, Naunheim RS. Cervical spine motion during extrication: a pilot study. West J Emerg Med. 2009;10(2):74–78. WWW.JEMS.COM MARCH 2013 JEMS 39
  • NEW JERSEY EMS RESPONSE TO SUPERSTORM SANDY AIDED BY PRE-PLANNING & PREPAREDNESS PHOTO COURTESY OCEAN COUNTY A new inlet carved out by Superstorm Sandy washed out a portion of a bridge and numerous homes in Mantoloking, N.J. Casino Pier in Seaside Heights was destroyed by Superstorm Sandy. 40 JEMS MARCH 2013
  • >> BY HENRY P. CORTACANS, MAS, CEM, NREMT-P; & TERRY CLANCY, PHD, NREMT-P support those initiatives, and a team of more than 300 people, trained and ready to mobilize those resources and staff critical areas of operation. We will highlight some of the major areas of operation, share some lessons learned and best practices, and suggest areas where others can learn and adapt from our experiences. FRAMEWORK FOR PREPAREDNESS On Oct. 21, 2012, nine days before the storm arrived, a computer weather forecast model showed a hurricane hitting New Jersey. Our colleagues and I were in disbelief, and we shared the forecast with EMS stakeholders. Subsequent forecasts continued to confirm the storm’s path and its imminent landfall. On Oct. 26, 2012, the State of New Jersey’s “Tropical Storm/Hurricane Management Plan for EMS” was activated. This document provides a framework for the effective coordination of EMS resources should the state be threatened with a tropical system or major coastal storm. It was produced in 2008 after it was recognized that EMS agencies and organizations would be better prepared to respond to the overwhelming demands of such a natural disaster if a guidance document was available. When Sandy invaded the N.J. coastline, it had been implemented four times already. The plan provides: >> Detailed standard operating procedures when a tropical system (or equivalent WWW.JEMS.COM MARCH 2013 JEMS 41 PHOTO COURTESY OCEAN COUNTY I t was Sept. 16, 1903, more than 100 years ago, when an unnamed hurricane made landfall in New Jersey. Dubbed the “Vagabond Hurricane,” the storm struck Atlantic City with 80 mph winds and caused $8 million in damage (equivalent to $200 million today after inflation). The Vagabond Hurricane destroyed dozens of buildings, piers, barns and boats, scattering debris all along the beachfront. Strong winds downed telegraph and telephone wires all up and down the coastline. Moderate damage was reported from Cape May to Monmouth County, with Atlantic County encountering the most severe damage. One person was killed. Fast forward to October 2012, when another unprecedented storm took place. But this time, it wasn’t just a hurricane; it was the first of its kind—a “Superstorm” named Sandy, the largest storm ever recorded in the Atlantic Ocean. Sandy led to at least 40 deaths in New Jersey and left damage totaling in the billions of dollars. The New Jersey EMS Task Force (NJEMSTF), formed in 2004, was ready. The NJEMSTF was born from the Sept. 11, 2001, terror attacks and designed to prepare New Jersey’s EMS for large scale disasters and high impact events by providing three critical needs: project management for major regional EMS planning and preparedness initiatives, the procurement of specialized equipment and resources to
  • IN THE PATH OF DESTRUCTION >> CONTINUED FROM PAGE 41 IMAGE HENRY P. CORTACANS/GOOGLE EARTH Figure 1: Similar paths of the 1903 “Vagabond Hurricane” and Hurricane Sandy in 2012. 42 JEMS MARCH 2013 >> A statewide EMS communications and demobilization strategy. SUPPORTING DOCUMENTS The tropical storm/hurricane management plan references several other guidance documents that were used: New Jersey EMS Staging Area Management Plan: This plan defines specific, pre-identified locations that have been designated as PHOTO HENRY P. CORTACANS significant, major coastal storm) has the potential to impact New Jersey; >> Procedures for EMS at the state, county and local levels when the National Weather Service issues a tropical storm or hurricane watch/ warning for any portion of the New Jersey coast; >> Procedures for the evacuation of healthcare facilities using EMS resources; >> Procedures for the acquisition of mutual aid out-of-state EMS resources to support New Jersey operations through the Emergency Management Assistance Compact (EMAC) and the Federal Emergency Management Agency’s (FEMA) National Ambulance Contract; >> Guidance on the suspension of EMS operations (response) during increased, hazardous winds; >> Integration of EMS resources within the New Jersey Office of Emergency Management’s (OEM) Contraflow Plan; >> Regulatory waivers to increase EMS capability and response during such a disaster; and, regional EMS staging areas able to accommodate large numbers of resources. It also gives an overview of the staging process and identifies the resources and trained personnel that will support the plan. For Superstorm Sandy, two regional EMS staging areas were established. Before and continuing to operate early in the storm, a facility was set up in Egg Harbor Township, Atlantic County. A second location was established at MetLife Stadium in East Rutherford, N.J., two days after the storm hit. The NJEMSTF deployed staging area management trailers and teams to manage these locations. EMS assets were organized into strike teams, task forces and single resources, and each was deployed to various locations around the state for missions. New Jersey Helibase Helicopter EMS (HEMS) Management Plan: This plan defines specific, pre-identified locations that have been designated as HEMS helibases where large amounts of rotary wing air medical services can be coordinated during a regional disaster. The plan also provides an overview of helibase management and lists the resources and trained personnel that the NJEMSTF uses to support the plan. A helibase was established at TrentonMercer Airport. Additional New Jersey aircraft were placed into service. It was anticipated that search and rescue missions by air were going to be widespread after the storm passed. As it turned out, most of the missions were done by ground; however, this facility was prepared to coordinate large amounts of Regional EMS staging area at MetLife Stadium, home of the N.Y. Giants and N.Y. Jets, in northern New Jersey with ambulance strike teams ready for deployment.
  • a coordinated network for providing N.J. EMS Task Force Coordinator Terry Clancy briefs mutual aid crews to information, plan- use caution due to extremely hazardous conditions. ning, logistics and other operational support to EMS provid- prioritization and assignment of resources ers within the region. to multiple, simultaneous areas of operation Sandy was forecasted to have a state- to include emergency evacuation, mass casuwide impact, so a MACS was established alty surge, continuity of 9-1-1, search and and coordinated the tracking of hundreds rescue, mobile satellite emergency departof mission assignments. This allowed for the ment and shelter support. EMERGENCY RESPONSE TEXAS A&M ENGINEERING EXTENSION SERVICE/EMERGENCY SERVICES TRAINING Sp ia ized tr Specialized train g can be tailored to meet your needs in: Specialized training Emergency Medical Services Operations NIMS / ICS Exercise / Drills Human Patient Simulator Rescue HazMat Fire WMD US&R Ambulance Strike Team Emergency Operations Training Center Schedule these or any of our 130+ courses today! Choose 33 at www.jems.com/rs WWW.JEMS.COM MARCH 2013 JEMS 43 PHOTO COURTESY BOB KRANE PHOTO COURTESY BOB KRANE A convoy of ambulances from Philadelphia arrive at the N.J. staging area. medevac aircraft to various locations around the state should they be needed. New Jersey Multi-Agency Coordination System (MACS) Plan for EMS: This plan provides a flexible framework for establishing multi-agency coordination of EMS resources to support a large scale incident when a regional emergency situation threatens or significantly impacts multiple jurisdictions. This plan establishes
  • IN THE PATH OF DESTRUCTION >> CONTINUED FROM PAGE 43 Shore towns and urban areas were greatly affected. The urban cities of Jersey City and Hoboken both had their EMS headquarters destroyed by storm surge flooding and 10 ambulances were destroyed. This area had, severe fuel shortages and a population of more than 300,000 desperate people and no power. Dozens of the shore communities within Monmouth, Ocean and Atlantic counties also lost their buildings, ambulances and equipment. Houses lay where roads used to be, and remaining roads were buckled and looked like beaches. Call volume into the dispatch center was extremely high. EMTs and paramedics worked tirelessly throughout the storm with the remaining resources they had, despite, in many cases, losing their own homes and personal property. More than 1,000 mutual aid 9-1-1 missions were coordinated from the Regional EMS Staging Areas, the EMS divisions that were established and the MACS throughout the event. Hoboken EMS was severely impacted by record storm surge tidal flooding. They lost two ambulances, a communications trailer and a special operations truck. PHOTO COURTESY BRIAN DIECK CONTINUITY OF OPERATIONS A Hoboken University Medical Center patient is transported into an ambulance during a mandatory evacuation. The morning after Sandy, the first mutual aid convoy of ambulances is deployed for search and rescue operations along the barrier islands in Ocean County. 44 JEMS MARCH 2013 PHOTO COURTESY INDIANA EMS TASK FORCE Two emergency evacuations of hospitals took place, both in Hudson County, N.J. The night before the storm, Hoboken University Medical Center issued an emergency evacuation order. The Hudson County OEM EMS coordinator Mickey McCabe, with the assistance of the NJEMSTF, mobilized more than 40 ambulances from eight counties, including three medical ambulance buses (MABs) to transport more than 140 patients to other destinations. This was a good decision by hospital administrators, because Hoboken was under water and without power for more than a week. The second hospital evacuation took place at dawn, the morning after Sandy struck. Palisades General Medical Center in North Bergen is located adjacent to the Hudson River; water penetrated their emergency generators and disabled them. Four MABs from the NJEMSTF were deployed to rescue and relocate 83 patients in between tidal cycles. AP PHOTO/JULIO CORTEZ NS HOSPITAL EVACUATIONS
  • PHOTO HENRY P. CORTACANS Five ambulance strike teams assisted in search and rescue operations in Union Beach, which was devastated by the storm. Union Beach and the “Bayshore Region”—the Barrier Islands and Atlantic City—and many more locations received mutual aid ambulance strike teams (ASTs) and other task forces to assist with search and rescue operations. At one point during the storm, Mike Bascom, the Monmouth County OEM EMS coordinator made a request for five ASTs to assist with 500 trapped or missing people in the community of Union Beach. In Ocean County, the EMS coordinator, Steve Brennan, also used numerous strike teams to canvas the barrier islands while more than 20 structure fires burned and smoldered. In Atlantic City, residents were trapped in their homes and apartments because they didn’t heed evacuation recommendations. These and other search and rescue missions went on for days. PHOTO COURTESY ANDY CARUSO SEARCH & RESCUE Off-road, all-wheel drive ambulances from the N.J. EMS Task Force proved effective in navigating difficult terrain in Ocean County. 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 34 at www.jems.com/rs Choose 35 at www.jems.com/rs WWW.JEMS.COM MARCH 2013 JEMS 45
  • IN THE PATH OF DESTRUCTION >> CONTINUED FROM PAGE 45 SPECIALIZED EMS RESOURCES Almost every piece of the 100-plus NJEMSTF apparatus fleet was used in some type of capability in regards to the response to Sandy. We’ll touch on two critical resources: Mobile Satellite Emergency Department (MSED): Through a partnership with Hackensack University Medical Center, the NJEMSTF deployed a “mobile hospital system” four times. The complete MSED system consists of three tractortrailers and several support vehicles, and is equipped to function as a mobile emergency department. Mission 1 was deployed to Somerset County ahead of the storm as a result of lessons learned from Tropical Storm Irene. This area of the state was expected to be cut off significantly from river flooding based on rainfall forecasts. Its mission was to be a temporary field hospital to support area communities until flood waters receded, 46 JEMS MARCH 2013 The N.J. EMS Task Force and Hackensack Medical Center deployed their “mobile hospital system” in Ocean County to decompress swelling area emergency departments. This site treated more than 150 patients in the first few days after the storm. roads were cleared from debris and power was restored. They treated four patients during the three-day deployment, which included the delivery of a healthy baby boy during the height of the storm. Mission 2 was deployed to Ocean County after the storm as a result of a massive surge of patients flooding emergency rooms. The mission was to decompress hospitals by establishing such a facility. Patients were transported via MABs to this temporary location, triaged/treated and discharged or admitted to a fixed facility. Approximately 150 patients were seen over several days. Mission 3 was a “mobile hospital” deployed to Jersey City Medical Center to allow for extra capacity so that the damaged areas of the hospital could be repaired after being surrounded by five feet of water. This mission saw 1,301 patients. Mission 4 was deployed through EMAC to Long Beach, N.Y., in Nassau County at the request of the state of New York. It served as a “mobile hospital” to serve the residents and surrounding communities after Long Beach Medical Center was severely damaged and inoperable as a result of the storm surge flooding. This mission lasted 17 days, and nearly 160 patients were treated. Medical Ambulance Buses (MABs): The NJEMSTF maintains a fleet of 12 MABs. These resources served as “force multipliers” PHOTO COURTESY STATE OF PENNSYLVANIA EMS TASK FORCE Knowing ahead of time that NJEMSTF would be overwhelmed, and following the guidance in the previously mentioned plans, Ken Christensen, the N.J. Department of Health State EMS coordinator activated the EMAC system, the nation’s state-tostate mutual aid system. The initial request was for 75 ambulances to be deployed to N.J. before the storm. Indiana sent the first wave of ambulances. It had to come from that far away initially because Superstorm Sandy was going to potentially impact the entire northeast quadrant of the U.S. A total of 136 ambulances, as well as staff, and support and specialty vehicles, arrived from Indiana, Pennsylvania, Maryland and Vermont. Not only did these teams bring resources, but they brought experienced EMS providers, which was critical to the success of the operation. Dealing with a catastrophe of this type required “relief” and more staff to fill management roles. Additionally, many of these out-of-state professionals filled critical “leadership positions”—from assisting with staging area and camp operations to staffing critical roles at the MACS. The so-called “EMAC ambulances” remained in New Jersey through Nov. 11, 2012—almost two weeks after the storm hit. PHOTO HENRY P. CORTACANS EMERGENCY MANAGEMENT ASSISTANCE COMPACT (EMAC) Superstorm Sandy wrought significant damage to shore communities in Ocean County.
