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

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EMS Today Quick Take: Why do kids faint?

Syncope is common and can be a warning sign of a structural or electrical abnormality in the heart that may cause sudden death

Boston EMS vehicle explosion injures 2 FFs

The SUV crashed into a snowbank after its brakes failed, rupturing the gas tank and causing a fire which exploded an onboard oxygen tank

Code Green Story: Breakdown led to many personal realizations

For an EMT of 11 years the cumulative stress took a mental toll that was finally lessened by talking to other responders with their own burdens

When does pride become arrogance?

Let others cheer your EMS accomplishments instead of a boastful T-shirt or hoodie

Off-duty EMT pulls man from apartment building on fire

He ran into a building filled with smoke and helped rescue an elderly man; he also treated a woman for smoke inhalation

Wyo. EMTs may soon start work before completed criminal background check

Proposed bill speeds up start dates to combat EMS shortages by providing conditional licenses to those who have fulfilled all other requirements

London medic urinated on while treating patient

Man who assaulted the London Ambulance Service paramedic sentenced to 300 hours of community service

Discrimination in EMS ends when attitudes change

Most of us who are minorities want what everyone else wants – a fair chance to work in an honorable profession, and be respected for what we can do

Family: EMT stormed out of house, left stroke patient on floor

They filed a complaint with Rural/Metro, saying EMT got angry when asked to transport a man to the hospital and sat in the ambulance until his partner brought him back into the home

Colleagues mourn Pa. medic struck by coal truck at crash scene

West End Ambulance expressed its support for the family of medic Janice Livingston, 38, who was killed by a coal truck that "basically plowed through the emergency scene" on an icy road
Top

EMS1 Topic Articles

Boston EMS vehicle explosion injures 2 FFs

The SUV crashed into a snowbank after its brakes failed, rupturing the gas tank and causing a fire which exploded an onboard oxygen tank

Code Green Story: Breakdown led to many personal realizations

For an EMT of 11 years the cumulative stress took a mental toll that was finally lessened by talking to other responders with their own burdens

When does pride become arrogance?

Let others cheer your EMS accomplishments instead of a boastful T-shirt or hoodie

Off-duty EMT pulls man from apartment building on fire

He ran into a building filled with smoke and helped rescue an elderly man; he also treated a woman for smoke inhalation

Wyo. EMTs may soon start work before completed criminal background check

Proposed bill speeds up start dates to combat EMS shortages by providing conditional licenses to those who have fulfilled all other requirements

London medic urinated on while treating patient

Man who assaulted the London Ambulance Service paramedic sentenced to 300 hours of community service

Discrimination in EMS ends when attitudes change

Most of us who are minorities want what everyone else wants – a fair chance to work in an honorable profession, and be respected for what we can do

Family: EMT stormed out of house, left stroke patient on floor

They filed a complaint with Rural/Metro, saying EMT got angry when asked to transport a man to the hospital and sat in the ambulance until his partner brought him back into the home

Colleagues mourn Pa. medic struck by coal truck at crash scene

West End Ambulance expressed its support for the family of medic Janice Livingston, 38, who was killed by a coal truck that "basically plowed through the emergency scene" on an icy road

How Freedom House Ambulance Service became a national EMS model

Documentary film tells story of Freedom House creating jobs and providing a crucial service to the community in the 1960s
Top

EMS1 Columnist Articles

EMS Today Quick Take: Why do kids faint?

A child fainting, which is a syncopal episode, may be a significant medical event that requires a careful EMS assessment. Dr. Rhiana Ireland, an attending physician and EMS director, discussed causes, assessments, and treatments for children and adolescents that faint in a session at EMS Today in Baltimore, Md.

Overview of pediatric syncope

Syncope is a sudden brief loss of consciousness associated with loss of postural tone from which recovery is spontaneous. Syncope in children and adolescents is common and costly for EMS response and health care assessment of the cause. Fainting can be disabling for some children and most importantly syncope is a potential warning sign of sudden death.

Memorable quotes about pediatric syncope

"Twenty five percent of kids that DIE suddenly had a history of syncope. The previous episode may have been only chance to identify malignant syncope and save a child's life."

Key Takeaways

  • Syncope is common. Twenty to 50 percent of adolescents experience a syncopal episode
  • Exercise, emotion or stress, and loud noise may trigger a syncopal episode.
  • Benign syncope, which is also known as vasovagal syncope is the most common type. This type has an identifiable cause that can be modified. Patient's sense it coming and recovery quickly with no post-ictal period.
  • Malignant syncope is due to an underlying dysrhythmia, like prolonged QT-syndrome, or a structural abnormality, like cardiomyopathy, to the heart. Malignant syncope reveals itself intermittently because of an interruption of cardiac output. This type begins and ends abruptly.
  • Assessment for any syncopal episode should include vital sign monitoring, 12-lead ECG, and continuous EKG monitoring.
  • Seizures are not a syncopal episode. The post-ictal period is the distinguishing feature.

Learn more about pediatric syncope

Ireland showed several videos during the presentation of pediatric syncopal episodes. She used these to discuss benign versus malignant syncope, as well as syncope mimics. EMS educators could utilize these videos to discuss assessment and treatment of syncope.

Benign syncope: child faints during spelling bee

Malignant syncope: soccer player collapses during game

According to Ireland the cause of this fatal incident was a structural abnormality, cardiac myopathy.

