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Jems201206 dl

  1. 1. JUNE 2012 Always En Route At
  2. 2. Choose 11 at www.jems.com/rs
  3. 3. Choose 13 at www.jems.com/rs
  4. 4. Choose 14 at www.jems.com/rs
  5. 5. The Conscience of EMS JOURNAL OF EMERGENCY MEDICAL SERVICES 56 I Stroke of the Clock I ‘Time is brain’ when treating stroke patients By W. Ann Maggiore, JD, NREMT-P June 2012 Vol. 37 No. 6 Contents I 38 38 I Safety First I Richmond Ambulance Authority creates comprehensive culture of safety model By Rob Lawrence, MCMI; Bryan S. McRay, BA; Dempsey Whitt, NREMT-P/FP-C; Joseph P. Ornato MD, FACP, FACC, FACEP Products 2012 I I Hot 50 innovative new products showcased at the 29th annual JEMS EMS Today Conference Exposition Departments columns 9 I Load go I Now on JEMS.com 14 I EMS in Action I Scene of the Month 16 I From the Editor I Is EMS a Game? y A.J. Heightman, MPA, EMT-P B 20 I Letters I In Your Words 22 I Priority Traffic I News You Can Use 26 I Train the Trainer I Sim for Students y Al Kalbach, EMT-P B 30 I Tricks OF the TRADE I Do No Harm y Thom Dick B 32 I case of the month I Difficult Airway y Steven R. Allen, MD, Cayla G. Conover B 36 I Research review I What Current Studies Mean to EMS y David Page, MS, NREMT-P B 66 I Hands On I Product Reviews from Street Crews y Fran Hildwine B 68 I employment Classified Ads 71 I Ad Index 72 I The Lighter Side I EPI Coasters y Steve Berry B 74 I LAST WORD I The Ups Downs of EMS Aboutfrom Care Ambulance and an Orange County (Calif.) Fire Authority firefighter/paramedic the Cover EMS providers assess a female patient in an ambulance in Santa Ana. Patients presenting with stroke can exhibit a variety of signs and symptoms, including paralysis, sudden onset of confusion or loss of balance. Read “Stroke of the Clock,” pp. 56–65, to learn more hallmarks of stroke, treatment options and a personal account of how stroke can affect the lives of the victims and their families. Photo Vu Banh Premier Media Partner of the IAFC, the IAFC EMS Section Fire-Rescue Med www.jems.com June 2012 JEMS 7
  6. 6. Choose 15 at www.jems.com/rs
  7. 7. LOAD GO  log in for EXCLUSIVE CONTENT A Better Way to Learn JEMSCE.com online continuing education program n us o follow App-licable Apps Photo istockohoto.com Do you love your smartphone or tablet? Device-lover and EMS instructor Keith Widmeier, NREMT-P, CCEMT-P, EMS-I, does. So he rounded up some of the latest EMS-related apps available for Apple and Android devices in four EMS-friendly categories. If you have an app-capable device, “EMS Apps Assist Providers in the Field” might just help you help your patients. JEMS.com offers you original content, jobs, products and resources. But we’re much more than that; we keep you in touch with your colleagues through our: Facebook fan page; JEMS Connect site; Twitter account; LinkedIn profile; Product Connect site; and Fire EMS Blogs site. like us facebook.com /jemsfans s jems.com/article/technology/ems-apps-assist-providers-field Sponsored Product Focus The Practi-MAN Featuring patented ventilation system engaging both mouth and nose, the Practi-Man BLS manikin from WNL Safety is TWO manikins in one. A turn of the dial changes manikin from adult to child. It also includes: An audible clicker that verifies proper hand positioning correct compression depth; The only BLS simulator that requires head tilt/chin lift real pinching of the nose to get visible chest rise; Half the weight of competing products. s Check out their JEMS.com ad and Hands On review (p. 67). 54% May Poll Results How do you celebrate EMS Week? 17% I recognize it with coworkers. I don’t even know when it is! 17% My agency hosts an event. polling our Fans How long have you been in EMS? p ess than one year. L p years. 2–5 p years. 6–10 p years. 11–20 p More than 20 years. follow us twitter.com /jemsconnect get connected linkedin.com/groups? about=gid=113182 ems news alerts jems.com/enews s jems.com/poll2012/ Check it out jems.com/ems-products 13% Other. best bloggers The mobile version FireEMSBlogs.com s m.facebook.com/ques- tions/10150693378539794/ www.jems.com JUNE 2012 JEMS 9
  8. 8. Conscience of EMS JOURNAL OF EMERGENCY MEDICAL SERVICES The Conscience of EMS JOURNAL OF EMERGENCY MEDICAL SERVICES Editor-In-Chief I A.J. Heightman, MPA, EMT-P I a.j.heightman@elsevier.com MANAGING Editor I Jennifer Berry I je.berry@elsevier.com associate eDITOR I Lauren Hardcastle I l.hardcastle@elsevier.com assistant eDITOR I Allison Moen I a.moen@elsevier.com assistant eDITOR I Kindra Sclar I k.sclar@elsevier.com online news/blog manager I Bill Carey I bill@goforwardmedia.com Medical Editor I Edward T. Dickinson, MD, NREMT-P, FACEP Technical Editors Travis Kusman, MPH, NREMT-P; Fred W. Wurster III, NREMT-P, AAS Contributing Editor I Bryan Bledsoe, DO, FACEP, FAAEM Editorial Department I 800/266-5367 I editor.jems@elsevier.com 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 t.francis@elsevier.com Production Coordinator I Matt Leatherman I m.leatherman@elsevier.com 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 e.zook@elsevier.com Sales Administrative Coordinator I Liz Coyle I l.coyle@elsevier.com SENIOR eMedia campaign manager I Lisa Bell I l.bell@elsevier.com advertising department I 800/266-5367 I Fax 619/699-6722 marketing director I Debbie Murray I d.l.murray@elsevier.com Marketing manager I Melanie Dowd I m.dowd@elsevier.com Director, Audience Development Sales Support I Mike Shear I m.shear@elsevier.com Audience development coordinator I Marisa Collier I m.collier@elsevier.com SUBSCRIPTION DEPARTMENT I 888/456-5367 REprints, eprints Licensing I Wright’s Media I 877/652-5295 I reprints@jems.com eMedia Strategy I 410/872-9303 I Managing Director I Dave J. Iannone I dave@goforwardmedia.com Director of eMedia Sales I Paul Andrews I paul@goforwardmedia.com Director of eMedia Content I Chris Hebert I chris@goforwardmedia.com EMS Today Conference Exposition reed exhibitions I Christine Ford I 203/840-5391 I cford@reedexpo.com ems today exhibit sales I 203/840-5611 Jeff Stasko I jstasko@reedexpo.com elsevier public safety vice president/publisher I Jeff Berend I j.berend@elsevier.com founding editor I Keith Griffiths founding publisher James O. Page (1936–2004) Choose 16 at www.jems.com/rs
  9. 9. Choose 17 at www.jems.com/rs
  10. 10. JOURNAL OF EMERGENCY MEDICAL SERVICES The Conscience of EMS JOURNAL OF EMERGENCY MEDICAL SERVICES EDITORIAL board William K. Atkinson II, PHD, MPH, MPA, EMT-P President Chief Executive Officer WakeMed Health Hospitals James J. Augustine, MD Medical Advisor, Washington Township (OH) 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 Fire-Rescue Adjunct Professor of Anatomy Physiology, Kaplan University J. Robert (Rob) Brown Jr., EFO Fire Chief, Stafford County, Va., Fire and 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 Ambulance Marc Eckstein, MD, MPH, FACEP Director of Prehospital Care, Los Angeles County/ USC Medical Center Medical Director, Los Angeles Fire Department Professor, Emergency Medicine, University of Southern California Charlie Eisele, BS, NREMT-P Flight Paramedic, State Trooper, EMS Instructor 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 SOM 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 Bureau of Police Special Response Team 12 JEMS JUNE 2012 Jeffrey M. Goodloe, MD, FACEP, NREMT-P Associate Professor EMS Division Director, Emergency Medicine, University of Oklahoma School of Community Medicine Medical Director, EMS System for Metropolitan Oklahoma City Tulsa 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 Keith Griffiths President, RedFlash Group Founding Editor, JEMS John J. Peruggia Jr., BSHuS, EFO, EMT-P Assistant Chief, Logistics, FDNY Operations 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 (Illinois) Community Hospital Robert J. McCaughan Chief, City of Pittsburgh EMS Chair, IAEMSC Metro Chief’s Section Robin B. Mcfee, DO, MPH, FACPM, FAACT Medical Director, Threat Science Toxicologist Professional Education Coordinator, Long Island Regional Poison Information Center 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 Edward M. Racht, MD Chief Medical Officer, American Medical Response Jeffrey P. Salomone, MD, FACS, NREMT-P Associate Professor of Surgery, Emory University School of Medicine Deputy Chief of Surgery, Grady Memorial Hospital Assistant Medical Director, Grady EMS Kathleen S. Schrank, MD Professor of Medicine and 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 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 Barry Smith, EMT-P CQI Coordinator, Regional EMS Authority (REMSA), Reno, Nev. 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 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 Fire Rescue
  11. 11. Choose 18 at www.jems.com/rs
  12. 12. EMS IN ACTION Scene of the month 14 JEMS JUNE 2012 Photo kevin Link
  13. 13. catching a fall P aramedics from Lethbridge Fire EMS in Lethbridge, Alberta, Canada, begin their assessment of a pedestrian who fell from a curb and became injured. The crew was confronted with a patient who appeared to be under the influence of alcohol and who was not able to adequately communicate with them. The crew performed a complete primary and secondary assessment. Because the patient was unable to communicate with them, they were unable to safely rule out a spinal injury. They carefully immobilized and packaged the patient. He was transported to a local hospital in stable condition. www.jems.com JUNE 2012 JEMS 15
  14. 14. from the editor putting issUes into perspective by A.J. HEIGHTMAN, MPA, EMT-P Is EMS A Game? Inefficiency can cost patient lives 16 JEMS JUNE 2012 Photo istockphoto.com Y ou get called to a wedding rehearsal dinner packed with excited family members and friends of the brideand groom-to-be. The people are there to celebrate the wedding of two of their favorite people when, suddenly and without warning, the bride’s grandmother collapses with nausea, weakness and respiratory distress. You were right around the corner from the restaurant when the call came in, so you arrived in less than a minute. The crowd’s emotions were already charged up before this medical emergency occurred. Now, you arrive and find the beautiful bride-to-be screaming over “Nanna,” who’s lying on her side, nauseous, vomiting and gasping for air. The bride-to-be’s grandfather and her “daddy” (Nanna’s son), are all standing in a circle around the woman when you reach her and set down your oxygen bag, airway case and medical kit. In the game of life, the cards are already stacked against you. You, in your role as the lead paramedic, kneel down to establish communications with the 85-year-old patient and start an assessment. She’s drooling and mumbling incoherently, and she has a confused look in her eyes as she tries to listen to you. She exhibits right-sided facial droop and is unable to follow your request to hold her arms out straight and level. One side of her body is clearly weaker than the other. Your partner readies the cardiac monitor and tries to politely place leads on her, but he can’t get them all in place because her dress, slip, girdle and bra are in his way. He’s hesitant to cut them open and expose her in front of her family. So he says, “I think I’ll wait to hook her up and run a 12-lead when we get her out to the rig.” He turns his attention to spiking an IV bag and readying it to administer to the patient. He begins to slap her hand to find a good vein to cannulate. He then says, “I can’t find any good veins and can’t get to Running a cardiac EMS call is similar to running a football play. EMS providers should be a well-oiled team. her antecubital without cutting open the tight sleeve of her dress.” You say, “OK, give me a minute, and I’ll take a look to see if I can find one.” Your partner then kneels next to her with the IV tubing dangling from his one hand and an alcohol prep, IV catheter and tape in his other hand, waiting for you to take a look. Engine 52 arrives, and the crew walks in without any extra equipment or the ambulance stretcher. One of the firefighters cracks open the valve on your oxygen (O2) tank, sets the regulator to 10 LPM, tears open the plastic bag of a high-concentration non-rebreather oxygen mask and fills it with oxygen so it’s ready to deliver 80–90% oxygen to the woman. A police officer arrives with his own O2 bag but places it down because he sees that yours is already on the floor near the patient. He then stands nearby with his small notebook open, waiting to hear her name and age for his police report. The engine’s company officer stands next to him with his computer open, waiting to chart the care being given—as it’s being given. Another firefighter stands near the “O2 firefighter” and awaits orders from you. The “O2 firefighter” dutifully stands by and awaits the OK from you to place the oxygen mask on the elderly patient who’s now very weak, pale and diaphoretic. Early signs of cyanosis are showing around her vomit-laced lips. He seems to be waiting for you to stop attempting communication with her before he places the mask on her face. The family and other nearby guests can clearly see she’s in trouble. Then they hear the lead paramedic say, “Where the hell is the suction unit?” The unassigned firefighter responds, “Out at the rig. Do you want it?” Suddenly, you hear the patient’s son shout, “Of course he wants it! She’s got a ton of vomit in her mouth.” You pull the radio off your hip and radio out to Engine 52’s driver/engineer, “Medic
