Always En Route At
Making Precious Minutes Count™

Making Lifesaving Faster,
Easier, Better.
A sudden cardiac arrest (SCA) response is a stre...
We Listened...

X Series






4 Traces
Real-time CPR Feedback
Steve Dunn, Ph.D., Professor
Thanks to a dedicated EMS team and use of the
ResQPOD®, Steve survived and was able to see


JEMS 200-City Survey shows recession continues to affect EMS in 2012 & beyond
By Michae...
Choose 14 at www.jems.com/rs



EDITOR-IN-CHIEF I A.J. Heightman, MPA, EMT-P I aheightman@pennwell.com
MANAGING EDITOR I Jennifer Berry I jenniferb@penn...
Accurate from the First Breath

World’s smallest portable
self-contained capnometer
EMMA™ (Emergency Mainstream Analyzer) ...

President & Chief Executive Officer,
WakeMed Health & Hosp...
When urgency and bravery are
essential job requirements, the
success of your business depends
on a commercial vehicle that...




rews from the Fort Worth (Texas) Fire Depar...





Why crew resource mana...
This month, we feature some of the
positive feedback we received about
a JEMS.com article on the...

Responding TO THE FLU
EMS leaders need to build a community plan




A tent is set up for patients with flu...

flu and any other hazards that occur in
the future.
Sign up for coca@cdc.gov f...
The JEMS Family of Products:

Helping You Save Lives

JEMS, Journal
of Emergency
Medical Services

Your o...

Lower profile zipper Station/EMS boot
> Built in Arch Support
> St...
Editor’s note: This article is an EMS Insider exclusive. The complete version is
available in this mo...



Closely oversee storage, han...



Do you know what your stretche...



A healthy-appearing young ma...
Explore the possibilities.
Become part of our vibrant and
nationally recognized online
learning community!

When severe ca...



New study conclude...
What we know: Paramedic interpretation of
ECGs with STEMI has been shown to have a high
degree of sensitivity,...
This article is sponsored by Ferno’s 2020 Vision series.

Blue sky disc...
Choose 24 at www.jems.com/rs
The leaders of the first
responder and transport agencies (n=485) serving the 200
most populous cities in t...





How long

can an organization
hold its breath?

from two-paramedic tr...
An indication of changed transport unit
staffing was reported in the n...

A high number of 2012 respondents participate in clinical trials: Fifty...
Table 7: 200-City Respondents Average Transport Charge
BLS non-emergency
BLS emergency


