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

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EMS1 Daily News

Ohio health network suggests EpiPen alternatives

Opponents suggest training non-medical personnel to use a vial and syringe to inject epinephrine could be risky.

‘Hacksaw Ridge’ tells the story of WWII medic and hero Desmond Doss

Doss objected to killing but enlisted and served without a weapon, earning the Medal of Honor.

Medical providers see Uber as a viable option for non-emergency patients

Some hospitals are embracing the ridesharing app for patients with limited transport options.

What do I know? I’m just a paramedic

Dealing with customers is a challenge, to say the least

5 signs the last EMS crew had a bad shift

In EMS, shift change is one of the biggest indicators of how the rest of the day is going to go.

5 Pokémon characters that remind us of paramedics

Relating Pokémon characters to EMTs is surprisingly easy

Fla. man survives lightning strike, spider, snake bites

The 31-year-old says "It's been a rough four years."

Alaskans feel even greater sting of controversial EpiPen price hikes

Without insurance, it's possible for some Alaskans to pay over $800 for a two-pack of EpiPens.

Defibrillator gives Wash. man another chance

Rapid intervention by a volunteer FF and a trainer at the gym had the man breathing by the time EMS arrived.

Austin medics treat 52 patients for K2 in a single day

Some of the patients were found unconscious or experiencing seizures.
Top

EMS1 Topic Articles

Ohio health network suggests EpiPen alternatives

Opponents suggest training non-medical personnel to use a vial and syringe to inject epinephrine could be risky.

‘Hacksaw Ridge’ tells the story of WWII medic and hero Desmond Doss

Doss objected to killing but enlisted and served without a weapon, earning the Medal of Honor.

Medical providers see Uber as a viable option for non-emergency patients

Some hospitals are embracing the ridesharing app for patients with limited transport options.

What do I know? I’m just a paramedic

Dealing with customers is a challenge, to say the least

5 signs the last EMS crew had a bad shift

In EMS, shift change is one of the biggest indicators of how the rest of the day is going to go.

5 Pokémon characters that remind us of paramedics

Relating Pokémon characters to EMTs is surprisingly easy

Fla. man survives lightning strike, spider, snake bites

The 31-year-old says "It's been a rough four years."

Alaskans feel even greater sting of controversial EpiPen price hikes

Without insurance, it's possible for some Alaskans to pay over $800 for a two-pack of EpiPens.

Defibrillator gives Wash. man another chance

Rapid intervention by a volunteer FF and a trainer at the gym had the man breathing by the time EMS arrived.

Austin medics treat 52 patients for K2 in a single day

Some of the patients were found unconscious or experiencing seizures.
Top

EMS1 Columnist Articles

‘Hacksaw Ridge’ tells the story of WWII medic and hero Desmond Doss

By Megan Wells, EMS1 Contributor

Hacksaw Ridge a new film directed by Mel Gibson – recounts the incredible story of WWII Army medic Desmond Doss, who is credited with saving 75 lives during the Battle of Okinawa in 1945.

Doss is known as the first conscientious objector in the military, not because he didn’t want to serve, but for his persistence to remain a non-combatant while serving. According to the Library of Virginia, Doss preferred the term "conscientious cooperator," stating, "While I believe in the commandment 'Thou shall not kill’ and that bearing arms is a sin against God, my belief in freedom is as great as that of anyone else, and I had to help those boys who were fighting for it.”

Doss specifically requested assignment to medical duty so he could help save, rather than take, human lives. He was the only soldier on the front lines without a weapon.

His stance on violence was not widely accepted in the military, and he was often harassed for his religious beliefs. His courageous rescue efforts while under fire during operations on Guam in 1944 and in the Philippines between 1944 and 1945, earned him a pair of Bronze Stars, and the harassment ceased.

Doss, a Private First Class, U.S. Army, Medical Detachment, 307th Infantry, 77th Infantry Division was deployed during the Battle of Okinawa, one of the bloodiest and largest battles of World War II.

A biography of Doss states, “Doss was in the thick of the battle and ministered to the wounded between 29 April and 21 May. On the first day, he was credited with rescuing 75 men who had come under withering artillery, mortar, and machine-gun fire at the top of a cliff.”

His courage earned him the Congressional Medal of Honor, presented by President Harry Truman in 1945. His Medal of Honor citation lists unbelievable details of his extreme bravery, for example, “He treated 4 men who had been cut down while assaulting a strongly defended cave, advancing through a shower of grenades to within 8 yards of enemy forces in a cave's mouth, where he dressed his comrades' wounds before making 4 separate trips under fire to evacuate them to safety.”

Doss was disabled by the injuries he sustained during the war. He died in 2006 at age 87, but his legacy lives on. ‘ Hacksaw Ridge’ premieres November 4 with Andrew Garfield as Doss.

What do I know? I’m just a paramedic

By Justin Schorr, EMS1 Contributor

I get yelled at while at work. It happens more than I’d like, but sometimes I just can’t seem to get things right.

I’ve either shown up late, been rude or didn’t complete the tasks I was assigned to do. And sometimes I get yelled at for doing exactly what I’m supposed to do. You may be thinking that I’ve got an overbearing boss or supervisor who just doesn’t get it. But it isn’t my boss who yells at me, it’s my customers.

Randal, the noted philosopher and video clerk in the movie Clerks, once said, “This job would be great if it wasn’t for the (expletive) customers.” His associate casually asks, “Which ones"”

“All of them.”

If you’re fortunate enough to work in a position that doesn’t require you to directly interact with the end user of your work, congratulations, you’ve hit the jackpot. Dealing with customers is a challenge, especially when they expect something other than what you provide or question the manner in which you provide it.

As a paramedic, you’d think it would be all hugs and kisses since we respond to life-or-death emergencies and handle them with our education, training, equipment, and experience, all integrated with the entire healthcare system. Still, we get yelled at.

“What took you so long"!” a mother shouts through clenched lips, barely keeping the lit cigarette in her mouth. “My daughter is having an asthma attack and it takes you 4 minutes to get here" And where’s the ambulance, I called for an ambulance, why did you bring the fire truck"”

It is a challenge, nay a skill, to be able to assess an 18-month-old’s breathing while the mother is screaming. Our usual instructions for her to quit smoking and the baby will improve over time are met with a tirade of expletives about her rights to live her life the way she wants. I get yelled at for doing my job because she doesn’t want to hear what my job actually is.

