Jems201207 dl

The
Conscience
of EMS
JOURNAL OF EMERGENCY MEDICAL SERVICES

32

I Rethinking Delivery Models I

EMS industry may shift deployment methods

By Johnathan D. Washko, BS-EMSA, NREMT-P, AEMD

[July 2012]

July 2012 Vol. 37 No. 7

Contents
I 52

38 I Engulfed in an Instant I

Lessons learned from Navy jet crash response
y Bruce Nedelka, NREMT-P A.J. Heightman, MPA, EMT-P
B

52 I No Need for Speed I

Improving accuracy of nursing home response-level requests
y Lori L. Boland, MPH, Steve G. Hagstrom, NREMT-P
B

I 60

60 I Silent Struggle I

Drowning is a leading cause of unintentional
injury death
y Justin Sempsrott, MD; Andrew Schmidt, DO, MPH;
B
Seth Hawkins, MD, FACEP, FAAEM, FAWM; Bryan
Bledsoe, DO, FACEP, FAAEM

I 38
Departments columns
9 I Load go I Now on JEMS.com
14 I EMS in Action I Scene of the Month
16 I From the Editor I Return to Joplin
y A.J. Heightman, MPA, EMT-P
B

20 I Letters I In Your Words
22 I Priority Traffic I News You Can Use
26 I lEADERSHIP sECTOR I Discipline
y Gary Ludwig, MS, EMT-P
B

28 I Tricks OF the TRADE I Old Friends
y Thom Dick
B

30 I case of the month I More Than a Headache
y Fred W. Wurster III, AAS, NREMT-P
B

78 I employment Classified Ads
82 I Ad Index
84 I Hands On I Product Reviews from Street Crews
y Fran Hildwine
B

88 I The Lighter Side I Young’ns of EMS

y Steve Berry
B
90 I LAST WORD I The Ups Downs of EMS

About models thatCoverand effective allow the prehospital industry to innovate,
the are efficient
Service delivery

improve evidence-based clinical practice and make the shift to more immediate care in the field. Read
more about service delivery models in “Rethinking Delivery Models: EMS industry may shift deployment
methods,” p. 32–36, and see how your service measures up. Photo iStockPhoto.com

Premier Media Partner of the IAFC, the IAFC EMS Section Fire-Rescue Med

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July 2012

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The word “summer” is often synonymous with the word “water.”
Unfortunately for EMS providers, it also means more awareness
on how to treat drowning patients.
We’ve got you covered. Check
out the bonus content for this
month’s clinical education article, “Silent Struggle: Drowning is
a leading cause of unintentional
injury death,” pp. 60–76. And
for those of you who champion
the cause, it also includes more
information on the non-profit
group Lifeguards Without Borders.
s jems.com/journal

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Conscience
of EMS

The
Conscience
of EMS
Editor-In-Chief I A.J. Heightman, MPA, EMT-P I a.j.heightman@elsevier.com
MANAGING Editor I Jennifer Berry I je.berry@elsevier.com
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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
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art director I Liliana Estep I alildesign@me.com
Contributing illustrators
Steve Berry, NREMT-P; Paul Combs, NREMT-B
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(1936–2004)

Choose 16 at www.jems.com/rs


The
Conscience
of EMS

EDITORIAL board
William K. Atkinson II, PHD, MPH, MPA, EMT-P
President Chief Executive Officer
WakeMed Health Hospitals
James J. Augustine, MD
Medical Advisor, Washington Township (OH) Fire Department
Director of Clinical Operations, EMP Management
Clinical Associate Professor, Department of
Emergency Medicine, Wright State University
steve berry, NRemt-p
Paramedic EMS Cartoonist, Woodland Park, Colo.
Bryan E. Bledsoe, DO, FACEP, FAAEM
Professor of Emergency Medicine, Director, EMS Fellowship
University of Nevada School of Medicine
Medical Director, MedicWest Ambulance
Criss Brainard, EMT-P
Deputy Chief of Operations, San Diego Fire-Rescue
Chad Brocato, DHS, REMT-P
Assistant Chief of Operations, Deerfield Beach Fire-Rescue
Adjunct Professor of Anatomy Physiology, Kaplan University
J. Robert (Rob) Brown Jr., EFO
Fire Chief, Stafford County, Va., Fire and Rescue Department
Executive Board, EMS Section,
International Association of Fire Chiefs
carol a. cunningham, md, FACEP, FAAEM
State Medical Director
Ohio Department of Public Safety, Division of EMS
Thom Dick, EMT-P
Quality Care Coordinator
Platte Valley Ambulance
Marc Eckstein, MD, MPH, FACEP
Director of Prehospital Care, Los Angeles County/
USC Medical Center
Medical Director, Los Angeles Fire Department
Professor, Emergency Medicine,
University of Southern California
Charlie Eisele, BS, NREMT-P
Flight Paramedic, State Trooper, EMS Instructor
Bruce Evans, MPA, EMT-P
Deputy Chief, Upper Pine River Bayfield Fire Protection,
Colorado District
Jay Fitch, PhD
President Founding Partner, Fitch Associates
Ray Fowler, MD, FACEP
Associate Professor, University of Texas Southwestern SOM
Chief of EMS, University of Texas Southwestern Medical Center
Chief of Medical Operations,
Dallas Metropolitan Area BioTel (EMS) System
Adam D. Fox, DPM, DO
Assistant Professor of Surgery,
Division of Trauma Surgery Critical Care,
University of Medicine Dentistry of New Jersey
Former Advanced EMT-3 (AEMT-3)
Gregory R. Frailey, DO, FACOEP, EMT-P
Medical Director, Prehospital Services, Susquehanna Health
Tactical Physician, Williamsport Bureau of
Police Special Response Team

12

JEMS

JULY 2012

Jeffrey M. Goodloe, MD, FACEP, NREMT-P
Associate Professor EMS Division Director,
Emergency Medicine, University of Oklahoma School of
Community Medicine
Medical Director, EMS System for Metropolitan
Oklahoma City Tulsa

David E. Persse, MD, FACEP
Physician Director, City of Houston Emergency Medical Services
Public Health Authority, City of Houston Department. of Health
Human Services
Associate Professor, Emergency Medicine, University of Texas
Health Science Center—Houston

Keith Griffiths
President, RedFlash Group
Founding Editor, JEMS

John J. Peruggia Jr., BSHuS, EFO, EMT-P
Assistant Chief, Logistics, FDNY Operations

Dave Keseg, MD, FACEP
Medical Director, Columbus Fire Department
Clinical Instructor, Ohio State University
W. Ann Maggiore, JD, NREMT-P
Associate Attorney, Butt, Thornton Baehr PC
Clinical Instructor, University of New Mexico,
School of Medicine
Connie J. Mattera, MS, RN, EMT-P
EMS Administrative Director EMS System Coordinator,
Northwest (Illinois) Community Hospital
Robert J. McCaughan
Chair, IAEMSC Metro Chief’s Section
Robin B. Mcfee, DO, MPH, FACPM, FAACT
Medical Director, Threat Science
Toxicologist Professional Education Coordinator,
Long Island Regional Poison Information Center
Mark Meredith, MD
Assistant Professor, Emergency Medicine and Pediatrics,
Vanderbilt Medical Center
Assistant EMS Medical Director for Pediatric Care,
Nashville Fire Department
Geoffrey T. Miller, EMT-P
Director of Simulation Eastern Virginia Medical School,
Office of Professional Development
Brent Myers, MD, MPH, FACEP
Medical Director, Wake County EMS System
Emergency Physician, Wake Emergency Physicians PA
Medical Director, WakeMed Health Hospitals Emergency
Services Institute
Mary M. Newman
President, Sudden Cardiac Arrest Foundation
Joseph P. Ornato, MD, FACP, FACC, FACEP
Professor Chairman, Department of Emergency Medicine,
Virginia Commonwealth University Medical Center
Operational Medical Director, Richmond Ambulance Authority
Jerry Overton, MPA
Chair, International Academies of Emergency Dispatch
David Page, MS, NREMT-P
Paramedic Instructor, Inver Hills (Minn.) Community College
Paramedic, Allina Medical Transportation
Member of the Board of Advisors,
Prehospital Care Research Forum
Paul E. Pepe, MD, MPH, MACP, FACEP, FCCM
Professor, Surgery, University of Texas
Southwestern Medical Center
Head, Emergency Services, Parkland Health Hospital System
Head, EMS Medical Direction Team,
Dallas Area Biotel (EMS) System

Edward M. Racht, MD
Chief Medical Officer, American Medical Response
Jeffrey P. Salomone, MD, FACS, NREMT-P
Associate Professor of Surgery,
Emory University School of Medicine
Deputy Chief of Surgery, Grady Memorial Hospital
Assistant Medical Director, Grady EMS
Kathleen S. Schrank, MD
Professor of Medicine and Chief,
Division of Emergency Medicine,
University of Miami School of Medicine
Medical Director, City of Miami Fire Rescue
Medical Director, Village of Key Biscayne Fire Rescue
John Sinclair, EMT-P
International Director, IAFC EMS Section
Fire Chief Emergency Manager, Kittitas Valley Fire Rescue
Corey M. Slovis, MD, FACP, FACEP, FAAEM
Professor Chair, Emergency Medicine,
Vanderbilt University Medical Center
Professor, Medicine, Vanderbilt University Medical Center
Medical Director, Metro Nashville Fire Department
Medical Director, Nashville International Airport
Barry Smith, EMT-P
CQI Coordinator, Regional EMS Authority (REMSA), Reno, Nev.
Walt A. Stoy, PhD, EMT-P, CCEMTP
Professor Director, Emergency Medicine,
University of Pittsburgh
Director, Office of Education,
Center for Emergency Medicine
Richard Vance, EMT-P
Captain, Carlsbad Fire Department
Jonathan D. Washko, BS-EMSA, NREMT-P, AEMD
Assistant Vice President, North Shore-LIJ Center for EMS
Co-Chairman, Professional Standards Committee,
American Ambulance Association
Ad-Hoc Finance Committee Member, NEMSAC
keith wesley, MD, facep
Medical Director, HealthEast Medical Transportation
Katherine H. West, BSN, MED, CIC
Infection Control Consultant,
Infection Control/Emerging Concepts Inc.
Stephen R. Wirth, Esq.
Attorney, Page, Wolfberg Wirth LLC.
Legal Commissioner Chair, Panel of Commissioners,
Commission on Accreditation of Ambulance Services (CAAS)
Douglas M. Wolfberg, Esq.
Attorney, Page, Wolfberg Wirth LLC
Wayne M. Zygowicz, BA, EFO, EMT-P
EMS Division Chief, Littleton Fire Rescue

