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

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EMS1 Daily News

Fire chief: Medic's death changed our roadside response

The volunteer fire district now blocks roads at crash scenes after a newly minted medic was hit and killed by a truck

Russian paramedics attacked by kickboxers

Kickboxers started a fight, lost and then attacked the medics called to help them

4-year-old survives Colo. crash that kills family

The girl's family was killed after a train hit their van at a railroad crossing

Watch: FDNY EMTs get engaged at NYC Pride parade

The proposal was captured on video as the couple embraced and kissed as onlookers cheered. (Photo courtesy Facebook)

Wis. EMS, fire depts. battle staffing problems

Some chiefs believe merging departments and increasing MABAS might be necessary if departments can't raise funds via taxes

2 men presumed dead found alive in W.Va. flooding

The discovery lowers the death toll to 23; the number of dead includes 20 bodies found and 3 people who are missing and presumed dead

Reality training: Administering pediatric medication

Use this hands-on training exercise to improve equipment familiarity, reinforce medication cross-check processes and increase provider confidence to treat sick kids

Lightning strike injures paramedic, EMT

The two Kentucky EMS providers were loading a motor vehicle collision patient into the ambulance when the rig was struck by lightning

Impaired driver plows into crash scene, injures medics

Two Acadian Ambulance EMTs and two bystanders were struck while tending to an accident victim

Medics treat 10 stabbing victims during white nationalist protest

Members of the Traditionalist Worker Party and counter protesters were treated for stab wounds, cuts, scrapes and bruises
Top

EMS1 Topic Articles

Fire chief: Medic's death changed our roadside response

The volunteer fire district now blocks roads at crash scenes after a newly minted medic was hit and killed by a truck

Russian paramedics attacked by kickboxers

Kickboxers started a fight, lost and then attacked the medics called to help them

4-year-old survives Colo. crash that kills family

The girl's family was killed after a train hit their van at a railroad crossing

Watch: FDNY EMTs get engaged at NYC Pride parade

The proposal was captured on video as the couple embraced and kissed as onlookers cheered. (Photo courtesy Facebook)

Wis. EMS, fire depts. battle staffing problems

Some chiefs believe merging departments and increasing MABAS might be necessary if departments can't raise funds via taxes

2 men presumed dead found alive in W.Va. flooding

The discovery lowers the death toll to 23; the number of dead includes 20 bodies found and 3 people who are missing and presumed dead

Reality training: Administering pediatric medication

Use this hands-on training exercise to improve equipment familiarity, reinforce medication cross-check processes and increase provider confidence to treat sick kids

Lightning strike injures paramedic, EMT

The two Kentucky EMS providers were loading a motor vehicle collision patient into the ambulance when the rig was struck by lightning

Impaired driver plows into crash scene, injures medics

Two Acadian Ambulance EMTs and two bystanders were struck while tending to an accident victim

Medics treat 10 stabbing victims during white nationalist protest

Members of the Traditionalist Worker Party and counter protesters were treated for stab wounds, cuts, scrapes and bruises
Top

EMS1 Columnist Articles

Reality training: Administering pediatric medication

Administering pediatric medication can be one of the most dangerous and anxiety-provoking procedures paramedics perform. It is also a situation that is rarely encountered by most paramedics, which leaves few opportunities to practice and to build confidence.

Studies on medication administration, in real and simulated pediatric patients, show frequent and sometimes fatal medication errors even when reference tools are used. Paramedics and students need realistic training to help prepare for these high-risk, low-frequency situations.

One study found that over one-third of the 360 medications administered to children over two years were incorrect. Eighteen percent of those patients received a dose greater than 20 percent outside of the correct dose range. Paramedics also rarely performed pediatric medication administration in this study.

In another retrospective chart review study, children under 12 years old who received a medication made up less than 1 percent of EMS responses, and only one-third of paramedics administered any medications to children over the study period [1].

A study of a simulated pediatric anaphylaxis scenario found that over half of paramedics administered an incorrect dose of epinephrine, and 20 percent administered a higher epinephrine dose than an adult in cardiac arrest should receive. This was despite paramedics using a number of reference tools during the scenario [2].

Weight-based pediatric medication administration involves several steps, and there are opportunities for error at each one. Pediatric emergencies are also stressful situations, which further compromises cognitive skills. A study examining the root causes of errors in pediatric simulation identified these nine causes.