“This man’s bag fell onto my wife’s arm and made a red mark, I want a report taken!” is a far more common 911 call at a major airport than you want to believe. The plane is held at the gate until paramedics arrive in less than 6 minutes to address this ‘life-or-death emergency.’

As I walk into the jet bridge near the aircraft, I can hear yelling between 3 men. Turns out one of them is a police officer trying to calm the other two. One is complaining that he was bumped and a bag fell and he apologized. The other is irate that his wife has been ‘injured’ and demands action from the police.

“There you are, thanks for taking your sweet time. My wife’s arm is red and I demand you take a report immediately.” I glance behind me, wondering if someone who actually does that is nearby. When I ask the man and his wife, who has yet to chime in on the discussion, to exit the plane, he erupts into an expletive-laced outburst that results in his forcible removal from the plane at the request of the flight deck.

He was eventually detained by police for half an hour as a safety precaution, all the while screaming about how we’re all going to be fired, that we are incompetent, and that he will see to it that our careers are destroyed.

About 50 feet away, his wife and I can still hear him, but she consents to an assessment of the ‘arm injury’ that started this all. Nothing is wrong, even remotely. “Why didn’t you mention that you were OK" All of this could have been avoided,” I ask, rolling her shirt's sleeve back down and placing my hand over hers.

“You’re not a doctor, I should have the ambulance take me in to get checked out. It’s OK, you’ll get paid, that man on the plane will pay.”

When I tried to explain that the man on the plane was not detained, questioned or otherwise held, nor will he in any way be responsible for her decisions, her voice rose, and I decided it best to walk her back towards the husband, who had apparently run out of things to say and was simply grinding his teeth and murmuring about his rights.

As we walked, I offered an arm under her elbow in case she needed to steady herself. “Get your damned hands off of me. You can’t touch me,” she said, clearly disgusted with my presence.

Folks call 911 when they don’t know what else to do. Emergency or not, we’ll come running as fast as we can.

A young child having an asthma attack needs an Advanced Life Support assessment, possible treatment, and an evaluation of conditions to eliminate future events. That child, in particular, needed a home free of constant cigarette smoke to get healthy, but mom won’t listen to me—I’m just a paramedic.

A sore arm that used to be red can be uncomfortable, but likely does not require an ambulance to the hospital just “to get checked out.” Paramedics can make a fair assessment and diagnosis to advise you on the most appropriate manner of seeking additional care if needed.

What we don’t want to do is get yelled at for doing what we’ve been trained to do. Customers and their family berate paramedics all day long simply because of their misunderstanding of our capabilities, responsibilities, and mission.

That said, would this job be great without the customers" This job wouldn’t exist without the customers. Ultimately, I’d rather they yell at me than the alternative: Not be able to yell, or talk, or breathe.

Inside EMS Podcast: EMS education, funding and management in this week's news

Download this podcast on iTunes, SoundCloud or via RSS feed

In this week's episode of Inside EMS, co-hosts Chris Cebollero and Kelly Grayson discuss the importance of community paramedicine, EMS education and the "fire vs EMS" debate through this week's top news. After a Conn. city considers adding paramedic units to a fire station, Cebollero and Grayson discuss how the firefighter union disapproved of the possbility. The two discuss how leaders need to adapt and take on an educative role while working with the workforce of today.

A recent Nevada law allowing community paramedicine to be covered under Medicaid reimbursements, prompting the question of whether federal funding for such services will soon follow.

What can EMS learn from 100 years of the National Park Service?

Yellowstone, Yosemite, Glacier and the Grand Canyon are among the crown jewels of America that are under the stewardship of the National Park Service. Since August 25, 1916 the staff and volunteers of the federal agency have protected 412 national parks, monuments, battlefields, military parks, historical parks, historic sites, lakeshores, seashores, recreation areas, scenic rivers and trails and the White House.

Last week I visited several parks and monuments in South Dakota and Wyoming. During my hikes and explorations I contemplated the NPS 100-year anniversary and the lessons EMS leaders and providers can draw from the agency as it looks forward to its second century.

1. Uniformity from park to park
Park rangers have a distinct uniform, regardless of their work location or position in the NPS. Park visitors can quickly identify a ranger by the gray shirt, green pants and tan hat with a band. All park staff wear an NPS patch on their left shoulder.

EMS provider uniforms vary widely in color, styling and formality. Our uniforms are sometimes indistinguishable from law enforcement, often carry more fire department branding or try to carry over the trim of hospital scrubs or lab coats.

NPS vehicles are white with a single green stripe. NPS fire vehicles have a red stripe. Vehicle branding and specifications, likely easing purchasing across the NPS, is consistent.

2. A variety of services is available for visitors with different needs and wants
The NPS offers a multitude of services to meet the needs and interests of visitors. Front-country driving routes, scenic overlooks and interpretive programs cater to the majority of visitors looking to have a short-duration, low intensity experience. A smaller group of visitors can journey deep into the backcountry and wilderness of the larger parks. Devils Tower in Wyoming, the first national monument, offers visitors scenic views, ranger-led programs, overnight camping, hiking trails and rock climbing.

EMS, through programs like community paramedicine, is just beginning to explore how it might cater its expertise and service offerings to the people they served. For most agencies it is no longer enough to simply be a 911 response agency. EMS, in the second half of its first century, will interact with its customers through a combination of short patient contacts, ongoing community outreach programs and long-term connections with high-frequency utilizers.

3. Predictable, transparent fees are charged for access and experiences
The NPS charges an entrance fee for some of its properties and then visitors pay additional fees for experiences like overnight camping at the Badlands National Park or an interpretive tour of the Jewel Cave. In addition visitors can make donations to parks and a percentage of gift shop receipts are returned to the park. The fee system, though it varies from park to park, is expected, predictable and transparent to park visitors.

When a patient asks, "What will this ambulance ride cost"" the best answer is usually, "It depends." EMS fees depend on insurance coverage, level of service provided and local practices for billing. The specific cost, before providing care is rarely predictable or transparent.

4. Paid staff, volunteers and contractors work together as a team
The NPS provides services to visitors with 22,000 professional staff and 221,000 volunteers. The paid staff likely have specialized training and are considering the NPS as a career. Volunteers, often with unique expertise, are able to supplement the paid staff, support the different needs of the park and contribute in areas aligned with their interests. There are likely some parks with high numbers of professional staff and only a handful of volunteers. As well as some parks that are highly reliant on volunteers.