  15. 15. Choose 19 at www.jems.com/rs
  16. 16. FROM THE EDITOR continued from page 16 21 to Engine 52 engineer, bring in the suction unit.” Then you hear comments yelled from the crowd: Don’t just stand around. Do some“ thing for her.” You brought all that crap in here, and “ you don’t even have anything to clear her airway out?” Give her some oxygen. Why is that “ fireman just holding that mask in his hand? Put it on her face. She’s turning blue.” Where’s the stretcher? They brought “ in a computer and left the stretcher outside.” Quit playing doctor, she’s having a “ ‘stroke!’ Get her out of here!” You’ve heard that last statement before, and it makes your blood boil. You look at the guy saying it and tell him, “Sir, I am not playing doctor. I’m a paramedic trying to take care of this woman. Please let me do my job.” His reply is, “I see what you and your partner are trying to do, but everybody else is standing around with their hands in their pockets. Why are you two the only ones working on her?” It’s a rude awakening. His comments hit you like a wet wash cloth. You suddenly realize you’re in the middle of a large crowd of people with a very sick patient who’s clearly having a cardiovascular accident complicated by an unstable airway, and only two of the seven responders on scene (28.5%) are actively involved in patient care. You begin to bark out orders. To the O2 firefighter: “Suction her airway, put that O2 mask on her and get an 8 endotracheal tube and large straight blade ready for me.” To the engineer: “Please get a few peo ple to go out with you and get our stretcher in here ASAP. And, while you’re out there, tell dispatch to call the stroke center and advise them we are declaring a stroke alert and will be there in 20 minutes.” To the police officer: “Officer, please get a tablecloth and use a few people to create a curtain to give our patient some privacy while we cut her clothes open to put electrodes on her and start a humeral IO.” 18 JEMS JUNE 2012 To the fire captain: “Captain, could you hold off on charting, get the EZ-IO drill out of our kit and ready it for my partner please?” To your partner: “Mike, cut her clothes, get that 12-lead running, establish an IO and draw some blood to check her glucose level.” Things begin to happen rapidly now. The patient is cared for. Her frail body is covered by a sheet and blanket, and you exit the restaurant with your precious cargo. The woman’s husband is escorted to the ambulance by the fire captain and told that his wife is being taken to a specialty center. He’s then buckled into the front passenger seat of the ambulance to accompany her to the hospital. The police officer sees a large crowd of “out-of-town” relatives piling into their cars to attempt to follow the ambulance to the hospital. He politely orders them not to do so because it would be unsafe and tells them weren’t happening quick enough.” Lessons Learned You walk away realizing there was a lot to be learned from this call. You were operating at only 28.5% efficiency and in an uncoordinated manner. You also realize that if it was your grandmother lying on the floor and the same approach was taken to her care, you’d be upset like the patient’s son was. At the station, the captain calls you all together for a quick post-incident discussion of the call and says that it wasn’t managed as well as it could have been. He tells the crews that this was an example of how they need to function as more of a team on medical calls, much like they do at a structure fire. He compares it to a football team that has to go out on the field and march down the field in the last two minutes to score a winning touchdown. He points out that, in football, each play is planned and called in advance—like an ALS You suddenly realize that you’re in the middle of a large crowd of people with a very sick patient who’s clearly having a cardiovascular accident, complicated by an unstable airway, only two of the seven responders on scene (28.5%) are actively involved in patient care. to follow his cruiser to the hospital. After turning over your patient to the hospital emergency department (ED) staff, you come out to clean and restock your ambulance and find a few of the crew standing around the back of the ambulance. One pulls out a cigarette to have a smoke. Two others are laughing about a skit they saw the night before on Saturday Night Live. As this is occurring, you see the family arriving and heading toward the ED entrance. You tell the crews, “Folks, the call’s not over until we’re out of sight of the family. Let’s clean up and save all the nonwork related stuff for back at the station.” The patient’s son then walks over and thanks you and the rest of the personnel involved for taking such good care of his mother. He apologizes for getting too “wound up” at the scene but says he just got upset because he felt like things “just protocol—and everybody is expected to execute their assignment without the quarterback having to tell each team member who they need to block, where to run or how to hold the football. The crew gets the analogy, understands their inefficiencies and realizes that their inactions, or delayed actions, could cost a patient their life. They then agree to follow the “pit crew” approach that the department’s EMS training coordinator has been preaching for months. In an odd, but practical, way, EMS is, in fact, very much like a game. There’s always an objective to each patient situation and a prescribed action plan (and tasks) that are developed in advance of “playing the game” to enable the best, most organized and methodical players to win. The winner of the game of EMS is your patient. JEMS
  17. 17. Comprehensive, Credible, Educational... JEMS Products Help You Save Lives. Jems, Journal of Emergency Medical Services jems.com Website With content from writers who are EMS professionals in the field, JEMS provides the information you need on clinical issues, products and trends. Your online connection to the EMS world, JEMS.com gives you information on: • Products • Jobs • Patient Care • Training • Technology Available in print or digital editions! Product Connect jems.com eNewsletter Sign up now for the weekly JEMS.com eNewsletter. Get breaking news, articles and product information sent right to your computer. Read it on your time and 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 find and easy for you to read. Go to www.jems.com/ems-products FREE WEBCASTS did you Miss a live webcast? Check out the archives at www.JEMS.com/webcasts. • May the G-Force Be With You • CPAP in EMS: The Standard of Care Argument • Top 5 Ways an In-Vehicle Router Improves EMS Operations Patient Care • CPR Quality Improves Survival • Breathe Deeply: How CPAP and Ventilation Can Help Your Patients • Simulating Work: How to Effectively Incorporate Simulation into Prehospital Care • Connecting Care Teams and Collecting Data: How it helps both you and your patient—The Houston Experience • Blast Injuries: What You Need to Know • CPAP for Everyone! • Effective Documentation in a Digital World • How Mechanical CPR Devices Are Changing EMS Protocols • Decide to Save Lives • CPAP: Filling The Sails to Respiratory Relief • Influenza: Is This an Emergency? • Technologies Practices: Is EMS Driving Hospital Care? • Top 5 Ways an In-Vehicle Router Improves EMS Operations Patient Care • Universal Capnography: What, When, How and Why! Go to www.JEMS.com
  18. 18. LETTERS in your words This month, readers chimed in on two feature articles: one from May JEMS that discussed the prevalence of bedbugs (“What’s Buggin’ EMS: How to rid your rigs of a bedbug infestation,” by Wayne Zygowicz, BA, EFO, EMT-P) and one April clinical education article on treating penetrating trauma wounds (“Breaking the Surface: Arm yourself with knowledge about penetrating trauma,” by Bryan E. Bledsoe, DO, FACEP, FAAEM, EMT-P; Michael Casey, MD, Ryan Hodnick, DO). In addition to the interest these two articles garnered, a Street Science review on JEMS.com by Keith Wesley, MD, FACEP Marshall Washick, NREMT-P, added to the long-standing debate over the effectiveness of endotracheal intubation (“Study Analyzes Use of ETI vs. King LT-D for Cardiac Arrest Patients). Finally, we asked our Facebook fans to fill in the blank: “You know you’re a medic when ______.” Read what they said. Bedbugs Bugging You? We have ambulances getting patients with bedbugs on a weekly basis. It’s become a huge epidemic among our “hometels” in San Diego. We subcontracted with a company that comes out and completely disinfects the entire ambulance from top to bottom. This involves taking every single piece of equipment out of the ambulance that isn’t bolted to the ground. They take you out of service immediately after you notify a supervisor that you had a contamination. Four hours later, they put you back in service. I suppose they’re using such an aggressive approach because a few of our fire stations got infested with bedbugs after contact with a patient. Gross. ETI Debate This study’s researchers have reanalyzed that first attempt “placement” is more successful for King LT-Ds over endotracheal intubation (ETI). There is no data included in this study to support patient outcomes with regards to cardiac arrest outcome data. It’s certainly possible that a bag-valve mask (BVM) plus an orophayrangeal airway (OPA) until intubation is indicated in the patient would provide better end-result outcomes than either of these options. Just because something is more successfully inserted doesn’t mean it’s a better option for use. Lauren Dengate Via Facebook A pediatric study comparing ETI and King Airway LT-Ds is about to be published in Prehospital Emergency Care. It was a small study in simulated patients, but it’s the first pediatric study looking at the King Airway that I’m aware of. Examining Tom Steiner Via Facebook   illustration steve berry Our department uses Tyvek suits for everyone, including the patient. We carry a can of pyrethrum that we can spray down the crew, inside a bus. Then, we call an exterminator who comes out who treats the entire truck. Next, we strip down and place our clothing into a dryer on high for 30 minutes. We are placed out of service for the duration. This is a daily occurrence. Jeffrey Mancini Via Facebook Choose 46 at www.jems.com/rs 20 JEMS JUNE 2012 020_021LETTERS.indd 20 6/15/2012 3:20:47 PM