  • Incorrect use of the Broselow length-based resuscitation tape.
  • Impaired calculation ability under stress.
  • Inaccurate weight estimate.
  • Faulty recall of doses.
  • Unaided calculations.
  • Wrong milligram/kilogram dose for route of administration.
  • Errors converting the dose in milligrams to volume administered in milliliters.
  • Volume measured from wrong end of prefilled syringe.
  • Failure to cross-check calculations.

Two of the author's recommendations are to provide "hands on continuing education of pediatric medications and drug dilutions, using syringes to draw calculated volumes of medications in the context of a simulated case," and "periodic competency testing on the use of medication dosing reference cards or other cognitive aids" [3].

Hands-on training
Here is one exercise that gives participants several opportunities to practice the steps of medication administration and to gain experience using reference tools for children of different ages and sizes in a short period of time.

First, make index cards with a medication and a condition it is used to treat. Some examples are:

  • Epinephrine: one card for cardiac arrest and another for anaphylaxis.
  • Benzodiazepines: Midazolam, lorazepam, or diazepam for seizure treatment.
  • Dextrose: for hypoglycemia (which may need to be diluted from a 50 percent to 25 percent concentration).
  • Fentanyl or morphine: for pain management.
  • Naloxone: for opioid overdose reversal.
  • Diphenhydramine: antihistamine for allergic reaction.
  • Adenosine: for supraventricular tachycardia.
  • Amiodarone: for cardiac arrest.

Next, get a supply of expired medications, fill empty medication vials with fluid or label training vials with the medications you plan to use in the training session. Store the medications in drug kits similar to ones used in the field.

Then recruit some pediatric volunteers. Have training participants bring their children to training, have an open house or community outreach activity at a station or arrange a visit to a school or daycare center. Give each child one of the cards. Instruct the children to hand the card to a team of two paramedics or students.

Using reference tools, have the team practice estimating the child’s weight, determining the dose of the medication on the child’s card in milligrams, the volume of medication in milliliters that should be administered and the route of administration.

Have one participant draw the amount of the simulated medication into a syringe (or identify the volume if the medication is supplied in a prefilled syringe), verbalize and confirm with a partner the dose, volume and route to administer, and waste the fluid in to a sink or garbage can.

Teach your students or personnel to use this medication cross-check process (also see video at the end of this article) or something similar and specific to your department’s protocols.

Give the children different cards throughout the exercise and have them rotate among the paramedic teams. This training exercise exposes participants to a variety of conditions, patient sizes and medication doses to calculate.

Here are seven tips to make the exercise a success.

  1. Make it fun for the kids. Incorporate the exercise into a station open house or community outreach activity. Rent an inflatable bounce house, hand out coloring books and junior paramedic stickers, or use it as an opportunity to promote bike or pool safety.
  2. Use blunt tips for syringes instead of needles to make sure the children are not fearful of getting an injection.
  3. Use the exercise to identify areas for system improvement not to punish individuals for making mistakes.
  4. Test different strategies in crew resource management and medication cross checks, and measure how long it takes to determine the accurate dose of the medication.
  5. Get samples of pediatric medication reference tools to pilot during the exercise and see which one works best for your service.
  6. Investigate how pediatric equipment is organized in bags.
  7. Debrief after the exercise. Ask participants how comfortable they feel administering medications to children and how the process can be improved.

In the comments share your experience with this training activity or something similar, as well as your questions for improving pediatric medication administration.

References:

  1. Hoyle JD, Davis AT, Putnam KK, Trytko JA, Fales WD. (2012) Medication dosing errors in pediatric patients treated by emergency medical services. Prehospital Emergency Care, 16:1, 59-66.
  2. Lammers R, Willoughby-Byrwa M, Fales W. (2014). Medication errors in prehospital management of simulated pediatric anaphylaxis. Prehospital Emergency Care, 18:2, 295-304.
  3. Lammers R, Byrwa M, Fales W. (2012). Root causes of errors in a simulated prehospital pediatric emergency. Academic Emergency Medicine 19:37-47

Frequent Flyers: Who restocked the rig?

See all of Lenwood Brown's comics .

Inside EMS Podcast: News topics of the week

Download this podcast on iTunes, SoundCloud or via RSS feed

In this week's Inside EMS Podcast, co-hosts Chris Cebollero and Kelly Grayson review this week's top news, including a crash that disintegrated an ambulance, a new bill giving LODD benefits to EMS personnel and how a good Samaritan was charged $140 for helping crash victims.

