Robert Vroman, M.Ed., BS NREMT-P

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AHA CPR guidelines: Get in step with the 2015 updates

An in-depth analysis of the research based updates for the treatment of out of hospital cardiac arrest

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EMS1 Topic Articles

Air ambulance companies under scrutiny for excessive costs

Despite their lifesaving capabilities, Montana lawmakers might regulate air medical services

AHA CPR guidelines: Get in step with the 2015 updates

An in-depth analysis of the research based updates for the treatment of out of hospital cardiac arrest

Shooting victim calls Uber for ride home

The 20-year-old man refused to go to the hospital and insisted the Uber driver bring him home instead

Deputies rescue newborn found buried alive

Deputies found the girl after people on a bike path heard her cries and called authorities

Suspected burglar dies in chimney after resident lights fire

The 19-year-old man died of smoke inhalation and burns

3-D video simulates severe bleeding for combat medics' training

Fluid dynamics principles used to calculate and model highly realistic anatomy and bleeding from a shrapnel wound

35 injured after Virginia bus overturns

The bus was transporting college students to three Virginia campuses

Man takes ambulance for joy ride, strands patient and EMTs

The patient, who was in respiratory distress, was transported to a hospital after another ambulance was called

Pa. paramedic/firefighter dies in off-duty car crash

Scott Jones, 33, died after a two-car crash sent both vehicles off the roadway and down an embankment

How capnography can be used to identify sepsis

Quantitative waveform capnography can be a reliable surrogate for lactate monitoring in detecting metabolic distress in sepsis patients

EMS1 Columnist Articles

AHA CPR guidelines: Get in step with the 2015 updates

In October of 2015, the American Heart Association released the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) . This publication represents the most current recommendations for improving survival from cardiac arrest. In many cases, the AHA did not significantly change previous recommendations but simply clarified meanings. However, in other cases, the AHA made recommendations that did not previously exist.

Chain of Survival: Affirmed yet revised
The AHA continues to recognize the relevancy of the Chain of Survival; however, it recognizes the important differences between responding to a cardiac arrest in the out-of-hospital (OOH) environment and responding to an arrest that occurs inside the hospital. The role of the lay rescuer is significantly more important in the OOH setting where, ideally the patient receives CPR and defibrillation before the EMS team arrives on the scene. Without those early interventions, the chances of survival decrease.

Although early CPR and defibrillation still have value for cardiac arrest occurring in the in-hospital setting, those initial responders are often health care providers with some degree of professional training. In many of these cases, patients display clear warning signs of impending cardiac arrest. Prompt recognition of those warning signs and appropriate intervention could possibly prevent the cardiac arrest from occurring in the first place.

Multiple studies since the release of the 2010 AHA Guidelines demonstrate a decrease in the incidence of in-hospital cardiac arrest when hospitals implemented a system of medical emergency team (MET) responses to patients with signs of impending cardiac arrest [1-10]. Thus, the 2015 recommendation is for hospitals to implement MET responses based on early warning signs.

In the OOH environment, the emergency medical dispatcher (EMD) plays a key role in the chain of survival once the bystander accesses the EMS system. The AHA states that after identification of an unconscious adult patient with abnormal or absent breathing, it is reasonable for the EMD to assume the patient is in cardiac arrest. The recommendation is for the EMD to provide compression-only instruction until EMS arrival.

Resuscitation: A concerted effort
Most of the sequential assessments and actions for CPR remain unchanged from the 2010 recommendations. Although one of the limitations of any patient care algorithm is the linear presentation of the steps, the AHA acknowledges that EMS responses rarely involve a single person. A team of responders can therefore accomplish multiple tasks simultaneously.

Approach the victim cautiously, making sure the scene is safe before proceeding. Upon contact with the victim, verify unresponsiveness and send someone to get an AED or manual defibrillator. Determine whether the patient is breathing normally. Unresponsive patients who are not breathing normally have a high likelihood of being in cardiac arrest [11-19].

Do not confuse gasping with normal breathing. Gasping occurs frequently in patients who develop sudden cardiac arrest, but rapidly disappears as time progresses. In one study, EMS responders witnessed gasping in about 20 percent of patients when the EMS response time was less than seven minutes [20]. However, when the EMS response time was greater than nine minutes, only 7 percent of the patients were still gasping. Gasping is associated with increased survival to discharge rates [21].

Simultaneously during the breathing assessment, check the patient's carotid artery to verify pulselessness. Because health care providers often have difficulty determining whether a pulse is present [22-28], withhold chest compressions only when absolutely sure the pulse is present. In many instances, health care providers also take too long to make a decision [22,25]. Do not spend more than 10 seconds checking for a pulse. If the pulse is absent or you are unsure if the pulse is present, begin chest compressions.

Chest compression recommendations
The original recommendation for where to place the hands when performing chest compressions comes from canine studies extrapolated to humans [29]. Over the years, recommendations for hand positioning when performing chest compressions have migrated from two fingers above the tip of the xiphoid process to the lower half of the breastbone. Two studies since the 2010 AHA Guidelines failed to identify an optimal alternative hand placement position for closed chest massage in adults [30,31]. Therefore, the 2015 Guidelines do not change hand placement recommendations made in 2010.

