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

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EMS1 Daily News

Pilot killed in Colo. air medical crash identified

Patrick Mahany, 64, was a decorated Vietnam veteran and flew for Flight for Life for 27 years

Bees attack, kill Texas man

The bees continued to swarm and attack the ambulance as paramedics treated the 65-year-old man

Ambulance used to chauffeur student to a Denmark school gala

A uniformed driver for Falck ambulance is in trouble for driving a student to a school event with the emergency lights on

Colo. medical helicopter crashes; pilot dead from injuries

2 other crew members have non-life threatening injuries from crash that occurred as helicopter departed hospital

2 FDNY EMTs seriously injured in ambulance collision

SUV and ambulance collided near end of Brooklyn Bridge; condition of civilian is unknown

Semi strikes SD ambulance in highway intersection

The S.D. ambulance rolled before coming to rest on its wheels in a water-filled ditch; serious injuries to front-seat passenger

Driver veers off street; destroys NY home's front porch

The unidentified driver was taken by ambulance to hospital; no injuries to home's residents

Report: Iowa city #1 for EMTs and paramedics

Ranking is based on analysis and comparison of salary, cost of living, job availability and local amenities in 750 US cities

NC medic’s widow receives honors from National EMS Memorial Bike rider

Paramedic presents commemorative dog tags to the widow of Capt. McKinney, who was killed assisting motorists earlier this year

Medics’ fatigue, sleep investigated by Good Morning America

Paramedic and researcher discusses the dangers and causes of sleep deprivation among EMS providers
Top

EMS1 Topic Articles

Pilot killed in Colo. air medical crash identified

Patrick Mahany, 64, was a decorated Vietnam veteran and flew for Flight for Life for 27 years

Bees attack, kill Texas man

The bees continued to swarm and attack the ambulance as paramedics treated the 65-year-old man

Ambulance used to chauffeur student to a Denmark school gala

A uniformed driver for Falck ambulance is in trouble for driving a student to a school event with the emergency lights on

Colo. medical helicopter crashes; pilot dead from injuries

2 other crew members have non-life threatening injuries from crash that occurred as helicopter departed hospital

2 FDNY EMTs seriously injured in ambulance collision

SUV and ambulance collided near end of Brooklyn Bridge; condition of civilian is unknown

Semi strikes SD ambulance in highway intersection

The S.D. ambulance rolled before coming to rest on its wheels in a water-filled ditch; serious injuries to front-seat passenger

Driver veers off street; destroys NY home's front porch

The unidentified driver was taken by ambulance to hospital; no injuries to home's residents

Report: Iowa city #1 for EMTs and paramedics

Ranking is based on analysis and comparison of salary, cost of living, job availability and local amenities in 750 US cities

NC medic’s widow receives honors from National EMS Memorial Bike rider

Paramedic presents commemorative dog tags to the widow of Capt. McKinney, who was killed assisting motorists earlier this year

Medics’ fatigue, sleep investigated by Good Morning America

Paramedic and researcher discusses the dangers and causes of sleep deprivation among EMS providers
Top

EMS1 Columnist Articles

Inside EMS Podcast: Dr. Bledsoe talks EMS protocols, community paramedicine

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

In this week's Inside EMS podcast, hosts Chris Cebollero and Kelly Grayson talk with guest Bryan Bledsoe, and emergency physician, paramedic and EMS educator on a range of topics that include training, protocols and community paramedicine.

Bledsoe explores “clinical guidelines” and when it’s acceptable to deviate from protocols, why it’s necessary to c hange the training standard for EMS providers, and the role community paramedicine will play in the future of EMS.

What to expect in paramedic school, clinical rotations, and field internship

Lights and Sirens: the Education of a Paramedic is an autobiographical account of Kevin Grange’s paramedic training at the acclaimed UCLA Daniel Freeman / Center for Prehospital Care Paramedic Education Program. Seasoned paramedics will be reminded of what made paramedic training so difficult and awesome at the same time and aspiring paramedics will benefit from insights of what is ahead for their training. Grange’s account takes readers through the trials and tribulations he and his classmates encountered in the classroom, skills lab, scenario testing, simulations, emergency department clinical rotations, and field internship with the LAFD.

There are many paramedic books that simply chronicle the tragic, odd, violent and occasionally uplifting patients which paramedics encounter everywhere. Michael Morse ( Rescuing Providence and Responding), Peter Canning ( Paramedic on the Front Lines of Medicine), Michael Perry ( Population: 485 - meeting your neighbors one siren at a time), and Kelly Grayson ( En Route: A paramedic’s stories of life, death, and everything in between) have published outstanding memoirs of life on the streets and the stress of being a paramedic. While their books have a narrative arc and compelling characters, they usually launch with the ambulance leaving quarters and well into the author’s EMS career.

Grange’s account is unique because he is writing at the cusp of his EMS career. As the reader follows him through school the final outcome - surviving a challenging internship with the LAFD - is very much in doubt. Especially, as several of his classmates fail out of the program when they are unable to meet the very high performance standards.

For EMS educators, “Lights and Sirens” is a great glimpse into the day-to-day operation of the well-known UCLA Center for Prehospital Care. The paramedic program teachers, skill instructors and directors, including Dr. Baxter Larmon and Heather Davis, are internationally known and recognized for their leadership and research into effective paramedic education. Grange’s account of the program sequencing - classroom to clinical to field internship, the criteria to stay eligible to complete the program, and specific instructional activities - gave me ideas and inspiration for my role as an educator and paramedic program advisory chair. For educators, UCLA has many features to emulate and replicate.