  • LESSONS LEARNED As you would expect with an incident of this size, lessons came through during the event and after evaluation. Incident management assistance should be established early and continue until operations cease. Although New Jersey had an Incident Management Team through an EMAC request, this resource came in several days after the disaster took place. With a catastrophe of this magnitude anticipated, EMS leaders will need additional support for the long-term – especially when the impact is statewide and “all-hands” are continuously operating. Choose 36 at www.jems.com/rs PHOTO HENRY P. CORTACANS when it came to evacuation of healthcare facilities, relocation of non-ambulatory medical needs patients, transport of sick people to the mobile hospital to alleviate the jam-packed emergency rooms, a place to rehab and continued MCI operations. During the storm, 10 of these resources were available, and the MABs transported close to 1,000 people since being were placed in-service. An emotional farewell as Union Beach EMS Chief Carlos Rodriguez (right) thanks Pennsylvania EMS task force leaders for their help during the weeklong operation. The MSED experienced, at times, a shortfall of available physicians. Once again, in a “statewide” disaster, pulling these types of resources from surrounding, nonimpacted states would have solved our manpower shortages. Understand the scope of practice of all response levels and how they will integrate into the existing EMS system. Although the state doesn’t normally recognize EMT-Intermediates, during the disaster the state acknowledged (via the EMAC) that EMT-Intermediates could practice to the level at which they were trained. This created some confusion within our own EMS system at times and was mitigated with a quick explanation explaining what EMT-Intermediates do. Critical incident stress management (CISM) is crucial during and after the event. We believe the integration of CISM is paramount to ensure the mental well-being of responders, especially when they are also personally impacted. Long deployments can stress responders, especially those with personal or family commitments. States sending agencies via an EMAC should ensure that all responders can stay beyond the agreed EMAC request should an extension be granted. This ensures continuity of operations and does not create a hardship for the sending state. Activate the EMAC system early. This was only the second time New Jersey requested out-of-state EMS resources. N.J. learned during Tropical Storm Irene that activating this system early ensures resources are Choose 37 at www.jems.com/rs WWW.JEMS.COM MARCH 2013 JEMS 47
  • IN THE PATH OF DESTRUCTION PHOTO COURTESY CHARLES MONDARO >> CONTINUED FROM PAGE 47 N.J. EMS Task Force medical ambulance buses stand at the ready. These valuable, high-capacity assets were used heavily and transported hundreds of patients. in position and mission ready when you need them. Establish inter-state relationships before a disaster occurs. Knowing who your outof-state partners are ahead of time only enhances the coordinated response when disaster strikes. These previous relationships established can make a big difference. “donated food.” Although intentions from the public are generally good, EMS crews have no way of knowing if donated food was properly stored or contaminated. It’s best to stick with meals, ready to eat (MREs) products or food supplied from trusted sources. Also, maintaining public health and hygiene are important to pre- Anticipate the need to change or waive regulations. The N.J. Department of Health issued two waivers of regulations during the storm. The first waiver was for ALS and permitted mobile intensive care units (MICU) to be staffed by one EMT and one paramedic, instead of the standard staffing protocol, which requires a minimum of two paramedics. The second waiver issued permitted licensed BLS agencies to use one EMT and one first responder as minimum staffing as opposed to two EMTs per regulation. This increased the state’s capabilities during the disaster where resources were limited. Establish a plan; exercise your plan and improve your plan. Every time you exercise or use your plan, you will find ways to enhance or improve it. PLANNING & TEAMWORK Table 1: Superstorm Sandy response by the numbers INCIDENT NUMBER OF OCCURENCES Hospital evacuations 2 State shelter openings 5 Acute care hospitals that lost power 39 Long-term care facility evacuations 16 Healthcare facilities that lost power 196 Healthcare facility resident evacuations More than 1,700 Out-of-state EMAC ambulances supporting N.J. 136 Mutual aid mission assignments More than 1,000 (still evaluating) N.J. EMS headquarter buildings damaged/destroyed 23 Households in N.J. without power during the height of the storm Deaths as a result of Sandy 40 Injuries/illnesses that occurred directly due to Sandy Homes damaged/destroyed Dollars in damages Healthcare facility evacuations should always take place prior to an anticipated disaster. This is especially true for the most vulnerable locations. Carbon monoxide illnesses and fatalities need to be included in the plan. A large amount of carbon monoxide illnesses and fatalities took place after Sandy struck. This was due to the incorrect use of generators and damaged utilities. EMS responders should be equipped with personal carbon monoxide detectors when providing 9-1-1 services to areas that don’t have power. Be careful about what you eat. A number of EMS responders fell ill after eating 48 JEMS MARCH 2013 More than 2.6 million More than 1,000 300,000 $38 billion vent outbreaks, such as norovirus. Fuel shortages in a regional disaster should be anticipated. Have a backup plan with several other potential suppliers should the preferred ones not be able to meet your needs. The lack of widespread power is accompanied by a widespread loss of technology. If your computer email servers and backup systems are all affected, you’ll have to wait until they are restored. Some EMS leaders were without email services for several days. It’s a good plan to use a backup email during disasters, such as Yahoo Mail or Gmail. Both are alternative options because they have redundant systems worldwide. In the end, the New Jersey EMS community and our out-of-state partners pulled off an incredible feat. Sure, there were challenges at times; however, because of all the pre-existing relationships, plans, resources, procedures and people that were in place, it all paid off. Today, New Jersey is not just known for its 127 miles of picturesque shoreline and beaches, but it’s also known for its dedicated and prepared EMTs and paramedics, who went above and beyond the call of duty during the largest EMS response in state history. Henry P. Cortacans, MAS, CEM, NREMT-P, serves as the state planner assigned to the Urban Areas Securities Initiative of the N.J. EMS Task Force. He has been involved in EMS and emergency management for more than 20 years. He holds a master’s degree from Fairleigh Dickinson University specializing in terrorism/securities studies and emergency management administration. He is also a certified emergency manager through the International Association of Emergency Managers. Terry Clancy, PhD, MA, NREMT-P, currently serves as the New Jersey EMS Task Force coordinator overseeing the task force’s day-to-day activities within the Office of EMS. She has more than 20 years of experience in the field of EMS, public health and healthcare initiatives at the local, county and state levels. She is a licensed N.J. Health Officer, holds a Bachelor’s Degree in healthcare administration, a Master of Arts in health education, and a PhD in public health.
  • “Pinnacle is where change is happening ... where change is being defined.” CHIEF BRUCE EVANS Upper Pine River Fire Protection District Bayfield, Colo. TM AUGUST 5–9, 2013 OMNI PLANTATION AMELIA ISLAND A REMARKABLE EVENT FOR EMS LEADERS EXPERIENCE Pinnacle this year and gain not just an understanding of important topics, but critical insight into the trends you need to know about as an EMS leader. For complete program details, faculty information, registration JACKSONVILLE, FL PINNACLE-EMS.COM Copyright © Fitch & Associates discounts and more, visit pinnacle-ems.com or call 816-431-2600 today. Choose 38 at www.jems.com/rs Experience something unique. Experience something inspiring. EXPERIENCE PINNACLE. 49 WWW.JEMS.COM MARCH 2013 JEMS
  • THE PREHOSPITAL CARE RESEARCH FORUM PRESENTS ... Selected abstracts for presentation at the 31st annual EMS Today Conference & Exposition in Washington, D.C., March 5–9, 2013 FOUNDING PARTNERS UCLA Center for Prehospital Care JEMS FRIEND FISDAP DONOR Armstrong Medical AFFILIATES National Association of EMS Educators National Association of EMTs BOARD OF ADVISORS ASSOCIATES Scott Bourn, PhD, RN, NREMT-P Lawrence H. Brown, MPH, TM Megan Corry, MA, EMT-P Edward Dickinson, MD, FACEP, EMT-P William J. Koenig, MD, FACEP Todd F. LeGassick, MPH Gregg Margolis, PhD, NREMT-P David Page, MS, NREMT-P Chris T. Ryther, MS, NREMT-P Paul Bishop, MPA, EMT-P Andrew Stern, MPA, MA, NREMT-P Dwayne Clayden, MEM, BHSc, EMT-P Twink Dalton, RN, MS, CNS, NREMT-P Ronald Stewart, MD Robert A. De Lorenzo, MD, FACEP, MSM Walt Alan Stoy, PhD, EMT-P, CCEMT-P Johathan Studnek, PhD, NREMT-P Robert Delagi, MA, NREMT-P Philip Dickison, MD, NREMT-P, FACEP Mike Taigman, EMT-P Wiliam F. Toon, MEd, NREMT-P Thomas Dunn, PhD, EMT-B Attila Üner, MD, MPH, FAAEM Scott Eamer, BS Donald Walsh, PhD, EMT-P Antonio R. Fernandez, MS, NREMT-P Paul Werfel, NREMT-P , MS Mic Gunderson, EMT-P David M. Williams, PhD Nancy Hays, MPH Christopher Shane Henderson, AS, EMT-P David Hostler, PhD, NREMT-P, CSCS Billy James, PhD, EMT-P Todd LeDuc, MS, CFO, CEM Jeffrey Lindsey, PhD, EMT-P, CFO, EFO Mark Marchetta, BS, RN, NREMT-P Mary Kay Margolis, MHA, MPH Richard Narad, DPA, JD Madeleine O’ Donnell, BNg, BEd, MEd Robert J. Philip, MPH, NREMT-P Louise Reynolds, PhD ADVISOR EMERITUS Marv Birnbaum, MD, PhD Elizabeth Criss, RN, MEd DIRECTOR Baxter Larmon, PhD, MICP EMS RESEARCH FELLOWS Melissa Bentley, BS, NREMT-P Jennifer Purcell, MS, CHES, NREMT-P, CCEMT-P 50 JEMS MARCH 2013
  • Letter to Our Readers T he Prehospital Care Research Forum at UCLA believes that it’s the responsibility of emergency medical professionals worldwide to develop a body of evidence that examines prehospital emergency care. Our mission is to assist, recognize and disseminate prehospital care research conducted at all provider levels. Each year, we acknowledge those authors who have contributed to the science of EMS through the publication of this supplement and their subsequent presentations. As part of our ongoing pledge, the Prehospital Care Research Forum at UCLA continues to educate the medical community through a variety of seminars, lectures and workshops throughout the country. These presentations are designed to demystify the research process and provide participants with the tools to conduct research in their community. I would like to thank our volunteer Board of Advisors and Associates. Without the dedication of these volunteers none of this would be possible. In addition to the hard work of many, many people, much of our success can be attributed to the commitment of several organizations dedicated to research in prehospital care. I would like to acknowledge our Founding Partners: Jems Communications (now known as PennWell Public Safety), Friend: FISDAP and Donor: Armstrong Medical. The generous support of these fine organizations and our affiliation with the National Association of EMS Educators and the National Association of EMTs are what enable the Research Forum to fulfill our mission. The future of EMS depends on the quality and quantity of research we produce. We invite you to take a stand, conduct research in your community and submit it in 2013 for the greater benefit of EMS. Sincerely, Baxter Larmon, PhD, MICP Director, Prehospital Care Research Forum at UCLA TABLE OF CONTENTS 52 Decreasing Mortality of Cryptic Septic Shock in EMS Patients—Oral & Poster; Ryan T. Mayfield, MS, NREMT-P; & Mary Meyers, MHA, EMT-P 52 Probability of ROSC as a Function of Timing of Vasopressor Administration—Oral & Poster; Christopher Johnson, EMT-B; Michael W. Hubble, PhD, NREMT-P; Jamie N. Blackwelder, EMT-B; William P. Bozeman, MD; Kevin T. Collopy, BA, CCEMT-P, FP-C; Sara Houston, BS, EMT-P; Melisa D. Martin, MHS, EMT-P; Delbert S. Wilkes, EMT-P; & Jonina D. Wiser, EMT-B 54 Estimation of Patient Weight and Laryngoscopic Grade of View Achieved By Paramedics Performing Endotracheal Intubation—Poster; Bradley Demeter, MD; Emily Guhl, BA; Peter Lazzara, BS, EMT-P; Leslee Stein-Spencer, RN, MS; James Walter, MD; & Eric Beck, DO, EMT-P 54 Work Exhaustion Associated with Personal and Work-Related Characteristics among NREMTs—Poster; Jennifer Eggerichs, MS, CHES, NREMT-P; & Melissa A. Bentley, MS, NREMT-P 52 The Accuracy of Emergency Medical Dispatcher-Assisted LaypersonCaller Pulse Check Using the Medical Priority Dispatch System Protocol—Oral & Poster; Greg Scott, MBA, EMDQ-I; Jeff Clawson, MD; Mark Rector; Dave Massengale; Mike Thompson; Brett Patterson; & Christopher Olola, HO, PhD 55 Out-of-Hospital Cardiac Arrest in North Carolina: Epidemiology and Patient Factors Associated With Return of Spontaneous Circulation— Poster; Emily Wilikins, EMT-B; Stephen Taylor, BS, EMT-P; Caitlyn Boyles, EMT-B; Doran A. Grossman-Orr, EMT-B; Lennie Cooper, EMT-P; & Michael W. Hubble, PhD, NREMT-P 53 Probability of a Shockable Presenting Rhythm as a Function of EMS Response Time—Oral & Poster; Ginny O’Brien, BS, EMT-P; Michael W. Hubble, PhD, NREMT-P; Daniel R. Wesley, AS, EMT-B; Patricia A. Dorian, EMT-B; Matt J. Losh, EMT-B; Robert Swain, EMT-P; & Stephen Taylor, BS, EMT-P 55 Physiologic and Clinical Management Factors Associated with Patients Experiencing Cardiac Arrest after EMS Contact—Poster; Mark Pinchalk, MS, EMT-P; & Ronald N. Roth, MD 55 53 Estimates of Cost-Effectiveness of a Comprehensive Influenza Vaccination Program for Emergency Medical Services Personnel— Poster; John Deal, BS, NREMT-P, FP-C; Michael W. Hubble, PhD, NREMT-P Short Board MVC Extrications: Current Practices and Opinions of New Hampshire EMS Providers—Poster; Angela Shepard, MD, MPH; & Chief Clay Odell, NRP, RN 56 53 Influence of Vasopressin on Achieving Out-of-Hospital Return of Spontaneous Circulation—Poster; Brittany McCormick, EMT-B; Casey Schmidt, EMT-B; Emily Wilkes, DH, AA, AS, NREMT-P; Kim Woodward, BS, BA, EMT-P; Benjamin Young, EMT-B; Evelyn Wilson, MHS, NREMT-P; Melisa Martin, MHS, EMT-P; & Michael Hubble, PhD, NREMT-P Paramedics’ Perceptions of Mechanical Chest Compression Devices for Use in Adult Out-of-Hospital Cardiac Arrest—Poster; Darren Figgis, MSc, DIMC; Brian Carlin; Dr. Cathal O’Donnell; & Dr. Niamh Cummins 56 Aspirin Administration by Emergency Medical Dispatchers Using a Protocol-Driven Aspirin Diagnostic and Instruction Tool —Poster; Greg Scott, EMD-QI, MBA; Tracey Barron, BSc; Jeff Clawson, MD; Brett Patterson, EMD-I; Ronald Shiner, AAS; Donald Robinson, BCA; Fenella Wrigley, FCEM; James Gummett; & Christopher Olola, PhD WWW.JEMS.COM MARCH 2013 JEMS 51
  • PCRF ABSTRACTS >> CONTINUED FROM PAGE 51 1. Decreasing Mortality of Cryptic Septic Shock in EMS Patients >> By Ryan T. Mayfield, MS, NREMT-P; & Mary Meyers, MHA, EMT-P Introduction: Patients in septic shock have been shown to have a high mortality rate. Patients who fall into the subset of cryptic septic shock—patients with a systolic blood pressure above 90 mmHg but with an elevated blood lactate—are at an even higher risk of mortality. Previous research has shown that EMS treatment can lower blood lactate levels before hospital arrival, but no studies to date have looked at the impact early identification by EMS might have on patient mortality Hypothesis: The mortality rate of patients in cryptic septic shock identified by EMS before hospital arrival will be lower than if it is identified after hospital arrival. Methods: This prospective study was IRB approved and given a waiver of informed consent. In November 2008, about 950 EMTs and paramedics were trained on identifying patients with septic shock and evaluating blood lactate levels. To measure blood lactate levels, the paramedics were provided with the Lactate Pro© blood lactate meter by Arkray Inc. Between May 1, 2009, and Dec. 31, 2011 patients more than 18 years old who were not pregnant with suspected septic shock underwent blood lactate readings by EMS. Septic patients with a lactate reading of ≥ 4.0 mmol/l were considered to be in cryptic septic shock if their corresponding systolic blood pressure was above 90 mmHg. Results: During the study period, 167 patients with cryptic septic shock, confirmed by an emergency department physician diagnosis were transported by EMS. Out of the 167 patients, 82 (49.1%) were identified by EMS before arrival and 9 (0.5%) died in the hospital (Crude OR=0.061, CI 0.024 to 0.140, p=0.001). Of the 85 patients who were not identified, 57 (67.1%) died in the hospital (Crude OR=16.51, CI 6.78 to 41.41, p=0.001). Conclusion: Many studies state the key to surviving septic shock is early identification. In this sample of cryptic septic shock it appears there is an almost 16 times greater chance of survival if patients are identified by EMS before arrival at a hospital. Further studies must be conducted to know if this can be replicated. 