  19. 19. There are simply too many providers with not enough [endotracheal intubation] skills. It’s easy to say ‘train more,’ but large departments are hard pressed to have the time, money tracking ability to keep medics properly trained. alternative airways for pediatrics in the prehospital setting is a perfect area for further research. Alabama EMSC be and leave the subtle politics out of it. Andrew Friedman, NREMT-P Leesburg, Virginia Via Facebook I would say ETI no doubt. It’s a tube that goes into the trachea; King tubes rarely do. It’s a blind airway device that’s fine for a rapid need to provide ventilation, but why not just use an OPA and a BVM? We got rid of practicing rapid sequence intubation because many couldn’t properly intubate, wouldn’t cooperate with capnography or couldn’t figure out that they tubed the stomach. I personally think there needs to be a rigorous airway course in all schools, and I also think all ALS agencies need to drill on the importance of ETI, the proper techniques and the appropriate use. Manda Lin Author Bryan E. Bledsoe, DO, FACEP, FAAEM responds: First, I am a hunter and a gun owner. There was a great deal of discrepancy in these numbers, and multiple sources were reviewed. We had two weapons experts, one military and the other civilian, review the document and they made no comments. There appears to be a great deal of irritability regarding this, and the purpose was primarily to give relative examples—not be totally precise in terms of ballistics. The purpose of the article is more related to penetrating trauma than ballistics, and in the future it might be prudent to leave the ballistics out. There was no hidden agenda. Via Facebook A King is obviously easier and causes minimal disruption of the most important part, which is CPR. Endotracheal tubes are important when they’re needed, but it depends on which medics are doing the tubing. There are simply too many providers with not enough skills. It’s easy to say “train more,” but large departments are hard pressed to have the time, money and tracking ability to keep medics properly trained. Stuart Rhinehart Via Facebook Surface Issue? Let’s just stick to the science please. In the article, it mentions “assault rifles.” Epic fail gang. Most “assault” rifles are of smaller caliber than hunting rifles. They’re nothing more than military-style rifles, and the term “assault rifles” is a political term that isn’t needed in a magazine like JEMS. To nitpick some more, the ballistic charts are far from accurate, nor do they list a source. The AK 7.62 X 39 doesn’t come in 168 grain and doesn’t achieve the optimistic figures you give it, just as the 30-06 is bit more potent than you state, and it’s a more common hunting round. This begins to make me wonder if there is an agenda behind this article because the numbers aren’t exact. So let’s be accurate as a science-based article should What MAkes a MEdic? Eric Henry: You find yourself staring at everyone’s veins, from family friends to total strangers. Crystal Haynes: The term “frequent flyer” has nothing to do with getting on a plane. Tiffany Johnson Groves: You sit down with your family at dinner, and your food is gone in 90 seconds flat. Dylan Beickman: You run on a regular patient, and play the game “how much of the patient healthcare record can I complete before I get there?” Michael White: When you were an EMT, friends always introduced you as a paramedic, and now that you’re actually a paramedic, friends introduce you as an EMT. Also, you know every homeless person in town on a first-name basis and have no problem having a casual conversation with them even while you’re off duty, even while all your friends are trying as fast as they can to get away. Cheryl Menkhorst: You’ve stopped at a red light, made sure it was clear and went through ... in your personal car, followed by “oh crap, I am not in an ambulance.” JEMS Choose 20 at www.jems.com/rs www.jems.com JUNE 2012 JEMS 21
  20. 20. PRIORITYUSE TRAFFIC NEWS YOU CAN Breaking the RULES Is it always a bad thing? Types of Errors LeSage stressed learning to identify and distinguish the three types of errors: human error (HE), ARB and reckless behavior (RB). LeSage is a proponent of not punishing individuals for HE or ARB. Instead, these are coaching opportunities for management. For example, LeSage introduced the severity outcome bias. He believes the natural tendency is to punish employees for ARBs or HE based on severe outcomes. More simply stated, an entire agency might be pencilwhipping their checklists before the start Photo istockphoto.com P aul LeSage, assistant chief (ret.) for Tualatin Valley (Ore.) Fire and Rescue, talked at the Fire-Rescue Med conference about high-reliability organizations (HROs). He told a story about a law enforcement officer who accidentally shot a naked man out of a tree. The story goes that two law enforcement officers were called to a large urban mall where a naked man in a tree had drawn quite the crowd. Fire and EMS was called to standby. Law enforcement officers decided they’d have to use a Taser to get the man out of the tree. They asked EMS what they thought about that plan. “Awesome,” was their unified response. The first officer aimed and missed. He instructed his partner to shoot. She did, and she hit the man. As he fell to the ground, they realized she had mistakenly grabbed her gun and not the Taser weapon. LeSage explained that 74% of errors are caused by a failure to intervene. EMS could have realized this was a poor plan, but they let law enforcement continue. More to the point, the law enforcement personnel were demonstrating at-risk behavior (ARB). One of the factors in this situation was that the law enforcement policy was to carry both their weapons on the same side of their body. Had the policy dictated wearing the weapons on opposite sides, this story might have had a different outcome. best kind, according to LeSage, is peer-to-peer coaching. If you can get the entire system involved, it may deter that behavior. Finally, reckless behavior warrants punishment. Reckless behavior is a conscious disregard for a substantial and unjustifiable risk. Although LeSage believes these types of errors are rare, they are the type The idea of HROs originated in the Navy, to enable anyone to that deserve punishment. stop dangerous actions from occurring. Again, the key is educating yourof their shift, but no one is punished until self, your staff and your external imposers something goes wrong. LeSage says this how to differentiate between these errors. just encourages an environment in which employees hide their mistakes, leaving man- Event Investigation agement with little understanding about the So your agency has an error. Now what? problems in their agency. Now comes the event investigation. LeSage It’s a difficult balance of accountability says one of the biggest mistakes you can vs. punishment. Not punishing employees make during the investigation is to first ask sounds great in theory, but how do you the employee what the procedure requires. satisfy an angry board of directors or city He suggested that the only people who councilmen who want to see someone fall know the procedure manual back to front on the sword? are your new recruits. And what happens when a new EMS provider says after a call, “That’s not how we’re supposed to do it?” Internal External Imposers Instead of hammering out the policy Internal and external imposers are those who keep the rules. Externally, a lawyer that no one follows, the better approach is may find the ARB or HE negligent, but the to identify what the normal procedure is. internal imposer (e.g., chief) coaches the There’s likely an ARB occurring throughout employee not to make the mistake again and the agency. LeSage introduces five quesensures proper training for the entire agency tions, numbered in both chronological order and order of importance: to reduce the ARB. 1. What happened? The key to keeping those external impos2. What normally happens? ers satisfied—which admittedly may be no 3. What does procedure require? small feat—is to get their buy-in up front. 4. Why did it happen? Involve these decision makers in your event 5. How were we managing it? investigation. LeSage provided algorithms to Following that line of questioning will help determine the difference between HE, allow internal imposers to identify the probARB and RB. His system means HE results in counsel- lem, tie it to a current practice (likely an ing. Explain to the employee that you’re ARB), reflect on the actual policy and prosorry the mistake happened but also tell pose a new solution. Numerous agencies them they have an obligation to tell you across the U.S. are using this practice to minhow to avoid it from happening again and imize errors and learn from their mistakes. identify the problem within the organiza- Keep an eye out for more about HROs from tion’s training. ARBs require coaching. The LeSage on JEMS.com. —Lauren Hardcastle For more of the latest EMS news, visit JEMS.com/news 22 JEMS JUNE 2012
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  22. 22. continued from page 22 I f you haven’t been affected yet, it’s probably just a matter of time until you are. The national drug shortage is really starting to hit home for EMS agencies, and there’s no relief in sight for the foreseeable future. Nearly half of the drugs on a shortage list recently released by the Federal Drug Adminstration (FDA) are administered by EMS providers, and many of those medications are used to treat seizures, cardiac arrests and other life-threatening conditions that occur in the prehospital setting. As a result, many EMS agencies have been forced to make hard choices among alternatives that range from bad to worse. Some use alternative medications, or even expired medications, in the face of this crisis. Other agencies are simply waiting for direction from their state or regional EMS agencies and hoping for the best. But this raises an important question: Could an EMS agency incur liability for taking these kinds of actions or for failing to take any action at all? General Rules The more prepared you are to weather a drug shortage, the less likely you are to incur liability. Of course, EMS agencies can never completely inoculate themselves from lawsuits. But devising clinical strategies that best promote patient care in the event that critical prehospital drugs become completely unavailable can decrease the likelihood of being sued successfully. Fortunately, prehospital professionals are protected from liability if they act in good faith and without gross negligence in most states. Some states specifically provide immunity for EMS personnel if they follow applicable protocols or medical direction from an authorized physician, again presuming the EMS provider acts in good faith and without gross negligence. Many states also provide similar liability protection for the EMS agency itself, and for physicians who develop protocols or provide medical direction, if such activities are done in good faith and without gross negligence. That means that in most states, a plaintiff will likely have to prove that an EMS agency went far beyond “ordinary negligence” if they want to successfully sue the agency. But that may not be the standard in every state, and the immunity statutes and gross negligence standards may not apply to decisions regarding which medications to carry. Regardless of whether a simple negligence standard or gross negligence standard applies, most courts will ultimately look at things like whether EMS agencies acted in the best interests of their patients, followed applicable rules and protocols, and actually took reasonable and timely action when faced with a potential drug shortage. Generally, courts understand we’re often faced with circumstances beyond our control. There may be circumstances for which there’s simply no viable alternative to a medication that’s unavailable. In such cases, courts are often reluctant to impose liability. But EMS agencies still need to prepare for contingencies so that it’s clear what happens in the event that there are no alternatives. Protocols Photo A.J. Heightman Could EMS Drug ShortageS Present Liability Risks for the Industry? State laws and local protocols may dictate how your agency can address drug shortage concerns. For examIs your