Among the challenges that Grange and his classmates face is four days a week of classroom lectures for four months, two months of clinical rotations - mostly in the emergency department, and then two dozen 24-hour shifts with an LAFD ambulance. Grange goes beyond a simple play-by-play account of his experience and delves into his emotions as well as the role of paramedics in the health care system. He writes this about a visit to the UCLA cadaver lab during the A&P section of the course:

“As I stood there, a human heart in my I hads, I though several distinct things: I was reminded again of the sacredness of human life...And I felt that UCLA’s medical school was validating the work paramedics did by inviting us students to their main campus...They didn’t consider us mere operators of a red taxi with the word “ambulance” written on the outside, but an important link in the continuum of care that began with a 911 call and ended - hopefully - with the patient walking out of the hospital.”

The final section of the book - the Field Internship - is the most gripping. Every patient encounter is an experience for Grange to learn and a harrowing opportunity to fail. Grange is honest about his struggles to meet the expectations of his preceptors while trying to apply his classroom and ED experience to very ill or injured patients in difficult situations.

For experienced paramedics I think “Lights and Sirens” will take you back to the anxiety and struggles of paramedic school. For aspiring paramedics you won’t master 12-Lead ECG interpretation or a dopamine drip calculation, but you will get helpful insights about the challenges that are ahead for you in paramedic school.

Lights and Sirens: The Education of a Paramedic” is available on Amazon and wherever books are sold.

'I'm pissed:' How EMS handles it's own with mental health issues

By Paramedic, 9 years in EMS.

Hello. I struggle with depression and PTSD. I said it. And I will no longer be ashamed to admit it.

I started in the fire service when I was 16 years old as a cadet at my local volley department. I have been a paramedic for almost three years now. I’m 25 years old. I’ve wanted to be a firefighter since I was a small child, and I am now a career firefighter. I’m not leaving this career, but shit has to change.

The EMS/Fire communities have a stigma about mental health. We go on psych calls and all we think is negative. We have all been on the attempted suicide when you say “why can’t they just get it right"” We have been on the panic attack where all you want to do is slap them because it’s four in the morning and you just want to sleep. We all have our own stories of our own patients and experiences on how pissed off we get with psych patients. Even I’m guilty. And I’m here to say it needs to stop.

But … maybe you haven’t said it. Maybe it has pissed you off that your partner has said it, but you stayed quiet. Because you don’t want to be labeled as the “not fun” partner, or the stick in the mud, or whatever the hell the kids are saying these days. That, right there, also has to stop. You need to speak up, and you need to be loud and strong when you do.

As I previously said, I struggle with depression. I have been low enough that I have had my gun to my head, and I pulled the trigger. The gun had its first ever failure, and I’m still here. I have never told ANYONE that before. You’re welcome. I have nightmares. I have anxiety so bad that sometimes I can’t hardly breathe. I don’t like going out unless there’s alcohol involved. And I drink. I drink a lot. Because I’d rather be numb than hurting. Now, why would I ever want to tell anyone that in a system where, instead of encouraging treatment and help for our peers, we discount how people are feeling and what brought them to where they are" Why would I expect anything different from all of you" What makes me think that you’re not just going to judge me" The answer … I don’t. I don’t think anything different will happen. But I hope it does.

I never thought I was ashamed of my depression or trying to hide my PTSD; I figured that it was none of their business. It was my fight, and mine alone. Sure, I told my CLOSE friends, but I never really let a lot of people in to know what I was going through.

We have failed

But I am pissed. I’m FUCKING PISSED AT EMS/FIRE FOR HOW IT HANDLES ITS OWN WHEN IT COMES TO OUR OWN MENTAL HEALTH! And THAT is why I’m telling you all this. Because I was ashamed. I was afraid. And I refuse to be any more. I refuse to be silent when I know there are people on ambulances and engines going through exactly what I’m going through. Because, brothers and sisters, we have failed. I have failed. You have failed. We let our system become this broken. Now is time for fixing it.

Let me repeat: we have failed. We have failed our patients. We have failed our spouses. We have failed ourselves. But most of all, we are failing each other. All I needed was to be able to reach out and talk to someone, but I was afraid to tell them the extent of my problems. I did have one friend that I could lean on, but now I realize that even that is unfair. It’s unfair of me to put the weight of my world on her shoulders, just the same as I was getting pissed at everyone in my life putting the weight of their world on my shoulders. We need to be able to talk to all of our coworkers about this. But, alas, we can’t. So I’m going to get help. I hate the idea of therapy. I hate the idea I’m not strong enough to deal with my own problems. But I’m not strong enough right now. I need help. So I’m going to get it. And I’m telling all of you because hopefully that will inspire even just ONE of you to also get the help you need.

That’s my rant; here’s my call to arms. Talk to someone. Right now. Tell them how you’re feeling. Instead of saying “next time I hope they get it right,” try this one: “I hope they get the help they need to be better.” Instead of us being callous and hiding the fact that some days our job is just plain shitty, we need to talk about it. We need to be okay saying, “I need help.” We can’t let ourselves get to the point that the only reason we’re still alive is the fact we have a cheap gun. I see change, slowly but sort of. I’m not expecting everything to get better overnight. But take a chance. Talk about how you’re really feeling instead of hiding behind a mask of bitterness and “gallows humor.”

I’m done being silent. I’m done being afraid.

Why I care less and less about following EMS protocols

I have found that the longer I practice in EMS, the less I care about protocols. I haven’t followed mine in years.