The original recommendation for chest compression depth in the average adult called for the rescuer to push the sternum to a depth of 3 or 4 centimeters (about 1.0 - 1.5 inches) towards the vertebral column [29]. Since that original recommendation, researchers have searched for the optimal chest compression depth. In the 2010, the AHA recommended a chest compression depth greater than previously recommended [32]. Although more recent evidence does not contradict this statement [33-36], there is some evidence to suggest that compression depths greater than 2.4 inches may result in an increase in patient injuries [37].

In response the AHA now recommends that health care providers compress the chest to a depth of at least two inches, but no deeper than 2.4 inches. In order to hit this narrow target, the AHA recommends the use of audiovisual feedback devices that allow real time corrections to poor compression technique.

After compressing to the proper depth, the AHA recommends health care providers allow full recoil of the chest before delivering the next compression (32). Animal studies suggest that incomplete recoil, also known as rescuer leaning, can negatively impact cerebral and coronary perfusion [38-41]. Other studies suggest leaning is common among health care providers [42-45]. So, despite the lack of conclusive evidence associating leaning with worsened clinical outcomes, the AHA recommends health care providers avoid leaning on the patient's chest while performing chest compressions.

One important determinate of Return of Spontaneous Circulation (ROSC) and neurologically intact survival is the actual number of chest compressions health care providers deliver to the patient during each minute of the resuscitation period [46,47]. An in-hospital study demonstrated improved outcomes with the delivery of 80 chest compressions per minute (46) and an out-of-hospital observational study found improved outcomes when EMS personnel delivered 68-89 compressions per minute (47). To compensate for the compression interruptions that occur with defibrillation attempts, ventilation, or to switch chest compressors, the 2010 Guidelines recommended a chest compression rate of at least 100 compressions per minute [32].

Although this recommendation clarifies the minimum number chest compressions per minute, the recommendation did not indicate a maximum number of compressions beyond which survival outcomes could be negatively affected. Since 2010, two studies suggest the optimal chest compression rate likely lies between 100 and 120 chest compressions per minute [48,49]. This forms the bases for the 2015 recommendation.

The 2015 Guidelines also includes a recommendation to continue to provide 30 chest compressions followed immediately by two ventilations. This recommendation remains unchanged from the 2010 Guidelines and is based on consensus opinion rather than definitive evidence [32].

All about the beat
A caveat to the standard 30:2 compression ventilation ratio is that rescuers must minimize interruptions in chest compressions. This is true for both the potentially therapeutic pauses that accompany ventilation and defibrillation, and the non-therapeutic pauses, such as moving the patient to the ambulance. To illustrate the importance of minimizing interruptions, the AHA defined a new metric, chest compression fraction (CCF), that did not exist in 2010.

The CCF represents the proportion of time during the resuscitation attempt that someone is actually pushing on the patient's chest [47]. Minimizing interruptions in chest compressions allows rescuers to spend more time compressing the sternum, which results in higher CCF. Higher CCF increases the likelihood of survival [47,50]. Although an expert panel consensus found a CCF of 80 percent achievable [51], the 2015 recommendation calls for rescue teams to achieve a CCF of at least 60 percent.

An alternative to the standard 30:2 compression/ventilation ratio gaining traction in the out-of-hospital environment is a continuous chest compression model, either with active asynchronous ventilation delivered without interrupting compressions or with passive ventilation in the early stages of the resuscitation attempt.

Ventilation recommendations
The 2010 Guidelines recommended asynchronous ventilation with continuous chest compression, but only after the insertion of an advanced airway [32]. A newborn manikin model of cardiac arrest demonstrated higher minute ventilation when breaths were delivered asynchronously via bag-mask with continuous chest compressions compared to coordinated ventilations and compressions [52].

Animal studies of asynchronous ventilation during continuous chest compression could find no difference in outcome compared to standard CPR [53,54]. A recent large cluster-randomized trial with crossover involving more than 23,700 patients suffering OOH cardiac arrest could find no survival advantages associated with continuous chest compressions and asynchronous ventilation compared to standard CPR [55].

In the passive ventilation approach, EMS providers generally deliver three cycles of 200 continuous chest compressions with a rhythm analysis and defibrillation attempt after every two hundred compressions and ventilation occurs passively through elastic recoil of the patient's chest [56-60]. In many of the agencies, rescuers maintain airway patency with an oropharyngeal airway and then place an oxygen mask over the patient's face to allow passive oxygen delivery [56]. Despite the fact that some suggest that passive ventilation created by compression only CPR cannot generate tidal volumes adequate for effective gas exchange [61,62], the 2015 Guidelines considers continuous chest compression with delayed ventilation to be a reasonable approach to the early management of a witnessed OOH arrest with a presenting rhythm of ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT).

In the first published report on the use of passive oxygen insufflation in the management of OOH cardiac arrest, researchers found lower arterial carbon dioxide partial pressures and higher pH and partial pressure of arterial oxygen in the passively ventilated patients compared to the patients receiving traditional ventilation [63]. Subsequently, in a larger study of OOH cardiac arrest, researchers could not find a difference in ROSC, survival to hospital admission, or survival to ICU discharge rate between patients passively oxygenated and those receiving conventional oxygenation and ventilation techniques [64].