2. Probability of ROSC as a Function of Timing of Vasopressor Administration >> By Christopher Johnson, EMT-B; Michael W. Hubble, PhD, NREMT-P; Jamie N. Blackwelder, EMT-B; William P. Bozeman, MD; Kevin T. Collopy, BA, CCEMT-P, FP-C; Sara Houston, BS, EMT-P; Melisa D. Martin, MHS, EMT-P; Delbert S. Wilkes, EMT-P; & Jonina D. Wiser, EMT-B Introduction: Vasopressors (epinephrine and vasopressin) have been associated with return-of-spontaneous circulation (ROSC) but not long-term survival. A recent retrospective study reported a greater likelihood of ROSC when vasopressors were administered within the first 10 minutes of arrest. However, it is unlikely that the relationship between ROSC and the timing of vasopressor administration is a binary function (i.e., <10 vs. >10 minutes). More likely, this relationship is a function of time measured on a continuum, with diminishing effectiveness even within the first 10 minutes of arrest, and potentially, some lingering benefit beyond 10 minutes. However, this relationship remains undefined. 52 JEMS MARCH 2013 Objective: To develop a model describing the likelihood of ROSC as a function of the time interval between call-receipt and first vasopressor administration measured on a continuum. Methods: This retrospective study of cardiac arrest was conducted using the North Carolina Prehospital Care Reporting System (PREMIS). Inclusionary criteria were all adult patients suffering witnessed, non-traumatic arrests between Jan. 1, 2012, and June 30, 2012. Chi-square and t-tests were used to analyze the relationships between ROSC and call receipt-to-vasopressor-interval (CRTVI); patient age, race, and gender; endotracheal intubation; AED use; first presenting cardiac rhythm; and bystander CPR. A multivariate logistic regression model calculated the odds ratio of ROSC as a function of CRTVI while controlling for statistically significant variables from the univariate analyses. Results: Of the 1,150 patients meeting inclusion criteria, 518 (45.0%) experienced ROSC. ROSC was less likely with increasing CRTVI (OR=0.95,p<0.01). Compared to patients with shockable rhythms, patients with asystole (OR=0.36,p<0.01) and PEA (OR=0.57,p<0.01) were less likely to achieve ROSC. Bystander CPR was a predictor of ROSC (OR=2.4,p<0.01), whereas race, age and AED were not. Conclusion: The study found that time to vasopressor administration is significantly associated with ROSC, and that for every one-minute delay between call-receipt and vasopressor administration, the odds of ROSC declined by 5%. Similar to previous studies, the study observed an increased likelihood of ROSC among patients presenting with shockable rhythms and receiving bystander CPR. These results support the notion of a time-dependent function of vasopressor effectiveness across the entire range of administration delays rather than just the first 10 minutes. 3. The Accuracy of Emergency Medical Dispatcher-Assisted Layperson-Caller Pulse Check Using the Medical Priority Dispatch System Protocol >> By Greg Scott, MBA, EMDQ-I; Jeff Clawson, MD; Mark Rector; Dave Massengale; Mike Thompson; Brett Patterson; & Christopher Olola, HO, PhD Introduction: Knowing the pulse rate of a patient in a medical emergency can help determine patient acuity and the level of medical care required. Little evidence exists regarding the ability of a layperson 9-1-1 caller to accurately determine a conscious patient’s pulse rate. Hypothesis: When instructed by a trained emergency medical dispatcher (EMD) using the scripted Medical Priority Dispatch System protocol Pulse Check Diagnostic Tool, a layperson-caller can detect a carotid pulse and accurately determine the pulse rate in a conscious person. Methods: This nonrandomized and noncontrolled prospective study was conducted at three different public locations in the state of Utah. A healthy, mock patient’s pulse rate was obtained using an electrocardiogram monitor. Laypeople initiated a simulated 9-1-1 phone call to an EMD call-taker who provided instructions for determining the pulse rate of the patient. Layperson accuracy was assessed using correlations between the layperson’s finding and the ECG reading. Results: Two hundred sixty-eight laypeople participated; 248
  • (92.5%) found the pulse of the mock patient. There was a high correlation between pulse rates obtained using the ECG monitor and those found by the laypeople , overall (94.6%, P<.001), and by site, gender, and age. Conclusions: Laypeople, when provided with expert, scripted instructions from a trained 9-1-1 dispatcher over the phone, can accurately determine the pulse rate of a conscious and healthy person. Improvements to the 9-1-1 instructions may further increase layperson accuracy. 4. Probability of a Shockable Presenting Rhythm as a Function of EMS Response Time >> By Ginny O’Brien, BS, EMT-P; Michael W. Hubble, PhD, NREMT-P; Daniel R. Wesley, AS, EMT-B; Patricia A. Dorian, EMT-B; Matt J. Losh, EMT-B; Robert Swain, EMT-P; & Stephen Taylor, BS, EMT-P Introduction: Survival from cardiac arrest is associated with having a shockable presenting rhythm (VF/pulseless VT) on EMS arrival. A concern is that several studies have reported a decline in the incidence of SPR over the past few decades. One plausible explanation is that contemporary cardiovascular therapies, such as increased use of statin and beta blocker drugs, may shorten the duration of VF/VT after arrest. As a result, EMS response time would become an increasingly important factor in the likelihood of a shockable presenting rhythm, and consequently, cardiac arrest survival. Objective: To develop a model describing the likelihood of shockable presenting rhythm as a function of EMS response time. Methods: This study conducted a retrospective observational study of cardiac arrest using the North Carolina Prehospital Care Reporting System (PREMIS). Inclusionary criteria consisted of all adult patients suffering nontraumatic cardiac arrest witnessed by a layperson between Jan. 1, 2012, and June 30, 2012. Patients defibrillated before EMS arrival were excluded. Chi-square and t-tests were used to analyze the relationship between shockable presenting rhythm and patient age, gender and race; response time measured as elapsed minutes between 9-1-1 call receipt and scene arrival and the presence of bystander CPR. A multivariate logistic regression model was used to calculate the odds ratio of a shockable presenting rhythm as a function of response time while controlling for statistically significant variables identified by the univariate analyses. Due to the risk of bias from small sample sizes, all response time categories with less than five patients were excluded. Results: A total of 563 patients met inclusion criteria. Overall, a shockable presenting rhythm was observed in 159 patients (28.2%). A shockable presenting rhythm was less likely with increasing EMS response time (OR=0.92,p<0.01) and age (OR= 0.98,p<0.01), while males were more likely to have a shockable presenting rhythm (OR=1.87,p<0.01). Race and bystander CPR were not associated with a shockable presenting rhythm, although EMS response time was longer among patients with bystander CPR compared to those without bystander CPR (9.83 vs. 8.83 minutes, p<0.01). Conclusions: This study found that for every 1 minute of added ambulance response time, the odds of a shockable presenting rhythm declined by 8%. This information could prove useful for EMS managers tasked with developing EMS system response strategies for cardiac arrest management. 5. Estimates of Cost-Effectiveness of a Comprehensive Influenza Vaccination Program for Emergency Medical Services Personnel >> By John Deal, BS, NREMT-P, FP-C; Michael W. Hubble, PhD, NREMT-P Introduction: Because of their frequent contact with vulnerable patients, vaccination against influenza is recommended for all health care workers. Vaccination has been shown to decrease influenza transmission to patients as well as reduce worker illness and absenteeism. However, the vaccination rate among EMS workers remains low and most EMS agencies are reluctant to mandate vaccination because of the unknown economic consequences of mandatory, employer-provided vaccination programs. Objective: To estimate the cost-effectiveness of a mandatory, employer-provided influenza vaccination program for EMS personnel. Methods: Using estimates from published reports on influenza vaccination, a cost-effectiveness model of an employer-provided vaccination program in an urban EMS system of 100 employees was developed from the perspective of the EMS employer. Model inputs included vaccination costs, vaccination rate, infection rate, and costs associated with absenteeism, lost productivity due to working while ill (presenteeism), and medical care for treating illness (medical office visits and prescription drugs). To assess the robustness of the model, a series of univariate and multivariate sensitivity analyses were performed on the input variables. Results: In the base case scenario, the proportion of employees contracting influenza or influenza-like illness was estimated to be 19% (19) among vaccinated employees compared to 26% among nonvaccinated employees. The costs of vaccine, consumables and employee time for vaccination totaled $40.86 per vaccinated employee. For a theoretical EMS system of 100 employees, the cost of mandatory vaccination was estimated to be $4,086. Compared to no vaccination, a mandatory vaccination program would save $20,122 (or $16,036 in net savings). The total savings were 4.9 times the cost of the vaccination program as derived from avoided absenteeism ($7,241), avoided presenteeism ($10,963), and avoided medical costs of treating influenza/influenza-like illness ($1,918). Through sensitivity analyses the model was verified to be robust across a wide range of input variable assumptions. The net monetary benefits were positive across all ranges of input assumptions, but cost savings were most sensitive to the vaccination uptake rate. Conclusions: This cost-benefit analysis suggests that an employerprovided influenza vaccination program is a cost-effective strategy for reducing EMS employee absenteeism, presenteeism, and influenza/influenza-like illnesss health care costs. 6. Influence of Vasopressin on Achieving Out-of-Hospital Return of Spontaneous Circulation >> By Brittany McCormick, EMT-B; Casey Schmidt, EMT-B; Emily Wilkes, DH, AA, AS, NREMT-P; Kim Woodward, BS, BA, EMT-P; Benjamin Young, EMT-B; Evelyn Wilson, MHS, NREMT-P; Melisa Martin, MHS, EMT-P; & Michael Hubble, PhD, NREMT-P Introduction: Epinephrine has been used since 1906 in the treatment of cardiac arrest. However, recent clinical trials have not been able to demonstrate a clear benefit compared to a placebo. More WWW.JEMS.COM MARCH 2013 JEMS 53
  • PCRF ABSTRACTS >> CONTINUED FROM PAGE 53 recently, vasopressin has been suggested as an alternative to epinephrine. However, previous investigations of vasopressin have provided mixed and inconclusive results when compared to epinephrine. Objective: To compare the rate of return of spontaneous circulation (ROSC) between patients receiving vasopressin plus epinephrine vs. epinephrine alone in out-of-hospital cardiac arrest. Methods: This study conducted a retrospective observational study of cardiac arrest using the North Carolina Prehospital Care Reporting System (PREMIS), a statewide EMS patient database. Inclusionary criteria consisted of all adult patients suffering nontraumatic cardiac arrests in North Carolina between Jan. 1, 2012, and June 30, 2012, who received at least one dose of vasopressin and/or epinephrine. Chi-square and t-tests were used to analyze the relationship between ROSC and vasopressin use; patient age, gender, and race; witnessed arrest; EMS response time; shockable presenting rhythm; endotracheal intubation; and the presence of bystander CPR. A multivariate logistic regression model was used to calculate the odds ratio of ROSC as a function of vasopressin use while controlling for statistically significant variables identified by the univariate analyses. Results: A total of 1,831 patients met the inclusion criteria, of which 19.6% (359) received vasopressin. Overall, 28.2% (516) achieved ROSC. Vasopressin was not associated with increased rate of ROSC (OR1.0,p=0.74). ROSC was more likely among females (OR=1.3,p=0.01), witnessed arrests (OR=1.6,p<0.01), and shockable presenting rhythm (OR1.9,p<0.01), endotracheal intubation (OR=0.5,p<0.01) and bystander CPR (OR=0.6,p<0.01) were negatively associated with ROSC, although EMS response time was longer among patients with bystander CPR compared to those without (10.5 vs. 8.7 minutes, p<0.01). Conclusion: In this statewide, retrospective analysis, vasopressin made no difference in the rate of ROSC compared to epinephrine alone. 7. Estimation of Patient Weight and Laryngoscopic Grade of View Achieved By Paramedics Performing Endotracheal Intubation >> By Bradley Demeter, MD; Emily Guhl, BA; Peter Lazzara, BS, EMT-P; Leslee Stein-Spencer, RN, MS; James Walter, MD; & Eric Beck, DO, EMT-P Introduction: Field intubations are frequently complicated by challenging patients, austere environments and limited equipment, although as with hospital intubations, safe and expeditious airway management is expected. A common metric in the literature for such a standard is the “first pass” success rate. Objective: To identify demographic, environmental and technical variables that might predict first-pass success of field endotracheal intubation Method: This study retrospectively reviewed 137 field intubations reported by paramedics in a large, urban, fire-based EMS system for variables that might predict first pass success, including a provider’s estimation of patient weight and a novel data point in the literature on prehospital airway management: the CormackLehane laryngoscopic grade of view. Results: The maximal grade of view achieved on first attempt was significantly greater in cases of first pass success compared 54 JEMS MARCH 2013 to intubation that required a second attempt (C-L Grade 1.41±0.6 v. 3.47±0.7, p<0.01). The care providers’ estimation of patient weight also correlated with first pass success (mean 82.1±31.3kg v. 97±34.9, p=0.05). There was a stepwise progression in mean weight from an unimpeded view of the glottic opening (C-L Grade 1, 79.7±32.1kg, n=69); to visualization of some of the vocal cords (C-L Grade 2, 82.2±21, n=29); to visualization of only the epiglottis (C-L Grade 3, 89.9±40.5; n=14; to inability to visualize either the glottis or epiglottis (C-L Grade 4, 102±30.2, n=11). Conclusion: These data suggest that an estimation of patient weight might correlate with airway difficulty, as increases in weight appear to predict less favorable views of the glottis during direct laryngoscopy and correspond with lower rates of first pass success. 8. Work Exhaustion Associated with Personal and WorkRelated Characteristics among NREMTs >> By Jennifer Eggerichs, MS, CHES, NREMT-P; & Melissa A. Bentley, MS, NREMT-P Introduction: Work exhaustion is the depletion of emotional and mental energy needed to meet job demands, and the impact of work exhaustion in EMS is a growing concern. The objectives of this study were to characterize work exhaustion in a cohort of nationally certified EMS professionals and to determine if work exhaustion was associated with personal and work-related characteristics among nationally certified EMS professionals. Hypothesis: There are personal and work-related characteristics associated with work exhaustion among EMS professionals. Methods: In 2010, a questionnaire was sent to all nationally certified EMS professionals eligible for recertification. A 3-item work exhaustion scale was used to assess work exhaustion (Strongly Agree=1 to Strongly Disagree=6). A summation of all three items divided by three was used to compute the outcome variable. This questionnaire also contained previously validated demographic and work-life characteristics. Multivariable linear regression modeling was used to test the study hypothesis (á=0.05). Results: A total of 24,586 (33.9%) people completed the questionnaire. The majority of respondents were EMT-Basics (50.9%; 12,514), male (73.3%; 18,021) and had an average age of 40 (SD=10.5). Respondents reported high disagreement of work exhaustion (mean=5.28, SD=0.93). Statically significant predictors of work exhaustion included highest level of education completed (high school diploma/GED â=1; some college â= -0.006, SE=0.02; Associates or Bachelors â=-0.053, SE=0.02; Graduate Degree â=-0.057, SE=0.03); excellent overall health (agree â=1; disagree â=-.127, SE=0.03); excellent overall physical fitness (agree â=1; disagree â=-.388, SE=0.02); years of experience (less than 1 year â=1; 1-4 years â=-0.041, SE=0.19; 5-10 years â=-0.198, SE=0.19; 11-20 years â=-0.346, SE=0.19; 21 or more years â=-0.458, SE=0.19); volunteering (yes â=1; no â=0.039, SE=0.01); and job satisfaction (agree â=1; disagree â=-1.385, SE=0.03). The overall model fit was R2=0.195. Conclusion: This is the first study that has assessed work exhaustion in EMS professionals. As years of experience increased and job satisfaction decreased, work exhaustion increased in this population. Likewise, those people who did not volunteer