Is the 10 volunteers to one paid staff a comparable ratio for combination EMS departments to consider" The high participation of volunteers in the NPS might point to opportunities for public EMS agencies with all paid staff to integrate community-minded volunteers into non-clinical areas of operations.

The NPS also shifts some of the visitor experience and care to concessions operators. Hotels, restaurants, retail stores and recreational tours are often the domain of contactors working inside the park and within the regulations set by the NPS. The use of contractors is familiar to EMS agencies that contract certain types of calls, such as non-emergent transfers to private providers. Patient billing, staff hiring, education and fleet maintenance are other areas to consider contracting to a concession operator.

5. Career advancement and mobility
NPS professionals are able to, and often expected, to move between parks to advance their careers. Their knowledge, skills and abilities are transferable throughout the system. We met an interpretive ranger and educator at Devils Tower who was at his fourth park, including previous stints at Everglades National Park and Shenandoah National Park. He expects to be at Devils Tower for several years before moving to his next assignment.

Local protocol approval processes and licenses, based on state-specific scope of practice documents, make it difficult for paramedics to move between systems within a state and nearly impossible to move to services in different states. The Recognition of EMS Personnel Licensure Interstate Project is model legislation for States to make it easier for EMS providers licensed in one state to practice in other states. Making it easier for EMS professionals to move between organizations, including transition from the military to civilian EMS, is essential to the future of EMS.

Have you worked in a National Park as a paramedic or EMT" Tell us about your experience in the comments. What are other lessons for EMS from the NPS" Find Your Park to join in the NPS celebration.

This is your profession. Make of it what you will

I recently had the honor and privilege of addressing a number of paramedic school commencement exercises. While it is always a privilege to speak about EMS to my peers, I am particularly honored by these opportunities, because I was asked to speak not based upon a proposal I had submitted on a particular topic, but because of who I am, and my place in the EMS profession. It’s a tall order to fill, particularly because David Givot has already done it so well, but this is my answer.

**********

Congratulations, you’ve finished the marathon that is paramedic school. You’ve memorized your drug dosages, you’ve learned complex anatomy and physiology, and the pathophysiology of dozens of diseases. You’ve survived the crucible of pharmacodynamics and pharmacokinetics, and been baptized in acid-base balance and the nuances of the electron transport system. You’ve practiced megacodes and intubation until you can do them in your sleep.

And right now, if your teachers have done their jobs right, you’re brimming with confidence, tempered with the sober realization of the responsibility that will soon be in your hands. You’re ready to go out and save some lives.

But none of you, really, know what’s in store for you. Even I don’t know, and your teachers don’t know.

For the duration of your course, they’ve struggled with the daunting task of educating the paramedics of the future, without actually knowing what the paramedic of the future will be. Medicine is changing so fast, none of us can predict what form EMS will take — and what will be your role in it — in 10 or 20 years. What we do know is that it will be different than it is now.

So what I will tell you here today has nothing to do with medicine.

I’m going to talk about the truths that will serve you well over a long career, no matter what form that career will take. Even when technology and the forces of health care finance have radically transformed the face of your profession, there will still be patients, there will still be practitioners, and there will still be peers.

And your relationships with each of them will be what make the difference between your life’s calling and paramedicine being just another job.

Choose your mentors wisely
In the coming months, you’re going to learn how to apply the lessons of the classroom to practice on the street, and people with more time on an ambulance than you will have differing ideas of how to do that. I want you to choose your mentors well, because age does not necessarily convey experience, and experience does not necessarily convey wisdom.

The paramedics with twenty years of experience are far outnumbered by the paramedics with one year of experience repeated twenty times, for whom the only lessons learned were how to dodge calls, and the location of all the burger joints that give EMS discounts.

You’ll know the real EMS professionals not only by their clinical acumen, but by how they treat people. They’re the people with superior knowledge and skills, who have also discovered that a kind word and holding a hand are great therapy, too.

Clinical knowledge and technical skill don’t make you a great paramedic, they merely make you a competent one. You can’t take pride in those things. They’re what you owe to each and every patient.

The best thing you can give to your patients, the gift that distinguishes a great paramedic from a good one, is your compassion. Your patients are never going to understand or appreciate your mad intubation skills, or your encyclopedic knowledge of cardiology. They’re going to notice — and remember — how nice you were.

Never stop learning
I want you to become lifelong learners. Roughly half of what you learned in class — paramedic school, nursing school or medical school — is wrong. The problem is, no one knows which half.

The only way you will ever discover what information was valid and what was not, is by constantly trying to learn new things. If you spend just 15 minutes a week reading current EMS and emergency medicine research, you will be among the top 10 percent of your profession. If, five years from now, you are still approaching patient care in the same way you do now, you will have fallen far behind.

Do the small things well
I want you to understand that the little things matter. As Aristotle said, "We are what we repeatedly do. Excellence, therefore, is not an act, but a habit."

A supervisor once told me, "If you show up to work on time with your uniform pressed and your boots shined, turn in billable paperwork on time, wash your rig inside and out every shift, and don’t get any patient complaints … you can retire here, without ever having been a good paramedic."

And he’s absolutely right. You can spend twenty years doing just enough to get by, being comfortably anonymous and drawing a paycheck, and EMS will never be more than just a job to you.

What’s more, you can climb the career ladder into management with the same strategy. Management is filled with people who were great employees and mediocre medics. And a great many of them are poor leaders, as well.

Your standards should always be higher than your employer’s.

"If it falls your lot to be a street sweeper, sweep streets like Michelangelo painted pictures, sweep streets like Beethoven composed music, sweep streets like Leontyne Price sings before the Metropolitan Opera. Sweep streets like Shakespeare wrote poetry. Sweep streets so well that all the hosts of heaven and earth will have to pause and say: Here lived a great street sweeper who swept his job well."
- Martin Luther King, Jr.

There is no such thing as a call that is beneath you. Even a routine BLS transfer affords you the opportunity to enrich your life by connecting with another human being. Pay attention to little details, both in the care you provide, and the way you treat people, and you may one day become that rare creature, the great manager who was also a great paramedic.

Never doubt your impact
Many of you will go to work at agencies where the culture is the polar opposite of the admonitions I’m giving you today. You’ll feel outnumbered by apathetic or burned out co-workers, people whose commitment to our profession extends no farther than their next patient and their next paycheck.

