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Choose 11 at www.jems.com/rs
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
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
I PUTTING STANDARDS ON THE MAP I
I FORCED TO WAIT I
Oklahoma leaders create comprehensive set of evidence-based
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
By David Baumrind, BA, EMT-CC & Christopher Watford, BSc, NREMT-P
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
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
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?
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.
PREMIER MEDIA PARTNER OF THE IAFC, THE IAFC EMS SECTION & FIRE-RESCUE MED
LOAD & GO
LOG IN FOR EXCLUSIVE CONTENT
A BETTER WAY TO LEARN
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
FEATURED BLOG: EMS
JEMS.com offers you
original content, jobs,
products and resources.
But we’re much more
than that; we keep
you in touch with
> Facebook fan page;
> JEMS Connect site;
> Twitter account;
> LinkedIn profile;
> Product Connect site; and
> Fire EMS Blogs site.
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.”
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.
EMS NEWS ALERTS
vision.com to watch
the latest 2020 Vision
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.
Setting our sights on the future of EMS
CHECK IT OUT
2/4/13 1:56 PM
EDITOR-IN-CHIEF I A.J. Heightman, MPA, EMT-P I firstname.lastname@example.org
MANAGING EDITOR I Jennifer Berry I email@example.com
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MEDICAL EDITOR I Edward T. Dickinson, MD, NREMT-P, FACEP
Travis Kusman, MPH, NREMT-P; Fred W. Wurster III, NREMT-P, AAS
CONTRIBUTING EDITOR I Bryan Bledsoe, DO, FACEP, FAAEM
ART DIRECTOR I Liliana Estep I firstname.lastname@example.org
Steve Berry, NREMT-P; Paul Combs, NREMT-B
Vu Banh, Glen Ellman, Craig Jackson, Kevin Link, Courtney McCain, Tom Page, Rick Roach,
Steve Silverman, Michael Strauss, Chris Swabb
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FOUNDING EDITOR I Keith Griffiths
James O. Page (1936–2004)
bringing change to life
Choose 15 at www.jems.com/rs
Choose 15 at www.jems.com/rs
WILLIAM K. ATKINSON II, PHD, MPH, MPA,
President & Chief Executive Officer,
WakeMed Health & Hospitals
JAMES J. AUGUSTINE, MD, FACEP
Washington Township (Ohio) Fire Department
Associate Medical Director,
North Naples (Fla.) Fire Department
Director of Clinical Operations, EMP Management
Clinical Associate Professor, Department of
Emergency Medicine, Wright State University
STEVE BERRY, NREMT-P
Paramedic & EMS Cartoonist, Woodland Park, Colo.
BRYAN E. BLEDSOE, DO, FACEP, FAAEM
Professor of Emergency Medicine, Director, EMS Fellowship,
University of Nevada School of Medicine
Medical Director, MedicWest Ambulance
CRISS BRAINARD, EMT-P
Deputy Chief of Operations, San Diego Fire-Rescue
CHAD BROCATO, DHS, REMT-P
Assistant Chief of Operations,
Deerfield Beach (Fla.) Fire-Rescue
Adjunct Professor of Anatomy & Physiology,
J. ROBERT (ROB) BROWN JR., EFO
Fire Chief, Stafford County (Va.) Fire & Rescue Department
Executive Board, EMS Section,
International Association of Fire Chiefs
CAROL A. CUNNINGHAM, MD, FACEP, FAAEM
State Medical Director,
Ohio Department of Public Safety, Division of EMS
THOM DICK, EMT-P
Quality Care Coordinator,
Platte Valley (Colo.) Ambulance
BRUCE EVANS, MPA, EMT-P
Deputy Chief, Upper Pine River Bayfield Fire Protection,
JAY FITCH, PHD
President & Founding Partner, Fitch & Associates
RAY FOWLER, MD, FACEP
University of Texas Southwestern School of Medicine
Chief of EMS,
University of Texas Southwestern Medical Center
Chief of Medical Operations,
Dallas Metropolitan Area BioTel (EMS) System
ADAM D. FOX, DPM, DO
Assistant Professor of Surgery,
Division of Trauma Surgery & Critical Care,
University of Medicine & Dentistry of New Jersey
Former Advanced EMT-3 (AEMT-3)
GREGORY R. FRAILEY, DO, FACOEP, EMT-P
Medical Director, Prehospital Services, Susquehanna Health
Tactical Physician, Williamsport (Pa.) Bureau of
Police Special Response Team
JEFFREY M. GOODLOE, MD, FACEP, NREMT-P
Professor & EMS Section Chief
Emergency Medicine, University of Oklahoma School of
Medical Director, EMS System for Metropolitan
Oklahoma City & Tulsa
President, RedFlash Group
Founding Editor, JEMS
DAVE KESEG, MD, FACEP
Medical Director, Columbus Fire Department
Clinical Instructor, Ohio State University
W. ANN MAGGIORE, JD, NREMT-P
Associate Attorney, Butt, Thornton & Baehr PC
Clinical Instructor, University of New Mexico,
School of Medicine
CONNIE J. MATTERA, MS, RN, EMT-P
EMS Administrative Director & EMS System Coordinator,
Northwest (Ill.) Community Hospital
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
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,
Assistant Vice President, North Shore-LIJ Center for EMS
Co-Chairman, Professional Standards Committee,
American Ambulance Association
Ad-Hoc Finance Committee Member, NEMSAC
KEITH WESLEY, MD, FACEP
Medical Director, HealthEast Medical Transportation
KATHERINE H. WEST, BSN, MED, CIC
Infection Control Consultant,
Infection Control/Emerging Concepts Inc.
STEPHEN R. WIRTH, ESQ.
Attorney, Page, Wolfberg & Wirth LLC.