However, in both of these studies, passive insufflation occurred through specially modified endotracheal tubes thereby limiting generalization of the results to passive insufflation through an oxygen mask. A retrospective analysis of a statewide OOH cardiac arrest database found that passive ventilation using an OPA and an oxygen mask improved neurologically intact survival after witnessed VF/pVT when compared to bag-valve-mask ventilation [57]. For unwitnessed VF/pVT and non-shockable rhythms, survival was similar. Until more clinical data is available, the AHA does not recommend the routine use of passive ventilation during conventional CPR.

Defibrillation recommendations
Another strategy common in the EMS environment is to deliver a period of CPR, typically 1.5 – 3 minutes, before administering a defibrillation attempt. This approach is colloquially known as priming the pump. Twelve studies of varying complexity have failed to show any outcome advantages offered by up to 180 seconds of chest compressions before delivery of the first defibrillation attempt [65-76]. For patients being monitored, defibrillate as quickly as possible after the patient develops VF/pVT. For patients in cardiac arrest who are not being monitored, perform CPR while someone retrieves the defibrillator and applies the pads. As soon as the defibrillator is ready, deliver a shock and resume CPR beginning with chest compressions.

Naloxone administration recommendations
In 2014, the U. S. Food and Drug Administration approved for sale a naloxone autoinjector for use by the general public [77]. Almost immediately, the AHA Training Network asked for guidance on how to incorporate this device into current training programs. The International Liaison Committee on Resuscitation (ILCOR) attempted to review research relevant to the question of whether naloxone administration to patients suspected of having opioid toxicity in addition to CPR provided any survival benefits compared to standard CPR alone but could not find any [78].

Despite the lack of evidence, the consensus opinion was that it is reasonable for appropriately trained health care providers to administer intramuscular or intranasal naloxone to patients who are not breathing normally and are suspected of overdosing on opioids. For patients in cardiac arrest with a known or suspected opioid overdose, health care providers can consider administering naloxone, but only after initiating CPR.

Oxygen – how much"
Over the past few years, researchers and clinicians began questioning the value of administering high-concentration oxygen to patients who suffer cardiac arrest, especially once the patient achieves ROSC. An observational OOH cardiac arrest study utilizing high-concentration oxygen administration during the resuscitation period found that increases in PaO2 levels correlated with increased rate of survival to hospital admission with a non-significant trend toward improved neurological outcome [79]. On the other hand, several studies have demonstrated increased mortality and poor neurologic status associated with higher levels of the maximum measured PaO2 during the post-resuscitation period [80-83]. Other studies have been unable to demonstrate this harm [84-88].

Thus, the AHA recommends that EMS providers deliver high-concentration oxygen via bag-mask during the resuscitation attempt when CPR is in progress. However, once the patient achieves ROSC and the health care team can reliably measure oxyhemoglobin saturation, the AHA states it is reasonable to titrate oxygen delivery to achieve a saturation value of at least 94 percent.

Advanced airway recommendations
At the advanced level, one issue that remains controversial is whether EMS personnel should insert an advanced airway during the resuscitation attempt. Although many studies demonstrate worsened outcomes with ventilation through an advanced airway compared to bag-mask ventilation [89-95], the results of these studies may actually demonstrate the effects of other variables rather than the type of airway used. For example, patients who do not respond to CPR and the initial defibrillation attempt likely have more profound metabolic derangements than those who respond early. The AHA recommends EMS personnel provide oxygenation and ventilation with either a bag mask or with an advanced airway. The decision on what specific advanced airway (endotracheal or supraglottic) should be based on the training and skill level of the responders. There are no recommendations on the optimal timing for the insertion.

Vasopressor use during cardiac arrest
Another controversial subject is whether the administration of vasopressors during the resuscitation attempt offers any survival advantages for the patient. Since 2010, one randomized control trial (RCT) [96] and one large observational trial [97] found patients who received epinephrine were more likely to achieve ROSC in the field compared to patients who did not received epinephrine. However, the RCT study was stopped early and was therefore unable to evaluate whether epinephrine provided any long-term survival advantages. The observational trial found that epinephrine administration was associated with a decreased chance of survival to one-month after discharge with good functional outcome.

Another observational trial could not demonstrate any improvements in ROSC, survival to hospital admission, survival to hospital discharge, or good neurological recovery [98].

The only study to compare exclusive vasopressin administration to exclusive epinephrine administration could find no differences in the rates of ROSC, 24-hour survival or survival to hospital discharge between the two groups [99].

Another study randomized patients to receive either vasopressin to epinephrine [100]. If the patients did not respond to the initial drug, all patients received epinephrine from that point forward. Adding vasopressin to the standard management of cardiac arrest did not improve survival to hospital discharge rates.

As a result, the AHA continues to recommend epinephrine as the vasopressor of choice for the management of cardiac arrest. The AHA has removed vasopressin from the cardiac arrest algorithm.

When to administer epinephrine"
Now that the AHA has simplified the cardiac arrest algorithm by removing one of the vasopressors, one should consider the issue of timing. The 2010 Guidelines recommended vasopressor administration after the second defibrillation attempt for shock-refractory rhythms. Without any new evidence to support a change, the AHA continues to recommend that strategy for shockable rhythms.