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  1. 1. FEBRUARY 2013 Always En Route At
  2. 2. Making Precious Minutes Count™ Making Lifesaving Faster, Easier, Better. A sudden cardiac arrest (SCA) response is a stress-test for Emergency Medical Providers because time matters. You need your equipment to be rugged and to support you every step of the way. Philips best professional-grade AED yet, the HeartStart FR3 is designed to make lifesaving faster, easier, and better. professional-grade AED among leading global manufacturers.* It is designed to be rugged and reliable. SCA response. For more information or a product demonstration, contact your dedicated Account Manager or call 800.533.0523 Choose 11 at www.jems.com/rs 800-533-0523 www.boundtree.com
  3. 3. We Listened... Introducing X Series X X X X X X X X X X X X X TM Small Light 4 Traces Real-time CPR Feedback NIBP Adult, Pediatric, and Neonatal Patient Modes Microstream ® etCO 2 12-lead ECG (on-screen, static, and dynamic) WiFi Bluetooth ® Masimo ® rainbow ® SET Sp0 2 /SpCO ®/SpMet ® 3 Invasive Blood Pressure Channels (IBP) 2 Temperature Channels Xtremely Small, Light, and Powerful For more information on the X Series Monitor/Defibrillator, call 1-800-804-4356 or visit us at www.zoll.com/xseries. ® Follow ZOLL on Facebook. © 2012 ZOLL Medical Corporation. All rights reserved. X Series and ZOLL are trademarks or registered trademarks of ZOLL Medical Corporation in the United States and/or other countries. All other trademarks are the property of their respective owners. Masimo, Rainbow, SET, SpCO, and SpMet are trademarks or registered trademarks of Masimo Corporation. Microstream is a registered trademark of Oridion Medical 1987 Ltd. Choose 12 at www.jems.com/rs
  4. 4. Steve Dunn, Ph.D., Professor Thanks to a dedicated EMS team and use of the ResQPOD®, Steve survived and was able to see his oldest son graduate from college. Choose 13 at www.jems.com/rs
  5. 5. ® 28 I FORECAST OF THE FUTURE? I JEMS 200-City Survey shows recession continues to affect EMS in 2012 & beyond By Michael J. Ward, MGA FEBRUARY 2013 VOL. 38 NO. 2 Contents 36 I PUTTING STANDARDS ON THE MAP I 40 I FORCED TO WAIT I I 36 Oklahoma leaders create comprehensive set of evidence-based protocols By Jeffrey M. Goodloe, MD, NREMT-P, FACEP; David S. Howerton, NREMT-P; & Tammy Appleby, NREMT-B The effect of the peri-shock pause on automated external defibrillators By David Baumrind, BA, EMT-CC & Christopher Watford, BSc, NREMT-P 48 DEPARTMENTS & COLUMNS 5 I LOAD & GO I Now on JEMS.com 10 I EMS IN ACTION I Scene of the Month 12 I FROM THE EDITOR I It’s No Accident I SKIN DEEP I 54 I BRIDGING ADVERSITY I Understand common skin infections, how to treat them & how to protect yourself By Cynthia Goss, BA, MICP; James F. Goss, MHA, MICP; Joslyn De Los Santos, EMT-B; Dave Williams, MICP; Ann Fang, EMT-B; & Randy Yergenson, MICP Your EMS organization can succeed & thrive during turbulent times By Larry Boxman, EMT-P By A.J. Heightman, MPA, EMT-P I 48 13 I LETTERS I In Your Words 14 I PRIORITY TRAFFIC I News You Can Use 20 I LEADERSHIP SECTOR I Locked Up By Gary Ludwig, MS, EMT-P 21 I TRICKS OF THE TRADE I Heavy Duty By Thom Dick 22 I CASE OF THE MONTH I A ‘Racing Heart’ By Dennis Edgerly, EMT-P 24 I RESEARCH REVIEW I What Current Studies Mean to EMS By David Page, MS, NREMT-P 26 I 2020 VISION I What Does 2020 Hold? Sponsored by Ferno 2020 Vision Series 66 I HANDS ON I Product Reviews from Street Crews By Dominic Silvestro, EMT-P, EMS-I 68 I LIGHTER SIDE I Experiential Music Salvation By Steve Berry 70 I AD INDEX 71 I EMPLOYMENT & CLASSIFIED ADS 72 I LAST WORD I The Ups & Downs of EMS About theeconomy affect the field of EMS in 2013? Find out in “Forecast of the Future? Cover How will the state of the JEMS 200-City Survey shows recession continues to affect EMS in 2012 & beyond,” pp. 28–35, an annual survey of the most populous U.S. cities, conducted by Fitch & Associates. The survey covers a wide variety of topics, including dispatch, first response, transport, medical direction and performance measurement. IMAGE WRAGG/ISTOCKPHOTO.COM PREMIER MEDIA PARTNER OF THE IAFC, THE IAFC EMS SECTION & FIRE-RESCUE MED WWW.JEMS.COM FEBRUARY 2013 JEMS 3
  6. 6. Choose 14 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 INSTANT INFO Do you have questions about how your EMS agency can leverage social media and use it to get information out to your community during an emergency? If so, have no fear. Journalist and EMS Today Conference & Exposition speaker Richard Huff, NREMT-B, will address common concerns and provide tips in his 8 a.m. March 7 session, “Harnessing the Digital World: Challenges for Today’s Leaders When Everyone Has a Computer in Their Hands.” For information on this and other great sessions for EMS providers, educators and managers, check out our show site. ▲ EMSToday.com FEATURED BLOG: EMS S ON LLOW U FO JEMS com JEMS.com offers you MS original content, jobs, products and resources. But we’re much more than that; we keep you in touch with your colleagues through our: > Facebook fan page; > JEMS Connect site; > Twitter account; > LinkedIn profile; > Product Connect site; and > Fire EMS Blogs site. 12-Lead WHAT’S WRONG WITH MR. WILSON? It is a sunny January afternoon at the ER when you are called to see a 57 year old male complaining of feeling “really sick.” You find your patient lying in the bed in room 3. He looks pale and short of breath. You introduce yourself and ask him why he has come in today. He says, “About two weeks ago, I started feeling short of breath, with a cough. I got much more tired than usual. I went to see my doctor, who said I had an upper respiratory infection and prescribed me some antibiotics. I rested at home for a few days, and started to feel a little better. Then, I began to go downhill again. Felt so awful today, barely have enough energy to walk, so I had my wife drive me to the ER.” LIKE US facebook.com /jemsfans FOLLOW US twitter.com /jemsconnect RESCUE AIRWAYS WEBCAST EMS providers love to learn on the go, and our webcasts are the solution to making you more efficient. (This is especially true when you’re posting in a parking lot or corner and have a lot of down time.) So no matter where you are, make sure to check out our next webcast, which will be at 10 a.m. Feb. 17. In the session, sponsored by Mercury Medical, renowned EMS physician Ray Fowler, MD, FACEP, will use the latest science to discuss trends and benefits of rescue airways. ▲ jems.com/webcasts GET CONNECTED linkedin.com/groups? about=&gid=113182 EMS NEWS ALERTS JEMS.com Visit www.ems2020 vision.com to watch the latest 2020 Vision Leadership Series video interviews. Where do you see EMS going in 2020? That was the question put to four EMS visionaries—James J. Augustine, MD, FACEP; Matt Zavadsky, MS-HSA, EMT; David Page, MS, NREMT-P; and moderator A.J. Heightman, MPA, EMT-P. For hours, we flmed them while they created a new future. Join the 2020 EMS Visionaries LinkedIn group to get engaged in the discussion. www.FernoEMS.com Setting our sights on the future of EMS 1302jems_REV_5 5 http://linkedin. ems2020vision.com jems.com/enews CHECK IT OUT jems.com/ems-products BEST BLOGGERS FireEMSBlogs.com WWW.JEMS.COM FEBRUARY 2013 JEMS 5 2/4/13 1:56 PM
  8. 8. ® EDITOR-IN-CHIEF I A.J. Heightman, MPA, EMT-P I aheightman@pennwell.com MANAGING EDITOR I Jennifer Berry I jenniferb@pennwell.com ASSOCIATE EDITOR I Allison Harden I allisonm@pennwell.com ASSOCIATE EDITOR I Ryan Kelley I rkelley@pennwell.com ASSISTANT EDITOR I Kindra Sclar I kindras@pennwell.com ONLINE NEWS/BLOG MANAGER I Bill Carey I billc@pennwell.com 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 ART DIRECTOR I Liliana Estep I alildesign@me.com CONTRIBUTING ILLUSTRATORS Steve Berry, NREMT-P; Paul Combs, NREMT-B CONTRIBUTING PHOTOGRAPHERS Vu Banh, Glen Ellman, Craig Jackson, Kevin Link, Courtney McCain, Tom Page, Rick Roach, Steve Silverman, Michael Strauss, Chris Swabb DIRECTOR OF ePRODUCTS/PRODUCTION I Tim Francis I timf@pennwell.com PRODUCTION COORDINATOR I Matt Leatherman I matthewl@pennwell.com PUBLICATION OFFICE 800/266-5367 I Fax 858/638-2601 ADVERTISING DEPARTMENT 800/266-5367 I Fax 858/638-2601 ADVERTISING DIRECTOR I Judi Leidiger I 619/795-9040 I j.leidiger@jems.com WESTERN ACCOUNT REPRESENTATIVE I Cindi Richardson I 661/297-4027 I c.richardson@jems.com SENIOR SALES COORDINATOR I Elizabeth Zook I elizabethz@pennwell.com 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 SUBSCRIPTION DEPARTMENT I 888/456-5367 I DIRECTOR, AUDIENCE DEVELOPMENT & SALES SUPPORT I Mike Shear I mshear@pennwell.com • MARKETING DIRECTOR I Debbie Murray I debbiem@pennwell.com MARKETING & CONFERENCE PROGRAM COORDINATOR I Vanessa Horne I vhorne@pennwell.com • CHAIRMAN I Frank T. Lauinger PRESIDENT & CHIEF EXECUTIVE OFFICER I Robert F. Biolchini CHIEF FINANCIAL OFFICER I Mark C. Wilmoth SENIOR VICE PRESIDENT & GROUP PUBLISHER I Lyle Hoyt I lyleh@pennwell.com VICE PRESIDENT/PUBLISHER I Jeff Berend I jeffb@pennwell.com • • www.EMSToday.com EXECUTIVE DIRECTOR I Jeff Berend CONFERENCE DIRECTOR I Debbie Murray EDUCATION DIRECTOR I A.J. Heightman EVENT OPERATIONS MANAGER I Amanda Wilson EXHIBIT SERVICES MANAGER I Raymond Ackermann EXHIBIT SALES REPRESENTATIVE I Sue Ellen Rhine I 918/831-9786 I sueellenr@pennwell.com EXHIBIT SALES REPRESENTATIVE I Tracy Thompson I 918/832-9390 I tracyt@pennwell.com • FOUNDING EDITOR I Keith Griffiths FOUNDING PUBLISHER James O. Page (1936–2004) ® bringing change to life Choose 15 at www.jems.com/rs Choose 15 at www.jems.com/rs ®
  9. 9. Accurate from the First Breath World’s smallest portable self-contained capnometer EMMA™ (Emergency Mainstream Analyzer) is a fully selfcontained mainstream capnometer that requires no routine calibration and virtually no warm up time.1 With rapid measurement of end-tidal CO2 and respiration rate, EMMA can help providers guide ventilation rates and assess the effectiveness of CPR allowing them to make adjustments in the course of treatment, breath by breath. 800-257-3810 | www.masimo.com © 2013 Masimo Corporation. All rights reserved. 1 EMMA Users Manual. Choose 16 at www.jems.com/rs
  10. 10. ® EDITORIAL BOARD WILLIAM K. ATKINSON II, PHD, MPH, MPA, EMT-P President & Chief Executive Officer, WakeMed Health & Hospitals JAMES J. AUGUSTINE, MD, FACEP Medical Director, Washington Township (Ohio) Fire Department Associate Medical Director, North Naples (Fla.) Fire Department Director of Clinical Operations, EMP Management Clinical Associate Professor, Department of Emergency Medicine, Wright State University STEVE BERRY, NREMT-P Paramedic & EMS Cartoonist, Woodland Park, Colo. BRYAN E. BLEDSOE, DO, FACEP, FAAEM Professor of Emergency Medicine, Director, EMS Fellowship, University of Nevada School of Medicine Medical Director, MedicWest Ambulance CRISS BRAINARD, EMT-P Deputy Chief of Operations, San Diego Fire-Rescue CHAD BROCATO, DHS, REMT-P Assistant Chief of Operations, Deerfield Beach (Fla.) Fire-Rescue Adjunct Professor of Anatomy & Physiology, Kaplan University J. ROBERT (ROB) BROWN JR., EFO Fire Chief, Stafford County (Va.) Fire & Rescue Department Executive Board, EMS Section, International Association of Fire Chiefs CAROL A. CUNNINGHAM, MD, FACEP, FAAEM State Medical Director, Ohio Department of Public Safety, Division of EMS THOM DICK, EMT-P Quality Care Coordinator, Platte Valley (Colo.) Ambulance BRUCE EVANS, MPA, EMT-P Deputy Chief, Upper Pine River Bayfield Fire Protection, Colorado District JAY FITCH, PHD President & Founding Partner, Fitch & Associates RAY FOWLER, MD, FACEP Associate Professor, University of Texas Southwestern School of Medicine Chief of EMS, University of Texas Southwestern Medical Center Chief of Medical Operations, Dallas Metropolitan Area BioTel (EMS) System ADAM D. FOX, DPM, DO Assistant Professor of Surgery, Division of Trauma Surgery & Critical Care, University of Medicine & Dentistry of New Jersey Former Advanced EMT-3 (AEMT-3) GREGORY R. FRAILEY, DO, FACOEP, EMT-P Medical Director, Prehospital Services, Susquehanna Health Tactical Physician, Williamsport (Pa.) Bureau of Police Special Response Team 8 JEMS FEBRUARY 2013 JEFFREY M. GOODLOE, MD, FACEP, NREMT-P Professor & EMS Section Chief Emergency Medicine, University of Oklahoma School of Community Medicine Medical Director, EMS System for Metropolitan Oklahoma City & Tulsa KEITH GRIFFITHS President, RedFlash Group Founding Editor, JEMS DAVE KESEG, MD, FACEP Medical Director, Columbus Fire Department Clinical Instructor, Ohio State University W. ANN MAGGIORE, JD, NREMT-P Associate Attorney, Butt, Thornton & Baehr PC Clinical Instructor, University of New Mexico, School of Medicine CONNIE J. MATTERA, MS, RN, EMT-P EMS Administrative Director & EMS System Coordinator, Northwest (Ill.) Community Hospital MIKE MCEVOY, PHD, REMT-P, RN, CCRN EMS Coordinator, Saratoga County, N.Y. EMS Editor, Fire Engineering Magazine Resuscitation Committee Chair, Albany (N.Y.) Medical College MARK MEREDITH, MD Assistant Professor, Emergency Medicine and Pediatrics, Vanderbilt Medical Center Assistant EMS Medical Director for Pediatric Care, Nashville Fire Department GEOFFREY T. MILLER, EMT-P Director of Simulation Eastern Virginia Medical School, Office of Professional Development BRENT MYERS, MD, MPH, FACEP Medical Director, Wake County EMS System Emergency Physician, Wake Emergency Physicians PA Medical Director, WakeMed Health & Hospitals Emergency Services Institute MARY M. NEWMAN President, Sudden Cardiac Arrest Foundation JOSEPH P. ORNATO, MD, FACP, FACC, FACEP Professor & Chairman, Department of Emergency Medicine, Virginia Commonwealth University Medical Center Operational Medical Director, Richmond Ambulance Authority JERRY OVERTON, MPA Chair, International Academies of Emergency Dispatch DAVID PAGE, MS, NREMT-P Paramedic Instructor, Inver Hills (Minn.) Community College Paramedic, Allina Medical