EMS agency at risk with how you manage ple, in some states, medical directors are given wide the drug shortage crisis? latitude in determining which drugs will be carried on the ambulance and in developing local clinical proto- agencies and facilities. State ambulance or EMS assocols. In these states, alternative therapies that involve ciations may be able to help organize group purchasmore widely available medications can be more eas- ing options to increase EMS buying power. There are ily implemented. In other states, changing a drug may also established purchasing cooperatives that may be require going through a bureaucratic process that could able to help. Hospitals may have much better buying power with drug manufacturers and can obtain prefertake several months. States that rigidly regulate EMS drug lists, or have ence in purchasing drugs that are in short supply. Just statewide protocols that include specific medica- make sure these agreements dictate that you’ll pay fair tions, may need to invoke an emergency rule-making market value for the medications and have the agreeprocesses to respond to these challenges and allow ment reviewed by your legal counsel for potential Antitheir EMS agencies to continue to provide high-quality Kickback Law concerns. Always follow laws and protocols: When considpatient care. Nevertheless, certain strategies can be applied universally, and applying these strategies can ering and/or using alternative treatments and medications, or when using drugs with lapsed expiration help reduce the risk of liability for EMS agencies. Inventory frequently: EMS agencies should inven- dates, always adhere to applicable laws, protocols tory all their drugs and check their expiration dates and medical direction. If there’s a way to relax those on a frequent basis. Agencies should assign drugs with laws and protocols, pursue those avenues. Consider more recent expiration dates to be used before those obtaining an emergency exception from the state if with later expiration dates. It’s a good practice to look one is available. Consider viable alternatives: EMS agencies, in at historical usage rates for your organization so the organization knows when it has fallen below a critical conjunction with their medical directors, need to be level. Also, ensure medications are properly distrib- proactive in making protocol recommendations when uted among vehicles and establish benchmark levels a drug is in short supply or when a drug will likely be in for medications on each ambulance in adherence with short supply. Is there an equivalent medication that’s safe? If so, consider any side effects and other contraapplicable laws and protocols. Track shortages: EMS agencies should also assign indications of its use. If there’s a way to have medicaan individual or committee to track drug shortage tions approved beyond their expiration date, consider information and trends on a local, regional and national this option. Or the agency may wish to consider using level. The American Society of Health-System Pharma- compound medications. Have a contingency plan: The cists (ASHP) maintains the most current Pro Bono is written by agency should have a contingency list of drugs in short supply and anticiattorneys Ryan Stark, plan in place in the event there’s no pated dates of resolution. You may also Doug Wolfberg and Steve drug, or viable alternative, available. wish to work with state and regional Wirth of Page, Wolfberg Consider other treatments, besides EMS agencies. Wirth LLC, a national medication, that might assist the Work cooperatively: Other providEMS-industry law firm. Visit patient. Work with medical direcers may have what you need. If state the firm’s website at www. tors to develop protocols that deal law permits, consider implementing pwwemslaw.com for more EMS law information. with worst-case scenarios. JEMS purchase agreements with other EMS Conduct a keyword search for “drug shortage” at JEMS.com for more information. 24 JEMS JUNE 2012
  23. 23. Choose 22 at www.jems.com/rs
  24. 24. Higher Learning Practice Educational Theories Put into by Al Kalbach, EMT-P Sim for Students Master the use of simulation in your classroom E MS has used simulation for decades in the form of CPR manikins, task trainers and standardized patients (i.e., real “victims” moulaged and simulating illnesses and injuries). However, with the advancement of high-fidelity (HF) manikins and the use of standardized patients in critical-thinking exercises, we’re now capable of offering scenarios that immerse students and providers in real-world exercises. And it’s had great results in improving the educational process and changing a lot of the traditional behaviors. Case in point: the 2012 JEMS Games. The use of HF manikins proved essential in providing a scenario that simulated a deterio- rating patient and provided the participating teams a platform to perform all necessary treatments in a realistic environment. The Laerdal/JEMS folks strategically designed and implemented an integrated educational approach by creating an article about asthma and announcing that asthma would be seen in the competition. In conjunction with this new educational approach, Laerdal provided its comprehensive Discover Simulation Toolkit to each JEMS Games attendee. The teams obviously paid attention, which emphasizes a key point of simulation: It’s designed to be constructive, not critical. Simulation is a safe place to learn, make mistakes and take away positive reinforcement. The Theory S imulation in healthcare is used for education, evaluation, research and system integration. The goal of this article is to assist the instructor in building a relevant scenario and providing a positive learning experience for the student. We can divide the simulation experience into the four “Ps:” Prepare; Practice; Present; and Post-review. Learn your simulator’s capabilities: Many institutes and departments have purchased HF manikins to augment their training program. Their use ranges from critical-thinking exercises to using the simulator as an advanced “task trainer.” Although all positively enforced training is good, it’s recommended that the instructor participate in training sessions offered by the manufacturer, and simulation-based training offered by such recognized organizations as the Society for Simulation in Healthcare (www.ssih.org), to understand the components of a successful simulation program. Skilled educators and technical consultants are also available to assist with planning and developing simulation learning. EMS conferences now regularly have simulation as a topic, so this can help the opera- 26 JEMS JUNE 2012 photo glen ellman Prepare This year’s JEMS Games competitors demonstrated ALS skills on Laerdal’s HF manikins. tor keep current on trends. High-stakes risk assessment: Every training institute and department has its own unique risks and encounters. A primary goal of your simulations should be how to address the high-stakes situations that your students/EMS providers encounter. Is there a trend your students are struggling to grasp? Is there a new method or protocol you want them to learn? Has a prob- lem been encountered that affects crew or patient safety? You can gather the information from classroom and exercise performance, patient charting/documentation, crew reports, hospital/command feedback and any stakeholder resource. Once the risk is identified, you can begin to plan your strategy for a simulation exercise. Critical-thinking points: No matter the exer-
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  26. 26. Higher Learning continued from page 26 cise, critical-thinking points should be limited to the main point of the exercise. Let’s take the subject of identifying an ST-elevation myocardial infarction (STEMI) patient and transporting the patient to an appropriate facility. The provider should be able to do the following: 1. Identify STEMI; 2. now of and be capable of directing K appropriate care; 3. ommunicate with command physiC cian and recommend STEMI alert; and 4. ommunicate well with receiving facilC ity staff. This example stays within the parameters of care, treatment and transport of a STEMI patient. It doesn’t add complications or “gotcha” points. advanced cardiac life support and pediatric ALS and standards. This saves you from having to build these programs from scratch. However, you should ask yourself whether the program meets the needs of your simulation education because if it doesn’t, you’ll have to build or modify your program to suit your specific needs. Scenario building/environment: We emphasize that instructors need to be able to program and operate their simulator efficiently. Sketch out your scenario into a logical flow. Using a template or flow chart is an ideal way to lay out the scenario on paper. Check all sections for accuracy and have your key instructors check and agree that all points are included in the template. Building scenarios in your simulator’s program: This will vary by each manufacturer and even between models from any manufacturer. Consider your critical-thinking points as key trigger points in your simulation. Other triggers can be skills and procedures that normally would be encountered in the given scenario. Simulator manufac- turers provide a good number of skills and procedures, but you may want to add more to meet your specific needs. Running a program “on the fly:” This type of program is completely manual. It depends on the simulation operator to make all necessary parameter changes and record all critical-thinking and skills assessments. Obviously, the operator needs to be familiar with the simulator and its systems to be able to run an “on the fly” program successfully. This type of program can also be used for situations in which a preprogrammed or built scenario fails to advance and critical parameters need to be changed. The practice S kills: Simulators are also valuable because they can be used effectively to develop, maintain or augment various lifesaving skills. This can include the administration of drugs, advanced airway care, medication and most BLS and ALS skills. Simulators have the ability for instructors to log skills in real time as they occur, and some skills are automatically logged by the program. The instructor can also log in during the scenario run and make comments that may aid in instruction after the scenario is complete. Pre-programmed scenarios: Many simulator manufacturers have common, frequently seen (and seldom seen) simulations for clinical (medical and traumatic) cases, to get you started. They also offer programs you can purchase that are designed to meet the needs of specific healthcare practices. For example, you can purchase programs that meet Practice Now that your simulation is operational and loaded with key simulation scenarios, you should do run-throughs with key instructors and personnel to be sure that all key criticalthinking points have been met, correct procedures are implemented and all teaching points are included. Running the program will alert the instructor to possible conflicts or errors in the program as well. A checklist of critical-thinking points and skills should be provided to each instructor to ensure all training criteria have been met. Use this “shake-down run” to ensure you work out any bugs and eliminate surprises. photo glen ellman Presenting to the Masses After starting the simulation, allow students to immerse themselves into the care of the patient. 28 JEMS JUNE 2012 You’re now prepared to present your simulation to the learners. Make sure that everything they need to learn is presented in advance and that all required equipment is in place before you start. The learner should be made aware of the type of simulation they’ll be participating in and given an outline of what’s expected of them before they start. Allow sufficient time for learners to check equipment and environment for their comfort. It’s recommended to advise the students to check their environment and ask any questions they may have before starting.
