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1. MARCH 2013
ISSUE
Always En Route At
t

2. Making Precious Minutes Count™
Macro. Mini. All Set.
When a patient requires intravenous therapy, EMS providers need to
administer care as quickly as possible. The AMSafe-3® IV Administration
Set features a 3-in-1 multi-drip chamber that allows providers to select a
10, 15 or 60 drop setting on the spot.
The AMSafe-3 drop setting can be adjusted without interrupting patient
care. Since the device combines three IV sets into one, it reduces inventory
and takes up less room on an ambulance or in an equipment bag.
1712-30204
1712-30304
D38301
AMSafe-3 IV Set, 91”, 1 luer activated
AMSafe-3 IV set, 89” with backcheck valve,
AMSafe-3 IV Set, 83”, 1 luer activated
injection site and 1 pre-pierced injection site,
1 pre-pierced injection site, 1 luer activated
injection site and 1 pre-pierced injection
site and pre-pierced injection sites, slide
For more information or a product demonstration,
contact your dedicated Account Manager or call 800.533.0523
Choose 11 at www.jems.com/rs
800-533-0523
www.boundtree.com

3. Choose 12 at www.jems.com/rs

4. Barbara Spoden
Thanks to a dedicated EMS team and use of
the ResQPOD®, Barbara survived and was able to
return to playing with her granddaughter.
Choose 13 at www.jems.com/rs

5. ®
28
I SPINAL IMMOBILIZATION I
Time for a change
By Jim Morrissey, MA, EMT-P
MARCH 2013 VOL. 38 NO. 3
Contents
I 40
40
50
I IN THE PATH OF DESTRUCTION I
New Jersey EMS response to Superstorm Sandy aided by
pre-planning & preparedness
By Henry P. Cortacans, MAS, CEM, NREMT-P; & Terry Clancy, PhD, NREMT-P
I THE PREHOSPITAL CARE RESEARCH FORUM
PRESENTS ... I
Selected abstracts for presentation at the 31st annual EMS
Today Conference & Exposition in Washington, D.C.,
March 5–9, 2013
58
DEPARTMENTS & COLUMNS
I EXPANDING THE MISSION I
60
I PLANNING LIKE AN OLYMPIAN I
5 I LOAD & GO I Now on JEMS.com
10 I EMS IN ACTION I Scene of the Month
12 I FROM THE EDITOR I ‘Special Stretchers’
By A.J. Heightman, MPA, EMT-P
14 I LETTERS I In Your Words
16 I PRIORITY TRAFFIC I News You Can Use
20 I LEADERSHIP SECTOR I Impact Ahead
22 I
24 I
80 I
82 I
By Gary Ludwig, MS, EMT-P
TRICKS OF THE TRADE I Batteries
By Thom Dick
CASE OF THE MONTH I Forward Fall
By Michael Orland, MD
HANDS ON I Product Reviews from Street Crews
By Dominic Silvestro, EMT-P, EMS-I
LIGHTER SIDE I The Slow Farewell
By Steve Berry
Mission: Lifeline will incorporate EMS recognition in STEMI &
cardiac resuscitation systems of care
By Chris Bjerke, MBA, BSN; Gary Wingrove, EMT-P; Franklin Pratt, MD; J. Lee Garvey,
MD; & A. Gray Ellrodt, MD
How London Ambulance Service successfully handled their
‘summer of sport’
By Jason Killens, MStJ, JP
70
I REVIVING FREEDOM HOUSE I
76
I BUILT TO SHARE I
How the storied ambulance company has been reborn
By Megan Corry, MA, EMT-P; Casey Keyes, BA, NREMT-B; & David Page,
MS, NREMT-P
The Bay Shore/Brightwaters Rescue Ambulance’s new vehicle will
respond to multiple incident types and provide mutual aid
By Bob Vaccaro
84 I EMPLOYMENT & CLASSIFIED ADS
87 I AD INDEX
88 I LAST WORD I The Ups & Downs of EMS
I 60
Aboutvehicle involved in a multiple vehicle crash in Springfield, Mo., is being
the Cover
The driver of a
assessed prior to extrication by a Springfield Fire Department firefighter. The issue of when
to fully immobilize patients and on what devices is explored in-depth in this month’s issue
of JEMS. Read more, p. 12 and pp. 28–39. IMAGE JOSEPH THOMAS
PREMIER MEDIA PARTNER OF THE IAFC, THE IAFC EMS SECTION & FIRE-RESCUE MED
WWW.JEMS.COM
MARCH 2013
JEMS
3

6. The responsive
emergency team
delivers exceptional
CPR
And they choose Physio-Control
to help make it happen.
Today’s responsive emergency team is always looking to elevate the
level of care they deliver, and they rely on evidence and data to get
them there. With the CPR Solution from Physio-Control, they have the
science-based, guidelines-consistent tools they need to respond better
to patients—and the demands of constant performance improvement.
uninterrupted hands-free compressions
featuring comprehensive CPR analytics
with capnography and CPR Metronome
Visit our booth #811 at EMS Today 2013 in Washington D.C. to see
CPR innovation in action and receive a T-shirt.
physio-control.com/CPR
Choose 14 at www.jems.com/rs
©2013 Physio-Control, Inc. Redmond, WA

7. LOAD & GO
LOG IN FOR EXCLUSIVE CONTENT
A BETTER WAY TO LEARN
JEMSCE.COM
ONLINE CONTINUING
EDUCATION PROGRAM
S ON
LLOW U
FO
FEATURED BLOG: Rescuing
Providence
THE JOURNEY
I take for granted the things I do that make up most days; starting IV’s, administering aspirin and nitro, assessing vital signs, stopping blood from leaving
peoples bodies et al, but one of those mundane tasks I’ll never think of as business as usual again.
Last night, while talking with a group of friends, a meeting if you will, one
of the members of the group, who struggles with addiction spoke of his recent
overdose, and subsequent revival and spiritual awakening.
“I know how much I can do, and how much I can’t,” he explained. “Trust me, people who OD don’t
do so by accident.”
JEMS.com offers you
JEMS com
MS
original content, jobs,
products and resources.
But we’re much more
than that; we keep
you in touch with
your colleagues
through our:
> Facebook fan page;
> JEMS Connect site;
> Twitter account;
> LinkedIn profile;
> Product Connect site; and
> Fire EMS Blogs site.
Sponsored Product Focus
MULTI-PATIENT MONITORING SYSTEM
The new Multi-Patient Monitoring System (MPMS) from First Line
Technology allows emergency personnel to stay connected and
provide constant monitoring for up to 20 patients during
triage, transport and care. The MPMS includes a roll and carry bag
wired to charge both the (included) Wireless Vital Signs
Monitor devices and a remote monitoring device.
LIKE US
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▲ Check out their ad on JEMS.com!
FOLLOW US
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DATA WEBCAST
Check out our next webcast, which will be at 10 a.m. (Eastern
time) March 20. In this webcast, sponsored by ZOLL Data, firefighter/paramedic and EMS 10: Innovator in EMS Awardwinner John Pringle will present, “Update on 360-degree Data:
How to collect better data in the field.” He will give you practical steps to successfully integrate new electronic tools into
your emergency response systems.
▲ jems.com/webcasts
GET CONNECTED
linkedin.com/groups?
about=&gid=113182
EMS NEWS ALERTS
JEMS.com
Visit www.ems2020
vision.com to watch
the latest 2020 Vision
Leadership Series
video interviews.
Where do you see EMS going in 2020?
That was the question put to four EMS
visionaries—James J. Augustine, MD, FACEP;
Matt Zavadsky, MS-HSA, EMT; David Page,
MS, NREMT-P; and moderator A.J. Heightman,
MPA, EMT-P. For hours, we flmed them
while they created a new future. Join the
2020 EMS Visionaries LinkedIn group to get
engaged in the discussion.
www.FernoEMS.com
Setting our sights on the future of EMS
http://linkedin.
ems2020vision.com
jems.com/enews
CHECK IT OUT
jems.com/ems-products
BEST BLOGGERS
FireEMSBlogs.com
WWW.JEMS.COM
MARCH 2013
JEMS
5

8. ®
EDITOR-IN-CHIEF I A.J. Heightman, MPA, EMT-P I aheightman@pennwell.com
MANAGING EDITOR I Jennifer Berry I jenniferb@pennwell.com
ASSOCIATE EDITOR I Ryan Kelley I rkelley@pennwell.com
ASSISTANT EDITOR I Kindra Sclar I kindras@pennwell.com
ONLINE NEWS/BLOG MANAGER I Bill Carey I billc@pennwell.com
ASSOCIATE WEB EDITOR I Nicole Reino I nicoler@pennwell.com
EDITORIAL DIRECTOR I Shannon Pieper I shannonp@pennwell.com
MEDICAL EDITOR I Edward T. Dickinson, MD, NREMT-P, FACEP
CONTRIBUTING EDITOR I Bryan Bledsoe, DO, FACEP, FAAEM
ART DIRECTOR I Liliana Estep I alildesign@me.com
CONTRIBUTING ILLUSTRATORS
Steve Berry, NREMT-P; Paul Combs, NREMT-B
CONTRIBUTING PHOTOGRAPHERS
Vu Banh, Glen Ellman, Craig Jackson, Kevin Link, Courtney McCain, Tom Page, Rick Roach,
Steve Silverman, Michael Strauss, Chris Swabb
DIRECTOR OF ePRODUCTS/PRODUCTION I Tim Francis I timf@pennwell.com
PRODUCTION COORDINATOR I Matt Leatherman I matthewl@pennwell.com
PUBLICATION OFFICE
800/266-5367 I Fax 858/638-2601
ADVERTISING DEPARTMENT
800/266-5367 I Fax 858/638-2601
ADVERTISING DIRECTOR I Judi Leidiger I 619/795-9040 I j.leidiger@jems.com
WESTERN ACCOUNT REPRESENTATIVE I Cindi Richardson I 661/297-4027 I
c.richardson@jems.com
SENIOR SALES COORDINATOR I Elizabeth Zook I 951/244-1245 I elizabethz@pennwell.com
REPRINTS, ePRINTS & LICENSING I Rae Lynn Cooper I 918/831-9143 I raec@pennwell.com
VICE PRESIDENT, MARKETING SERVICES I Paul Andrews I 240/595-2352 I
marketingservices@pennwell.com
SUBSCRIPTION DEPARTMENT I 888/456-5367
DIRECTOR, AUDIENCE DEVELOPMENT & SALES SUPPORT I Mike Shear I mshear@pennwell.com
MARKETING & CONFERENCE DIRECTOR I Debbie Murray I debbiem@pennwell.com
MARKETING & CONFERENCE COORDINATOR I Vanessa Horne I vhorne@pennwell.com
•
CHAIRMAN I Frank T. Lauinger
PRESIDENT & CHIEF EXECUTIVE OFFICER I Robert F. Biolchini
CHIEF FINANCIAL OFFICER I Mark C. Wilmoth
SENIOR VICE PRESIDENT & GROUP PUBLISHER I Lyle Hoyt I lyleh@pennwell.com
VICE PRESIDENT/PUBLISHER I Jeff Berend I jeffb@pennwell.com
•
•
www.EMSToday.com
EXECUTIVE DIRECTOR I Jeff Berend
CONFERENCE DIRECTOR I Debbie Murray
EDUCATION DIRECTOR I A.J. Heightman
EVENT OPERATIONS MANAGER I Amanda Wilson
EXHIBIT SERVICES MANAGER I Raymond Ackermann
EXHIBIT SALES REPRESENTATIVE I Sue Ellen Rhine I 918/831-9786 I sueellenr@pennwell.com
EXHIBIT SALES REPRESENTATIVE I Tracy Thompson I 918/832-9390 I tracyt@pennwell.com
•
•
FOUNDING EDITOR I Keith Griffiths
FOUNDING PUBLISHER
James O. Page (1936–2004)
®
bringing change to life
®
Choose 15 at www.jems.com/rs