But I want you to remember one thing: one person can make a difference.

A lone, mad monk named Martin Luther sparked the Protestant Revolution. Jonas Salk’s vaccine ended the scourge of polio. Five hundred seventy-six Florida voters decided the 2000 Presidential election.

Less than three percent of colonists took up arms in the American Revolution. They were outnumbered four-to-one by their own countrymen, yet they still managed to throw off the yoke of the most powerful nation in the world.

All it takes is a few committed people too angry to accept the status quo, too naive to realize that meaningful change is impossible, and too stubborn to quit. Be a Three Percenter for EMS, and we can shape the future of this profession ourselves.

In closing, I urge all of you to become stewards of emergency medical services. Live the example of your wise mentors. Pass on that culture of compassionate professionalism and learning to the next generation. Constantly question dogma. Call out unprofessionalism and misbehavior when you see it, and don’t let unethical acts hide behind a false notion of brotherhood.

This is your profession. Make of it what you will.

Admiration, respect for caregivers everywhere

Over the years I have made claims about the occupational hazards facing EMS providers. Bloodborne pathogens, violence, ambulance crashes and the myriad of musculoskeletal injuries suffered from every day lifting and moving are part and parcel of field care medicine. Even as the industry works to improve workplace safety, EMTs and paramedics continue to face career-ending events on a daily basis.

Then, a video of a little boy spreads through the internet over the weekend, and it puts things into perspective.

The boy was just pulled from the remains of his home in Aleppo, Syria after it was hit by bombs. A rescuer is seen carrying the child from the wreckage into the back of an ambulance. The rescuer places the boy in the jump seat and goes back to help rescue others. The child is mute and appears dazed. His head is bloody and his clothes and body are covered in concrete dust.

It’s very hard to fathom what it must be like to be a civilian EMS provider working to rescue victims of war. Mainstream media often romanticizes or overly dramatizes the working conditions of a war zone.

The simple fact is the work is not romantic or dramatic. It is ugly, hard and gruesome. A civil defense group known as the White Helmets has been a large part of Syria’s EMS and rescue system in antigovernment held territories since the conflict began. Funded by various outside agencies, the group has reportedly lost 134 of its own members during the fighting. The group members are apparently targeted by opposing forces as they attempt to rescue civilians.

In the U.S., we get understandably anxious and upset when we have to deal with the occasional carnage of violence and the rare mass casualty event. I’m not sure if I can begin to understand what it feels like to respond to such incidents on a daily basis. It’s no wonder that most veteran combat medics or corpsmen rarely talk about their experiences in active war theaters; and the constant threat of being killed for doing your job is the stuff of nightmares and post-traumatic stress.

Mind you, I am not choosing a side in the conflict. I don’t have to agree or disagree with the political aspects of the conflict in order to admire and respect those who unquestioningly respond to the call for help, even at great peril to one's own life.

I'm proud that in some small way, my work is connected to theirs even though we are literally worlds apart both geographically and ideologically. Just as it is with my fellow EMS providers at home, I hope and pray for their physical and emotional well-being as they do the best they can.

Prove It: Real-time feedback devices improve CPR training

Today is training day for the crew of station 27. After breakfast, dispatch places both the engine and the medic crews out of service and sends them to the training center. Today’s class is a CPR refresher course.

However, this refresher course is different than any previously taught. Today, the instructors are adding a new CPR feedback device to the manikin practice, which will provide real-time performance data to the crew. The instructor explains the devices will help insure everyone provides the correct rate, depth, and recoil. The device also provides an audible warning when a pause in chest compressions lasts for 10 or more seconds. The instructor explains the department will place one of these devices on every response vehicle in the city during the next week in the hopes of fine-tuning CPR performance and improving out-of-hospital cardiac arrest survival rates for the community.

Initially, the devices are a bit cumbersome for the crew. No one has ever used one before and it takes some getting used to. As each of the firefighters and medics take turns on the manikin, they slowly begin to adjust their performance based on the feedback provided by the device.

However, one of the station officers is becoming increasingly frustrated with the device. He grumbles about being CPR certified for more than 25 years and he does not need a machine to tell him how to do CPR. He thinks his department could have saved the money spent for these devices on something with a greater benefit to the department.

Despite the best intentions of the training officer, the lieutenant remains unconvinced the device will actually change the way he and his crew perform CPR.

Study review: CPR performance with a feedback device
Using a manikin, researchers measured the impact that various CPR feedback or prompt devices had on specific CPR quality metrics, such as chest compression depth, compression rate, inadequate recoil and incorrect hand position [1]. The participants were all nurses who had previous experience with CPR, but had never used any type of feedback or prompt device. Each nurse either worked in the emergency department or as part of the EMS team with an average (mean) work experience of 12.4 years. Before starting the study, members of the research team trained the nurses to correctly use each of the devices.

The researchers compared manual CPR without the use of a device (standard CPR) to CPR using each of three commonly available devices; TrueCPR™ Coaching Device from Physio-Control, CPR-Ezy™ from Health Affairs, LTD. and the iCPR app from DSign S.r.l. Random assignment determined which device (or no device) each nurse would start with. Each nurse performed eight minutes of single rescuer CPR with the randomly assigned device (or no device).

Upon conclusion, the nurse rested for 20 minutes before being assigned to one of the remaining options. This process continued until each nurse performed eight minutes of CPR with each of the three devices and eight minutes of standard CPR without a device.

After completing all four CPR sessions, each nurse also completed a survey that described a personal level of confidence, whether each device was easy and comfortable to use and whether each device provided a distraction from performing CPR.

Researchers collected the data for this study during the summer of 2014, before the release of the 2015 AHA CPR Guidelines. As a result, the researchers compared all CPR quality measures to those recommended by the 2010 European Resuscitation Council (ERC) Guidelines, which called for a chest compression depth of at least 5 cm (50 mm), a rate between 100 and 120 compressions per minute, full chest recoil and hands positioned on the lower half of the sternum [2].