Syncope mimic: breath holding spell

Pediatric syncope assessment and treatment

EMS providers may not appreciate the severity of a syncopal episode or a syncopal mimic, like intentional choking or fainting games. A thorough assessment, including a history, physical exam, blood sugar, and 12-lead ECG, is necessary to diagnose the cause of the syncopal episode.

When does pride become arrogance?

Growing up in the California bay area, it was only natural to be a 49ers fan. In fact, I don’t know if I ever considered it a choice. My family was stocked with diehard fans of the red and gold. It helped that the team spent much of my junior high and high school years collecting five Super Bowl rings. In my youthful perspective, the men of Candlestick Park were amazing and none appeared more super-human than Jerry Rice.

While Rice’s accomplishments have become the stuff of football history, the thing that impressed me the most about his Hall of Fame career had nothing to do with the touchdowns or the gravity defying catches. For me, as an impressionable teenager, I was most amazed by what he did after the play.

Unlike most of his contemporaries, both then and now, when Jerry Rice scored a touchdown he would casually jog to the back of the end zone, set the ball on the ground and jog back to the sidelines. No dancing. No jumping into the crowd. Not so much as a fist pump. Jerry Rice not only performed like he was super-human, when he was done, he walked away with the casualness of a businessman catching a city bus. And I was in awe.

The trouble with T-shirts

Today while surfing Facebook, my old football hero came to mind at the strangest of moments. There in my news stream I saw an ad for a fire service sweatshirt … again. I’ve seen this same ad no less than a half dozen times now.

The ad shows a hoodie with an elaborate circular emblem across the back. The banner boldly announces “I Save Lives”. Beneath that the outer ring explains that EMTs belong to a dying breed. Inside the emblem is another proclamation that less than 2 percent of people can live up to the demanding skill set of the modern firefighter/EMT.

All together there is a whole lot of public service bravado packed into this single piece of clothing. The comment stream below the advertisement is divided between the 'I-must-have-this' crowd and the 'not-in-this-lifetime' crowd.

I think you know which side I fall on.

Each time I see the ad now, I sigh. And I long for Jerry Rice. I long for men and women of quiet professionalism who do their jobs and move on. I long for individuals who let others cheer for the accomplishments.

Perhaps it would be easier to dismiss if this was a one-off kind of thing. But it seems like I see these public service T-shirts and slogans everywhere and they’re only getting worse proclaiming ‘I fight what you fear;’ ‘Be safe or I get to see you naked;’ ‘Risking ours saving yours.’ All of them beg the question: When does pride become arrogance"

We didn’t invent bravery, heroism or service

It might help to remember that we didn’t invent this whole idea of public service or personal sacrifice. Our grandfathers stormed beaches in distant countries while hell rained down upon them, and our grandmothers took to the factories to rivet together war planes.

They marched in the streets for human rights and kicked down the doors of burning buildings with sooty faces and wood handled axes. They build cities of iron and steel that scraped the sky with only a keen sense of balance and the willingness to swallow their fear.

When they were done, they packed up and went home. They wore a quite sense of accomplishment and the pride of knowing that they had done their jobs well, for themselves and for us. None of them asked for a T-shirt. If you had made one, they would have smiled and put it away in a drawer.

When I think of the accomplishments of the generations that have gone before, I am sometimes forced to wonder if we have it within us to create a future that is worthy of our past.

In defense of pride

None of this is to say that there is anything wrong with pride. Pride in a job well done is natural. It’s also healthy. I don’t want to rob anyone of their pride. We should be proud of what we do. But I wonder if it wouldn’t serve us to recapture some of the quiet, humble pride of our fathers and grandfathers.

When I walk by the T-shirt vendors and scroll through my Facebook stream I wonder if we couldn’t all use a bit more Jerry Rice. Jerry seemed like he knew something about greatness that many of us seem to be missing. In fact, he knew several things.

He knew that performance when it counted was an expectation of his job. He knew that after his meticulous preparation, tireless practice and constant training, success wasn’t an unknown. It was his expectation. Jerry would have been surprised if he didn’t score the touchdown. And lastly, I think he knew that cheering and applause are best left to others.

Autobiographies aside, we can’t write our own histories. The story of who we are is best left for others to tell. We can’t make ourselves greater by telling others about our own greatness any more than we can make our jokes funnier by laughing at our own punchlines. It’s tempting to try, but it just never works.

Knowing the difference

We can be proud without being prideful. We can be confident without being arrogant. It isn’t as hard to differentiate one from the other as you might think. Pride and confidence lead us toward pro-social, healthy behaviors like a willingness to work hard, a desire to improve by to advancing our knowledge and skill and an internal sense of accomplishment.

Prideful arrogance displays itself as dominance and aggression, and it is not born from our sense of accomplishment but our fear of failure. It feeds on our insecurities. When we feel drawn to proclaim that we are somehow elite or to shout, ‘I fight what you fear!’ we are announcing to the world our own insecurity. This is no longer genuine pride, it is hubristic pride. In all acts of arrogance there is a seed of selfish insecurity.

The difference between pride and arrogance is a matter of degree. It isn’t a light switch that is either on or off. In all of our behaviors we manage to what degree we are motivated by pride and to what degree we are motivated by insecurity. Do we come from a place of authentic pride or fearful arrogance" And perhaps only we know for sure.

