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

They barricaded themselves in their bedroom after it attacked their baby; 22-pound Lux has a history of violence and will get medical attention and therepy

She was taken to a local hospital; the driver managed to escape the wreck and flee the scene

The explosion killed one person and injured 15 others; a resident in a nearby building smelled gas shortly before the explosion

The ambulance service achieved its re-accreditation this week

With all respect to the physician community, please think bigger

From providing access to medical records and dictionaries, to streaming live video to an emergency room physician for guidance on patient care, wearable technologies are connecting paramedics, EMTs and hospitals in new ways. Here are five wearable technologies for EMS providers that have the potential to improve access to data and support the emerging telemedicine model. Epson and Evena Medical’s ...

Doctors used oxygen, chest compressions and a defibrillator to successfully bring rhythm back to his heart, six months after had a procedure for an irregular beat

AMR will increase patient charges by 5 percent, and reimburse the city for services historically provided by the fire department

An ambulance and medic shortage has caused the department to fall short of of a state-mandated response goal

The patient tore out his IV and tried to escape from the vehicle, causing them both to fall onto the pavement

She was taken to a local hospital; the driver managed to escape the wreck and flee the scene

The explosion killed one person and injured 15 others; a resident in a nearby building smelled gas shortly before the explosion

The ambulance service achieved its re-accreditation this week

With all respect to the physician community, please think bigger

From providing access to medical records and dictionaries, to streaming live video to an emergency room physician for guidance on patient care, wearable technologies are connecting paramedics, EMTs and hospitals in new ways. Here are five wearable technologies for EMS providers that have the potential to improve access to data and support the emerging telemedicine model. Epson and Evena Medical’s ...

Doctors used oxygen, chest compressions and a defibrillator to successfully bring rhythm back to his heart, six months after had a procedure for an irregular beat

AMR will increase patient charges by 5 percent, and reimburse the city for services historically provided by the fire department

An ambulance and medic shortage has caused the department to fall short of of a state-mandated response goal

The patient tore out his IV and tried to escape from the vehicle, causing them both to fall onto the pavement

The plane nose dived 75 feet into the ground when the parachute got entangled and they were both seriously injured; the skydiver says he'll jump again

Clinicians, like paramedics who intubate patients with poor airway control, will use a few ways to describe the condition of the airway before beginning laryngoscopy, such as a Mallampati Score or Cormack-Lehane Grading. It may be easy to think that one evaluation method is like another, and use them interchangeably. It's better to know that each one provides information about the airway that is distinct from the other.

Airway Class is what you see when looking in the mouth. It’s a means of predicting difficult intubation, and is measured as a Mallampati Score based on how much room there is inside the mouth.

Airway Grade is what you see in the posterior pharynx with a laryngoscope. It is a more accurate measure of how much trouble you are going to have passing a tube, and is evaluated with a Cormack-Lehane Score.

Both are easy to do

Keeping score with ‘class’

If you ask the patient to open their mouth wide and you see a lot of room and large dark space, that is a Mallampati Class 1. If you see some room but not a lot, that’s a Class 2. If you see just a little room, that’s a Class 3. If you don’t see anything but tongue, that’s a Class 4.

Since Mallampati is for predicting how much trouble you might have intubating, if the patient is a Mallampati Class 4, get ready for a challenge.

Getting good ‘grades’

Cormack-Lehane Grading is done with a laryngoscope. It is what you see when performing direct laryngoscopy, and it’s a more accurate way of predicting the actual difficulty of putting a tube in. It’s also used to document how tough the airway really is.

If you see the entire glottis after positioning the laryngoscope, that is a Grade 1 Airway. If you have a partial view, that’s a Grade 2. If you can only see the epiglottis, that’s a Grade 3. If you cannot see the epiglottis, that’s a Grade 4, or very difficult.

Have all your equipment prepared before attempting, including your back up airway devices. You might be well served to go straight to a video-laryngoscope on your first attempt if you have one. Don’t wait for a failure; prepare for it.

In EMS, most patients that we intubate are unconscious and/or non-breathing. That makes it tough to have them open their mouth for us, which often makes it challenging to get a Mallampati Score for Airway Class before attempting intubation.

There is one important exception and that’s when we do rapid sequence intubation (RSI). Medics should always assess Mallampati before pushing the syringe plunger. Take an extra few seconds to know what you are getting into before you jump off the deep end.

Remember, Class and Grade don’t always correlate. They are not interchangeable or different ways of saying the same thing.

A Mallampati Class 1 is not always a Cormack-Lehane Grade 1 airway. Neither is a Mallampati Class 4 always a nearly impossible intubation — it just flags you to consider the possibility early enough to be ready for it.

I hope that clears up any confusion about what these two different scores really mean.

Evolving technology has made EMS more sophisticated in its ability to assess patients in the field.

Equipment such as pulse oximetry, glucometry, capnography, multi-lead electrocardiograms, and portable labs have increased the diagnostic capability of EMS providers. It’s just too bad that the rest of the medical profession has had difficulty understanding the increasing sophistication of those in the field.

A recent article points to a Rhode Island ER being the first to test Google Glass on medical conditions — and envisions “...an ambulance crew someday responding to a stroke victim, using the eyeglass technology to provide real-time video and audio to a neurologist back at the hospital who could then order a clot-busting, brain-saving drug immediately.”

Um, couldn’t we do that now, sans glasses" Education standards require paramedics to understand essential functions of the brain, how and why strokes occur, and how to identify them early. EMS providers have been shown to be fairly accurate in identifying strokes using standardized assessments. We perform a limited set of tests to rule out hypoxia and hypoglycemia. We assist in identifying who is a candidate for therapy and who is not. With all respect to the physician community, please think bigger than this.