Results: Feedback device comparison
The only study condition to achieve the recommended chest compression depth of 50 mm was CPR performed while using the TrueCPR™ feedback device. With this device, nurses achieved significantly deeper chest compressions than with the other devices or no device at all. In decreasing order, nurses achieved a mean chest compression depth of 54.5 mm with TrueCPR™, 45.6 mm with CPR-Ezy™, 44.6 mm with standard CPR using no feedback device and 39.6 mm using the iCPR app. Not only did the TrueCPR™ device produce deeper average chest compressions, but the device also produced the highest proportion of compressions meeting the ERC depth recommendations.

All three of the devices had a significant impact on chest compression rate. The only condition that produced a chest compression rate outside of the recommended rate (100-120 per minute) was standard CPR without the use of a device. In decreasing order, nurses performed CPR at a mean rate of 129 compressions per minute using standard CPR with no device, 110 compressions per minute using TrueCPR™, 104 compressions per minute using the iCPR app, and 102 compressions per minute using CPR-Ezy™.

Since the ERC recommended a compression depth greater than 50 mm, full chest recoil should also be greater than 50 mm. Use of the TrueCPR™ device resulted in a significantly higher proportion of compressions meeting the recommendation for chest recoil. In decreasing order, the proportion of compressions meeting the ERC recommendations for chest recoil was 78 percent with TrueCPR™, 70 percent with CPR-Ezy™, 68 percent with standard CPR using no device, and 65 percent using the iCPR app.

The manikin and software program used in this study were able to measure whether the compression point was on the lower half of the sternum (correct), or in some other location, such as too far to one side or too high or low on the chest (incorrect). Use of the TrueCPR™ device resulted in the highest proportion of compressions in the correct position. In decreasing order, the proportion of chest compressions with the correct pressure point was 98 percent with TrueCPR™, 95 percent with standard CPR using no feedback device, 93 percent with CPR-Ezy™, and 77 percent using the iCPR app.

Finally, the researchers created a metric called effective compression, which was defined as the proportion of compressions meeting the ERC recommendations for depth, recoil, and hand position. TrueCPR™ significantly outperformed any of the other conditions. In decreasing order, the proportion of effective chest compressions was 86 percent with TrueCPR™, 40 percent with CPR-Ezy™, 38 percent with standard CPR using no device, and 33 percent using the iCPR app. The proportion of effective chest compressions associated with TrueCPR™ remained significantly better regardless of whether the measurement occurred at the beginning of the eight-minute CPR period (90 percent) or the end (76 percent).

In a head-to-head comparison of user satisfaction variables between the three devices, the study participants found the TrueCPR™ device easiest and most comfortable to use. The device also provided the user with the highest level of confidence and produced the least amount of distraction.

In the multivariate regression analysis, the researchers also found that both provider experience and work location influenced the overall proportion of effective chest compressions. Nurses with more experience outperformed those with less experience when performing standard CPR without a device and when using the iCPR app. Additionally, those nurses primarily assigned to EMS fieldwork outperformed those assigned to the ED when performing standard CPR without a device and when using the iCPR app.

What this means for you
The term feedback device is commonly used to describe a variety of tools with a common goal to improve the quality of CPR provided during a resuscitation attempt. However, the term may or may not actually describe the way the device works. True feedback devices offer information about what rescuers are actually doing, so they can make real time adjustments to CPR performance. In this study, the TrueCPR™ and the CPR-Ezy™ devices functioned as true feedback devices.

Prompt devices on the other hand do not provide information about how rescuers are performing. While the rescuer can make real-time adjustments to CPR performance based on that information, the device is not actually measuring what the rescuer is doing. For example, metronomes use an audible tone to prompt the rescuer to perform chest compressions at a predetermined rate, but cannot measure if the rescuer is actually performing synchronized compressions.

Intuitively, it is reasonable to expect feedbacks devices to outperform prompt devices. However, all feedback devices may not have the same impact on performance. In this study, only one of the feedback devices significantly outperformed the prompt device. Incidentally, that feedback device even outperformed standard non-device assisted CPR.

Generally, CPR training utilizing a real time feedback component results in improved student performance. Use of the TrueCPR™ device during CPR training improved compression rate and depth performance on a manikin by a group of in-hospital healthcare providers [3]. In a randomized controlled trial involving trained rescuers, one type of feedback device utilizing pressure sensing technology (CPR-Ezy™) significantly improved compression depth while a different device utilizing an accelerometer (Q-CPR™) resulted in worsening depths [4]. Researchers at the Medical University of Vienna found improved CPR measures when medical students received feedback during training, but performance measures associated with a mechanical device were no better or no worse than those associated with feedback from a trained human instructor [5].

However, the impact of this improved training on clinical outcomes is less clear. Early studies could find no significant improvement in outcome variables associated with the use of a feedback device in either the in-hospital [6] or out-of-hospital environments [7]. More recently, a multi-center study of in-hospital cardiac arrest could not demonstrate any survival advantages associated with the addition of feedback devices to a standard resuscitation attempt [8].

In contrast, secondary analysis of data collected during an investigation of CPR quality related to the use of one specific real-time audio-visual feedback device during an out-of-hospital resuscitation attempt transported by a helicopter demonstrated that use of the device resulted in increased survival to emergency department arrival, but not increased survival for an additional 24-hours or increased survival to hospital discharge [9]. Similarly, use of the Cardio First Angel™ CPR device instead of manual CPR with no feedback device in ICU patients resulted in improved ROSC and reduced rib fractures in ICU patients [10]. In contrast, the odds of surviving neurologically intact following an out-of-hospital cardiac arrest were reduced by about 50 percent when rescuers used the Q-CPR feedback device during the resuscitation [11].

In the largest trial to date to address this issue, researchers with the Resuscitation Outcomes Consortium could find no survival advantages provided by the use of a feedback device during resuscitation from out-of-hospital cardiac arrest [12]. The most recent meta-analysis of clinical trials using audio-visual feedback devices during resuscitation could find no evidence the devices improve clinical outcomes [13].

In a before and after observational study, the addition of real-time audiovisual feedback along with a targeted CPR quality training curriculum improved clinical CPR quality metrics, which resulted in an increased likelihood of both survival to hospital discharge and favorable function outcome [14]. However, because of the nature of this study no one can be sure whether the improved outcome measures resulted from the real-time feedback, the increased focus on quality CPR training, or some other unmeasured variable.