Got your attention, didn’t I"

Right about now, some of you are nodding in agreement, while the rest of you are aflame with righteous indignation, wondering, “Who does this EMS cowboy think he is, and is his medical director aware of his attitude"”

When I say I don’t follow my protocols, I mean that my thought processes and patient care decisions no longer involve, “What’s the next step in the algorithm"” That doesn’t mean that my actions are in contravention to my medical director’s wishes. Far from it. It merely means that I have matured beyond the type of provider for whom most protocols were intended.

Believe me, I was once a big believer in protocol adherence. I hated the first set of protocols I worked under, mostly the barriers between those procedures I could do on my own, and those for whom I had to obtain orders from medical control. And when I was given the opportunity to rewrite our system protocols, I jumped at the chance, and set about erasing as many of those barriers as I could.

I found out rather quickly that some providers needed those barriers. Some of them needed the reassurance of having rules to follow, and little responsibility in the way of decision-making. Other providers needed the ceiling until their skills and knowledge caught up with their confidence and ego.

I was that second type of provider.

I didn’t do any overt harm in those days, but I did perform a slew of unnecessary invasive procedures under my mantra of, “Over treat many, under treat none.” It took me a solid five years before I realized that the greatest ALS skill I could muster as a provider was restraint. The more I knew, the less I did.

What brought this to mind were Steve Whitehead’s recent columns on protocol adherence. In one of them, Steve talks about the Dreyfus Model of Skill Acquisition. I first encountered a condensed version of the Dreyfus model years ago in one of Bryan Bledsoe’s lectures, in which he categorized EMS providers in three levels; novice, competent, and expert. If one were to draw parallels with EMS provider certifications, one might see EMTs as novices, experienced EMTs or AEMTs as competent practitioners, and paramedics as expert practitioners.

That was the goal of paramedic education as far back as 1999, when the one of the stated goals at a 1999 DOT Paramedic Curriculum rollout was to “turn out a graduate paramedic with the skills and knowledge of a five-year paramedic trained under the previous curriculum.”

That may have been the goal, yet rarely was it the reality. In practice, what most paramedic programs do, even now, is turn out another novice practitioner with an expanded skill set and drug box. They are no more capable of clinical decision making than they were as new EMTs. They have merely demonstrated the ability to memorize algorithms, protocols and drug dosages, because that’s what their educational programs and certification exams deemed as competency. And there’s nothing wrong with that. There is a place in EMS for people all across the competency spectrum, even the novices.

But there is everything wrong with being content to stay there. Mastering your craft often means outgrowing your protocols, and sometimes even your agency. In a perfect world, every agency’s protocols would allow room to grow and mature as a provider, but in the world we live in, many don’t. And if you’re content in working in such a system, that’s okay too. Many EMS systems only require that their crews drive safely and not kill any patients.

Oh, and turn in their billing paperwork on time.

But let’s not kid ourselves that being a better protocol monkey than your peers makes you an expert at your craft. Protocols, policies and procedures cannot anticipate every situation. At some point, you have to make judgment calls, and sometimes that judgment call may mean deviating from the protocol in the patient’s best interest. If your agency is one that punishes such judgment calls, then it’s time to admit that you have outgrown that agency.

As we mature as providers, where once we saw rules, we begin to see guidelines. Where I once was taught absolutes, and in turn taught those absolutes to my students, I now see nuance. When partners ask me about my patient care decisions, or peers seek my opinion on a patient presentation, my answer is often, “It depends.”

And there is no answer more confounding to a novice provider than, “It depends.” They want answers, and all “it depends” offers is more questions.

When rules may be better off broken

Case in point, a colleague was involved in an ambulance accident not long ago. He was responding to an emergency call, lights and siren activated, and keeping to the left lane, as our driving policy dictates.

But he was a new EMT, and still thundering in his mind was the repeated admonition in his emergency driving class, “Never pass on the right.” When you’re a new EMT, rules like that may as well be carved on stone tablets.

So he kept to the left lane, just as policy dictates. And when it came time to turn right at an intersection, he did so… from the inside left lane. He smacked a car on the outside lane. Nobody was injured, but a response was delayed by minutes, and that delay could have impacted patient outcome adversely.

When I asked him, “Why did you turn across traffic lanes to make that turn, when you had plenty of room to merge into the outside lane before turning right"” he answered, “The policy says we always pass on the left. I was following the rules.”

“And what if those rules had injured you or the other driver"”

For that, he had no answer. Or more accurately, he had an answer, but it took wrecking an ambulance to make him wonder if it was indeed the right one.

My colleague learned a valuable lesson, and hopefully so did my agency. He wasn’t disciplined, and I feel confident that our employer’s just culture management strategy will determine that a flawed policy was at least partly to blame for the accident. Frankly, I don’t remember being told that rule in my new hire orientation, but among our novice EMTs, it’s practically dogma.

Hopefully, it doesn’t take harming a patient to make them challenge the dogma.

You can judge the quality of your agency by how it handles your questioning. If such questions are unwelcome, then you can either mature somewhere else, or remain an untrusted, lowly paid novice where you are.

Your choice.

Quiz: Test your knowledge of cardiac emergencies

Chest pain is a frequent patient complaint, but not all chest pain is due to a cardiac emergency. As an EMS provider understanding the anatomy and physiology of the cardiac and respiratory systems, as well as the mechanism of action for treatments, like defibrillation, aspirin, and nitroglycerin, is important for effective patient care.

Take this quiz from Limmer Creative to test your knowledge of cardiac emergencies and when you are done make sure to scroll down for key points about cardiac emergencies and additional training resources.

4 key points about cardiac emergencies

1. Cardiology is a diverse topic

From chest pain to resuscitation, there is a lot to know. It isn’t as easy as learning about chest pain and taking a CPR course. You must know how to resuscitate a patient from start to finish with high performance CPR and an AED.