However, the recommendation for when to administer the first dose of epinephrine in non-shockable rhythms is different. Three studies suggest improved outcomes with earlier (rather than later or not at all) administration of epinephrine (101-103). Thus, after initiating CPR, it is reasonable for EMS providers to administer epinephrine as early as possible when patients are in a non-shockable rhythm.

Antiarrhythmic recommendations
The other group of medications routinely administered during a resuscitation attempt is the antiarrhythmics. Two trials demonstrated that amiodarone provided short-term survival advantages compared to lidocaine in patients who suffered an OOH cardiac arrest and presented in Vf/pVT [104-105]. Amiodarone continues to be the recommended first-line antiarrhythmic agent in shock refractory cardiac arrest rhythms. Lidocaine remains an acceptable alternative. For patients with hypomagnesemia or torsades do pointes, the AHA recommends substituting magnesium sulfate for amiodarone.

Corticosteroid use in cardiac arrest
It is worth mentioning a recommendation that applies exclusively to the in-hospital environment. An animal study demonstrated that corticosteroid administration reverses the vasopressin hyporesponsiveness often seen in septic shock [106]. In vitro studies of human arteries found that corticosteroid administration inhibits the endotoxin-mediated contractile depression response to norepinephrine during septic shock [107]. Other researchers have demonstrated that cardiac arrest produces a sepsis-like syndrome during the post-resuscitation period [108] leading to speculation that corticosteroids may enhance the cardiovascular effects of epinephrine and result in higher survival rates following cardiac arrest [109].

A small RCT of OOH cardiac arrest could not demonstrate any survival advantages associated with corticosteroid administration [110]. In a small prospective, non-randomized trial, patients arriving in the emergency department with CPR in progress received either a corticosteroid during the resuscitation attempt or an injection of plain saline [111]. Patients who received the corticosteroid had significantly higher ROSC rates compared to those who received the plain saline. Moreover, if the corticosteroid was administered within six minutes of the patient's arrival in the emergency department, the difference in ROSC rates was even more striking. However, there was no difference in survival to hospital discharge or 1- and 7-day survival rates between the two groups. The exact role of steroids in the management of OOH cardiac arrest remains unclear.

However, for patients who develop cardiac arrest as an in-patient in the hospital, two RCTs found improved survival to hospital discharge associated with the administration of a combination of vasopressin, epinephrine, and methylprednisolone administered after achieving ROSC if the patient developed shock [112,113]. Although the AHA does not recommend this drug combination for OOH resuscitation, hospital personnel may consider administering the drugs.

Managing hypotension
EMS personnel should continue to place a high priority on identifying and correcting hypotension (defined as a systolic blood pressure less than 90 mm Hg or a mean arterial pressure (MAP) less than 65 mm Hg) during the post cardiac arrest phase. During the period, if the rescue team can reliably measure oxyhemoglobin saturation, the team can begin titrating oxygen administration to achieve a saturation value of at least 94 percent.

The use of antiarrhythmic infusions
For patients who achieve ROSC after presenting in a shockable rhythm, many EMS providers administer an antiarrhythmic infusion in an effort to prevent the patient from re-arresting. The 2010 Guidelines acknowledged that although patients could receive antiarrhythmics during this time, there was no evidence to support or refute the continued use of any prophylactic antiarrhythmic agent during the post-resuscitation period [114].

For the 2015 Guidelines, the AHA reexamined this issue. One prehospital observational study of OOH cardiac arrest patients found conflicting results [115]. Using one method of data analysis found an association between prophylactic lidocaine administration during the post cardiac arrest period and reduced odds of re-arrest from either VF/pVT or non-shockable rhythms, improved survival to hospital admission rates, and improved survival to hospital discharge rates. A second method of data analysis could only demonstrate a reduction in re-arrest from VF/pVT following lidocaine administration. Therefore, the AHA changed the previous recommendation to state that health care providers can consider administering lidocaine once the patient achieves ROSC following VF/pVT.

Beta blocker use after ROSC"
The AHA also looked at another class of antiarrhythmic medications not commonly used for cardiac arrest in the OOH environment. An observational study of in-hospital cardiac arrest found that either oral or intravenous administration of beta-blocking agents within the first 72 hours of the post resuscitation period was associated with survival to hospital discharge [116]. The AHA now recommends that hospital personnel consider administering either oral or intravenous beta-blockers within 72 hours of admission following cardiac arrest due to VF/pVT. This recommendation does not extend to the OOH environment.

Targeted Temperature Management – how cold"
The AHA made several modifications to the existing recommendations concerning targeted temperature management (TTM). In 2010, the strength of recommendation for initiating therapeutic hypothermia varied depending on cardiac arrest rhythm and location of the arrest [114]. The current guidelines upgrade the strength of the recommendation for TTM to the highest level for all comatose patients who achieve ROSC regardless of the presenting rhythm or whether the arrest occurred in the OOH or hospital environment.

The previous guidelines recommended that health care providers achieve a temperature of 32 C to 34 C. Since publication of those guidelines, one RCT compared the outcomes between patients cooled to 33 C and those cooled to 36 C [117]. There was no difference in mortality or neurologic function between the two groups suggesting that cooler temperatures conferred no outcome advantages. As a result, the AHA expanded the target range for hypothermia to temperature of 32 C to 36 C.