If you aren’t certain of where your motivations begin you may need to experiment. You may want to begin by cleaning out your T-shirt drawer. Practice focusing on building the people around you and less on worrying about your image. And by all means, if you’re fortunate enough to score an EMS touchdown, place the ball gently on the field and jog back to the sidelines. You might be surprised at how good a little humility can feel.

Discrimination in EMS ends when attitudes change

I shake my head, sadly not in disbelief, but at the simple sad fact that many of our departments continue to be run by Neanderthals. And, I know that’s insulting to Neanderthals.

Discrimination hurts. For race, sex, age and other protected classes, discrimination is unlawful. For departments that discriminate against its EMS providers, that’s just plain wrong. But I digress.

I think that in this day and age, who you would want to come to your door in the middle of the night to render emergency services would be the person most qualified to do so. Nearly all departments have minimum qualifications in aptitude, skills and knowledge to perform the required tasks; if you meet the qualifications, you deserve the chance to work in this profession in an environment that supports your efforts and not resent them.

Makes sense, right"

But clearly it doesn’t, to quite a few departments across our nation of the free, where all persons are allegedly equal under the law. There is a certain amount of entitlement in departments that wish to protect the status quo, that yearn for the “good old days” and simply can’t stand the concept that people of all colors and both sexes perform the job just as well – or better – than those who currently occupy those positions.

Most of us who come from the minority aren’t asking for a handout or a free pass. We want what everyone else wants – a fair chance to work in an honorable profession, and be respected for what we can do. Not too much to ask for.

The pace of organizational change can be glacial, unless the law intervenes and imposes the will of society upon the agency. Then, legal intervention simply drives the discrimination underground, making the visible signs less so.

Having seen departments go through court-mandated changes in hiring and work practices, I can attest that it's ugly. But unless leadership from both administration and line staff close ranks and make a concerted, sustained effort to make the workplace a safe, enjoyable environment for all, that’s all that there is to make things right.

If even a small percentage of these allegations are true, I suggest that the city has a good set of lawyers that have kept the monetary awards to a minimum. I’m less sure about how much longer that situation will continue.

How EMS use of ventilators has evolved

Mechanical ventilators have evolved significantly in the last decade. Advances in technology, as well as an increased understanding of the physiology and effects of mechanical ventilation have had a profound impact on ventilator use.[1]

Ventilators are used in many clinical areas including operating rooms, emergency departments, critical care transport units, and air medical transports. Smaller, user-friendly portable ventilators show great potential for more widespread use in the prehospital setting, including 911 responding ambulances.

Why a ventilator"

Positive pressure ventilation with a bag-valve mask (BVM) device is a fundamental skill at the BLS level. Delivering effective BVM ventilations can be difficult, and requires considerable practice to be done correctly.[2] Bag-valve mask ventilations, while a critical and proven intervention for respiratory failure, are limited in their ability to provide consistent and accurate tidal volume and do not provide the protections of an advanced airway device.[3]

Positive pressure ventilations with an advanced airway in place can provide a more efficient and protected means of ventilation over a bag-mask device. However, variables in pressure, tidal volume, rate, and oxygen concentration all present potential complications for patients undergoing positive pressure ventilation in the pre-hospital setting.[4] The use of a mechanical ventilator allows for control of ventilation rate, volume, pressure, and oxygen concentration, as well as continuous monitoring of carbon dioxide and oxygen levels.

Ventilator basics

Mechanical ventilation is provided using two basic methods: volume controlled modes and pressure controlled modes. As the name implies, volume controlled modes are designed to achieve a programmed tidal volume with each ventilation at whatever pressure is necessary within a safe limit. Pressure controlled modes are targeted at delivering ventilations until a set pressure is achieved, with tidal volume being regulated by lung compliance, and airway resistance. All types of mechanical ventilation use some combination of these two basic modes.[5]

Ventilators also allow for adjustment of positive end-expiratory pressure (PEEP), and control over the fraction of inspired oxygen (FiO2). Delivering a more precise FiO2 can better ensure an adequate amount of oxygen is available to the patient, without causing oxygen toxicity or hyperoxia.

Standard initial settings for volume delivery usually fall between 6-8 mL/kg, with a maximum recommended volume of 10 mL/kg. Pressure settings usually max out at 20 cm H2O, but may vary by machine.[6] The standard recommended setting for positive end expiratory pressure is anywhere from 0-15, depending on patient complaint. FiO2 levels are also patient dependent.[7]

Many ventilators also provide settings for non-invasive ventilation methods, such as continuous positive airway pressure (CPAP), bi-level positive airway pressure (BiPAP), and proportional assist ventilation (PAV). Non-invasive methods of ventilation are useful in a variety of conditions where respiratory failure is imminent.[8]

While EMS personnel commonly use CPAP in the prehospital setting, BiPAP capabilities provide more customization for varied patient presentations. PAV settings allow for dynamic inspiratory assistance in patients experiencing respiratory difficulties in order to achieve pre-set tidal volume targets.

Pre-hospital Use

Currently, the use of a portable mechanical ventilator is a mainstay of critical care patient transport via both air and ground. A small number of EMS agencies have introduced automatic transport ventilators as an addition to ALS protocols. These simplified ventilators provide more consistent minute volume than traditional positive pressure ventilation with a bag-valve device.[9] There is also evidence that the use of automatic transport ventilators may allow paramedics to complete other tasks related to patient care, as they are not directly involved in manual ventilation.[10]

Prolonged manual ventilation with a bag-valve device is harmful and often increases patient mortality.[11] The introduction of automatic transport ventilators into 911 responding ambulances could have significant impact on patient outcomes, particularly in rural areas with longer transport times.