Remote sensing technology will help extend the reach of the medical field. We are moving toward a decentralized approach to health care in this country; it’s simply cheaper and just as effective to receive medical attention in clinics and health centers, compared to hospitals. Greater preventive efforts will go even further in reducing the overall cost.

Telemedicine will allow fewer physicians to effectively oversee a web of health care professionals who are prepared to function interdependently, as a team, to better care for patients.

Using a piece of equipment as an electronic leash is counterproductive to that approach. I’ve seen these quotes before, from physicians who mean well, but don't realize how they denigrate the industry in making such comments. Yes, EMS will have to continue to do its housecleaning and improve the consistency of its educational model. But many parts of the country are already there, and doing some amazing things in improving overall community health.

Technology like Google Glass should augment and enhance that function, not restrict and limit it. Have some trust in the human component of the system.

He’s looking at me. Eyes that have seen twice the years that mine have bore into mine — trusting me, hoping that I am capable, that I take my craft seriously, that I am competent.>

His inability to articulate the thoughts that run through his mind as I evaluate the weakness on his left side fill him with frustration. But he’s an old man, and old men can handle frustration.

I do not need to be a mind reader to know what he is thinking. People his age have survived parents, siblings, friends, and even children who have lived full lives and died in their seventies.

He knows that this is it, his run is over, and it is his turn. His eyes betray the outward calmness though; no man that holds even a trace of lucidity can face his own demise without trepidation. His eyes tell me what I already know. He wants to live, even if for just another minute, preferably a day, maybe another season, perhaps one more Christmas.

No other choice

And I am here to make it so. He has to believe in me; he has no other choice, there is nobody else. All of the people he has known — the children he has raised, friends, lovers, teammates — all come together in this moment. And it’s me he shares his final moments with, sucking oxygen from the non-re-breather, flinching when I stick his skin with a 20 gauge catheter, letting me attach the leads, trying to squeeze both of my hands when I tell him, smiling a half-smile when I ask.

I call the hospital and relay to them the events that have transpired, and they decide that he is not a candidate for tPA. At least three hours have passed since the first sign of CVA symptoms, and I wonder if I should have stretched the truth and told the person at the end of the line that the patient was fine two hours ago, and not five, like his son had told me when I responded to their home.

So it’s the two of us now, his son following close behind, even though I asked him not to. The IV is running, the 02 is flowing, his rhythm is erratic and I have done all I can do for now. The captain’s chair sits empty and the report will have to wait — because I have clicked off the phone, put down my pen, and am holding his hands in mine quietly telling him to squeeze.

The final moments

He closes his eyes but the connection between us remains, and I don’t let go until I have to.

His heart stops soon after we arrive at the ER, and a trauma room full of people are at his side. His family waits outside the door as CPR, epi, and more epi, then atropine and whatever else they see fit to revive him is pushed through his veins. But nothing works; he is pronounced dead at 21:52, some 95 years after he was born.

I take a moment before going in service, and think of how fortunate I am to have the ability and opportunity to do what I do.

"Death and taxes and childbirth! There’s never any convenient time for any of them!” — Scarlett O’Hara, "Gone with the Wind."

Scarlett sounds a bit like a cynical, burned-out old medic, doesn’t she" Can you imagine how much trouble she’d be in if she’d had Facebook"

I’m betting almost every member of our profession considers taxes to be the most inconvenient of Scarlett’s big three, which is why I compiled a few end-stage tax-filing tips for EMS folks who’d rather respond to a high-rise without elevators than tackle taxes.

Admit it: When Prissy, Butterfly McQueen’s character in "Gone with the Wind," wailed “I don’t know nothin’ ‘bout birthin’ babies,” you felt a little smug. You knew “birthin’ babies” was no big deal; they’re slimy and slippery, but nature pretty much runs the show. Preparation and practice help.

It’s the same with tax returns, except no one gets to name them, and universal precautions are of no use (finding a safe place to say that was on my bucket list.) It also helps to think of the IRS as “nature.”

With a little planning and patience, most of you should be able to file your own taxes. Before we cover some of the basics, let me emphasize I’m a medic, not a lawyer or an accountant. I don’t think I even own a suit anymore (I had to get rid of them when they all suddenly shrank around the middle).

Also, I’m assuming you’re not incorporated, you don’t have employees, and your risk tolerance is appropriate for an EMS provider, but not necessarily for a tightrope walker with ADHD.

Get it together

At its simplest, tax preparation requires two kinds of information: taxable income and deductible expenses. The IRS guides you through the rest with booklets and forms, some of which make ACLS algorithms seem straightforward.

However, once you know your income and expenses, serious complications are no more common than, say, breech presentations. And what do you do when you see a butt instead of a head" I mean after you wish you hadn’t gone back in service so soon"

You follow procedures and hope for the best. It’s the same with taxes.

Taxable income is mostly money you made working or investing. Employee wages are reported to you and the IRS on W-2 forms you’re supposed to get through the mail, on line, or with a paycheck before February 1.

You should also receive 1099 forms showing money you earned as a contractor or investor — e.g. speaking fees, bank-account interest, stock dividends, and proceeds from sales of stock or other assets. Stuff all those W-2s and 1099s into an envelope labeled “2013 Income.” Add “not nearly as much as I deserve” if indignation motivates you.

What were your expenses"

Tax-deductible expenses are usually harder to reconstruct because, other than charitable donations, they’re not routinely reported to you by the recipient.

“Tax deductible” means expenditures that offset your taxable income, often dollar for dollar. Interest on loans (including mortgages), state income taxes, property taxes, self-employment costs, and charitable contributions are examples of items that are usually 100 percent deductible.

Medical and employee expenses are subject to minimums you have to exceed before you can deduct them. However, it’s common for EMS providers to meet those criteria. Try using checkbook registers or bank and credit-card statements to reconstruct deductible expenses.