  • reported less work exhaustion. Key EMS stakeholders should focus attention on these predictors to monitor those people at a higher risk of work exhaustion. 9. Out-of-Hospital Cardiac Arrest in North Carolina: Epidemiology and patient factors associated with return of spontaneous circulation >> By Emily Wilikins, EMT-B; Stephen Taylor, BS, EMT-P; Caitlyn Boyles, EMT-B; Doran A Grossman-Orr, EMT-B; Lennie Cooper, EMT-P; & Michael W. Hubble, PhD, NREMT-P Introduction: Although the epidemiology and outcome of outof-hospital cardiac arrest are known to vary geographically, published descriptions of out-of-hospital cardiac arrest are limited to those of EMS systems in urbanized areas. Larger-scale studies are needed to better describe the epidemiology of out-of-hospital cardiac arrest and factors associated with return of spontaneous circulation (ROSC) in nonurban areas. Objective: To perform a statewide, population-based, retrospective study of the epidemiology of out-of-hospital cardiac arrest and patient factors associated with ROSC. Methods: The PREMIS system, a comprehensive and mandated data collection system for all North Carolina EMS systems, was queried for out-of-hospital cardiac arrest occurring between Jan. 1, 2012, and June 30, 2012. Descriptive statistics, Chi-square and t-tests were used to summarize the epidemiology of out-of-hospital cardiac arrest. Results: During the study period, North Carolina EMS agencies responded to 4,111 out-of-hospital cardiac arrests, of which 5.6% (230) were of traumatic origin, 39.1% (1,607) were female patients, and 3.8% (156) were pediatric patients (<18 years). Arrests were witnessed by laypeople in 49.4% (2,030) of cases, 18.0% (740) presented with a shockable rhythm on EMS arrival, and 44.7% (1,838) achieved ROSC. Males were more likely to present with a shockable rhythm (21.2% vs. 13.1%, p<0.01) and more likely to experience a traumatic arrest (7.3% vs. 3.1%, p<0.01). Those with ROSC were more likely to be female (47.7% vs. 42.6%, p<0.01), present with a shockable rhythm (62.4% vs. 41.9%, p<0.01), have a witnessed arrest (50.3% vs. 41.6%, p<0.01), and experience a nontraumatic arrest (48.0% vs. 29.2%, p<0.01). There was no difference in age (61.9 vs. 60.7 years, p=0.10) or EMS response time (10.4 vs. 10.0 minutes, p=0.14) between patients with and without ROSC. Conclusion: Compared to reports from mostly urbanized EMS systems, out-of-hospital cardiac arrest s in North Carolina were similar in terms of age, gender, cause of arrest, frequency of witnessed arrest, and rate of ROSC, while EMS response times were comparatively longer and fewer patients presented with a shockable rhythm. Patient factors associated with ROSC included being female, witnessed arrest, nontraumatic arrest, and shockable presenting rhythm. These findings describe out-of-hospital cardiac arrests in North Carolina which includes a mixture of urban, suburban and rural areas and offers a broader depiction of OHCA than some other studies. 10. Physiologic and Clinical Management Factors Associated with Patients Experiencing Cardiac Arrest after EMS Contact >> By Mark Pinchalk, MS, EMT-P; & Ronald N. Roth, MD Hypothesis: Cardiac arrest occurring in prehospital patients after EMS contact is associated with measurable physiological deraignment and the failure of EMS providers to provide key prehospital interventions. Methods: Retrospective chart review in a single urban ALS EMS system of medical patients who experienced a cardiac arrest after EMS contact and on whom an advanced airway (endotracheal intubation or King Airway) was attempted. Trauma cases were excluded. This was a retrospective chart review that only included cases in which advanced airway placement was attempted. Results: Forty-four cases were identified from Jan, 1, 2010, to Sept. 30, 2012. The mean time from EMS contact to the patient arresting was 15.8 +/- 7.8 minutes. The mean Glasgow Coma Score was 10.1 +/- 5.0. The ECG was abnormal (tachycardia or bradycardia) 50% (22/44) of the time. In all, 57.7% (15/26) of patients had an initial SpO2 of < 90% and 44.8% (13/29) were hypotensive with a systolic blood pressure of < 90. For clinical management, 75.0% (33) of the patients were moved to the ambulance before the arrest. Of the patients, 72.7% (32) were documented to have been placed on oxygen; 26.3% (5/19) of patients with respiratory complaints were placed in CPAP; 40.9% (18) received positive pressure ventilation via bag valve mask (BVM); 25.0% (11) of patients had a successful IV or IO line placed; 46.2% (6/13) of hypotensive patients received an fluid bolus; and 31.6% (6/19) of respiratory patients received a respiratory medication. Conclusion: Altered mental status, hypoxia, initial tachycardia or bradycardia, and hypotension appear to be physiological findings associated with cardiac arrest after EMS patient contact. Early movement of the patient to the ambulance; failure to manage respiratory problems with CPAP or BVM ventilation; failure to obtain IV access; and failure to administer fluids for hypotension appear to be clinical management issues associated with cardiac arrest after EMS contact. An educational program targeted to early identification of dangerous physiological findings and critical clinical early interventions might improve patient outcomes. 11. Short Board MVC Extrications: Current Practices and Opinions of New Hampshire EMS Providers >> By Angela Shepard, MD, MPH; & Chief Clay Odell, NRP, RN Introduction: Many currently accepted practices in EMS are supported only by historical practice or professional consensus. Spinal immobilization is one area in which long-held beliefs are being called into question. Anecdotal evidence implies that short board devices are used less frequently than EMS training programs teach and many protocols direct. To assess practice patterns and opinions in New Hampshire, the New Hamphsire Bureau of EMS surveyed providers about their use of short boards during motor vehicle collision extrications. Methods: A short survey was distributed at two regional EMS conferences and a required EMS instructor training. Participation was voluntary and anonymous. Results: Two hundred and three completed surveys were returned. Most providers reported using short boards infrequently during MVC extrications that met standard criteria for short board use. Of WWW.JEMS.COM MARCH 2013 JEMS 55
  • PCRF ABSTRACTS >> CONTINUED FROM PAGE 55 respondents who reported a short board usage rate, 62.6% (127) of the responses were for rates of 25% or lower. In fact the most frequently chosen response, selected by 45.8% (93) of respondents, was 0 to 5%. Only 14.3% (29) of respondents reported using a short board 95 to 100% of the time. While 78.8% (160) of respondents were “very confident” in their ability to apply a short board during extrication, their confidence in the device itself was significantly lower. Only 23.6% (48) of respondents indicated they were “very confident” the device effectively immobilized the spine during extrication. One hundred and four respondents (51.2%) chose to write comments. Most frequent comments included: time consuming, difficult to apply in many cars, and application increases movement of patient. Many respondents questioned the value in MVCs noting the lack of evidence to support its use or preferring to use only c-collar and manual stabilization. Nine respondents voiced strong support for short board usage in MVC extrications. Conclusion: Short board usage for MVC extrication is low among New Hampshire EMS providers responding to our survey. Providers feel confident in their ability to apply the device but are unsure it provides effective spinal protection during extrication. Additional study of short board devices is recommended to determine the clinical relevance of this practice. 12. Paramedics’ Perceptions of Mechanical Chest Compression Devices for Use in Adult Out-of-Hospital Cardiac Arrest >> By Darren Figgis, MSc, DIMC; Brian Carlin; Dr. Cathal O’Donnell; & Dr. Niamh Cummins The HSE National Ambulance Service (NAS) attends approximately 1,700 out-of-hospital cardiac arrests annually. Several devices for performing mechanical chest compressions (m-CPR) are being evaluated for possible future use. The opinion of paramedics regarding which device is most suited to their use has not yet been elicited. Objective: This study was designed to ascertain paramedics’ perceptions of, and experience with, three m-CPR devices currently being used in Ireland. Methods: Twenty-five members of the NAS participated in this study. Following a standardized instruction interval (video observation) in device assembly and application, subjects were asked to initiate mechanical chest compressions on the simulated victim (manikin) of out-of-hospital cardiac arrests (manikin). Assembly time was recorded using a stopwatch. Participants were then asked to complete a questionnaire regarding their experiences using each of the devices. Results: Of the 25 participants (84% male), 40.0% (10) had no prior experience using any m-CPR device. 16.0% (4) reported previous clinical experience using the AutoPulse, 24% (6) reported having used the Life-Stat, and 12.0% (3) reported having used a version of the LUCAS device in clinical practice. More participants reported feeling either “comfortable” or “very comfortable” using the LUCAS2 (92.0%; 23), than either the AutoPulse (88.0%; 22) or the Life-Stat (72.0%; 18). Subjects reported the LUCAS2 device as being more portable (ease of carry), and easier to assemble and position on the manikin. 56 JEMS MARCH 2013 Overall, 20.0% (5) rated their first preference for the AutoPulse, 12.0% (3) preferred the Life-Stat and 68.0% (17) preferred the LUCAS2 for use in their clinical work environment. However, more subjects required assistance with setting-up the LUCAS2 device (36.0%; 9) than either the Life-Stat (2.04%; 6) or the AutoPulse (20.0%; 5). Conclusion: The LUCAS2 m-CPR device was chosen by NAS personnel as being easier to use in an EMS ambulance setting. However, more participants required assistance initiating mechanical chest compressions using this device than the others. The LUCAS2 also appears to have more consistent depth and rate of compressions in accordance with current international guidelines for provision of CPR. 13. Aspirin Administration by Emergency Medical Dispatchers Using a Protocol-Driven Aspirin Diagnostic and Instruction Tool >> By Greg Scott, EMD-QI, MBA; Tracey Barron, BSc; Jeff Clawson, MD; Brett Patterson, EMD-I,; Ronald Shiner, AAS; Donald Robinson, BCA; Fenella Wrigley, FCEM; James Gummett; & Christopher Olola, PhD Introduction: The American College of Cardiology and the American Heart Association recommend early aspirin administration to patients with symptoms of acute coronary syndrome (ACS)/acute myocardial infarction (AMI). The primary objective of this study was to determine if emergency medical dispatchers (EMDs) can provide chest pain/heart attack patients with standardized instructions effectively, using an Aspirin Diagnostic and Instruction Tool (ADxT) within the Medical Priority Dispatch System before arrival of an emergency response crew. Methods: This retrospective study involved three dispatch centers in the United Kingdom and the United States. Six months of data were analyzed involving chest pain/heart attack symptoms taken using the MPDS Chest Pain and Heart Problems/Automated Internal Cardiac Defibrillator Protocols. Results: The EMDs successfully completed the ADxT on 69.8% (30,810) of the 44,141 cases analyzed. The patient’s mean age was higher when the ADxT was completed, than when it was not (mean ±standard deviation (SD): 53.9±19.9 and 49.9±20.2; p<0.001, respectively). The ADxT completion rate was higher for second-party, than first-party calls (70.3% and 69.0%; p=0.024, respectively). A higher percentage of male patients took aspirin (91.3% and 88.9%; p=0.001). Patients who took aspirin were significantly younger than those who did not (mean±SD: 61.8±17.5 and 64.7±17.9, respectively). Unavailability of aspirin was the major reason (44.4%; 19,598) why eligible patients did not take aspirin when advised. Conclusions: EMDs, using a standardized protocol, can enable early aspirin therapy to treat potential ACS/AMI prior to responders’ arrival. Further research is required to assess reasons for not using the protocol and the significance of the various associations discovered. Call for Abstracts 2013: www.pcrf.mednet.ucla.edu
  • “ “ “The workshops and interaction with peers and other first responders ensures that all my operations keep current with local/state and federal requirements. Vendor exhibits are also a great way to view and operate both current and new equipment needed for the job.” - Stephen Larison, Chief Fire and Emergency Service United States Air Force What You Hear is True. Attendees can’t stop talking about Fire-Rescue Med. And can you blame them? Fire-Rescue Med ofers outstanding education and networking events and an exhibit hall with the newest and technology and products. www.iafc.org/frm 2013 ®
  • MISSION: LIFELINE WILL INCORPORATE EMS RECOGNITION RECOG IN STEMI & CARDIAC RESUSCITATION SYSTEMS OF CARE >> BY CHRIS BJERKE, MBA, BSN; GARY WINGROVE, EMT-P; FRANKLIN PRATT, MD; J. LEE GARVEY, MD; & A. GRAY ELLRODT, MD A s you may have read in the October JEMS sponsored article, “Accelerated Success: Mission Lifeline program dedicated to tracking STEMI treatment,” Mission: Lifeline is an American Heart Association (AHA) program that focuses on improving systems of care for ST-segment elevation myocardial infarction (STEMI) and out-of-hospital cardiac arrest treatment. The program, which was initially developed in 2007 to improve care by reducing the barriers that existed in STEMI treatment. The focus on out-of-hospital cardiac arrest systems of care was added in April 2012. The Mission: Lifeline process begins with the initial identification of symptom onset, which may occur with a STEMI patient experiencing chest pain or, in the case of cardiac arrest, the recognition by a family member or a bystander that a patient is unconscious and not breathing. Mission: Lifeline then lays out critical elements for ideal patient care at each stage, from prehospital EMS to referral centers to receiving centers. The program also focuses on community involvement, with the goal of training more than 50% of the public in being able to initiate CPR. Thus, the system of care begins with the community (bystander CPR), then moves to EMS and the hospital, and finally returns to the community as the patient is discharged. For more about the science behind this program, read “Accelerated Success: Mission Lifeline program dedicated to tracking STEMI treatment” on p. 51 of October JEMS. IDEAL SYSTEM ELEMENTS What are the elements that make up an “ideal” system of care? Mission: Lifeline focuses on the importance of data collection, quality improvement and feedback mechanisms to all parties involved in caring for the STEMI and cardiac resuscitation patient. The program uses the ACTION RegistryGet with the Guidelines (GWTG) data registry. The next version (2.4) of the registry will incorporate more prehospital data elements 58 JEMS MARCH 2013 that can be collected and reported. Mission: Lifeline Receiving Center reports are available for receiving centers that are percutaneous coronary intervention-capable and provide aggregate-level data on time metrics and quality outcomes for STEMI patients. The Mission: Lifeline regional reports provide aggregate data on specified regional hospital data, allowing hospitals to compare their performance against other hospitals in their region. These reports are available quarterly to all hospitals that are contracted with ACTION Registry-GWTG and registered with Mission: Lifeline. In addition, Mission: Lifeline hospital recognition was launched in 2009 to recognize hospitals that meet evidence-based recommendations in the treatment of STEMI care. The recognition program has grown since its beginning and this past year awarded 226 hospitals for meeting achievement criteria. RECOGNIZING EMS The next obvious step in the evolution of the acknowledge program is to recognize the medical professionals who are the first point of contact in the continuum of care—EMTs and paramedics. Today’s prehospital professionals follow evidence-based guidelines in the treatment of heart attacks and are now equipped to interpret ECG results for STEMI. This allows for early alerts to hospitals. The public should be educated that EMS is far from simply a transport method; but rather can shave precious minutes off life-saving treatment time by activating the emergency response system. Accordingly, the Mission: Lifeline program is pleased to announce the development of such a recognition program for EMS. This initiative will focus on three important “achievement measures.” EMS providers must perform these measures at least 85% of the time to qualify for recognition. No one measure can drop below 75%, and the three measures must equal an 85% composite score. An agency must achieve all three measures to be eligible for achievement. This is an annual recognition that will be made available in 2014, using self-reported data. The three measures are: 1. Percentage of patients who are older than 35 years who present with nontraumatic chest pain and for whom EMS obtains prehospital 12-lead ECGs; 2. Percentage of STEMI patients with first prehospital medical contact-to-balloon-inflation of first device used time within 90 minutes; and 3. Percentage of STEMI patients taken to a referral hospital that administers fibrinolytic therapy with a door-to-needle time within 30 minutes. The recognition program committee will begin reviewing 2013 data in February 2014. The following are the designated recognition levels : >> Bronze: One quarter; >> Silver: Four quarters; and >> Gold: Eight quarters. (The first will be awarded in 2015.) MORE TO COME We hope this recognition will highlight the essential role of the EMS community in improving survival and life quality for patients with the extreme manifestations of heart disease. Additional information will be announced on the Mission: Lifeline website, www.heart.org/missionlifeline and Facebook page, www.facebook.com/ AHAMissionLifeline. Chris Bjerke, MBA, BSN, is the national director for the American Heart Association. Gary Wingrove, EMT-P, is with Gold Cross/Mayo Clinic Medical Transport in Minnesota. Franklin Pratt, MD, is medical director for the Los Angeles County Fire Department. J. Lee Garvey, MD, is medical director for the Chest Pain Evaluation Center at Carolinas Medical Center, N.C. A. Gray Ellrodt, MD, is chief of medicine of cardiology for Berkshire Medical Center at the University of Massachusetts Medical School. PHOTO ACILO/ISTOCKPHOTO.COM Expanding the Mission