Pre-hospital use of non-invasive ventilation methods (CPAP, BiPap, and PAV) has been shown to reduce in-hospital mortality rates.[12] The addition of automatic transport ventilators with greater ability to customize settings for CPAP, BiPAP, and PAV would allow pre-hospital personnel to deliver respiratory support tailored to each patient’s specific needs.

Future technology

With traditional ventilators, ventilator supported breaths are initiated by pressure changes in the machine’s ventilator circuit. This causes a delay in the delivery of ventilations. Developments in technology now allow for neutrally adjusted ventilator assist (NAVA). With NAVA, bipolar electrodes detect signals travelling down the phrenic nerve to the diaphragm, and use this signal as the stimulus to initiate mechanical ventilations. This allows for very precise volume delivery and a decreased chance of pressure-related complications.[13] Other developments in ventilator technology include the ability to enter a patient’s weight to generate suggested initial settings.

The potential benefits of widespread automatic transport ventilator use on ALS ambulances are significant. Advances in technology should continue to create ventilators that are smaller, more user friendly, and easily adaptable to the pre-hospital environment.

References

1. Bristle, Timothy J., et al. "Anesthesia And Critical Care Ventilator Modes: Past, Present, And Future." AANA Journal 82.5 (2014): 387-400.

2. Cummins RO, Austin D, Graves JR, Litwin PE, Pierce J.

Ventilation skills of emergency medical technicians: a teaching challenge for emergency medicine. Ann Emerg Med 1986; 15: 1187–92

3. NA, J. U., et al. "Influence Of Face Mask Design On Bag-Valve-Mask Ventilation Performance: A Randomized Simulation Study." Acta Anaesthesiologica Scandinavica 557.9 (2013): 1186-1192.

4. Prekker, Matthew E., et al. "The Process Of Prehospital Airway Management: Challenges And Solutions During Paramedic Endotracheal Intubation." Critical Care Medicine 42.6 (2014): 1372-1378.

5. "Anesthesia And Critical Care Ventilator Modes: Past, Present, And Future."

6. "Anesthesia And Critical Care Ventilator Modes: Past, Present, And Future."

7. Archambault PM, St-Onge M. Invasive and noninvasive ventilation in the emergency department. Emerg Med Clin North Am. May 2012;30(2):421-49, ix.

8. McNeill, GBS, and AJ Glossop. "Clinical Applications Of Non-Invasive Ventilation In Critical Care." Continuing Education In Anaesthesia, Critical Care & Pain 12.1 (2012): 33-37.

9. Gervais HW, Eberle B, Konietzke D, Hennes HJ, Dick W, “Comparison of blood gases of ventilated patients during transport”. Critical Care Medicine 1987;15:761-763

10. Weiss, Steven J., et al. "Automatic Transport Ventilator Versus Bag Valve In The EMS Setting: A Prospective, Randomized Trial." Southern Medical Journal 98.10 (2005): 970-976.

11. Maharjan, R. K., R. P Aacharya, and P. N. Prasad. "Impact Of Duration Of Prolong Manual Bag Ventilated Patients In The Emergency Service." Journal Of Institute Of Medicine 36.2 (2014): 57-65.

12. Rowe, Brian H. "Review: Prehospital Noninvasive Ventilation For Severe Respiratory Distress Reduces Hospital Mortality." ACP Journal Club 160.10 (2014): 1.

13. "Anesthesia And Critical Care Ventilator Modes: Past, Present, And Future."

How to improve your bag-valve mask technique

Before EMS providers can deliver effective ventilation, they must control the airway. It is the single most important prehospital intervention. Although this sounds like a simple step, it is not always easy to do. Many experts attribute inadequate control of the airway as a major cause of preventable death in the prehospital environment.

Manual airway maneuvers

The most basic category of all techniques used to insure a patent airway is manual airway maneuvers. These techniques form the foundation for all airway control maneuvers both in the field and hospital.

Following unconsciousness in most patients, the muscles of the throat relax. In a supine position, this loss of muscle tone allows a portion of the tongue to shift from the oral cavity into the oropharynx. Tilting the head back and lifting the chin displaces the jaw toward the front of the body and pulls the tongue out of the patient’s airway. When properly performed, the head tilt/chin lift maneuver has no complications and is the preferred method of manual airway control in unconscious patients.

However, proper execution of this maneuver requires manipulation of the head, which moves the patient’s neck. If a neck injury is present, the head tilt/chin lift maneuver could worsen the injury. For this reason, EMTs and paramedics suspecting the presence of spinal injury should use an alternative manual airway maneuver, such as the jaw thrust.

Although manual airway maneuvers are effective at establishing a patent airway, rescuers often find them difficult to maintain for prolonged periods. Many find it useful to add the assistance of some type of mechanical airway maneuver, or airway adjunct to maintain airway patency. These include oropharyngeal and nasopharyngeal airways.

Bag-valve mask ventilation

One critical skill all EMS providers must master is effective bag-valve mask ventilation (BVM). Unfortunately, BVM ventilation by out-of-hospital (OOH) care providers often results in inadequate ventilation and may be potentially dangerous for both intubated and non-intubated patients.

Manikin studies demonstrate that EMTs using a standard BVM deliver mean tidal volumes significantly lower than those recommended by the American Heart Association[1]). In the same study, EMTs achieved recommended ventilation volumes in only 27 percent of the ventilation attempts[2].