2. Know your A&P

To really know about cardiology you must know anatomy, physiology and pathophysiology. From blood flow to perfusion to signs and symptoms of cardiovascular disease, you’ll do better if you understand how it works—and what happens when it doesn’t work.

3. Our toolbox is getting bigger

Administering or assisting with medications such as nitroglycerin (NTG) and aspirin is part of the EMT’s scope. CPAP and 12-lead acquisition is rapidly advancing into the purview of the EMT.

4. Oxygen may not be helpful

And last but not least we can’t forget about oxygen. Science has changed the way we look at our old friend the “wonder drug.”

Learn more about assessment and treatment of cardiac emergencies

Don’t let response times overshadow the role of EMS

In the early days of EMS, response times were a way to measure how well a system was performing. It was easy to measure, and there was the prevailing thought that having a “fast ambulance” arriving at your door translated to better patient outcomes.

Fast forward a few decades and research continues to prove what most old timers have known for decades - short response times, in most circumstances, have very little to do with saving lives or improving outcomes. However, this idea does unwittingly reinforce the public’s expectations about what our industry is all about, and reinforces unsafe work practices that contribute to crashes, injuries and deaths.

I’m not criticizing how the idea came about - history is what it is. But it frustrates me greatly that in 2015 we continue to sign EMS contracts that include response times as an assumed parameters of “success,” which translates to “compliance.” No doubt there are a few time sensitive incidents - airway obstruction, anaphylaxis, cardiac arrest - where two to three minutes may make the difference. But greater public participation and easier access to lifesaving procedures could just as easily - and more cheaply - cover that difference.

Meanwhile, the focus on response times has blurred our vision on what we really do - provide care, compassion and continuity of health services to our communities. This is one study that points to the need to look more closely at our critical role as the gatekeepers of health care in a prehospital setting. What we say or do with our patients can help set the tone for the rest of their experiences within the health care continuum.

For instance, identifying STEMI and stroke, and channeling them to appropriate receiving centers - that’s making a difference. Providing follow-up care, preventing medical maladies from happening in the first place - that will make a difference. Running hot to a stubbed toe - not so much.

It would be pretty awesome for EMS system planners to take the risk of educating government officials and policy makers as to what the EMS system version 3.0 should look like. We could save lives, save money, and save grief using the evidence that has accrued over the past 15 years about response times. It would be far sighted to build contractual parameters that explore all of the services an EMS system could provide as a cohesive, integrated approach to field care, referral and transport.

It’s really time to move on and get with the times; just not the response times.

Benefits of applying CRM to cardiac arrest resuscitation

Historically, emergency training for EMS personnel primarily focused on individual acquisition and mastering of discrete technical skills. These include basic and advanced airway management techniques, CPR, IV access and medication administration. Educators and even system administrators often did not focus on the behavioral and communication skills necessary for medical personnel to effectively provide emergency care in the realities of a dynamic team-based environment.

While courses such as International Trauma Life Support (ITLS) or Advanced Cardiac Life Support (ACLS) mention the importance of teamwork, the primary value of these courses is in ensuring each attendee has attained baseline knowledge about a specific critical event. In fact, direct observation of team performance under actual clinical conditions suggests these courses do little to prepare an individual for a leadership role within the team.[1]

Poor leadership leads to poor outcomes

Often the major obstacles to effective management of cardiac arrest are not lack of knowledge about the treatment algorithms but rather poor leadership and the lack of explicit task distribution during the resuscitation attempt.[2] An emergency department evaluation of a trauma team found the presence of clear leadership led to improved treatment guideline adherence and earlier development of a definitive treatment plan.[3]

Effective teamwork does not automatically happen simply because a group of emergency responders arrive on the scene of a medical emergency.[4] “Outer-loop,” or non-team-leader-initiated communication is common during a resuscitation attempt and has the potential to be distracting for the team leader as well as other non-participating members.[5] Successful teams are composed of responders who understand the roles and responsibilities of every other member.[6] These teams are trained to cooperate and reduce conflict.

Airlines and EMS

Recently, experts have turned to a concept known as crew resource management (CRM) to address the non-technical skills necessary for critical care teamwork.[7] These non-technical skills include communication, teamwork, and leadership.[8] CRM originates from attempts in the late 1970s to make air travel safer.[9] Reports from the time found dangerous flying conditions often resulted from communication or social skill failures of the flight crew rather than a lack of technical knowledge. Unfortunately, these failures in many cases resulted in the loss of lives.

Simulation helps build teamwork

One component of crew resource management training is the use of simulation. Through even simple and inexpensive forms of simulation, educators and training officers can recreate many of the conditions that may have interfered with a rescue team’s ability to effectively manage a critical event. Arguably, the greatest value of simulation in resuscitation training lies in the repeated exposure of the rescue team to those conditions in a safe environment until the team can perfect an action, a procedure or a conversation.[10]

Following the simulation exercise, the rescue team must engage in a debriefing session during which each team member has the opportunity to critically examine every aspect of the exercise and learn where errors occurred. Team members can then suggest solutions to prevent the breakdown from occurring again. Without debriefing, simulation is generally ineffective as team members are not aware of their mistakes and may continue to perform the same incorrect actions or continue to engage in ineffective communication patterns.

Simulation exercises and targeted resuscitation training translate into improvements in clinical performance. A case-controlled study of in-hospital cardiac arrest found internal medicine residents trained on a human patient simulator showed significantly higher adherence toACLS standards than residents trained without the simulator.[11] Cardiac arrest teams receiving pit-crew resuscitation training significantly reduced the no-flow rate during the first 10 minutes of the resuscitation attempt in the emergency department.[12] Although not sufficiently powered to detect a change, the reduction in no-flow rate trended toward improved survival outcomes.