  • Improve your patient care skills NAEMT courses provide high quality, cost effective, evidence-based education to help you better care for your patients. Sign up today to take a PHTLS, AMLS, EPC, TCCC or EMS Safety course. All courses are CECBEMS accredited and meet NREMT recertification requirements. Learn more at www.naemt.org. Serving our nation’s EMS practitioners Choose 39 at www.jems.com/rs Choose 40 at www.jems.com/rs EMS Recruiting Just Got a Lot Easier. HR/RECRUITING TEAM: JEMS.com is a great source for EMS recruitment! JEMS.com EMS Jobs can help you fill your open positions faster and more cost-effectively than other recruiting methods. Post your job opportunity to thousands of qualified EMS professionals and begin finding the qualified candidates you need … immediately! It’s easy to fill out the online form and submit your opening. The job will post within 24 hours of submission and then you can begin your screening process. Interested in making your job listing stand out? Upgrade your Basic Job Listing to a Featured Job Listing where it will be posted at the top of the EMS Jobs page as well as highlighted in rotation throughout JEMS.com. In addition, your listing will be featured in the JEMS.com eNewsletter (sent to over 49,000* EMS professionals). *January 2013: Publisher’s Data For more information, please go to www.jems.com/ems-jobs/post-job WWW.JEMS.COM MARCH 2013 JEMS 59
  • PHOTOS COURTESY LONDON AMBULANCE SERVICE EMS planning started the day London won the Olympics bid. 60 JEMS MARCH 2013
  • Duty Station Officer Ken Randall as venue commander. HOW LONDON AMBULANCE SERVICE SUCCESSFULLY HANDLED THEIR ‘SUMMER OF SPORT’ >> BY JASON KILLENS, MSTJ, JP EMS providers responded to some calls on special bicycles. WWW.JEMS.COM MARCH 2013 JEMS 61
  • PLANNING LIKE AN OLYMPIAN >> CONTINUED FROM PAGE 61 P lanning for the London 2012 Olympic and Paralympic Games began on the day it was announced that London would host the Games. That day was July 6, 2005, and as Trafalgar Square and towns and cities around the United Kingdom erupted with joy when the words “the Games of the 30th Olympiad in 2012 are awarded to the city of London” rang out around the world from Singapore. Those of us in London Ambulance Service (LAS) operations had a different reaction. We took a deep breath and said to ourselves that we had a massive task to deliver on. But the following day, London was thrown into chaos as suicide bombers targeted the underground subway system at the height of the morning rush hour. Fifty-two people lost their lives in what was to aid planning. Equally there were many new organizations that we needed to develop relationships with. One of these was the London Organising Committee of the Olympic Games (LOCOG). Specifically with LOCOG, a full-time senior operational manager from LAS was seconded into the organization to aid planning and share experiences. Although London Ambulance Service has experience in planning for sporting and cultural events on a massive scale, its administrators had never planned for multiple venues working simultaneously across the city over a protracted period whilst the eyes of the world were on us. We learned from previous host cities about the nature, type and number of patients who may be seen. We also learned some of the more operational issues around accreditation and the “post EMS held a pre-planned aid arrival briefing at Goldsmiths College in London. the first multi-sited and simultaneous use of suicide bombers as a weapon of terror in the UK. The London Ambulance Service would later be subject to intense scrutiny of its response to the bombings but would draw lessons from that day that enhanced our capability across the Olympic and Paralympic period. OBSERVATIONAL LEARNING A planning team of six was established in 2007. It was tasked with working full-time across many partner organizations to scope and understand the scale and complexity of the Games. We worked with existing agencies and were able to use relationships that had been developed over many years Choose 41 at www.jems.com/rs 62 JEMS MARCH 2013 Games effect.” Members of the planning team, which sought to learn lessons from previous host cities, travelled to Beijing for the 2008 Olympic and Paralympic Games as well as other major sporting events. The single biggest lesson learned from other host cities and those that had hosted such events as the Pan American and Commonwealth Games was this, “Don’t leave planning until the Games are upon you and resource the planning team to be able to respond to the demands placed upon it.” RIGOROUS TESTING Our planning team worked full-time for five years to prepare LAS to respond to the
  • increased call volume received during the Games. In the six to 12 months leading up to the games they gained support from the Games Time Command Team of senior officers on a half-time basis. These additional officers bought the total planning team to 12 from 2011–2012. Testing for the Games began years before the opening ceremony and involved command post, table top and live play exercises. The program culminated with three sets of live sporting events in Olympic venues London on a back street industrial park. It was located immediately across the Thames River from the Millennium Dome—now renamed the O2 Arena. We had a vision for the ODC. We wanted to transform it into a flagship, albeit a temporary one, for the Games. It would be open 24 hours a day, and be the center for EMS response. All ambulance service staff being deployed to Games venues and cultural events would be mustered, briefed, fed and deployed from the ODC. The building was a shell and after a bit of cleaning we installed temporary catering facilities along with showers, toilets, lockers, briefing rooms, a canteen, internet café plus a vehicle preparation and equipping area. The ODC became a working super-station for the Olympics and was one of the key success stories of the Games for us. Our dedicated OECR, which was built in 2008, was open 24 hours a day during the Games. It was where we managed deployments and responses in each of the four Games delivery zones. The 36 position Prehospital providers were also ambassadors. across the city. We were clear from the outset that each of these test events across each venue would see the actual Games Time Command Team together with the paramedics and EMTs who would be deployed throughout the venues. This enabled those who would actually provide prehospital care at the venues during the Games to become acquainted with new venues while establishing relationships others, such as LOCOG venue managers. During the final set of tests events in May 2012, two months before the opening ceremony, we deployed paramedics and EMTs from around the country into the venues. The Olympic Deployment Centre (ODC) was opened and our Olympic Event Control Room (OECR) managed deployments and responses to emergency calls. CENTRAL OPERATIONS The ODC was an empty warehouse in East Choose 42 at www.jems.com/rs WWW.JEMS.COM MARCH 2013 JEMS 63
  • PLANNING LIKE AN OLYMPIAN >> CONTINUED FROM PAGE 63 cap, among other items of Games specific personal issue equipment. The planning team didn’t only have to negotiate and agree how we would deliver services across the Games and its multiple venues. We also had to make sure we complied with the bid commitments, the requirements of the individual sport federations and LOCOG. We also had to arrange accommodation, feeding and transport for 200 staff from outside London. LET THE GAMES BEGIN A bicycle responder patrols the Southbank by Tower Bridge. control room links via our CAD system to our main control room, while having the benefit of access to a network of closedcircuit TV cameras across the city. We considered how we would deliver existing service requirements, such as response time performance standards and clinical quality, while deploying hundreds of paramedics and EMTs to sporting venues and cultural events. It was clear that even with restrictions on planned workforce abstractions, which included a deferral of all training across the summer of 2012, we would need an additional short-term boost to the workforce. There are eleven National Health Services ambulance services across England. We are the biggest and busiest handling over 1.6 million emergency calls per year. Each of the other English ambulance services agreed to send pre-planned aid to London for the Olympics and Paralympics, boosting our dedicated Games specific workforce to 500 paramedics and EMTs. Outside of the Games for business as usual we have a paramedic and EMT workforce of 3,000. Each ambulance service around England works slightly differently. Because each has different policies and procedures, it was necessary to provide training to each member of the Games cohort. Over four days, a training team from London visited each ambulance service in England to provide training to staff. The training package was completed in London when paramedics and EMTs began to arrive in late July for the Games. Paramedics, EMTs and Emergency Medical Dispatchers (EMDs) from around England arrived in London over three days. Each day, those arriving received an initial briefing and their personal issue LAS baseball We began the briefings for the staff working in the Olympic Stadium with a degree of anticipation on the day of the opening ceremony. It was too late if we had forgotten something. We would have to adapt, flex and improvise. Our past five years of planning was predicated on this and had provided a framework for delivery that could be adjusted to meet operational requirements on the day. Our Games Time Delivery Strategy provided a firm foundation for this flexibility. It complimented existing event and mass gathering doctrines in London. As the opening ceremony began and Queen Elizabeth jumped from a helicopter over the Olympic Stadium in a spoof, James Bond-style sequence, we all sat glued to the television and watched. It was at that point I knew this was going to be something special. I had been involved in the planning and delivery of many large events in London over the past 10 years. These included the Live8 concert, G8 and G20 summits, New Year’s Eve celebrations, Notting Hill Carnival, London Marathon, state visits Presenting Complaint by Zone For this table’s data and additional tables from London Ambulance Service, scan the above code or visit jems.com/journal and click on “March.” 64 JEMS MARCH 2013
  • You deserve the best. the best benefits the greatest opportunities the strongest voice advocating on your behalf Join NAEMT today. www.naemt.org | 1-800-346-2368 National Association of Emergency Medical Technicians Serving our nation’s EMS practitioners Choose 43 at www.jems.com/rs Choose 44 at www.jems.com/rs Choose 45 at www.jems.com/rs Choose 46 at www.jems.com/rs WWW.JEMS.COM MARCH 2013 JEMS 65
  • PLANNING LIKE AN OLYMPIAN >> CONTINUED FROM PAGE 64 delivered, and Londoners, visitors and spectators alike were able to travel without incident. The same was true for us with limited disruption to emergency response—perhaps as a result of the detailed route and access planning undertaken. Equally as important to the provision of EMS at Games venues was the service we provided to the rest of London. We termed this “maintaining service delivery” (MSD), or core business. We had planned this to Paramedics celebrate success at the Olympic Stadium shown on a big screen. GAME-DAY(S) RESPONSE of the Pope and other famouse people, the royal wedding and the Queen’s Diamond Jubilee. But this was different. It was something else. Day one of the Games followed, and our plans were working well. Although there were issues with some of the logistics, they were insignificant in comparison to the scale and complexity of the operation. Deployments of EMTs and paramedics on foot, in ambulances, on motorbikes and pedal cycles were underway. We had people in venues, at cultural events and standing by at transport hubs. Our Olympic Information Unit (OIU) was in full swing. It operated 24-hoursa-day and provided strategic briefings on activity, incidents and relevant issues to key internal and external stakeholders. This unit worked to compliment the control room and was at the center of our EMS response during the Games. Reserves were planned for each day of the Games, depending on the perceived risk. Our assessment of risk was based on known events, the competition schedule, the weather forecast and other intelligence. The reserves consisted of ambulances and special assets. The special assets allowed us to be prepared to respond to such specific types of threats as chemical, biological, radiological and nuclear events. They included special equipment supply and mobile control vehicles, plus teams of staff able to provide urban search and rescue, high-angle rescue and swift-water rescue. As each day of the Olympics passed, we saw increased demand but weren’t as busy as we had expected. Overall activity across London during the Games rose by about 10%. We saw some traffic congestion when the Games lanes went live, but the road network and public transport network 
  • 
  •   Olympic GamesActivity %&! %!! $&!  #&! $!! #!! "&! "!! &! ! 
  •    
  •    
  •     
  •  %) "* ) &% % "%" % ##$  '% #( "" )) "" ##& "" $*'  66 JEMS 
  •   MARCH 2013   
  •   Olympics providers came from all over England. provide the same emergency service to Londoners in non-Olympic boroughs while delivering world-class responses and care at Olympic venues. A senior colleague oversaw the planning and delivery of MSD. We reconfigured many aspects of routine service delivery to release capacity to support Olympic or core delivery. The basis of this planning was our existing business continuity arrangements. This approach meant that staff members were already familiar with how we would do things when challenged, and it meant that we were less likely to see confusion. Existing plans formed the basis of our MSD and Olympic planning, keeping our delivery as close to what we normally do as possible and not inventing something new for the Games —both of which reduced the potential for error.
  • THANK YOU TO OUR SPONSORS With the help of these organizations, we provide a forum for quality education in EMS. We sincerely appreciate their support. Association Sponsors Additional Sponsors TM JEMS Games Sponsors Founding Sponsor Supporting Sponsors ES ON N CE E D REN AR NFE REP L CO ISM P ONA OR NATI R INTER R & TER TE DISAS MAR WA S CH 7-9 HIN , 2 G T O 01 N, 3 D C MARCH 5 - 9, 2013 WASHINGTON, D.C. S TM
  • PLANNING LIKE AN OLYMPIAN >> CONTINUED FROM PAGE 66 Spectators were the largest patient group during the Olympic and Paralympic Games, closely followed by those making up venue workforce. Although no major or multi casualty incidents happened over the 30 days of sport, a number of incidents happened in which critically ill patients presented with cardiac arrests, ST-elevation myocardial infarctions and convulsions in venues. Our teams worked alongside the volunteer workforce of LOCOG and LOCOG Medical (a separate team within the organizing committee that provided first aiders, nurses and, in some cases, doctors in first aid rooms) to provide initial treatment before conveying them to emergency departments (EDs). A bike medic tends to the needs of a patient at an Olympics venue. SUMMARY LOCOG Medical managed thousands of patient contacts across all the Games venues without our intervention. A polyclinic in the athlete’s village had extensive diagnostic options, including X-ray and magnetic resonance imaging for athletes and the Olympic family. These helped limit the number of patients who needed transport to the ED. Although the delivery was seamless, there were “behind the scenes” moments in the final stages of planning that made us think. We received additional requests for ambulance cover at training venues that hadn’t been planned for on short notice. In addition, the torch relay attracted bigger crowds than initially planned for. Some of the planning assumptions and agreements changed on short notice for various reasons. This meant we had to adjust our plans while also solving human resource issues that you would expect to see among a workforce of around 500 across a six-week period. As part of the National Health Service (NHS) ambulance service Games cohort, more than 500 staff were deployed across 18 venues and 30 days of sport in London. In doing so, they delivered in excess of 165,000 hours of standby and care, responded to nearly 1,500 Games-related incidents and conveyed 800 patients to emergency departments across the capital. After such an influx, it wasn’t easy to return to business as usual. Officials with Workload byDate and     
  •    Zone-Olympics        MARCH 2013                 JEMS
  •   68 previous host cities had advised us that there would be a feeling of “what next” once the Games concluded. When I first heard this, I thought the opposite would be the case. I expected feeling relieved of overwhelming emotion as well as from the exhaustion of the long days. I do have to say that although this was the case, it’s also true that there is a “post Games” come down. We had just been part of a fantastic summer of sport with a brilliant medal tally from Team Great Britain and Paralympics Great Britain that, of course, helped the euphoria. But we did feel a real sense of uncertainty about what to do next. We had spent five years planning for it, lived it for the past six months and been part of it for the past 30 days. And now it was over. Overwhelmingly the experience was truly great. There was an immense sense of pride in achievement and participation on the part of every EMT, paramedic EMD, officer and ambulance service employee who helped deliver prehospital care at the Games. The Games and cultural events were a truly oncein-a-lifetime experience. We were privileged to be part of that experience, to provide prehospital care during the Games and to be able to say we were part of something that inspired a generation.
  •  Jason Killens, MStJ, JP, is deputy director of operations at the London Ambulance Service NHS Trust and was the gold commander for the Olympic and Paralympic Games 2012.