The AHA no longer recommends the prehospital use of chilled saline as a method of inducing hypothermia. Five RCTs using chilled IV fluids following ROSC [118-122], one trial using chilled IV fluids during the resuscitation attempt [123], and one trial using intra-nasal cooling [124] could find no survival or neurological recovery benefits offered by prehospital cooling. In one of the chilled saline trials, initiating cooling in the field actually increased the risk of re-arrest and post resuscitation pulmonary edema [122].

Destination criteria for post cardiac arrest"
The AHA attempted to answer the question of whether transport to a facility that specializes in the care of a patient who has suffered an OOH cardiac arrest improves the outcome. Although the data is limited, there is one prospective study that indirectly addressed the question [125]. Researchers found that transport to a critical care facility improved neurologically favorable one-month mortality compared to transport to a non-critical care facility, even when the patient did not achieve ROSC in the field. Thus the AHA recommends that EMS agencies collaborate with key stakeholders in the community and approach the problem of OOH cardiac arrest from a system perspective rather than from an individual agency standpoint. Part of this approach is the consideration of transport to specialized cardiac arrest hospitals.

Termination of resuscitation by EMS providers
The AHA recommends EMS personnel consider terminating the resuscitation efforts when the team is unable to achieve an ETCO2 reading greater than 10 mm Hg 20 minutes after intubation. However the AHA does not recommend using ETCO2 readings as the sole criterion for making that decision. Additionally, the AHA advises against using any ETCO2 value as a criterion for making a decision to terminate resuscitation in non-intubated patients.

Expect continuous updates to the guidelines
Overall, changes in the 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care are relatively minor. The publication represents the culmination of years of work by the most respected resuscitation researchers in the world. This publication also marks the beginning of a new era in resuscitation guidelines as the American Heart Association transitions away from a five-year periodic update to a web-based format that will allow continuous updates. This should help minimize the inconsistencies that sometimes occur when EMS Medical Directors update system protocols and treatment guidelines with new science between the five-year official updates made by the American Heart Association.


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Medic student's revolt with his co-workers against an abusive boss led to 30-year career in emergency medicine

Medics carrying firearms has been hotly debated by EMS professionals for the last couple of years, but it’s old news to Ed Gilbertson, Program Director of Community Paramedicine for Little Rock’s Metropolitan EMS system (MEMS).

"People I rode with 30 years ago carried guns, but it wasn’t because of the patients or the neighborhood," says the 53-year-old RN and former paramedic. "It was because of their boss."

Fear and loathing in Little Rock
Gilbertson is referring to the owner of now-defunct Medic-Vac Ambulance, a man we’ll call Bud. When Gilbertson went to work for Bud as an EMT in 1983, Medic-Vac was the only EMS agency in Arkansas’s capital.

"We served Little Rock and surrounding areas — maybe 200,000 people," Gilbertson recalls. "This was back in the day when you had a dispatcher sitting at a desk with one radio and one telephone line."

Gilbertson says Bud had a contentious relationship with city administrators.

"He didn’t care much for rules and regulations. He figured he had some leverage because he ran the only game in town. If he got angry with the city, he’d remove all the ALS items from the trucks and drop to a BLS level. Our medics used to carry their own equipment for those situations."

Such initiative had to be kept secret from Bud, though.

"He was known to get physical with his employees if they displeased him," Gilbertson says. "He threw one of our guys through a plate glass window. Everyone hated working for him, but if you wanted to be a paramedic in Little Rock, that’s what you had to do."

Just before Memorial Day in 1984, Medic-Vac responded to a three-wheeler wreck in a remote part of their district. The teenage victim had life-threatening injuries and was in shock.

"The paramedics on that call — two of the finest, smartest people I worked with — figured the kid wouldn’t make it by ground to a hospital, so they called our dispatcher and asked him to launch the helicopter.

That cost Medic-Vac a transport. Bud was furious.

"He came down to the office that night, beat up the dispatcher and fired the two medics for taking money out of his pocket."

Time for a change
When the night shift reported, some coworkers wanted to quit. They didn’t want a confrontation with a man many considered psychotic. "Bud could have easily replaced those people, then continued doing business as usual," says Gilbertson.

He and his partner, a paramedic named Kevin McCoy, decided to intervene.

"We convinced almost everyone to quit at the same time," says Gilbertson. "We wanted to shut Bud down, then help the city take over and fix this. Meanwhile, we’d work for free to keep EMS up and running."

Gilbertson and McCoy drafted a petition-like letter of resignation that 21 of 24 workers signed the next day. As of May 25, 1984 at 10:00 a.m., Medic-Vac was down to three employees: the boss, his assistant and the assistant’s brother.

Medic-Vac lasted two more days. By then Little Rock, its hospitals, neighboring EMS squads and even the American Red Cross had loaned people, vehicles and supplies to an interim agency that would become MEMS. McCoy was considered the best candidate to take charge, but family obligations made that impossible. Gilbertson was appointed chief of operations instead — a lot of responsibility for a 22-year-old still in paramedic school.

"So here I was," Gilbertson says, "this kid with one year of EMS experience in some ragtag service suddenly charged with buying ambulances, sourcing equipment, and developing policy.

"I guess you could say I had a very steep, very quick learning curve."