One problem associated with ineffective ventilation is the inability of EMS personnel to provide effective mask seal on the BVM[3,4] (The American Heart Association (AHA) recommends use of EC clamp as a technique for sealing the face mask to the patient’s face during assisted ventilation[5]. However, attempting to provide an effective BVM seal using a single-hand EC clamp often tilts the mask to the left and allows air leakage from under the right side of the air-cushion[6].

Some argue that replacing the EC clamp with a rotated mask hold may provide a more effective seal[7]. This hold combined with a “chin lift grip” and a newly designed ergonomic face mask may help improve mask seal when performed by a single rescuer[8].

Two-person BVM technique

Side by side comparisons demonstrate that a BVM technique that utilizes two rescuers instead of one provides consistently more effective ventilation than a single person technique[9,10,11,12]. In this two-person technique, one rescuer can deliver the recommended tidal volume by squeezing the bag while the second rescuer can use both hands to provide an effective mask seal on the patient’s face. For the rescuer holding the seal, replacing the two-handed EC clamp with the thenar eminence grip improves ventilation efficacy[13].

The thenar eminence grip is achieved by using muscles at the base of the thumb to place downward pressure on the mask while using the other four fingers of each hand to pull the jaw into the mask. However, given the personnel restrictions that often accompany EMS responses, two person BVM techniques are not always feasible.

Avoiding gastric insufflation

During BVM-assisted ventilation, rescuers must use caution to avoid generating high airway pressures. In general, inspiratory pressures greater than 20 cm H2O in the adult patient increases the risk of forcing air through the esophagus and into the stomach, a condition known as gastric insufflation[14]. Gastric insufflation increases the risk of regurgitation and subsequent aspiration of stomach contents.

Although a number of factors contribute to high airway pressures, EMS personnel who ventilate patients slowly, deliver smaller tidal volumes, and reduce the inspiratory period decrease the risk of gastric insufflation. In addition, ventilation using a bag-valve device equipped with a pressure-responsive, flow-limiting valve reduces mean airway pressure and the likelihood of gastric insufflation compared to using a standard BVM[15]. An inspiratory pressure of 15 cm H2O provides the reasonable balance between effective ventilation and the risk of gastric insufflation[16].

Use of pressure manometers and filters

One simple tool to monitor inspiratory pressure is a manometer, which EMS personnel can place within the breathing circuit between the BVM and the patient. Pressure manometers allow the EMS provider to see exactly how much pressure is being created in the patient’s airway with each ventilation attempt. EMTs and paramedics can then adjust ventilation techniques to avoid unwanted pressures. The use of an in-line manometer during BVM ventilation of a simulated infant has been shown to decrease peak inspiratory pressure[17].

Some BVM devices have an option to install an inline bacterial/viral filter to reduce pathogen introduction into the patient’s airway and contamination of the healthcare provider by the patient’s exhaled breath. The filters are small but do introduce an increase in dead space volume by about 25 to 50 mL, not thought to be clinically relevant. The devices have a filtering efficiency greater than 99.99 percent and are effective against a number of pathogens including viruses that cause hepatitis, influenza, and SARS[18,19].

It is important to note however, that filtering efficiency is highly dependent upon how the device is tested. Viruses and bacteria are smaller than water droplets. Any testing method that utilizes pathogens nebulized in an aqueous medium will likely appear more efficient than they really are[20]. This is because the filter is actually trapping water droplets that contain the pathogens.

It is possible a testing method that utilized dry air as the transport medium for the pathogen would yield different results. Pathogen transmission is still possible even when utilizing these filters. EMTs and paramedics must take additional protective measures such as the use of personal protective equipment that include taking droplet precautions.

In some cases, paramedics may need to begin inhaled drug therapy while simultaneously providing assisted ventilation, especially following endotracheal intubation. Unfortunately, the efficiency of drug delivery via nebulizer during mechanical ventilation varies from 0 to 42 percent[21]. Case reports in an adult[22] and two infants[23] suffering from bronchoconstriction refractory to nebulized beta-agonists report almost immediate improvement in aeration and lung compliance following the endotracheal instillation of undiluted bronchodilators.

For acute exacerbations of asthma requiring endotracheal intubation, the AHA recommends endotracheal administration of undiluted beta-agonists as soon as tube placement is confirmed rather than continued use of nebulizers[24].

References

1. Berg, R. A., Hemphill, R., Abella, B. A., Aufderheide, T. P., Cave, D. M., Hazinski, M. F., Lerner, E. B., Rea, T. D., Sayre, M. R., & Swor, R. A. (2010). Part 5: Adult basic life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 122(suppl 3), S685-S705. doi:10.1161/CIRCULATIONAHA.110.970939

2. Lee, H. Y., Jeung, K. W., Lee, B. K., Lee, S. J., Jung, Y. H., Lee, G. S., Min, Y. I., & Heo, T. (2013). The performances of standard and ResMed masks during bag-valve-mask ventilation. Prehospital Emergency Care, 17(2), 235-240. doi:10.3109/10903127.2012.729126

3. Bauman, E. B., Joffe, A. M., Lenz, L., DeVries, S. A., Hetzel, S., & Seider, S. P. (2010). An evaluation of bag-valve-mask ventilation using an ergonomically designed facemask among novice users: a simulation-based pilot study. Resuscitation, 81(9), 1161–1165. doi:10.1016/j.resuscitation.2010.05.005

4. Noordergraaf, G. J., van Dun, P. J., Kramer, B. P., Schors, M. P., Hornman, H. P., de Jong, W., & Noordergraaf, A. (2004). Airway management by first responders when using a bag-valve device and two oxygen-driven resuscitators in 104 patients. European Journal of Anaesthesiology, 21(5), 361–366.