9. Accurate from the First Breath
World’s smallest portable
self-contained capnometer
EMMA™ (Emergency Mainstream Analyzer) is a fully selfcontained mainstream capnometer that requires no
routine calibration and virtually no warm up time.1 With
rapid measurement of end-tidal CO2 and respiration
rate, EMMA can help providers guide ventilation rates and
assess the effectiveness of CPR allowing them to make
adjustments in the course of treatment, breath by breath.
800-257-3810
|
www.masimo.com
© 2013 Masimo Corporation. All rights reserved.
1
EMMA Users Manual.
Choose 16 at w ww.jems.com/rs

10. ®
EDITORIAL BOARD
WILLIAM K. ATKINSON II, PHD, MPH, MPA,
EMT-P
President & Chief Executive Officer,
WakeMed Health & Hospitals
JAMES J. AUGUSTINE, MD, FACEP
Medical Director,
Washington Township (Ohio) Fire Department
Associate Medical Director,
North Naples (Fla.) Fire Department
Director of Clinical Operations, EMP Management
Clinical Associate Professor, Department of
Emergency Medicine, Wright State University
STEVE BERRY, NREMT-P
Paramedic & EMS Cartoonist, Woodland Park, Colo.
BRYAN E. BLEDSOE, DO, FACEP, FAAEM
Professor of Emergency Medicine, Director, EMS Fellowship,
University of Nevada School of Medicine
Medical Director, MedicWest Ambulance
CRISS BRAINARD, EMT-P
Deputy Chief of Operations, San Diego Fire-Rescue
CHAD BROCATO, DHS, REMT-P
Assistant Chief of Operations,
Deerfield Beach (Fla.) Fire-Rescue
Adjunct Professor of Anatomy & Physiology,
Kaplan University
J. ROBERT (ROB) BROWN JR., EFO
Fire Chief, Stafford County (Va.) Fire & Rescue Department
Executive Board, EMS Section,
International Association of Fire Chiefs
CAROL A. CUNNINGHAM, MD, FACEP, FAAEM
State Medical Director,
Ohio Department of Public Safety, Division of EMS
THOM DICK, EMT-P
Quality Care Coordinator,
Platte Valley (Colo.) Ambulance
BRUCE EVANS, MPA, EMT-P
Deputy Chief, Upper Pine River Bayfield Fire Protection,
Colorado District
JAY FITCH, PHD
President & Founding Partner, Fitch & Associates
RAY FOWLER, MD, FACEP
Associate Professor,
University of Texas Southwestern School of Medicine
Chief of EMS,
University of Texas Southwestern Medical Center
Chief of Medical Operations,
Dallas Metropolitan Area BioTel (EMS) System
ADAM D. FOX, DPM, DO
Assistant Professor of Surgery,
Division of Trauma Surgery & Critical Care,
University of Medicine & Dentistry of New Jersey
Former Advanced EMT-3 (AEMT-3)
GREGORY R. FRAILEY, DO, FACOEP, EMT-P
Medical Director, Prehospital Services, Susquehanna Health
Tactical Physician, Williamsport (Pa.) Bureau of
Police Special Response Team
8
JEMS
MARCH 2013
JEFFREY M. GOODLOE, MD, FACEP, NREMT-P
Professor & EMS Section Chief
Emergency Medicine, University of Oklahoma School of
Community Medicine
Medical Director, EMS System for Metropolitan
Oklahoma City & Tulsa
KEITH GRIFFITHS
President, RedFlash Group
Founding Editor, JEMS
DAVE KESEG, MD, FACEP
Medical Director, Columbus Fire Department
Clinical Instructor, Ohio State University
W. ANN MAGGIORE, JD, NREMT-P
Associate Attorney, Butt, Thornton & Baehr PC
Clinical Instructor, University of New Mexico,
School of Medicine
CONNIE J. MATTERA, MS, RN, EMT-P
EMS Administrative Director & EMS System Coordinator,
Northwest (Ill.) Community Hospital
MIKE MCEVOY, PHD, REMT-P, RN, CCRN
EMS Coordinator, Saratoga County, N.Y.
EMS Editor, Fire Engineering Magazine
Resuscitation Committee Chair, Albany (N.Y.) Medical College
MARK MEREDITH, MD
Assistant Professor, Emergency Medicine and Pediatrics,
Vanderbilt Medical Center
Assistant EMS Medical Director for Pediatric Care,
Nashville Fire Department
GEOFFREY T. MILLER, EMT-P
Director of Simulation Eastern Virginia Medical School,
Office of Professional Development
BRENT MYERS, MD, MPH, FACEP
Medical Director, Wake County EMS System
Emergency Physician, Wake Emergency Physicians PA
Medical Director, WakeMed Health & Hospitals
Emergency Services Institute
MARY M. NEWMAN
President, Sudden Cardiac Arrest Foundation
JOSEPH P. ORNATO, MD, FACP, FACC, FACEP
Professor & Chairman, Department of Emergency Medicine,
Virginia Commonwealth University Medical Center
Operational Medical Director,
Richmond Ambulance Authority
JERRY OVERTON, MPA
Chair, International Academies of Emergency Dispatch
DAVID PAGE, MS, NREMT-P
Paramedic Instructor, Inver Hills (Minn.) Community College
Paramedic, Allina Medical Transportation
Member of the Board of Advisors,
Prehospital Care Research Forum
PAUL E. PEPE, MD, MPH, MACP, FACEP, FCCM
Professor, Surgery, University of Texas
Southwestern Medical Center
Head, Emergency Services, Parkland Health & Hospital System
Head, EMS Medical Direction Team,
Dallas Area Biotel (EMS) System
DAVID E. PERSSE, MD, FACEP
Physician Director,
City of Houston Emergency Medical Services
Public Health Authority, City of Houston Department.
of Health & Human Services
Associate Professor, Emergency Medicine,
University of Texas Health Science Center—Houston
EDWARD M. RACHT, MD
Chief Medical Officer, American Medical Response
JEFFREY P. SALOMONE, MD, FACS, NREMT-P
Trauma Medical Director, Maricopa Medical Center
Professor of Surgery,
University of Arizona College of Medicine—Phoenix
KATHLEEN S. SCHRANK, MD
Professor of Medicine & Chief,
Division of Emergency Medicine,
University of Miami School of Medicine
Medical Director, City of Miami Fire Rescue
Medical Director, Village of Key Biscayne Fire Rescue
JOHN SINCLAIR, EMT-P
International Director, IAFC EMS Section
Fire Chief & Emergency Manager,
Kittitas Valley (Wash.) Fire & Rescue
COREY M. SLOVIS, MD, FACP, FACEP, FAAEM
Professor & Chair, Emergency Medicine,
Vanderbilt University Medical Center
Professor, Medicine, Vanderbilt University Medical Center
Medical Director, Metro Nashville Fire Department
Medical Director, Nashville International Airport
WALT A. STOY, PHD, EMT-P, CCEMTP
Professor & Director, Emergency Medicine,
University of Pittsburgh
Director, Office of Education,
Center for Emergency Medicine
RICHARD VANCE, EMT-P
Captain, Carlsbad (Calif.) Fire Department
JONATHAN D. WASHKO, BS-EMSA, NREMT-P,
AEMD
Assistant Vice President, North Shore-LIJ Center for EMS
Co-Chairman, Professional Standards Committee,
American Ambulance Association
Ad-Hoc Finance Committee Member, NEMSAC
KEITH WESLEY, MD, FACEP
Medical Director, HealthEast Medical Transportation
KATHERINE H. WEST, BSN, MED, CIC
Infection Control Consultant,
Infection Control/Emerging Concepts Inc.
STEPHEN R. WIRTH, ESQ.
Attorney, Page, Wolfberg & Wirth LLC.
Legal Commissioner & Chair, Panel of Commissioners,
Commission on Accreditation of Ambulance Services
(CAAS)
DOUGLAS M. WOLFBERG, ESQ.
Attorney, Page, Wolfberg & Wirth LLC
WAYNE M. ZYGOWICZ, BA, EFO, EMT-P
EMS Division Chief, Littleton (Colo.) Fire Rescue

11. When urgency and bravery are
essential job requirements, the
success of your business depends
on a commercial vehicle that won’t
back down from a challenge. With
an Adaptive Electronic Stability
Program® 1 and both Best-In-Class*
payload capacity and standing
height, only the 2013 Freightliner
Sprinter is designed to answer the
call as boldly as you do every day.
freightlinersprinterusa.com
DRIVEN LIKE YOU.
©2013 Daimler Vans USA, LLC *Based on a comparison of the
Automotive News classification of full-size commercial vans.
1 No system, regardless of how advanced, can overcome the laws of
physics or correct careless driving. Please always wear your seat belt.
Performance is limited by available traction, which snow, ice and other
conditions can afect. Always drive carefully, consistent with conditions.
Best performance in snow is obtained with winter tires.
Choose 18 at www.jems.com/rs
Choose 17 at www.jems.com/rs