From paramedic to problem solver
Gilbertson somehow managed to finish his paramedic training while running MEMS, then stepped away from his management role several months later to return to the field. All along he had a very different career path in mind.

"I wanted to be a nurse anesthetist," the Chicago native says. "I’d talked with the anesthetists quite a bit when I was practicing intubations during medic rotations. I figured I’d get my BSN, get experience in critical care, then go back to school."

By 1993, Gilbertson had achieved two thirds of those objectives. He was working as an RN at Little Rock’s old Southwest Hospital when he was asked to serve as assistant director of that facility’s problematic emergency department.

"The director was focused pretty much on her other responsibilities in the ICU, so I had free reign over the ER," Gilbertson says.

"Thanks to some really good folks working for me, we turned that place around. Then I was hired by another hospital to do the same kind of work in their ER.

"I guess I got pretty good at managing and fixing broken departments."

From 2000 through 2014, Gilbertson accepted a variety of EMS troubleshooting assignments lasting anywhere from six months to two years. His paramedic certification became a casualty of that lifestyle.

"As much as I loved being a medic, it wasn’t how I was paying the mortgage anymore," Gilbertson says. "I just didn’t make the effort to get recertified."

That didn’t stop MEMS from inviting him back last January to run their new community paramedic program. Gilbertson says the challenge isn’t just to teach the medics about public health, but also to educate the public about EMS.

"The system is like a bicycle that’s not put together yet; then you give it to your kid without a wrench or a set of instructions.

"Citizens don’t understand how to use EMS. They figure the easiest thing to do is call 911 and somebody will figure out what they need."

Opportunity rocks
So whatever happened to Bud, his boss from the bad old days"

"He might still be alive," Gilbertson says. "I wouldn’t know. I’ve seen him around Little Rock from time to time. I just kind of go the other way.

"As bad as it was, working at Medic-Vac opened doors for me. If you want to grow, personally and professionally, you have to be willing to walk through those doors and see what’s on the other side."

Best EMS-themed cakes and other baked goods

Birthdays, weddings, holidays, celebratory events call for cakes, or cookies, or cupcakes. If you are an emergency responder, what better way to celebrate than with an EMS- or fire-themed dessert"

We asked our EMS1 Facebook fans to share their favorite first responder-themed baked goods. We saw some beautiful cakes, cookies and cupcakes. Here are our top picks:

Ambulance pursuit of a reckless driver is not how EMS can serve the community

EMS providers are helpers. We help not only the sick and injured, but also the community as a whole, through volunteer activities, training, performing well-being checks and safety inspections.

But is it stepping over the line when we give chase to a possible drunk driver who is putting the community at risk"

Each decision we make in our business is layered with risks and benefits. A reasonable decision would tip the balance of benefit over risk. Most of the time, the decisions we make usually are low in risk.

However, in this case emerging from Johnson County, North Carolina, pursuing a civilian vehicle at high speed in an ambulance seems to be heavily laden with risk of injury to the crew and other members of the public.

Had the crew not given chase, would the alleged drunk driver proceeded at a slower pace, reducing the risk of a major crash" The crew took a very big risk in trying to help contain this reckless driver.

Could the crew have recorded the license plate of the vehicle, a description of the driver, and radioed that information to law enforcement" That might have been the more prudent decision to be made in this situation.

Even though there were no serious consequences related to the incident, other than disciplinary action for the crew, the end does not justify the means of putting the public at undue risk.

While I applaud the crew for wanting to make a difference, pursuing a reckless driver is not the way to do it.

How EMS agencies become stronger through consolidation

Saving money is a challenge all organizations struggle with. One of the easiest ways to save money is to grow. It may seem counterintuitive at first, but sometimes more is less based on the concept of economies of scale [1].

This refers to the notion that as more of an item is produced, each individual item costs less to make. The same rule is true for a provided service.

There are fixed and variable costs that go into operating an ambulance service. Whether a service uses three ambulances or 15, there are certain fixed costs for factors such as the building, managers, support staff and medical directors. As the number of ambulances in an EMS operation increases, those fixed costs are spread across the entire fleet. As a result, each ambulance and the calls they respond to cost less per unit of work.

Advantage: Purchasing
Large EMS organizations can take advantage of economies of scale when they purchase supplies by paying less per item than a smaller organization purchasing fewer units of each supply. For instance, if an EMS organization needs 20 uniform shirts they are going to pay more per shirt than an organization that buys 300 shirts. The uniform manufacturer enjoys economies of scale and can pass on some of the cost savings to the customer.

Organizations that buy a high volume of supplies, such as IV fluids, uniforms, catheters, and oxygen masks can command a discount from suppliers based on their procurement volume. Not only is the supplier taking advantage of economies of scale, they also don’t want to lose a valuable customer.

Advantage: Recruitment
Most EMS providers want to be part of a winning team. Large organizations can typically attract more talented employees and managers than smaller, lesser-known organizations.

Large organizations provide several benefits that attract potential employees. In addition to being part of a well-known team, employees typically receive better health insurance and other benefits at a lower price.

Since larger organizations by nature require more employees, there is more frequent opportunity for promotion or to move into a role beyond simply staffing an ambulance. Large organizations have bike teams, special operations, community paramedics, full-time educators, full-time quality assurance staff, mechanics, dispatchers, and other positions.