Come and join the discussion.

Paramedics, firefighters need more suicide response training

Based on a news report out of Huntington, W.Va., there were several mistakes made during a recent call for a suicidal individual.

The fire department responded to a man threatening to jump from a bridge. The incident stretched out over more than 14 hours. During that time, one firefighter used the department union's Twitter account to post updates. He also posted videos to YouTube.

The trouble began when some in the mental health community called out the fire department for insensitive language used in the posts.

Obviously, there is a lot that has been and will be said about the right and wrong ways to represent the fire department on social media outlets. But that's not what jumped out at me in this story.

The local reporter was sharp enough to ask if this was a training problem — were firefighters properly trained to handle suicidal patients"

The answer is that it is a training issue and they were not prepared for it.

And it is not exclusively a Huntington issue. The report said many firefighters in West Virginia are not trained to handle suicide cases. And it's no great leap of the imagination to see how this lack of training extends to many parts of the United States.

In short, it's not this firefighter's, this department's or this state's problem. It is our problem.

It may not be the greatest problem facing fire and EMS personnel, but it is a problem — and a growing one at that. In 2014, Illinois reported that 72 percent of that state's suicide deaths occurred in the home. Whether it is at home, work or a public setting — other than police — fire and EMS are first on scene.

The American Foundation for Suicide Prevention reports that the rate of suicides in this country has increased every year between 2005 and 2014, the last year it posted statistics for. In addition to being the 10th leading cause of death in the U.S., for every suicide death, there are about 25 attempted suicides.

That 25-to-1 ratio makes me think of commercial fire alarms and the vast number that are false alarms. Those on slower departments are constantly reminding themselves to treat every alarm as a real one so as to not be lulled into complacency.

Where familiarity breeds contempt with false alarms, the calls for suicidal patients may be a case of both familiarity and unfamiliarity breeding contempt.

Are we too quick to assume that teen with a bottle of pills is only threatening suicide because she wants attention, or that the neighborhood drunk is always doing some "damned crazy thing""

It comes back to a training thing. When we're not trained to recognize and handle suicidal patients, we naturally assign our own meaning to the situations.

Fortunately, the fire service is paying closer attention to suicide in an effort to reduce it in our own ranks. Fire Chief, EMS1 and FireRescue1 has devoted a lot of energy to covering this issue — and I'm happy to say, so too have our competitors.

Suicide recognition and response training
This attention is hopefully a gateway to improve overall suicide recognition and response training. One recommendation from the Illinois Department of Health is to include this training as part of the academy and annual refresher training like CPR — this suggestion mirrors that for teaching firefighters about their own mental health.

The Illinois Department of Health offers these four recommendations for first responders.

1. Ensure the safety of everyone present
This includes eliminating access to lethal means. If available, contact law enforcement who are trained in suicide prevention to intervene. Law enforcement officers should be aware of the dangers of a "suicide by cop" situation, where a suicidal person threatens harm to others in attempt to provoke officers to fire at him or her

2. Assess the person for need of medical treatment
Address any serious medical needs first, and if not equipped to handle mental health issues, involve somebody who is, such as a mental health clinician or crisis intervention worker. If not aware of the appropriate professional to contact, ask a supervisor for direction.

3. Establish rapport with the person
Listen carefully and speak with the person in a non-confrontational manner.

4. Assess the person for risk of suicide
Determine whether an attempt has already been made while keeping them under constant observation. If the person is suicidal, arrange for them to be transported to a local hospital or mental health center.

Sober legal advice for LAFD's new EMS program

The Los Angeles Fire Department is proposing a new program to address the problem of frequent users on and near the famed Skid Row. As an attorney committed to the protection and defense of EMS providers and advocating for the best in patient care, I have mixed feelings about the SOBER unit.

The issues are real. Like most large metropolitan departments, LAFD EMS resources can respond to the same person multiple times in a single day for generally non-emergent reasons. Those calls for emergency care are often related to the use or abuse of drugs and alcohol — problems better suited to a social worker and a substance abuse counselor than a paramedic, ambulance, and an emergency room.

The proposed solution is a unit staffed with an EMS provider and a community outreach worker who will follow a checklist and triage the individual either to a hospital or to a new sobering center. The idea — as an idea — is brilliant. I love it!