Improved outcomes through pit-crew training

EMS agencies implementing pit-crew resuscitation training report doubling survival rates over historical controls.[13] Other systems report higher neurologically intact survival rates compared to the national average after implementing a system-tailored pit crew resuscitation model.[14]

Tailored pit crew training provides an opportunity for many EMS systems to improve survival following out-of-hospital cardiac arrest. This type of training integrates evidence-based medicine with crew resource management principles to improve team dynamics and patient care delivery.

References

1. Cooper, S., & Wakelam, A. (1999). Leadership of resuscitation teams: ‘Lighthouse leadership’. Resuscitation, 42(1),27–45. doi:10.1016/S0300-9572(99)00080-5

2. Marsch, S., Muller, C., Marquadt, K., Conrad, G., Tschan, F., & Hunziker, P. R. (2004). Human factors affect the quality of cardiopulmonary resuscitation in simulated cardiac arrests. Resuscitation, 60(1), 51–56. doi:10.1016/j.resuscitation.2003.08.004

3. Hoff, W., Reilly, P., Rotondo, M., DiGiacomo, J. C., & Schwab, C. W. (1997). The importance of the command-physician in trauma resuscitation. Journal of Trauma, 43(5), 772–777.

4. Salas, E., Sims, D. E., Klein, C., & Burke, C. S. (2003). Can teamwork enhance patient safety" Forum Risk Manage Foundation Harvard Medical Institutions, 23, 5-9.

5. Taylor, K. L., Ferri, S., Yavorska, T., Everett, T., & Parshuram, C. (2014). A description of communication patterns during CPR in ICU. Resuscitation, 85(10), 1342-1347. doi: 10.1016/j.resuscitation.2014.06.027

6. Oandasan, I., Baker, G., Barker, K., Bosco, C., D’Amour, D., Jones, L., Kimpton, S., Lemieux-Charles, L., Nasmith, L., San Martin Rodriguez, L., Tepper, J., & Way, D. (2006). Teamwork in healthcare: Promoting effective teamwork in healthcare in Canada. Retrieved from http://www.cfhi-fcass.ca/Migrated/PDF/ResearchReports/CommissionedResearch/teamwork-synthesis-report_e.pdf

7. Flin, R., & Maran, N. (2004). Identifying and training non-technical skills for teams in acute medicine. Quality and Safety in Health Care, 13 (Suppl 1), i80–i84. doi:10.1136/qshc.2004.009993

8. Briggs, A., Raja, A. S., Joyce, M. F., Yule, S. J., Jiang, W., Lipsitz, S. R., & Havens, J. M. (2015). The role of nontechnical skills in simulated trauma resuscitation. Journal of Surgical Education, 72(4), 732-739. doi: 10.1016/j.jsurg.2015.01.020

9. Fisher, J., Phillips, E., & Mather, J. (2000). Does crew resource management training work" Air Medical Journal, 19(4), 137–139. doi:10.1016/S1067-991X(00)90006-3

10. Hunt, E., Shilkofski, N., Stavroudis, T., & Nelson, K. (2007). Simulation: Translation to improved team performance. Anesthesiology Clinics, 25(2), 301-319. doi:10.1016/j.anclin.2007.03.004

11. Wayne, D. B., Didwania, A., Feinglass, J., Fudala, M. J., Barsuk, J. H., & McGaghie, W. C. (2008). Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: a case-control study. Chest, 133(1), 56–61.

12. Ong, M. E., Quah, J. L., Annathurai, A., Noor, N. M., Koh, Z. X., Tan, K. B., Pothiawala, S., Poh, A. H., Loy, C. K., & Fook-Chong, S. (2013). Improving the quality of cardiopulmonary resuscitation by training dedicated cardiac arrest teams incorporating a mechanical load-distributing device at the emergency department. Resuscitation, 84(4), 508-514. doi:10.1016/j.resuscitation.2012.07.033

13. Glendenning, D. (2012). Putting the pit crew approach into practice. EMS World, 41(11), 41-47.

14. Braithwaite, S., Friesen, J. E., Hadley, S., Kohls, D., Hinchey, P. R., Prather, M., Karonika, M., Myers, B., Holland, W. D. 2nd., Eason, C. M., & Carhart J. (2014, Nov.). A tale of three successful EMS systems. How coordinated “pit crew” procedures have helped improve cardiac arrest resuscitations in the field. Journal of the Emergency Medical Services, Suppl, 28-35.

Broadening the approach to pediatric assessment

EMT and paramedic curriculum covering pediatric assessment has historically focused on the pediatric assessment triangle (PAT), strategies for approaching different age groups, and pediatric airway management considerations. Although these foundational principles are still relevant in the primary assessment of pediatric patients, changes in the health and behavior of today’s children necessitate a broader approach to the overall pediatric patient assessment. Childhood obesity, lack of routine wellness checks or receiving vaccinations, pediatric mental health issues, and an increase in drug and alcohol abuse among pediatric patients all influence the field assessment of young patients.

Review of the pediatric assessment triangle

The pediatric assessment triangle refers to the triad of assessment categories used for the primary evaluation of a pediatric patient. Appearance, work of breathing, and an assessment of circulation via skin signs make up the points of the triangle. Any variance from normal is considered significant and indicative of some type of distress.

Rapid assessment of these three components allows the provider to quickly identify and treat life-threatening conditions in an infant or child. The assessment triangle is simple, easy to remember and a useful tool in the initial assessment of a sick or injured child.