Tips from post-consolidated EMS professionals
I spoke with members of several EMS organizations that have consolidated, merged, or expanded into other areas. Each organization had their own unique reason for growing, but all were able to take advantage of growth benefits. Each organization has a pearl to share from the process they undertook.

1. Don’t rush the process
Guardian EMS, a critical care interfacility organization based in Oklahoma City, acquired "Plus" EMS which was close to failing due to low revenue. Guardian was looking to expand, and confident that they had the ability to improve the billing operations at Plus.

In addition to the acquisition of additional equipment and market share, Guardian obtained an outstanding medical director. The Guardian EMS merger, like most, was complicated and time-consuming.

"Any EMS leader thinking of consolidating should plan on it taking a significant amount of time," said Kyle Norris, Guardian’s former clinical director. "Don’t rush it."

2. Show and sell the benefits
Across Sedgwick County, Kansas, each municipality had its own standalone communications division. Each organization had its own dispatch center, radio system, and personnel. Depending on the location of the caller requesting EMS, calls would be placed on hold and transferred to the EMS system’s dispatch center. After the transfer was answered, the EMD process would begin

Sedgwick County officials wanted to reduce the time required to activate critical EMS resources.

"Transferring a 911 caller several times can lead to stressful and costly delays," said Steve Cotter, the former EMS director.

Consolidating multiple dispatch centers into one central system saved both time and money, and it created smoother day-today operations for the region. An unexpected benefit for the field crews was the ability for personnel from separate agencies to quickly communicate directly with each other by simply switching to that assigned channel.

As with many regions across the country, some personnel were hesitant to hand over dispatch to another organization because they felt they knew their area better than anyone else.

"This is a challenge to overcome, but with today’s mapping software, AVL systems, and CAD ability, this usually becomes a non-issue," Cotter said.

Still, anticipate hesitance and be prepared to show the benefits of consolidation. Just like anyone else, you’ve got to be able to effectively "sell" the idea.

3. Watch how everything fits into the big picture
Since 2008, Grady EMS has been providing EMS services to Atlanta, Georgia, and several surrounding towns with no government subsidy. I talked to EMS Operations Vice President Michael Colman to learn how they are able to do this and still have room to grow.

"You’ve got to watch everything," Colman said. "For instance, if a rep wants to sell you a different warning light system on the ambulance you are ordering, you’ve got to think about things like what shape the light heads are. If it’s different from your current version, that means you’ll be forced to keep additional replacement parts in inventory. That costs money. It doubles your current costs for stocking that part. That kind of thing seems trivial but they add up to very real costs."

In addition to "watching everything" Grady has its own in-house maintenance department complete with a remounting service, towing service, and a paint shop. It’s important for the organization to return trucks to service as soon as possible.

"If the ambulance is stuck in the shop, we still have to pay for it but it’s not earning any money," Colman said.

Over the last several years, Grady EMS has expanded into other regions. Most recently, Grady EMS was awarded the contract for Pike County in rural, central Georgia.

Grady won the bid for the county in part because they are able to take advantage of economies of scale. In most organizations, an important objective is to grow and increase revenue as available. In this instance, the objective was to bring cost-effective evidence-based health care to another region of Georgia.

There were also several unexpected benefits. One of the most visible was the equipment and ambulance upgrade. Additionally, the local EMS providers were given the opportunity to keep their jobs and retain their pay rates. In addition to keeping their pay and seniority, employees now have cheaper, more comprehensive health benefits and new benefits, like a matching 401k.

An expected challenge came locally from some who were skeptical of an "outside" organization moving into their area. That skepticism can be reduced when patients receive high-quality care and EMS personnel are provided with a quality work environment and benefits.

Survive or thrive
It’s no secret that teamwork and collaborative efforts can achieve more than would be possible by a divided effort. Often, smaller organizations would love to provide the benefits and advantages of a larger organization, but they simply cannot.

Consolidating resources or merging with another organization can greatly increase the ability of an EMS organization to survive and even thrive. If you are leading an EMS organization near death, consider the benefits of joining forces with a neighboring organization. It is likely you will be stronger together than if you stay separate.

Rank and file: Getting the attitude right from the start

By Dr. Shana Nicholson, Faculty Member, Emergency and Disaster Management at American Military University

The U.S. Fire Administration reports that there are about 1.2 million firefighters in the United States. The level of experience and knowledge within the fire service is as big of a range as the personalities, but there is not always enough of an emphasis on sharing knowledge.

The fire service is wrought with tradition and dedication to helping others, yet it often fails to help young firefighters understand and respect these traditions in a positive way. We in the fire service must foster a positive attitude and a level of respect among the rank and file.

Many young and eager newbies enter the fire service wanting to charge into a fire scene to save the world with complete disregard for safety and authority. They quickly become “Facebook firefighters,” posting every scene on their social media accounts.

Full story: Rank and file: Getting the attitude right from the start

Inside EMS Podcast: We need stiffer punishment for EMS assaults

Download this week's episode on iTunes , SoundCloud or via RSS feed

In this week’s Inside EMS podcast, co-hosts Chris Cebollero and Kelly Grayson discuss the top news stories of the week:

Stiffer punishment sought for attacks on UK medics

120 dead in Paris from gunmen, suicide bombers

Why the mentally ill don't receive the attention they deserve

7 ways to promote EMS and fire grants

One way to enhance a fire or EMS agency's grant application is to look for an opportunity to explain how the department will promote and market the grant award and implementation.