EMS IN ACTION
Scene of the month

14

JEMS

JULY 2012

Photo Bernie Deyo

Air Transport

E

mergency personnel place a patient into a medical helicopter
for transport to a trauma center. The patient was ejected from
his vehicle after it rolled several times in a remote area. Los Angeles
County Fire Department (LACoFD) paramedics provided BLS and
ALS care, including assessment, oxygen administration and C-spine
precautions, to the patient prior to his airlift. LACoFD operates one
of the most progressive, multi-functional helicopter systems in the
country, with crews able to perform fire suppression, EMS, search
and rescue, and extraction functions via their helicopters.

www.jems.com

JULY 2012

JEMS

15

from the editor
putting issUes into perspective

by A.J. HEIGHTMAN, MPA, EMT-P

Return to Joplin

Crews rebound from the tornado’s horrible aftermath

Photo AP/Mark Schiefelbein


meet with the crews and supervisors and
speak at a staff picnic on the first anniversary
of the tornado, I accepted immediately.
METS and NCAD cover the Joplin area in a
unique and cooperative response system (see
Last Word, p. 90). Many of the region’s EMS,
fire personnel and emergency department
nurses work for one or both agencies.
I arrived in Joplin the day after President
Barack Obama’s speech at the Joplin Community College and was not at all surprised
to learn that the elected officials, fire crews
and law enforcement staff were allowed into
the facility, but the EMS crews, the ones who

EMS crews were confronted by dead bodies and patients who ranged
from having minor injuries to pieces of rebar sticking out of their skulls.

16

would be able to contribute the most
if the president or another attendee
collapsed during the ceremony, were
stationed outside the auditorium at
their nine ALS units.
It’s a common story that stinks
and will probably only change when
an elected official chokes to death on
a martini olive and it takes 12 minutes for a crew to get to that person’s
obstructed airway.
The community college, METS and
NCAD are an important part of the
Joplin tornado history because the tornado tore through the center point
of their two primary response districts and
dozens of the emergency personnel were at
the community college instead of Joplin High
School, which was not large enough to hold
the high school’s graduation, when the tornado tore through the high school, hospital
and their homes minutes after graduation
ceremonies had concluded.
What follows are photos from that fateful day and my visit. I hope they show you
the unimaginable obstacles the METS and
NCAD EMS crews faced and how they have
rebounded, physically and emotionally, in the
year since that horrible day.
Photo AP/Charlie Riedel

T

he tornado that tore
through Joplin Mo., on
May 22, 2011, killed 165
people and injured 1,500 others; it decimated thousands
of homes, business, churches,
nursing homes and St. John’s
Mercy Hospital—one of the
town’s two hospitals.
It received international attention for weeks. Much of the attention centered on the many lives
lost at one of the nursing homes
and St. John’s. Many of the media
stories focused on heroic civilian
efforts, including road crews that cleared the
road early with chainsaws and assisted citizens and firefighters in finding and extricating
trapped individuals.
But like so many other disasters, the efforts
of the local and mutual aid EMS agencies,
which found, triaged, treated and transported
scores of injured to medical facilities throughout a 12-hour period after the tornado, went
largely ignored by the national media.
So when Jason Smith, director of Metro
Emergency Transport System (METS), and
Rusty Tinney, director of the Newton County
Ambulance District (NCAD), invited me to

JEMS

JULY 2012

NCAD EMS Director Rusty Tinney and the first ambulance that arrived at E. 20th St.
Range Line Road encountered more than a dozen dead bodies and people searching
for relatives and friends who had been sucked out of the walk-in freezer at a fast food
restaurant. Only four of the 12 people who tried to take refuge in the freezer survived.

FROM THE EDITOR

This is all that remained of the Greenbriar Nursing Home after the
tornado ravaged the area. Eighteen were killed at this location.


METS NCAD crews established patient collection and treatment areas near the tornado’s path of
destruction—a path that traversed both ambulance service areas.


A.J. Heightman (left) NCAD Director Rusty Tinney
stand at the Pizza Hut one year after the incident.
Many of the restaurants and stores have already
been rebuilt, but the horrible sights seen by the EMS
crews will always remain in their memories.


Photo Courtesy A.J. Heightman

continued from page 16


The remains of Joplin High School, where hundreds of lives would have been lost had the
school been used for its graduation ceremony. The school’s sign was modified and became a
lasting symbol of hope for the community.

Photo AP/Jeff Roberson

Photo A.J. Heightman


St. John’s Mercy Hospital, its emergency department and medical
helicopter took a direct hit.

Rusty Tinney (left) METS Director
A Joplin City building was used as temporary hospi- Jason Smith stand in the temporary
multi-section modular hospital
tal after the tornado.

Temporary trailers were erected after the tornado to house patients
and equipment that survived the destruction of St. John’s.

18

JEMS

JULY 2012




Members of Missouri Task Force One search-and-rescue team stand
by as heavy equipment moves debris from a tornado-damaged Home
Depot store.

The spacious emergency department of the tempo- Crews from METS NCAD gather to
rary prefab, modular, which is now named Mercy remember that fateful day in 2011 at
the May 23, 2012, crew picnic.
Hospital Joplin.

SaveDATE
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March 5 – March 9, 2013

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LETTERS
in your words

Photo glen ellman

This month, readers comment on
a few recent JEMS articles. One
reader discusses the information
in an article on cultural sensitivity (“Breaking Barriers: Practice
cultural sensitivity to provide
care to immigrant communities,”
May JEMS) by Emily Coffey, BA,
NREMT-P, and Keith Widmeier,
NREMT-P, CCEMT-P, EMS-I, and
another had concerns with the
type of care shown in an April
EMS in Action photo spread
(“Active Assessment.”)
Finally, JEMS Facebook fans
chime in on a quote by Thom
Dick that reminds providers
to take extra time to make all
patients feel valued.

Faith Practices
I was mystified by the article “Breaking Barriers,”
which had the following in a caption: “Most
Americans aren’t opposed to porcine insulin, but
Jewish and Muslim patients might choose to accept
the risks of hyperglycemia rather than receive this
particular medication.” I cannot speak for the Muslim
faith, but as an Orthodox Jewish rabbi, my jaw
dropped. The first law of Judaism commands us to

break every law in order to save a life.
There is no objection or law that prohibits the use
of porcine insulin. Just the opposite is true: We are
commanded to do whatever is necessary in order to
save our lives and maintain our health. No person of
the Jewish faith would ever accept the risks of hyperglycemia in order to avoid a medication coming from
any animal source.
I’m extremely confused where the author got this

Another day of death,
mayhem and chaos over.
Wha’cha watching?

illustration steve berry

1,000 Ways
to Die

20

JEMS

JULY 2011

information, and it’s absolutely contrary to our faith.
Rabbi Baruch Stone, NREMT-I
Cambridge, Massachusetts
Author Keith Widmeier, NREMT-P, CCEMT-P, EMS-I
responds: According to the informational booklet,
Informed Choice in Medicine Taking: Drugs of Porcine
Origin and Clinical Alternatives (www.keele.ac.uk/
pharmacy/npcplus/medicinespartnershipprogramme/
medicinespartnershipprogrammepublications/
drugsofporcineoriginandclinicalalternatives/drugs-ofporcine-origin.pdf), porcine medications may be an
issue for a number of faiths, but it’s more likely to be
an issue for Judaism and Islam.
The booklet goes into discussion about potential
exemptions as well. However, I feel that this discussion is straying from the overall message of the article.
Regardless of faith—our patients’ or our own—it is
imperative that we, as providers, respect the decisions
made by our patients. Patients have the right to decide
what treatment they choose to accept—or not
accept—and providers should not attempt to downplay
the importance of the patient’s faith for the desired
medical treatment.

Check the Basics
In the April JEMS article, “Active Assessment,” paramedic Brian Pearce was doing what I call a double
pulse check.
I teach in a private paramedic college, and I notice
all the students are trained to practice this, and I disagree with it. I understand
the thought behind it, but
we must consider that the
American Heart Association
(AHA), Heart and Stroke
Foundation of Canada and
Journal of the American
Medical Association have
referenced that 60% of
healthcare providers can’t
adequately check for a
carotid pulse.
I’ve taken a dozen students and had them access
a carotid pulse, and all 12
couldn’t find a pulse in a
timely fashion. We live in a
culture of fat necks, meaning many patients have lots
of adipose tissue in their
necks. Unless a provider
uses a head tilt/chin lift to
bring carotid artery closer
to the surface, how can
anyone truly feel a carotid

and radial at the same time?
If a medic comes across an unconscious patient, they should assume they’re
dead, check a carotid only first, then check a radial if there’s a pulse to see if
pressure is adequate. I don’t care if I’m perfusing the finger, but I do care if the
brain is being perfused.
Let’s just follow AHA guidelines instead of changing what works. Assess
responsiveness, open airway and check for breathing and pulse while using a
head tilt/chin lift. This step still follows the current 2010 guidelines: If there is no
breathing and no pulse, then get on the chest and start compressions. Let’s get
back to the basics.
Arne Larsen
Simcoe County, Ontario, Canada

Words of Wisdom

Below are comments from the JEMS Facebook Fan page in
response to the following quote by columnist Thom Dick:

‘Next time you kneel in front of somebody
you don’t know or sit beside someone
in that ambulance of yours, look them
straight in the eye. While they’re with you,
they’re important.’ —Thom Dick
—Dennis Youngberg: Treat them as if they were your mother/father.
—Moe Altazan: We’re all guilty of this at one time or another. It takes practice and compassion; we have to make it a natural habit.
—Marcia Chapman: Too many are paying more attention to their clipboard
or computer than to their patients. Building a rapport with your patient is
just as important as any of your other skills—it takes practice to develop and
ongoing use to master.
—Smiley Rie: So very true. It might not be an emergency to us, but to most
of them it is. And my other favorite saying is this: “It’s not about our egos; it’s
about the patient.”
— ohn Michael Fisher: I was taught this during school so now it’s second
J
nature for me, but I only sit in the jump seat if I’m playing with the monitor,
doing something airway, or if the patient falls asleep. I always sit on the bench
and play to precept everyone.
—Sharon Cox: True words. I can’t stand it when paramedics or EMTs don’t
talk to their patients or are too clinical with them. A kind word, a smile, a held
hand and a little reassurance goes a long way.
—Curtiss Orde: Amen to Thom’s quote. JEMS

Do you have questions, comments or concerns
about recent JEMS or JEMS.com articles?
We’d love to hear from you. E-mail your letters to
editor.jems@elsevier.com or send to 525 B St. Suite
1800, San Diego, CA 92101, Attn: Allison Moen.

www.jems.com

JULY 2012

JEMS

21

PRIORITYUSE
TRAFFIC
NEWS YOU CAN

Zombie Drug
Despite sanction, patients continue to use drug known as ‘bath salts’

tlnors/istockphoto.com

T

he meteoric rise of the street drug
called “bath salts” has taken a grip
on prehospital providers and emergency departments (EDs) nationwide. Many
experts say they’re most alarmed by the
short amount of time it has taken for this
drug to become so prominent.
Bath salts is the most common street
name for certain synthetic cathinones,
including methylenedioxypyrovalerone
(MDPV) and methedrone. It’s a broadly
available psychoactive drug that mimics
the effects of other stimulants such as methamphetamine, ecstasy and cocaine.
In 2010, there were 303 calls to poison
control centers nationwide for probable

Bath salts are stimulants, and their symptoms are
simliar to those from methamphetamine, ecstasy
and cocaine use.
bath salts complications. The first third of
2012 has already resulted in 1,007 calls. If
this trend persists, this will equate to more

Photos Courtesy NEMSMBR

QUICK TAKE
During EMS Week, dozens of people from EMS systems all
over the U.S. gathered to participate in the 2012 National
EMS Memorial Bike Rides (NEMSMBR), with routes starting
in both Boston, Mass., and Paintsville, Ky. Both routes ended
in Alexandria, Va. The ride is held annually to honor EMS
providers who have died in the line of duty and to advocate
for safety in EMS and the wellness of EMS providers.
Over the seven days, close to 100 riders, called “Muddy
Angels,” participated per day on the East Coast route and
seven riders on the Kentucky route. Another 20–25, affectionately known as “Wingmen,” provided support. Twentytwo states were represented among the participants.
For some, it was a return to the ride, but for others, it
was their first ride. For both, many moments and emotions
were experienced along the way.
The 2012 ride was also especially meaningful for many,
as the group rode to honor Lori Foster-Mayfield, a paramedic from Reno, Nev., who died unexpectedly in January.
“Due to our previous year’s accounts of the ride, as well
as the outpouring of support for Lori and her passion for
her profession, 14 people from the Reno area joined us on
the ride,” says Trish Hamilton, a flight nurse and Lori’s best
friend. “For me, [the decision to ride] was the best decision
I could have made. My Muddy Angel family is like no other
friendship or family out there. They are some of the best
people I have ever known.”
It’s a grueling journey, both mentally and physically.
However, the spirit of the ride, those who are being honored
and the feeling of family among the Muddy Angels heals
muscles, hearts and souls. —Tim Perkins

Beth Kirkland Davis and Trish
Hamilton (above) read during
a Memorial Service for Muddy
Angel Lori Foster-Mayfield.

More of the latest EMS news is at JEMS.com/news

22

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JULY 2012

than 3,000 calls in 2012; a tenfold increase
from 2010.
Common side effects include euphoria, anxiety, confusion, insatiable desire for
more of the drug and paranoia. Hyperthermia, cardiovascular collapse, rhabdomyolysis and renal sequalae are more
severe and potentially fatal consequences
of use. It’s crucial that prehospital providers understand the risk for these potentially
fatal complications and that ED evaluation,
monitoring and treatment is the appropriate definitive therapy.
The news headlines continue to publicize
the bizarre and severe actions of those abusing this new street drug. The latest shocking

headline reveals a crazed individual in Florida who is suspected of chewing off the face
of another man after taking bath salts. The
suspect has been repeatedly described as a
“Zombie,” highlighting the severe psychoactive effects of this medication.
Other headlines include suicides, strangulations and homicidal actions by those
under the influence. One notable case in
West Virginia involved a man who allegedly
dressed in women’s clothing and stabbed a
stolen goat to death—all while under the
influence of bath salts.
Prehospital and ED personnel also report
bizarre, unpredictable and very dangerous
actions from individuals under the influence of bath salts. These patients exhibit
dangerous, unpredictable, combative
behavior that put bystanders and EMS providers in danger.
Treatment modalities include restraining the individual as necessary, providing
cardiovascular support, treating hyperthermia and administering benzodiazepine for

agitation. This is to prevent harm to the
patient, as well as preventing further hyperthermia and muscle activity that could
result in rhabdomyolysis.
Beta-blocker administration for hypertension is contraindicated because it causes
a spike in blood pressure, which is attributed
to unabated alpha-adrenergic stimulation.1
In response to the substantial rise in
abuse and emergency department visits
related to bath salts, the Drug Enforcement
Agency (DEA) imposed an emergency sanction classifying MDPV as a Schedule I controlled substance. That puts it in the same
category as heroin and lysergic acid diethylamide (LSD). Prior to this action, more
than 30 individual states had criminalized
the drug.
For the short term, there are indications that the DEA’s action may be blunting nationwide use of the drug. However,
this sanction may have limited long-term
consequences because chemists of synthetic drugs may be able to slightly alter the

chemical compound so it isn’t classified as
the prohibited compound.
Examples of alternative chemicals being
manufactured to replace the now-illegal
bath salts include naphyrone, which is sold
as “cosmic blast.” Naphyrone is gaining
popularity in Europe and is spreading to the
US. Symptoms and dangers are nearly identical to bath salts.
EMS providers need to remain vigilant
for these potential patients and be aware of
the various treatment modalities. They also
need to maintain crew safety around these
potentially violent patients.
—Jon Nevin, NREMT-P, BS, MBA

References
1. Michigan Department of Community Health. (April
30, 2012). ‘Bath Salts’ Health Care Provider Fact
Sheet. In Michigan. Retrieved June 11, 2012, from
www.michigan.gov/documents/mdch/Bath_
Salts_FAQ_Health_Care_Providers_April2012_
v2_384317_7.pdf.

Patient Handling Errors The legal risks of gravity By Doug Wolfberg Steve Wirth

O

ne of the areas of EMS operations that often
seems to be taken for granted is patient handling—or “lifting and moving,” as we referred to it
in EMT class. Oftentimes, this critical area might be
given short shrift in training programs. Changes in
technology can also lead to crew member unfamiliarity with the use of new equipment. And sometimes,
simple mistakes can allow gravity to overtake our best
efforts, resulting in patient drops and other patient
handling errors.
Although hard data on the number of patient
drops is hard to come by, anecdotally, we usually
receive a couple of calls a month with these types of
cases. The legal defense of “patient drop” cases usually
involves a mechanical evaluation of the stretcher and
other equipment. But most of the time, this inspection (typically done by a mechanical engineer or other
such expert) reveals no deficiencies with the equipment. Most of the time, these incidents are caused by
human error. Good, old-fashioned negligence, as we
like to call it.
In cases that come down to unvarnished human
error, little can be done to pull a rabbit out of a hat
in court: Negligence is negligence. And negligence
does not require the violation of a protocol or written policy to be actionable in court. (When was the
last time you read an EMS protocol that said “don’t
drop the patient?”) Negligence is the failure to

Get help when you need it. Let’s face it. Ameriuphold the standard of care applicable to the circumstances (or, put another way, the failure to act ca’s obesity epidemic takes its toll on EMTs and medics
as a reasonably, prudent EMT or paramedic would every day. Know your physical limitations when lifting
under the circumstances). No violation of a written patients. If you need extra assistance, ask for it before
protocol or policy is necessary for a jury to find that making the situation worse by attempting to move
not dropping patients is firmly within the EMS stan- a patient who is too heavy for you and your partner.
Asking for help is no admission of failure or defeat if it
dard of care.
Here are a few suggestions for preventing unneces- means a safer move for you and your patient.
Work as a team. Ensure patients are moved in
sary liability arising from the ill effects of gravity that
a delicate dance of coordination by all members of
result in patient drops:
Train your people. Make sure your crews are your team. One team leader should provide a clear lift
properly trained not only in proper lifting and mov- count, so that all personnel are exerting at the same
ing techniques (which can also help reduce workplace time. If other crew members are needed to back up
injuries), but also in the proper use of your agency’s the carriers on stairs, on icy or snow-covered drivespecific equipment. Newer technologies, such as pow- ways or to help navigate other hazards when moving
ered cots, assisted lift devices and locking systems, can the patient, ensure those conditions are addressed
require a greater comfort level to operate than tradi- before or during the move to minimize risks. Move all
obstacles ahead of time if they can be moved and may
tional equipment.
Maintain your equipment. Follow the manu- impede your path of movement. In this regard, a little
facturer’s suggested policies regarding periodic inspec- preplanning goes a long way.
Though some of this advice
tion, maintenance and replacement
Pro Bono is written by
may seem elementary, focusof equipment and devices used to
attorneys Doug Wolfberg
ing on improving patient handling
lift or move patients, such as stretchand Steve Wirth of Page,
practices can help prevent injuries
ers, stair chairs and backboards. This
Wolfberg Wirth LLC, a
to crew and patients, and it can
stuff doesn’t last forever, so don’t try
national EMS-industry law
reduce the chances of legal liabilto squeeze more life out of a piece of
firm. Visit the firm’s website
at www.pwwemslaw.com for
ity arising from these preventable
equipment that has reached the end
more EMS law information.
types of human errors.
of its life span just to save a few bucks.