There are a number of possible reasons why no study has ever been able to clearly demonstrate clinical improvement with the use of any of these devices. First, survival following out-of-hospital cardiac arrest is time dependent. Patients generally have more favorable outcomes when ROSC occurs sooner rather than later. To increase the chances of survival, the first three links in the chain of survival should occur before EMS personnel arrive on the scene. If they do not, the chances of survival significantly decrease. By the time EMS arrives on the scene to begin using a feedback device, it is possible the window of opportunity for many of the early variables known to improve survival has already closed.

Although simulation data shows the use of feedback or prompt devices does improve CPR metrics, it is possible the improvements do not represent meaningful or useful data for real patients. Performing CPR on a manikin during a training situation is different than performing CPR on a human being in the ICU or ED, which is different still from performing CPR in the out-of-hospital environment.

The 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care recommends the use of feedback devices as an adjunct to CPR training [15]. If feedback devices are not available, instructors should substitute prompt devices during CPR training.

Feedback and prompt devices appear to improve CPR quality metrics obtained during the simulated management of cardiac arrest. However, not all of the devices perform equally. EMS agencies considering the addition of feedback devices to the management of out-of-hospital cardiac arrest should investigate all options before choosing a particular technology.

The author has no financial interest, arrangement, or direct affiliation with any corporation that has a direct interest in the subject matter of this presentation, including manufacturer(s) of any products or provider(s) of services mentioned.

References

  1. Truszewski, Z., Szarpak, L., Kurowski, A., Evrin, T., Zasko, P., Bogdanski, L., & Czyzewski, L. (2016). Randomized trial of the chest compressions effectiveness comparing 3 feedback CPR devices and standard basic life support by nurses. American Journal of Emergency Medicine, 34(3), 381–385. doi:10.1016/j.ajem.2015.11.003
  2. Koster, R. W., Baubin, M. A., Bossaert, L. L., Caballero, A., Cassan, P., Castrén, M., Granjag, C., Handley, A. J., Monsieurs, K. G., Perkins, G. D., Raffay, V., & Sandroni, C. (2010). European Resuscitation Council guidelines for resuscitation 2010 section 2. Adult basic life support and use of automated external defibrillators. Resuscitation, 81(10), 1277–1292. doi:10.1016/j.resuscitation.2010.08.009
  3. Wutzler, A., Bannehr, M., von Ulmenstein, S., Loehr, L., Förster, J., Kühnle, Y., Finn, A., Storm, C., & Haverkamp, W. (2015). Performance of chest compressions with the use of a new audio-visual feedback device: A randomized manikin study in health care professionals. Resuscitation, 87, 81-85. doi:10.1016/j.resuscitation.2014.10.004
  4. Yeung, J., Davies, R., Gao, F., & Perkins, G. D. (2014). A randomised control trial of prompt and feedback devices and their impact on quality of chest compressions--a simulation study. Resuscitation, 85(4), 553-559. doi:10.1016/j.resuscitation.2014.01.015
  5. Pavo, N., Goliasch, G., Nierscher, F. J., Stumpf, D., Haugk, M., Breckwoldt, J., Ruetzler, K., Greif, R., & Fischer, H. (2016). Short structured feedback training is equivalent to a mechanical feedback device in two-rescuer BLS: A randomised simulation study. Scandinavian Journal of Trauma, Resuscitation, and Emergency Medicine, 24(1), 70. doi:10.1186/s13049-016-0265-9
  6. Abella, B. S., Edelson, D. P., Kim, S., Retzer, E., Myklebust, H., Barry, A. M., O'Hearn, N., Hoek, T. L., & Becker, L. B. (2007). CPR quality improvement during in-hospital cardiac arrest using a real-time audiovisual feedback system. Resuscitation, 73(1), 54-61. doi:10.1016/j.resuscitation.2006.10.027
  7. Kramer-Johansen, J., Myklebust, H., Wik, L., Fellows, B., Svensson, L., Sorebo, H., & Steen, P. A. (2006). Quality of out-of-hospital cardiopulmonary resuscitation with real time automated feedback: A prospective interventional study. Resuscitation, 71(3), 283-292. doi:10.1016/j.resuscitation.2006.05.011
  8. Couper, K., Kimani, P. K., Abella, B. S., et al. (2015). The system-wide effect of real-time audiovisual feedback and postevent debriefing for in-hospital cardiac arrest: The cardiopulmonary resuscitation quality improvement initiative. Critical Care Medicine, 43(11), 2321-2331.
  9. Sainio, M., Kämäräinen, A., Huhtala, H., Aaltonen, P., Tenhunen, J., Olkkola, K. T., & Hoppu, S. (2013). Real-time audiovisual feedback system in a physician-staffed helicopter emergency medical service in Finland: The quality results and barriers to implementation. Scandinavian Journal of Trauma, Resuscitation, and Emergency Medicine, 21, 50. doi:10.1186/1757-7241-21-50
  10. Vahedian-Azimi, A., Hajiesmaeili, M., Amirsavadkouhi, A., Jamaati, H., Izadi, M., Madani, S. J., Hashemian, S. M. R., & Miller, A. C. (2016). Effect of the Cardio First Angel™ device on CPR indices: A randomized controlled clinical trial. Critical Care, 20(1), 147. doi:10.1186/s13054-016-1296-3
  11. Pearson, D. A., Darrell Nelson, R., Monk, L., Tyson, C., Jollis, J. G., Granger, C. B., Corbett, C., Garvey, L., & Runyon, M. S. (2016). Comparison of team-focused CPR vs standard CPR in resuscitation from out-of-hospital cardiac arrest: Results from a statewide quality improvement initiative. Resuscitation, 105, 165-172. doi:10.1016/j.resuscitation.2016.04.008
  12. Hostler, D., Everson-Stewart, S., Rea, T. D., Stiell, I. G., Callaway, C. W., Kudenchuk, P. J., Sears, G. K., Emerson, S. M., Nichol, G., & the Resuscitation Outcomes Consortium Investigators. (2011). Effect of real-time feedback during cardiopulmonary resuscitation outside hospital: Prospective, cluster-randomised trial. British Medical Journal, 342, d512. doi:10.1136/bmj.d512
  13. Kirkbright, S., Finn, J., Tohira, H., Bremner, A., Jacobs, I., & Celenza, A. (2014). Audiovisual feed- back device use by health care professionals during CPR: A systematic review and meta-analysis of randomized and non-randomized trials. Resuscitation, 85(4), 460–471. doi:10.1016/j.resuscitation.2013.12.012
  14. Bobrow, B. J., Vadeboncoeur, T. F., Stolz, U., Silver, A. E., Tobin, J. M., Crawford, S. A., Mason, T. K., Schirmer, J., Smith, G. A., & Spaite, D. W. (2013). The influence of scenario-based training and real-time audiovisual feedback on out-of-hospital cardiopulmonary resuscitation quality and survival from out-of-hospital cardiac arrest. Annals of Emergency Medicine, 62(1), 47-56. doi:10.1016/j.annemergmed.2012.12.020
  15. Bhanji, F., Donoghue, A. J., Wolff, M. S., Flores, G. E., Halamek, L. P., Berman, J. M., Sinz, E. H., & Cheng, A. (2015). Part 14: Education: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 132(suppl 2), S561–S573. doi:10.1161/CIR.0000000000000268

What can CDC data tell us about first responder suicide?