I admire and respect the LAFD for its very creative forward-thinking and willingness to solve problems. I am impressed that they are willing to break free of the chains of tradition to reach for a better, broader and more appropriate approach to patient care and people care.

In practice, however, I have grave concerns.

I am fearful for the EMS provider on the street who, when something goes wrong, will be left out in the bitter cold with nothing more than a good idea to protect him or her from the wolves.

Problem: Rigid regulatory climate
Local and state polices, protocols and procedures in California are not very flexible and are vigorously and, at times, viciously enforced.

The very first time an individual is transported to the sobering center only to go into cardiac arrest — at any point during or after transport — it is the paramedic who will be investigated, disciplined and likely face an administrative law judge who will determine whether the paramedic's license should be revoked at the behest of the State EMS Authority.

The paramedic will find little refuge in an LAFD pilot program when California's EMS Authority comes banging on the door.

Problem 2: Liability for assessment
According to the story, the paramedic would check the patient's mental status and for “evidence of head injury or seizure activity.” What does that mean and how does a paramedic adequately check for such things"

We all know that in the field evidence of a head injury or seizure activity is not the same as proof of a head injury or seizure activity. Nevertheless, the way I read the news, it is the paramedic who will be held liable for making the mistake; and why not" They are now held liable for mistakes.

How to make this work
For what it’s worth — and legally speaking — I think this can work and I believe it can be a great success for everyone.

First, policies, protocols and procedures that protect the paramedic from liability, while ensuring only the highest in compliance to established standards would have to be codified and accepted by the State EMS Authority before the SOBER unit's first call.

This is not something that needs to happen just in the city, but at the state level because it is the state who will come after the paramedic’s license.

Next, paramedics will have to undergo extensive training and continuing education on the new policies, protocols and procedures as well as comprehensive training on patient care documentation. The proposed checklist will have to be extensive and very clearly documented on every call.

Then, there will have to be a comprehensive and closely monitored quality-control element to aggressively prevent and eliminate policy fallouts and detect and manage negative trends. This is not necessarily because the paramedics will make mistakes, but because patients will complain.

I guarantee an intoxicated person who wants to go to the hospital will be taken to a sobering center and a complaint — or lawsuit — will be filed for which the paramedic will be left holding the bag when EMSA gets involved.

Lastly, LAFD needs to be prepared for the unintended consequences. The residents of Skid Row have a better communication network than Facebook will ever imagined.

It will not be long before the word spreads about free rides to the sobering center. On hot days and cold nights the demand for the SOBER units will grow faster than the department’s ability to keep up and that means more rescues out of service and on Skid Row.

If LAFD truly wants this to work and puts its best people on it and if they don’t rush into as a public relations opportunity, the SOBER program is bound to succeed and be a model for agencies nationwide. I hope it works.

911 outages a danger to all

When I was working as an EMS communication center supervisor, a veteran dispatcher perfectly described the center’s function as the "head of the beast."

While most EMS providers perform critical field functions, personnel within a modern day 911 call center are responsible for coordinating all of an EMS system’s resources. From call intake, pre-arrival instructions and dispatch, to resource monitoring, inter- and intra-agency coordination and scheduling routine calls, a 911 telecommunications center has to be functional 100 percent of the time.

Beyond the training and expertise of its human resources, the technical aspects of the system must also be of high quality, and the ability to rapidly bring backup systems online must be reliable.

As the recent breakdown of the Baltimore 911 system demonstrated, the potential of a major crisis caused by a system failure can’t be understated. Judging from the media reports, it looks like the incident was handled quickly, with some concern about communicating the backup plan to the general public.

What’s more interesting — and concerning — to me is the second part of the article. It’s true that most current 911 systems are rooted in older "Plain Old Telephone Service" (POTS) technology.

Hundreds and thousands of miles of copper wires connect a community’s landline phones to a separate system that allows automatic number identification and automatic location identification to happen when a 911 call is placed. A traditional 911 system can allow a telecommunicator to lock the connection with the caller or even to re-establish contact when the line is open.

The entire system is also antiquated. In today’s world of modern telephony and the convergence of digital data with voice, the existing 911 system is unable to deliver the data throughput necessary to transmit or sustain things like video calls or text messages. Such abilities can be delivered through internet-based communication systems, similar to many of the business-oriented communication systems now exist.

POTS does have one major difference. It is a closed system.

Internet systems are by nature, open.