12. EMS IN ACTION
SCENE OF THE MONTH
10
JEMS
MARCH 2013
>> PHOTOS JOSEPH THOMAS

13. PEDIATRIC IMMOBILIZATION
S
t. John’s/Mercy (Mo.) EMS Paramedic Christy Biram carries a 3-year-old female pediatric patient on a pediatric backboard to a waiting ambulance at the scene of a crash
that involved two vehicles colliding at a stoplight. The vehicle the pediatric patient was in
was hit when another vehicle allegedly ran a red light. The girl was secured properly in a
child safety seat and had been extricated from the vehicle and car seat by her mother prior
to EMS arrival. Her only injuries were abrasions to her thighs and clavicles from the safety
seat restraints. She had been placed in spinal mobile restriction by Springfield Fire Department prior to EMS arrival. She was transported to a Level 1 trauma center, where she was
treated and released. The driver of the other car collided with one of the stoplight posts,
causing the battery to fly out of the vehicle and hit a pedestrian who narrowly missed getting hit by the vehicle. The pedestrian had a minor leg injury but refused care on scene, and
the driver of the vehicle that ran the light had to be extricated and was transported to an
emergency department. Note the crew’s professionalism, covering the patient’s body surface with a turnout coat after exposing and assessing her lower torso.
WWW.JEMS.COM
MARCH 2013
JEMS
11

14. FROM THE EDITOR
PUTTING ISSUES INTO PERSPECTIVE
>> BY A.J. HEIGHTMAN, MPA, EMT-P
‘SPECIAL STRETCHERS’
How two eliminated words impacted immobilization options
I
t’s amazing how committees, lim- FERNO FULL-BODY VACUUM MATTRESS
splinting; and pad the splint carefully to
ited research and the omission of
prevent pressure points and discomfort to
a few words can change protocols
the extremity [and the patient].”
and affect the delivery of patient care
Morrissey’s article gives you the
and comfort. Jim Morrissey’s article,
science, research and reasons to
“Spinal Immobilization,” pp. 28–39,
allow your crews to use multiple
is an epic piece of work, backed by FERNO’S EASYFIX VACUUM MATTRESS/STRETCHER
proven “special stretchers,” in addi36 footnoted references that illustrate COMBINATION
tion to the traditional longboard,
we over-board patients, waste preto immobilize patients and “splint”
cious time at penetrating injury calls
their injuries.
and make patients uncomfortable by
I spent a day with Poway (Calif.)
placing them on hard surfaces that do
Fire Department Captain Andy Page
not fit their anatomy or support their
and crews from Engine 3711 and
injuries without proper padding and
Medic 3791. We applied, secured,
weight distribution.
moved and transported paramedic/
I’m going to take you back to 1971,
firefighter Jon Maxwell up and down
when EMS got its “roots” in formalstairways in some of the latest “speized education with the release of the
cial stretchers” designed to properly
initial EMT textbook, Emergency Care
immobilize his spine.
and Transportation of FERNO’S MODEL 137 FLEXIBLE STRETCHER WITH BUILT-IN
We used: ConvenHARTWELL MEDICAL EVAC-U-SPLINT
MATTRESS/STRETCHER USED ALONG
the Sick and Injured. RESTRAINTS USED IN TANDEM WITH A VACUUM SPLINT
tional
scoop-style
WITH A HARTWELL COMBICARRIER
The first AAOS textstretchers; Full-body
book stated:
vacuum platforms;
“Carefully splint the
Vacuum splints and
injured spine, avoiding
a
Ferno
Flexible
abnormal or excessive
Stretcher. We also used
motion. Be sure that the
Ferno’s EasyFix Vacinjured person is properly
uum Mattress/Stretcher
splinted and transported
that is being used
on a long backboard or
throughout Europe
special stretcher withand was recently introout bending or twisting
duced in the U.S.
the spine in any direction.”
Most of the devices
I call your attention to the important words “or special offered more comfort and security than a longboard without extra
stretcher” because those words were somehow omitted from padding. The vacuum devices were also durable, easily moldable to
subsequent editions of the AAOS and most other textbooks. the patient, and tended to better “cradle” the patient securely. We
Those omitted words resulted in decreased use of scoop and used SSCOR and Laerdal suction devices to speed up the process.
canvas stretchers with slat supports, and SKED stretchers, in
Perhaps the most interesting finding was that vacuum matsome systems, and should be added back into our protocols and tresses used in conjunction with the Ferno flexible stretcher and its
textbooks to allow crews to use multiple devices to accomplish six conveniently-located handles, offered the best body mechanics
spinal immobilization.
and positioning to maneuver our patient down stairways and
The “General Principles of Splinting” section in the 1971 around tight corners, proving that some things haven’t changed
AAOS textbook presented treatment considerations that still since 1971, when this type of flexible stretcher was first introduced
hold true today:
to EMS.
“All fractures should be ‘splinted where they lie’; Apply the splint or banSee a demo of the EasyFix Mattress at www.youtube.com/watch?v=-WF73wKdfZM
dage before moving or transporting the patient; With some very important
exceptions, a severely angulated fracture should be straightened prior to
12
JEMS
MARCH 2013

15. The Safe Choice
Introcan Safety® 3 Closed IV Catheter
helps shield against
Needlesticks
Blood Exposure
Catheter Complications
From start to finish, Introcan Safety 3 provides:
Fully automatic safety shield that protects against needlesticks.
Multiple-access septum that helps prevent blood exposure.
Advanced stabilization that minimizes catheter movement to help
reduce irritation and associated restarts.
Lower cost and less waste from insertion through disposal.
introcansafety.bbraunusa.com
1-800-227-2862
The following is a list of supporting documents and reference material:
1) Tosini, et al “Needlestick Injury Rates According to Diferent Types of Safety-Engineered Devices: Results of a French Multicenter Study”, Infection Control and Hospital Epidemiology, Vol. 31, No. 4 April 2012 pp. 402-407
2) Bausone-Gazda D, et al, A Randomized Controlled Trial to Compare the Complications of 2 Peripheral Intravenous Catheter-Stabilization Systems, Journal of Infusion Nursing, 2012, Nov-Dec: 33(6):371 84
3) Shears G MD, Comparing an Intravenous Stabilizing Device to Tape, Journal of Infusion Nursing, Vol. 29, No. 4 July/August 2006
4) B. Braun Engineering Data on File
5) B. Braun Introcan Safety 3 Cost Analysis Model
6) McNeill, EE, et al, A Clinical Trial of a New All-in-one Peripheral Short Catheter, JAVA, 2009, Vol. 14, No. 1, pp. 46-50
13-3611_2/13_JEMS_BB
7) Infusion Nurses Society (2011), Infusion Nursing Standards of Practice, Journal of Infusion Nursing Supplement, Vol. 34, No. 15, Std. 22, Std. 36
Choose 18 at www.jems.com/rs

16. LETTERS
IN YOUR WORDS
ADDING TO THE
A
D
DISCUSSION
PHOTO COURTESY PHYSIO-CONTROL
This month, we feature some
T
strong opinions from readers on
s
two recent articles. The first is a
t
response to a JEMS.com Street
r
Science column “Are the BenS
efits of Mechanical CPR Worth
e
the Interruption Time?” by Keith
t
Wesley, MD, FACEP, and MarW
shall J. Washick, BAS, NREMT-P,
s
that reviewed a study examining
t
interruption time in mechanii
cal CPR. The second comment is
c
from one of our Facebook fans,
f
who takes issue with Thom Dick’s
w
August “Tricks of the Trade” colA
umn advising on “Psych Transu
fers: Know how to deal with these
f
types of patients.”
t
MECHANICAL CPR ADVANTAGES
We read the article “Are the Benefits of Mechanical CPR
Worth the Interruption Time?” (www.jems.com/article/patient-care/are-benefits-mechanical-cpr-worthinterr) with great interest. We participated in the NALE
project and submitted our data as part of the article
published in Resuscitation.
The authors of the review bring up some important points about the findings, but we fear they do not
answer the question posed in the title of their article.
We have extensive experience using the mechanical compression device with more than 1,200 uses to
date. One of the first things we learned when deploying the device was that crews put it as a priority and the
other, time-important interventions were delayed. We
had to put it into our protocols and train our people
to place it later in the event, after other interventions
were completed.
Next, we learned that placing the device tended
to cause everyone else to pause and help out. This
is much like our previous experience with intubation
where everyone stopped what they were doing until
the “vital” procedure was completed.
We changed our protocol again and trained our
staff how to place the device with no or minimal interruptions in other tasks. We now have a procedure
where the device is placed in stages and the maximum
interruption in compressions is 15 seconds.
The benefits of the device are many. We can see
in our cases that interruptions are minimal and short
once the device is placed. That may be the best argument when discussing whether the interruption is
worth it. We see it as accepting an early 15 second delay
which then prevents multiple delays later in the event.
14
JEMS
MARCH 2013
During our quality assurance reviews, we see interruptions as providers tire and switch users, or as the
patient’s location is changed.
There is a real challenge in any research pertaining to
cardiac arrest right now. That challenge is trying to associate one treatment with a definitive improvement in
outcome. This is a rapidly changing body of knowledge
and there is no agreed-upon protocol. So the question
of whether the delay in compressions when placing the
device is worth it is a difficult question to answer and
maybe should not be asked. A better question might
be “What are the advantages of using a mechanical
compression device, and how does it fit into a system
approach to care of the cardiac arrest victim?”
Our extensive experience is a resounding “yes,” it
is a vital part of our overall approach to improving the
community’s and emergency care system’s response to
cardiac arrest.
Charles Lick, MD
Paul Satterlee, MD
Allina Health EMS
PSYCH ISSUES
I am sorry Thom … while I’m
sure you are a great medic
and all, I just feel much of
this is bad advice. The main
reason being, why would/
should EMS be transporting patients that are currently off their meds and/or
known to be diagnosed at the hospital as psychotic,
are potentially suicidal and/or homicidal, when we
have very little to no education in handling this? Isn’t
it enough that we have to occasionally deal with
potentially psychotic, suicidal or homicidal patients?
I read a story from a provider just last night who
described a situation where a psych patient, who
went nuts during an inter-facility transport, was able
to free themselves, threaten the provider and then
proceed to jump out of the ambulance and run away.
The truth is, as long as these patients don’t require
some sort of medical intervention en route to the
receiving medical/psychological treatment facility,
there is absolutely no reason whatsoever that they
should not be transported by law enforcement. Law
enforcement officers have the training and authority
to safely handle these patients, not EMS providers.
Jason M.
Via Facebook
Author Thom Dick, EMT-P, responds: Thanks, Jason,
for highlighting these issues. I think no matter who we
are or how great our skill, we don’t “know” very much
about most of the sick people we meet—certainly not
during the brief span of an ED visit. But even if we could
be sure somebody’s etiology is psychological, does that
somehow transform them into something less than a
sick person? I don’t think it does.
I agree with you that we all need and deserve to
understand more about behavioral disorders. The
Western medicine to which we all subscribe endorses
a pathetic approach to people with mental illness.
Your health insurance company will typically pay for
a 60-minute first visit with an internist. Care to guess
what they’ll allow for a first visit with a psychiatrist,
for a much more complex problem? On average,
they’ll pay a psychiatrist for 15 minutes.
What we call caring for mental patients basically
amounts to throwing drugs at them. It’s no wonder. The
standard Diagnostic and Statistical Manual (DSM) you’ll
find on the desk of every ED physician is republished
every few years as a means of classifying people with
psychiatric illnesses. The current edition, the DSM-IV,
lists six technical editors—all with published direct financial ties to pharmaceutical companies. Five of those six
are linked to the same pharmaceutical company (Eli Lilly).
As for bad advice, every one of the suggestions in
this article would have helped the crew you describe
to sense, predict and prevent the incident they experienced, as well as protect the patient and the public
who were also endangered.
It’s sad that, after all these years, the EMS texts
we trust either ignore this important part of field medicine or recommend procedures that are sure to get us
injured along with the sick people we care for.
In my opinion, this is medicine we’re doing here.
Medicine is supposed to help people. We’re supposed to help people. And a cage car is just not part
of that process.