Legal Commissioner & Chair, Panel of Commissioners,
Commission on Accreditation of Ambulance Services
DOUGLAS M. WOLFBERG, ESQ.
Attorney, Page, Wolfberg & Wirth LLC
WAYNE M. ZYGOWICZ, BA, EFO, EMT-P
EMS Division Chief, Littleton (Colo.) Fire Rescue
EMS IN ACTION
SCENE OF THE MONTH
>> PHOTO GLEN ELLMAN
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.
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!
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.
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,
It’s critical that we all
learn how to avoid
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
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.
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.
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
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
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!
Best EMS Advice
PHOTO COURTESY MATHIAS KOHRING
Aw, shucks. It figures; I put on eyeliner today and
something finally makes me tear up!
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.
From our Facebook Audience
Our Facebook fans responded to the
question: “What is the best EMS advice
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
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
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.
NEWS YOU CAN
Responding TO THE FLU
EMS leaders need to build a community plan
AP PHOTO/ THE NEWS-GAZETTE, HEATHER COIT
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
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.
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
AP PHOTO/MATT ROURKE
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
and other teaching materials
and bulletins across different shifts
>> 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
>> 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
>> CONTINUED FROM PAGE 15
flu and any other hazards that occur in
Sign up for firstname.lastname@example.org 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
—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
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
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
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
easy to manipulate or forge. Just
about every state has a registry
of certified personnel that the
agency can check to verify status
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
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FEBRUARY 2013 JEMS
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(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
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/
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
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
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
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
PRESENTED BY THE IAFC EMS SECTION
>> BY GARY LUDWIG, MS, EMT-P
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-
PHOTO A.J. HEIGHTMAN
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
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
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.
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
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.
TRICKSOUR PATIENTS & OURSELVES
OF THE TRADE
>> BY THOM DICK, EMT-P
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
And thanks to a smart medic named Steve
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,
We took one of our new self-lifting cots to
the county coroner’s office in our
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
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
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
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
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
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
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
PHOTO DENNIS EDGERLY
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.
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
Explore the possibilities.
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When severe cases present, patients can have acute heart failure
and be comatose. These cases can be referred to as thyroid storms.
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
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.
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Online Master’s Degree
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.
March 15 application deadline
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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
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
PHOTO KEVIN LINK
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
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.
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.
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
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.
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.
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Visit www.pcrfpodcast.org for
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 email@example.com.
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This article is sponsored by Ferno’s 2020 Vision series.
WHAT DOES 2020 HOLD?
Blue sky discussion brings futuristic visions to the present
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
vision.com to watch
the latest videos
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
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
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
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.)
Forecast of the
JEMS 200-CITY SURVEY SHOWS
RECESSION CONTINUES TO
AFFECT EMS IN 2012 & BEYOND
>> BY MICHAEL J. WARD, MGA
FORECAST OF THE FUTURE?
>> CONTINUED FROM PAGE 29
can an organization
hold its breath?
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
(82.5%) survey participants this year:
>> Some 29 (27.9%) organizations
Percentage of incomplete responses
reported a hiring freeze or not
Cities Represented (n=200)
filling vacancies. This was the
Cities with a single respondent
third year for some;
Cities with multiple respondents
Cities with no response
>> A total of 22 (21.2%) suspended
Response Breakdown (n=88)
pay-for-performance or costFirst responder only
of-living increases. This was
the fourth year for some;
First response & transport
>> In all, 16 (15.4%) reduced
ALS non-transport (e.g., fly car)
ALS first response that accompanies BLS/ILS trans- 6.8% (6)
port provider in all ALS transports
>> A total of 13 (12.5%) changed
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
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.
EXPANDED BLS FIRST RESPONDER
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
>> Twenty-three (26.1%) applied 12-lead
>> Twenty-two (25.0%) administered
>> Twenty-one (23.9%) administered
>> 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
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
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
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
participation in field operations. For the
remainder with prehospital participation,
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
for physicians requires a minimum of
12 months of clinical experience as the
primary or consulting physician respon■ 8
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
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
time to arrive at a scene. Five
ing ST-elevation myocardial
or measure cardiac
arrest survival scores?
(6.4%) organizations extended
infarction (STEMI), pulmoor eliminated response time
nary edema, asthma, seizure,
requirements to non-life
trauma and cardiac arrest in
the urban environment.
TRANSPORT UNIT WORK SCHEDULE
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
More than 50%
Table 4: Pre-arrival CPR Activities
AED converts to viable
rhythm prior to ALS
More than 50%
measure cardiac arrest survival scores
was 39 (44.8%). (See Table 2, p. 31.)
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.
Table 5: STEMI Performance
Less than 50%
STEMI patients received
intervention in less than 90
minutes from 9-1-1 call (n=31)
ble rhythm before ALS arrived, and occasional witnessed cardiac arrests. (See Table
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
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
>> 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
>> 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
MD Participation (n=98)
Riding with supervisor
In assigned response vehicle
No physician field time
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;
Table 7: 200-City Respondents Average Transport Charge
ALS non- emergency
>> Sixty-eight (77.3%) to stroke centers;
>> Sixty-five (73.9%) to burn centers;
>> Sixty-two (70.5%) to pediatric specialty
>> Thirty-eight (43.2%) to labor and
>> Thirty-five (39.8%) to post resuscitation hypothermia receiving
>> Twenty-seven (30.7%) to hyperbaric
>> Twenty-four (27.3%) to psychiatric
>> 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
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
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
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
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
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/
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.
3. Cone D, Brice J. (June 2010). EMS as a recognized
subspecialty: Implications for fellowship training. In NAEMSP.org. Retrieved Nov. 5, 2012, from
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
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.
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/
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 firstname.lastname@example.org
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.