Transportation Member of the Board of Advisors, Prehospital Care Research Forum PAUL E. PEPE, MD, MPH, MACP, FACEP, FCCM Professor, Surgery, University of Texas Southwestern Medical Center Head, Emergency Services, Parkland Health & Hospital System Head, EMS Medical Direction Team, Dallas Area Biotel (EMS) System DAVID E. PERSSE, MD, FACEP Physician Director, City of Houston Emergency Medical Services Public Health Authority, City of Houston Department. of Health & Human Services Associate Professor, Emergency Medicine, University of Texas Health Science Center—Houston EDWARD M. RACHT, MD Chief Medical Officer, American Medical Response JEFFREY P. SALOMONE, MD, FACS, NREMT-P Trauma Medical Director, Maricopa Medical Center Professor of Surgery, University of Arizona College of Medicine—Phoenix KATHLEEN S. SCHRANK, MD Professor of Medicine & Chief, Division of Emergency Medicine, University of Miami School of Medicine Medical Director, City of Miami Fire Rescue Medical Director, Village of Key Biscayne Fire Rescue JOHN SINCLAIR, EMT-P International Director, IAFC EMS Section Fire Chief & Emergency Manager, Kittitas Valley (Wash.) Fire & Rescue COREY M. SLOVIS, MD, FACP, FACEP, FAAEM Professor & Chair, Emergency Medicine, Vanderbilt University Medical Center Professor, Medicine, Vanderbilt University Medical Center Medical Director, Metro Nashville Fire Department Medical Director, Nashville International Airport WALT A. STOY, PHD, EMT-P, CCEMTP Professor & Director, Emergency Medicine, University of Pittsburgh Director, Office of Education, Center for Emergency Medicine RICHARD VANCE, EMT-P Captain, Carlsbad (Calif.) Fire Department JONATHAN D. WASHKO, BS-EMSA, NREMT-P, AEMD Assistant Vice President, North Shore-LIJ Center for EMS Co-Chairman, Professional Standards Committee, American Ambulance Association Ad-Hoc Finance Committee Member, NEMSAC KEITH WESLEY, MD, FACEP Medical Director, HealthEast Medical Transportation KATHERINE H. WEST, BSN, MED, CIC Infection Control Consultant, Infection Control/Emerging Concepts Inc. STEPHEN R. WIRTH, ESQ. Attorney, Page, Wolfberg & Wirth LLC. Legal Commissioner & Chair, Panel of Commissioners, Commission on Accreditation of Ambulance Services (CAAS) DOUGLAS M. WOLFBERG, ESQ. Attorney, Page, Wolfberg & Wirth LLC WAYNE M. ZYGOWICZ, BA, EFO, EMT-P EMS Division Chief, Littleton (Colo.) Fire Rescue
  11. 11. When urgency and bravery are essential job requirements, the success of your business depends on a commercial vehicle that won’t back down from a challenge. With an Adaptive Electronic Stability Program® 1 and both Best-In-Class* payload capacity and standing height, only the 2013 Freightliner Sprinter is designed to answer the call as boldly as you do every day. freightlinersprinterusa.com DRIVEN LIKE YOU. ©2013 Daimler Vans USA, LLC *Based on a comparison of the Automotive News classification of full-size commercial vans. 1 No system, regardless of how advanced, can overcome the laws of physics or correct careless driving. Please always wear your seat belt. Performance is limited by available traction, which snow, ice and other conditions can afect. Always drive carefully, consistent with conditions. Best performance in snow is obtained with winter tires. Choose 18 at www.jems.com/rs Choose 17 at www.jems.com/rs
  12. 12. EMS IN ACTION SCENE OF THE MONTH >> PHOTO GLEN ELLMAN DANGEROUS ENTRANCE C rews from the Fort Worth (Texas) Fire Department and Medstar Mobile Healthcare attend to a woman who was complaining of neck and back pain after being struck by a vehicle after it crashed into a building in Fort Worth. The driver lost control of the vehicle before slamming into the building. Fort Worth Fire crews ensured the scene was safe and the building and vehicle were stabilized before patient extrication occurred. The patient was safely immobilized and transported by MedStar Mobile Healthcare to John Peter Smith hospital in Fort Worth, where she was treated for major injuries. No other people were in the room of impact at the time of the crash. A second patient in another room was struck by debris and treated for minor injuries. 10 JEMS FEBRUARY 2013
  13. 13. WWW.JEMS.COM FEBRUARY 2013 JEMS 11
  14. 14. FROM THE EDITOR PUTTING ISSUES INTO PERSPECTIVE >> BY A.J. HEIGHTMAN, MPA, EMT-P IT’S NO ACCIDENT Why crew resource management is a must! Y ears ago, the National Highway Traffic Safety Board moved away from calling motor vehicle collisions “accidents” because nothing’s really an accident. Collisions and other catastrophes are most often the result of human error, the merging of multiple unanticipated occurrences or issues that should have been foreseen by the individuals or agencies involved. All you have to do to see how disasters can be avoided is watch any “accident” clip on YouTube. Examples include trucks oversteering or making sudden, sharp turns that cause their loaded trailers to topple, and operators driving too fast for conditions or being tired and using poor judgment. See http://youtu.be/ZGkgLB34Yso. AN EVERYDAY OCCURRENCE We see these things every day in EMS and fire rescue operations, and we’re often the victims of them. We witness trucks with heavy loads being escorted slowly through town by police vehicles or front and rear escorts with warning flags and lights, but we then passively accept an engine or ladder truck racing through town at high speeds. Prime examples of EMS circumstances that can be avoided or corrected before harming or killing someone include flying aeromedical missions in bad weather, failing to slow down when roads are wet or icy, and allowing five firefighters to be positioned on a roof weakened by heat and fire. Fatigue is also a major factor in many so-called accidents. I remember one such incident when I worked 10 hours at my regional EMS director job and then worked a 12-hour shift as a paramedic on a Friday night. I hoped for a slow shift so I could catch a few ZZZZs and recharge my batteries, but instead we were running all night. It was my turn to drive toward the end of the shift, and I drove through two consecutive red lights before my partner, also tired, 12 JEMS FEBRUARY 2013 It’s critical that we all learn how to avoid ‘accidents’ before they occur. noticed it and told me to pull over. I was driving like an intoxicated person whose judgment was impaired, but I was too disoriented to realize or acknowledge it. Countless incidents like mine happen every day, and the unfortunate thing is we know they’re occurring and we fail to take steps to eliminate them. As an EMS operations director, I couldn’t stop my employees from holding down other jobs after they left my service. So I wrote a standard operating procedure that gave the crews the authority and responsibility to politely “flag” their partner and stop them from driving the remainder of the shift. There was no disciplinary action required unless the “disabled” driver failed to comply. PASSIONATE ABOUT SAFETY When two engines lost thrust after a flock of geese struck US Airways Flight 1549 on Jan. 15, 2009, it could have resulted in a fatal “accident.” However, the actions of pilot Captain Chesley B. “Sully” Sullenberger III and his crew took the incident from being potentially disastrous to heroic. Sullenberger, who is internationally recognized for the emergency water landing of US Airways Flight 1549 in the Hudson River, is a humble, consummate professional. His quick thinking, years of training, rapid actions and focus on pre-determined and rehearsed tasks saved everyone on board. Sullenberger graduated from the U.S. Air Force Academy with the Outstanding Cadet in Airmanship Award. He served as a fighter pilot for the U.S. Air Force from 1975–1980. After a long, distinguished career in the Air Force, he became an airline pilot with Pacific Southwest Airlines, later acquired by US Airways. Before he retired in March 2010, Sullenberger was an active and ardent safety advocate, selected to perform accident investigation duties for the U.S. Air Force, and serving as an Air Line Pilots Association (ALPA) representative during a National Transportation Safety Board investigation. More importantly, Sullenberger was instrumental in developing and implementing the crew resource management (CRM) course used by US Airways. He has taught the CRM concept throughout the world and helped many professionals adapt it for their industry. The International Association of Fire Chiefs (IAFC) did so in 2003 in an epic document that should be read by all emergency personnel. (See www.iafc.org/files/pubs_CRMmanual.pdf for more). Since his March 2010 retirement from US Airways, Sullenberger has authored the New York Times best-selling books Highest Duty: My search for what really matters and also Making a Difference: Stories of vision and courage from America’s leaders. SAFETY IN YOUR AREA What must be emphasized is that it was not just Sullenberger and his crew’s actions that day that saved 155 people on the plane and perhaps thousands had they crashed into downtown Manhattan. Rather, it was his lifelong study and belief in accident avoidance and CRM that saved the day. Nothing happens by accident, and it’s critical that we all learn how to avoid “accidents” before they occur. I encourage you to read Sullenberger’s books and the IAFC’s Crew Resource Management document, and adopt principles of high reliability organizations at your agency. It will improve your operational efficiency, increase your ability to resuscitate patients, and keep you, your crews, and members of your community alive.
  15. 15. APPLAUDING PUBLIC SERVICE This month, we feature some of the positive feedback we received about a JEMS.com article on the Virginia Beach (Va.) Department of EMS Santaon-the-Air program In “Santa Comforts Children over the Air” (www. jems.com/article/patient-care/santacomforts-children-over-air), author Bruce Nedelka, NREMT-P, provided us with a history on the growing program. Also featured here, we find out some of the best EMS advice our JEMS Facebook fans have received. PHOTO COURTESY BILL TIERNAN, THE VIRGINIAN-PILOT LETTERS IN YOUR WORDS Author Bruce Nedelka, NREMT-P, recently sent us an update on the program: I appreciate the placement in the magazine and on the website. A late entry into the program this year was the Virginia State Police! The Southeastern Virginia sector heard about the plan and asked to be included. Since their radios were not ORION channel equipped, our Virginia Beach 9-1-1 Center worked with the Virginia Beach ComIT Radio Team to develop a radio patch that allowed the state troopers to use their existing radios, set to a special tach channel, that was then linked to the ORION channel. This just goes to show how much our Virginia Beach people really enjoy this annual program. Preliminary information from the Big Man in the Red Suit points to 2012 as being the busiest on record! I think this is awesomeness! Public service can be reaching out to your community in as many or as little ways as you want. I’m all about whole-health, which means people’s spirits are as important as their bodies. Vanessa J. Via Facebook This is fantastic example of public service. The public won’t care how much we know until they know how much we care. Way to go Virginia Beach EMS! Bravo Zulu! James B. Via Facebook Best EMS Advice PHOTO COURTESY MATHIAS KOHRING M Aw, shucks. It figures; I put on eyeliner today and something finally makes me tear up! Lee W. Via Facebook I thought JEMS readers would appreciate this photo of my son’s “emergency vehicles” wooden toy set. You will note there is a rescue, an engine, a police car and yes, a taxi. The irony is overwhelming. Mathias K. From our Facebook Audience Our Facebook fans responded to the question: “What is the best EMS advice you’ve gotten?” Adam H.: “Time and experience are the only things that will teach you discretion. Until then, over-treat many and under-treat none.” Lee W.: Eat when you can, sleep when you can, and pee when you can. Or by the end of the day you’ll be starving, tired, wet and useless. Debee M.: Always look like you know what you’re doing, even if you don’t! Todd I.: Twenty years ago by Lt. Carlos A. Ramos, Jr. (NYC EMS), “You will never get in trouble for up triaging.” Still use that line with the newbies 20 years later. Thank you. James R.: It’s a crisis, but it’s not your crisis. Be calm, do the job right. Chrissy P.: Be a duck ... Calm and smooth on the surface even while paddling like hell underneath. Shane D.: The day to stop learning is the day you should quit. Brad V.: Eat your fries first! Jimmy S.: My first ped’s full arrest … another seasoned medic put his hand on my frantic spinning shoulder and said, “Son, he’s not getting any more dead.” I calmed down and everything was good from then on. Paul G.: If you think bad calls don’t bother you, you are probably in denial. Take care of your back and your mind. Ana-Maria G.: You have a duty to act, not a duty to cure. Ryan A.: No matter what type of patient you have and what tools or medications you carry, reassurance is the best medicine. Christine D.: Vicks vapor rub around and nostrils prevents one from smelling the most stinky of smells. Matthew C.: Always remember: You’re writing a report for 12 people that were too stupid to get out of jury duty; document with that mentality. Steve W.: Riding with my captain and a very green Paramedic student doing textbook compressions when my captain yells at him, “Shut up, damn it! We don’t count in real life!” Dennis S.: Oxygen is good for everything. Take a deep cleansing breath before you start evaluating or treating the patient. WWW.JEMS.COM FEBRUARY 2013 JEMS 13