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Choose 19 at www.jems.com/rs

18. PRIORITYUSE
TRAFFIC
NEWS YOU CAN
NFFF Response to Violent Incidents
Nine questions first responders should ask
T
IMAGE COURTESY NATIONAL FALLEN FIRE FIGHTERS
he Newtown (Conn.)
school shooting and
Webster (N.Y.) ambush
of firefighters provide increased
awareness of violence against
emergency responders. East Hartford (Conn.) Fire Chief John Oates,
writing for the National Fallen Fire
Fighters (NFFF), has provided nine
questions responders should ask:
1. Do you use risk/benefit analysis for every call?
2. Do you have an effective relationship at all levels with the
law enforcement agencies in
your community?
3. How good is the information
you get from your dispatcher?
4. Do you allow members to
“first respond” directly to the
scene?
5. Does your law enforcement
agency use an incident management system?
6. When responding to a potentially violent incident, do you Cover of the NFFF report “Firefighter Life Safety Initiative 12.”
seek out a law enforcement
PREVENTING LINE-OF-DUTY INJURY
officer when you arrive?
7. Have you told your fire officers/per- Everyone Goes Home is a national prosonnel that it’s OK to leave the scene gram by the National Fallen Firefighters
Foundation to prevent line-of-duty deaths
if things start to turn bad?
8. Is there a point at which you don’t and injuries. In March 2004, a Firefighter
respond or limit your response to vio- Life Safety Summit was held in Tampa,
Fla., to address the cultural, philosophilent incidents?
9. Is your uniform easily mistaken for cal, technical and procedural problems
that affected safety within the fire service.
law enforcement?
These questions came from a March 2012 The most important domains were identifocus group of 35 participants representing fied, resulting in 16 Firefighter Life Safety
29 organizations. The NFFF-commissioned Initiatives. Everyone Goes Home started
report from this group, “Firefighter Life as a way of implementing initiatives at the
Safety Initiative 12 Final Report: National local level.
NFFF asked subject matter experts to
protocols for response to violent incidents
should be developed and championed,” is develop a white paper for each initiapart of a resource package covering 16 Fire- tive. Chief Oates provided the Initiative
fighter Life Safety Initiatives of the Everyone 12 report. The Novato, Calif., 2007 summit developed actionable objectives to
Goes Home program.
support each of the Firefighter Life
Safety Initiatives.
Noting that there was, “an absence
of response protocols for violent
incidents in many fire departments”
a focus group met in Anne Arundel County, Md., in 2012 to develop
an expanded report for Initiative 12,
including the nine questions.
There’s no enforcement authority or funding to implement the
Firefighter Life Safety Initiatives.
Some feel that more effort should
be directed against those who
assault responders.
‘PARAMEDICS ARE
NOT PUNCHING BAGS’
New South Wales, Australia, ambulance service acting Commissioner
Mike Willis announced a zero-tolerance policy toward violence against
EMS personnel, noting on the agency’s website that there were six
assaults against paramedics in early
December.
There’s a perception that sanctions
against those who assault EMS personnel
are inadequate. In Illinois it’s a felony to
assault a first responder; however, Chicago
paramedics claimed, in a WLS-TV ABC
News 7 report, that those who assault them
get trivial punishment.
One technique that has been used is to
fill a courtroom with emergency responders in uniform. In January, the New York
Post reported that two dozen EMS workers
filled a Manhattan courtroom to support
their colleague who was allegedly choked
by a drunken assistant district attorney.
— Michael J. Ward, MGA
Reports referenced in this article are
available at: www.everyonegoeshome.
com/news/2013/initiative12_012913.html
For more of the latest EMS news, go to jems.com/news
16
JEMS
MARCH 2013

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20. PRIORITY TRAFFIC
>> CONTINUED FROM PAGE 16
SERVING THOSE WHO SERVE
Effectively treating military
personnel & veterans
F
irst responders are a critical first contact point for members of the armed
forces and veterans in crisis. Many EMS and
other emergency response agencies aren’t
effectively prepared to effectively serve those
who serve. For example, first
responders often don’t have
sufficient knowledge of military culture and few know
how to de-escalate calls
involving military members
and veterans.
Special programming at
this year’s 2013 EMS Today
Conference & Exposition will focus on serving this special population. The conference
will feature presentations by a team from
Arizona’s Military/Veteran First Responder
Initiative. This effort, facilitated by the Arizona Coalition for Military Families (ACMF),
brings together public and private sector
partners from the military, government and
community to focus on strengthening crisis
response for military members and veterans,
including those experiencing post-traumatic
stress and traumatic brain injury.
The training, which has
been developed by the ACMF
over the past four years, is
nationally recognized as a
best-practice approach to
improve the coordination of
care through training and networking personnel.
In the past year, through this
partnership, more than 2,200 first responders in Arizona have received training, with
plans for several hundred more this spring.
This initiative fits into a larger state effort to
build community capacity to care for and
support service members, veterans and their
families, including initiatives around behavioral health, higher education, employment
and faith-based communities.
The Arizona Coalition for Military Families and partners are currently exploring
how to expand this training effort to reach
first responders across the country.
The presentation team at EMS Today
Conference & Exposition will include Captain Dean Pedrotti of the Phoenix Fire
Department, SSG (Ret.) Patrick Ziegert of
the Office of the Arizona Attorney General and Colleen Day Mach of the Arizona
Coalition for Military Families. The main
presentation is Friday, March 8, from 8–10
a.m. with a presentation on post-traumatic stress on Saturday, March 9, from
10–10:30 a.m.
— Thomas Winkel, MA, LPC, NCC
DUTY TO ACT ARE YOU ALWAYS ON CALL?
S
cenario: A medic stops at the grocery store after her shift. She’s still in her
company uniform and witnesses an older man drop to the floor, apparently unconscious. Does the medic have a legal duty to act? Probably not. If
she chooses to walk on by, can she be held legally liable? Again, probably not.
Why? Because she doesn’t have a legal duty to act.
Tort law requires four elements for a plaintiff to hold a defendant legally
responsible for a personal injury. These elements are 1) a legal duty to act; 2) a
breach of that duty; 3) proximate causation (i.e., the defendant’s breach of duty
was the legal cause of the plaintiff’s harm); and 4) damages (i.e., losses or harm
that merits financial compensation). Unless an EMS provider has a legal duty to
the patient, they cannot be held liable in tort law.
In our scenario above, the medic was off duty, having completed her shift.
The fact that she was in uniform doesn’t change the analysis; your legal duty to
act isn’t dependent on your wardrobe.
To use the reverse of this example, if the medic was on duty, spilled grape
juice on her uniform at work and changed into a non-uniform shirt, she still has
a duty to respond when called. Certainly, the fact that the medic was in uniform while off duty at the grocery store, probably with a patch or some insignia
that identified her employer, still doesn’t create a legal duty to act when she
witnessed the man fall to the floor. Of course, it could raise a public relations
issue if the medic elects not to provide assistance to the patient, but it doesn’t
give rise to a legal duty.
As this scenario makes clear, there’s a difference between a legal duty and
a moral duty. Certainly, many EMS providers feel they may have a moral duty
to act in this scenario, though that is a personal decision that the law permits
each of us to make based on our own values and beliefs. In fact, this is why most
states have Good Samaritan laws: to incentivize people to act on behalf of a
fellow human being in peril even though they may have no legal duty to do so.
Can the medic’s employer be held liable for the medic’s failure to act?
They possibly can in the court of public opinion, but not in tort law. If the
agency is dispatched to respond, of course,
that’s a different story. But her employer
cannot be held liable simply because an offduty employee decided not to render aid as
a bystander.
What are the liability ramifications in this
case if the medic does choose to act and provides care to the patient? Can
the medic be held liable? Can her employer? Let’s start with the medic herself.
When she decided to act voluntarily, most states’ laws would hold her liable
only for harm that resulted from gross negligence, recklessness or intentional
misconduct—not for acts of ordinary negligence. (Gross negligence vs. ordinary
negligence is a threshold issue that is typically decided by the judge before the
case goes to trial.)
Some individual EMS providers choose to carry personal liability insurance
to address concerns about personal liability, though in truth it’s quite rare for
an EMS provider to have to pay out of their own pocket in a tort case. (In fact,
we haven’t encountered it in our nearly 20 years in the practice of law.)
Lastly, what is the liability of the medic’s employer if the medic chooses to
act, in her uniform, while off duty? That is a bit more complex. If the employer
has a policy (or even an unwritten expectation communicated to employees)
making it a job requirement to provide off-duty care as a bystander, then it
can possibly be held liable, because any errors or omissions committed by the
medic would then likely be found to have occurred in the course and scope
of her employment. However, in our experience, it’s unlikely (and inadvisable)
for an EMS agency to have such a policy, which means the agency itself could
most likely not be held liable for any acts or omissions committed by one of
its employees off duty.
The concept of a legal duty to act is a basic principle of tort law, and is the
threshold issue in determining whether an EMS provider can face liability for
their acts or omissions.
Check out the most interesting and bizarre cases at jems.com/case
18
JEMS
MARCH 2013
Pro Bono is written by
attorneys Doug Wolfberg
and Steve Wirth founding
partners of Page, Wolfberg &
Wirth, a national EMS industry law firm. Visit the firm’s
website at
www.pwwemslaw.com.