EMS workers usually can deduct unreimbursed costs of uniforms, union and professional dues, job searches, job-related education and travel, and medical equipment, once the total of those and other so-called miscellaneous expenses exceeds 2 percent of your income.

Not deductible are payroll taxes, commuting expenses, and workplace meals. You can deduct the cost of cleaning your uniform, but not the price of the spaghetti you spilled on it.

Put all your expenses in an envelope marked “2013 Expenses.” Congratulate yourself if you’ve gotten this far without testing levels on that old nitrous oxide unit.

Crunching numbers

If you could simply send the IRS your income and expenses envelopes and let them figure your taxes, what a wonderful world this would be. Unfortunately, our government doesn’t employ enough people to track global warming and do our taxes. You have to fill out some forms, physically or online. Here are a few of the most common:

• 1040 (A/EZ): The main page of your return, summarizing income, deductions, exemptions (earnings not taxed), taxes, and credits (instant rebates). Almost everyone files one of these. You’ll need a calculator or tax preparation software and plenty of time — at least as long as it would take you to watch three episodes of "Emergency!" with commercials.
• Schedule A: You get to make an important decision before completing this form: Are you going to itemize your deductions, or would you be better off taking the standard deduction ($6,100 for a single filer in 2013)" It’s simply a matter of choosing the bigger number.
• Schedule B: If you earned more than $1,500 from interest and dividends, you’ll have to list them here.

Someone with lots of free time should write separate pieces on Schedule C (business earnings) and Schedule D (capital gains). Those of you who need those forms have my sympathy; its an exceptional opportunity to see if those anger-management classes are working.

You can download these and other tax forms at www.irs.gov, or order them through the mail.

You probably wouldn’t have read this far if you’re comfortable doing your own taxes. Keeping real-time income and expense records requires much less effort than year-end reconstruction (at least it seems that way mid-reconstruction), and lowers the probability of a surprise tax bill next year.

Some colleagues tell me they procrastinate because tax preparation is so much work involving so little money. I tell them it’s not too late to get organized. I also tell them it’s not too late to go to nursing school.

Tomorrow is another day!

By Allison G. S. Knox, American Military University
InPublicSafety.com

Emergency Medical Services (EMS) is an intriguing policy area because it encompasses numerous issue areas at the local, state and federal levels of government. Emergency medical technicians (EMTs) and paramedics are cross-trained between emergency medicine and public safety, which allows them to be creative and resourceful when handling 9-1-1 emergencies.

While it makes sense to an EMT or paramedic that they handle these diverse 9-1-1 situations, to lawmakers it can be enormously challenging to figure out how to categorize EMS among their many policy issues. Thus, it is often difficult for lawmakers to figure out specifically how to handle EMS-related issues.

Insight into the Legislative Process

Members of Congress (Representatives and Senators at the federal level of government) usually have legislative assistants who handle a portfolio of issue areas. Within these issue areas, legislative assistants follow the wants and needs of the elected official’s constituents as well as various pieces of legislation heading to the Senate and House floors, respectively.

Read full story: EMS and the burden of explanation to lawmakers

If you’ve been in EMS for more than a few years, you’ve possibly been considered for a supervisory position. In some EMS organizations the opportunities for promotion can come surprisingly fast, especially if you are good at being an EMT or paramedic.

For some reason we believe that being good at the job is a strong predictor of success at the supervisory level. It isn’t true, but the belief is persistent.

If you are a standout or strong performer in the back of the ambulance, you’ve probably already been approached with the suggestion, “Have you ever thought of promoting to supervisor"”

EMS supervision is a tough job. The years I spent as an EMS supervisor were not my favorite years in EMS. They were often lonely and filled with conflict.

I didn’t like being the bearer of bad tidings, or being a sounding board for a seemingly endless stream of gripes and complaints about the operation. I wasn’t used to people questioning my credibility and worst of all, I missed transporting patients to the hospital.

What my years in the supervisor vehicle did give me was a profound respect for people who are good at leadership in general, and EMS leadership in particular. Supervisors are tasked with the continuous monitoring of the system, deployment and resource utilization, while also looking after their employees’ welfare and well-being.

It’s a tough job.

Some do it very well and some … not so well. Since I left my supervisor vehicle for new horizons, I’ve made some observations about what good EMS leaders do consistently well. There is no single model of leadership that always works.

Great leaders come in all sizes, genders and personality types. Regardless of who they are, great EMS leaders tend to master these five traits.

1. Build up the weakest members of the team

On every EMS supervisor’s team, there will be several poor performers. Some individuals will be low performers because they are burned-out or disengaged.

Some will have knowledge deficits and some will need skills improvement. Some will lack experience. Some will have too many bad habits.

For many leaders, these individuals will be identified as the “problem children,” the proverbial thorns in the supervisor’s side. Many leaders will decide that the best course of action is to somehow weed these individuals out.

Great EMS leaders will labor to discover the proper way to build these people up. They will ask themselves, what kind of support does this individual need from me to become better at what he does"

Great EMS leaders make their charges better at what they do. They build people up.

2. Listen intently with a desire to understand

Just about any leadership book will mention the importance of listening. Stephen Covey called it seeking first to understand before being understood, and John Maxwell called it the law of connection.

It’s nearly impossible to find a well-known leadership tome that doesn’t espouse the importance of listening. But good leaders don’t just listen, they listen differently and people sense the difference.

When you are frustrated about something or attempting to convey an idea, have you noticed that you can tell the difference between a person who is listening with the intention of understanding and someone who listens long enough to begin formulation a response" When you are listened to by someone who genuinely is seeking to understand you, it feels different.

That’s the way good leaders listen. When they interrupt, it’s usually to check their understanding of your words. When they respond, it’s often with clarifying questions or a rephrasing of your ideas and feelings. Good leaders listen completely.