  16. 16. PRIORITYUSE TRAFFIC NEWS YOU CAN Responding TO THE FLU EMS leaders need to build a community plan AP PHOTO/ THE NEWS-GAZETTE, HEATHER COIT A wise old fire chief once taught me, “Big challenging incidents are a gift, especially if they last a few days. Use them to obtain and apply the tools you will need over the next few years.” With that in mind, I share some ideas about using the current major influenza outbreak to build a better response plan and durable programs for future outbreaks. For the EMS leader, this is an important responsibility to your community. The community is relying on emergency services to be available for all emergencies, despite volumes of ill patients in the emergency departments (EDs), ambulances, or community clinics. Current efforts must include the cooperation of ED staff within the region’s EMS systems. Success in response to the current influenza outbreak also contributes to the community appreciation of the healthcare system, as we adapt to the recent healthcare changes. As of mid-January, the Centers for Disease Control and Prevention (CDC) reported that 48 states reported widespread geographic influenza activity for the week of Jan. 6-12, 2013. This increased from 47 states in the previous week. Fortunately, the outbreak volume of illness hasn’t yet been accompanied by a large number of fatalities. The population affected has been largely the older members of the community, including some A medical assistant administers a flu shot to a woman in Champaign, Ill. The largest patient population affected this year so far have been the elderly age group. nursing home outbreaks. Few pediatric deaths have been reported. EMS systems across the country have been extraordinarily busy, as have EDs. With an older population affected by the viruses, many of the presenting symptoms prompting EMS activation have been “shortness of breath,” “chest pain,” or “high fever.” Patients have generally been very ill, and required hospitalization. This has put pressure on the available inpatient beds, Vehicle Disinfection Tips We’re all hearing about the high case rate of seasonal influenza this year. The case rate is currently 29.4% higher than usual at this time. Influenza is an illness that we can be protected from by annual participation in the vaccine program, yet participation by healthcare workers remains a low 33%. A couple of things have occurred that EMS personnel should be aware of. First, because of the low participation rate by HCWs, most medical facilities have made annual seasonal influenza vaccine a “condition of employment”. This is viewed as a patient safety measure. Medical facilities are requiring EMS personnel who declined vaccine to wear a surgical mask when entering the facility. Since influenza is a droplet transmitted illness, EMS personnel can reduce risk for patients and themselves by insuring that vehicles are cleaned after each transport. And, that a surgical mask is used on the patient to contain secretions. No and some urban areas have had problems with hospital diversion. STAYING WELL A few immediate actions are available for EMS response. If EMS staff haven’t had the bug already, there’s still an opportunity to benefit from this season’s vaccine. Several operating practices help staff avoid the contagious diseases: Don’t get within 6 feet of ill patients unless it’s needed; special cleaning solution is needed. Any hospital grade disinfectant approved by the EPA or bleach/water solution at 1:100 (1/4 cup bleach to 1 gallon of water) is all that is needed. The focus of cleaning is directed at high contact areas; items that the patient was in contact with or items that were used to care for the patient. Remember, that your vehicle have a complete air exchange rate every two minutes. Therefore, there is no need to air out a vehicle or have a vehicle out of service. —Katherine West, RN, BSN, MSEd Check out the most complex and bizarre EMS cases at jems.com/case 14 JEMS FEBRUARY 2013
  17. 17. AP PHOTO/MATT ROURKE CDC IMAGE COURTESY CENTERS FOR DISEASE CONTROL & PREVENTION A tent is set up for patients with flu symptoms, just outside the emergency entrance at the Lehigh Valley Hospital in Allentown, Pa. More than 11,000 flu cases have been confirmed in the state. This map, released by the Centers for Disease Control & Prevention, shows the spread of the flu across the U.S. during the week ending Jan. 12, 2013. place a mask on coughing patients; wash hands and keep them away from the face; get appropriate rest and exercise. These good habits allow EMS providers to be confident because any form of contagious disease becomes concerning, and be able to reassure their family that they won’t bring any bugs home to them. Additional opportunities to modify operating processes to improve the safety of staff and patients exist. Be sure to be stocked with enough masks, gloves and hand cleaning materials. They are the first lines of protection. EMS staff can limit exposures by safely reducing the number of personnel that are exposed to an ill patient who doesn’t need more than one staff member to provide care. Keep ventilation at high levels in the patient compartment and deliver patients to negative pressure or other protected areas of the ED. Reduce the amount of exposed materials in the back of the ambulance, and clean the exposed surfaces. If possible, reduce any time lingering on scene and in transport, and complete documentation and other duties away from the ill patient. What opportunities can be built through the response to the current outbreak? >> Conduct the meetings between EMS and hospital leaders, to eliminate EMS diversion, rerouting, or offload delays. Make the process changes durable, so that the behavior doesn’t return. >> Establish a process for receiving, processing, and utilizing the strategies and documents that the CDC is producing and making available to EMS providers. >> Develop an illness surveillance program with community public health officials, and use the information to report the level of illness publicly. Develop an approach that allows EMS leaders to assist in educating the community on how to avoid illness, treat it at home, and when to enter the emergency system because the illness has progressed to high acuity. >> Develop an electronic learning management system that gets timely materials to your employees. This has become a critical tool for EMS agencies to deliver information of timely infection control and other teaching materials and bulletins across different shifts and roles. >> Improve the use of personal protective equipment by EMS staff, and processes that reduce exposures. >> After sequential issues involving widespread outbreaks of various viruses in recent years, EMS personnel deserve a wellness program that offers the best possible protection from contagious diseases, whether they come in blood or droplet form, or exist in other potentially infectious materials. EMS patients deserve the same. >> Institute a non-threatening employee illness reporting system, so there is early warning about an illness affecting multiple staff members. Develop a vaccination plan for the staff. Let staff know you’re caring for their health and safety, or over time, they won’t come to work. These steps further prove that emergency leaders are concerned about the welfare of their staff members and will help protect them from WWW.JEMS.COM FEBRUARY 2013 JEMS 15
  18. 18. PRIORITY TRAFFIC >> CONTINUED FROM PAGE 15 flu and any other hazards that occur in the future. Sign up for coca@cdc.gov for more updates. This site offers regular news briefs that highlight any critical information or programs that have become available across all areas of public health. Another daily source of information is available at www.cdc.gov/flu. —James J. Augustine, MD MASS CASUALTY TRIAGE STANDARDS An update on developing a national guideline for mass casualty triage was provided at the annual meeting of the National Association of EMS Physicians (NAEMSP) in Bonita Springs, Fla., including announcement of a free online training resource. The drive for a national standard was launched in a special section of the April-June 2004 edition of Prehospital Emergency Care. The available literature was reviewed and dispatch KEEP YOUR CERTIFICATION CURRENT S everal regions of the country have recently been hit with investigations into falsification of EMS certifications and misrepresentation of continuing education training that was never completed. EMS providers, managers and instructors have gotten in some very hot water. In one recent case, an individual who wasn’t certified as a paramedic started an IV on his girlfriend and was charged with criminal battery. Failure to maintain proper certification and then functioning only within the scope of practice for that certification is a professional—as well as personal—responsibility of all EMS providers. And every EMS agency needs to be proactive to make sure it employs only certified individuals to comply with state law, as well as the reimbursement requirements for Medicare, Medicaid and other payers. It may be tempting to be sloppy about keeping current certification, especially when a shortage of qualified EMS personnel exists in some parts of the country. You might think, “Well, they’re too busy to check on it.” Or you may be the busy EMS manager who can’t keep up with all the daily job responsibilities, let alone verifying current certifications. But the consequences of not maintaining certification are very significant to both the individual and the EMS agency and range from potential criminal charges, civil lawsuits and administrative actions. Your EMS agency can also be fined or sanctioned by the state EMS office, which can lead to a major public relations nightmare. And if you aren’t properly certified to provide care to a Medicare patient, obligations to refund any reimbursement your agency obtained may exist because of failure to meet the basic “crew and vehicle requirements” of the Medicare regulations that are a condition of payment. We’ve seen a few cases in which EMS agencies simply didn’t have an effective system in place to regularly monitor certification status of EMS personnel. In a few isolated cases, we’ve also seen certifications lapsed for many months before the agency became aware of it—there’s no excuse for that. Here are some tips for keeping current and for verifying EMS certification: >> Know the rules: Although most states follow the National Registry requirements, your state may have different requirements and those rules change periodically, so stay current with the EMS regulations in your state. >> Check your status frequently: Most states have online capability to check your certification status and continuing education credits. Don’t wait until the last few days of your certification to check and learn you need 10 more hours of continuing education to stay certified. >> Check official sources: The days of the EMS agency only accepting a paper “copy” of someone’s EMT or paramedic card as verification of current certifications is long gone. These cards are too methodology assessed. The 2004 assessment concluded that field triage procedures are intended to allow prehospital personnel to determine whether any given patient requires the resources of a trauma center. Existing triage procedures didn’t adequately address mass casualty incidents (MCIs) or CBRN (chemical, biological, radiological, and nuclear) issues. NAEMSP led a workgroup as part of the Centers for Disease Control and Prevention Pro Bono is written by attorneys Doug Wolfberg and Steve Wirth founding partners of Page, Wolfberg & Wirth, a national EMS industry law firm. Visit the firm’s website at www.pwwemslaw.com. easy to manipulate or forge. Just about every state has a registry of certified personnel that the agency can check to verify status of certification. >> Consider EMS management software to monitor and keep track of certifications and continuing education: Some very good “people management” products are available for EMS that can keep track of the various certification dates and current number of course credits with “reminders” to make the process more manageable. This can help avoid lapsed certifications in the first place. >> Never misrepresent yourself: This can get you in big trouble. Always be truthful about your current certification status when asked by your agency or by any government official. EMS agencies need to be equally truthful when they uncover a lapsed certification. The penalties for misrepresentation can be far greater than if you simply forget and let your certification lapse. >> Function within your certification: Never provide medical care that is outside the scope of your certification. Make certain that all procedures you perform are approved in accordance with your state EMS law and your medical director. >> Seek legal counsel: If you learn that one of your staff has a lapsed certification, a whole host of potential legal vulnerabilities exist. The organization could be the subject of a civil suit for negligent supervision or negligent retention of staff. Its EMS license could be on the line. There could be potential “overpayment” issues where your agency may need to refund Medicare or Medicaid if your agency didn’t meet the licensure requirements for a certified crew for the specific transports involving the “lapsed” individual. You need qualified legal advice in this situation. In addition to checking current EMS certifications, EMS agencies are also responsible to check criminal history information for relevant criminal convictions. You also need to check the federal government database to ensure that the staff member hasn’t been excluded by the federal government from participating in federal healthcare programs. The bottom line is that individual EMS providers must take personal responsibility for their own certification. EMS managers can’t take a “hands off” approach assuming their staff will maintain current certification as this is an essential element of legal compliance for the EMS agency. The penalties for non-compliance to both EMS providers and agencies are simply too great a risk. Fortunately, this risk can be easily avoided. Register for the 2013 EMS Today Conference: www.emstoday.com/register.html 16 JEMS FEBRUARY 2013