Conduct a keyword search for “drug shortage” at JEMS.com for more information.

24

JEMS

JULY 2012

LEADERSHIP SECTOR
presented by the iafc ems section

by gary ludwig, ms, emt-p

Discipline
P

icture this scenario: Two of your
paramedics respond to a scene. Your
patient’s wife called for you to treat
her husband, who’s threatening suicide. He
has been drinking and admits he took some
of his pain prescription drugs.
Once the paramedics get to the scene,
the husband is agitated and uncooperative.
He’s adamant that he doesn’t want to be
transported to a hospital. The paramedics
try to gain his cooperation and try to get
some history and vital signs, but he tells
them, “You ain’t touching me” and “I ain’t
going to no hospital.”
This is a difficult scenario for the paramedics because they have a patient who
isn’t cooperating. According to the medical
director’s protocols, however, anyone who’s
threatening suicide or can’t pass a series
of questions to verify they’re competent to
deny treatment and transport must be transported to a hospital facility.
Finding themselves in a quandary, the
paramedics decide to call the police. Once
the police arrive on the scene and find that
the patient is refusing treatment and transport to a hospital, they tell the paramedics there’s nothing they can do because the
patient is refusing treatment and transport.
The paramedics decide not to transport the
patient to the hospital.
The two paramedics on the scene are
good employees. They always come to work,
are never tardy and generally cause no problems. Several letters from citizens in their
personnel file reflect excellent customer service skills over the years. The employees’ files
lack disciplinary action. For the most part,
these paramedics are excellent employees.
On this particular day, they made a bad
decision. The EMS providers decided not
to transport the patient who was denying
any treatment and transport, and the police
officers said they weren’t going to intervene.
The providers had the patient sign their standard refusal of care form, and they exited the
scene with the patient’s wife protesting.

26

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july 2012

After the Call
Several hours later, the 9-1-1 center receives
another call from the patient’s wife. This time
her husband is unconscious with labored
breathing. When another ambulance arrives,
they have to intubate the patient and transport him to the hospital.
EMS management later discovers what
happened, conducts an investigation and
suspends each paramedic on the original call
for 10 days.
Is it the right decision to suspend both
employees? Some would argue that the paramedics in this case should be suspended, and
others would argue that they should receive
further education to understand the protocols and refine their decision-making skills.
Many would argue that discipline isn’t
about punishment for doing something
wrong; instead, it’s to change the behavior
of the employee’s who made the wrong decision. Others would argue that the paramedics in this situation shouldn’t be suspended
because they’re good employees who
weren’t unwilling to do the job, rather they
weren’t fully aware of all the options available to them in the decision-making process.
They possibly could have called their
supervisor and asked what they should do.
Or they could have asked the police officers
to call one of their supervisors and have them
respond to the scene to assist with options
to manage the patient who should go to the
hospital but was refusing to go.
Some would argue that when you suspend two employees who made a wrong
decision, you will take two good paramedics
who are generally excellent employees and
destroy their motivation for the job.
Some would argue that the suspensions would dampen the employee’s
enthusiasm to come to work, never
be tardy, and treat patients and family members with excellent customer
service skills because the employee
didn’t act intentionally or believe they
were making a poor decision.

The final step
should be to administer the discipline. This
final step should come
only after the EMS providers
have been taught, coached and
counseled and the desired
results aren’t achieved.
Remember, the
purpose of discipline is to
change behavior, not to punish the employee.
The disciplinary phase should
also include an
assessment of the
desired behavior
you’re trying to
achieve. The severity of the disciplin- Punishing your
ary action should employees
be based on the unnecessarily may
potential conse- lead them to quit.
quences the behavior could cause to the department.
During my years, I’ve seen managers in
fire and EMS organizations hand out discipline like they were handing out candy. I
even worked for one manager who finished
every department-wide memorandum with
the statement, “Failure to follow this memorandum will result in discipline.” Of course,
those memos went over like a lead balloon,
and he couldn’t figure out why there was
such dissension in the organization or why
he couldn’t hold a job anywhere.
Bottom line: Discipline isn’t always the
answer. JEMS
Gary Ludwig, MS, EMT-P, is a deputy fire chief
with the Memphis (Tenn.) Fire Department.
He has 34 years of fire and rescue experience. He’s chair of the EMS Section for the
International Association of Fire Chiefs and
can be reached at www.garyludwig.com.

Photo istockphoto.com.

The difference between discipline punishment

TRICKSour patients ourselves
OF THE TRADE
caring for

by Thom Dick, EMT-P

Old Friends
Harnessing people’s wheelchairs

Y

Photos Thom Dick

hundred pounds. But fortuou ever think about
nately, people who depend
wheelchairs,
Lifeon those devices also tend to
Saver? We see them
have one or more standard
so often I reckon most of us
wheelchairs, and they can get
rarely give ’em much thought,
by with them for a short time.
but so many of the people
My first EMS employer
you meet every day are totally
was affiliated with a medidependent on them.
cal equipment supplier, and
Some chairs are pretty
I learned my lessons early
sophisticated and weigh more
about wheelchairs from
than you can lift. And some
them. You can expect a basic
of their owners have had
folding wheelchair to have
names as big as Itzhak Perla mass of 20 kg. Its weight
man, Christopher Reeve, and
increases depending on its
Stephen Hawking. Franklin D.
optional attachments and the
Roosevelt was often popularsize of the patient it’s designed
ized with a wheelchair during
to accommodate.
WWII, and actor Raymond
Types of attachments
Burr’s award-winning Ironmight include adjustable
side character never appeared
footrests, removable handwithout one.
rails, reclining backrests,
But famous or not, the
head supports and oxygen
U.S. Fire Administration has
racks; and each of those
estimated as recently as 1999
adds weight. Many attachthat 1.8 million Americans
ments can be removed prior
depend on wheelchairs.1 The
to loading a wheelchair, and
World Health Organization
they should be. You can stow
currently estimates that 1%
them under the bench seat.
of the world’s population—
Of course, if you’re in a Type
some 65 million—are in need
I or Type III ambulance, the
of wheelchairs.2 And to many
outboard compartments
of the people we transport in
might be better.
ambulances, their wheelchairs
Before you handle any
are absolutely essential.
wheelchair, consider that
So how do you load a
wheelchairs can be dirty.
wheelchair? Where do you
They’re subject to spills and
stow one safely in an ambubathroom accidents, and
lance, and what do you do if
many of them aren’t cleaned
you simply can’t take one with
often. I think it’s a
you? You don’t exactly know
good idea to glove
those things when you start Knowing how to handle a
wheelchair is an important
up before you handle
out as a new EMT, do you?
aspect of patient care.
one, and clean your
To be sure, you simply can’t
transport some kinds of chairs in an ambu- hands afterward. Also, make it a habit
lance. A powered wheelchair or scooter is to lock the brakes every chance you
non-collapsible, and its motor, batteries and get. That’s a must before you help
heavy wheels can raise its weight to several someone into a wheelchair or out of one. It’s

28

JEMS

JULY 2012

also necessary to lock the brakes before you
lift a wheelchair because you’ll need to grip
one of its main wheels to do so.
Collapsing and expanding a wheelchair is
easy if you know what you’re doing, but you
can look pretty silly otherwise. To collapse
one, grip the front and rear edges of its seat
and lift abruptly (thus the gloves). To expand
it, push downward with both hands simultaneously on the rigid supports attached to
the right and left edges of the seat. Any time
you stow a chair, make sure it’s folded and
firmly secured with a buckle strap (such as
the safety harness on your captain’s chair, for
instance). Even a lightweight wheelchair can
turn deadly and bounce around the inside of
your compartment.
Finally, if you’re transporting a chair from a
patient’s home, there’s a good chance it’s not
clearly identified as their property. Do them a
huge favor. Attach a piece of two-inch cloth
tape to the rear-facing surface of the seat back,
and print their name on it with a felt marker.
Apply the tape at an oblique angle, so you
attract more attention. Even manual wheelchairs are expensive (up to $500 a pop), and
they can get lost in hospitals. You wouldn’t
want that to happen on your shift if you could
so easily prevent it, would you? JEMS

References
1. USFA. Oct. 1999. Fire Risks for the Mobility Impaired.
In Ogilvy Public Relations Worldwide. Retrieved April
29, 2012, from www.usfa.fema.gov/downloads/pdf/
publications/fa-204-508.pdf.
2. Disabilities and Rehabilitation: Guidelines on the
provision of wheelchairs in less-resourced settings. In
World Health Organization. Retrieved April 29, 2012,
from www.who.int/disabilities/publications/technology/wheelchairguidelines/en/.
Thom Dick has been involved in EMS for
42 years, 23 of them as a full-time EMT and
paramedic in San Diego County. He’s currently
the quality care coordinator for Platte Valley
Ambulance, a hospital-based 9-1-1 system in
Brighton, Colo. Contact him at boxcar_414@yahoo.com.

CASE OF THE MONTH
DILEMMAS IN DAY-TO-DAY CARE

BY Fred W. Wurster, III, AAS, NREMT-P

More than a Headache
Patient’s symptoms found to be much more serious

Patient Assessment
The patient responds by whispering his
name and saying he has a headache and that
it hurts to open his eyes. You question the
patient about his reasons for being treated at
the facility, and he reports he’s an alcoholic
who drinks approximately one gallon of
vodka a day and has since he was 14. He has
been “clean” for six days.
The patient denies any other medical conditions, reporting that he doesn’t take any
prescribed medications and has an allergy to
Penicillin. According to the patient’s chart,
he’s taken several medications to aid in his
detoxification process. You and your partner
look at each and try not to pass judgment
because you’ve encountered many patients
here in the past who haven’t been truthful
with their complaints.
While you continue to question the patient,
he suddenly grabs the back of his head and
states, “This is the worst headache I’ve ever
had; it feels like someone is cutting into my
brain.” You obtain a baseline set of vital signs
that reveal the following: BP=168/118; HR=92
and regular; RR=18 and non-labored.