5. Hazinski, M. F. (Ed.). (2011). BLS for healthcare provider’s student manual. Dallas, TX: American Heart Association

6. Matioc, A. A. (2009). The adult ergonomic face mask concept: Historical and theoretical perspectives. Journal of Clinical Anesthesia, 21(4), 300–304. doi:10.1016/j.jclinane.2008.08.018

7. Perel, A., Berkenstadt, H., Yusim, Y., & Ezri, T. (2009). The rotated mask hold. Journal of Clinical Anesthesia, 21(8), 617-618. doi: 10.1016/j.jclinane.2009.03.005

8. Matioc, A. A. (2012). The "rotated mask hold" and "chin lift grip" may improve the one-hand face mask ventilation airway maneuver. Journal of Clinical Anesthesia, 24(2), 167-168. doi:10.1016/j.jclinane.2010.04.002.

9. Davidovic, L., LaCovey, D., & Pitetti, R. D. (2005). Comparison of 1- versus 2-person bag-valve-mask techniques for manikin ventilation of infants and children. Annals of Emergency Medicine, 46(1), 37–42. doi:10.1016/j.annemergmed.2005.02.005

10. Jesudian, M. C., Harrison, R. R., Keenan, R. L., & Maull, K. I. (1985). Bag-valve-mask ventilation; Two rescuers are better than one: Preliminary report. Critical Care Medicine, 13(2), 122–123.

11. Otten, D., Liao, M. M., Wolken, R., Douglas, I. S., Mishra, R., Kao, A., Barrett, W., Drasler, E., Byyny, R. L., & Haukoos, J. S. (2013). Comparison of bag-valve-mask hand-sealing techniques in a simulated model. Annals of Emergency Medicine, 63(1), 6-12. doi:10.1016/j.annemergmed.2013.07.014

12. Wheatley, S., Thomas, A. N., Taylor, R. J., & Brown, T. (1997). A comparison of three methods of bag valve mask ventilation. Resuscitation, 33(3), 207–210. doi:10.1016/S0300-9572(96)01024-6

13. Gerstein, N. S., Carey, M. C., Braude, D. A., Tawil, I., Petersen, T. R., Deriy, L., & Anderson, M. S. (2013). Efficacy of facemask ventilation techniques in novice providers. Journal of Clinical Anesthesia, 25(3), 193-197. doi:10.1016/j.jclinane.2012.10.009

14. Weiler, N., Heinrichs, W., & Dick, W. (1995). Assessment of pulmonary mechanics and gastric inflation pressure during mask ventilation. Prehospital Disaster Medicine, 10(2), 101–105.

15. von Goedecke, A., Wagner-Berger, H. G., Stadlbauer, K. H., Krismer, A. C., Jakubaszko, J., Bratschke, C., Wenzel, L., & Keller, C. (2004). Effects of decreasing peak flow rate on stomach inflation during bag-valve-mask ventilation. Resuscitation, 63(2), 131-136. doi:10.1016/j.resuscitation.2004.04.012

16. Bouvet, L., Albert, M. L., Augris, C., Boselli, E., Ecochard, R., Rabilloud, M., Chassard, D. & Allaouchiche, B. (2014). Real-time detection of gastric insufflation related to facemask pressure-controlled ventilation using ultrasonography of the antrum and epigastric auscultation in nonparalyzed patients: A prospective, randomized, double-blind study. Anesthesiology, 120(2), 326-334. doi:10.1097/ALN.0000000000000094

17. Karsdon, J., Stijnen, T., & Berger, H. M. (1989). The effect of a manometer on the mean airway pressure during hand ventilation, an in vitro study. European Journal of Pediatrics, 148(6), 574-576.

18. Guardian EMS Products. (2013). Main flow bacterial/viral filter. Retrieved from http://www.guardianemsproducts.com/main-flow-bacterial-filter-1605.html

19. Ventlab Corporation (n.d.). Product reference guide. Retrieved from http://www.ventlab.com/newpdf/CATALOG.pdf

20. Demers, R. R. (2001). Bacterial/viral filtration: let the breather beware! Chest, 120(4), 1377-1389.

21. Dhand, R., & Tobin, M. J. (1997). Inhaled bronchodilator therapy in mechanically ventilated patients. American Journal of Respiratory and Critical Care Medicine, 156(1), 3–10. doi:10/1164/ajrccm.156.1.9610025

22. Verbeek, P. R., Gareau, A. B., & Rubes, C. J. (1988). Treatment of asthma-related respiratory arrest with endotracheal albuterol. Annals of Emergency Medicine, 17(4), 358-360. doi:10.1016/S0196-0644(88)80782-0

23. Carroll, C. L., & Goodman, D. M. (2004). Endotracheal albuterol treatment of acute bronchospasm. American Journal of Emergency Medicine, 22(6), 506-507. doi:10.1016/j.ajem.2004.07.014

24. Sinz, E., Navarro, K. W., & Soderberg, E. S. (2013). ACLS for experienced providers: Manual and resource text. Dallas, TX: American Heart Association

Hero of the Week: 11-year-old saves dad

We’ve got to hand it to 11-year-old Josh Williamson, who sprang to action with his 56-year-old father collapsed from a heart attack in his flat in England.