  19. 19. The JEMS Family of Products: Helping You Save Lives JEMS.com Website JEMS, Journal of Emergency Medical Services Your online connection to the EMS world, JEMS.com gives you information on: Products Jobs Patient Care Training Technology With content from writers who are EMS professionals in the feld, JEMS provides the information you need on clinical issues, new products and EMS trends. Available in print and digital editions! JEMS.com eNewsletter Product Connect The JEMS eNewsletter gives you breaking news, articles and product information. It’s free to subscribe … stay ahead of the latest news! Giving you the detailed product information you need, when you need it. We collect all the information from manufacturers and put it in one place, so it’s easy for you to fnd and easy for you to read. Go to www.jems.com/ems-products Archived Webcasts Approaches to Shock Management ® TM Free … Available 24/7! For more information on the JEMS Family of EMS Products: www.JEMS.com 17 WWW.JEMS.COM FEBRUARY 2013 JEMS
  20. 20. PRIORITY TRAFFIC >> CONTINUED FROM PAGE 16 AIRPOWER® R8 Lower profile zipper Station/EMS boot > Built in Arch Support > Steel toe protection > Chemical/bloodborne pathogen protection > Waterproof & breathable Quality shoes for law enforcement, fire and rescue services, hunting, work wear, and leisure time HAIX® North America Inc. 2320 Fortune Drive, Suite 120, Lexington KY 40509 Phone 859-281-0111, Fax 859-281-0113, Toll free 866-344-HAIX (4249) www.haix.com Choose 18 at www.jems.com/rs 18 JEMS FEBRUARY 2013 (CDC) sponsored Terrorism Injuries: Information Dissemination and Exchange (TIIDE) project to develop a national guideline for mass casualty triage. The result was a 2008 proposed guideline, entitled SALT (sort, assess, life-saving interventions, treatment and/ or transport) triage. SALT was developed based on the best available science and consensus opinion. It incorporates aspects from all of the existing triage systems to create a single overarching guide for unifying the mass casualty triage process across the U.S. Attention was focused on international communities that experience frequent MCIs and have well-developed EMS response practices. Implementation of SALT hasn’t been rapid. Lerner, Coule and Schwartz described the journey since the 2008 paper was published. Part of the CDC TIIDE work included a list of essential elements for a mass casualty triage system. The result of this effort is the 2011 Model Uniform Core Criteria (MUCC) that is the proposed national standard for all mass casualty triage systems. NAEMSP obtained support and buy-in from most of the medical and EMS organizations. In the presentation, the absence of MUCC support from fire department organizations was noted. The issues in replacing thousands of Simple Triage and Rapid Treatment triage tags was also discussed. In January, the National Disaster Life Support Foundation offered free training on SALT triage. This online training program consists of a 22-minute video, links to articles on SALT mass casualty triage and a downloadable presentation for teaching SALT. The program offers a five-question quiz that will result in a certificate after successful completion. —Michael J. Ward, MGA Take the quiz here: http://register.ndlsf.org/ mod/page/view.php?id=2056 QUICK TAKE NEW NATIONAL REGISTRY DIRECTOR TAKES REINS The National Registry of Emergency Medical Technicians (NREMT) Board of Directors announced the selection of Severo (Tré) Rodriguez, III, MS, AEMCA, NREMT-P, as the new executive director. A reception welcoming Rodriguez was held at the NAEMSP conference in January. Rodriguez will replace William E. Brown, Jr., as executive director. The selection was made after a 14-month national search process, led by immediate past chairman, Peter Glaeser. The search committee included NREMT board members, staff and legal counsel. On behalf of the board, Chairman Tommy Loyacono said in a statement, “The board of directors is excited about Tré’s appointment as our next executive director. He has worked in EMS for his entire life as a clinical provider, educator and administrator. He has a unique combination of knowledge and life experiences that we believe make him an ideal person to work with our national partners and lead the National Registry to the next level.” Rodriguez is a Texas native and was certified as a paramedic in the state in 1993 and nationally in 1994. He has extensive experience in EMS education in Texas, Florida and Ontario, Canada. He’s currently completing his doctoral studies in learning management. More NREMT updates: NREMT.org
  21. 21. AMR CHIEF STEPS DOWN Editor’s note: This article is an EMS Insider exclusive. The complete version is available in this month’s issue of EMS Insider. Subscribe to become an insider at pennwell.omeda.com/cgi-win/emsi.cgi?paid A merican Medical Response Inc. (AMR) announced the departure of President Mark Bruning, effective January 14. William A. Sanger, chief executive officer (CEO) of AMR’s parent company, Emergency Medical Services Corporation, has stepped in as interim president. Bruning, 54, began his 30-year career at AMR as an EMT and holds the distinction of being the first field caregiver to ever lead that company. “As a general rule, [corporate leaders] have never worked in the field; never got up at 2 a.m. to run a call,” says AMR Air Ambulance CEO Randy Strozyk. “It’s a testament to his skill and strength that he rose to this level.” After a stint in the U.S. Navy, Bruning returned to Colorado to attend college, He took an EMT class during his sophomore year and, shortly thereafter, joined A-1 Paramedics/AMR as an EMT. Starting at minimum wage and working many hours of overtime to make ends meet and to hone his craft, Bruning soon went on to paramedic school and continued his EMS career in Colorado Springs, Colo., the community where he grew up. He cared for the sick and injured and learned hard life lessons. It was his crew who were among the first on scene when United Airlines flight 737 crashed in 1991, killing all on board. Bruning took those experiences with him as he rose through the ranks at AMR, serving as a vice-president, and then CEO of the company’s central division, where he was acknowledged for his efforts to improve patient care and streamline customer service at the local level. Under his leadership, Bruning helped take a disjointed community of EMS providers and create a robust, system-wide EMS authority that still serves his Colorado Springs community. He also served as the president of the Emergency Medical Services Association of Colorado (EMSAC). In 2005, he was awarded the Peg Hamilton award by the EMSAC Board of Directors for outstanding service to the Association and its members. In 2008, he became AMR’s executive vice president. He was named president in May 2009. “I’ve had a great career,” Bruning says. “I’ve had so many amazing mentors along the way, from the very start as an EMT through field supervisor and on through all of my various leadership positions.” In 2004, he got a big break when AMR selected him to participate in an exclusive accelerated development leadership program. He was assigned a mentor—Sanger. “I was given a lot of one-onone time with him and the opportunity to learn from his 40 years of successful leadership in healthcare,” Bruning says of Sanger. As Bruning reflects on his 30-year career at AMR, he calls it a “great ride.” “I have had my share of challenges, but far more opportunities to work with amazing people and to be part of so many incredible experiences I never imagined possible. I consider myself one of the luckiest guys in EMS,” he says. “I wouldn’t trade it for anything.”—Teresa McCallion, EMT-B For more EMS news, visit jems.com/news Choose 19 at www.jems.com/rs WWW.JEMS.COM FEBRUARY 2013 JEMS 19
  22. 22. LEADERSHIP SECTOR PRESENTED BY THE IAFC EMS SECTION >> BY GARY LUDWIG, MS, EMT-P LOCKED UP Closely oversee storage, handling & distribution of narcotics A WIDESPREAD PROBLEM Speaking of Google, perform a Google search for “theft of ambulance drugs,” and you will see this problem isn’t isolated to a small town in Massachusetts. Regardless of the size of the EMS agency, there’s always the possibility that a paramedic with access to the drugs may be tempted to steal narcotics for use by themselves or a loved one, or to sell to someone else. Most paramedics who get caught tampering with narcotics have substanceabuse problems; they’re typically given a probationary period to go through drug treatment programs. But a recent article highlighted the case of a Washington para- 20 JEMS FEBRUARY 2013 PHOTO A.J. HEIGHTMAN G oogle is a phenomenal search engine. Within seconds of typing in a keyword, your search returns hundreds of related websites. But Google is good for much more than just searches. Google can also drop you an “email alert” on a specific keyword. By using this feature, I receive news alerts for articles and other news published on such keywords such as “fire chief,” “EMS” and my department. I was recently reading through the headlines for my once-a-day news alerts for “fire chief,” when I spotted a headline that said, “Massachusetts fire chief facing drug charges resigns.” Interested in this article, I clicked on it to learn that this past summer, prior to his resignation, the fire chief from Princeton, Mass., had been placed on paid leave after the Board of Selectmen learned that he was facing criminal charges connected to theft of drugs, including fentanyl, morphine and valium. It is alleged that he was stealing narcotics from the fire department’s ambulance. Whether this fire chief is guilty, the incident certainly brings attention to the need for other EMS managers to ensure that the narcotics carried by their EMS agency are controlled properly. Climate-controlled, secure drug locker is aboard a Tulsa Fire Department ALS unit. medic with 22 years of experience who was sentenced to 27 months in prison for stealing fentanyl. After his release from prison, he will be on another three years of supervision, plus he is required to pay $8,000 in restitution to the fire department from which he was stealing the drug. As is usually the case, the paramedic had been using the drug himself. The discovery and subsequent investigation was triggered when other paramedics noticed the fentanyl vials had been tampered with. SOME SOLUTIONS cases where testing revealed narcotics abuse, I’ve seen plenty of examples of alcohol, marijuana and cocaine use. Some EMS agencies seal narcotics in a tamper-evident bag. The narcotic is still visible through the bag so it can be checked for expiration date and clarity, but the paramedic can’t access it until they unseal the bag to use or if they have tampered with the bag to access the drug. Regardless of the method your agency chooses, you must have a strong policy in place describing how the narcotic is stored and who handles it, as well as required documentation of checking the narcotics from one shift to another, including looking for evidence of tampering. The policy should also address what to do if a narcotic has been tampered with and how to handle missing drugs and damaged packaging. The policy should also include how the narcotic is accessed—with a key, swipe card or key coded into an electronic lock. MINIMIZE THE RISK Narcotics theft is a serious matter. Usually lost in the discussion is the fact that the patient didn’t receive the drug they needed for their condition, and on top of that, the hospital may be reluctant to give additional drugs since they’re under the impression the patient has already received the needed dosage. As EMS managers, it’s imperative that you give significant attention to the storage, handling and distribution of narcotics in your agency. Proper policies and check and balances, along with awareness of the problem of narcotics theft, are all part of ensuring your department minimizes its exposure to narcotic tampering. So how can you stop narcotics tampering? After querying colleagues around the country, I’m not sure there’s a truly foolproof method because if someone wants to steal narcotics, they will find a way. Still, the fact that no one solution is perfect doesn’t mean you shouldn’t put measures in place to reduce the likelihood of narcotics theft. Using an electronic lockbox, for which each paramedic has their own access code, is one solution. Although it may not show who tampered with a narcotic, it will give an electronic recording of who accessed the lockbox and when. Some EMS agencies do drug checks Gary Ludwig, MS, EMT-P, is a deputy randomly or “for cause” with their fire chief with the Memphis (Tenn.) Fire employees. My experience working Department. He has 30 years of fire and in major cities is that you will always rescue experience. He’s chair of the EMS catch someone with an illegal substance in Section for the International Association of Fire their system. Although I haven’t seen many Chiefs and can be reached at www.garyludwig.com.