Transport
The patient begins to writhe in pain, complains about increasing pain in his head and
vomits twice profusely. You secure the patient
and stretcher and prepare for transport. You

30

JEMS

JULY 2012

hospital. The patient remains
apply the ECG monitor and
unresponsive with unchanged
administer 4 LPM of oxygen.
vitals. The emergency departYou establish an IV and adminment (ED) staff takes him to
ister 4 mg of Zofran for nausea.
radiology for a computed
As you begin transport, you
tomography scan.
ask the patient how he’s feeling,
A few moments later, the
but he doesn’t answer. You ask
ED physician informs you that
again and note that he now has
the patient is in extremely critisonorous respirations.
cal condition. He tells you the
Current vital signs are now:
Be wary when responding
BP=198/168; HR=110; RR=8 to a call at a familiar facility patient has a substantial suband are shallow and abnormal because the patient could arachnoid hemorrhage and has
in pattern. You begin to assist have an unknown underly- just gone into cardiac arrest.
Resuscitation attempts are
the patient with ventilations ing condition.
with a bag-valve mask and your partner noti- unsuccessful, and the patient is pronounced
fies the hospital of the sudden change to the dead about 30 minutes later.
patient’s condition.
While you ventilate the patient, he Subarachnoid Hemorrhage
becomes extremely agitated and begins to A subarachnoid hemorrhage occurs when
thrash around. Although he’s not seizing, blood enters the subarachnoid space because
he becomes difficult to control. This contin- of a variety of reasons. It usually occurs
ues for a few minutes, and then he suddenly from a ruptured cerebral aneurysm or as a
becomes somewhat alert and says, “some- result of a traumatic head injury. The classic
thing is really wrong.”
or textbook symptoms of one are a rapid
A repeat set of vital signs still shows a dra- onset of a “thunder-clap” headache, which
matically elevated blood pressure at 218/176, is often reported to be the worst headache
with a HR=118, and now the patient’s respira- someone has ever experienced. Other associtions seem more normal at 14 per minute. ated symptoms include vomiting, confusion,
You conduct a blood glucose test, and it’s 86 decreased levels of consciousness and somemg/dL. The patient’s skin doesn’t feel hot, and time seizure activity.
all the other physical exam findings are within
Subarachnoid hemorrhage has a 50% mornormal limits.
tality rate, and of that 50%, about half the
About five blocks away from the hospital, patients expire before reaching a hospital.
the patient lets out a scream that startles you Patients who survive usually have some form
and your partner. He clutches his head, and of lasting effects, and early recognition and
then becomes unresponsive. You immedi- rapid transporting to an appropriate facility is
ately start ventilating again, because his res- paramount to their survival.
pirations are extremely shallow and irregular.
Prehospital treatment should be supportive
You notice he has extremely unequal pupils of symptoms (if allowable by your protocol)
and that his pressure has increased substan- and should be initiated as soon as possible to
tially to 276/224 with a HR of 126 and RR of 6. optimize the outcome for your patient. JEMS
You continue to assist the patient’s ventilations and prepare for intubation. The patient Fred W. Wurster III, AAS, NREMT-P, is the director
is successfully intubated with ease, as he has of training for the Good Fellowship Training Institute
no gag reflex. He’s sedated with 5 mg of in West Chester, Pa. and a flight paramedic with
Versed as part of your post-intubation seda- PennSTAR in Philadelphia, Pa. He’s also a JEMS techtion protocol, and then you arrive at the nical editor. Contact him at fred.wurster3@verizon.net.
Photo Yuri Arcurs/Dreamstime.com

I

t’s a Thursday afternoon, and you’re dispatched to a local substance abuse rehabilitation facility for a person complaining
of a headache. While en route, you and your
partner discuss how many times you’ve
responded to this facility for calls that don’t
seem legitimate. Additional information is
obtained from the 9-1-1 center that reveals
you’re responding to a 48-year-old male complaining of a headache and dizziness. You
arrive and are escorted to the patient, who’s
located at the nursing station. The patient is
seated and holding his head with his hands.
You introduce yourself and ask what’s wrong.

istockphoto.com

EMS industry
may shift
deployment
methods

By Johnathan D. Washko, BS-EMSA, NREMT-P, AEMD

F

or many outsiders, running an ambulance service can often appear to be an
easy thing. Although EMS appears to be
simple, it isn’t.
EMS’ first 30 years or so have been solely
focused on proving to the medical community that it could perform tasks that, traditionally, only doctors could do. So few have
stopped to ask the questions associated with
how we should perform these tasks.

How EMS Provides Care
This is the same problem found in most of
the healthcare industry today. The focus
on providing the best medicine money can
offer has generated exceptional clinical
results for patients, but those results have
tremendous costs with one of the most
uncoordinated, stove-piped, expensive and

32

JEMS

JULY 2012

inefficient healthcare delivery systems on
the planet. The same often holds true for
much of EMS.
The medicine we in EMS provide on a
daily basis is the foundation of our existence
(and the clinical outcomes from these efforts
are widely unknown and/or debated), but
the methodologies we employ to deliver this
medicine to our patients drives 70–80% of
our costs, based on the delivery model used.
We’re talking about the procedures, practices, schedules and deployment methodologies that are used by your EMS system to get
your clinicians, medicine and equipment to
the patient within some sort of “acceptable”
time frame (i.e., response time).
The debate to define “acceptable”
response times is finally coming to a head,
with evidence-based research and customer

satisfaction and expectations driving this
definition; however, many EMS leaders are
also pushing EMS delivery methods to the
forefront because of the economic downturn and healthcare reform.
Prehospital medicine across the U.S. is,
for the most part, standardized, but the
system designs used to deliver these services are as diverse and variable as the species on our planet. System designs range
from inefficient and ineffective, to highly
efficient and effective with many variables,
including wages and benefit costs, accountability, response-time reliability and measured clinical outcomes from these efforts,
separating “the men from the boys.”
Some of the most efficient and effective
EMS delivery systems today often provide
better clinical outcomes and service reliabilities as their most expensive counterparts,
proving that throwing money at a problem
isn’t always the answer.
Anecdotally, when you look at cardiac
arrest return of spontaneous circulation
(ROSC) rates across the country and then
look at the system delivery models used to
achieve these results, you either see static
deployment models (station-based systems)
or dynamic deployment models (i.e., highperformance EMS) as the common delivery
mechanisms. (Hybrids containing methodologies from both genres also exist.) Both
these service-delivery models can produce
excellent cardiac arrest survival outcomes,
but at what cost?
Some have attempted to correlate survival rates with the number of active paramedics used in the system, but I find this
absurd. (I know the e-mail inbox will be
filled after this one with those who disagree
with this statement.)

Response Times
Whether dispatch life support through prearrival instructions, first responder, BLS or
ALS, the bottom line is the response times
count ... period. Response times ensure
high-quality CPR is initiated. These factors
are what the clinical research indicates we
need to do to improve neurologically unimpaired walk-out-of-hospital survival rates.
The importance of ALS is definitely heading toward the stabilization side of the equation, post ROSC, and not where we thought
it made a difference, in the initial conversion
into ROSC.
Many would debate whether ROSC is the

Delivery Models


best way to measure an EMS system’s clinical effectiveness. I would
strongly agree it needs to be greatly diversified; however, ROSC is all
we currently have to examine for comparative purposes.

Cost of Success
Now let’s look at the costs to achieve these results. Statically deployed
EMS systems are, by design, an expensive way to provide services,
especially for urban and suburban population centers. Rural EMS
systems are a different animal and aren’t included in this group.
As EMS providers, we see these system designs as the means to
earn money sleeping, but these designs are often ineffective clinical delivery models because of poor response-time reliability.
However, one thing is reasonably certain. Static deployment
systems are the most inefficient and costly way for us to deliver
EMS service. Clinically effective static deployment models exist,
but they’re even more expensive to operate than their ineffective
counterparts because these systems throw away tons of money or
manpower to solve response-time problems.
Dynamic deployment systems on the other hand (those that
match supply with demand—both temporally and geospatially),
are frequently effective clinical delivery models because of superior
response-time reliability, and they are the most cost-efficient means
to achieve services, because they use the appropriate amount of
resources to meet patient-care needs.
These models are the most unpopular with EMS providers
because productivity and efficiency are balanced with good clinical care, sacrificing down time. Sitting in the front of an ambulance and being placed on a street corner is not as comfortable as
responding from a warm bed in a station’s bunk room, but it gets
the medicine into a critically ill patient’s veins a lot quicker.
So the proverbial EMS dichotomy—to station or not to station,
is the question. The answer depends on the size of your region’s
wallet, tolerance for change, politics and willingness to provide
tax subsidies. Many urban and suburban dynamic deployment systems, with excellent clinical outcomes, have operated with little to
no tax subsidies for decades.
Few (if any) static deployment models exist in urban or suburban regions with excellent clinical outcomes that, accounting for
all costs, operate without some sort of subsidy (and usually a big
one). This can be an eye-opening observation for elected officials
and the public alike.

Resistance to Change
So because we know how to do it better, faster and cheaper, why doesn’t
everyone pursue this? The answers lie in human nature, political pandering, an unwillingness to abandon “tradition” and the economy.
Where do we go from here?
Although our industry will continue the eternal debate on EMS
system design issues, a storm of unparalleled magnitude is brewing.
This storm, also known as healthcare reform, will change our lives
in EMS as we know it.
Having an efficient and effective service delivery model is the
foundation by which innovation, evidence-based clinical practice
and the shift from treating a majority of our patients in the hospital to treating the majority of our patients in the prehospital realm
will evolve. This change should be a metamorphosis by which EMS
www.jems.com

JULY 2012

JEMS

35

Delivery Models

How is Your Oxygen Supply?

will springboard itself from being a rounding error in the federal
CMS budget to becoming a significant contributor and provider to
the U.S. healthcare system.