After completing the primary assessment of a pediatric patient, providers modify their existing adult assessment to more appropriately meet the developmental stage of the child. Particular emphasis is placed on identifying common pediatric complaints such as respiratory infections and febrile seizures.

Although this approach is effective, it leaves the potential for discounting certain diseases or conditions as “adult” problems. Given the changes in health of today’s pediatric patient population, these “adult” conditions may be more prevalent in children than previously believed. Because of this, a broader approach is needed when performing a pediatric patient assessment.

A broader approach to the pediatric assessment

In the United States, 27 percent of children entering kindergarten are overweight or obese; by the 8th grade almost 39 percent are overweight or obese.[1] Assessment of an overweight or obese child requires the EMS provider to broaden their differential diagnosis list to include conditions previously reserved for the adult population.

The prevalence of non-insulin dependent diabetes, a disease formerly considered rare in the pediatric population, has dramatically increased in children in recent years.[2] A study of diabetes in youth found that 22 percent of U.S. children with type 2 diabetes have early indications of kidney disease, and are at increased risk for hypertension, hyperglycemic emergencies and diabetic retinopathy.[3]

Pediatric type 2 diabetes is most common among minority groups, and generally presents with a slow and insidious onset. A thorough pediatric patient assessment should include blood glucose testing, and providers should have a high index of suspicion for diabetic emergencies in children who are overweight or obese.

Along with the increase in childhood obesity has come an increase in pediatric gallbladder disease,[4] non-alcoholic fatty liver disease,[5] and irritable bowel disease.[6] These diseases, like type 2 diabetes, are not traditionally thought of as childhood ailments, but must now be considered when assessing a pediatric patient with abdominal complaints. Careful questioning is important in order to obtain the specific details of the onset, duration and nature of the patient’s symptoms.

Providers may need to question both the child and the parent in order to gain a complete understanding of the presenting complaint, a process that can be challenging even for experienced providers.

Consequences of vaccine non-compliance

Many diseases previously controlled by vaccinating children have recently reappeared as serious public health concerns. Pertussis, measles, and influenza have infected individuals, particularly children, in steadily increasing numbers.

The anti-vaccine movement’s campaign falsely touting the dangers of the H1N1 influenza vaccine caused 70 million doses of the flu vaccine to be wasted in 2010[7], and 49 percent of influenza-associated pediatric deaths that year occurred in unvaccinated children[8].

In 2012, the United States experienced the largest outbreak of pertussis in 50 years, with the majority of cases occurring in unvaccinated children[9]. Between 2000 and 2011, two out of every three people infected with measles were unvaccinated. In 2013, most measles cases were in children whose parents had purposefully not immunized their children.[10]

These statistics clearly indicate the need for prehospital providers to consider vaccine preventable diseases when assessing pediatric patients. Providers need to re-familiarize themselves with the signs and symptoms of diseases previously considered “rare.” Parents should be questioned regarding the immunizations and boosters their children have received. Children presenting with potentially contagious infections, such as measles, should be managed accordingly with all appropriate precautions.

Pediatric mental health

Another change to the pediatric patient population is the increase in pediatric patients with mental health disorders. Although anxiety, bipolar disorder, and depression have traditionally been thought of as adult conditions, they can and do affect the pediatric patient population.

In recent years, pediatric depression has become a common reason for emergency department visits.[11] Of children diagnosed with depression, 2.4 percent will attempt suicide.[12] The assessment of pediatric patients must include consideration of any pertinent mental health signs or symptoms. Insomnia, irritability, isolation, and aggression may all be indications of early mental illness. Providers must maintain an index of suspicion of the potential for self-harm when caring for pediatric patients, particularly in those children with a previous diagnosis of a mental health condition.

Education as an assessment component

Patient and family education can be added as an integrated component of the pediatric patient assessment. Many of the illnesses affecting children today are preventable. Educating children and their families in a professional and compassionate manner could provide the knowledge needed to prevent future emergencies. Discussing the importance of proper nutrition, physical activity, immunization and mental health care can be done throughout the assessment, treatment, and transport process.

Becoming familiar with local resources for free and low cost physical activities for children, preventative health services, and mental health providers will allow the EMS provider to refer patients and families to programs that may be of help to them. Identifying families that may benefit from such education and resources allows prehospital providers to alert hospital staff, so that the education may continue throughout the care of the patient.

The assessment of a pediatric patient must include not only the traditional pediatric assessment triangle, but also take into account the many differing aspects of the pediatric population. Obesity-related diseases, vaccine preventable disease, mental illness and the need for education can all be considered when assessing a child in the prehospital setting. By considering these additional factors, EMTs and paramedics are able to deliver high quality, compassionate care to this very important patient population.

References

1. Cunningham, Solveig A., Michael R. Kramer, and KM Venkat Narayan. "Incidence of childhood obesity in the United States." New England Journal of Medicine 370.5 (2014): 403-411.

2. Dabelea D, Mayer-Davis EJ, Saydah S, Imperatore G, Linder B, Divers J, et al. Prevalence of type 1 and type 2 diabetes among children and adolescents from 2001 to 2009. JAMA. May 7 2014;311(17):1778-86.

3. Maahs DM, Snively BM, Bell RA, Dolan L, Hirsch I, Imperatore G. Higher prevalence of elevated albumin excretion in youth with type 2 than type 1 diabetes: the SEARCH for Diabetes in Youth study. Diabetes Care. Oct 2007;30(10):2593-8.