  27. 27. Start the simulation and allow the students to immerse themselves into the care of the patient. You should only interrupt if there’s a safety concern or if the student(s) prompt you. If possible, it’s best for the instructor to be in a separate room or other remote location where you can view the entire process. Let the scenario flow. You should have an on-screen checklist of the points and skills you want covered. This will help you in the debriefing process. The instructor running the simulation usually acts as the voice of the patient via microphone and headset. Video recording is another tool commonly used in the simulation process. Students should be made aware they’re being recorded for educational purposes only and that the video won’t be stored or used to embarrass or show negative outcomes. Post-Simulation Review Student debriefing (review) should be accomplished immediately after the scenario is concluded or as soon as feasible. Debriefing is the process by which students interactively review their performance after completing a simulation exercise. The procedure should be guided by session objectives, course material and student comments and questions. Instructors should serve as a resource and interject goals and outcomes of the scenario in a positive manner, not act as a lead voice in the debriefing process. Instructors should debrief and review participants to reflect on the presentation and its benefits in the learning process as soon as possible after the simulation presentation. The instructor can have debriefing files generated during the simulation. Some simulators have the capability of recording video that synchronizes with the debriefing file. Key points that occur can be marked in the file for fast retrieval and playback during the debriefing. In your review, consider the following: ere the main critical thinking points covered in the simulaW tion? ere all skills addressed and completed? W id the participants respond appropriately to the presented D scenario? ere crew and patient safety appropriate? W as there anything else that should have been covered to meet W the goals of the scenario? hat’s the feedback from the participants? W Conclusion Healthcare HF simulation is advancing and has joined the ranks of aviation, space flight, military and other high-stakes roles. With the continual advancement of computer science and simulation design, we can provide a safe learning environment for EMS providers and produce a more effective and efficient EMS system. JEMS Al Kalbach, EMT-P, is a simulation specialist for Good Fellowship Training Institute in West Chester, Pa. He’s also the owner of Safety Watch LLC. Contact via e-mail him at al@safetywatchtraining.com. Resources https://ssih.org/about-simulation www.jems.com/article/training/simulation-play-key-role-2012-jemsgames Choose 24 at www.jems.com/rs www.jems.com JUNE 2012 JEMS 29
  28. 28. TRICKSour patients ourselves OF THE TRADE caring for by Thom Dick, EMT-P Do No Harm It’s important to not inflict unnecessary pain 30 JEMS JUNE 2012 Photo Thom Dick J ust when you think you’re never going to be surprised again in your life, you get the surprise of your life. I recently spent a week in a hospital because I had to have an ankle removed. I learned a ton, Life-saver. Then, I spent a week in a skilled nursing facility (SNF) and learned another ton. Gotta say, I received some great care (and a renewed sense of humility) in that SNF. You’ll probably be reading about my stay there, someday. But that’s another story. This one’s about something that happened in the hospital. I’ve often marveled that the word “hospitality” is mostly made out of “hospital,” and yet the staff in so many hospitals seem to understand so little about hospitality. (Small wonder there’s a joint commission.) As evidence, I’d like to tell you about my IV. That’s it, just the IV. I won’t bore you with the rest of a very long list of observations I made before and after the Versed part, which came right after the IV. (I think.) My wife and I reported to a surgery center, where a nurse named Karen gathered my clothes and a whole lot of information about me. Now, I have great veins. I know that because they’ve all been found by student EMTs and medics. In particular, I have great “intern’s” veins. (You know the ones. They’re the veins formed by that big branch of the cephalic vein that intersects with the crease of the lateral wrist.) Well, Karen started exploring the veins on the backs of my hands before she settled on my left intern’s vein, which was so prominent I could see its shadow. I don’t know how she could have missed it with that big 20, but she managed. Finally, after poking, digging and stabbing, she nailed it. I have hairy arms. I noticed Karen was going for the IV without shaving the hair on my wrist and thought maybe I should say something. But I was too slow, so she poked me and slapped an OpSite on top of all that hair, then plenty of tape on top of that. Writing this, I would like to tell you Taking the time to shave a patient’s arm before starting an IV may seem simple, but they’ll appreciate it. (and her what happened in the course of the next five days. On the day after surgery, the site had to be re-taped because the IV became unstable. To secure it, another nurse simply added more tape (circumferentially, I might add). The day after that, another nurse ripped all the tape off (but left the original OpSite, clinging only to my hair) and just replaced the tape. When I asked her to moisten the tape with alcohol before ripping it off, she said she was too busy to do that. Two days later, I mentioned to a fourth nurse that the IV was falling out (again). By that time, a lot of congealed blood was visible in the tubing. The nurse cleared the line by flushing it and shoving the congealed blood into my vein. I’m sure it’s now a space-occupying lesion in one of my lungs. Then he asked if I minded having a newly graduated nurse start a replacement IV. I agreed, and within five minutes, a pair of really young nurses entered the room with an IV tray. When they started ripping the tape off, I asked them if they would please moisten the tape with an alcohol prep. One of them kept on ripping, saying he didn’t have time for that, so this time I insisted. Sure enough, the alcohol soaked through the backing on the tape, and within seconds it had softened the adhesive. The tape came right off. But then they treated me like a smart ass for making the suggestion. “Sorry,” I said. “I’ve started a lot of IVs in my life, and I just know it works.” That didn’t impress them, especially after I asked them to shave the site this time. In fact, one of them looked at me as though I was being a jerk. “You know,” he said. “We’re not students. We’re nurses.” “I’m just telling you,” I said. “It really hurts when people rip that tape off of somebody’s hairy skin. Not to mention the added risk of infection.” I know you start lots of IVs on hairy people. And sometimes when you do, you’re in a real hurry. But do them a favor. Hell, do me a favor. Give ’em the benefit of a onesecond shave. They may never know the difference. In that case, let me say this in advance. Thank you! JEMS Thom Dick has been involved in EMS for 42 years, 23 of them as a full-time EMT and paramedic in San Diego County. He’s currently the quality care coordinator for Platte Valley Ambulance, a hospital-based 9-1-1 system in Brighton, Colo. Contact him at boxcar414@yahoo.com.
  29. 29. Choose 25 at www.jems.com/rs
  30. 30. CASE OF THE MONTH DILEMMAS IN DAY-TO-DAY CARE BY Steven R. Allen, MD Cayla G. Conover Difficult Airway Providers treat patient with multiple gunshot wounds Assessment Treatment Providers learned that the patient was allegedly in an altercation with another man outside a bar. The conflict became violent, and the patient sustained multiple gunshots to his chest and right thigh. The patient was unresponsive with labored breathing and unstable vital signs. He did not present with signs of external exsanguinations. In addition to his hemodynamic instability, the patient was noted to have crepitus over his left chest. The patient was unresponsive and had a Glasgow Coma Scale (GCS) score of 3. He was unable to protect his airway, so providers attempted an endotracheal intubation (ETI) with a 7-0 endotracheal tube (ETT) by the firstarriving EMS crew. However, this was aborted because of the patient’s strong gag reflex. The patient was transported to the landing zone, where a PennStar flight crew performed rapid sequence intubation. On the first attempt, the patient was noted to have a very swollen airway with poor visualization of airway landmarks. The plain radiograph of the head and neck shows the bullet hole, which is marked by the paperclip. The patient was transported emergently to undergo a computed tomography (CT) scan with an angiogram of the neck and left lower extremity to assess for vascular injuries of the neck and injured leg, respectively. 32 JEMS JUNE 2012 After two failed attempts with standard laryngoscopy, the providers successfully placed the ETT using the King Vision video laryngoscope blade. Successful ETI was confirmed with endtidal carbon dioxide (EtCO2), and breath sounds were confirmed bilaterally. Providers noted subcutaneous emphysema, which was demonstrated with palpable crepitus over the patient’s left chest and hemodynamic instability, which prompted needle decompression of the left chest. The patient’s vital signs improved with these interventions. A rapid evaluation of his wounds at the scene identified a single wound just inferior to his left clavicle and multiple wounds to his left thigh, all of which weren’t actively bleeding. A C-collar was placed on the patient, and he was transferred to the flight stretcher and transported to the trauma center by an air medical crew. Trauma Center Care On arrival at the trauma center, the trauma Images Courtesy Steve Allen A fire rescue crew responded to a call that described someone who was reportedly “shot in the chest.” The scene was secured by law enforcement before EMS arrival. On arrival at the scene, EMS providers discovered a patient reportedly in his 30s who was unresponsive in the supine position with multiple gunshot wounds to his chest and extremities. This CT scan shows the angiography of the neck. Note the degree of tracheal deviation due to hematoma and swelling.
