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

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EMS1 Daily News

Top 5 EMS videos of 2014

Our top videos this year ranged from disturbing and serious, to seriously funny

Medics reminded to remain vigilant after NYPD fatal shooting

The retaliation killing of two police officers has sent a shock wave through all of public safety, including EMS

Reaction to ambush killings of 2 NYC cops

Gunman announced online that he was planning to shoot two "pigs" in retaliation for the in-custody death of Eric Garner

Man killed in head-on crash with Conn. ambulance

Four people on board the ambulance were doing training, and suffered only bumps and bruises in the collision

Prepackaged caramel apples linked to 4 deaths

Since mid-October, there have been 28 cases across 10 states of people sickened from a bacteria; the CDC is trying to determine which brands are involved and how the candy became infected

Mich. medic jailed for stealing cash from dead patient

A paramedic has been sentenced to 15 days in jail for stealing $80 from the patient's home while on an ambulance run

Community paramedicine pilot approved in Calif.

The program will include a wide range of community paramedicine services, which will be evaluated by an independent team when it concludes in 2017

2 NYPD officers killed in ambush attack

An armed man walked up to two officers sitting inside a patrol car and opened fire Saturday afternoon

How EMS can help end distracted driving in 2015

Most Americans know texting and driving is dangerous but do it anyway; EMS can change this by educating children

Va. hospital under federal investigation for prescription drug thefts

The US DEA served Lynchburg General Hospital pharmacy with a warrant related to hundreds of thousands of dollars in possible thefts from ambulance drug boxes
Top

EMS1 Topic Articles

Top 5 EMS videos of 2014

Our top videos this year ranged from disturbing and serious, to seriously funny

Medics reminded to remain vigilant after NYPD fatal shooting

The retaliation killing of two police officers has sent a shock wave through all of public safety, including EMS

Reaction to ambush killings of 2 NYC cops

Gunman announced online that he was planning to shoot two "pigs" in retaliation for the in-custody death of Eric Garner

Man killed in head-on crash with Conn. ambulance

Four people on board the ambulance were doing training, and suffered only bumps and bruises in the collision

Prepackaged caramel apples linked to 4 deaths

Since mid-October, there have been 28 cases across 10 states of people sickened from a bacteria; the CDC is trying to determine which brands are involved and how the candy became infected

Mich. medic jailed for stealing cash from dead patient

A paramedic has been sentenced to 15 days in jail for stealing $80 from the patient's home while on an ambulance run

Community paramedicine pilot approved in Calif.

The program will include a wide range of community paramedicine services, which will be evaluated by an independent team when it concludes in 2017

2 NYPD officers killed in ambush attack

An armed man walked up to two officers sitting inside a patrol car and opened fire Saturday afternoon

How EMS can help end distracted driving in 2015

Most Americans know texting and driving is dangerous but do it anyway; EMS can change this by educating children

Va. hospital under federal investigation for prescription drug thefts

The US DEA served Lynchburg General Hospital pharmacy with a warrant related to hundreds of thousands of dollars in possible thefts from ambulance drug boxes
Top

EMS1 Columnist Articles

How EMS can help end distracted driving in 2015

I am sure you know distracted driving is dangerous and puts you at greater risk of a collision. In a recent survey 98 percent of respondents reported knowing that texting and driving is dangerous. Inexplicably 74 percent of them did it anyway.[1]

As EMS providers we witness the danger and carnage of distracted driving nearly every day. Almost 10 people are killed every day in the United States in collisions that involve a distracted driver.[2] That is more than 3,500 fatalities from distracted driving in the last 12 months. This year an estimated 421,000 people were injured in collisions that involved a distracted driver.[3]

EMS is at great risk

Not only are we called upon to care for the victims of distracted driving collisions, but our life and safety are at considerable risk as we travel the roads and highways of our communities. The danger is especially significant when we are out of our vehicles attending to an emergency and traffic continues to stream by. Daniel Callaway, a volunteer firefighter/EMT, was struck when he came to the assistance of a driver involved in a crash.

In 2012, NHTSA reported that at any given moment 5 percent of drivers had a phone to their ear and estimated that almost that same percentage of drivers were using a hands-free device.[4] Remember that anytime you find yourself standing on the side of the road or in an intersection, 10 percent of the vehicles near you are being driven by a distracted driver. Ensure that awareness of distracted drivers and the high likelihood of a secondary collision is part of your crash scene training.

We know it's bad and we do it anyway

Distracted driving is not the only types of high risk behaviorwhere a large percentage of people acknowledge know it’s dangerous yet still engage in that behavior anyway.

Distracted driving is a unique high-risk behavior. Knowledge of the danger has not impacted participation. For other dangerous behaviors, like smoking or drug use, knowledge of the danger is universal and that is reflected in a low percentage of Americans participating in the risky behavior.