The boy immediately started CPR, and called 999, saying it looked like his father was dead, but keeping his cool. Once medics arrived, he watched over them as they worked on his dad, offering to help and moving furniture and opening doors when they moved him to the ambulance.

Paramedics were able to confirm a pulse and at the hospital Williamson shook all the responder’s hands, thanking them for saving his father, and even giving paramedic Rachael Cavill a hug. She recalls his reaction when she told him his father’s heart was working but that he was still doing very poorly.

“Josh’s reply brought a tear to my eye,” she said. “He just said, ‘thank you. I am not ready to lose my dad yet.’”

'Paramedic Chief' Feb. 2015: 5 tips to avoid a workplace lawsuit; How to be 'EMS Strong'

In this month's edition of Paramedic Chief, Michael Gerber talks about what it means to be EMS Strong. The EMS advocacy campaign has officially launched, and he reminds us that we're a respected part of the health care community.

Nick Nudell examines how EMS can benefit from the in-home caregivers' use of digital information, and a new legal column by Page, Wolfberg & Wirth cautions leaders to set the tone for their workplace, or else risk a lawsuit.

Jay Fitch covers five ways to hold a productive EMS meeting, and John Becknell explains how EMS leaders can learn from the experience of following.

Clinical solution: Female with belly pain

The causes of abdominal pain can range from simple (mild constipation) to life-threatening (abdominal aortic aneurysm or acute MI). Because so many diseases can present with abdominal pain, the key to building a differential diagnosis in such cases is performing a detailed history and physical exam. These are both skills that providers of any level can perform, though it takes practice to become and maintain proficiency.

Taking a history

In her book “Every Patient Tells a Story,” Dr. Lisa Sanders discusses the idea that patients spend a significant amount of time crafting the narrative of their illness and the events leading up to their symptom onset.[1] Sanders states that there is value in asking a question while taking a patient’s history and actually listening to the answer. In addition to being on faculty at the Yale Medical School, Sanders was a technical advisor for the TV show “House, M.D.” and is an experienced diagnostician.

All too often, medical providers ask something of the patient and immediately start thinking about the next question. If you stop and listen, the patient will tell you what is wrong.

After understanding where the pain is located, begin by asking the patient about the quality of the pain and its severity. Has the location moved" Has the pain increased in severity" In cases of abdominal pain, the history of the event is especially valuable. In addition to simply understanding what the patient was doing when the pain began, also try to determine if there is anything which makes the pain better or worse. Sometimes pain is positional or can occur after eating or immediately upon waking in the morning. Each of these questions about the pain allows you to narrow down the list of potential diagnoses.

For abdominal pain, be sure to ask about bowel and urinary habits. Understanding when a patient’s body is not acting in a way that is consistent with what is “normal” (for him or her) can provide clues about a possible disease.[2]

For female patients of child-bearing age, it is also important to obtain specifics of her sexual and menstrual history. In patients who might be pregnant a presenting symptom of abdominal pain should generate a “must not miss” diagnosis of ruptured ectopic pregnancy which is a potentially life-threatening condition. Be sure to ask these questions in an environment that respects the patient’s privacy. In many states even minor patients have a protected right to access “sensitive services” which are those related to sexual and reproductive health. Be sure to understand and follow your local laws.

Performing a detailed physical exam

When preparing to perform a physical exam on a patient complaining of abdominal pain, you should first determine the location of the pain. After taking a history of the complaint from the patient, then inspect the abdomen looking for swelling or bruising. Often the patient, a family member or caregiver can inform you if the patient’s physical presentation is different from normal (i.e. acute swelling of the abdomen rather than chronic obesity). When palpating the abdomen, begin in the quadrant furthest from the area the patient is complaining about and continue to speak with the patient. Doing so can distract the patient and allow you to determine how much the pain radiates and how severe it actually is.[2] Since conditions like heart attack and pneumonia present with symptoms that include abdominal pain it is important to rule out these diagnoses as well.

During the physical exam you need to see and feel the patient's actual skin. Look for surgical scars and if present ask about the procedure that caused the scar.

Building a differential diagnosis

In addition to determining a working diagnosis it is important in abdominal pain patients to include several serious “must not miss” diagnoses. When pain presents in the epigastric (upper abdominal) region, myocardial infarction should be considered as a possible cause. In sexually active women of child-bearing age a possible diagnosis of ectopic pregnancy should be considered when pain presents in the right or left lower quadrants. In such cases, menstrual history can be valuable in ruling out the concern for an ectopic pregnancy.[2]

While most prevalent in patients age 10-19, appendicitis has become increasingly common in patients between the ages of 30 and 69.[3] Findings of interest for acute appendicitis as your working diagnosis include:[2]

  • The location of the pain near McBurney’s Point which is roughly half way between the top of the hip and the umbilicus
  • Migration of the pain gradually to the right of the abdomen
  • Lack of vaginal bleeding
  • Guarding, which is tensing of abdominal muscles to palpation

Treatment

After obtaining a history and performing a physical examination, you determine that while Lori likely has an appendicitis, there is still a concern that she may be experiencing a ruptured ectopic pregnancy. Since her vital signs remain stable, you assist her into a position of comfort on the stretcher and transport non-emergent to the local hospital. On another return trip to the same facility you hear that Lori’s CT scan showed appendicitis and that she was taken to surgery. She is expected to fully recover and be discharged the follow morning.