  31. 31. team performed the primary survey and placed the patient on the monitor to measure vital signs. They recorded a heart rate of 106 beats per minute; blood pressure of 79/48 mmHg and EtCO2 of 31 mmHg. During the primary survey, the trauma team used direct laryngoscopy and color change capnography during their primary assessment to confirm the patient’s airway was in the correct position. Because the patient underwent needle decompression of his left chest, a left tube thoracostomy was immediately placed in the standard fashion without a return of air or blood. The patient was sedated after intubation and remained with a GCS of 3. Although movement of extremities couldn’t be assessed on this evaluation due to sedation, the patient presented with priapism, which is concerning for a spinal cord injury. The wounds were again identified and marked, and plain radiographs were obtained to assess the trajectory. A single wound was identified over the left chest just inferior to the clavicle with a primary bullet fragment in the This intra-operative photograph demonstrates the near-complete transection of the left common carotid artery near the level of the clavicle. midline of the neck. Two wounds were identified on the left thigh. There was no active bleeding from the wounds. The patient was transported emergently to undergo a computed tomography (CT) scan with an angiogram of the neck and left lower extremity to assess for vascular injuries of the neck and injured leg, respectively. Cessation of blood flow was recorded in the left common carotid artery with reconstitution above the bifurcation. The CT angiogram of his left leg was normal. The patient was moved emergently to the operating room for exploration of his neck to identify and Choose 26 at www.jems.com/rs www.jems.com JUNE 2012 JEMS 33
  32. 32. Case of the month continued from page 33 repair the injury to the carotid artery and assess for injuries to the trachea, esophagus and surrounding structures. The patient underwent a median sternotomy that was extended up onto the neck to better expose the carotid artery. A destructive injury of the common carotid artery at the level of the clavicle was identified. The carotid artery was controlled in the chest and repaired with a saphenous vein interposition graft. The trachea was assessed and found to be uninjured. An endoscope identified a small area of ecchymosis on the esophageal wall. However, because of the presumed injury and the patient’s inability to eat for a prolonged period of time, a percutaneous feeding tube was placed in his stomach. The patient was found to have a complete spinal cord transection at C-6 with associated quadriplegia. He suffered ventilator-dependent respiratory failure and required a tracheostomy for prolonged ventilator support. He was weaned from the ventilator and discharged to an inpatient rehabilitation center, where he continues to improve. Discussion ETI is the standard of care for definitive airway management. Success rates of ETI in the prehospital setting vary significantly in the literature. The presence of a difficult airway in any setting is a life-threatening scenario, which requires significant skill and forethought with other alternatives in the event that standard strategies fail. Multiple reports have demonstrated higher incidence of unanticipated difficult intubations in the prehospital setting compared to those in the operating room. Although the incidence of difficult intubation is only 2% in elective anesthesia care, the incidence in the prehospital environment approaches 10%.1 Management of an airway in the prehospital setting may be difficult for many reasons: The patient is in extremis, hemodynamically unstable or uncooperative; The patient has particular injury patterns, such as fractures and trauma to the face and neck with associated bleeding and swelling in and around the neck and orpharynx; or The patient has emesis and aspiration. Choose 27 at www.jems.com/rs 34 JEMS JUNE 2012 Although controversy surrounds the use of ETI in the prehospital setting, there’s also a body of evidence that demonstrates the benefits in patient outcomes with prehospital intubation in patients with traumatic brain injury, cardiac arrest and risk for loss of airway patency or aspiration.2 Prehospital providers must weigh the risks and benefits to the establishment of an artificial airway. Complications related to ETI include unrecognized esophageal intubation with associated hypoxia and hypoventilation, oropharyngeal or tracheal injury or even hyperventilation, which may lead to cerebral ischemia.1 With these risks in mind, providers need to consider the risks of not establishing a definitive airway prior to transport of the patient. In the case presented here, in which the patient had labored breathing and increased swelling of the patient’s neck, a delay in airway control could’ve been a mortal decision because loss of airway patency was imminent. Multiple airway management algorithms have been established. One study defines a
  33. 33. difficult airway as a failure of tracheal intubation after a single attempt in a patient with a Cormack-Lehane class IV airway or two failed attempts in a patient with a CormackLehane class of III or less.2 Most recently, a variety of video laryngoscopes (VLs) have been advocated to facilitate successful ETI in the case of a difficult airway. The proposed benefit of using a VL is improved visualization of anatomy with improved graphics on the monitor in contrast to the minimal view one may see on a traditional laryngoscope—especially in dark, austere environments. Early studies have demonstrated quicker intubation and improved success rates in ETI with a VLs when used by medical students, nurses and paramedics.1,3 However, these data are preliminary and haven’t been reproduced. Other studies have demonstrated the advantages of VLs in patients with difficult anatomy compared with a Macintosh laryngoscope. Although video-assisted intubation may have its advantages, it’s not recommended as a first-line technique in standard intubations.3 Conclusion Penetrating wounds to the chest and neck may present EMS providers with significant challenges related to airway management. It’s important to use sound judgment whenever a case requires definitive airway management because it’s key to act quickly to secure the airway in cases involving traumatic brain injury or impending airway loss. A difficult airway may be encountered in those patients with penetrating injuries to the head, neck or chest. The provider must be skilled at ETI. In the case that standard intubation is unsuccessful, the provider must be able to use other means to establish the airway, which may include a bougie, laryngeal mask airway, video laryngoscopy or even a surgical airway. JEMS Steven R. Allen, MD, is an assistant professor of surgery at the University of Pennsylvania in Philadelphia. He’s board certified in surgery and surgical critical care and practices as a trauma surgeon and surgical intensivist. He can be contacted via e-mail at Steve.Allen@uphs.upenn.edu. Cayla G. Conover is an undergraduate student at Temple University in Philadelphia. She’s a biology major with plans to attend medical school. References 1. Butchart AG, Tjen C, Garg A, et al. Paramedic laryngoscopy in the simulated difficult airway: Comparison of the Venner A.P. Advance and GlideScope Ranger video laryngoscopes. Acad Emerg Med. 2011;18(7):692–698. 2. Warner KJ, Sharar SR, Copass MK, et al. Prehospital management of the difficult airway: A prospective cohort study. J Emerg Med. 2009;36(3):257–265. 3. Dupanovic M, Fox H, Kovac A. Management of the airway in multitrauma. Curr Opin Anaesthesiol. 2010;32(2):276–282. Resources Combes X, Jabre P, Margenet A, et al. Unanticipated difficult airway management in the prehospital emergency setting: Prospective validation of an algorithm. Anesthesiology. 2011;114(1):105–110. Choose 28 at www.jems.com/rs www.jems.com JUNE 2012 JEMS 35
  34. 34. RESEARCH REVIEW ems What current studies mean to by David Page, MS, NREMT-P Epinephrine’s Effects Study examines drug’s influence on cardiac arrest survival Hagihara A, Hasegawa M, Abe T, et al. Prehospital epinephrine use survival among patients with outof-hospital cardiac arrest. JAMA. 2012;307(11):1161–1168. pinephrine has been the mainstay of cardiac arrest management for decades, but is it effective? These authors used a Japanese national database of prospectively collected cardiac arrest data to see whether epinephrine was associated with positive outcomes. This analysis included 417,188 arrests between 2005–2008. Return of spontaneous circulation was observed in 18.5% of patients who received epinephrine (2,786 of 15,030), and 5.7% (23,042 of 402,158) of patients who didn’t receive epinephrine. The overall survival rate for the epinephrine group was 5.4%, but only 1.4% had good neurological outcomes. The non-epinephrine group had a 4.7% survival rate, and 2.2% had good neurological outcomes. Although this study sampled a large number of patients and was published in a prestigious medical journal, we need to be careful about the conclusions we draw from it. The authors discuss some major limitations: Japanese EMS personnel started giving epinephrine in 2006, but the data doesn’t include the amount that was given. Hospital care was variable. The authors don’t know whether in-hospital epinephrine was given or whether therapeutic hypothermia was used. I also think the study needs information on immediate conversion of v fib and v tach without prolonged resuscitation, rate of compressions, mechanical compression/ decompression, ventilation rates, oxygen administration, excessive pauses and use of an impedance threshold device. Effective, outcome-driven cardiac arrest management is multi-factorial. The authors addressed the need for a randomized placebo controlled trial, and I completely agree. Obtaining ethics board approval for 36 JEMS JUNE 2012 Photo david page E Researchers examined whether epinephrine was associated with positive cardiac arrest outcomes. a trial of such a standard medication as epinephrine will be challenging. We should applaud these authors for taking another step to lay the groundwork for more intentional studies in the future. The bottom line is we should remind ourselves that all interventions come with unintended consequences. We need to continue with practicing the status quo, but we also need to be careful with epinephrine and get more involved in research. Bottom Line What we know: Epinephrine is used widely. Studies in 2007 and 2009 showed increases in ROSC but not in survival to hospital discharge. What this study adds: This study provides evidence that epinephrine is associated with ROSC but not with survival to discharge. I IV Analysis I Selker HP, Beshansky JR, Sheehan PR, et al. Outof-hospital administration of intravenous glucoseinsulin-potassium in patients with suspected acute coronary syndromes: The IMMEDIATE randomized controlled trial. JAMA. 2012;3;307(18):1925–1933. B y way of disclosure, I want to state that one of my medical directors is involved in this study. So I claim immediate bias and conflict of interest, but I still think it’s a good idea to report on this study and its results, especially because this column previously reported the initial use of the “ACI-TIPI” predictive ischemia scale used in this trial. (Search JEMS.com for “research review.”) The group of researchers studied the use of glucose insulin and potassium (GIK) to protect from myocardial injury during acute coronary syndromes. The idea was to give agents that might protect the cells from metabolic derangements (promoted by elevated free fatty acids, or FFAs) and reperfusion injury. Cellular FFAs and their derivatives are believed to accumulate during ischemia, disrupt the mitochondria, increase intracellular calcium and promote arrhythmias. GIK might be a relatively safe, cost effective and plausible way to begin prehospital treatment. The original goal of this study was to enroll more than 15,000 prehospital patients because the benefits were thought to be dependent on early administration. Unfortunately, the National Institutes of Health changed the study due to the lack of resources and funding to include in-hospital administration, and enrollment was curtailed at 880 patients. One-year outcome data is still being collected. So the final data isn’t yet available. For now, this paper reports that GIK didn’t seem to stop further myocardial damage (i.e., no statistical difference was found in the patients who progressed). The authors suggest this may be because