  23. 23. TRICKSOUR PATIENTS & OURSELVES OF THE TRADE CARING FOR >> BY THOM DICK, EMT-P HEAVY DUTY Do you know what your stretcher weighs? cheap. These are expensive tools, and they’re really heavy. They do a great job of loading and unloading, so they’re perfect for bed-tobed interfacility transfers. But if your job is taking care of sick people wherever you find them, bring your imagination—and maybe some strong friends. These devices are getting better. But precisely because they’re so heavy, they don’t always facilitate movement. I have a question for you, no matter what kind of stretcher you use. How much sometimes, especially the ones we seldom access. And thanks to a smart medic named Steve Steele,youmaybeabouttodiscoveroneyou’ve never harnessed. Steve thought of visiting the coroner’s office in our service area. Coroner’s office workers don’t get a lot of conversational visitors. Maybe for that reason, they’re friendly. They have coffee. And they have accurate, cot-sized scales. We took one of our new self-lifting cots to the county coroner’s office in our little town. The sales rep had told our crews (twice) that those cots weighed 120 lbs. At the time of this publication, the manufacturer’s website lists them at 125 lbs., without a mattress or straps—like you could ever run a call that way. According to the coroner’s scale, that number was actually 141 lbs. And equipped the way we use them, they weigh 172. Good to know, right? The whole point of which is not how some manufacturers market their products. Everything you attach to a cot adds to its weight, and there are some tools you simply must attach to a stretcher to make it an ambulance cot. The point is, know your resources. Be sure of your facts, by doing routinely what the field teaches you every day: to wonder about stuff and investigate it. And if you decide to visit the people who do that other tough job, maybe you could take them some coffee. You deserve to know the weight of your ambulance cot. A coroner’s scale is specifically designed to weigh wheeled stretchers, with or without human remains. PHOTO ISTOCK.PHOTO.COM/BELTERZ OK, Life-Saver. More about ambulance cots. If you’ve read JEMS for a while, you may recall they’ve published a ton of stuff in the past 34 years about stretchers, ambulance cots, patient movement strategies and even the history of it all. They’ve spent time with pioneers, designers, mechanics and patients—some of whom are no longer alive. And sadly, they’ve also published stories about fine caregivers who walked away from the work they loved, damaged forever by the nature of their calling and the designs of their tools. I’ll never stop bringing this up. You’d have to kill me. And according to some really sick people I’ve known, there is life after death—so maybe not even then. At about the turn of the current century, a Canadian medic named Mike Catoe collaborated with engineer Joe Legasse to develop the first self-lifting cot. It was made of stainless steel, and powered by compressed air from an SCBA tank. Joe bought the idea and called it the LiteLift. He founded a company called Tech Lite to produce it and, to our amazement, brought us a pre-production model. We played with that thing for four whole days, and learned more about it than you would ever want to know. JEMS published its story about 10 years ago. I’m not sure if Tech Lite is still developing ambulance cots. Last I heard, their name had changed to Tactical. But the idea of a self-lifting cot secured its place in history. Three manufacturers subsequently developed analogous products of their own. Two of them are active, including one whose president once told me to forget the whole idea, because it just couldn’t be done. Anybody who’s ever used a modern selflifter will tell you, its power doesn’t come does it weigh? I mean, really. Not according to the specs on a manufacturer’s website, but in your ambulance, the way you really use it. You deserve to know that, Life-Saver. It’s a critical variable, like the fuel level in your vehicle—essential to the analysis of any transport challenge. You need it at your fingertips on every call, along with your number of available crewmembers, your destination, your routing, your patient’s status and weight, the weather and temperature, and the topography between you and your ambulance. We all overlook resources, Thom Dick has been involved in EMS for 41 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@comcast.net. WWW.JEMS.COM FEBRUARY 2013 JEMS 21
  24. 24. CASE OF THE MONTH DILEMMAS IN DAY-TO-DAY CARE >> BY DENNIS EDGERLY, EMT-P A ‘RACING HEART’ A healthy-appearing young man presents puzzling symptoms 22 JEMS FEBRUARY 2013 PHOTO DENNIS EDGERLY T he information dispatch sent to you was for a 24-year-old male with a “racing heart.” The slender young man sitting on the couch appears anxious as you approach. He’s awake and alert, acknowledging your presence by looking at you and saying, “Hey.” As you begin your assessment, you feel warm skin and a rapid, irregular pulse. The patient confirms his chief complaint is a racing heart, and he feels hot and dizzy. He adamantly denies drug use and tells you this has never happened to him before. He says he caught a “bug” and has had a sore throat for several days along with feeling hot all the time. He reports having no energy for the past week and has been experiencing frequent diarrhea. He attributes all his symptoms to his recent illness. Today, however, his racing heart and dizziness have him concerned. Your physical exam reveals a healthyappearing young male. He’s anxious but responding appropriately. His skin is hot to the touch and breath sounds are clear. His pulse is weak and irregular at a rate of 160 beats per min. His blood pressure is 96/68, and respirations are 20 per minute. His pulse oximetry is 98% on room air, and the capnogram has a good waveform with an end-tidal carbon dioxide reading of 28 mmHg. The cardiac monitor shows rapid atrial fibrillation. Your partner establishes an IV while you continue your physical exam. A blood glucose evaluation reads 210 mg/dL. The patient denies a diabetic history. During your physical exam, his anterior neck is tender to palpation, and you notice a red, spider-like mark on the patient’s cheek, which you know to be a spider angioma. He denies recent trauma, chest pain or shortness of breath, and he remains aware of his rapid heart rate. He agrees that being transported for evaluation is a good idea. During transport, you administer a 250 mL fluid bolus of normal saline and Grave’s disease and viruses are common causes of acute hyperthyroidism. see a change in blood pressure to 100/70. The patient remains anxious and requests a window be opened because he’s so hot. You deliver the patient to the emergency department with no further changes. You tell the receiving physician you’re perplexed about the patient’s presentation. The physician tells you she will run some tests and let you know what she finds. DIAGNOSIS Following up with the emergency physician later that day, you learn that the patient’s symptoms were secondary to hyperthyroidism, most likely triggered by a viral infection. The thyroid gland secretes thyroxine, commonly known as T4, and triiodothyronine, more commonly referred to as T3. Thyroid secretion is primarily regulated by thyroid-stimulating hormone (TSH), also known as thyrotropin, that’s released by the anterior pituitary gland. Thyroxine is the most prevalent hormone secreted from the thyroid, and almost all of it is converted to T3 in the body. TSH levels have an inverse relationship to T4 and T3 levels—all of which are intimately involved in metabolism. A decrease in thyroid function, called hypothyroidism, can cause a decrease in metabolic rate up to 50%. An increase in thyroid function, called hyperthyroidism, can increase metabolic rate more than 60%.1 The patient in this case had hyperthyroidism. Common causes of acute hyperthyroidism include Grave’s disease and viruses. Hyperthyroidism presents with general signs of increased metabolism, including weight loss and heat intolerance. In addition, it can cause anxiety, abdominal pain, increased defecation and diarrhea, double vision, neck tenderness, palpitations and such arrhythmias as atrial fibrillation and dyspnea. Hyperthyroidism can also cause an increase in blood glucose levels and spider angiomas. Severe presentations are rare, accounting for less than 10% of hyperthyroid cases.2
  25. 25. Explore the possibilities. Become part of our vibrant and nationally recognized online learning community! When severe cases present, patients can have acute heart failure and be comatose. These cases can be referred to as thyroid storms. TREATMENT Prehospital care is mostly supportive. Consider other causes of the patient’s symptoms, such as myocardial infarction and toxic ingestions. Support the patient’s blood pressure with fluid and cardiac rhythm management. In the case of extreme anxiety, the administration of a benzodiazepine is appropriate. Beta blockers can be administered to relieve the effects of the elevated thyroid levels. Long-term care will be focused on the cause of the hyperthyroidism. Although not a common call for EMS, it’s important to remember the role of the thyroid gland and include alterations in thyroid function as part of our differential diagnosis and patient care reports. Dennis Edgerly, BS, EMT-P, began his EMS career in 1987 as a volunteer firefighter EMT. He’s the paramedic education coordinator for the paramedic education program at HealthONE EMS. Contact him at Dennis.Edgerly@Healthonecares.com. Experience WCU’s rich history of quality instruction in emergency medicine. Graduates of our programs have pursued careers as paramedics, educators, physicians, physician assistants, researchers, and Emergency Medical Services administrators. Our professional degrees include: Online Bachelor’s Degree March 1 application deadline F O R M O R E I N F O R M AT I O N G O T O : emc.wcu.edu Online Master’s Degree REFERENCES 1. Guyton AC, Hall IE, editors: Textbook of Medical Physiology. W.B. Saunders Company: Philadelphia, Pa., 862–864, 2000. 2. Nayak B, Burman K. Thyrotoxicosis and thyroid storm. Endocrinol Metab Clin North Am. 2006;35(4):663–686. M March 15 application deadline F O R M O R E I N F O R M AT I O N G O T O : mhs.wcu.edu YOUR TIME. YOUR PLACE. YOUR CHOICE. Choose 20 at www.jems.com/rs Choose 21 at www.jems.com/rs WWW.JEMS.COM FEBRUARY 2013 JEMS 23
  26. 26. RESEARCH REVIEW EMS WHAT CURRENT STUDIES MEAN TO >> BY DAVID PAGE, MS, NREMT-P IS THE LIFT WORTH IT? New study concludes many lift-assist calls will result in callbacks I THE ‘LIFT-ASSIST’ CALL I Cone DC, Ahern J, Lee CH, et al. A descriptive study of the ‘lift-assist’ call. Prehosp Emerg Care. 2012;17(1):51–56. doi: 10.3109/10903127.2012.717168. Epub 2012 Sep 12. s I write these words, my radio is crackling with Ladder 7 being dispatched routine for a “lift-assist” (LA). Will this be a transport? Probably not. My hope is that this new study might prompt a long overdue revision of how EMS handles these cases. This study reviewed 1,087 LA responses (5% of all calls in this Brandford, Conn., firebased EMS system) to 535 unique addresses from 2004 to 2009. The authors report that in half of these cases, EMS was called back to the same address within 30 days. Although data was incomplete for the early years of the study, it appears that many callbacks were for the same patient (85%) and that half of these (55%) were transported during the second call. Such data confirms a London Ambulance Service study showing that 47% of elderly (more than 65 years old) fall patients not transported initially summoned help again with two weeks, and half of these were then transported. The authors reference several studies where EMS crews have screened elderly patients to receive home-based case management to prevent falls. They note that the “move away from reflexive, responsebased intervention and toward proactive preventive measures reflects a general interest in the EMS community.” One major limitation of this new study, which the authors acknowledge, is a lack of outcomes data for these patients. Without this data we don’t know if the non-transport was helpful or hurtful. Still, Cone and co-authors should be commended for tackling the difficult issue of lift-assists. At minimum, we should all be asking ourselves, “Is this the ONE—a lift-assist where we will return to find a patient whose 24 JEMS FEBRUARY 2013 PHOTO KEVIN LINK A Careful evaluation of a lift-assist patient will help you to determine if transport is necessary. weakness, illness, injury or failure to care for themselves has resulted in a much worse problem?” From this study we know that more than one quarter of these patients will end up in the hospital anyway, and that EMS spent an average of 21 minutes responding to these cases. From a risk/cost-benefit ratio, transport may be a better solution for the EMS system—but we don’t know if this is the best bet for the patient until we study their outcomes. The bottom line: Evaluate those LA patients very carefully. You (or your EMS system) will be called back to at least half of them. I ECG INTERPRETATION ACCURACY I Bhalla MC, Mencl F, Gist MA, et al. Prehospital electrocardiographic computer identification of ST-segment elevation myocardial infarction. Prehosp Emerg Care. doi:10.3109/10903127.2012.722176. Epub ahead of print 2012 Oct 15. W hy learn to interpret ECGs if the machine will do a better job? Congratulations to Bhalla and co-authors, who reviewed 200 12-lead ECGs to double-check the accuracy of the machine’s interpretation. The results were predictable, based on previous studies: The machine’s specificity was 100%. All ECGs labeled “acute MI suspected” were correctly diagnosed. No earth-shattering news here. Unfortunately, however, sensitivity was 58%. This means 42 patients with ST-elevation myocardial infarction (STEMI) would have been missed if we rely only on the machine’s interpretation. Interestingly, half of the missed STEMIs had an interpretation of “data quality prohibits interpretation.” The authors astutely point out that obtaining ECGs en route to the hospital and artifact in general may be causing the machine to hiccup. This will no doubt sound familiar to those of us with some experience in the field. At times, it takes some fiddling around with cables, patches, patient coaching and especially patience to settle everything down for the tracing to be good enough for machine interpretation. It should also be noted that 131 STEMI ECGs were excluded from this sample due to transmission problems, or the first ECG did not show STEMI. The authors also point out that this study was the catalyst to allow field activation of catheterization labs. Way to go.