3. Keep private feedback private

Great supervisors have a way of saving their feedback for the appropriate time. They treat performance feedback as sacred ground. You’ll never hear a really good supervisor bad-mouth another individual in a public forum, or in a private conversation when the individual in question isn’t around.

When folks are recognizing and criticizing another member of the team, it’s tempting for someone in a leadership position to want to affirm that feedback. The temptation is a desire to let people know that you also recognize poor performers or disengaged members of the team. The desire is to send the message, “I know about this. I’m on top of things.”

Participating in negative observations only serves to undermine team trust in their leader. Once a leader has crossed the line and participated in employee bashing (constructive or not) they have sent the message that negative performance feedback is not sacred. Team members want to know that, if their turn comes to be the subject of the rumor mill, their supervisor isn’t going to participate in airing the dirty laundry.

4. Communicate challenging expectations

Subordinates don’t want to feel that making the right choices is a guessing game. They want leaders who are clear about their expectations. Most folks will work hard to meet even the most challenging of expectations. But they need to have those expectations communicated clearly.

Poor supervisors wait for people to fail to meet expectations and then they point out the failure — or they point it out to others. Great leaders communicate their expectations clearly and then motivate others to perform to a high standard. They do so daily, using the most powerful tool available.

5. Lead by example

Leadership by example is the most difficult aspect of leadership. It is difficult because it challenges those in leadership positions to maintain their own high standards every hour of every day. Once a leader falls short of the standard just once, it gives everyone permission to disregard the standard.

If a leader expects others to look professional, her uniform needs to be impeccable every day. If she expects subordinates to show up to work early, she needs to be even earlier.

If he demands a rig checkout be completed every shift, the supervisor unit needs to be perfectly stocked. If he expects fast turn out times, he needs to run when the tones go off.

Leadership by example touches every aspect of an EMS leader’s job. Great leaders embody the high standards that they demand. And for that reason, they are respected.

In all areas of human endeavor, there are those who lead well and those who lead poorly. EMS is no exception. We have our share of great leaders and poor leaders.

If you are aspiring to a leadership position or if you are currently in a leadership role in your organization, good leadership can be learned. It’s never too early to begin growing your influence and practicing your leadership skills.

What things do you feel are essential in an EMS leader" Leave us a comment and let us know.

An unstable spinal column with an undamaged spinal cord probably represents one of the greatest management challenges for emergency medical personnel.

In 2010, the National Spinal Cord Injury Statistical Center[1] reported approximately 12,000 new cases of spinal cord injury in the United States each year. Injuries to the spinal cord can produce catastrophic consequences — usually immediately following the traumatic event, although some effects do not fully develop until sometime after. In some patients, damage to the boney vertebrae may occur but the cord itself may be intact.

Rescue devices such as long backboards, short backboards, and extrication vests offer restrictions to movement, but they do not immobilize[2].

Advanced care providers have long recognized the potential harm that accompanies the use of rigid spinal immobilization, especially if prolonged.

Rescue work involves movement, as paramedics and EMTs must relocate the patient from hostile to more stable environments. Every device applied in the field only fastens externally to the patient; the skin and muscle will continue to slide across the skeletal frame and produce bone movement. Additional movement occurs during transport as the patient’s body is subject to the laws of physics and inertia.[3]

The spine board was developed as an extrication tool,[4] for EMS to use in conjunction with a cervical collar and restraining straps to prevent secondary spinal cord injury resulting from patient movement to the hospital. In many areas, this procedure has remained a standard of care for almost half a century, despite the lack of convincing evidence that the procedure improves patient outcome. [5]

Rigid spine boards

Bauer and Kowalski[6] demonstrated that immobilization on a long spine board resulted in significant reductions in forced vital capacity (volume of air that can be forced from the lungs after taking the deepest inhalation possible), forced expiratory volume (maximum volume of air that can be forcibly exhaled in one second), and forced expiratory flow (average airflow over specific portions of the spirometry curve) among healthy non-smoking males. These reductions, when coupled with airway or thoracic injuries, or in patients with a history of respiratory pathology, may significantly reduce the ability for adequate self-ventilation.

Researchers in North Carolina found similar reductions in pulmonary function testing associated with immobilization on a long spine board in children ages 6 to 15.[7]

Immobilization on a rigid backboard altered subsequent physical examination findings in about 20 percent of healthy volunteers by inducing cervical and lumbar midline point tenderness where none previously existed[5]. This could result in unnecessary and expensive testing when the patient arrives in the emergency department.

Research also demonstrates that immobilization on a rigid spine board can result in the development of pressure ulcers. Pressure ulcers develop over bony prominences in individuals that are immobilized on hard surfaces. The weight of the body and the unforgiving nature of the surface impair blood flow to the area, resulting in localized ischemia, cellular death and tissue necrosis.

Increasing the duration of immobilization or the magnitude of the applied pressure will increase the rate of pressure ulcer formation[8]. A study of patients with spinal cord injury found that all in-patients who developed skin ulcerations recalled no attempt to move or rotate them off the backboard within the first two hours after injury to relieve the pressure[9].

In contrast, all patients who did not develop ulcerations had the pressure relieved within the first two hours by someone who rotated their body off the spine board.

Researchers in New Orleans demonstrated a direct relationship between the duration spent on a spine board and the development of pressure ulcers within the first eight days of hospitalization[10]. As many as 31 percent of trauma patients will develop pressure ulcers as the result of immobilization on a backboard[11].[12]

Berg[13] (et al) found that immobilization for periods as short as 30 minutes can produce significant reductions in localized tissue oxygenation in healthy patients. Lerner and Moscoti[12] found that trauma patients spend an average of 64 minutes on a backboard including the time spent in the field. However, if radiographs were required for spinal injury clearance and backboard removal, total backboard time exceed three hours.