How to Change

MOGS-100

Benefits of an Oxygen System:
Become Completely Self-Sufficient
Fill High Pressure Oxygen Cylinders
Transportable to Disaster Site
Transfill Directly to a Vehicle

Generate OXYGEN
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How and why will this happen? It comes down to pure economics. Once reimbursements shift from a fee-for-service model into
bundled and/or capitated payment models (whether it be from
an accountable care organization or other capitated reimbursement methodology) that reward continuum of care coordination
and service integration vs. the current model, which financially
rewards uncoordinated and inefficient care based on the volume
of patients we see, we’ll see a shift emerge in how medicine is produced. More importantly, the service delivery models used by this
medicine, will change for the better. EMS can play a significant role.
My interpretation of this is that EMS will be at the forefront of this
change because the prehospital realm is our oyster, and we know it
well. When you break an EMS system into its component parts, you
find four primary activities: public safety, public health, disaster preparedness, response and recovery, and healthcare. The proportions
by which EMS performs these functions can be widely debated.
The fact of the matter remains that for most EMS systems, reimbursement from healthcare-based insurance is the primary mechanism for funding and typically pays indirectly for non-healthcare
related functions, such as public safety, public health and the various
stages of disaster management.
I envision a day not too far from now when someone will call
9-1-1 and the dispatcher (a clinician) will work through a clinicaldecision algorithm and help the patient determine the appropriate
locus of care, which will become alternative methods of healthcare
service delivery, including community based/expanded scope paramedics and self care, and not elicit the typical U.S. EMS response.
In several innovative EMS systems, paramedics are already visiting patients in their homes (in some cases, in tandem with a nurse,
nurse practitioner or physician’s assistant) to perform diagnostic
testing on site and come up with alternative treatment regimens that
would include on-site treatment options, transportation to alternative (less expensive) modes of care (e.g., urgent care) or treatment
and transportation to the emergency department for those patients
who truly require it clinically.
Cutting edge, high-performance EMS systems are already blazing
a path. EMS system design innovators are at the forefront of the revolution and evolution of our industry. They’re some of the ones taking
the risks, creating something from nothing—many without additional reimbursement—to help carve the path most of us will eventually follow once the storm has passed … if we survive it. Those
systems with the ability to embrace change will survive in the new
normal. For the ones that don’t, I suggest you build a storm shelter
and stock it well. JEMS
Jonathan D. Washko, BS-EMSA, NREMT-P, AEMD, is assistant vice president of operations
for North Shore–LIJ Center for EMS located in NYC and Long Island, N.Y., and is president
of Washko Associates, LLC, a leading EMS consultancy group dedicated to improving EMS
agency performance around the globe. He’s also a member of the JEMS Editorial Board. He
may be contacted at jwashko@nshs.edu or jwashko@washkoassoc.com.

Lessons learned from
Navy jet crash response
By Bruce Nedelka, NREMT-P A.J. Heightman, MPA, EMT-P

V

irginia Beach, Va., is the largest city in
the Commonwealth of Virginia and
ranked No. 41 in the 2011 JEMS survey of
the top 200 cities in the U.S. Its 310 square
miles and 38 miles of shoreline is home to
approximately 450,000 residents and more
than a million daily guests during the summer resort season. The city is also home to
several large corporations, including STIHL
Inc. and LifeNET Health, and it’s the heart
of a large military population in America,
with Little Creek, Fort Story, Dam Neck,
Naval Station Norfolk and Oceana bases.
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Antonio P. Turretto Ramos/AP

An aerial view shows
the damage caused
when a military jet
crashed into the Mayfair Mews retirement
community apartments
in Virginia Beach, Va.

Lessons Learned
1. Scene tape should be deployed, and policed, as

early as possible into a major incident. This will
establish and maintain a large, controlled scene
perimeter and ensure security for personnel,
patients and their assets.

2. The onslaught of media attention is often too

much for the one agency’s public information officer (PIO) to handle, so a coordinated
approach should be established early into an
incident by all of the public safety PIOs and the
city media communications manager (MCG).

3. Use of established social media communications

is often effective and should be explored.

4. Multiple news releases; frequent, scheduled and

Copyright (c) 2012, The Virginian-Pilot. Reprinted with permission

announced media updates; and traffic message
signs on the interstate roads should be used.

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JEMS

39

Engulfed in an Instant
About VBEMS
Virginia Beach Department of Emergency
Medical Services (VBEMS) is a third-service
volunteer-based department with more
than 1,100 volunteer members staffing the
city’s 10 volunteer rescue squads, plus 28
full-time paramedics and four full-time
brigade chief field supervisors to augment
the volunteers.
The department responded to approximately 39,000 calls for service in 2011. In
addition to emergency care and ambulance
transportation, VBEMS also operates an allvolunteer Marine rescue team, heavy rescue
service, two mass casualty incident (MCI)
vehicles, an all-volunteer search and rescue
unit, and bike teams. VBEMS also supplies
the paramedics for the Virginia Beach special weapons and tactics team and air medical unit; manages post-disaster, medically
friendly shelters; and provides lifeguard service for the city’s Sandbridge and Little Island
Park beaches. The city doesn’t own any ambulances; all 35 of the VBEMS ambulances and
support vehicles are purchased and operated

by the 10 volunteer rescue squads. The rescue station buildings are in some cases solely
owned by a volunteer rescue squad. In most
cases, they’re a city-owned facility housing
fire department and EMS resources together.
The calm afternoon and the lives of
those living in the retirement community
of Mayfair Mews in Virginia Beach were
forever changed just after noon on April
6. It was at that moment when a U.S. Navy
F/A-18 jet with a student pilot and trainer
on board experienced serious engine failure from nearby Naval Air Station (NAS)
Oceana and plunged to the ground, crashlanding into the buildings and courtyard of
an apartment complex. Instantly, several
buildings were engulfed in flames fed by jet
fuel. The dark black plumes of thick smoke
could be seen miles away.
The pager tones that sounded for the
incident were just like the ones that had
dispatched thousands of calls before. However, this alert announced a call that would
test the Virginia Beach EMS, fire and police
departments, dispatch center and the city’s


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JULY 2012

entire Emergency Response System like
they’d never been tested before.
The Emergency Communications and
Citizens Services Department 9-1-1 Center
initially received a frantic cell phone call
telling them about the crash and the fire.
Almost instantly, the inbound queue was
flooded with 80 calls.

Scan here to listen
to actual 9-1-1 radio
transmissions from
the incident.
This number quickly escalated to 200.
At the time of the initial call, 13 staffed
ambulances, five staffed paramedic rapid
response zone cars, one EMS duty supervisor (EMS-5) and two assistants (EMS-6 and
7) were on duty. However, within an hour,
more than 170 volunteers were involved
and 30 ambulances were staffed.
During the first 90 minutes of the crash,
more than 20 other 9-1-1 calls for ambu-


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lances were dispatched. These included a
motor vehicle crash with entrapment, and
several serious medical cases. Although
the turnout of EMS volunteers was so great
that none of the cases for ambulances in
Virginia Beach required mutual aid, surrounding cities sent fire apparatus to backfill fire stations.
Because of the heavy volume of calls
received by 9-1-1, EMS Chief Bruce Edwards
assigned an EMS division chief to the 9-1-1
center to assist in triaging calls and refining automatic response matrices and managing the EMS field resources. This was a
helpful function because of the increased
9-1-1 call volume and communications.
Some callers gave conflicting information regarding the location and what was
unfolding. Some were more precise. All,
however, were desperate for help. Cathy
Fowler, a 24-year veteran Virginia Beach
dispatcher, was on the EMS console that
day. “When it became clear that we had a
major incident, we all got so focused on
our jobs that the 9-1-1 center had an amaz-

ing calmness. There was no idle talk; we all
did what we have been trained to do,”
Fowler says.
The first inbound call entered the system at 12:06:07 p.m. The initial simulcast
dispatch was announced to EMS and fire
units at 12:07:28 p.m. Although the dispatcher’s voice was calm, the message was
clear: There was a confirmed plane crash.
The initial assignment included the duty
district chief, Battalion 1; Engines 11, 8 and
3; Navy engine 31; Ladder 11; Ladder 8;
Safety 1; and Fire Squad 3.
The EMS units dispatched were EMS-5
(duty field chief); EMS-3 (duty division
chief); ambulances 1420, 1425 and 827;
MCI-2; and rapid response medic zones 14
and 08. Virginia Beach public safety radio
communications is all digital with multiple
frequencies and banks. EMS and fire are
separate departments, and each has its own
primary dispatch channel and dispatchers.
Calls are often “simulcasted” over both
EMS and fire channels, by either dispatcher,
to announce co-response calls. Doing so


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serves several purposes, such as giving
the same dispatch information about the
location and the same incident nature to
all units. Units then acknowledge the dispatcher via radio or on mobile data terminal (MDT) and respond to the call.
Radio traffic and communications
on the primary and tactical channels in
the early minutes could have become
uncontrollably chaotic with such a large
response. However, primary channel radio
traffic was controlled. This can be attributed to several key factors:
First, the dispatcher’s voice was not frenzied. Had he sounded excited, field providers could have picked up on that emotion,
and each individual’s adrenaline rush could
have escalated;
Second, fire department and EMS personnel had been involved in numerous
training exercises and drills to prepare
them to handle this type of situation. During the years, more cooperative, multijurisdictional drills between VBEMS,
Virginia Beach Fire Department (VBFD),


military fire and EMS, Norfolk International Airport, and local hospitals, plus
many large outdoor events in the city’s
resort areas, proved to be invaluable
rehearsals for this incident. It made the
development of on-scene unified incident
command much smoother and familiar.
Although the first 9-1-1 call was still
being received, Virginia Beach police officers near the crash site advised dispatcher
Tonya King that they heard the thunderous
crash and could see the smoke.
King says, “My first thought was that
what I was being told on the radio couldn’t
be real. But when I looked at my computer
screen and saw 9-1-1 calls flooding in, I
knew this was truly the real thing.”