First, look for specific questions on the application that ask about a grant award and program marketing strategy. If there are no such questions about promotion, use an addendum or "other information" field to outline the promotion and marketing strategy.

When building a grant marketing strategy, consider all of the steps in the grant process as opportunities to promote your efforts to the community. During the application process, reach out to the local media to explain which grants are being sought, the need the grants will solve for the department and how this will aid the community. This can be done by one-off or quarterly news releases. If the agency has an officer comfortable with the media, invite the media representatives for an interview.

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Clinical solution: 4-year-old male having a seizure

Children with special health care needs
Periodically the U.S. Department of Health and Human Services releases the results of the National Survey of Children with Special Health Care Needs with the most recent report covering 2009 and 2010. For that period of time it was estimated that 11.2 million children (representing 15.1 percent of children in the U.S.) have special health care needs [1]. For the purposes of the survey, children with special healthcare needs are defined as:

Those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.

While the definition includes behavioral and emotional conditions, this column will focus on medical presentations. Additionally, while asthma and other chronic (but often well-controlled) medical conditions are include in the definition, EMS providers may find themselves responding to residences where families care for children with extremely complex medical histories and presentations. Initially, such calls may be difficult for EMS to respond to but with a few tips and planning some of the confusion can be mitigated.

The prevalence of special health care needs in the pediatric population increases with age, a fact that researchers attribute both to later development of medical conditions and certain conditions, like autism, which can only be diagnosed after certain developmental milestones have been reached [1].

Children with durable medical equipment
A piece of durable medical equipment is a device that provides assistive or life-sustaining support to a patient. Examples can be as varied as a wheelchair, walker or ventilator. For the purposes of the National Survey, mobility devices (wheelchairs and walkers) are separated from other equipment. Children with special health care needs utilize durable medical equipment at a rate of greater than 11 percent [1]. This means that in a given community, EMS providers have a reasonable chance of responding to patients with such equipment in the home. Familiarizing yourself with the adult and pediatric patients in your community who rely on this equipment can help reduce confusion when an emergency call comes in. For such calls, parents or full-time caregivers are often well-trained and can assist with managing equipment during transport.

Be sure to speak with your medical director in advance to determine what equipment may be transported with a patient. It may be necessary to disconnect certain equipment or to take a different approach to treatment and transport. For instance, a patient with a tracheostomy who is ventilator-dependent may have power or oxygen requirements for that piece of equipment that cannot be met in your ambulance. In that case, however, realize that chronic ventilator patients have carefully titrated respiratory settings and that even a short period of BVM ventilation may have long-term consequences. If there is ever a question about how to best manage a complex patient with durable medical equipment contact online medical control and discuss the specific situation using parents and caregiver expertise as appropriate.

Parents as a resource
Of children in the survey with special health care needs, nearly 65 percent received "family centered care" which is defined as "an approach to planning, delivery and evaluation of health care whose cornerstone is active participation between families and professionals" [1]. In these settings, parents of patients are typically knowledgeable about their child’s medical history and conditions. Additionally, parents often understand how to operate and troubleshoot any durable medical equipment their child relies on. In all these cases, like with most pediatric patients, EMS providers can rely on parents to calm and soothe patients and to guide EMS providers through the normal presentation for the patient.

In cases where a patient is presenting as altered or ill one of the first questions of parents or caregivers should be what the patient’s baseline is. It may be that drowsy and nonverbal, while concerning to EMS staff, is consistent with a particular patient’s baseline. Establishing a clear understanding of the patient’s usual presentation is invaluable when building a differential diagnosis and developing a treatment plan.

Additionally, parents can provide guidance on how best to approach assessing and treating a particular patient. It may be necessary to perform a blood pressure or listen to lung sounds on a parent or favorite stuffed animal to establish a rapport with the patient. EMS providers would likely not know what approach will work best without parental guidance. When the patient’s acuity permits, enlist parental help early on in the call.

After talking with Stephen’s mother and father, you find that he has been ill recently with flu-like symptoms and that his pediatrician warned his parents that increasing seizures might be expected. Stephen’s mother followed the pediatrician’s guidelines on administering the diazepam to halt his seizure but they would still like him to be transported for evaluation. Given Stephen’s slow respiratory rate, relative to his age, and mild hypoxia, you elect to administer blow-by oxygen and enlist his father to hold the mask. You also gently open Stephen's mouth to look for any blood or secretions. Until Stephen becomes more oriented you ask his parents to comfort him in the recovery position; resting on his side. He gradually returns to consciousness and by the time ALS arrives he is consistent with his baseline mentation.

As you provide a report to the ALS transport crew you agree with the paramedic that she should take Stephen to the emergency department. Though Stephen does have a history of seizures his recent events have been more frequent and severe. Additionally, Stephen received medication for his seizure before your arrival and warrants additional assessment during transport.

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. (2013). The National Survey of Children with Special Health Care Needs Chartbook 2009–2010. Rockville, Maryland: U.S. Department of Health and Human Services. Retrieved from


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