Cooney, Wallus, Asaly, and Wojcik[14] found the total time spent immobilized on a backboard can exceed seven hours when EMS first transports patients to a tertiary center and then transfers the patient to a Level 1 trauma center.

Vacuum spine boards

In an attempt to provide a more comfortable method for immobilizing the spine for transport to the emergency department, many EMS agencies are using a vacuum type splint device. Vacuum splints are flexible, waterproof shells filled with polystyrene beads similar to a very large beanbag.

Early in the application process, the splint is soft and malleable. Rescuers can push the beads into the recesses and voids between a patient and the splint. However after withdrawing the air, the splint conforms to the shape of the patient and becomes rigid.

In a side by side comparison with a rigid backboard, the vacuum splint device was judged more comfortable by the patient, was faster for rescuers to apply, and resulted in less body movement in the event the patient required tilting[15]. Healthy volunteers reported significantly less pain at 30 and 60 minutes when immobilized on a vacuum rather than a rigid spine board[16].

Pressure of about 35 mm Hg applied to the surface of the skin will significantly reduce blood flow through a capillary bed[17]. Interface pressures on good to high quality hospital mattresses vary between 30 and 60 mm Hg[18].

Researchers using pressure-mapping sensors on 20 healthy volunteers demonstrated that rigid spine boards produce the highest tissue interface pressures at the patient’s scapulae, sacrum, and heels when compared to the use of a standard, soft overlay mattress or a vacuum mattress[4].

The volunteers also rated the rigid spine board as the least comfortable device. This is consistent with a study by Lovell and Evans that demonstrated tissue interface pressures as high as 147 mm Hg with a rigid spine board, 115 mm Hg when the board was padded, but 37 mm Hg with a vacuum mattress[19].

The U.S. Army Institute of Surgical Research[20] has designated the vacuum spine board to be the immobilization method of choice during transport of patients suffering from potentially unstable thoracolumbar fractures. Unfortunately, military researchers could not demonstrate a significant reduction in pressure ulceration development associated with vacuum spine board use compared to historical controls using rigid spine boards[21].

However, more patients in the vacuum spine board group required endotracheal intubation, and thus were motionless for longer periods of time. There are anecdotal reports of awake and oriented patients becoming claustrophobic during prolonged transport while immobilized in a vacuum spine board.

Nonetheless, vacuum spine boards appear to provide a very promising alternative to the rigid spine boards historically used in EMS. These devices immobilize as well as backboards, are more comfortable for the patient, and reduce tissue interface pressures, which may reduce the development of pressure ulcerations resulting from the immobilization procedure itself.

References

1. National Spinal Cord Injury Statistical Center (NSCISC). (2010). Spinal cord injury. Facts and figures at a glance. Retrieved from https://www.nscisc.uab.edu/

2. Shafer, J. S., & Naunheim, R. S. (2009). Cervical spine motion during extrication: A pilot study. Western Journal of Emergency Medicine, 10(2), 74-78.

3. Perry, S. D., McLellan, B., McIlroy, W. E., Maki, B. E., Schwartz, M., & Fernie, G. R. (1999). The efficacy of head immobilization techniques during simulated vehicle motion. Spine, 24(17), 1839–1844.

4. Keller, B. P., Lubbert, P. H., Keller, E., & Leenen, L. P. (2005). Tissue-interface pressures on three different support-surfaces for trauma patients. Injury, 36(8), 946-948.

5. March, J. A., Ausband, S. C., & Brown, L. H. (2002). Changes in physical examination caused by use of spinal immobilization. Prehospital Emergency Care, 6(4), 421-424.

6. Bauer, D., & Kowalski, R. (1988). Effect of spinal immobilization devices on pulmonary function in the healthy nonsmoking man. Annals of Emergency Medicine, 17(9), 915-918. doi:10.1016/S0196-0644(88)80671-1

7. Schafermeyer, R. W., Ribbeck, B. M., Gaskins, J., Thomason, S., Harlan, M., & Attkisson, A. (1991). Respiratory effects of spinal immobilization in children. Annals of Emergency Medicine, 20(9), 1017-1019. doi:10.1016/S0196-0644(05)82983-X

8. Vickery, D. (2001). The use of the spinal board after the pre-hospital phase of trauma management. Emergency Medicine Journal, 18(1), 51-54. doi:10.1136/emj.18.1.51

9. Linares, H. A., Mawson, A. R., Suarez, E., & Biundo, J. J. (1987). Association between pressure sores and immobilization in the immediate postinjury period. Orthopedics, 10(4), 571–573.

10. Mawson, A. R., Biundo, J. J. Jr., Neville, P., Linares, H. A., Winchester, Y., & Lopez, A. (1988). Risk factors for early occurring pressure ulcers following spinal cord injury. American Journal of Physical Medicine and Rehabilitation, 67(3), 123-127.

11. Baldwin, K. M., & Ziegler, S. M. (1998). Pressure ulcer risk following critical traumatic injury. Advances in Wound Care, 11(4), 168-173.

12. Watts, D., Abrahams, E., MacMillan, C., Sanat, J., Silver, R., Van Gorder, S., Waller, M., & York, D. (1998). Insult after injury: Pressure ulcers in trauma patients. Orthopaedic Nursing, 17(40), 84-91.

13. Berg, G., Nyberg, S., Harrison, P., Baumchen, J., Gurss, E., & Hennes, E. (2010). Near-infrared spectroscopy measurement of sacral tissue oxygen saturation in healthy volunteers immobilized on rigid spine boards. Prehospital Emergency Care, 14(4), 419-424. doi:10.3109/10903127.2010.493988

14. Cooney, D. R., Wallus, H., Asaly, M., & Wojcik, S. (2013). Backboard time for patients receiving spinal immobilization by emergency medical services. International Journal of Emergency Medicine, 6(1), 17. doi:10.1186/1865-1380-6-17

15. Johnson, D. R., Hauswald, M., & Stockhoff, C. (1996). Comparison of a vacuum splint device to a rigid backboard for spinal immobilization. American Journal of Emergency Medicine, 14(4), 369-372. doi:10.1016/S0735-6757(96)90051-0

16. Cross, D. A., & Baskerville, J. (2001). Comparison of perceived pain with different immobilization techniques. Prehospital Emergency Care, 5(3), 270-274.