  35. 35. the medication wasn’t administered early enough because the damage had already started. Interestingly, although not statistically significant, the mortality rate at 30 days was 4.4% with GIK and 6.1% without GIK. If we add a composite end point of cardiac arrest in combination with mortality (e.g., patients who arrest, as well as those who died), then the difference would be statistically significant (6.1% with GIK and 14.4% without GIK; P=0.01). GIK needs to be tested more, but it appears that it may be a safe and effective therapy to decrease cardiac arrest and death in patients with acute myocardial infarctions. I Emotion Work I Williams A. A study of emotion work in student paramedic practice. Nurse Educ Today. 2012;Apr 2 [Epub ahead of print]. T oo often we focus on research that’s quantitative (research that attempts to measure something numerically). Qualitative research is focused on descriptive and human factors. In this project, Williams interviewed eight paramedic interns in England. The objective was to describe the emotions and coping mechanisms that a new paramedic student has when they’re faced with cardiac arrests and other critical cases. This study is a great reminder that our new clinicians need support as they’re involved in new critical events. They observe these through the lens of a novice, like a magnifying glass that accentuates their emotions and reactions. Williams discusses two main themes: “getting on with the job” and “struggling with emotion,” the latter of which relates to students struggling to control and suppress their emotions. Educators beware: It’s essential for you to prepare for and support your students through these emotions. JEMS Choose 29 at www.jems.com/rs Visit www.pcrfpodcast.org for audio commentary. David Page, MS, NREMT-P, is an educator at Inver Hills Community College and a paramedic at Allina EMS in Minneapolis/ St. Paul. He’s a member of the Board of Advisors of the Prehospital Care Research Forum. Send him feedback at dpage@ehs.net. Choose 30 at www.jems.com/rs www.jems.com JUNE 2012 JEMS 37
  36. 36. Richmond Ambulance Authority creates comprehensive culture of safety model The Richmond Ambulance Authority has worked hard to create and foster a culture centered on safety in all areas. 38 JEMS JUNE 2012
  37. 37. By Rob Lawrence, MCMI; Bryan S. McRay, BA; Dempsey Whitt, NREMT-P/FP-C; Joseph P. Ornato, MD, FACP, FACC, FACEP T he Institutes of Medicine’s landmark publication To Err is Human estimates that at least 44,000 and perhaps as many as 98,000 Americans die in hospitals each year as a result of medical errors.1 And hospital patient safety incidents account for $6 billion in extra costs annually in the U.S.2 Is EMS any different? In a 2002 Prehospital Emergency Care study, the authors wrote a consensus statement that represented the views of several respected operational medical directors regarding the national state of EMS safety.3 The group identified common EMS errors and concluded, “Standard operating procedures to prevent and recover from such errors in the field are in their infancy.” Shortly thereafter, several researchers conducted a survey of 283 EMS providers attending a North Carolina EMS conference and found that one or more errors had occurred during the previous year in 44% of those surveyed.4 However, only half of the errors were reported to their supervisor or medical director. In 2008, two authors wrote an editorial calling for the establishment of a national center for EMS provider and patient safety.5 A national center doesn’t exist yet. However, a number of local and state initiatives, such as the Missouri Center for Patient Safety, are beginning to focus on at least some aspects of safety in EMS. This article describes the comprehensive, multidimensional safety program developed and implemented at the Richmond Ambulance Authority (RAA), a highperformance EMS system serving Richmond, Va. RAA is a self-operated public utility model EMS system employing a system status management approach to its deployment, command, control and communications. It’s a member of the Coalition of Advanced EMS Systems and is accredited by both the Commission on the Accreditation of Ambulance Services and the National Academy of Emergency Medical Dispatch as an Accredited Center of Excellence. RAA employs unit hour utilization (UHU) as its currency to ensure that all available income is transformed into helping deliver world-class EMS. A unit hour is equal to one hour of service by a fully equipped and staffed ambulance available for dispatch or assigned to a call. UHU is a measure of productivity, which compares the available resources (i.e., unit hours) with the actual amount of time those units being used for patient treatment and transport or Photos Richmond Ambulance Authority Transformation to AN EMS Culture of Safety Choose 31 at www.jems.com/rs www.jems.com JUNE 2012 JEMS 39
  38. 38. Safety First continued from page 39 productive activity. UHU is the measurement of unit hours “conTaking Safety to the sumed” in productivity compared Streets 2011 Data with the total staffed unit hours. In Fatality rate for EMS providers simple terms, UHU monitors the is 2.5 times higher than the provision of resources available in national average. the right quantity, at the right time Non-fatal injury rate for EMS practitioners is five times and in the right place to perform, higher than the rate for other treat and transport efficiently. healthcare providers. Conceptually, RAA operates EMS providers are seven times within a total quality and safety more likely than the average bubble, employing lessons learned worker to miss work as result of an injury. from other high-quality, safety-oriented industries, such as nuclear • Transportation-related Fatalities and aviation. (per 100,000) In 2008, RAA’s operational National average: 2.0 medical director, a pilot with first Firefighters: 5.7 Studies comparing and contrasting EMS with both national and public Police officers: 6.1 hand experience in how aviation safety incident data reveals a telling story and provides focus in the immehas achieved a high level of safety, insti- EMS practitioners: 9.6 diate need to develop and embrace a safety culture across EMS. gated a successful error self-reporting • Fatal Occupational Injuries program patterned after the Aviation non-work related governing emergency driving and RAA’s 12 (per 100,000) Safety Reporting System (ASRS) devel- National average: 5.0 injuries and standards of driving adopted from the Allsafe oped by the National Aeronautics Firefighters: 16.5 miss 10 shifts or Driving System. and Space Administration (NASA). Police officers: 14.2 more must pass Focus on safe vehicle operation is main EMS providers: 12.7 The NASA system was designed to the PAT before tained through consistent reiteration of the detect all near misses and to translate they’re cleared to 12 standards of driving via periodic safety lessons learned into operational process permanently return to work. campaigns as well as safety talking points changes rather than blaming individuals for highlighted by field providers and safety and human errors. risk staff during everyday operations. Checks Induction to the Organization RAA’s approach to safety pervades all lev- Introducing, developing and embedding a and balances are kept on drivers via an onels and departments, from the frontline to the culture of safety are core functions of the board road safety system. The “black box back office. This starts in the pre-hire phase. new employee orientation program. The ini- technology” interactively monitors preset Conceptually, RAA also looks ahead to plan tial classroom-based induction covers scene driving parameters, giving the vehicle operaand anticipate the next set of safety issues that safety, the operating principles of all of RAA’s tor immediate feedback through the use of may arise. key pieces of equipment, safe and skilled audible tones. Monitored parameters include operation of vehicles, and correct appropriate patient transfer techniques. Pre-Hire Process All new employees are immersed in safety RAA’s approach to safety begins even before the employees receive an offer letter. RAA from orientation through field preception. contracts with an occupational health ser- For 26 shifts, RAA’s field training officers vice that conducts a pre-hire physical agility carry on where the classroom left off, providtest (PAT) on all field operations candidates ing practical instruction and leadership by to determine their existing muscular skeletal example in a controlled environment, ensurstrength, which is often predictive of future ing that providers are prepared to operate physical problems, such as a back injury. The safely as RAA crew members. RAA instruccomputer-based system RAA has used for the tors also teach the National Association of past two years has proven to be an effective EMTs’ safety course to its employees. predictive tool. For example, RAA now factors the PAT Safe Driving results into its decision whether to offer New hires are required to be emergency vehiemployment to an applicant. Some highly cle operator course (EVOC) qualified prior qualified candidates have failed to make it to employment at RAA. From this baseline, to the initial New Entry Orientation because safe and skilled vehicle handling is built on they haven’t met the PAT requirements. with the successful completion of the inAs a prudent risk-reduction measure, staff house driver training program. This program RAA uses data and reports to identify and correct members who have suffered either work or includes a review of EVOC material, state laws potential safety issues before they occur. 40 JEMS JUNE 2012