The Centers for Disease Control and Prevention released a review of suicide rates by occupational group on July 1, 2016 [1]. The report is based on data obtained from the National Violent Death Reporting System, one of the databases the CDC uses to track suicides.

The CDC researchers used the Standard Occupational Classification system to categorize people into occupations. The Standard Occupational Classification system uses primary and secondary classification groups to classify occupations. EMTs and paramedics are members of group 29, Healthcare Practitioners and Technical Occupations. Firefighters and police officers are members of group 33, Protective Service Occupations.

While initially hopeful that this review would improve the information available about the suicide rate in first responders, it has some limitations that prevent any conclusions from being made about first responder suicide.

SOC group limitations
Standard Occupational Classification groups are broad designations with multiple sub-classifications in each category. First responders do not have their own category, and are split into two categories with multiple other professions.

For example, group 29 also includes physicians, pharmacy technicians and traditional Chinese herbalists. While group 33 also includes animal control workers, crossing guards and playground monitors. This means that the suicide rate for Standard Occupational Classification groups 29 and 33 include people from a number of other professions and do not accurately represent the suicide rates of first responders.

A person’s Standard Occupational Classification grouping was also based on their listed profession on their death certificate or other official record. Since people can only be assigned to one group it is likely that a large percentage of volunteer first responders were not classified as members of groups 29 and 33, further skewing the numbers.

The 17 states included in the review reported 12,312 total suicides or about one-third of the total number of suicides in 2012 [1]. Of the 12,312 individuals, a total of 450 were classified into group 29 and 295 into group 33. Given how broad these groups we have no way of knowing what percentage of each group were first responders or if the percentage of first responders included had a statistically significant impact on the suicide rate for the overall group.

What we can learn
Unfortunately for first responder suicide prevention, not much can be ascertained from the report. Some groups, such as the legal professions group, are more homogenous, and thus the information provides an accurate idea of the suicide rate within that field. The CDC plans on releasing another review using the 2014 data from 32 states.

The importance of numbers
An accurate idea of the suicide rate among first responders is an important step towards understanding the problem and lowering the rate. The data can also help us track suicide clusters or identify other patterns that might exist. Having an accurate idea of the suicide rate is also vital to knowing if interventions and education aimed at reducing the suicide rate are successful in subsequent years.

While the CDC does collect suicide data via the National Violent Death Reporting System, first responder suicides are not tracked by the government in the same way line of duty deaths are. If you know of a first responder suicide you can make a confidential report to either the Firefighter Behavioral Health Alliance or The Code Green Campaign.

Reference

1. Suicide Rates by Occupational Group — 17 States, 2012. Weekly / July 1, 2016 / 65(25);641–645.

Tips for respiratory assessment and just-in-time education

Taking a role as a field trainer is no simple task. Many EMS services give the nod to strong, experienced EMTs and paramedics and expect that good clinical skills will directly translate to effective teaching strategies. While some trainees may be clinically savvy and simply need direction, some new hires require far more intensive assistance and a department's strongest clinician may not be a natural teacher.

The difficulties of being a trainer
There are a few particular difficulties faced by both new and experienced field trainers. First, there is a desire to mold every trainee into a newer version of yourself. While you may be a great clinician, there are many ways to accomplish the goal of providing safe, effective patient care and being a carbon copy of your trainer isn’t necessarily one of those steps.

Remember that you have countless individual experiences that have shaped the type of provider you are today and you likely approach calls differently today than you did at the beginning of your career. A brand new EMT or paramedic simply can’t be a carbon copy because he or she doesn’t have your breadth of experience.

One potential approach, in conjunction with your agency leadership and medical director, is to develop an understanding of the measurements for success in your field training program. For instance, it could be as simple as identifying objectives that a new hire should be able to do:

  • Know the protocols
  • Perform an assessment
  • Build a differential diagnosis
  • Design and execute a treatment plan
  • Document assessment and care

By designing objectives in this way, a new hire can be evaluated on his or her ability to practice medicine broadly without staying in the training program until trauma, STEMI, stroke and cardiac arrest all get checked off the to-do list. This approach requires faith by the trainer and agency that a provider with those skills and knowledge of the protocols can make good treatment decisions when faced with a new situation.

A second difficulty faced by trainers in the EMS environment is how far to let a trainee go down the wrong path before intervening. There are obviously situations which would pose a patient safety risk, and in such instances the trainer must step in quickly.

In other cases, however, the call may simply not be moving fast enough or a trainee may make a small mistake. It is important to remember that providers learn from their mistakes and as long as an immediate safety issue isn’t present, there is educational benefit to letting small problems play out. This gives the trainee an opportunity to recognize and correct mistakes and give insight into how he or she responds to challenging situations. A trainer should not be too quick to jump in if a patient safety concern does not exist.

Coaching in the moment
Once the decision to intervene is made, the trainer needs to understand how best to provide coaching. Obviously a potentially serious medication error should be handled differently than forgetting to check a blood glucose on a patient complaining of dizziness with no diabetic history.

A new EMS provider may feel self-conscious or lack confidence. Abruptly jumping in with a dismissive or rude comment likely won’t result in a lesson learned and may further distance the trainee.

In the patient case, a man with shortness of breath, the trainer starts off on the right path, asking the trainee to review common causes of respiratory distress while responding. From there the call heads downhill quickly. Dismissive or diminutive comments are common and the approach isn’t so much one of guidance as it is hazing.

A more productive approach would have been to suggest particular assessments or treatments in an attempt to jog the trainee’s memory. Often trainees can be guided back onto the correct path by breaking the cycle of questioning which has led them astray.