17. Ryan, D. W., Allen, V., & Murray, A. (1997). An investigation of interface pressures in low air loss beds. International Journal of Clinical Practice, 51(5), 296-298.

18. Defloor, T. (2000). The effect of position and mattress on interface pressure. Applied Nursing Research, 13(1), 2-11. doi:10.1016/S0897-1897(00)80013-0

19. Lovell, M. E., & Evans, J. H. (1994). A comparison of the spinal board and the vacuum stretcher, spinal stability and interface pressure. Injury, 25(3), 179-180. doi:10.1016/0020-1383(94)90158-9

20. United States Army Institute of Surgical Research. (2012). Joint theater trauma system clinical practice guideline: Spine injury surgical management and transport. Retrieved from http://www.usaisr.amedd.army.mil/assets/cpgs/Cervical_and_Thoracolumbar_Spine_Injury_9_Mar_12.pdf

21. Mok, J. M., Jackson, K. L., Fang, R., & Freedman, B. A. (2013). Effect of vacuum spine board immobilization on incidence of pressure ulcers during evacuation of military casualties from theater. Spine Journal, 13(12), 1801-1808. doi:10.1016/j.spinee.2013.05.028

The appeal of powered cots and stair chairs is that they reduce injuries to EMS providers and perhaps to patients. At any given moment, 9.4 percent of all EMTs and paramedics are out of work from an injury or illness, and busy systems often skyrocket up to 19 percent.

This is compared to 1.3 percent of the general public, which makes you readily appreciate EMS as a dangerous job[1-2]. More than half of EMS, workers compensation claims — a whopping 65 percent — involve back injuries[3]. Do powered cots and stair chairs reduce injuries"

Oddly, there is just a single study on powered ambulance cots published in a peer-reviewed journal[4]. That’s it: one study.

Austin Travis County (Texas) EMS studied injury rates before and after implementing use of power cots in 2006. Between 1999 and 2006, the injury rate averaged 61 percent. This rate dropped to 29 percent after power cots were placed in service.

Confounding the results were a number of other safety initiatives that may or may not have affected injury rates. Regardless, the data seems compelling.

Manufacturers such as Ferno and Stryker have testimonials and case studies demonstrating cost savings and injury reductions as some of the many advantages of their powered lifting equipment. But these are not peer-reviewed studies nor is it possible to confirm that the implementation of powered cots directly resulted in less injuries to EMS providers.

Powered cots and parachutes

But how much scientific data do we really need"

In 2003, the British Medical Journal called into question the use of parachutes to protect people jumping out of airplanes[5]. The authors aptly noted that despite the wide use of parachutes, there was little research to support their effectiveness.

There are, in fact, numerous reports of people surviving falls from planes without the benefit of parachutes. They concluded, (quite sarcastically) that those who believe everything must first be validated by a scientific study should “come down to earth with a bump.”

Like parachutes, are the benefits of powered cots and stair chairs so obvious that we really don’t need studies to prove it" There are no magic bullets to eliminate the high incidence of back injuries among EMS workers.

Remember the back-support belt rage" Back belts were supposed to be the answer to preventing strain injuries in warehouses, shipping companies, and yes, even in EMS. While you can still purchase a back belt today, in 1994 the Centers for Disease Control informed the public that there was no good scientific evidence to support the use of back belts[6].

Likewise, the CDC pointed out, there was no good evidence that argued against the use of back belts. Putting all your safety eggs into the back belt basket might not be such a good idea, the CDC implied. Today, the decision of whether or not to use a back belt is best left to the individual employee.

What we do know

We know for certain is that EMS continues to sustain injuries at a faster rate than the rest of the workforce[7].

We also know that a significant percentage of EMS worker injuries are back injuries[8]. A review of adverse events reported to the FDA shows that from 1996 to 2005, EMS professionals were injured in 53 percent of all ambulance stretcher adverse events[9].

Back injuries are expensive to both workers and employers. The costs can be staggering, especially when EMS workers are left permanently unable to perform their duties.

While the evidence favoring use of powered cots and stair chairs is slim, it seems obvious that our current equipment is injuring both patients and EMS workers9. In fact, while we often think of vehicle crashes as the most common EMS liability exposure, a 2008 study of 275 EMS liability claims paid by insurers found 41 percent involved patient handling while only 31 percent involved vehicle movement or collisions[10]. Of the patient handling claims against EMS services, half were stretcher or stair chair tips and drops. While these data were not described in detail, there is a strong association between provider injury and patients being dropped. When an EMS worker slips trying to carry a stair chair, or injures their back attempting to load a stretcher into an ambulance, patients often fall off the chair or stretcher as a consequence. Manufacturers seem to know this and are continually evolving their designs to eliminate these injuries.

Rather than waiting for proof that powered cots and stair chairs reduce injuries, what we really need to do is implement their use on a broader scale, making note of what costs and savings are achieved. For services that have demonstrated significant advantages through the use of new technology, the data should be published so others will make an investment.

The scarcity of published data coupled with the fact that the majority of services have yet to implement powered lifts-capable patient movement, screams for those who have gone down this road to share their experience for the betterment of our profession.

References:

1. Studnek JR, Ferketich A, Crawford JM. On the job illness and injury resulting in lost work time among a national cohort of emergency medical services professionals. Am J Ind Med. 2007; 50:921-931.