  • TM February 4 – 8, 2014 WASHINGTON, DC WHERE PEOPLE, PRODUCTS AND IDEAS Serving the emergency services community, EMS Today provides professionals with a valuable combination of progressive education, developed by industry experts and JEMS contributors, and the latest equipment from leading manufacturers. Emergency services personnel rely on EMS Today to help develop their careers, create networking opportunities and provide an environment where camaraderie, pride of service and dedication to saving lives is celebrated. For information on the 2014 program, events and registration, please visit www.EMSToday.com. Mark your calendars now for 2014! Presented by ®
  • PHOTOS COURTESY DAVID PAGE The St. Paul Fire Department EMS Academy is training its seventh class of “Freedom House” providers. 70 JEMS MARCH 2013
  • HOW THE STORIED AMBULANCE COMPANY HAS BEEN REBORN >> BY MEGAN CORRY, MA, EMT-P, CASEY KEYES, BA, NREMT-B, & DAVID PAGE, MS, NREMT-P I t might seem ironic to some that Minnesota, a state not known for diversity, is the birthplace of one the most diverse EMS departments in modern day U.S. history. It might also seem ironic that its inspiration, the diverse Pittsburgh EMS agency—called Freedom House Ambulance Service, was dissolved during the height of its support by prominent clinical leaders due to politics. It’s certainly an ironic twist of fate that 45 years after training its first class of lowincome African Americans, Freedom House was reborn. The new Freedom House Ambulance Service, this one launched in St. Paul, Minnesota, was created by a collaboration of area organizations recognizing a need to not only diversify its mostly Caucasian workforce, but also to provide an occupational opportunity for populations in underserved communities. The rebirth of the St. Paul program was illuminated by powerful speeches from three of the original Freedom House Ambulance Service members at the spring 2012 St. Paul Fire Department (SPFD) EMS Academy graduation, but the groundwork and spark for the new Freedom House Ambulance Service began much earlier. BIRTH OF THE ORIGINAL FREEDOM HOUSE It was 1966. For African-American communities like the Hill District of Pittsburgh, The new Freedom House diversifies the EMS workforce in the Twin Cities. unemployment was epidemic. Social services fueled by the death of his 11-year-old daughwere nonexistent. Calls for emergency medi- ter from an acute asthma attack and a pascal assistance were returned with silence, sion for bringing advanced emergency care delayed responses or inadequate care. to the patient in his research and practice. These conditions were unacceptable The convergence of these forces birthed to community activists Phil an audacious, communityHallen and James McCoy. based, employment and trainTogether, they proposed a proing program that was the gram that provided economic seed of paramedicine and the opportunity and emergency home of one of the first (and medical care to a community most diverse) ALS training that had neither. programs in the U.S.—FreeThey enlisted the expertise of dom House Ambulance SerPeter Safar, MD, a prominent Darnella Wilson is one vice. However, the Freedom anesthesiologist. Safar, a pioneer of the original Freedom House program has often of resuscitation techniques, was House providers. been neglected in EMS history. WWW.JEMS.COM MARCH 2013 JEMS 71
  • REVIVING FREEDOM HOUSE >> CONTINUED FROM PAGE 71 Freedom House Enterprises recruited 25 young African Americans from their community. This included several veterans returning from Vietnam and others who carried the burdens of poverty, drugs and alcohol abuse. They began training the first class of students in 1967. With Safar involved, the program was rigorous, requiring long days in the classroom and lab. Safar noted early on that some of the students lacked basic skills in reading and math. However, as a testament to their persistence and the commitment and quality of the instructors, many of the students obtained their general educational development (GED) degree and continued with their medical training well after Freedom House. Safar never swayed from his vision, and the Freedom House recruits had the support of the faculty, their community and each other. Their loyalty and drive to succeed carried them through the challenging program, which consisted of more than 160 hours of preparatory training in anatomy, physiology, medical ethics and advanced resuscitation techniques. The year-long program also required six weeks of hospital-based training in the operating room and emergency department, the intensive care unit, the morgue and medical wards. The recruits also were required to attend medical rounds and lectures with residents, something many EMS programs don’t incorporate even today. They were trained, mentored, monitored and evaluated on the job, where they responded to emergencies under the watchful eyes of, and in consultation with physicians. Freedom House Ambulance and the unexpected success of the once-underemployed and impoverished recruits realized Safar’s vision of bringing bring critical lifesaving care to underserved patients. Special Premier of the Documentary ‘Freedom House’ A special 90-minute documentary on Freedom House Ambulance, sponsored by Jones & Bartlett Learning, will be presented from 7:30 to 9 p.m. March 7 at the EMS Today Conference & Exposition in Washington, D.C. Registered attendees will be admitted free to the premier at the Washington Convention Center. Q&A to follow. EARLY FREEDOM HOUSE OPERATIONS Freedom House Ambulance Service started 72 JEMS MARCH 2013 The EMS Academy became the first EMT class open to the public inside the city limits. with two donated police “wagons” and operated on a shoe-string budget. They responded to more than 5,800 calls in their first year, transporting more than 4,600 patients, mostly from within the AfricanAmerican districts of Pittsburgh. Word of this novel program spread rapidly through the community, particularly after the 1968 riots following the assassination of Martin Luther King, Jr. In fact, Freedom House medics worked together in an unprecedented collaboration with the largely white police force to provide emergency care to the sick and injured in communities devastated in the wake of the riots. The activities of the Freedom House Paramedics are some of the first accounts of paramedics providing ALS skills in the field, and this timeline could arguably place Freedom House paramedics as the first in the nation to provide this level of care. By 1973, with new grant funding, Freedom House was able to obtain its signature orange-and-white ambulances, which were packed with the latest medical equipment. They continued to carry model advancements in emergency care while providing compassionate care to a onceabandoned community. As the public began hearing about this new service, the cry “send Freedom House” led to a further expansion of the service into other regions of Pittsburgh, where Freedom House paramedics often encountered racial tensions. The expansion continued, and the service hired an increasingly integrated workforce. In 1974, Safar assigned a young critical care resident, Nancy Caroline, MD, as the new medical director of the Freedom House ambulance service. Caroline often rode out with the crews, advising them by phone and catching a brief nap at their station on a stretcher between shifts. Caroline was mentor, teacher and friend to many of the crew members during her tenure at Freedom House Ambulance. She led the service through advancements in the areas of disaster medicine and critical care in the streets. She even obtained a Department
  • of Transportation grant and developed the first paramedic textbook Nancy Caroline’s Emergency Care in the Streets, which became one of the most widely used, and popular, paramedic textbooks for years. END OF AN ERA Despite the involvement and support of clinical leaders, like the outspoken Safar and the young and ambitious Caroline, the political winds were shifting in Pittsburgh. A newly elected mayor chose to replace the Freedom House paramedics by funding a city-run ambulance service. To preserve the original communitybased service, Safar insisted on a written agreement that “grandfathered” the Freedom House paramedics into this new service. But once in place, this agreement was systematically dismantled, leaving only a fraction of the original personnel. Many original members, like paramedic pioneer John Moon, remained and advanced through the ranks despite encountering racial barriers along the way. Others took their training and experience elsewhere, becoming leaders in public health and safety in other major cities. FAST FORWARD There’s no shortage of EMTs or paramedics in St. Paul. In fact, the Twin Cities of Minneapolis and St. Paul have three strong paramedic schools, and EMS employers report a large pool of applicants. Why then would it be necessary to launch a new and unique recruitment and education program for EMS in the area? The answer is a lack of diversity. Although official statistics from most Twin Cities ambulance services are not kept, Minnesota EMS leaders acknowledge that less than 2% of paramedics in the Twin Cities are non-Caucasian. Although many EMS agencies have escaped public criticism for their lack of diversity, the St. Paul Fire Department (SPFD) has been scrutinized for this over the past decade. The entrance test and hiring practices have been the subject of several contentious lawsuits and many newspaper stories. In response, SPFD has been proactive in the recruitment and hiring of diverse candidates. SPFD may actually be the most diverse ambulance service in the state. Today, the department boasts 80 members of diverse ethnicity (18%) and 19 women (4%) out of its 435 members.1 Some might even ask if 18% diversity is enough. After all, isn’t the state of Minnesota 85% Caucasian? The non-Caucasian populations of St. Paul and Minneapolis are 37% and 44%, respectively.2,3 This includes large Hmong, Hispanic and Somali groups—each of whom have unique language, cultural, and healing practices. At the time of publication, SPFD has yet to hire its first Hmong firefighter/EMT, and other local providers have no black or Hispanic EMTs or paramedics. The reality is that the issue of diversity in EMS requires a deeper contextual perspective and rests on more than just skin color. If serving our communities with excellent medical care requires better understanding of these cultures, couldn’t we just educate the current workforce? Becoming more culturally competent should be the goal of any healthcare provider, and wouldn’t we also want to hire at ® Surge Capacity. Mortuary Response. Mass Casualty Transport. Firefghter Rehabilitation. Functional Needs Evacuation. Bus Stretcher Conversion Kit™. How will you use it? EMS Today Booth #1656 www.firstlinetech.com | @FirstLineTech | sales@firstlinetech.com Choose 47 at www.jems.com/rs WWW.JEMS.COM MARCH 2013 JEMS 73
  • REVIVING FREEDOM HOUSE >> CONTINUED FROM PAGE 73 PARTICIPANT PROFILES Tianna Ross: Prior to the EMS Academy, Tiana didn’t consider becoming an EMT and didn’t have a clear idea of what to do after completing high school. She helps care for Tianna Ross her brother as if she were a single parent. Near graduation, one of her guidance counselors told her about the summer EMT class that paid an hourly wage. Ross signed up with the program and, despite a rocky start, completed the EMS Academy. She now works on the BLS service. When asked about how she has changed as a result of the Academy, Ross states, “When I was in high school I thought that I was just going to get a job in retail or fast food and I was going to stay there for the rest of my life. And since this program, I know I’m not going to be working a dead-end job. I know my future is bright, and I know that good things will come to me.” Clarence Fraser: After a brief attempt at a college football career, Clarence returned home to cope with his attention deficit hyperactivity disorder. Although his acaClarence Fraser demics improved, he was forced to withdraw because he couldn’t afford the school’s tuition. He enrolled in the 2010 class of the EMS Academy and is now one of the senior members of the BLS service. Fraser is completing his advanced EMT classes and aspires to become a paramedic at St. Paul Fire. Koua Xiong: The Twin Cities are home to the largest concentrated Hmong population in North America. One of the early calls the BLS service took was for a Hmong man Koua Xiong who didn’t speak English. Luckily, Koua Xiong was on the call. Koua, a crewmember of the BLS service, understood his cultural and personal needs. Koua remarks, “I was happy I took the call. I knew from the start that any of my co-workers would have difficult conversing and explaining what they were doing.” He learned about the EMS Academy in a local Hmong newspaper. When he first started the EMT course, his reading levels were at seventh grade. After EMT certification 10 weeks later, he tested at an 11th grade level. He now works on the BLS service and with Allina Health EMS, and he’s finishing up his associate’s degree and paramedic curriculum. 74 JEMS MARCH 2013 least some personnel who are already fluent l in both language and cultural practices of i these groups? t Sadly, if you ask a Hmong, Hispanic or African-American child from a lowo income family in the inner city what career i they might dream of, “emergency medical t services” is simply not on the top of their s list. Unfortunately, even if it was, their l guidance counselors might be quick to g point out that low pay, difficult access to p expensive training, and a competitive job e market make other careers more attractive. m The educational reality in our inner-city schools is an economic and racial catastros phe. Minnesota’s black and Latino students p have some of the worst reading and math h scores in the country (45 and 38 points lower s than their white counterparts).4 Inner-city t y youth of diverse ethnicity have a higher likel lihood of ending up in the penal system than i in college. It’s not just a matter of appropriate repr resentation and good patient care. Having a l labor force that is representative of the communities that we serve allows economic m opportunity for all of the city’s residents. It o can also save taxpayers millions if we reverse c the path of one young person who might t otherwise be disenfranchised from educao tion and employment as a whole. t If even one of these youth at risk embraces a career, earns a living that supe ports their family, and avoids jail, there’s an p average cost savings of $20,000–30,000 per a year in court costs and governmental assisy tance for food and shelter; the savings to the t taxpayer are significant.5 t So you can now see why SPFD’s visionary Chief Tim Butler, jumped at the chance a EMS ACADEMY DIVERSITY BY THE NUMBERS Eighty-one EMT class graduates have a NREMT first-attempt pass rate of 85%. >> Forty-two percent (42%) of the participants are African-American. >> Fifteen percent (15%) are Hispanic. >> Eleven percent (11%) are Asian. >> Eleven percent (11%) are Caucasian. >> Nine percent (9%) are Native American/ American Indian. >> Ten percent (10%) are multicultural. >> Two percent (2%) are other. >> Fifty-four percent (54%) are female. to work with the city’s already successful St. Paul Parks and Recreation Department Youth Job Corps (YJC) and Inver Hills Community College (IHCC) to start an innovative new EMS program. YJC places low-income youth in summer jobs around the city. In 2009 a surplus of youth and the dollars to pay them brought the Parks and Fire departments together. The initial idea was to have YJC workers helping clean fire stations, much as they help dig ditches for the highway department or clean parks facilities. Instead, Butler suggested that these funds be used to train interested applicants as EMTs. The EMS Academy provided free EMT training and an hourly pay of $7.50 per hour for low-income city residents under the age of 24 who qualified for YJC. These students wouldn’t otherwise be able to afford the training, books, and certification exam costs. With all of the EMT classes at the time being offered in suburban colleges that required difficult commutes, the EMS Academy became the first EMT class open to the public inside the city limits. When the program began to experience serious challenges in coordinating the needs of low-income youth, additional partnerships became critical. The Community Action Partnership of Ramsey and Washington Counties provides a social worker who can help troubleshoot emergency food, medical, and shelter needs. Adult basic education specialists from the St. Paul Public School’s Hubbs Center help inside the classroom providing instructional support, precourse work and remediation. SUCCESS—BUT WHAT KIND? The SPFD hiring list is created nearly every four years and is highly competitive, with 3,000 initial applicants vying for a small number of openings. After the first three EMS Academy classes, the employment statistics and rates of graduates continuing to college painted the program in a good light. However, it also became apparent that the graduates were securing jobs in many healthcare venues, e.g., emergency departments and nursing homes, but not inside the EMS workforce. Area ambulance services indicated they were passing over EMS Academy EMT graduates because of their lack of experience. The program was at an impasse.