21. QUICK TAKE
AWARD WINNERS
FireEMS blogger, JEMS sister
sites gain recognition
Fire/EMSBlogs blogger Michael Morse,
who pens the Rescuing Providence blog,
was one of three Rhode Island writers
who received the prestigious MacColl
Johnson Fellowships from the Rhode
Island Foundation. Morse, who was one
of three writers to receive $25,000, writes
about his work as an EMT/firefighter
with the Providence Fire Department at
http://rescuingprovidence.com.
Two JEMS sister publications were
named Jesse H. Neal Awards competition finalists. The Law Officer
Facebook page is up for Best Use of
Social Media, and FirefighterNation.
com is being considered for Best
Website. The American Business Media
considers the Neal Awards the industry’s most prestigious and sought-after
editorial honors.
BOOK REVIEW
Alright, Let’s Call it a Draw: The Life of John Pryor
By Richard (and John) Pryor, based on the life and death of John Pryor, MD
John P. Pryor, MD, FACS, former
trauma program director for the
Hospital of the University of Pennsylvania in Philadelphia, JEMS author
and JEMS Editorial Board member,
was killed by an enemy mortar
round in Mosul, Iraq on Christmas
morning of 2008. This posthumous biography, penned by John’s
younger brother, Richard, is a moving and in-depth look into the life
of an EMT turned trauma surgeon.
It provides a rarely written view
of the motivation and dedication
behind heroic behavior.
John Pryor’s journey began as a humble EMT in
upstate New York. Like many JEMS readers, an inner
voice compelled John to serve his fellow man. Ultimately, he decided that he wanted to be a surgeon.
This seemingly impossible dream led him to Grenada
in the Caribbean, Buffalo, N.Y., and Philadelphia as well
as onto the pile at the World Trade Center on Sept. 11,
2001. Reading this book helps one realize that anything
can be accomplished once you set your
mind to doing so. It’s also a powerful and
sometimes painful insight into the costs
involved in achieving these dreams.
Alright, Let’s Call it a Draw is an eloquently detailed compilation of stories
and incidents that became the pivotal
moments in the life of Dr. John Pryor. It
details the life events that made him a
man of conviction, a man of integrity, and
a family man. This book reveals the unique
characteristics of John’s life that resulted
in an exceptional individual whose family,
colleagues, friends and all who knew him
would ultimately be proud of.
Every EMS provider will see a little bit of themselves in
the life of John Pryor. Anyone who ever wondered what
medical school is like will gain an inside perspective. This
book is a must read for every emergency services provider. You won’t be able to put it down. To obtain a copy,
go to www.drjohnpryor.com.
—Mike McEvoy, PhD, REMT-P, RN, EMT-P
& A.J. Heightman, MPA, EMT-P
Choose 20 at www.jems.com/rs

22. LEADERSHIP SECTOR
PRESENTED BY THE IAFC EMS SECTION
>> BY GARY LUDWIG, MS, EMT-P
IMPACT AHEAD
I
t’s final! In June 2011, the U.S. Supreme
Court upheld the Patient Protection and
Affordable Care Act (PPACA), commonly known as Obamacare. This past
November, President Barack Obama won
reelection and Democrats maintained a
majority control of the Senate. Any hopes
Republicans had of repealing the law went
away with those two opportunities. By the
end of Obama’s second term, many of the
PPACA’s core components will have been in
effect for three years or more. There’s really
no turning back; healthcare as we know it is
going to change.
The healthcare bill was 2,733 pages long
and EMS is only referenced a few times in the
document. But the effect on EMS will be dramatic. I suspect that many EMS systems will
look totally different in 10 years.
I know; you’ve heard this rhetoric before.
About 15 years ago, we heard that managed
care organizations would be the “gatekeepers” that would keep people from unnecessarily calling 9-1-1 to go to an emergency
department (ED). We heard that call centers
for insurance providers would properly evaluate the caller and route them to the appropriate level of care instead of calling 9-1-1.
Those changes largely failed to materialize.
CHANGES TO MANAGED CARE
The problem with managed care is that it
was mainly an effort by some insurance
providers to control costs and profits, and
it was voluntary. The PPACA will be legally
required. Besides the 2,733 pages of the bill
itself, more than 14,000 pages of federal regulations have already been written.
In addition, the PPACA is partially funded
through tax reforms (e.g., a 2.3% tax on medical devices costing more than $100). Expect
those manufacturers to pass that cost on
to you when you purchase devices costing
more than $100.
Although nobody truly knows how these
changes will affect healthcare, there’s one
thing we can be sure of: People are still
20
JEMS
MARCH 2013
PHOTO ALLKINDZA/ISTOCKPHOTO.COM
Obamacare will transform future EMS systems
readmittals and other quality of care issues,
hospitals may partner with the local EMS
system to perform a variety of services.
These can include checking on the patient
with home visits for the first three days, or if
complications arise, transporting the patient
to another level of care.
START PREPARING NOW
EMS managers should prepare now for the
changes that are coming. As patients with
insurance are moved to management systems and existing Medicare patients are
moved to ACOs, prepare for initial call load
increases. This should be followed by a leveling-off period. Start meeting with your local
hospital administrators to discuss partnerships that can come about with the implementation of the PPACA.
As the saying goes, “Chance favors the
prepared mind.” EMS systems that start
preparing for the long-term impacts of the
PPACA will no doubt reap the benefits.
going to get shot, have heart attacks at the
ball game and get into auto accidents going
home from work. Our 9-1-1-based EMS systems will still be needed to address such
medical emergencies.
What’s most likely to change for EMS
is how we deal with chronically ill patients
who call 9-1-1 because they have waited
too long to address their medical problem
or because they lack health insurance and
use the ED as an entry into the healthcare
system to address their problem. For Medicare patients, these needs will most likely be
met through accountable care organizations
GLOSSARY
(ACOs), which are just starting to form.
The main function of an Accountable
The main function of an ACO is to moniCare Organization (ACO) is to monitor
tor and control reimbursements for healthand control reimbursements for healthcare providers while also monitoring the
care providers while also monitoring the
quality of the care being provided. The
quality of the care being provided. The
PPACA allowed for the establishment of a
PPACA allowed for the establishment
Medicare Shared Savings Program (MSSP),
of a Medicare Shared Savings Program
which allows for ACOs to contract with
(MSSP), which allows for ACOs to conMedicare. Under this type of scenario, the
tract with Medicare. Under this type of
ACO would need to be totally responsible
scenario, the ACO would need to be
for the quality, cost, care and management of
totally responsible for the quality, cost,
at least 5,000 Medicare recipients.
care and management of at least 5,000
An ACO can deny or reduce payment if
Medicare recipients.
the provider isn’t meeting quality standards.
For example, reimbursement can be
denied when a patient is readmitted
to a hospital within three days for the
Gary Ludwig, MS, EMT-P, is a deputy
same problem. It’s therefore in that
fire chief with the Memphis (Tenn.) Fire
hospital’s interest to make sure the
Department. He has 30 years of fire and
patient doesn’t get readmitted for the
rescue experience. He’s chair of the EMS
same problem.
Section for the International Association of Fire
How does this affect EMS? To avoid such Chiefs and can be reached at www.garyludwig.com.