  • I am confident that a very high percentage of Americans know smoking is bad for their health. About 18 percent of Americans smoke, the lowest percentage in decades.[5]
  • I am hopeful that the gap between Americans that know heroin is dangerous and the 1.6 percent of Americans that have used heroin is vast.[6]
  • I am not sure how many of us realize that soda is bad for our long-term health, but encouragingly less than half of Americans drink soda each day.[7]

I am encouraged that various education campaigns about the dangers of distracted driving have been so successful. Clearly knowledge has changed. Unfortunately behavior, even for EMTs on the job, has not.

Kids lead the way on behavior change

"Dad, where is our fire extinguisher"" my 7-year-old asked as she burst through the door after school.

"Under the kitchen sink," I said.

"Is it still good"” she asked. “The firefighters told me to check as soon as I got home."

We looked at the extinguisher and confirmed it was functional and up-to-date.

An hour later, in the middle of dinner, "Dad we need to practice our fire escape plan. Right now. The firefighter told us to practice the plan tonight at dinner. What is our escape plan""

As instructed ─ because who can put off a child that wants to prepare for an emergency ─ we pushed away from the table, leaving our meal half-eaten, and drilled our home fire escape plan. The firefighters, highly respected by my children, empowered my son and daughter with a specific call to action to practice a behavior.

My kids repeat this routine – fire extinguisher, smoke detector, and fire escape plan – every October after the firefighters visit their school. The firefighters give the kids knowledge and a script to use at home saying something like, "When you get home tonight – first thing – ask your parents where the fire extinguishers is kept." The kids dutifully follow the instructions and as a family we have a great fire safety review.

EMS, police, and fire can change distracted driving behavior

EMTs, paramedics, firefighters, and police officers, please engage the children that come to your stations and tour your ambulances, cruisers, and fire apparatus. Lead the campaign to change the dangerous behavior of driving while distracted.

Add a few minutes during every tour or classroom visit to discuss the dangers of distracted driving. Ask the kids, "Does your mom ever send or read text messages while driving you to school"" or "Does your dad talk on the phone on the way to soccer practice""

I suspect many of the kids will answer yes and with minimal prodding tell a near-miss story or an actual collision they were involved in to you and their classmates. Kids love telling stories.

Next, equip the kids to change behavior in the vehicles they ride in. Something simple will do. I know kids will be glad to help you, their role models and heroes, make the roads safer.

"Mom, we both know that our risk of crashing goes up if you are texting. The paramedics said you should put down your phone, focus on driving, and ask me about my day at school."

Or

"Dad, we both know distracted driving is dangerous. The EMTs told me you should move your phone out of reach as we drive to soccer practice."

My script to stop distracted driving

I have a script that I have used on paramedic partners driving the ambulance, taxi drivers, bus drivers, and friends and family. My script is simple and well-rehearsed, "Please put down your phone. I have two young children at home. They need me to get home today. I will do the same for you – not look at or use my phone – while I am driving. Thanks for putting down your phone."

I use something similar when an EMS chief calls me while driving their department issued vehicle. "Chief I am glad to talk, but for the safety of you and those around you let's reschedule for a time you are not driving. When can I call you back""

Give the kids the script and an assignment

My script works – one vehicle and one driver at a time. As an emergency responder you have the opportunity to exponentially multiply the number of people, especially children, using a script to change driving behavior, in turn making the roads safer for you and the communities you serve.

References

1. Drivers get a rush from text messaging: http://www.washingtonpost.com/blogs/dr-gridlock/wp/2014/11/06/drivers-get-a-rush-from-text-messaging/

2. Distracted Driving: http://www.cdc.gov/motorvehiclesafety/distracted_driving/

3. What is Distracted Driving: http://www.distraction.gov/content/get-the-facts/facts-and-statistics.html

4. Driver Electronic Device Use in 2012: http://www-nrd.nhtsa.dot.gov/Pubs/811884.pdf

5. Smoking and tobacco use, fast facts: http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/

6. DrugFacts: heroin http://www.drugabuse.gov/publications/drugfacts/heroin

7. Nearly Half of Americans Drink Soda Daily: http://www.gallup.com/poll/156116/nearly-half-americans-drink-soda-daily.aspx

Inside EMS Podcast: Why the flu shot matters for EMS

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

In this week’s Inside EMS Podcast, hosts Chris Cebollero and Kelly Grayson discuss flu season, and keeping the workforce safe.

“What distresses me is that so many people, even in EMS, think that the flu shot gives you the flu,” Grayson said.

Cebollero agreed, saying parents who don’t give their kids flu shots also contribute to the problem of vaccine denial in general. As a result, diseases such as the measles, whooping cough and mumps are making a return.

“We’re losing our herd immunity, and they don’t grasp that concept,” Grayson said. “We’re starting to see diseases we thought we had pretty much eradicated, and now we’re having outbreaks, right here in a first world nation.”