Response Activates
Within the first hour, the staff of 13 dispatchers increased to 34 as their preplanned emergency response team was
activated, calling in off-duty dispatchers
and supervisors. The additional personnel
enabled multiple command and tactical

channels to be staffed and allowed several
personnel to make the required return calls
to hundreds of 9-1-1 hang-ups.
Close behind that officer were two other
EMS members, one of which was an off-duty
EMS volunteer Special Weapons and Tactics
(SWAT) medic and the other was Jay Leach,
an EMS Volunteer Brigade Chief who was an
on-duty paramedic (Zone-14) at the time and
was part of the initial dispatch assignment.
Both were near Laskin Road and Birdneck
Road when the crash occurred.
Citizens joined forces with emergency
responders to work feverishly to get residents out of the buildings, remove the
injured and find the pilots. Initial reports
indicated that only one pilot and parachute
were seen. However, dozens of additional
calls came in with unconfirmed and conflicting reports of a second pilot being
involved. This led to several minutes of
intense searching and confusion: Was
there one pilot or were there two?
Police officers and citizens quickly
located one pilot and called for an EMS


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team to treat his injuries. Although a few
units and personnel were already staging
near 24th Street and Birdneck, access to
the pilot was south of Fleming Drive. An
incoming ambulance was flagged down
by police as they were driving north on
Birdneck from the area of Interstate. That
ambulance loaded the pilot, advised EMS-5
and continued on to the hospital. Confirmation was then received from citizens
and Oceana Air Traffic Control that a second pilot had been on board.
A radio message from Brigade Chief
John Fusco, the Duty Shift Commander,
advised inbound units to be vigilant in
their search for signs of a parachute or pilot
as they approached the scene. Crews knew
the pilots had been ejected and thought
they had a good chance of finding the missing pilot if they located a parachute.

An Unexpected Find
Pat Kavanaugh, a resident of Mayfair Mews
and a retired Virginia Beach Volunteer
Rescue Squad member, opened his sliding

photo courtesy jon kight

photo courtesy Bobby Hill/VBEMS Foundation

Crews transport the second pilot after he landed in the front porch of a man’s home.
door after the crash to investigate. To his
shock and amazement, he found the missing F/A-18 pilot lying on the patio with a
parachute hanging on the side of the building. After Kavanaugh reached the pilot’s
side, he heard the pilot utter, “I’m sorry I
destroyed your home.”
Kavanaugh’s EMS training and experi-

ence instinctively kicked in. He conducted
a quick patient survey and found no lifethreatening injuries. He then elicited the
help of several neighbors and police officers
to drag the pilot away from the burning
building. An EMS crew was then directed
to the location, and the pilot was moved
quickly to an awaiting ambulance to be


transported to Sentara Virginia
Beach General Hospital.
As can be expected with so
many calls flooding the 9-1-1
center and nearly 100 citizens
and first responders on the
scene, some erroneous information came in during the first
hour or more. One of the more
tense time periods for incident
commanders and responding
crews came when reports continued that the second pilot
was missing.

The Search
It was then known that the two
pilots had been ejected as the plane fell to
the ground. The fighter jet’s canopy was
found behind an undamaged building near
the entranceway into the complex.
EMS-5 radioed again to incoming units
that the second pilot was still missing and
that they should include trees, ditches and
rooftops in their search. Bystander reports


of a pilot being in the burning rubble were
proven wrong when the radio cracked
that the second pilot was found conscious
and alert.
The fire units took up positions according to a fire pre-plan and recommended
an immediate second alarm. That was
closely followed by a third and then a fourth
alarm. Available fire resources were quickly
depleted citywide, so mutual aid from three
neighboring cities were requested. Special-

ized crash rescue units from NAS Oceana
were dispatched along with one of their
engines and ambulances.

Location Details
The Mayfair Mews apartments are located
just north of Interstate I-264 at Birdneck
Road and Fleming Drive. Northbound
traffic on Birdneck Road quickly became
jammed. As northbound traffic congestion
grew increasingly worse, access by respond-

ing emergency vehicles was also slowed. So
when EMS-5 arrived, Fusco made a series of
quick decisions, including a request for the
dispatcher to assign a medical tactical channel and announce that any incoming units
must approach from the north—Laskin
Road—not from I-264 or south Birdneck
Road (see map, p. 39). Laskin Road quickly
became a controlled intersection by police
and a good access point for emergency vehicles and first responders in private vehicles.

Priority Cell Phone VoIP Access
Verizon Wireless is the wireless provider for the city
of Virginia Beach. It’s also a major Virginia wireless
provider. With the crush of citizen cell phone use
(for voice and data), the wireless towers quickly
became overloaded, and many calls were not able to
go through. This hindered operations for police, fire,
EMS and other agencies at the scene and created a
level of frustration among providers that needs to be
addressed for future incidents.
At a post-incident discussion with a representa-


46

JEMS

JULY 2012

tive of Verizon Wireless of Southeastern Virginia,
VBEMS learned about Verizon’s emergency wireless
public access (WPA) system, which allows authorized
emergency responders to have priority access to cell
phone sites. That priority service is part of post-9/11
legislation to improve first responder communications during emergencies. It relies on local jurisdictions to determine the users and policies.
Although WPA may sound like a solution, it also
has its limitations. Regardless of the carrier, only a

specific capacity can be used, and when that
capacity reaches its maximum, no other access
is possible. A better alternative is to use pushto-talk or other technologies, such as texting or
tweeting on a pre-established emergency Twitter account. Each uses voice over Internet protocol (VoIP) and sends digital “packets” in a way
that allows far more users to access it at once.
It was also learned through a post-incident
review that although the user of a cell phone


photo courtesy Bobby Hill/VBEMS Foundation

Ten ambulances were staged on Birdneck Road facing north for clear egress if transportation to a
hospital was needed.

may feel as though their call didn’t go through,
it’s possible that the individual’s call was in a
“queue” and would have eventually connected
when a wireless cell became available. Despite
this knowledge, first responders will not hold
on indefinitely without any indication as to
when the call will ultimately connect. The lesson learned from this is that VoIP alternatives
need to be established and practiced before a
major incident occurs.

With that problem resolved, emergency
units could then travel northbound in the
southbound lanes from I-264 to access
the scene.

Use of Tactical Channels
The Virginia Beach EMS and fire computeraided dispatch (CAD) system has eight shared
tactical channels. The initial tactical channel
assigned to EMS operations was changed
twice as the fire department expanded its


operations. That led to some radio communications confusion in the first hour or so of the
incident. In the after-action meeting, senior
EMS command staff decided to consider
altering the EMS medical command tactical
channel allocation on any future incidents
of this magnitude and consider assigning the
lesser used, but universally accessible, EMSadmin channel as its initial working tactical channel. This pre-planned EMS tactical
channel would provide a clear channel for

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47


photos courtesy Bobby Hill/VBEMS Foundation


EMS crews readied their equipment for triage at a staging area, and a special MCI unit (far right) was waiting in preparation for news of any wounded patients.
EMS operations and is highly unlikely to be
overtaken by expanding fire operations.
EMS day-shift captain Earnie Delp (radio
designation EMS-6) arrived on scene and
became the incident’s medical branch director. He established a staging area for arriving
ambulances, personnel, EMS crash trucks
and the EMS MCI unit early, a lesson learned

in training and from past incidents.
Almost all units followed the directive to
arrive at the scene by traveling south from
Laskin Road. The few that did not, or could
not, were delayed in traffic congestion.
During the quickly unfolding incident,
multiple proper vehicle staging and positioning was critical, and leaving adequate space


48

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JULY 2012

for ingress and egress of units was essential.
Within a few minutes of arrival, Delp communicated by cell phone with the charge
nurse at Sentara Virginia Beach General
Hospital, the primary destination for the first
patients. He provided a preliminary size up
of the incident and a warning about potential mass casualties. This early alert provided
ample opportunity for hospital administration to activate the hospital’s external disaster
plan, mobilize its personnel, call in off-duty
staff and prepare for the worst.
At this point, more units were beginning
to arrive in rapid succession. When EMS
Division Chief Ed Brazle (EMS-22) arrived,
his collateral responsibility as the department’s emergency management coordinator
helped define the forward triage area. Brazle
directed the on-scene crews to bring stretchers and other specified equipment to the corner of Fleming and Birdneck and be ready to
receive patients.
This was a good location for staging
equipment and personnel because it allowed
for rapid ingress and egress by crews in the
event that a patient required a stretcher. In
addition, there was a UPS store with a parking lot at that corner. The parking lot ultimately served as the location for command
post tent for unified command. EMS officers participated in the unified command
in key leadership positions, including area
command, medical branch director and
liaison officer.
Triage, treatment and transportation
sector officers were also appointed early,
and EMS area command director EMS-5
was advised. The system was gearing
up for what was logically expected to be

heavy casualties. Deputy EMS Chief William Kiley and Operations Medical Director Stewart Martin were now on scene.
After completing an initial scene walkaround, Brigade Chief Joseph Corley
established a rehab location at the southeast corner of Fleming and Birdneck. He
assigned a rehab officer and assisted in
deploying equipment and personnel.
Within about 10 minutes of establishing that rehab location, the first wave of
firefighters began to arrive after mounting the initial, aggressive fire attack and
evacuations. The EMS team attended to
them and documented each encounter
as they awaited recall into the scene. This
reinforces the need for rehab to be established and announced to all personnel as
early as possible.
The initial incident commander followed the fire department’s pre-plan for
the apartment complex and located the
command post where the first-in district
chief and battalion chiefs parked near the
fire buildings with easy access through the
parking lot from Birdneck Road.
However, one of the initial 5 feeder
hoses laid by the first-in apparatus, which
caused problems for emergency vehicles
and equipment by blocking access to
several areas. After realizing this, fire
crews enlisted the assistance of several
citizens to help move the heavy hose and
resolve the problem.
Some 45 minutes into the call, it was
believed that few, if any, civilian injuries
would be coming to the waiting triage
teams. Thoughts then began to shift to
establishing a temporary morgue because
of the multiple buildings heavily engulfed
in flames.

tion operations was selected on a side
street in front of the initial on-site morgue
location. The plan called for the deceased
to be brought to the decontamination area
to be thoroughly decontaminated. They
were then to be placed into a body bag
with a second body bag over the first one to
ensure any contaminants from the first bag
were encased in the second.
It was initially believed that there would
be a significant number of deceased as the
building searches continued. Therefore, it
was felt that the local medical examiner’s

office wouldn’t be suitable because of its
limited capacity.
During a subsequent discussion at the
command post, the police commander
decided that the anticipated volume of
fatalities would be better staged at the Law
Enforcement Training Academy (LETA)
located less than a mile south on Birdneck
Road. Commanders felt that facility would
be more secure and private than the initial open location on the side street. LETA
was readied as the collection point for any
fatalities but wasn’t actually used for its

Expecting the Worst
The initial location selected for the morgue
was on one of the side streets of the complex. This proved to be an inappropriate
location because command wanted all
bodies to be decontaminated before they
were placed in body bags and delivered to
the morgue. This is because of the significant presence of airborne carbon-fibers
and fuel created by the burning plane and
buildings. Therefore, fatalities couldn’t
simply be bagged and transported.
Therefore, an alternative location that
was more suitable for the decontaminaChoose 41 at www.jems.com/rs
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49


converted purpose because no fatalities
were discovered.