23. Choose 21 at www.jems.com/rs

24. TRICKSOUR PATIENTS & OURSELVES
OF THE TRADE
CARING FOR
>> BY THOM DICK, EMT-P
BATTERIES
Preventing failures we can’t afford
I
PHOTO THOM DICK
survived a grade-school envilate-model diesel depends on a supronment where academic failure
ply of urea (and why). And that if
meant physical pain. My teacher
you’re having steering issues, the first
would command me to put my hands
thing you should wonder about is
on my desk, and she would play rap
the air pressure in your tires. Think
music on them with a maple pointer.
of it the way you think about anatAnd that was nothing, compared to
omy and physiology.
what awaited me at home when my
By far, the most common kinds of
dad returned from work.
critical failures I’ve seen are failures
My crime: not “applying” myself.
to start. It turns out, they’re also the
Nothing less than a B would do,
easiest to prevent—partly by crews
because in Pop’s view, non-achievewho understand their instruments,
ment meant lack of effort.
and partly by proactive agencies
Looking back, I don’t recall my
that adhere to scheduled preventive
slightly neurotic teachers enjoying Batteries eventually fail, no matter what we do. Preventing
replacement of their batteries.
their work any more than I did mine. failures to start is the key to making sure those failures
The thing about batteries is they
don’t harm a patient.
And not surprisingly, they sucked at it.
all eventually fail. A good commerI loved auto shop, though; got straight
As you know, an ambulance can either cial ambulance-sized battery should cost
As in auto shop. Auto shop, music and writ- earn you a living or kill you on any day of about $200, and the average ambulance
ing. Grew up with Rochester QuadraJets, your career. It can kill other people, too. To has two of those. They should be replaced
235 and 327 Chevy engines, and VW bugs. operate, it needs to be able to start, steer, about once a year (even if they work just
Listened to the Wolf Man every night, play- stop and stay running. It also needs to pro- fine), they should be protected from rapiding Patsy Cline, Gene Pitney, The Righteous vide a stable interior environment, and its charging, and their connections should be
Brothers, Motown, and later The Beach safety restraints need to work. You don’t kept tight and squeaky-clean. You know
Boys and Beatles. Idolized Walter Cronkite need a mechanic or a supervisor to tell you what they’ll cost, so you can budget for
and dreamed of being him someday. Then when any of those systems fails; and when their replacement.
in 1970, as a young journalism student, I they do, you’re like a pilot. Nobody gets to
Now let’s think about the consequences
found a job as an ambulance attendant. I argue with your decision to put yourself of a failure. When a battery fails, it’ll typiinstantly recognized my calling in life. Of out of service.
cally do so when you least expect it to.
course, if you worked for an ambulance serI’ve learned to see critical failures not You can’t project what it’ll cost. A pair of
vice in those days, it was probably a small just as events that prevent you from run- dead ones is too big to jump-start, they
one. And in small organizations, everybody ning calls, but as events that could pre- place unacceptable stress on alternators,
does more than one job.
vent you from running calls. So, an engine they generate towing bills and they’re surOne of my jobs between calls was man- that cranks hard or leaks fluids needs to rounded by three-sided billboards that
aging a fleet: tracking the licenses, buying be taken out of service. So does a tire that say “we screwed up.” And worst of all,
the batteries, checking the tires and log- reveals excessive or unusual wear.
they interrupt our basic mission of helpging the maintenance. I was untaught, so I
In fact, your ambulance will almost ing sick people.
made a lot of mistakes. But I loved ambu- always warn you before it fails. So you
Don’t think this is important? OK, Lifelances, and I learned a ton about what probably deserve to understand how
Saver. Put your hands on the table
makes them safe and reliable. I take care of it works and what it’s telling you.
in front of you. ...
a fleet to this day.
Mechanical education is partly
Thom Dick has been involved in EMS
There are two kinds of vehicle failures, your agency’s responsibility and
for 41 years, 23 of them as a full-time
Life-Saver. One is the kind that takes you partly yours. Given your access to
EMT and paramedic in San Diego County.
out of service immediately. Most agencies the Internet, there’s no reason why
He’s currently the quality care coordinacall those critical failures. The other kind, a you shouldn’t know some of the
non-critical failure, needs to be fixed none- same stuff your vehicle tech knows. For tor for Platte Valley Ambulance, a hospital-based
theless. But it won’t keep you from run- instance, that a cracked windshield can 9-1-1 system in Brighton, Colo. Contact him at
ning a call.
defeat your airbag restraints. That your boxcar414@comcast.net.
22
JEMS
MARCH 2013

25. A REVOLUTION IN EMERGENCY CARE
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With so many advantages, it clearly puts you at an advantage.
Choose 22 at www.jems.com/rs
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26. CASE OF THE MONTH
DILEMMAS IN DAY-TO-DAY CARE
>> BY MICHAEL ORLAND, MD
FORWARD FALL
Get a handle on handlebar injuries
I
t’s 2 a.m. on a Friday night and a
medic unit responds to a call of a
“pedestrian struck.”
On arrival, city law enforcement declares
the scene to be safe and directs the unit to
the opposite shoulder of the highway. EMS
providers find a 35-year-old male lying in
the prone position with a moderately damaged mountain bike beside him.
The patient says he was riding home from
his friend’s house when he got “bumped” by
a passing car, hit a pothole and fell forward
off his bike. Although his breath indicates
recent alcohol intake, he’s able to answer
questions in a moderately slurred voice.
Initially the patient refuses medical evaluation and transport to the hospital, but the
medics are able to convince him otherwise.
The airway is intact with no debris or
blood, and breath sounds are equal bilaterally. His respiratory rate is 22 and pulse
oximetry 96% on room air.
A cervical collar is placed on the patient,
and he is log-rolled and secured onto a
backboard. The heart rate is found to
be 110 mmHg with a blood pressure of
136/92. His helmet has an abrasion to the
front but is otherwise intact.
Your trauma exam is notable for a 2x3
cm round-shaped wound to the midline epigastric region, just inferior to the
xiphoid process, with moderate non-pulsatile bleeding. You note that when the
patient exhales following a deep inspiration, there’s a small bulge in the wound
that subsequently resolves with the following inspiration. No air movement or
bubbling from the wound is detected.
The abdomen is mildly distended with
moderate diffuse tenderness and there are
multiple partial thickness abrasions to the
bilateral elbows, hands and lower extremities. Although he’s clinically intoxicated, his
Glasgow Coma Scale (GCS) is determined
to be 15.
24
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MARCH 2013
PHOTOS COURTESY EDWARD T. DICKINSON
ASSESSMENT & TREATMENT
A deep breath by the patient produces a small bulge in the ring-shaped wound, indicating traumatic
abdominal hernia.
Once in the mobile unit, you place the
patient on 4 lpm oxygen via nasal cannula and a cardiac monitor. You secure a
sterile abdominal gauze pad over the open
abdominal wound.
The total scene time is 12 minutes, and
transport time to the local trauma center
is 20 minutes. You place an 18-gauge IV
in the patient’s right antecubital fossa and
administer 500 ccs of normal saline en
route. The dressing controls the bleeding
from the abdominal wound, and there’s
no significant clinical change in the patient
during transport.
TRAUMA CENTER CARE
On arrival to the trauma center, the trauma
team repeats the primary and secondary
surveys. Vital signs arenít significantly
changed: Heart rate is 112, respiratory rate
is 18, blood pressure is 132/88, and pulse
oximetry is 100% on room air. The trauma
team also performs a focused assessment
with sonography for trauma (FAST) exam,
which demonstrates a small amount of free
fluid in the right upper quadrant, specifically Morrisonís pouch.
A FAST exam, which is regularly performed during a trauma survey, uses four
different locations to place the ultrasound
and screen for free fluid in 10 distinct potential spaces. Free fluid, often blood in the
traumatic patient, is a strong indicator of
significant abdominal or thoracic injury, and
the FAST exam allows early identification of
these patients in order to expedite surgical
intervention. Morrison’s pouch is a potential
space between the inferior aspect of the liver
and superior aspect of the right kidney. It
is recognized as the most likely location to
identify free fluid associated with a serious
intra-abdominal injury.
Given the stable vital signs, a CT scan of
the head, cervical spine, chest, abdomen
and pelvis is performed to fully evaluate
the injuries. The CT scans demonstrate

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28. CASE OF THE MONTH
>> CONTINUED FROM PAGE 24
IMAGE COURTESY EDWARD T. DICKINSON
hernia will appear as a discrete bulge on
abdominal exam that may expand and
reduce with a change in abdominal pressure or remain constant. It’s important to
recognize this clinical sign and its association with significant traumatic injuries, but
no other specific care should be performed
except for a sterile dressing application to
any open wounds. Application of manual
pressure or compression of any kind to the
mass isn’t advised because it may exacerbate other injuries.
CONCLUSION
This CT scan demonstrates a 2 cm anterior fascial defect and associated abdominal wall hernia at
the site of the open wound.
a 2 cm anterior abdominal wall hernia
at the site of the open wound, injury to
two areas of the small bowel with likely
perforation given the surrounding small
foci of free air and a grade 2 liver laceration. The patient is immediately taken to
the operating room, where he undergoes
an exploratory laporatomy with resection
of two portions of the small bowel, suture
repair of the liver laceration and primary
repair of the abdominal hernia with mesh.
His post-operative course is uneventful,
and the patient is discharged to home one
week later.
DISCUSSION
At first glance, a fall from a bicycle can
often be mistaken as a non-significant
mechanism. As is often the case with lateral falls, a low level of energy is being distributed to a large area of the body or to an
extremity. However, forward falls from a
bicycle are frequently higher energy, which
is distributed to a smaller area of the body.
More specifically, the body can be
struck in the chest or abdomen by the
handlebars or the head by the ground or
stationary object. This focused impact in
combination with increased abdominal
pressure as a result of the initial impact of
the bicycle places the patient at significant
risk of injury to the abdominal wall and
anterior abdominal organs, including the
liver, spleen, stomach, bladder, colon and
26
JEMS
MARCH 2013
small bowel. Therefore, any patient who
falls at a high rate of speed or falls forward
off of a bicycle should be considered to
have suffered a significant mechanism of
injury and treated as such.
Blunt traumatic injuries from a bicycle
handlebar are more common in the pediatric population. A two-year retrospective
chart review at a major children’s hospital
found an average age of 8.8 years for this
injury, with 79% of patients in this population being boys. Of the 14 patients who
presented for evaluation to the ED, 11 had
a ring-shaped ecchymotic area noted in the
abdomen with a variety of lacerations and
abrasions. After evaluation, it was found
that 21% had an intestinal perforation and
21% had an abdominal wall hernia, as
large as 5 cm.1 In the multiple case reports
published, traumatic abdominal wall hernias due to a handlebar injury more often
occur in the lower abdomen and appear
as a ring- or circular-shaped ecchymosis,
abrasion or open wound.
In the pediatric population, a handlebar
injury is the most common cause of a traumatic abdominal hernia and isn’t a reliable
indicator for more significant traumatic
injuries. In contrast, seatbelt trauma in a
motor vehicle collision is the more frequent mechanism for abdominal hernias
in adults and is almost always associated
with other significant injuries.2
Clinically, a traumatic abdominal wall
In this case, the ALS unit provided prompt
and efficient care for their trauma patient;
starting with airway, breathing and circulation (ABCs), and proceeding through spinal
immobilization and secondary examination. They recognized the significant mechanism and were able to persuade the patient
to receive the care he required. Large-bore IV
access was obtained, fluid resuscitation was
initiated and appropriate wound care was
provided—all while expediting transport to
a trauma facility.
In summary, falling forward onto a bicycle places a patient at risk of a handlebar
injury and should be considered a significant traumatic mechanism that may cause
serious abdominal injuries with no major
outward signs of trauma on exam. A traumatic abdominal wall hernia will appear
as an area of ecchymosis or small wound
with an underlying bulge. Although this
doesn’t require specific care, it should be
recognized as a significant injury. In adults,
it may indicate additional serious abdominal injuries. As such, these patients should
be transported expeditiously to the closest
trauma center.
Michael Orland, MD, is a resident physician in emergency medicine at the Hospital of the University of
Pennsylvania and a former EMT with the Pennington
First Aid Squad. He can be reached at Michael.Orland@
uphs.upenn.edu.
REFERENCES
1. Karaman I, Karaman A, Aslan M, et al. A hidden danger of childhood trauma: Bicycle handlebar injuries.
Surg Today. 2009;39(7):572–574
2. Haimovici L, Papafragkou S, Kessler E, et al. Handlebar hernia: Traumatic abdominal wall hernia with
multiple enterotomies. A case report and review of
the literature. J Pediatr Surg. 2007;42(3):567-569.