  39. 39. seatbelt compliance, lights and sirens usage, acceleration and deceleration forces, turn signals and safe vehicle reversing. The latter feature also requires the use of a spotter who activates a reverse button located in the rear of the vehicle to alert the driver of any hazards. A weekly league table of emergency and non-emergency driving that scores vehicle operators is produced. In the rare event of a vehicle collision, road safety data is downloaded to analyze the activity of the vehicle at the time of the incident. This ability to instantly review the incident helps create a clear picture of what occurred, which allows RAA to fully understand the root cause of the incident so the operational changes can be made to prevent a recurrence. just regarding patient care but also regarding vehicular safety. The driver and the paramedic crew member are both responsible for the vehicle’s safety. They must work as a team to coordinate navigating to calls, obtain additional information from the mobile data terminals, work the siren and communicate on the radio. The single most important thing employees can do for their patients and for themselves is to have both sets of eyes looking outside the unit as much as possible. Crews are discouraged from performing any tasks during the response phase that aren’t absolutely critical to the current call. This is similar to the “sterile cockpit” rule used in aviation, which dictates that a crew isn’t allowed to have non-task critical conversation or distracting activity during the takeoff, approach and landing phases of flight. Safety All Day Every Day RAA’s operations are designed with efficiency and effective response in mind. The by-product of this planning is safety. We’re convinced that lights and sirens responses Self-Reporting Program The RAA self-reporting program provides an employee who makes a mistake the opportunity to report that incident without fear of punitive action, as long as it’s not a criminal act. Once reported, an investigation and root cause analysis are conducted by the clinical safety review committee, which is chaired by the operational medical director and attended by the chief operating officer, chief clinical officer and director of safety and risk. The goal is to identify whether a systemic issue needs to be addressed. As in the ASRS, an individual who self-reports is deemed to have an appropriate, positive attitude regarding safety and won’t have punitive action (including termination) taken against them provided the action: Was reported promptly; Was inadvertent and not deliberate; Wasn’t a criminal offense; Wasn’t due to a substantial lack of qualification or competency; and Wasn’t repetitive. Training, remediation and changes in protocols, processes and procedures typically result from self-reports to minimize the likelihood that a similar incident will occur involving any provider in the future. Reducing Risks The greatest risk and exposure to fatal vehicular accidents occurs during the response phase of any call. The team effort to deliver each vehicle and its crew to a call safely is of paramount importance. RAA emphasizes crew resource management (CRM) in its training and operations, not Choose 32 at www.jems.com/rs www.jems.com JUNE 2012 JEMS 41
  40. 40. Safety First continued from page 41 Table 1: Standard Driving Report for July 25–31, 2011 Total Driving: 17,138 miles Emergency Driving: 2,217 miles Non-Emergency Driving: 14,921 miles Average Daily Fleet Speeds (mph) Date Total Emergency Non-Emergency 7/25 28 28 28 7/26 27 26 27 7/27 31 26 32 7/28 28 27 28 7/29 25 25 25 7/30 26 29 26 7/31 29 29 29 reduce musculoskeletal injuries. An outward success in the past year has been the purchase of pneumatic lifting cushions. Patients are placed and then elevated by compressed air to a sitting position, from which they can be assisted to their feet. RAA is currently equipping its entire fleet with powered stretchers to reduce the amount of lifting required. Better back care is an issue RAA takes seriously in its effort to reduce staff injuries and attrition. One role of RAA’s operational team is to keep the workforce rested and prepared for the rigors of busy shifts, so RAA’s scheduling and shift-building rules prevent a member of staff from returning to work within eight hours of their last shift. should be used sparingly—and only when medically justified—to reduce the risk of vehicular accidents. Instead of basing units at fixed locations and requiring fast driving, Communication RAA uses system status management to RAA’s philosophy is that communication place units to post locations throughout the isn’t a skill reserved for the radio. Root cause city dynamically based on computer predic- analysis in aviation as well as EMS frequently tions of where the next most likely life-or-death calls will occur. This has proven to be highly accurate using historical data factoring in the time of day, day of the week, and month. The result is that RAA’s ALS units arrive on scene in less than or equal to eight minutes from the time of A team effort is essential for implementing a safety culture. the call receipt 93–96% of the time in all sectors of its service area on identifies a lack of communication between life-threatening calls, despite the fact that crew members on a day-to-day basis as a our average fleet speeds aren’t much differ- significant contributory factor to safety incient between emergency and non-emergency dents. RAA’s supervisors and managers train responses (see Table 1 ). crews to have open, frank and honest diaA response to calls in which dangerous logue with each other any time any issues— activity is suspected enacts the call staging even seemingly minor ones—occur. safety procedure. Crews are required to wait We also stress the importance of CRM, off scene until the area is cleared and deemed making it clear that each crew member has safe by police. Similarly, a crew on scene the responsibility to speak up promptly potentially compromising their safety has the within the chain of command whenever discretion to evacuate and await further back they have a concern that something isn’t up. All crew members have personal radios quite right. This is especially true if it might equipped with mayday buttons that issue a constitute a safety risk to the patient or silent alarm to dispatch and place the radio responding personnel. into continuous transmit mode. A mayday triggers an immediate top priority police Measuring Safety Success response to the ambulance location, which RAA’s transformation to a culture of safety is constantly monitored in dispatch using culture is an ongoing journey. Its mission is to RAA’s automatic vehicle locator system. provide world-class EMS, and we recognize Regarding the more common situations of we can’t do that without striving to be among lifting and moving a patient, RAA is always the safest EMS agencies in the world. Success looking for better devices and techniques to must be measured on multiple dimensions, 42 JEMS JUNE 2012 both for employees and patients. RAA has reduced worker’s compensation injury claims since it began a “culture change,” which reduced our NCCI experience modification factor (an insurance premium adjustment that recognized the merits or demerits of individual risks) from 1.04 to 0.83. This translates into a 20% premium reduction. RAA’s insurance carriers use RAA as a model of a best practice, and they refer clients with similar operations to RAA for information. Finally, for RAA, overall success is defined by keeping the promises we make to employees during orientation: “Our primary goal is to get you home in the same way you came to work. No injuries and no illnesses. You may be sore and tired, but you aren’t hurt or sick.” We work hard each day to meet or exceed this challenge. JEMS Rob Lawrence, MCMI, is chief operating officer at Richmond Ambulance Authority and was named a JEMS EMS 10: Innovator of EMS for his work on the Rider Alert program in 2011. Bryan S. McRay, BA, is the safety and risk director for Richmond Ambulance Authority. He has been involved in EMS for 22 years both in volunteer and career agencies. He’s currently pursuing his master’s in Public Administration. Dempsey Whitt, NREMT-P/FP-C, is the director of operations for the Richmond Ambulance Authority and serves in the Virginia Army National Guard’s 29th Infantry Division as the chief medical non-commissioned officer. Joseph P. Ornato, MD, FACP, FACC, FACEP, is professor and chairman of the Department of Emergency Medicine at Virginia Commonwealth University and Operational Medical Director for the Richmond Ambulance Authority. He’s also a member of the JEMS Editorial Board. References 1. Institute of Medicine. To Err is Human: Building a safer health system. Washington, D.C.: The National Academies Press, 2000. 2. Levenson D. Hospital patient safety incidents account for $6 billion in extra costs annually. Rep Med Guidel Outcomes Res. 2004;15(16):1–2,6–7. 3. O’Connor RE, Slovis CM, Hunt RC, et al. Eliminating errors in emergency medical services: Realities and recommendations. Prehosp Emerg Care. 2002;6(1):107–113. 4. Hobgood C, Bowen JB, Brice JH, et al. Do EMS personnel identify, report and disclose medical errors? Prehosp Emerg Care. 2006;10(1):21–27. 5. Paris PM, O’Connor RE. A National Center for EMS provider and patient safety: Helping EMS providers help us. Prehosp Emerg Care. 2008;12(1):92–94.
  41. 41. Choose 33 at www.jems.com/rs
  42. 42. 50 Innovative new products showcased at the 29th annual JEMS EMS Today Conference Exposition This year at the EMS Today Conference and Exhibition, a team of judges reviewed and evaluated numerous new products and innovations in EMS equipment, vehicles and programs on display by the nearly 300 exhibitors. These products were released to the EMS market within the previous eightmonth period. They reviewed products designed to not only improve your ability to deliver optimal emergency medical care to sick and injured patients, but products that also allow you to do it safely, more efficiently and with enhanced comfort for the patient. The review team rated each of the new and innovative products on their originality, functionality, ease of use and need in the EMS setting. Their selection of the 50 hottest products at EMS Today 2012 are presented here in random order for you to check out. Look for additional coverage of many other products reviewed in upcoming JEMS Hands On columns. 44 JEMS Hot Products JUNE 2012 Rip Shears info@ripshears.com www.ripshears.com RIP SHEARS is an innovative, compact, removable dual-blade cutter that attaches to almost any size and style trauma shears. It enables you to more rapidly remove the toughest and thickest clothing and turnout gear in seconds. Once you insert it in an opening, or start a cut with the shears, all you have to do is pull it through the material and it zips through it like a hot knife through butter. The replaceable blades used in the RIP SHEARS are made of 440 surgical-grade stainless steel that improve your cutting ability and sharp-edge retention and will last five times longer than standard carbon blades. LOLA Advanced Assessment 818/530-7900 www.lolaadvanced.com/about-us/ The LOLA Advanced Assessment stethoscope is an innovative tool that combines multiple patient assessment tools into one package: the stethoscope, penlight, pupil gauge and ruler. Each stethoscope comes with a clear set of comfortable earbuds, three extra pairs of earbuds and an extra battery for the light. The stethoscope head is stainless steel, and the tympanum is a clear plastic. A push button located conveniently on the top of the head activates the LED light. A pupil gauge with examples of pupil sizes from 1–8 mm is located right on the LOLA stethoscopes non-latex tubing, making it easy to see and use. There’s also a 40 cm ruler printed on the tube, complete with millimeter markings. Karl Storz Endoscopy America Inc. 424/218-8712 Bernd.bay@karlstorz.com www.karlstorz.com Karl Storz offers the portable C-MAC Video Laryngoscope, which has virtually no learning curve owing to its use of standard Macintosh and Miller blades for adults through neonates. The new C-MAC Pocket Monitor now offers even more portability as it sits right on the laryngoscope handle and can be used with all existing durable stainless steel C-MAC blades. The screen is movable and can be folded to the side of the laryngoscope for transportation and storage.

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