4. Mehta S, Lopez ME, Chumpitazi BP, Mazziotti MV, Brandt ML, Fishman DS. Clinical characteristics and risk factors for symptomatic pediatric gallbladder disease. Pediatrics. Jan 2012;129(1):e82-8.

5. Gökçe, Selim, et al. "The relationship between pediatric nonalcoholic fatty liver disease and cardiovascular risk factors and increased risk of atherosclerosis in obese children." Pediatric cardiology 34.2 (2013): 308-315.

6. Long, Millie D., et al. "Prevalence and epidemiology of overweight and obesity in children with inflammatory bowel disease." Inflammatory bowel diseases 17.10 (2011): 2162-2168.

7. Poland, Gregory A., and Robert M. Jacobson. "The age-old struggle against the antivaccinationists." New England Journal of Medicine 364.2 (2011): 97-99.

8. Centers for Disease Control and Prevention (CDC. "Influenza-associated pediatric deaths--United States, September 2010-August 2011." MMWR. Morbidity and mortality weekly report 60.36 (2011): 1233.

9. Cherry, James D. "Epidemic pertussis in 2012—the resurgence of a vaccine-preventable disease." New England Journal of Medicine 367.9 (2012): 785-787.

10. Gastanaduy PA, Redd SB, Fiebelkorn AP, Rota JS, Rota PA, Bellini WJ, et al. Measles - United States, January 1-May 23, 2014. MMWR Morb Mortal Wkly Rep. Jun 6 2014;63(22):496-499.

11. Sun, Diana, et al. "Emergency department visits in the United States for pediatric depression: estimates of charges and hospitalization." Academic emergency medicine 21.9 (2014): 1003-1014.

12. Cooper, William O., et al. "Antidepressants and suicide attempts in children." Pediatrics 133.2 (2014): 204-210.

How to buy an AED

Purchasing an AED can be as easy as going on the Internet, clicking a couple buttons and entering your department's credit card information. Within a few minutes you will have a confirmation email guaranteeing delivery of an AED within two to three business days.

Though it is easy to purchase an AED, there are a several factors to consider to ensure a successful AED purchase for your department.

1. Decide on AED features

The most important features of an AED are simplicity, reliability and durability. A few AEDs are water resistant while others are shock resistant to damage from being dropped.

AEDs are offered in two categories, semi automatic and fully automatic. Semi automatic defibrillators only deliver a shock after the operator pushes the deliver-shock button. Fully automatic defibrillators shock when the unit detects a shockable cardiac rhythm.

2. Ask questions

What is the AED manufacturer's track record for recalls, support, and product quality"

“When choosing a unit make sure you choose an AED that has a low recall rate. If you have a recall it can affect your entire fleet of AEDs,” said Jason Boudreault EMT-B, BLS Regional Faculty and Emergency Cardiovascular Care Chair for Northern California.

How will the company handle software updates for new treatment guidelines"

The American Heart Association (AHA) regularly releases new CPR guidelines that might impact the amount of energy delivered by a shock, the frequency of shocks, or the voice instructions for chest compressions between shocks.

When updates are required will you have to return the AED to the vendor or will they send a local representative to your station" Some vendors might be able to loan you up-to-date devices while your department's AEDs are re-programmed or serviced.

3. Know local and state requirements

When purchasing an AED, make sure you consult with your department’s medical director. Review applicable local and state laws to determine the requirements for equipping a vehicle or a building with an AED.

Local AED regulations often require up-to-date records of proper AED inspection and maintenance. Those records should include documentation of monthly AED inspections, training records for personnel, maintenance or repairs performed, usage, and defibrillation pad and battery expiration dates.

4. Obtain an MD prescription

An AED purchase requires a prescription. AEDs are manufactured and sold under guidelines approved by the Food and Drug Administration (FDA). Most AED vendors will provide the prescription with your purchase. Otherwise contact your medical director for a prescription.

5. Determine your budget

The cost for a single AED ranges from $1,000 to $2,400. Prices for packages, that include pads, batteries, storage case and CPR accessories range from $1200 to $2800.

“When considering your budget, you have to take into account more than the initial cost of the AED,” said Marco DeVito, EMT-P, an AED consultant in Illinois.

In addition to the initial purchase of the AED and accessories you will have to periodically replace the AED's batteries and electrode pads. You should expect to replace the pads every two to three years depending on the model and replace the batteries every few years.

Most AED unit batteries are specific to the model and can only be purchased from the manufacturer. Other AED units use alkaline batteries that can be bought from any store that sells batteries.

Don't forget to factor training costs into your initial budget, especially for the non-EMS personnel in your organization that will now have access to an AED. Provide regular refresher and recertification training on AED use and CPR.

6. Grant funding for AED purchasing

There may be AED grants available from local foundations and civic organizations. Make sure you are accessing up-to-date information about grants and beware of companies that say they offer grant assistance, but then overprice the AED. Many state and public health departments have grant programs to assist municipalities or first responder agencies with an AED purchase.

The best resource for AED grant information and funding are local and national non-for-profit agencies that work to raise awareness of sudden cardiac arrest. WNBA basketball player Tina Charles Hopey’s Heart Foundation provides AEDs to schools and recreation centers.

7. Purchase medical direction and AED management

You may benefit from adding a medical direction and AED management package to your purchase to help keep your AED program compliant with local and state laws for public access defibrillation requirements.

Program management helps with easy tracking of expiration dates, AED placement maps and status of AED trained responders. There are a number of web-based programs and services available to meet your specific needs.