  27. 27. BOTTOM LINE What we know: Paramedic interpretation of ECGs with STEMI has been shown to have a high degree of sensitivity, as high as 92% in one study (Trivedi 2009). What this study adds: More evidence that we can trust and act upon a machine diagnosis of STEMI, but need to very carefully evaluate any ECG, especially those where the machine is questioning the data quality. I RUNNING HOT & COLD I McMullan JT, Pinnawin A, Jones E, et al. The 60-day temperature-dependent degradation of midazolam and lorazepam in the prehospital environment. Prehosp Emerg Care. 2011;17(1):1–7. Epub 2012 Nov 13. D o you ever wonder if the temperature variations in your hot/freezing ambulance will cause some of our medications to inactivate? Kudos to McMullan and co-authors for studying this with two critical medications: midazolam (Versed) and lorazepam (Ativan). Refrigerated storage is recommended for lorazepam. This study involved 14 metropolitan EMS systems and a special study box that measured temperature every minute. Chromatography was used to determine drug concentrations in a single lab after 60 days. Results for 229 samples: Midazolam had no degradation and lorazepam had a 0.01 drop in concentration that was not statistically significant. One has to wonder what the temperature variation was in these boxes, as well as their storage locations (jump bags by a door versus cabinets near an air conditioner). The study did not document which vehicles had temperature-controlled drug compartments. The chart provided in the article shows lorazepam is clearly affected by temperatures above 75° F. We don’t know whether this degradation may have a clinically significant effect, especially in time periods longer than 60 days or high heat. Choose 23 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 and the JEMS Editorial Board. Send him feedback at dpage@ehs.net. Choose 23 at www.jems.com/rs WWW.JEMS.COM FEBRUARY 2013 JEMS 25
  28. 28. 2020 VISION LEADERSHIP SERIES This article is sponsored by Ferno’s 2020 Vision series. WHAT DOES 2020 HOLD? Blue sky discussion brings futuristic visions to the present I f you had your wishes, where would EMS be in 2020? It’s a tough question that involves prioritizing what’s most important to you while also using your creative juices to envision yourself in a completely new world. Would your vision focus on a systems model for EMS or on culture of safety? Would it include patientoriented and provider-friendly care, additional education, or technology that provides you with more detailed patient information the minute a call comes in and allows you to check in on patients remotely once they’ve transitioned from your care? These are some of the things introduced by the first group of participants filmed for the print- and Web-based 2020 Vision program, sponsored by Ferno, which asks JEMS.com Visit www.ems2020 vision.com to watch the latest videos HEALTHCARE FORECASTS Hot with a chance of snakebites Today’s weather may be mild with a chance of showers, but what will tomorrow be like? The 2020 visionaries postulated that an integrated healthcare industry will take a cue from the weather industry when prepping its providers for their workdays. They envision local, regional & national forecasts with updates on whether your patients are at risk for such things as snakebites or influenza, virus exposure, skin cancer due to weather conditions or respiratory distress due to smog in the environment. visionaries in the industry to not just ponder these questions and their answers, but also to come up with the steps that would be required to turn them into reality. This first 26 JEMS FEBRUARY 2013 From left, James J. Augustine, MD, Matt Zavadsky, A.J. Heightman & David Page present their vision. group of visionaries participating in the 2020 leadership series, so named as a forecast of what could be possible in EMS by the year 2020, included James J. Augustine, MD, FACEP; David Page, MS, NREMT-P; Matt Zavadsky, MSHSA, EMT; and moderator A.J. Heightman, MPA, EMT-P. They envisioned a 2020 that included all of these things—with integration of EMS into the overall health system. “We are the integrated, mobile healthcare solution that’s part of the master healthcare system,” Zavadsky said. “So we are just not the prehospital, not the out-of-hospital, not the after-hospital. We are integrated as part of the health system from both the preventative side from the episodic side, the unscheduled side, the after-care side and most importantly the technology side.” Augustine took it a step further. “Imagine in 2020 that we don’t have to use the hospital as the center of the healthcare system. Imagine if we could just say wherever they choose to be is the center of the healthcare system. focus of healthcare reform on increasing overall efficiency, the value that EMS providers bring to an integrated, more mobile system would be based on getting the right patient to the right place at the right cost. Heightman envisions a future in which EMS is more valuable, and providers can work just 40 hours a week. This allows them to and spend the other 20 hours they are now at work undertaking educational endeavors. And in 2020, they can put on a pair of glasses that and watch an educational video, take a seat at their pool, and learn things in a fun way that doesn’t take them away from their family. Page sees providers improving their knowledge not based on cookie-cutter expectations, but rather on what they personally need. By 2020, he envisions that education incorporates credentials into education so EMS is recognized and respected for the job that it’s doing. To watch segments of the Ferno 2020 Vision Series, go to ems2020vision.com. INCREASED VALUE OF EMS If EMS is an integrated part of a healthcare system where the hospital is no longer at the center, would the value of EMS inherently increase? In 2020, Zavadsky sees providers who are paid for the value they bring to the patient. Going hand-in-hand with the new 2020 Vision Leadership Series sponsored by w www.FernoEMS.com
  29. 29. Choose 24 at www.jems.com/rs
  30. 30. ABOUT THE DATA The leaders of the first responder and transport agencies (n=485) serving the 200 most populous cities in the U.S. were invited to participate in the 2012 JEMS 200-City Survey via e-mail. Conducted online, the survey included 75 questions. Many questions asked for multiple pieces of data. The completed survey response rate was 18.1% (n=88). Some of the 38 incomplete surveys provided many but not all answers and were included when appropriate. The survey covered a variety of EMS topics: dispatch, first response, transport, medical direction, performance measurement, effect of the economy, and system funding. Much of the information shared isn’t publicly accessible and, in many cases, is proprietary. Every effort has been made to protect the privacy of the respondents. All data is discussed in aggregate and doesn’t indicate individual cities or EMS organizations. Although accuracy is a key aim, this isn’t a scientific report, and the findings and conclusions haven’t been peer-reviewed. The results are dependent on the quality of the data received, as is the case with all research projects. All completed surveys were included in the data analysis. In many instances, data weren’t available or relevant for all respondents and a smaller sampling is indicated. Some questions also asked respondents to “check all that apply,” and as a result, the responses totaled greater than 100%. (See Table 1, p 30.) 28 JEMS FEBRUARY 2013 Forecast of the JEMS 200-CITY SURVEY SHOWS RECESSION CONTINUES TO AFFECT EMS IN 2012 & BEYOND >> BY MICHAEL J. WARD, MGA
  32. 32. FORECAST OF THE FUTURE? >> CONTINUED FROM PAGE 29 How long can an organization hold its breath? A from two-paramedic transport units ccording to the National Bureau of to one paramedic and one EMT staffEconomic Research, seven recesing; and sions have occurred since 1966. >> Twelve (11.5%) laid off employees. Six of the recessions lasted an average of Henry Farber makes the following 10.8 months. The most recent recession lasted 18 months, from December 2007 observation about the current recession in a 2011 National Bureau of Economic through June 2009. During each period of uncertainty, Research working paper on job losses: “It is organizations would “hold their breath” by clear that the dynamics of unemployment making temporary changes in operations in the Great Recession are fundamentally until the economy recovered and their rev- different from unemployment dynamics in enue streams renewed. However, this post- earlier recessions.” In the report, Farber notes fewer than half recession recovery has been unexpectedly weak. The U.S. Bureau of Labor Statistics who lost their job in the 2007–2009 recesnoted in 2012 that “many of the statistics sion had a job in 2010. Those who obtained that describe the U.S. economy have yet to new full-time jobs were making 21.8% less money. These factors directly relate to EMS return to their pre-recession values.” The response to the question posed revenue streams and workload. Since the 2008 survey, we have advoin this year’s 200-City Survey, “Has your organization experienced reductions in cated getting involved in the larger healthservice due to the current economic sit- care industry and learning of the changes uation?,” documents the effects that the and opportunities in EMS organizations. slow economic recovery have on EMS. The In each survey, we have identified trends, percentage of respondents that answered opportunities and issues. Results from this “yes” has noticeably increased in the past year’s survey indicate that the slow ecothree years: nomic recovery is imposing changes on >> It was 30% in 2010; even the most respected EMS operations. >> It was 37% in 2011; and >> It was 44% in 2012. Table 1: Responder Mix In addition, the following speSurveys Distributed (n=485) cific actions were identified by 104 Complete responses 88 Return rate 18.1% (82.5%) survey participants this year: Incomplete responses 38 >> Some 29 (27.9%) organizations Percentage of incomplete responses 7.8% reported a hiring freeze or not Cities Represented (n=200) filling vacancies. This was the Cities with a single respondent 6.5% (13) third year for some; Cities with multiple respondents 37.5% (75) Cities with no response 56.0% (112) >> A total of 22 (21.2%) suspended Response Breakdown (n=88) pay-for-performance or costFirst responder only 14.8% (13) of-living increases. This was Transport only 27.3% (24) the fourth year for some; First response & transport 50.0% (44) >> In all, 16 (15.4%) reduced ALS non-transport (e.g., fly car) 1.1% (1) ALS first response that accompanies BLS/ILS trans- 6.8% (6) staffing; port provider in all ALS transports >> A total of 13 (12.5%) changed 30 JEMS FEBRUARY 2013 DEPLOYMENT & STAFFING First responder information was provided on 92 of the 126 completed and incompleted surveys. First responders reported an overall increase in response time (allowing a longer time from dispatch to arrival) and respond to fewer 9-1-1 events. Some are using alternative vehicles with less staff. Almost half (47.7% of 88) of the responding cities are providing paramediclevel service. Work shift information was provided in 92 surveys. Fire departments continue to be the largest first responder agency, with 85.9% (79) of respondents working 24-hour shifts. (See Figure 1, below). Figure 1: First Responder Work Schedule FIRST RESPONDER WORK SCHEDULE 4% 1% 5% 4% 86% n 8 n 10 HOURS n 12 n 24 n 48 Four (3.8%) of 104 reported increasing their first responder response time. According to 38 respondents, a first responder is sent to every 9-1-1 incident; this 36.5% is noticeably lower than the 47.4% (55 of 116 respondents) that responded to every 9-1-1 incident in the 2010 survey. Forty of 88 firstresponder organizations follow emergency medical dispatch protocol recommendations, representing 45.5% of respondents. Twenty (22.7%) of 88 first responder agencies report using alternative vehicles for EMS responses, usually a one- or twoperson car or light truck. Some were EMT-level “alpha trucks,” and others were paramedic staffed. A continuing increase of alternative response vehicle use has been reported during the past three years.