Sophisticated and expensive processes exist to prevent unauthorized entry by those with more nefarious intent to disrupt public safety communications. To do so would be to interrupt the minute-to-minute operations. At best, that could mean dropped calls for service; at worse, a system may be unable to respond adequately to a major act of terrorism.

Florida officials described a 911 outage as a "very scary few hours." A report of the January incident, released last week, blamed the 911 outage as a mixture of human and technological error during a software upgrade, which rendered the system unstable.

Most EMS professionals never think about the reliability of their communication systems. It’s a mere inconvenience when a unit is unable to establish or maintain a connection or when dispatch sends the wrong unit or over triage a call.

But the nightmare scenario of an accidental or intentional major communication blackout, stranding responders in the field, and being unable to convey information among officials, other agencies and public weighs heavily in the minds of 911 system designers.

While the new technology may be more powerful, it does come with its weaknesses that can be exploited.

Are you smarter than an EMT student? Test your knowledge!

The introductory module of any course has important information, but EMT students frequently gloss over that content for the "cool" material in the airway or trauma chapters. This quiz will reveal if you paid attention in your classes on A&P, lifespan development, medical/legal and more. Are you smarter than an EMT student"

6 success steps for diagnosing altered level of consciousness

Patients with an altered level of consciousness are among the toughest to assess since there is no classic, "one size fits all" presentation.

The clinical presentation is often subtle, which makes recognizing changes in mental status a challenging endeavor. And, the underlying conditions that cause an ALOC have one of the largest differential diagnoses you may encounter in the prehospital setting.

Despite the many challenges, EMTs and paramedics who follow a structured approach with these patients are often able to find the cause and rule out worst-case scenarios. When you’re called to help someone who isn’t oriented to time, place or person, here are six ways to facilitate a successful patient contact.

1. Start with the ABCs
Avoid trying to discover the underlying reason for the patient’s ALOC before you do a primary assessment and treat any immediate life threats. If there is a deficit in one of the patient’s ABCs that isn’t the primary cause, it will certainly make the patient worse if left untreated.

An unstable airway will lead to hypoxia and central nervous system depression. Inadequate breathing will contribute to high levels of carbon dioxide in the blood and respiratory acidosis. Poor circulation will cause hypoperfusion in the brain.

Only after you’ve methodically checked a patient’s ABCs and treated any life threats, should you take a set of vital signs, inquire about the history of the present illness and obtain a SAMPLE history.

2. Do a detailed physical exam
Performing a physical exam is often the key to ruling in — or out — a possible cause for a patient’s ALOC. For a stroke, look for a lack of movement on one side of the patient’s body, unequal pupils or the presence of the Babinski’s reflex (the big toe of an adult fanning upwards) by firmly stroking on the sole of the patient's foot with a pen or penlight.

Seizure patients may present with oral trauma or incontinence.

The skin of patients with hypoglycemia is often pale, cool and clammy. Patients with hyperglycemia often present with hot and dry skin.

Look for constricted pupils on patients who have overdosed on opiates and cyanosis in patients who are hypoxic.

To search for possible infection sources, scan the patient for signs of dialysis devices and catheters.

Always examine the patient to search for trauma and obtain an ECG to make sure a cardiac event isn’t causing the mental status changes.

3. Search for underlying causes
After you’ve completed a primary assessment, physical exam and obtained a set of vital signs, begin your detective work to find or confirm the underlying cause. An altered mental status is not a disease state in itself, but is always caused by some underlying factor.

If the mnemonic AEIOU-TIPS (acidosis, alcohol, epilepsy, infection, overdose, uremia, trauma, tumor, insulin, psychosis, stroke) is difficult to remember on-scene try something different. I use the mnemonic SNOT (stroke, seizure, sugar, narcotics, oxygen, trauma, toxins, telemetry/EKG). This mnemonic is easier for me to remember and lists the most common causes for an altered mental status.

4. Interview multiple sources on scene
Since we can’t obtain reliable historical data from someone with an ALOC, enlist information from family members, friends, caretakers, nursing home workers and witnesses.

Begin by asking, "Is this normal for the patient"" which will immediately rule out dementia, Alzheimer’s or other pre-existing conditions that can cause chronic mental status changes.

Then, ask what they see different about the patient" Can they describe specifically how the patient is different" When did the change start and what they think might have caused it" Once you have this information, consider it in light of your other findings to discover a possible cause.