2. Maguire BJ, Hunting KL, Guidotti TL, Smith GS. Occupational injuries among emergency medical services personnel. Prehosp Emerg Care 2005; 9:405–411.

3. Hogya PT, Ellis L. Evaluation of the injury profile of personnel in a busy urban EMS system. Am J Emerg Med. 1990; 8: 308–311.

4. Studnek J, Crawford J, Fernandez A. Evaluation of occupational injuries in an urban emergency medical services system before and after implementation of electrically powered stretchers. Appl Ergon. 2012;43:198–202.

5. Smith CS, Pell JP. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomized controlled trials. BMJ. 2003; 327:1459-1461. Available at www.ncbi.nlm.nih.gov/pmc/articles/PMC300808/.

6. Centers for Disease Control and Prevention. Back Belts – Do they prevent injury" NIOSH Publication 94-127. October 1996. On-line, available at www.cdc.gov/niosh/docs/94-127/.

7. Centers for Disease Control and Prevention. Emergency Medical Services Workers Injury and Illness Data. NIOSH Workplace Health and Safety Topics. 2011. On-line, available at www.cdc.gov/niosh/topics/ems/data.html.

8. Reichard A, Marsh S, Moore P. Fatal and nonfatal injuries among emergency medical technicians and paramedics. Prehosp Emerg Care 2011;15:511–517.

9. Wang HE,Weaver MD, Abo BN, Kaliappan R, Fairbanks RJ. Ambulance stretcher adverse events. Qual Saf Health Care 2009;18:213–216.

10. Wang HE, Fairbanks RJ, Shah MN, Yealy DM. Tort Claims from Adverse Events in Emergency Medical Services. Prehosp Emerg Care 2008; 52:256-262.

A few years ago, I ran over someone in an ambulance.

It was dark, late at night, on a lonely section of a highway. At first, I thought it was road debris. When I stopped to inspect the ambulance for damage and found none, I was convinced I had run over a shredded semi-trailer tire.

It wasn’t until I reached the hospital an hour later, and found blood spattered all over the back doors of the ambulance, that I thought otherwise. Still, the human capacity for self-delusion is boundless, and on the drive home, my partner and I had halfway convinced ourselves that I had run over a road-killed deer.

When we saw the state troopers and crime scene unit on the way back home, that delusion was shattered.

I’m here to tell you, there is no feeling more horrible than the realization that you may have just killed someone.

Company response

As it turned out, the state police determined that I was the second or third vehicle to run over the body, and that he was almost certainly dead before I hit him. Still, the supervisor called to the scene was supportive, and concerned about my emotional welfare. I took a legally mandated drug test administered by the state police, and rode home in another ambulance, since mine was impounded for evidence collection.

Acadian’s crisis counselor called me before I even got back to the station. My local supervisor told me to take the next shift off. I told him I was capable of working, and I’d be there at shift change, as scheduled.

I went home and crawled into bed, and stared at the ceiling for nine hours. Two hours before my shift was scheduled to start, I called in sick. My supervisor immediately called me back and told me not to worry about it. No mention was made of the fact that calling in two hours before my shift violated Acadian’s call-in policy.

The crisis counselor called me again, as did my partner and the crew who gave me the ride back to my station. Everyone was concerned about my welfare, and made it clear that no matter what, they had my back.

Of course, the rumor mill being what it was, a number of other co-workers spread it around that I had mowed down a pedestrian and gotten away with it. The same guys who called to check on me set the rumormongers straight.

A suicide

Recently, an Acadian employee took his life behind one of our ambulance stations. His partner discovered the body, and attempted resuscitation. I can only imagine the mental and emotional anguish he went through, second only to the mental and emotional anguish that led a young, promising paramedic to take his own life.

And as in my case, Acadian took care of its own. They provided emotional support for his partner, arranged for crisis counseling, and took him off the rig. Since an ice storm had shut down local roads, they put him up in a local hotel, and then arranged for him to get home.

And of course, the rumor mill being what it is, most of Facebook heard about it before many Acadian employees and managers. It was widely disseminated that Acadian was heartless enough to make the partner complete his scheduled shift, even though the exact opposite was true.

In both his case and mine, the response flipped the paradigm about colleagues and corporations. In both cases, the supposedly heartless, profit-centered corporation was the first to reach out and assure the well-being of one of its employees.

Plenty of other commenters on Facebook offered their prayers and support for the medic who took his life, and the partner who found him. Just as many offered their scorn for Acadian, accepting at face value that a company would force an EMT to complete a shift after his partner killed himself.

Thoughts vs action

But I wonder how many went any farther than that" Has this phenomenon we call social media actually disconnected us, instead of bringing us closer together" How many people typed “How sad, praying for you!” and left it at that"

Is that enough" And what kind of anguish did it bring to the local manager who had to deal with the horror of that day, especially after reading hundreds of comments condemning him over a heartless act he didn’t commit"

I wonder how many people reached out to him and said, “Hey, are you okay" We appreciate everything you’ve done. Way to look out for your people.”

My gut tells me that plenty of people did, just not publicly. I imagine people volunteered to cover shifts for the medic’s partner. Probably those who knew the medic outside of work offered support to his family.

This being Cajun country, I’m sure someone brought food, because nothing says “I care about you,” quite like a covered dish and volunteering for babysitting duty.

But none of that came early enough for a young man with a full life ahead of him. When you’re isolated and depressed, it’s easy to convince yourself that you are truly alone, and that no one cares, and that, God forbid, your loved ones would be better off without you.

Depths of despair

Despair should never be allowed to whisper in a friend’s ear without a contrary voice assuring him that those dark thoughts are lies. I’ve suffered from depression, and I spent those dark months glued to the computer. Surfing the Internet and chatting online were easier than actual human interaction, even though the outside world was exactly what I needed to drag me out of my funk.