Personnel Accountability
One issue that arose at the scene was the
proper accountability of personnel. Many
volunteers and other first responders selfdispatched to the scene. Some didn’t have
proper identification and some weren’t
appropriately dressed.
Identification became an issue because
law enforcement officers who were under
orders to allow only authorized personnel
into the area began to refuse access for some.
The decision was made to announce over
radio systems and other communication
means that enough personnel were available at the site and no additional personnel
were needed.
In addition, for the purpose of uniformity
and security, law enforcement personnel
were advised that any member claiming to be
with EMS who failed to present proper identification was to be turned away. Although
some were unhappy they weren’t allowed
to become a part of “the big one,” restricting
access to only those with proper identification was for the best.
Personnel management issues stemmed
from having so many members on scene and
still arriving with no assignments, coupled
with a lack of patients. To solve the personnel management issues, Virginia Beach
Volunteer Rescue Squad Chief Roy White,
Jr. was assigned to manage the EMS personnel. Within 15 minutes, White established a
meeting place for all on-scene and arriving
personnel, assigned an assistant and got EMS
personnel accountability under control.
Accountability and identification wasn’t
limited to first responders. Support personnel, such as utility workers and civilian contractors called in by the Navy, also didn’t
always have proper identification. This posed
a challenge for the incident liaison officer,
EMS Division Chief Tom Green, who was
responsible for their accountability.
At large-scale incidents such as this, personnel management and accountability
needs to be established early in the incident to
account for and manage responding on-duty
and off-duty staff, as well as contracted or
requested support personnel. Incoming first
responders and activated support personnel
need to be advised of the scene’s restricted
access and that proper identification will be

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JULY 2012

required. The maximum number of EMS
personnel needed at the scene must be determined early in the incident—with overflow
personnel advised to report to a rescue station. This will better control on scene and
back-up resources and ensure the availability
of relief personnel should extended operations be needed.

The Media Rush
From the moment the incident was a confirmed plane crash and, more specifically,
a Navy F/A-18 fighter jet crash, incident
managers knew it was going to be a huge
media event.
Although it’s important to get the news
out, it’s more important to get correct information out. Rumors and misinformation
often run rampant during large incidents,
and this case was no different.
A media staging area was established
early on in the parking lot at 24th Street
and Birdneck Road. Initially, that designation actually meant little or nothing to
the reporters who wanted video of the fire
and interviews with patients, residents and
first responders.
Initially, no one was available or assigned
to corral and monitor the media location.
It took a while, but the scene became better defined, taped off and organized. Once
enough law enforcement and military
police were on scene, this area became well
organized, and personnel from the media
were redirected and briefed there. This also
became the established site for several formal news conferences.
Within two hours of the incident, the
city’s Media and Communications Group,
a component of the city manager’s office,
established a modified joint information
center at the city’s Emergency Operations
Center (EOC) and began to disseminate the
information to the public via social media
and standard news releases.
Inquiries from dozens of media outlets
from several countries flooded the 311
information center and EOC in during
the first eight hours at an out-of-control
pace. The incident was big news, initially
because of the military link, and it grew
even bigger as it became more and more
apparent that there were no fatalities and
only a handful of minor injuries. The
news media began to play up the “miracle”
aspect of such a large event.

Conclusion
The F/A-18 fighter jet crash into Mayfair Mews Apartments tested the
Virginia Beach emergency resources in
many ways. But the years of training and
MCI drills among all public safety
agencies and regional military, plus the
use of a unified incident command system, proved invaluable.
MCI drills typically concentrate on
handling a wide array of injuries and
numerous fatalities. They focus on
using proper triage methods and triage
tags. They establish working models for
successful unified command, branches
and divisions to effectively triage,
treat and distribute patients among all
area hospitals.
It was difficult to believe that both pilots
could eject from the jet seconds before it
hit the ground and have only relatively
minor injuries; by the time this fact was
discovered, the first-due ladder trucks,
engines and a district chief had arrived and
confirmed multiple apartment buildings
heavily engulfed in fire as a result of the
plane crash.
What MCI drills don’t usually focus on
is the type of multi-building incident that
requires massive logistics, resources and
personnel deployment to be involved in
extended search-and-rescue operations,
evacuations and the establishment of
multiple triage posts around an occupied
apartment complex, only to have no fatalities and very few minor injuries.
Much was learned by the incident
managers and crews in Virginia Beach.
The advanced training and use of unified
command on a routine basis helped the
agencies in their response, command and
control operations and on-scene actions.
All involved believe the lessons learned
from this case will help the Virginia Beach
emergency response system grow and
improve so that it can operate in an even
better manner at future incidents of this
magnitude. JEMS


Bruce Nedelka, NREMT-P, is a division chief and department public information officer for VBEMS. He can be
contacted at BNedelka@vbgov.com.
A.J. Heightman, MPA, EMT-P, is the editorin-chief of JEMS and a recognized mass casualty
incident management educator. Contact him at
a.j.heightman@elsevier.com.
www.jems.com

JULY 2012

JEMS

51

Photo Allina Health

No NEED FOR SPEED

Improving accuracy of nursing home response-level requests
By Lori L. Boland, MPH, Steve G. Hagstrom, NREMT-P

T

he following scenario will likely sound familiar. You’re dispatched to respond lights and
siren to a nursing home. On arrival, you find a resident who isn’t in need of emergent
transport. A cluster of facility residents appear confused and anxious about the arrival
of EMS, and the faces of nursing staff convey regret about the commotion caused by an
unnecessary lights-and-siren arrival.
You assess the patient, and your initial clinical instincts about the non-urgency of the situation
are confirmed. You begin to silently question the dispatch priority for this particular call. Was running “hot” through mid-day traffic really warranted? Many times, the answer is no.
It’s well established that aggressive lights-and-siren response by emergency vehicles puts providers, patients
and the public at increased risk of harm from motor vehicle crashes, and data suggest these risks are often
incurred with little or no real clinical benefit to the patient.1–5 Between 1990–2009, an estimated 85,000 motor
vehicle crashes involving ambulances occurred in the U.S., with 590 of those involving fatalities.6
Those figures amount to an average of 11 ambulance accidents per day and one ambulance-related fatality every
other week. Most EMS agencies make a genuine effort to reduce the risks by mandating education and training on
the safe operation of emergency vehicles during response and transport. But the other part of effectively reducing
risk is minimizing the frequency of unwarranted lights-and-siren response without compromising patient care.

Photos Allina Health

52

EMS providers on routine
or scheduled responses
to skilled-nursing facilities can take more time
obtaining patient medical
history from staff.

JEMS

JULY 2012

no Need for Speed

Augmenting Priority Dispatch Systems
Validated 9-1-1 medical priority dispatch systems in use across the
country have been implemented to improve the appropriateness and
efficiency of dispatched services—getting the right EMS resources to
the right people within the right time frame. But these algorithms are
mostly designed to evaluate EMS needs based on information provided
by 9-1-1 callers with no medical training, many of whom will access
the system only once in their lifetimes. Consequently, dispatchers are
trained to err on the side of caution, assuming the situation is urgent
when information provided by the caller is sufficiently vague or when
the caller is no longer in the presence of the patient.
According to 2010 data submitted to the National Emergency MediFigure 1: Ambulance Response Flowchart
Select Ambulance Response Level

Routine
Response

Scheduled
Transport

Call

EMS

Emergent
Response

Closest available unit;
no lights sirens; most
calls answered in less
than 25 mins

Ambulance assigned
to pick up patient at
scheduled times

9-1-1

651/222-0555

651/222-0555

Allina Health EMS
You may change response level at any time
Phone Guide
When you call 651/222-0555 a dispatcher will answer: “Allina Health
EMS. This is [their name].”
Proceed slowly with:
“Hi, this is [your name] at ”
[Name of facility]
[Address of facility]
Room [number].”
I am using the flow chart.
I would like a(n) (emergency/routine/scheduled) ambulance response”.

Then briefly describe medical reason for transport
All information will be repeated for verification and call may end.
cal Services Information System (NEMSIS), nearly one-third of EMS call
volume is attributable to healthcare facilities, including hospitals, clinics and nursing homes.7 Callers from these entities represent a different set of EMS summoners given their higher propensity for accessing
9-1-1 repeatedly and some degree of medical training. But many EMS
responders will attest that unnecessary lights-and-siren responses to
healthcare facilities, such as the situation described above, still occur.
EMS agencies should be committed to exploring strategies to further
refine dispatch prioritization at the local level.

A Skilled Facility Response Program


54

JEMS

JULY 2012

Allina Health EMS is the EMS provider of Allina Health, a not-for-profit
system of healthcare services providing care throughout Minnesota.
The ambulance service area covers 1,200 square miles in 100 communities in the Minneapolis and St. Paul metro area and includes about
one million residents.

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