5. Assess the environment
Every time you walk on scene — especially one involving an ALOC patient — take a moment to assess the environment and answer these questions.

  • Where was the patient found and in what position"
  • What are they wearing"
  • What objects, such as liquor bottles, medications or needles, surround the patient"

Over time, you’ll begin to see a correlation that sometimes exists between the environment and the chief complaint. For example, drug addicts often get high in out-of-the-way places such as bathrooms or vehicles.

Alleys are frequently the scene of assaults and someone who has a syncopal event after sitting on the toilet has often had a vagal episode, causing a drop in blood pressure and cerebral perfusion.

6. Treat what you can and follow up
At the end of the day, EMTs and paramedics don’t need to know the exact cause for a patient’s ALOC in the prehospital setting. All we need to do is treat the symptoms we can treat using the tools we have and transport the patient rapidly to the hospital for definitive care.

However, don’t fall into the trap of letting the call end when you hand over patient care. Follow up with the ED staff to learn what tests they performed and what they discovered, and keep a journal to document your interesting calls.

By keeping the mentality of always being a student and never a master, you will continue to learn and grow throughout your EMS career.

Tips to prevent, manage EMS scene disagreements

While much of the care provided in EMS is governed by protocols, providers are being given more latitude when deciding how best to treat a patient. In this way, protocols are being used to define a specific scope of practice, but medical care in the mobile environment is much more of a reflection of the individual provider than it once was.

With this shift towards individual practice the chances of an on-scene disagreement between providers increases. No longer can everyone simply point to a rigid protocol for guidance.

While increasingly common, not all disagreement is a bad thing. Several skilled, well-informed providers discussing possible treatment options for a complex patient is an effective and desired approach to medical care.

The most important aspect, however, is to develop a treatment plan in a collaborative fashion with the patient's best interests in mind.

Why we do what we do
Most EMS providers have been asked during a job interview some variation of the question: "What made you choose a career in EMS"" Many answered with some variation of, "To help people."

The fact that this answer is common, though, doesn’t make it any less true. Most providers of EMS, volunteer or career, started in the industry to help people.

That pledge to your patient, however, goes beyond just "helping." More specifically, that pledge is to be an advocate for your patient.

While that often means simply providing good medical care, it may also mean ensuring that a patient is comfortable prior to transport, is being seen quickly in the emergency department or is removed from an unsafe home situation.

In the context of an on-scene disagreement about how best to treat a patient, the best approach is to start from a position of patient advocacy and to proceed from there to a resolution.

How to manage differences of opinion
It is important to realize that loud, emotional disagreements between providers does not inspire patients' and bystanders' confidence in the EMS system. Alternatively, starting from a position of patient advocacy, both parties can calmly explain why their approach is most advantageous to the patient.

It’s not about being right. It’s about doing the right thing for the patient.

Above all else, keep the conversation civil and appropriate. Additionally, realize that while providers may disagree, they are both motivated by good intentions. The two treatment options likely aren’t that far apart in most cases.

The myth of rank
Local rules vary, but generally the agency with investigative jurisdiction has ultimate authority on the scene of emergency calls. This is relatively clear cut on a vehicle crash (police jurisdiction) or a structure fire (fire jurisdiction), but becomes muddy on medical calls that may involve police or fire agencies responded with an EMS agency.

As a result, many medical directors have a protocol that states that the individual with the highest level of licensure on a medical call has command of the scene. But what if a fire captain from a BLS engine and a firefighter paramedic from an ALS ambulance disagree on patient care"

Ultimately, sorting out rank is an operational function for each department and system to determine. On scene is not an appropriate time to have a discussion about the merits of rank versus licensure level. Save the operational questions for before or after a call.

Every EMS system has the provision to speak with a physician in real time when needed. If on scene medical providers are unable to reach a consensus about patient care, involving medical direction is a great option.

Doing so brings a third, likely unbiased party into the discussion who can make a decision based on the patient's presentation and available treatment options.

Conclusion
Feeling strongly that Sarah, a soccer player with a leg injury, should receive pain management before splinting, you ask to speak with the paramedic for a moment while his partner goes to get the stretcher.

"Here’s the thing," you say. "We tried to apply direct pressure to the open wound before we placed her leg in the splint and she seemed like she was in incredible pain. She has obvious deformity and her vital signs certainly demonstrate her level of distress.