  33. 33. EXPANDED BLS FIRST RESPONDER CLINICAL INTERVENTIONS An indication of changed transport unit staffing was reported in the number of clinical interventions BLS first responders are authorized to perform. The 88 (18.1% of 485 requested surveys) participants who responded to this question reported the following interventions: >> Twenty-three (26.1%) applied 12-lead application; >> Twenty-two (25.0%) administered asthma medication; >> Twenty-one (23.9%) administered nebulized medication; >> Thirteen (14.8%) inserted esophageal obturator airway devices; >> Eleven (12.5%) administered IV fluid; >> Nine (10.2%) applied continuous positive airway pressure devices; and >> Seven (8.0%) used adult/pediatric intraosseous devices. It’s not clear from the survey responses whether the “BLS” first response providers providing invasive care are credentialed as advanced EMTs or EMT-Intermediates. Within 88 organizations describing the level of first responder activity, 25 (28.4%) provided occasional paramedic level service, defined as 5–75% of the time. Paramedic level first responder service is provided 76–100% of the time by 42 (47.7%) organizations. When we looked at transport unit staffing in earlier surveys, a trend was not apparent. The 2012 survey shows that in communities where the state or local medical society doesn’t legislate a twoparamedic transport unit, agencies are moving to the one paramedic/one EMT staffing model. Communities are getting two paramedics to the incident by the first responder agency providing one paramedic and the transport agency providing the other. In some areas, the second paramedic is arriving in a one-person “fly car” or as an EMS supervisor. (See Figure 2, below.) Figure 2: Transport Unit Work Schedule states have been affected. The thinning of management and administrative staff affects the 200-City Survey, because we notice a third year of declining participation. Eighty-eight (18.1%) complete and 38 (7.8%) incomplete surveys were received from the 485 organizations contacted. For the first time, response rate dropped below 20%. Reflecting on the past three years of survey responses, many of the transport organizations surveyed have smaller staffs who are working longer hours with more responsibilities in systems where response requirements are being stretched. PHYSICIAN OVERSIGHT & RESEARCH Of the 98 agencies that responded to this question, 37 (38%) report no physician 3% participation in field operations. For the 5% remainder with prehospital participation, 5% 49% the physician either rides with a supervisor or has an assigned response vehicle. (See Table 6, p. 32.) Physician oversight of EMS field operations will be increasing in the next few years. Implementation of the Accreditation Council for Graduate Medical Education approved EMS fellowship program 38% for physicians requires a minimum of 12 months of clinical experience as the HOURS primary or consulting physician respon■ 8 ■ 10 ■ 12 ■ 24 ■ 48 sible for providing direct patient evaluation and management in the prehospital FEWER MIDDLE MANAGERS setting, as well as supervision of care proTRANSPORT SHIFTS Unless directly involved in patient care or vided by all allied health providers in the Transport unit information was provided required/funded by federal or state govern- prehospital setting. on 78 of the 126 completed and incomplete ment, many middle management positions The National Association of EMS surveys, representing 16.1% of the number were eliminated in 2012. This is a continu- Physicians (NAESMP) lists 58 EMS fellowof agencies queried. ing trend with required tasks reassigned to ship programs. The first board exams are Transport agencies that responded in administrators, senior field providers or scheduled for October 2013. Emergency 2012 show a shift to more 24-hour shifts, contracted out. physician focus on urban EMS perforan increase in allowable response time to Results are mixed. For example, munici- mance can be found in the “Evidence-Based incidents and more one-and-one staffing. pal transport agencies are dealing with Performance Measures for Emergency The survey shows 48.7% (38) working a an identity theft issue with the company Medical Services Systems: A model for 24-hour shift and 38.5% (30) working a contracted to perform ambulance billing. expanded EMS benchmarking” published 12-hour shift. This is different from earlier At the time of publication, 27 agencies in Prehospital Emergency Care. surveys, which reported the 12-hour shift (not part of the 200-City Survey) in 17 The U.S. Metropolitan Municipalities was the most frequent. (See EMS Medical Directors Figure 2, at right.) Consortium is continuing to Table 2: Utstein Standard A dozen (15.4%) organidefine EMS research, trials Do you use the Utstein zations are allowing more and demonstrations coverSystem design standard to calculate Percentage time to arrive at a scene. Five ing ST-elevation myocardial approach or measure cardiac (n=77) arrest survival scores? (6.4%) organizations extended infarction (STEMI), pulmoor eliminated response time nary edema, asthma, seizure, YES 33 42.9% requirements to non-life trauma and cardiac arrest in NO 44 57.1% threatening events. the urban environment. TRANSPORT UNIT WORK SCHEDULE WWW.JEMS.COM FEBRUARY 2013 JEMS 31
  34. 34. FORECAST OF THE FUTURE? >> CONTINUED FROM PAGE 31 A high number of 2012 respondents participate in clinical trials: Fifty-three (62.6%) of the 87 respondents answered “yes” to this question. The number or organizations that use the Utstein standard to calculate or CLINICAL CARE & TRANSPORT Survey participants this year report infrequent encounters of citizen CPR, few patients who had an automated external defibrillator (AED) shock them into a via- Table 3: ROSC Results ROSC on emergency department arrival 2012 (n=69) 2012 Percentage 2011 (n=55) 2011 Percentage 1–10% 15 22% 14 25% 11–20% 16 23% 6 11% 21–30% 11 16% 13 24% 31–40% 16 23% 15 27% 41–50% 4 10% 5 9% More than 50% 4 6% 2 4% Table 4: Pre-arrival CPR Activities Percentage Bystander CPR (n=56) AED converts to viable rhythm prior to ALS arrival (n=44) Witnessed arrest (n=57) 1–10% 27% 70% 25% 11–20% 9% 16% 14% 21–30% 21% 2% 16% 31–40% 20% 5% 12% 41–50% 11% 5% 14% More than 50% 13 2% 19% measure cardiac arrest survival scores was 39 (44.8%). (See Table 2, p. 31.) COMMUNITY INVOLVEMENT Slightly more than 41% (35 of 85) of the respondents formally partner with public health and/or social services to provide patient referral or follow-up for patients with high EMS use. This is lower than the 56.3% (36 of 64) that reported a formal partnership in 2011. Only 27.1% (23) of the respondents have ongoing prevention programs targeted to at-risk populations, which includes elderly fall prevention, congestive heart failure, diabetes and pediatric asthma. That is a slight decrease since 2011, when only 20 of the 68 respondents (29.4%) reported programs. Expansion of community paramedics and participation in accountable care organizations will increase EMS participation in prevention programs. 32 JEMS FEBRUARY 2013 Table 5: STEMI Performance Percentage 96–100% 86–95% 76–85% 51–75% Less than 50% STEMI patients received percutaneous coronary intervention in less than 90 minutes from 9-1-1 call (n=31) 13 4 4 4 6 ble rhythm before ALS arrived, and occasional witnessed cardiac arrests. (See Table 4, above.) The effect of continuous chest compression on patient outcome wasn’t noted in this year’s survey, and the rate of bystander CPR in 2012 is between the 2009 and 2010 results. Although the rate of AED conversion to a viable rhythm prior to ALS arrival is low, these numbers cover all applications of an AED by bystander and first responder. Many shocked were probably in a non-viable condition prior to AED application. Table 3, at left, provides the details. Questions on use of therapies, procedures and devices were answered by 82 (65.1%) participants. The following therapies (or lack thereof) are noteworthy: >> None (0 %) used ultrasound; >> None (0 %) used thrombolytics to treat stroke patients; >> Three (3.7%) used hypothermia for selected spinal cord injuries; >> Four (4.9%) administered thrombolytics to myocardial infarction patients; >> Nine (11.0%) administered nitrous oxide to treat various patients; >> Eleven (13.4%) placed patients in full-body vacuum splints for trauma patients; >> Thirty-three (40.2%) had hydrogen cyanide protocol to administer medications to burn victims; >> Fifty-two (63.4%) used hypothermia in cardiac arrest resuscitation >> Fifty-six (68.3%) performed spinal clearance in the field for trauma patients; >> Fifty-eight (70.7%) used carbon monoxide detectors in suspicious calls; >> Sixty-seven (81.7%) used tourniquets for trauma patients; and >> Seventy-seven (93.9%) used continuous positive airway pressure in patients with difficulty breathing. Only 13 of the 31 (41.9%) participants that responded to the STEMI question achieved percutaneous coronary intervention (PCI) in less than 90 minutes from Table 6: Medical Director Prehospital Participation MD Participation (n=98) On ambulance Riding with supervisor In assigned response vehicle Other field No physician field time 9 24 21 7 37 9-1-1 call more than 95% of the time. (See Table 6, above.) It’s uncertain whether this is due to transport time or community resources. In all, 88 (69.8%) participants had mandatory transportation protocols to the following types of specialty centers. >> Eighty-four (95.5%) to trauma centers; >> Sixty-eight (77.3%) to cardiac centers;
  35. 35. Table 7: 200-City Respondents Average Transport Charge BLS non-emergency BLS emergency 2012 $513.57 $645.78 2011 $594.04 $640.77 2010 $603.14 $654.58 ALS non- emergency ALS-1 emergency ALS-2 emergency $732.96 $841.95 $991.13 $769.08 $773.28 $906.05 $794.77 $821.34 $875.26 >> Sixty-eight (77.3%) to stroke centers; >> Sixty-five (73.9%) to burn centers; >> Sixty-two (70.5%) to pediatric specialty unit/centers; >> Thirty-eight (43.2%) to labor and delivery centers; >> Thirty-five (39.8%) to post resuscitation hypothermia receiving facility centers; >> Twenty-seven (30.7%) to hyperbaric centers; >> Twenty-four (27.3%) to psychiatric centers; >> Twenty-three (26.1%) to sexual assault centers; and >> One (1.1%) to a septic shock center. Eight (9.1%) of the survey participants had a policy allowing patients to be routinely transported by ambulance to destinations other than an emergency department. Half (44) of the survey participants have a policy allowing EMS-initiated refusal and denial of EMS transportation. COST OF TRANSPORT Table 7, above, compares the results for responses to the 2010, 2011 and 2012 surveys. Providers charge different rates based on the type of service, subsidy and geographic location. The year-to-year difference in amounts is most likely due to differing respondents each year rather than an indication of national trends. The best way to compare your charges is to benchmark with other similar providers in your geographic area. Billing can be extremely complex and requires constant continuing education and updates. Any organization, public or private, is subject to the federal Medicare and Medicaid rules—for which failure to comply can result in penalties and fines, and the provider is ultimately responsible regardless of whether the billing function is outsourced or retained internally. MORE PARTICIPATION NEEDED The 200-City Survey covers urban and metropolitan areas, the busiest and most complex EMS communities. This is neither a peer-reviewed nor scientific report. Regardless, its value to EMS is inherent. However, the value of the survey results decline when the response rate shrinks. In 2012, an extra effort was made to identify the correct contact person for 485 organizations that provide EMS service in the 200 biggest cities. Just 18.1% (88) of the surveys were completely filled out, so we used information from both complete and incomplete surveys to describe elements of big-city EMS. When the 200-City Survey began, we enjoyed a 50% return of complete responses. This year’s 200-City Survey reflects the extraordinary stress of a slow recovery from recession and uncertainty about the direction of EMS reimbursement. The survey was conducted in October, before the presidential election and the Medicare Payment Advisory Commission recommendations to Congress after the Government Accounting Office issued its study of ambulance service reimbursement. Almost a third (29) of the 88 full respondents anticipated further reductions in services during 2013. Disclosure: The author is an external, expert consultant with the consulting firm Fitch & Associates, LLC, which provides emergency service organizational and system audits for communities and individual organizations. RESOURCES 1. Business Cycle Dating Committee. (April 23, 2012) U.S. business cycle expansions and contractions. In National Bureau of Economic Research. Retrieved Dec. 2, 2012, from www.nber.org/ cycles/US_Business_Cycle_Expansions_and_ Contractions_20120423.pdf. 2. Bureau of Labor Statistics. (February 2012). The recession of 2007–2009. In U.S. Bureau of Labor Statistics. Retrieved Dec. 2, 2012, from www.bls. gov/spotlight/2012/recession/pdf/recession_bls_ spotlight.pdf. 3. Cone D, Brice J. (June 2010). EMS as a recognized subspecialty: Implications for fellowship training. In NAEMSP.org. Retrieved Nov. 5, 2012, from www.naemsp.org/documents/EMSFellowships_ SubspecialtyHandhouts.pdf. 4. Farber, Henry. (September 2011). Job loss in the great recession: Historical perspective from the displaced workers survey, 1984–2010. (NBER working paper no. 17040). In National Bureau of Economic Research. Retrieved Dec. 2, 2012, at www.nber.org/papers/w17040. 5. Myers JB, Slovis C, Eckstein M, et al. Evidencebased performance measures for emergency medical services systems: A model for expanded EMS benchmarking. Prehosp Emerg Care. 2008;12(2):141–151. 6. National Association of EMS Physicians. (November 2012). Fellowship programs. In National Association of EMS Physicians. Retrieved Nov. 05, 2012, from www.naemsp.org/Pages/FellowshipPrograms.aspx. 7. U.S. Government Accounting Office. (October 1, 2012). Ambulance providers: Costs & Medicare margins varied widely; Transports of beneficiaries have increased. In U.S. Government Accounting Office. Retrieved Dec. 3, 2012, from www.gao.gov/ assets/650/649018.pdf. Michael J. Ward, MGA, is a senior consultant at the international EMS consulting firm Fitch & Associates (www.fitchassoc.com). Ward spent 25 years with an urban county fire-rescue agency and a dozen years in academia. Contact him at mward@fitchassoc.com or 816/431–2600. The JEMS 200-City Survey is a joint research project in collaboration with Fitch & Associates, LLC (www. fitchassoc.com ). For 30 years, Fitch & Associates has been the leading international emergency services consulting firm and serves a diverse range of clients. Acknowledgement: The author acknowledges the great support of the Fitch project team members and their contributions to the article: Jay Fitch, PhD., Sharon Conroy, Tom Little and Melissa Addison. 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