It takes action. It requires re-engaging with life. Prayers and support after the act ring hollow. We should care enough to intervene before the act.

On Feb. 2, one of Bryan Bledsoe’s 4,845 Facebook friends posted a cry for help on his page.

Bryan acted, and sought to get the guy the help he needed. One hundred and eighty-eight of his friends posted supportive comments. A handful of those actually went beyond that, and found the guy’s employer, friends and family, and had the police intervene. That man has a second chance, and I pray he makes the most of it.

And I applaud the people who went beyond words of support, and took action. Quite likely, they saved a life.

Peer support

No one understands the pressures we face like a fellow EMT. Not your friends, your family, or your priest. I may discount the effectiveness of CISM and debriefings based upon the scientific evidence, but one tenet of CISM is invaluable: peer support.

Look for the signs of depression and burnout in your co-workers. Be alert for inappropriate anger, or flat affect, or the other physical manifestations of stress.

And when you do, reach out with more than words. Take them for a workout. Indulge in a little retail therapy. Go turn some ammunition into smoke and noise. Drag them out for a meal after your shift. Let them decompress, safe in the knowledge that their rant goes no further than the two of you.

Beer and nachos are an excellent remedy for burnout. The healing isn’t in the hops and barley and the cheese and chili, it’s in the fellowship with the person that has your back.

Look out for each other, because often, each other is all we’ve got.

Calls involving patients with acute psychiatric emergencies are often difficult to respond to. Frequently responding EMS personnel will have to develop a treatment plan without the ability to perform a complete assessment.

Additionally, such patients may be unable or unwilling to answer questions about their medical history. In some circumstances, however, the patient’s behavior on scene may lend clues to the underlying cause.

The condition of Excited Delirium Syndrome (ExDS) has historically been controversial. While law enforcement groups have blamed in-custody deaths on ExDS, groups like the ACLU have argued that these deaths are a result of excessive force by arresting officers1. Even so, in 2009, the American College of Emergency Physicians concluded that “…the consensus of the Task Force [is] that ExDS is a real syndrome of uncertain etiology”.2

One of the difficulties with ExDS is that both the cause and mechanism of the syndrome are not well understood. Patients using stimulants as well as those with significant psychiatric histories make up the two largest groups of patients suffering (and sometimes dying) from ExDS.2

According to ACEP, one potential pathway of the development of ExDS is the uncontrolled release of dopamine. This dopamine release is thought to be responsible for the hyperthermia often seen in ExDS patients.

Patients who died and were later diagnosed with ExDS often had a cause of death related to hyperthermia, significant acidosis, or both. During their analysis, the ACEP task force found that while cause and mechanism were misunderstood, patients later diagnosed with ExDS frequently presented with the same cluster of symptoms.

Increased pain tolerance, tachypnea, sweating, agitation and hyperthermia were present in 95 percent or higher of ExDS patients. Refusal to follow police orders, unusual strength and lack of tiring were present in 90 percent of cases.2

By understanding the symptoms most often associated with ExDS, EMS providers may be able to identify patients suffering from this condition, which will allow them to develop an effective treatment strategy in conjunction with other agencies on scene.

Since the underlying cause of ExDS is largely unknown, treatment in the prehospital setting focusses on management of three main symptoms: agitation, hyperthermia and acidosis.2

Agitation is best treated by rapidly obtaining physical control of the patient and sedating with medication. Since this will often require intramuscular injection of medication, it is important for law enforcement and EMS to discuss and coordinate a plan of action to ensure both patient and responder safety.

The ACEP task force did not find a link between Taser use and death in ExDS patients, so the use of such devices in controlling ExDS patients may be indicated. Hyperthermia in the ExDS patient can be treated by standard means including passive and active cooling. If available and approved by protocol, immersion cooling may be indicated.

Acidosis may be treated in the prehospital setting or later in the emergency department depending on specific protocols.2

Treatment

After the ambulance crew arrives on scene, all three agencies agree that the patient meets criteria for ExDS and formulate a plan. The paramedic from the ambulance draws up ketamine in a syringe equipped with a safety needle and advises the officers to restrain the patient. Once the patient is subdued the paramedic loudly announces “injection!” and then “clear!”

The officers release the patient and wait for the medication to take effect. As the patient becomes drowsy and compliant, he is placed on the gurney and restrained.

He is placed on continuous cardiac monitoring along with capnography and pulse oximetry. An IV is started and he is given cool fluids to treat both his hyperthermia and acidosis.

The transporting paramedic asks to bring a rider along from your rescue. En route, she calls in to the hospital to advise that they have an Excited Delirium patient in bound.

You are advised to report to the trauma bay to turn the patient over. Later that week, you receive a call from the EMS medical director letting you know that the patient recovered fully.

According to the patient’s wife he had started using cocaine recently and had become increasingly angry and aggressive. He agreed to enter a residential substance abuse treatment program.

References

1. Sullivan, Laura. "Death by Excited Delirium: Diagnosis or Coverup"" NPR, 26 Feb. 2007. Web. 12 Jan. 2014.
2. ACEP Excited Delirium Task Force. "White Paper Report on Excited Delirium Syndrome." (2009): N. pag. Web. 11 Jan. 2014.

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

Earth Day 2012 takes place this Sunday, with events planned held worldwide to increase awareness and appreciation of the Earth's natural environment. So, it's a good time to see what you can do at your agency to save both resources and money.

Consider using this PPE safety video in your EMT Basic or Refresher Class.

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

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

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

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

Slideshare is an online community and tool for sharing presentations.

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

If you have an OB patient about to deliver, do a U-Turn and put the patient backwards on the gurney. By placing their head at the "foot" of the gurney, this allows you to work out of the captain's chair and gives you more room. The hardest part of doing this is getting your partner to place the patient in this position. Old habits are hard to break and it may feel odd, but once in the truck ...