"Since we need to splint that leg tightly to control the bleeding and then wheel the stretcher across the field, I thought it would be better for her to be as comfortable as possible before we did that. I just don’t want to cause her anymore pain than we have to."

The paramedic thinks for a moment and says, "No, you’re absolutely right. Thanks for the suggestion. I wanted to get her to the hospital quickly knowing that she’s going to need surgery, but it’s worth taking a few minutes to make her comfortable"

He radios to his partner and asks her to bring the intravenous kit and narcotics box along with the stretcher.

Sarah receives 100 mcg of fentanyl before her leg is splinted and she is loaded on the stretcher for transport. En route she receives repeat doses of fentanyl every five minutes until her pain is well managed.

How to find child care to fit your odd EMT schedule

Summer is heating up, and while some families celebrate the vacation time, others aren’t sharing the excitement. For some EMS families, summer means child care will be even more challenging to find (and afford) than it already was. EMTs who already deal with overnight and holiday shifts now have to add the summer break to the chunk of time when their kids need a sitter.

If you are a single parent, have a spouse who works the same wacky schedule as yourself, and/or don’t have family nearby to lend a helping hand, finding coverage can be stressful. So what do you do when you need a sitter but can’t find options to accommodate your schedule and price range"

EMT-approved child care options

1. Au pairs

Au pairs are nannies (usually from abroad) who will live with you for a set period of time. Because they live with you, au pairs are usually available whenever you need them. The rates are typically factored per family as opposed to per child, so if you have more than one child the cost can be much lower than day care. The only consideration is that au pairs need to live with you.

We spoke with Summer Blackhurst, writer for GoAuPair.com, who has researched the company’s client base. She says, “I’ve found many parents in military, health care fields and emergency responder careers flock to au pairs. Their availability for evening and weekend and nighttime shifts makes their host family first priority at any hour in the day.”

2. Use an app or website

Technology has revolutionized child care. Many companies specialize in flexible child care options, and several apps and websites allow you to compare different sitters and negotiate a pay scale prior to securing your babysitter. Here are a few of our favorite:

3. Nannies

Nannies are slightly different from au pairs; they are full-time babysitters who go home rather than live with you. Nannies can be an expensive option, though. If you consider a nanny, a great place to scout is at a nearby college campus. Many students look for a flexible part-time job, and it may be easier to negotiate your rate with a college student than through an app like Care.com.

4. 24-hour daycare center

There is a rise in “extreme daycare” or 24/7 daycare options for parents who work unconventional hours. The concept is relatively new and may not be available in all cities, but it’s worth investigating. Just do a quick search online to see if there are any around-the-clock daycares near you.

5. Link up with someone at work

Do you have another co-worker with children who runs into the same situation" Is there any way to finagle your schedules or combine resources to help each other with child care" It may not be ideal, but it could be cost-effective.

How have you dealt with unique child care needs for your weird EMT work schedule" What are some options we missed"

Top

EMS1 Tips

7 ways to best use, or avoid, capnography in the field

EMS1 readers shared their suggestions on how to get the most out of the method

Active-shooter response: Are you physically ready?

Normally, I am strong believer that paramedics are at their best when they saunter into a scene, slowly walking and looking for clues and risks. But an active-shooter incident is going to require repetitive bursts of significant physical activity.

3 energy-saving tips for your EMS station

Earth Day, or any day, is a good time to see what you can do at your agency and home to save both resources and money.

How this video can "Keep Yourself Safe"

Consider using this PPE safety video in your EMT course or refresher class

CPR class instruction tips: 5 ways to make it great

My most recent healthcare provider recertification was memorable for all of the things the instructors did well.

Patient assessments: How to avoid free-for-alls

Substantial cajoling and adult guidance from mom in a Santa hat was required to initiate an orderly process of taking turns, appreciating a gift after it was opened, and taking occasional pauses for a meal or to welcome additional relatives.

Patient assessment is a non-linear process

On a skill sheet, patient assessment is presented as a linear process: First size up the scene, then complete the primary assessment followed by the secondary assessment.

Blood pressure reading tips and tricks for EMS

One of the things I'm most often asked by students and rookie EMTs is, "Kelly, how am I supposed to hear a blood pressure in the back of the rig?"

How to use Slideshare for EMS education and training

Slideshare is an online community and tool for sharing presentations.

How to get optimal battery life from your devices

The batteries in your wireless cell phone, tablet or laptop are probably not the same old Duracells you used in your childhood walky-talkies.
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