Basic respiratory assessment
The goal of the respiratory assessment should be to identify the underlying cause of the shortness of breath. In this case, the patient has a history of recent weight gain and a productive cough along with hypertension and hypoxia. Kristen has clearly gotten off track and seems to be focused on a potential COPD exacerbation given Steve’s history as a smoker. COPD is certainly one potential cause but there are others which are more likely. Rather than belaboring the smoking question, Kristen should focus on the onset of Steve’s respiratory distress, the nature of his cough and sputum it is producing and what his lungs sound like.

Another tip for respiratory assessment is to limit the number of open-ended questions. Family or other bystanders may be able to answer some questions and asking questions of the patient which can be answered by nodding yes or no or with hand gestures may keep them from feeling more short of breath.

Building a differential diagnosis
In this instance there are two potential causes of Steve’s shortness of breath: CHF and COPD. While Steve does not report a history of either diagnosis, many patients have a history of both and being able to differentiate between the two is key to treatment decisions.

Lung sounds are one potential clue with rales (bubbling) often associated with CHF and wheezes often associated with COPD. In some cases, however, CHF may present with wheezes as well. Steve’s recent weight gain and hypertension certainly suggest CHF. As the heart stops pumping effectively, fluid is retained and backs up in the extremities as well as the lungs.

A productive cough is also an important finding particularly if there is a report of sputum type and color. Yellow or green sputum may be associated with an infection — particularly in the presence of a fever —while pink sputum may be associated with fluid retention and CHF.

Based on the limited information collected by Kristen, CHF still seems to be the most appropriate working diagnosis. Providing this summary to her and asking her to work to confirm that diagnosis may help guide the remainder of her assessment and get her back on track.

Case conclusion
You realize quickly that your coaching of Kristen on this call has been misdirected. You mention that the rapid weight gain, hypertension and gradual onset of symptoms seem to point to CHF as an underlying cause. You ask Kristen to work to confirm that diagnosis and to build a treatment plan.

Kristen thinks for a moment and immediately listens to Steve’s lungs. "I can hear rales in both bases," Kristen reports. She then kneels down and checks for edema in Steve’s legs finding pitting on both lower legs.

Kristen turns to the firefighter and asks him to set up CPAP and then asks you to confirm the ETA for the ALS intercept. She seems to be back on track.

10 EMS screw-ups that can get you in trouble

Remember this video of a Florida paramedic dumping a patient off a stretcher last year" It sparked an emotional debate about whether job-related dissatisfactions were justifiable causes of bad behavior by caregivers. While most of us were lamenting the shame of the recorded spectacle my friend Tom Bouthillet, a paramedic, teacher and EMS1 columnist, had a more constructive contribution: Make that incident part of a "never-do" list for EMS providers.

Tom’s pretty busy teaching 12-lead-EKG interpretation to, like, everyone, so I told him I’d take this on. My chief criteria for items on the list were:

1. The never do's had to be EMS-related,

2. They had to apply to everyone in the field, regardless of certification, and

3. I had to know of at least one occurrence of each. That last rule allowed me to exclude such frivolous acts as hitting your partner with a tire iron. Hmm … could be the start of another list.

Here are my 10 never-do items in no particular order:

1. Knowingly responding to a call without essential supplies or equipment.
I had to add "knowingly" when I realized I’d otherwise broken this rule many times by relieving a crew that hadn’t refilled the oxygen or replaced the LifePak batteries during their shift. I’d get aggravated, then they’d get aggravated at me for being aggravated. Sometimes we’d lose sight of the main issue: not being able to deliver appropriate care.

2. Initiating unwanted physical contact with patients.
This isn’t just about inappropriate touching of patients; it also covers medical procedures conscious patients haven’t consented to. Let me just add that some of you are scaring me with talk of routine drilling for bone marrow instead of even attempting IVs. If I’m awake and you come at me with a power tool, I will aggressively seek safety.

3. Dropping patients from carrying devices.
This doesn’t have to be intentional to be alarming. In the days before powered stretchers, I came close to mismanaging heavy patients during two-person lifts more than once. The hardest part for me was putting my pride aside and admitting we needed more people. If the weight of a loaded scoop, stair chair or backboard divided by the number of lifters exceeds your personal limit, find another way or get help.

4. Delivering care not compliant with medical direction.
As much as I hate the "paragod" characterization of paramedics, I have to admit it applies to some of my colleagues — the ones who think medical school is an unnecessarily tedious route to independent practice. I would remind them that street experience, no matter how bold or intense, is not a substitute for medical direction.

5. Driving while distracted.
Since I was a kid, society has been reluctant to associate driving with death. We didn’t have seat belts in our ’62 Chevy Bel Air until my father installed them. When I started borrowing the car a few years later, blood alcohol was still an unfamiliar term. DWI and DUI were things criminals did — not parents or next-door neighbors. Now texting is another way to ruin many lives simultaneously while behind the wheel. Please stop.

6. Working while impaired.
The use of alcohol and other drugs during business hours isn’t a problem unique to EMS. Having a few drinks at lunch was a common practice when I was in the corporate world. I wish I could tell you executives started tempering their intake because of conscientiousness and a concern for others, but I don’t remember any change in midday libation until the IRS started limiting deductions for meals.

7. Failing to respond as dispatched.
There are two sides to this, both bad: going where you shouldn’t and not going where you should. In EMS, doing what we’re told usually works for everyone. The glamor of stubbornness and single-mindedness is a myth propagated by absurd, televised renditions of cowboy medics and their Hollywood-esque war stories.

8. Not possessing the required licenses or certifications.
It’s easier than it should be at some agencies to work without proper credentials. Even if you’re not a believer in earning whatever you claim to be, the prospect of unemployment plus penalties for impersonating medical providers should be reason enough to schedule refreshers with plenty of lead time.

9. Falsifying patient-care records.
If the obvious ethical issue isn’t enough to convince you, consider you’re an audit away from infamy if you document what you should have done.

10. Declaring a living patient dead.
Avoiding this mistake seems uncomplicated, given access to EKGs and physicians, yet we hear of new cases every year or so. Not a good way to make the six o’clock news. When death is not quite obvious in the absence of rigor mortis and dependent lividity, work your patient or you might have some ‘splainin’ to do.

That’s my list of never do's. What should we add"

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