  • In 2012, an amazing thing occurred. Three of the original members of the Pittsburgh Freedom House Ambulance Service delivered inspiring graduation speeches for the St. Paul Fire Department EMS Academy spring class. Seeing the similarities in the Pittsburgh and St. Paul projects, Butler approved a request to rededicate Station 51, which had been converted into a training academy, as Freedom House Station 51 in honor of the original members of Freedom House ambulance. During the original members’ St. Paul visit, a recently released documentary by Gene Starzenski was screened in a closed door summit of EMS leaders. The meeting provided insights as to the systemic barriers that inner-city youth face when seeking employment in Twin Cities EMS agencies. Access Gene Starzenski’s documentary on the Freedom House website. www.freedomhousedoc.com. Seeing that competent EMT graduates weren’t being hired was difficult for administrators. Although employers often cite the lack of diverse qualified candidates, the new, more rigorous requirement of qualified and experienced candidates was an even bigger challenge. Graduates’ lack of training, coupled with shrinking grants from foundations, prompted novel action on the part of the EMS Academy. Regions hospital, a local Level 1 trauma center which provides medical direction for SPFD and IHCC, had a pressing need to transport stretcher bound discharged patients home. The combination of these needs propelled a landmark event in Minnesota EMS: The creation of the SPFD non-emergency BLS ambulance scheduled transport service. A NEW FREEDOM HOUSE TRANSPORT SERVICE In July 2012 SPFD, in line with Mayor Coleman’s youth initiatives, the St. Paul Department of Human Rights, the Parks Department, Regions Hospital and IHCC received City Council approval to launch the EMS Academy YJC-BLS unit. Inver Hills instructors volunteered to coordinate additional training, scheduling “The vital part of what I learned from Freedom House was to help my fellow man.” —George McCleary, Freedom House paramedic and field supervision. Two college ambulances were leased to the city for $1 to minimize start-up costs. Regions Hospital and Allina Health EMS funded uniforms, pagers and other operational needs. The local EMS community embraced the idea and viewed it as a beneficial partnership and “feeder system” for diverse employees. Allina and HealthEast Medical Transportation, two local private ambulance services went as far as supporting it with additional donations and run referrals. Ten graduates of the EMS Academy were hired back at $7.50 per hour (without benefits) in a temporary YJC job class with St. Paul Parks, and placed under the supervision of SPFD for training. On July 9, 2012, the BLS service was officially launched. The new service has completed more than 500 runs in its first six months of operation. The funds generated by the ambulance service are able to wholly sustain the operation of the BLS ambulance service, and excess funds are used to support future Academy projects. In addition to providing a multilingual and culturally diverse ambulance service to St. Paul and receiving accolades from patients, the crew has found remarkable success securing jobs. Of the original 10member crew, seven now have jobs as EMTs with local ambulance services. All SPFD BLS unit workers are required to attend classes to further their EMS education, with the goal of attaining paramedic certification. Beyond those working for the BLS service, roughly 50% are pursuing further their education and 70% have found jobs in a medically related field. SUMMARY Freedom House is our national EMS legacy. It was a revolutionary idea born out of the convergence of political forces. It’s our EMS history, but it isn’t found in our textbooks. Today we labor over the need to build workforce diversity, create community paramedicine and increase physician interaction during paramedic training. Freedom House had all of those things, yet we have collectively forgotten. Freedom House isn’t about being the first. It’s about believing in the power of each individual to achieve success. It’s about building a system of clinical excellence and responsibility to the public. The original Freedom House paramedics became known for their advanced medical care, but to those they treated, they were known for their compassion and commitment to public service. Megan Corry, MA, EMT-P, is the Paramedic Program Director and Primary Instructor at the City College of San Francisco Paramedic Program and doctoral student at San Francisco State University. She is also on the Board of Advisors for the UCLA Prehospital Care Research Forum. She can be reached at mcorry@ccsf.edu. Casey Keyes, BA, NREMT-B, is the Saint Paul EMS Academy Program Coordinator through AmeriCorps VISTA. Keyes graduated from St. Olaf College where he worked as a volunteer EMT. He can be reached at casey. keyes@ci.stpaul.mn.us. David Page, MS, NREMT-P, is an EMS instructor at Inver Hills Community College and supervises the EMS academy, and the St. Paul Fire YJC-BLS unit. He is a field paramedic with Allina EMS in the Minneapolis/St. Paul area. He can be reached at dpage@ehs.net. REFERENCES 1. Hallman C. (Jan. 30, 2010). St. Paul wants more black firefighters. In Twin Cities Daily Planet. Retrieved from www.tcdailyplanet.net/news/2010/01/30/ st-paul-wants-more-black-firefighters. 2. Reilly K, Santiago T. (Summer 2012). St. Paul Trends Report. In St. Paul Department of Planning and Economic Development. Retrieved from www.stpaul. gov/DocumentCenter/View/60943. 3. U.S. Department of Commerce. (Jan. 10. 2013). Minneapolis (city), Minn. In U.S. Census. Retrieved from http://quickfacts.census.gov/qfd/ states/27/2743000.html. 4. Minnesota School Boards Association. (n.d.). Achievement Gap in Minnesota. In Minnesota School Boards Association. Retrieved from www.mnmsba. org/Public/MSBA_Docs/achievementgap.pdf. 5. U.S. Department of Justice. Federal prison system operation cost per inmate. In U.S. Department of Justice. Retrieved from www.justice.gov/archive/ jmd/1975_2002/2002/html/page117-119.htm. RESOURCES >> Bell RC. The Ambulance: A history. McFarland: Jefferson, N.C. 2008. WWW.JEMS.COM MARCH 2013 JEMS 75
  • PHOTOS BOB VACCARO THE BAY SHORE/ BRIGHTWATERS RESCUE AMBULANCE’S NEW VEHICLE WILL RESPOND TO MULTIPLE INCIDENT TYPES AND PROVIDE MUTUAL AID 76 JEMS MARCH 2013
  • >> BY BOB VACCARO I n certain areas around the country, we sometimes see a duplication of fire services and EMS, not to mention competition—sometimes downright animosity—between the two. But among the negative relationships, there are positive examples of fire and EMS working together in innovative, productive ways. The Bay Shore/Brightwaters Rescue Ambulance (BSBRA) organization, located on Long Island, N.Y., has found a way to provide and expand service to their community while continually working side by side with the Bay Shore Fire Department. A great example of this positive relationship is apparent in the latest addition to the BSBRA’s fleet. MULTIPLE USES Above: The vehicle is stocked with rehab supplies as well as needed first aid and medical supplies. According to BSBRA Chief of Department Bill Froehlich, the organization first had the idea to design a special operations vehicle some 10 years ago. “We already provide BLS and ALS services to our community but wanted to expand what we do,” Froehlich says. “The basic concept was to have a vehicle with which we could respond to MCI and rehab incidents. We didn’t want a heavy-rescue vehicle, because that would infringe upon what the local fire department was responsible for.” The idea A roof-mounted light mast supplies needed lighting to took a backburner until BSBRA Assistant a scene. Chief Gerald Guszack started working on the concept with earnest. “We had operated with an older ambulance and a van for a long time” Guszack says. “We really needed more space for our equipment. We also wanted the vehicle to have 4 x 4 capabilities because we had some areas in our district that were not accessible with our available vehicles.” Guszack also specced the vehicle with a front-mounted winch, a light tower, a heat and air-conditioning unit large enough to power a 15' x 30' tent, a microwave, a refrigerator, life preservers, and BLS and ALS medical equipment. “Initially we looked around locally and nationally at what other EMS organizations were using,” Guszack says. “Using the Internet also helped in our search for a manufacturer to build the vehicle of our choice.” And this was no simple build. The BSBRA wanted the vehicle to be able to respond to mass-casualty incidents (MCIs), large fires, rehab, triage, wild- More about BSBRAoperates with five ambulances: The Bay Shore/Brightwaters Rescue Ambulance The Bay Shore/Brightwaters Rescue Ambulance recently took delivery of this special operations vehicle built on a Chevy Kodiak C5500 chassis with body by Custom Fab. >> 2005 PL Custom >> Two 2003 PL Custom >> 1998 PL Custom >> 2009 Braun All five vehicles are built on Ford F-350 chassis. The organization also operates several fly cars and a paramedic ALS vehicle that carries narcotics, telemetry and defibrillators. The organization is staffed by 150 volunteer members and four paid members who work 6 a.m.–6 p.m., with duty crews covering the remainder. The response district covers eight square miles, with light industrial, restaurants, strip shopping centers, apartment complexes and a large waterfront area. During Hurricane Sandy, the company responded to an average of 25 runs per day for a total of 238 calls from Sunday through Wednesday of that week; 25 members were on duty during the week. WWW.JEMS.COM MARCH 2013 JEMS 77
  • BUILT TO SHARE >> CONTINUED FROM PAGE 77 The The BSBRA also operates this ALS paramedic vehicle vehicle. The rear A/C and heating unit is powerful enough to heat or cool a large tent. fires, hurricanes and any other major disaster locally and even in a mutual-aid capacity throughout Islip, Suffolk and Nassau counties, and the five boroughs of New York City. WORKING TOGETHER Before the BSBRA purchased the vehicle, it met with the chiefs of the Bay Shore Fire Department. “We discussed what we wanted to accomplish with the response of the vehicle,” Froehlich says. “Normally we have two ambulances respond to every fire scene, so this would be an additional option should the vehicle be needed. We explained that we weren’t trying to step on anyone’s toes and that we would like to work with them at all emergency scenes. They welcomed the idea 100%, which alleviated a great deal of stress.” A Bay Shore/Brightwaters Rescue Ambulance’s Closer Look The new rescue vehicle is built on a 2009 Chevrolet C5500 Kodiak crew cab chassis with Duramax diesel engine and Allison automatic transmission. The OEM front bumper was removed and replaced with a Buckstop bumper that houses a recessedmounted Warn 16,000-lb. winch. The truck is equipped with an Onan 20-kW Protec PTO generator that powers a Will-Burt NS4.5-9000(OPT) 9,000-watt light mast and two Hannay electric rewind cable reels with 200 feet of 8/3 cable. The body is a 13' all-aluminum walk-around rescue-style body equipped with ROM aluminum roll-up doors. The body top features two coffin compartments, one on each side of the body with a center walkway. These compartments are equipped with multiple adjustable shelves and slide-out trays, including a dual direction tray. Other features include a Whelen M Series Super LED warning-light package and Whelen Pioneer LED scene lights. 78 JEMS MARCH 2013 One of five ambulances operated by Bay Shore/Brightwaters Rescue Ambulance Ambulance. Like most organizations, the BSBRA went out for competitive bidding. “We received quotes from three manufacturers,” Froehlich says. “Great Lakes Specialty Vehicles represented Custom Fab & Body of Marion, Wis. We felt that Custom Fab was good for us, simply based on the fact that their company had built similar vehicles for other agencies nationwide.” Custom Fab also gave the BSBRA a great price. “Since we didn’t have grant money, this helped us out a great deal,” Froehlich says. “Our budget comes from a special ambulance district tax, so price was important for us going forward with the purchase.” Representatives from the BSBRA traveled to Custom Fab on at least four occasions to meet with engineers and oversee the build process. “They offered suggestions on what would or wouldn’t work, as well as being receptive to our ideas and implementing most of them,” Froehlich says. “The vehicle was delivered in record time and has worked out well for us. It came just in time for Hurricane Sandy.” The BSBRA fondly calls it Hercules. (For a related article on Hurricane Sandy response, see p. 38.) GET CREATIVE The BSBRA was proactive in their thinking. They planned for this purchase more than 10 years ago and designed the vehicle to not only help them expand their service to the community, but also to help the local fire department and other organizations through mutual aid. Preplanning in advance for your response district’s needs should be your first priority in any vehicle purchase. Also take into consideration budget constraints, and how the vehicle will respond and be used. In today’s poor economy, sharing equipment among agencies and working together is a great concept—one that should be expanded upon all over the country. Bob Vaccaro has more than 30 years of fire service experience. He is a former chief of the Deer Park (N.Y.) Fire Department. Vaccaro has also worked for the Insurance Services Office, the New York Fire Patrol and several major commercial insurance companies as a senior loss-control consultant. He is a life member of the IAFC.
  • Reward your personnel with a subscription to JEMS. JEMS makes a great appreciation gift, retention tool or incentive. Take advantage of discounts on multiple subscriptions. A one-year subscription to JEMS consists of twelve issues including the Buyer’s Guide and Hot Products issues. Call: (888) 456-5367 or visit www. JEMS.com
  • HANDS ON PRODUCT REVIEWS FROM STREET CREWS O2 for Mass Casualty Incidents Here is a quick math problem. How many additional ambulances do you need to provide emergency oxygen to eight patients? Now how many ambulances do you need to provide emergency oxygen to 16 patients? If you have the Multi-Manager O2 Administrator from Spiracle Technology/Ferno, the answer to this math problem is one ambulance. The Multi-Manager O2 Administrator has eight flow-control valves that are manifolded together. The manifold is mounted to a collapsible aluminum alloy tripod. Two Multi-Managers can be connected in a series allowing you to provide oxygen to 16 patients. Independent flow settings are: OFF, ¼, ½, 1, 2, 3, 4, 6, 8, 10, 15 and 25 LPM. A dust case is included. VITALS Dimensions when setup: 10.5" H x 18" L x 7" W Dimensions when stored: 2.75" H x 18" L x 6" W Weight: 6 lbs. Price: $1,145 www.spiracle.com 714/418-1091 Keep Your Hand Warm VITALS Color: White Sizes: Medium (8", with green cuffs), large (9", with yellow cuffs) & XL (10", with brown cuffs) Price: $1.69 per pair www.keybomedical.com 877/855-3199 If you have worked an emergency run in extremely cold temperatures you quickly realize that your medical gloves provide you with no protection from the elements. The gloves even seem to attract the cold to your hand and make it difficult to perform your job. Medical Glove Warmers from KEYBO Medical are ultra-thin liners that are thin enough to wear under your medical gloves. Made from 100% nylon, the glove warmers seamless knit allows for the stretch necessary for a close comfortable fit under your medical gloves. The middle and index fingers are open at the tip. This allows for the sensitivity you need when taking a pulse on your patient. ACLS? PALS? There Are Apps for That There’s nothing worse than test anxiety. Over years of teaching ACLS and PALS courses, I have seen everything from students’ hands shaking to breaking out in hives on test day. The ACLS and PALS Review Apps from Limmer Creative give you high-quality, realistic practice examinations to help you prepare for your ACLS and PALS tests. These apps are easy to use and are based on the 2010 American Heart Association guidelines. There are four, 25 question exams that include scenario-based questions just like the questions you will see on your ACLS or PALS test. After submitting your answer to each question, you are immediately told whether your answer is correct, and a detailed rationale is given for that answer to help you to improve and gain confidence in your ACLS and PALS knowledge. There are also integrated ECG strips to help you with your interpretation skills. The apps run on Apple iOS and Android based products. VITALS Operating system: Apple iOS, Android Web version: www.LC-Ready.com Price: $3.99 each www.limmercreative.com Dominic Silvestro, EMT-P, EMS-I, is a firefighter/paramedic for the Richmond Heights (Ohio) Fire Department. He is also an EMS coordinator and EMS educator for the University Hospitals EMS Training and Disaster Preparedness Institute and an adjunct faculty member at Cuyahoga Community College. He can be reached at d.silvestro@jems.com. >> IN THE NEXT ISSUE: 80 JEMS MARCH 2013 Whelen 360 Degree Remote Control Spotlight >> Rayovac On-The-Go Battery Charger >> Panasonic Toughpad Tablets
  • For more product reviews: www.jems.com/tags/Hands-On Not Your Typical Multi-Tools The Raptor Medical Shears are the latest in a long line of multi-tools from Leatherman. Developed over an 18-month period, the Leatherman team worked closely with special operations medics as well a fire/EMT professional. The Raptor Medical Shears are the result of these collaborations. The 420HC stainless-steel medic shear also includes an oxygen wrench, strap cutter, a carbide tip glass breaker and a ring cutter. All of the extra features on the shears can be used with the tool open or closed. The handles are made from glass-filled nylon that provides a secure grip and comfort in hot or cold weather conditions. The sheath allows you to store the shears in the open or closed position and rotates for your comfort. A removable pocket clip and lanyard attachment provides additional nonsheathed carry options. VITALS Color: Black handle with stainless shears Weight: 5.8 oz. Size: Shear length 1.9", closed length 5" Price: $70 www.leatherman.com 800/847-8665 Reduce Back Injuries Lifting with proper technique is an important factor in reducing and/or preventing back injuries. Unfortunately, lifting a patient who is on a backboard from the ground to your stretcher causes excessive torque on lower back muscles and knees. The EZ LIFT Rescue System from EZ LIFT Rescue Systems reinvents the traditional backboard. Designed with extendable handles, the EZ LIFT Rescue System allows crew members to lift from a safe position at or above the knees. The handles can be used for two, three or four person carries. The system comes ready to use right out of the box and is rated for up to 1,000 lbs. The EZ LIFT Head Bed lives on the board and is a comfortable and effective way to immobilize a patients head during transport. Head Bed replacements are sold separately or with the disposable adhesive head straps. VITALS Color: Blue Dimensions: 72" L x 18" W x 2.75" H Weight: 22 lbs. Price: $1,249 www.ezliftrescue.com 435/214-7141 >> Chinook Medical Gear Medical Operator TMK-MO >> North Coast Outfitters SR601J-49UW Stretcher >> Hartwell Medical BioHoop Collection Bag WWW.JEMS.COM MARCH 2013 JEMS 81