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30. 28
JEMS
MARCH 2013
PHOTO BY CHRIS SWABB

31. TIME FOR A CHANGE
>> BY JIM MORRISSEY, MA, EMT-P
rehospital spinal immobilization has long been
r
held as the standard of care for victims of blunt
h
or penetrating trauma who have experienced a
o
mechanism of injury (MOI) forceful enough to
m
possibly damage the spinal column. The majority
p
of EMS textbooks stress that any significant MOI, regardless of
f
b
signs and symptoms of spine injury, requires full-body immobilization, which is typically defined as a cervical collar being
applied and the patient being secured to a backboard with head
stabilizers in place.
This approach to patient immobilization has been accepted
and implemented as the standard of care for decades with little
scientific evidence justifying the practice.1–3 In addition, scant
data shows that immobilization in the field has a positive effect
on neurological outcomes in patients with blunt or penetrating
trauma.1,4–6 In fact, several studies and articles show that spine
immobilization may cause more harm than good in a select
sub-set of trauma patients.5–7
Many experts question the current practice of prehospital
spinal immobilization.1,2,4–15 There are now some guidelines,
textbooks and an increasing number of EMS agencies that support a progressive, evidence-based approach in an effort to
lessen unnecessary spinal immobilizations in the field.
It’s problematic to use MOI alone as the key indicator for
prehospital spinal immobilization. In addition, the harmful
sequelae and potential dangers of spine immobilization need
to be considered in any field protocol. We need to examine
appropriate spine injury assessment guidelines and algorithms
that allow for the selective immobilization of injured patients.
We also should review immobilization devices and techniques that are more appropriate for patients who do require
immobilization, or better termed, spinal motion restriction
(SMR), by EMS providers.
OUTDATED INDICATORS?
It typically takes several years for EMS textbooks to catch
up with new evidence and then additional time for the EMS
instructional community to modify curricula and change current practice. For example, definitions of mechanisms that
require spinal immobilization found in most EMS textbooks
are outdated and problematic. Such indicators for potential
spine injury as fall, damage to the vehicle, injury above the clavicle and mechanism of injury involving motion, are not particularly helpful when determining the best course of action
in the field.
Especially troubling has been the lack of emphasis on the
assessment of the patient before making a decision about
immobilization. Historically, more emphasis has been placed
on what happened to the vehicle or the best guess on how far
someone may have fallen, instead of what actually happened
to the person.
It isn’t the fall that causes injury; it’s the sudden stop at
the end. The more sudden the stop, the more likely an injury
results, especially if the kinetic energy was transmitted to the
head and/or neck.
The physical condition of the patient must also be considered. A young, athletic person is able to withstand more forces
than an elderly patient. So the spectrum of potential injuries is
best determined through a detailed history and physical exam.
Vehicle damage has long been considered a strong indicator
of potential spine injury, yet improvements in vehicular design
and construction should change the way we look at vehicle
damage. Vehicle technology and passenger protection is far
superior to what it has been, particularly since the 70’s when
EMS textbooks began advocating back boarding of patients in
vehicles with significant damage.
Vehicle damage zones are now inherently built into newer
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32. SPINAL IMMOBILIZATION
>> CONTINUED FROM PAGE 29
PRECAUTIONARY IMMOBILIZATION
PHOTO COURTESY JIM MORRISSEY/JOSH KENNEDY
It isn’t surprising that the term and practice
of “precautionary immobilization” has developed. It’s estimated that at least five million
patients are immobilized in the prehospital
environment in the U.S. each year. Most have
no complaints of neck or back pain or other
evidence of spine injury.3,11,12 (See Photo 2.)
EMS personnel historically have neither
been given the tools nor the authority to
make informed decisions about objectively
determining the need for prehospital spinal immobilization. This may be because
the emergency medical community thought
immobilization was always safe, conservative and always in the best interest of the
patient. However, evidence now shows that,
in some cases, spinal immobilization may
not be in the patient’s best interest.1–3,7,8,10–13
Some prehospital care providers will
admit that they often immobilize patients
without evidence of spine injury because
they want to avoid being questioned on
arrival at the emergency department (ED).
This dynamic can (and must) change with
education and outreach.
BACKBOARD-BASED IMMOBILIZATION
There are many situations (hostile environment, life threatening injuries) where spinal immobilization may be detrimental to good patient care. This training scenario emphasizes rapid extrication.
30
JEMS
MARCH 2013
victims of penetrating trauma without
neurologic deficits.20
In the setting of drowning, the 2010 evidence-based guidelines from the American
Heart Association state that “Routine c-spine
immobilization is a Class III (potentially
harmful) unless clear trauma is evident in the
history or exam, because it may unnecessarily delay or impede ventilations. ”21
PHOTO A.J. HEIGHTMAN
vehicles, designed to absorb and dissipate
the kinetic energy of a collision, and keep
the passenger cabin relatively isolated and
protected.16 An experienced paramedic once
said, “The cake box might be crumpled, but
the cake can be fine.”
Some textbooks accurately address this
issue. Even as far back as 1990, the American Academy of Orthopaedic Surgeons
addressed emergency medical responders
in an extended-care environment, stating,
“Patients with a positive mechanism of injury,
without signs and symptoms, and with a
normal pain response may be treated without full spine immobilization, if approved by
your medical control physician.” 17
Emergency medical personnel who work
in extended-care, tactical, combat and wilderness environments have long realized the
need to safely and accurately assess and clear
patients regarding spinal injuries.18,19
New guidelines from Prehospital
Trauma Life Support and the National
Association of EMS Physicians have
diminished the emphasis on immobilizing
Assessment is still the key to determining the
need for spinal immobilization.
In addition to patient discomfort and anxiety associated with backboard-based immobilization, there are several potentially
significant consequences. Standard immobilization requires the patient’s body to conform to a flat, hard surface. In addition, EMS
secures a cervical collar around the patient’s
neck and uses tape to secure the patient’s
head to the board.
This practice often increases patient
anxiety and has the potential to aggravate
underlying injuries. Standard spinal immobilization techniques can also take away the
patient’s ability to effectively protect their
own airway thus significantly increasing the
risk of aspiration.3–6,11,13
Patient vomiting, bleeding, airway drainage and swelling are common problems
associated with trauma patients. Even with
one EMS provider dedicated to the management of the airway and patient suction, it
cannot be assumed that a suction catheter
can handle the job when significant bleeding
and/or vomiting is presented.
The continued spinal stability of a patient
who is turned on their side to facilitate airway
drainage and control is also questionable.
Patients typically experience a significant

33. Choose 25 at www.jems.com/rs
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34. SPINAL IMMOBILIZATION
PHOTO COURTESY JIM MORRISEY/JOSH KENNEDY
>> CONTINUED FROM PAGE 30
Patients with penetrating trauma (ex., gunshots and stabbings) to the
head and torso usually do not benefit from spine immobilization.
shift in body weight and distribution, causing more movement to
the spine than the immobilization process was intended to prevent.
In a comprehensive review published in Prehospital and Disaster Medicine, healthy volunteers who were immobilized on a backboard were found to be “significantly more likely to complain of
pain when compared with immobilization on a vacuum mattress.”
Adverse effects of backboard-based immobilization documented in
this study include increased ventilatory effort, pain and discomfort.
In addition to pressure injury, the backboard may also be the
cause of pain—even in otherwise healthy volunteers. The resultant
posterior surface/back pain of immobilized patients has been documented to result in unnecessary radiographs and potential clinical
ambiguity regarding the cause of the pain.3,22 There’s an increased
cost associated with some of these complications.
It has been documented that supine patient immobilization
results in a 15–20% reduction in respiratory capacity, and that respiratory effectiveness is markedly reduced by the strapping systems
typically used.3,9,13 Patients are often either strapped securely, thus
having diminished respiratory capacity, or loosely secured, facilitating easier breathing. Neither scenario is ideal.
The challenge is exacerbated in obese patients, the elderly and
patients with such underlying diseases as congestive heart failure,
COPD, asthma and pneumonia.
Done properly, immobilization in the field takes time and multiple personnel. Time delay to the ED or trauma center arrival has
been cited as a significant problem for critical trauma victims. Several studies have looked at the risk vs. benefit of prehospital immobilization, with several authors and researchers questioning the
value of current practices.1,2,7,8,11,15
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JEMS
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35. Studies have also shown limited or no benefit of prehospital
immobilization of penetrating trauma patients. (See photos on
pages 32 and 33.) Unnecessary immobilization of this subset of
trauma patients can result in prolonged on-scene time and delayed
transport to definitive care, which may increase morbidity and
mortality.4–6,14,18,23–25
Several studies show that cervical collars by themselves aren’t
without risk or significant consequences.4,26–28 One study concludes
that cervical collars frequently increase intracranial pressure and
may be particularly harmful if used on head-injured patients.26
Another researcher observed that cervical collars “can result in
abnormal distraction within the upper cervical spine in the presence of severe injury.”28 In addition, cervical collars hide areas of
the head and neck, resulting in the increased possibility of missing
injuries or evolving problems, such as swelling, hematoma and
tracheal deviation.27,28
In addition, the longer a patient is immobilized, the more likely
that cutaneous pressure ulcers will develop, most notably in the
occipital, sacral or heel areas.9,12,22,29,30 This is especially true in elderly,
unconscious and neurologically impaired patients. This problem
may be significantly reduced with padding or use of a vacuum
mattress. Unfortunately, the vast majority of the patients who are
immobilized don’t get padding in voids or areas of significant body
weight/pressure or a vacuum mattress that distributes beads/padding in voids and uneven body surface areas.
THE PENETRATING TRAUMA PATIENT
As referenced earlier, there is a growing body of evidence that suggests penetrating trauma victims shouldn’t be routinely immobilized. Immobilization has been associated with higher mortality in
patients with penetrating trauma.4–6,14,23–25
Independent studies show that whether the penetrating trauma is
to the head, neck or torso, immobilization is unnecessary, interferes
BEGIN THE CHALLENGE AT:
PHOTO COURTESY JIM MORRISSEY/JOSH KENNEDY
heart.org/acls-ep
Tactical teams often use compact, flexible extraction devices.
Choose 28 at www.jems.com/rs
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33