8. Get the word out

Let the citizens and stakeholders for your agency know that you have purchased a new AED. When the City of West Chicago police department purchased and deployed 12 AEDs in their police officers’ vehicles, they publicized on the town’s website. Other ways to announce might be press conferences with local media and survivors of cardiac arrest. Your department can also post pictures of the new AEDs to its social networks and begin a conversation with the community

Finally, with dozens of AED models to choose from, don’t take the task of purchasing an AED without due consideration. Purchasing new AEDs for your department will take some hard work and commitment, but it will ultimately save lives in your community.

Del. medic looks back on 46 years in EMS

In 1968, when 18-year-old Barry Eberly was ready for EMS, he barely noticed that EMS hadn’t been invented yet.

“My father was a firefighter and ambulance attendant at the Camden-Wyoming (Delaware) Volunteer Fire Company,” Eberly said. “Being a typical son, I joined as soon as I could and ended up on the ambulance.

“My first call was an automobile accident. Our patient was a young lady who was alert and oriented; even I couldn’t do her any great harm.”

The “ambulance attendant” title Eberly and his father shared was a primitive EMS certification.

“Delaware was a little slow to pick up the concept of EMTs, but the title didn’t matter to me as much as the way I’d been brought up,” Eberly said. “My parents raised my sister and me to help people. Volunteering turned out to be an extension of that.”

Between 1968 and 1971, Eberly discovered he was a much better volunteer than a student.

“I was attending the University of Delaware and wanted to keep riding, so I got permission to respond with Newark’s fire department,” he said.

“Back in those days, when I was still in some sort of physical shape, I’d actually run a mile-and-a-half from the dorm to the station to make an engine or ambulance. I ended up spending too much time on that, which made me something less than the world’s best student.”

A Rumor of war

Eberly had resumed volunteering at Camden-Wyoming when he was summoned for duty halfway around the world.

“In 1971, Uncle Sam gave me a call and said he’d like me to visit Southeast Asia,” Eberly said, wryly, of his draft notice. “I tried to get into EOD (explosive ordnance disposal), just for the challenge, but my captain told me, ‘You don’t want to do that.’

“I was assigned to medical laboratory school at Fort Sam Houston in Texas, where they made me a lab tech. From there I went to Cam Ranh Bay in Vietnam to do free-radical assays and thin-layer chromatography on soldiers who were being tested for drugs.

“I had volunteered for Dust Off (Army medevacs) but was told it was a higher priority to clear people from drug abuse than pull them out of the jungle.”

Eberly says he learned more during 17 months in the service than he had in his previous 21 years.

“It was mostly figuring out how to get along with all kinds of people in a variety of physical and emotional states – not unlike what we do in EMS.”

Back to the world

Eberly returned to Delaware in 1972 and took a job riding ambulances for the city of Dover.

“As I got closer to figuring out what I wanted to do with my life, there were rumors the city might send people to paramedic school. I went in 1979.

“A lot of that had to do with the National Highway Safety Act and the paper on accidental death and disability (in 1966),” Eberly said. “That turned into a national movement.”

After 17 years as a paramedic and supervisor, Eberly became an instructor at Dover’s Bayhealth Medical Center. He started to see himself and his fellow educators as EMS gatekeepers.

“I found out not everyone learns at the same speed. Additionally, students don’t get equal opportunities; one may get four really good teaching cases in a day, while another goes a week without anything challenging.

“There seems to be a mindset that succeed or fail, everyone deserves an award, but I think most people who work in medicine know that some are cut out for it and some aren’t. Teachers are well-positioned to be part of that decision-making process.”

Life refractory to death

Eberly found an unusual call in 1994 especially educational.

“My partner, Dawn, and I had been assigned two paramedic students during a 14-hour shift. Sometime during that night, we got a call for a cardiac arrest.

“We found the patient, a man in his 80s, sitting in a recliner, quite obviously not breathing and most likely pulseless. Nevertheless, the student acting as team leader tried to engage the gentleman in conversation.

“Well, Dawn gave that kid a moderate hip check and advised both students they’d better start using some of the equipment we’d brought with us.

“It was one of those runs where you get complexes, pulses, and even respiratory effort every now and then. I was hopeful for a while, but we had pulseless bradycardia at the hospital. When that became asystole, the ER physician pronounced the patient. Then he changed his mind when I told him we’d seen signs of life earlier.

“We gave it another 20 minutes or so, during which the patient once again went into PEA followed by asystole. The physician pronounced him a second time, then went to talk to the family. Someone covered the patient with a sheet and we left the room.

“One of the hospital custodians who’d been cleaning up in that bay came to get me about five minutes later. He thought I’d want to see what was going on. He was right: The sheet over the 'dead' patient was rising and falling! I told the custodian to find the doctor, tell him not to say anything more to the family and come back right away. Then we took the sheet off and resumed resuscitation.

“The following morning that patient was extubated. He lived another three-and-a-half years neurologically intact.”

A slower pace

In 2014, after 46 years in EMS, Eberly retired.

Eberly monitors students in the simulation lab. (Image Barry Eberly)

“I’d been doing clinicals with students,” he said. “Sometimes we’d go 16 or 20 hours without seeing a patient older than me. I figured maybe the big EMS god in the sky was trying to tell me that now would be a good time to get serious about fly-fishing and golf.

“The truth is I miss EMS enormously. You develop a lot of relationships. It’s very satisfying to see people you’ve taught go out and do good things.

“On the other hand, I do enjoy fishing and golf.”

Author’s note: Eberly and Bruce Nepon are co-authors of the book Field Training Officer: Tips and Techniques for FTOs and Mentors and A Rumor of War is the autobiography of Marine Lieutenent Philip J. Caputo and his 16-month deployment to Viet Nam as Caputo explains, of "the things men do in war and the things war does to men."

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