  • THETHEY DIDN’T TELL YOU IN MEDIC SCHOOL LIGHTER SIDE WHAT >> BY STEVE BERRY THE SLOW FAREWELL If you can’t do anything else, laugh “Nothing is at last sacred but the integrity of your own mind.” he jovial cackle reverberated loudly off the captive walls—an unlikely resonance from such a sad and customarily dispirited place. I hate this necessitated habitat as much as I hate the disease that stole them from me. Yet, I could not help but generate a small grin knowing the incessant laughter I was now tracking would eventually lead me to them— beginning with my mother, whose laughter is so clearly identifiable, so boisterous and her self-imposed wit with nonstop laughter after complaining about the cook’s blender, which was no doubt being used to puree a patient’s food, not being subjugated to make her a margarita. “Happy birthday, Ma!” I whispered loudly so I didn’t frighten my father. Her eyes grew large as she reached to hug me. My father simply looked at me with curious uncertainty. “Birthday? What birthday?” she blurted. “We’re celebrating your father finally paying off his college student loan.” Not waiting for a reaction, my mother once again laughed at her cleverness. “How old are ya, Ma?” I asked as I smiled. delightfully contagious that even those outside the circle hypnotically gather to its source. Find my mother and I will find my father. She’s the only person he now recognizes, and they’re inseparable. Just as before, I found them sitting in the lounge of their Alzheimer’s residence home, holding hands. Today, however, it was my mother’s birthday and she was rewarding “Old enough not to give a $%#!,” she roars in between chortles. “All I know is I’m so old that all my friends in heaven think I didn’t make it… or is it hell? %$#! Where’s my margarita?” Today was a good day for my parents. My father was alert and my mother wasn’t repeatedly asking the same questions over and over again. They appeared happy and, —Ralph Waldo Emerson T 82 JEMS MARCH 2013 despite the series of small strokes (vascular dementia) that had raped my father’s brain, he was smiling each time my mother laughed. This is a sign of humor’s capacity to survive and sooth, I suppose. My mother’s dementia was diagnosed five years earlier—fifteen years after my father’s symptoms first began to appear. My mother is old-school; despite how his disease profoundly changed her, she insisted on taking care of my father alone up until her own cruel collection of cerebral symptoms began to manifest themselves, thereby making it impossible for either of them to be without the consistent care of assisted living. I had felt blessed that my father’s retirement would provide them with a safe, clean, and stimulating environment for the rest of their lives, so it breaks my heart every time I enter this regrettable facility—a facility so familiar to those of us in EMS. “Where’s the music? We need music in this %$#! Place!” my mother cursed sarcastically. “How about the Village People’s, Y-M-CA… except that we’ll sing it A-A-R-P,” I proposed straight-faced. My mother furrowed her brow for a second, thinking about what I had just said and then imparted a highpitched giggle that grew into a pulverizing snort. Delightfully surprised by the unexpected sound, she roared laughter until her eyes were filled with tears. “Now look at what you’ve done,” she whispered back at me loudly. Not waiting for an answer, she turned to one of the aides standing nearby yelling, “Hey Marge. These diapers aren’t going to change by themselves!” Again, my mother cackled as I tried to find a tissue to dry her eyes. As more residents began to gather around our small family get-together, it became increasingly clear that even in their late stages of dementia, these confused strangers hungered for more than just my mother’s birthday cake. They were invigorated by the smiles and laughter and wanted to be a part of it—except for one elderly woman who kept
  • yelling out each time my mother laughed, “What’s so %$#! funny?!” (This, by the way, only provoked my mother’s laughter to an even more brazen level.) It’s important to empower oneself with humor during those silly moments that Alzheimer’s can produce. Why shouldn’t laughter bargain its way in whenever possible? My mother’s mantra has always been, “What are ya gonna do? So laugh #@$!” “Hey ma! Knock! Knock! “Who’s there?” I asked. My mother grinned. “HIPAA,” I said. “HIPAA who?” she eagerly asked back. “Sorry, can’t tell ya,” I said. She laughed on cue, just like I knew she would. “Get it?” I asked her. “No,” she chuckled. “But it made you laugh,” she added as she playfully slapped my cheek. Mothers are good for that. As I prepared to leave, I could see the smile slowly fade from my mother’s face, despite her best effort to show otherwise. Despite all the laughter, I knew she was ready to leave this world of confusion and separation. I couldn’t hide my despair. Her scrapbook was fading before my eyes. As I averted my eyes, she grabbed my arm and said, “And don’t worry about your father. He’s always by my side. Where else am I going to apply my Post-it notes?” Occasionally I see my parents’ eyes in those geriatric patients my ambulance responds to—especially those who use humor to maintain what’s left of their dignity while in transit. I now regret not being more compassionate during my novice years as a paramedic toward those who cannot recall what happened 20 minutes ago, much less 20 years ago. They deserved better from me. As for my parents, I’m not sure how long their remembrances and laughter will last, but I treasure the gift of comical relief that my mother has instilled in me since the time the diapers were reversed, and I pray that it continues to allow my parents to thrive despite their undeserved clinical prognosis. Thanks, Ma. You are, and always will be, my favorite fan. Until next time, remember: What are ya gonna do? So laugh $#@! Choose 48 at www.jems.com/rs Steve Berry is an active paramedic with Southwest Teller County EMS in Colorado. He’s the author of the cartoon book series I’m Not An Ambulance Driver. Visit his Web site at www.iamnotanambulancedriver.com to purchase his books or CDs. Choose 49 at www.jems.com/rs WWW.JEMS.COM MARCH 2013 JEMS 83
  • Employment Assistant or Associate Professor in the Emergency Medical Care EASTERN KENTUCKY UNIVERSITY Eastern Kentucky University, located in Richmond, KY, is accepting applications for a tenuretrack Assistant or Associate Professor in the Emergency Medical Care (EMC) Program to start August 2013. The EMC program is accredited by the Committee on Accreditation of Educational Programs for the Emergency Medical Services Professions (CoAEMSP) and offers Associate and Baccalaureate degrees. The primary responsibilities may include EMT and Paramedic instruction, classroom and on-line instruction, student advising, and engaging in scholarly and professional service activities. Position Responsibilities: Ensures academic preparation of EMTs and Paramedic students; Teaches CPR, ACLS, PALS, and emergency medical responder courses; Coordinates and oversees clinical/field experiences of EMT or paramedic students; Advising for an assigned group of students; May act as a faculty advisor for student organizations; May teach Continuing Education programs on and off site; Ensures equipment is operational, up-to-date and in good working order; Works closely with administration; meets with students on a regular basis; assures all American Heart Association procedures are followed; Assists in completion of all evaluations and assessments; Engages in scholarly activities (including regional and national publication, presentations, etc.); Organizes, schedules, and oversees education and training at all levels; And performs other duties consistent with the University Faculty Handbook. A Master's degree required from a regionally accredited or internationally recognized institution by the time of appointment. Applicants must also hold Current Paramedic or Registered Nurse licensure with current NREMT by time of appointment and have 3-5 years of related experience--some of which must be in out-of-hospital emergency care. All interested applicants must apply at jobs.eku.edu for consideration (search requisition #0612858). All offers of employment are contingent on completion of a satisfactory background check. Eastern Kentucky University is an EEO/AA institution that values diversity in its faculty, staff, and student body. In keeping with this commitment, the University welcomes applications from diverse candidates and candidates who support diversity. 84 JEMS MARCH 2013 NREMT EMS RESEARCH FELLOWSHIP POSITION AVAILABLE The NREMT EMS Fellowship is a rare opportunity to pursue a doctoral degree while benefiting from mentoring, hands-on research skill development, and a unique education at both the NREMT and The Ohio State University (OSU). You must be highly motivated and committed to positively impact EMS on a national level. Research Fellows receive fully-funded tuition while pursuing graduate studies at OSU. Work responsibilities at the NREMT will include research activities, conference presentations, committee memberships, running projects, and publications. The ideal candidate is a Nationally Certified, field-experienced EMS professional possessing a Bachelor’s degree. Successful candidates must be able to gain admission to OSU graduate school for an approved Master’s and Doctoral studies program. To be considered for the position, please send a cover letter and your resume or vitae to Melissa Bentley, NREMT, P.O. Box 29233, Columbus, OH 43229 or mbentley@nremt.org by April 12th, 2013. The NREMT is an equal opportunity employer.
  • Employment Employment AtlantiCare is a great place to work with excellent benefits and real opportunities for career growth. In fact, 94% of AtlantiCare employees say they would recommend working at AtlantiCare to friends or family. We are also the recipient of the 2009 Malcolm Baldrige National Award for Quality. Join us and help make a difference, one person at a time. We have the following opportunities at our Egg Harbor Township location. Paramedics EMT-B Certified as a Paramedic by the State of New Jersey, current BLSHCP, ACLS, PALS or PEPP certifications required. Current National Registry and/or New Jersey Emergency Medical Technician - Basic Certification required. Current BLSHCP (professional rescuer or healthcare provider level) required. Full-Time, Days & Nights and Per Diem Specialty Care Transport RN Full-Time, Days & Nights and Pool Must have one year of full-time nursing care performing advanced clinical skills in the Critical Care Unit or Emergency Department. Possess Emergency Medical Technician - Basic, Health Care Provider CPR and ACLS. Possess PALS, PEPP or has successfully completed the Emergency Nurse Pediatric Course. Possess either PHTLS or BTLS. NJ Paramedic or National Registry Paramedic Certification is preferred. Also, CCRN or CEN is preferred. Per Diem/Pool Emergency Medical Communicators Full-Time and Per Diem Knowledge of local EMS systems/radio communications required. Certifications include BLSHCP, Emergency Medical Dispatch certification, National Registry or New Jersey Emergency Medical Technician - Basic Certification. Proof of completing ICS Courses ICS 100 and IS 700 required. 2 years’ experience is preferred. Apply online at www.atlanticare.org. EOE, m/f/d/v Equipment HAVE OPEN POSITIONS? Get them flled with a JEMS recruitment classifed. Reach our audience with your message! Eastern Region: Judi Leidiger, j.leidger@jems.com, 619-795-9040 Western Region: Cindi Richardson, c.richardson@jems.com, 661-297-4027 WWW.JEMS.COM MARCH 2013 JEMS 85
  • POWERFUL SOLUTIONS FROM SMART THINKERS avoid pending lawsuits EMS Research & Technology EMS Trend Analysis AVOID COSTLY FINES revenue generating ideas Exclusively for EMS Management EMS Insider provides you with the “inside information” on EMS. It’s a monthly publication from PennWell and affiliated with JEMS (Journal of Emergency Medical Services) so it has the best network of sources in EMS. That means 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! Subscribe to EMS Insider www.JEMS.com
  • ad direct Your source for immediate information on advertisers’ products and services Advertiser RS# RS# Page Page Advertiser RS# Page ADVANCED CIRCULATORY SYSTEMS INC. 13 2 M2 INC. 36 47 AMERICAN HEART ASSOC. 28 33 MASIMO 16 7 AMERICAN MILITARY UNIV. 41 62 MERCEDES BENZ 17 9 B BRAUN MEDICAL INC. 18 13 MERCURY MEDICAL 22 23 BOUND TREE MEDICAL 11 C2 MOORE MEDICAL CORP. 30 35 CENTRAL WASHINGTON UNIV. 37 47 NAEMT 40, 43 59, 65 CINDY ELBERT INSURANCE SERVICES 45 65 ONSPOT OF NORTH AMERICA 44 65 COLUMBIA SOUTHERN UNIV. 46 65 OXYGEN GENERATING SYSTEMS INTL. 48 83 COMPX SECURITY PRODUCTS 25 31 PENNWELL CORP. DEMERS AMBULANCES 21 21 PHYSIO-CONTROL INC. 14 4 ECOLAB 26 31 PINNACLE 2013 38 49 EMERGENCY MEDICAL PRODUCTS, INC. 34 45 PULMODYNE 15 6 FIRST LINE TECHNOLOGY LLC. 47 73 SANSIO 32 37 FITCH & ASSOCIATES 24 27 SPRINT 23 25 HAIX NORTH AMERICA INC. 29 34 STRYKER EMS 50 C3 HARTWELL MEDICAL 20 19 TEXAS A&M ENGINEERING EXTENSION SERVICE 33 43 57 VIDACARE CORP. 35 45 INTL ASSOCIATION OF FIRE CHIEFS 17, 59, 67, 69, 79, 86 JUNKIN SAFETY APPLIANCE CO. 39 59 WHELEN ENGINEERING CO., INC. 42 63 KNOX COMPANY 49 83 WITMER PUBLIC SAFETY GROUP 31 37 LAERDAL MEDICAL CORP. 51 C4 ZIAMATIC CORP. 27 32 LMA NORTH AMERICA 19 15 ZOLL MEDICAL 12 1 FREE advertiser and product information www.jems.com/rs IT’S FAST, IT’S EASY AND JUST A CLICK AWAY! WWW.JEMS.COM MARCH 2013 JEMS 87
  • LAST&WORD EMS THE UPS DOWNS OF In June 2012, a one-of-a-kind vehicle rolled into the Kansas Fire & Rescue Training Institute. Their new grain engulfment rescue training vehicle is a custom 35' trailer that includes a grain bin, grain hopper and a metal cutting station that allows them to replicate (to the extent possible) the “real world” environment in which grain rescues occur. The grain engulfment rescue course is delivered in local communities throughout Kansas and is unique for a state fire and rescue service training organization. Participants from the local fire department and the local grain facility are encouraged to train together. “The philosophy used recognizes that during grain emergencies, employees of the grain handling facility are an integral part of the rescue,” explains institute director Glenn Pribbenow. “By training together, firefighters and grain facility employees will be able to form a true team working to accomplish the rescue.” Institute staff has used the vehicle to teach more than 750 students in 47 grain engulfment rescue classes. An additional 42 classes are scheduled through the remainder of 2013 and into 2014, notes Pribbenow, with more requests being received daily. Both thumbs are up to the Kansas Fire & Rescue Training Institute at the University of Kansas Continuing Education for their collaborative and inclusive training approach as well as for the design of their unique simulation vehicle. PHOTOS COURTESY KANSAS FIRE & RESCUE TRAINING INSTITUTE INNOVATIVE RESCUE TRAINING The Kansas Fire & Rescue Training Institute’s grain engulfment rescue training vehicle unit was made possible by a $90,000 donation from the Kansas Feed & Grain Association, the Kansas Cooperative Council and the Kansas Farmers Service Association. PATIENT DATA PLEDGE In January, ZOLL Medical Corporation made a pledge that will facilitate the 360-degree patient data sharing that will help EMS agencies improve their quality assurance programs—ultimately improving overall patient care. The company made the pledge to allow data-sharing between ZOLL defibrillators and non-ZOLL data systems at the Masimo Foundation Patient Safety, Science & Technology Summit. An example, they stated in a prepared statement, is when EMS services transit 12-lead ECG data to a receiving hospital and each system uses data systems made by different manufacturers. ZOLL Chief Executive Officer Richard A. Packer said in the statement, “It’s all about connecting our devices to everyone’s devices to help improve patient care. From a patient perspective, providing data from ZOLL devices and integrating the information to other devices is doing the best we can for the patient.” We applaud ZOLL Medical Corporation for taking the first step in breaking down the walls of data ownership and making medical devices interoperable for the sharing for patient data, and we encourage other medical device manufacturers to take the leap as well. EMS providers and patients everywhere will benefit. POLICE OFFICER AEDS On Super Bowl Sunday, San Diego Project Heartbeat received great news. An Oceanside Police Department officer saved a civilian in cardiac arrest outside a Starbucks. Oceanside (Calif.) Police Department is one of the agencies in the San Diego County area that provides its officers, who are so often the first responders on scene, with the opportunity to check out an AED for their shift. “They’re on scene first. They’re there before EMS is there,” San Diego Project Heartbeat Community Relations Specialist Loralee Olejnik says. “We’ve really been pushing to get AEDs out in law enforcement vehicles just because we have had so much success.” The officer credited with the Super Bowl Sunday save got to the Starbucks within five minutes of the initial call, she says. By the time EMS providers arrived on scene, the patient didn’t need any more shocks. “The officers are moving. They’re already on their way when the call comes in,” Olejnik says. Oceanside police officers aren’t required to check out AEDs, but an AED is standard equipment for San Diego Harbor, which has the highest save rate out of the law enforcement agencies in the county. Olejnik says San Diego Project Hearbeat uses this information to go after grants that will help them provide more AEDs for officer vehicles, which she says officers can use on patients or even on each other if necessary. “It’s just another tool,” Olejnik says, adding that the program just received an initial grant to put at least one AED on a San Diego Police Department vehicle in each division. We congratulate law enforcement agencies like Oceanside Police Department and San Diego Harbor Police for pairing up with EMS agencies to ensure their officers are equipped to save lives of sudden cardiac arrest patients. JEMS (Journal of Emergency Medical Services), ISSN 0197-2510, USPS 858-060, is published 12 times a year (monthly) by PennWell Corporation, 1421 S. Sheridan Road, Tulsa, OK 74112; phone 918/835-3161. Copyright © 2013 PennWell Corporation. SUBSCRIPTIONS: Send $44 for one year (12 issues) or $74 for two years (24 issues) to JEMS, P.O. Box 3425, Northbrook, IL 60065-9912, or call 888/456-5367. Canada: Please add $25 per year for postage. All other foreign subscriptions: Please add $35 per year for surface and $75 per year for airmail postage. Send $20 for one year (12 issues) or $35 for two years (24 issues) of digital edition. Single copy: $10.00. POSTMASTER: Send address changes to JEMS (Journal of Emergency Medical Services), P.O. Box 3425, Northbrook, IL 60065-9912. Claims of non-receipt or damaged issues must be filed within three months of cover date. Periodicals postage paid at Tulsa, Oklahoma and at additional mailing offices. Advertising information: Rates are available at www.jems.com/about/advertise or by request from JEMS Advertising Department at 4180 La Jolla Village Drive, Ste. 260, La Jolla, CA 92037-9142; 800/266-5367. Editorial Information: Direct manuscripts and queries to JEMS Editor, 4180 La Jolla Village Drive, Ste. 260, La Jolla, CA 92037-9142. No material may be reproduced or uploaded on computer network services without the expressed permission of the publisher. JEMS is printed in the United States. GST No. 1268113153. 88 JEMS MARCH 2013
  • INTRODUCING XPS expandable patient surface THE ALL IN ONE SOLUTION FOR A VARIETY OF PATIENTS AND ENVIRONMENTS. XPS provides a stable, expandable patient surface area that can be easily retrofitted to work with compatible cots.1 XPS is adjustable with 7 locking positions and a wider mattress, designed with patient comfort in mind. For more info, call 800.874.4336 or visit www.getxps.com 1 Power-PRO XT, Power-PRO TL and Performance-PRO Choose 50 at www.jems.com/rs
  • n Essential See SimMa tency during omp e test team c JEMS Games the 2013 ! Competition Team Training in Realistic Environments SimMan Essential ® ® Essential bring greater realism laerdal.com/essential ©2013 Laerdal Medical. All rights reserved. Printed in USA. #13-13250 Scan code to watch a team training cardiac arrest scenario featuring SimMan Essential Choose 51 at www.jems.com/rs