References

[1] Sanders, L. (2009). Every patient tells a story: Medical mysteries and the art of diagnosis. New York, NY: Broadway Books.

[2] Stern, S. D., Cifu, A. S., & Altkorn, D. (2006). Abdominal pain. In Symptom to diagnosis: An evidence-based guide(pp. 9-31). New York: Lange Medical Books.

[3] Buckius, M., McGrath, B., Monk, J., Grim, R., Bell, T., & Ahuja, V. (2012). Changing epidemiology of acute appendicitis in the United States: Study period 1993-2008. The Journal of Surgical Research, 175(2), 185-190.

How sticking to an EMS public relations plan pays off

When it comes to building community support and awareness, a lot of EMS agencies have good intentions. They plan to distribute two or three positive press releases each month; simple stuff like CPR classes for the general public and new hire announcements. Everything starts out great, but things get busy and press release deadlines start to slip. Three releases a month becomes one, or even none. The slip isn’t planned, but it also isn’t punished.

Commit to a routine

Marketing and promotion are a lot like exercising. Some people love exercising and working out. They plan their schedules around their workout times.

I don't love working out, but I do swim laps three days each week. I’m not fast, but I’m consistent. For the last four years I have swam the exact same distance, the exact same way. I swim one mile non-stop, which is 33 laps. While that distance may seem impressive to some, it’s really not significant to a lot of swimmers. A swim team member, for example, swims several miles in a daily practice.

Commit with zero exceptions

Unless I’m travelling for more than a couple days (which is rare), there are zero exceptions to my three times per week rule. Why" Because the first time I make an excuse like it’s too cold, or it’s raining or I have somewhere else I’d rather be, I’ll use an excuse every time I don’t feel like swimming—which is pretty much every day.

I swim outside at a public fitness center (I live in Arizona) and even though the pool is heated it can still get cold, especially after the sun goes down in the winter months. One particular winter evening the temperature was in the 40s and there was a fog as heat rose off the pool into the cool air.

I often use my swim time to think about my day or come up with ideas for my clients. But on this day, as I was counting down the laps until I could go home, I began to wonder how many miles I’ve swum. Three days per week for at least 50 weeks each year, means I am swimming 150 miles each year.

Take pride in the ongoing public relations effort

I’m not saying that to brag—like I said, I’m not fast and to other swimmers a mile isn’t impressive. I know that. Yet I couldn’t help feeling proud of the total.

My swimming approach mirrors my public relations approach. A consistent and steady effort leads to big results over time.

A single mile of swimming isn’t going to get you in shape, just as one press release isn’t going to earn you a reputation as a go-to expert resource for a local reporter. Only as those miles, or press releases, add up will you realize the pay off. And the effort only adds up if you don’t take days off.

Why I write about alcoholic patients

My name is Michael, and I’m an alcoholic.

I did not choose to be one, had no idea I was one when I took my first drink, and had no idea how to manage the disease for 25years. I thought I was less than my friends and family that drank responsibly. I truly believed that I was weak, and pathetic. Every day I promised myself that I would not drink, and every day I broke my promise.

Looking back the solution seems so simple; don’t drink alcoholic beverages. Ever. Sometimes looking back is exactly what I need to do. It is easy to forget just how overwhelming an addiction is when you have managed to control it. When I forget how difficult it was to finally admit I was powerless over alcohol, another drink becomes closer to reality. I’ve managed to put 14 years of 24 hours together by taking things one day at a time, and am pretty sure that today, I will not waver.

So I write about alcoholism, and alcoholic patients. Complacency is deadly to a recovering alcoholic. Keeping the misery close to the front of my mind helps me stay sober. Helping other alcoholics helps me, and I have helped countless alcoholics while tending my own disease. The language of recovery is heard loud and clear by the people who need to hear it, and I like to think that my words, spoken in the back of the bus, and now written in confidentiality have made, and continue to make a difference.

These three articles address the problem head on. Many of my other articles strive to deliver the message of hope in less direct ways.

Thank you for reading, and helping keep me sober.

When the drunk driver is one of us

The state police arrived just as we extricated our victim, who emphatically slurred to us that he was an EMT and "on the list" for the next Providence Police Department Training Academy. With a DUI charge pending he's no longer on "the list."

The season of 'cheer' is hard on alcoholics

Our good friend Ethyl Alcohol is ready to infiltrate the body, mind and spirit of those who suffer from alcoholism, making their lives a contradiction of joy and despair. The holiday season amplifies the need to imbibe and pushes away the urge to resist.

Saving a life with 'the monkey on my belt'

He wasn’t always an alcoholic, he said, eyes downcast, voice barely audible. He went on, telling us of a childhood spent in foster homes and orphanages due to his birth parent’s inability to provide proper care for him and his twin siblings.

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EMS1 Tips

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

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

Active-shooter response: Are you physically ready?

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

Energy-saving tips for your station

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.

How this video can "Keep Yourself Safe"

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

CPR class instruction tips: 5 ways to make it great

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

Patient assessments: How to avoid free-for-alls

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

Patient assessment is a non-linear process

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

Blood pressure reading tips and tricks for EMS

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

How to use Slideshare for EMS education and training

Slideshare is an online community and tool for sharing presentations.

How to get optimal battery life from your devices

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