36. SPINAL IMMOBILIZATION
>> CONTINUED FROM PAGE 33
with and delays emergent care, and should be seriously reconsidered
as the standard of care.4–6,14,23
A Journal of Trauma article concluded, “Indirect spinal injury
does not occur in patients with gunshot wounds to the head.” The
authors state, “Protocols mandating cervical spine immobilization
after a gunshot wound to the head are unnecessary and may complicate airway management.”14
Another retrospective study showed similar concerns about the
use of a cervical collar with patients who have penetrating injuries
to the neck. This study suggests that avoiding the collar should be
the rule, and that a provider who chooses to apply a cervical collar
should have good justification. The authors also suggest that frequent examination of the underlying structures and tissue is warranted if a cervical collar is used.4
A comprehensive retrospective analysis of gunshot injuries to
the torso found that immobilization was of little or no benefit, even
if an unstable spine fracture was present. The authors argue that airway management, including intubation, is far more complicated
and problematic with prehospital spinal immobilization in place.5,6
In fact, failed airway management was reported to be the secondleading error preceding death of trauma patients, accounting for
16% of mortality in one study. This study also highlights the potential delay to definitive surgical treatment and the lack of neurologic
improvement after gunshot injury to the spinal cord, suggesting
that prehospital spinal immobilization is unjustified.5,6
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JEMS
MARCH 2013
For many trauma patients, a vetted field assessment criterion that
focuses on the assessment of the patient rather than the mechanism of injury would obviate unwarranted immobilization.3,11,31
Many emergency medicine specialists believe an accurate, reliable, simple-to-perform spinal injury assessment could reduce spine
immobilizations drastically. Thankfully, there is a trend in this direction across the nation.
The idea of “clearing” a patient of spinal injury in the field has
been, and continues to be debated. However, there are prehospital
spine assessment protocols that safely and accurately allow EMTs
and paramedics to omit prehospital spinal immobilization in certain patients.
Some EMS experts prefer the term “selective immobilization” to “clearing” the c-spine, but the end result is the same.
The end result is the reduction of the incidence of unwarranted
spinal immobilizations.
For example, the Maine spine injury assessment guidelines,
developed by Peter Goth, MD, in the 1990s, have been shown
to be accurate and safe.10,31,32 Several states and EMS systems
around the nation use this, or a similar protocol, to help decrease
the number of trauma patients being subjected to prehospital
spinal immobilization.
The origin of this type of spinal assessment was initially intended
to help ED physicians clinically decide if they can safely clear
patients from prehospital spinal immobilization and reduce or eliminate unnecessary radiographic studies. It has been shown that the
proper clinical exam and history is more accurate at predicting spine
injuries than X-ray review.10,32–35
The spine injury assessment guidelines that have been adopted

37. PHOTO COURTESY JIM MORRISEY/JOSH KENNEDY
by multiple prehospital systems are based on the Canadian C-spine
rule and the National Emergency X-Radiography Utilization Study
(NEXUS) low-risk criteria. Each has similar parameters, requiring
that the patient be awake, alert, conversant and without significant
distracting injury or intoxication.
In addition, the guidelines further state that the physical exam
should reveal no pain or tenderness to the posterior neck and back
and the neurologic exam must find normal motor and sensory function in the extremities.10,18,31,33–35
Studies show that prehospital care providers can safely apply
spine injury assessment criteria and not miss any clinically
significant spine injuries.10,31,32 Although these guidelines are
PHOTO CHRIS SWABB
Some patients, such as pediatric patients, require special spinal immobilization consideration.
Children have been immobilized acceptably in specialized spinal devices
for decades.
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38. SPINAL IMMOBILIZATION
Patients can be immobilized safely and comfortably via a combination of a backboard or other flexible or
scoop-type stretcher, such as shown here with a Hartwell Combi-Carrier/vacuum mattress combination.
However, long-established norms are
hard to break, and extensive training was
required to make this new policy successful. EMS schools, fire departments and other
EMS providers, as well as emergency department staff, needed to be exposed to the literature and trained in the new protocol.
Initial training and outreach has been
well received and the early indicators have
shown a significant reduction in spine
immobilizations. The end result is:
>> A better understanding of the need
for expeditious care under specific circumstances, in particular, the need
to move rapidly when penetrating
trauma is present;
>> All involved are empowered to break
the paradigm of “board them all” as
a result of understanding the importance of proper spinal/neurological
assessment and assessment parameters that allow crews to assess for serious spinal indications and perform
selective immobilization. We did the
same process decades ago when we
adopted rapid removal techniques for
36
JEMS
MARCH 2013
PHOTO A.J. HEIGHTMAN
A vacuum splint can be used as a highly moldable
and comfortable cervical immobilization device.
of patients. Many of these devices are
better suited to patient movement in
tight spaces and crew body mechanics when carrying and transferring
patients down stairways and other difficult environments.
Of course, crews have to take special
caution when dealing with and managing high-risk patients, including pediatric
patients, the elderly and those with such
degenerative bone disorders as osteoporosis. Field personnel need to be conservative while evaluating these patients and
should provide spinal motion restriction
when in doubt.33,34
UNCONVENTIONAL OPTIONS
Even with appropriate application of spine
injury assessment guidelines, some patients
still require some degree of prehospital spinal
motion restriction. Vacuum mattresses and
other break-away and flexible stretchers have
been used successfully throughout Europe
for years. They score well in several critical areas, including patient comfort, secure
immobilization, insulation, lack of pressure
PHOTO A.J. HEIGHTMAN
patients in lieu of spending precious
minutes placing splints and half backboards on critical patients. Little or no
untoward results occurred with that
change in procedure;
>> More attention to patient comfort and
pain instead of routine placement of
trauma patients on a hard, uncomfortable platform that often put them in
anatomically-incorrect positions for
extended time periods, made patients
unnecessarily claustrophobic lying
supine and immobile and exacerbation of respiratory distress in patients
due to the supine position, strap placement, and existing conditions such as
CHF, COPD or morbid obesity; and
>> The ability to deploy and maximize
the usage of alternative immobilization and transfer devices and stretchers such as vacuum mattresses, scoop
or CombiCarriers and flexible stretchers such as Ferno and SKED stretchers
and others that feature lateral patient
support slats and multiple handles for
convenient movement and transfer
PHOTO A.J. HEIGHTMAN
available, training and practice is needed to
become proficient at using these criteria.
Alameda County (Calif.) EMS has revised
its spine injury assessment protocol to
accurately reflect the current literature and
research. (See Figure 1, p. 38). Its goals in
2012 were to reduce unnecessary immobilization, and use treatment modalities in the
best interest of and provide the most comfort
to the patient. In some cases, this meant forgoing prehospital spinal immobilization to
expedite transport to a trauma center.
PHOTO ED DOERR
>> CONTINUED FROM PAGE 35
This patient is securely immobilized in a FERNO
Germa Easyfix vacumm mattress – stretcher.
Vacuum mattresses and stretchers pad voids
and distribute a patient’s weight evenly.

39. Choose 31 at www.jems.com/rs
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40. SPINAL IMMOBILIZATION
>> CONTINUED FROM PAGE 36
Figure 1: Alameda County (Calif.) 2012 Spinal Immobilization Procedure
POTENTIAL FOR
UNSTABLE SPINAL
INJURY?
YES
> Age > 65
> Meet Trauma Patient Criteria
for Mechanism of Injury (Section 3)
> Axial load to the head (e.g. diving injury)
> Numbness or tingling in extremities
If any one of the high-risk factors
above are present, strongly consider spinal
motion restriction (SMR).
A reliable patient is cooperative, sober and alert
without:
Significant Distracting Injuries
Language Barrier
YES
RELIABLE PATIENT?
NORMAL SPINE EXAM?
NORMAL MOTOR/SENSORY?
OMIT SMR
NO
Low-risk factors:
> Simple rear-end MVC
> Ambulatory at any time on scene
> No neck pain at scene
> Absence of midline cervical spine
tenderness
The low-risk factors above allow safe
omission of SMR.
sore development and, in the case of some
vacuum device configurations, allow crews
to utilize them without a cervical collar.12,29,30
When considering adding vacuum mattresses, vacuum stretchers or other immobilization devices to your arsenal, keep in mind
that they don’t require more effort or training
than using backboards. Vacuum mattresses
can also effectively pad voids, distribute
weight evenly and immobilize patients on
their side because the device can be “molded”
around the patient to best package them
safely. (See photos on page 36.)
However, keep in mind that backboards
38
JEMS
MARCH 2013
POSSIBLE SPINE
INJURY
APPLY SMR
SPINAL PAIN/TENDERNESS
Palpate vertebral column
thoroughly
MOTOR/SENSORY EXAM
Wrist or finger extension (both
hands)
Plantarflexion (both feet)
Dorsiflexion (both feet)
Check gross sensation in all
extremities
Check for abnormal sensations to
extremities (e.g. parathesias)
To obtain a copy of the complete
Alameda County Spinal Injury Assessment Procedure,
go to the web version of this article at jems.com/journal
still have a place, especially to restrain or
slide a patient out of an extrication mess.
There is also nothing that precludes you
from utilizing a combination of devices such
as a backboard or scoop-type stretcher to
remove a patient and transfer them to a
more moldable or comfortable secure surface such as a vacuum mattresses. Many
systems use this combination or deploy vacuum mattresses in conjunction with flexible
stretchers. (See photo, top of page 36.)
Another emerging school of thought
questions the need for traditional prehospital spinal immobilization at all—even for
patients who have positive evidence of a
spinal column or spinal cord injury. One
group of researchers who compared various extrication tools and methods found
that allowing a patient to self-extricate from
a vehicle with a cervical collar alone caused
less movement of the spine than the use of
cervical collar, KED extrication device and
standard extrication techniques.36 This triggers a series of questions that are beyond
the scope of this article. Groups such as the
National Association of EMS Physicians and
the U.S. Metropolitan Municipalities Medical
Directors and Global Affiliates Consortium