They also stressed the importance of wearing masks in EMS to protect both patients and providers, and the simple act of frequent hand washing and cleaning equipment – all aspects of good infection control that should be practiced outside of flu season as well.

In the news, they talk about a D.C. Fire and EMS investigation into why it took 22 minutes to respond to a man who died, which the union blamed on location glitches with dispatch technology.

“The way to fix these problems is not to bash each other and blame it all on leadership and blame it all on dispatch,” Grayson said.

They also discuss a Philadelphia paramedic who came under fire for an Instagram post that shows two black men pointing guns at the head of a white police officer.

“We have to remember that regardless of is we’re off duty, but we still represent our organizations, and we can’t put defaming posts on our [social media] page that will bring disgrace or bring disrespect not only to our career fields, but to our departments,” Cebollero said.

Grant funding implications of the Field EMS Bill

On February 25, 2013 Congressman Bucshon (R-Ind.) introduced H.R. 809 “Field EMS Quality, Innovation, and Cost Effectiveness Improvements Act of 2013.” Better known in the industry as the Field EMS Bill, it’s designed “to provide for improvement of field emergency medical services, and for other purposes.”

Many debate what that means, and are uncertain of what the bill actually does.

At its core, this bill:

  • Defines the term “EMS” or “emergency medical services” and “field EMS agency"
  • Recognizes the Department of Health and Human Services as the primary federal agency for emergency medical services and trauma care
  • Establishes the Office of Emergency Medical Services and Trauma as responsible for “improving the quality, innovation, or cost effectiveness of emergency medical services,” including delegating grant programs
  • Creates a National EMS Strategy
  • Establishes the System Performance, Integration, and Accountability (SPIA) grant program

While some within EMS argue that the bill does not do enough, or will not have a legitimate effect on daily operations of EMS, I challenge those to take another look at the actual document.

This bill attempts to redefine the foundation for EMS in the federal government.

Since 1966 when a convergence of political and medical actions focused the national interest on motor vehicle crashes, EMS has been placed under the Department of Transportation. At the time it seemed appropriate it now has created an identity crisis for EMS.

Is EMS considered public safety or public health"

This bill establishes that we are both, saying not only do we protect the public, but we also need to integrate ourselves into public health to allow a change in our culture.

It provides a clear definition of who we are and what we do for legislators and the public. It progresses us towards integration into the public health system by placing us under the Department of Health and Human Services, with our own office to create a centralized point for education, research, and funding.

Clinical scenario: Dispatched for a sick teenager

The tones at your station sound while you and your partner are checking out your vehicle in the morning. As you come up on the air and go en-route, dispatch provides the following update: “Rescue 74, I show you en route Priority 2 to 786 West Maine Ave. You’ll be responding on a 16-year-old female complaining of headache, nausea, vomiting and dizziness.

Patient assessment

You are met at the front door by a woman who identifies herself as the patient’s mother. The woman states that her daughter woke up this morning not feeling well. She reports that the patient has been “under the weather” for several days but is much worse this morning.

The patient has been reporting headache, neck pain, fever, sensitivity to light and nausea. The patient has a history of migraines, but her mother states that these symptoms are different.

The patient’s mother leads you to her daughter’s room. She looks over when you walk through the door and is sluggish and slow to respond. You turn a light on low in the room and see that the patient is pale and sweaty. You also notice a rash consisting of small pinpoint marks on her chest and arms.

At this point think about the following questions:

  • What are some potential diagnoses for this patient"
  • What about a “must not miss” diagnosis"
  • Are there any concerns you have moving forward with the care of this patient"
  • What are your next steps"

Post your answers below in the comments

Why medics need more than one EAP referral for PTSD

There have been some positive developments for British Columbia paramedics and their ability to access mental health care for acute stress and post-traumatic stress disorder (PTSD).

British Columbia Ambulance Service (BCAS) is expanding support services for its staff in this area; this comes after recent reports of several of their paramedics not being able to receive care for their condition or financial support while disabled.

I’m hoping that those who are suffering will be able to benefit, although it seems that there will be a legal settlement for at least one.

Given the nature of the work, the long hours, low pay and physical labor, it’s no surprise that EMS providers are subject to inordinately high levels of stress. We get physically injured at a higher rate than our fellow firefighters and police officers. I have no doubt that our “mental” injury rate is higher as well. Perhaps what is more disturbing to me is how EMS employers engage with their staff on these issues, or rather how they don’t.

Don’t get me wrong; I’m sure most agencies have employee assistance programs (EAP) that begin to address the issue of unhealthy stress. But an EAP referral can be superficial; not all cases of acute stress can be mitigated in one or two meetings or phone calls. What about longer term counseling" Or workers compensation if the employee is temporarily disabled" A lot of EAP programs may not get beyond the initial phase of support, placing the financial burden on the employee to continue care.

We certainly wouldn’t see this behavior in most disabilities involving a physical injury or illness, but mental illness can’t be seen, and according to some folks, can’t be real because it can't be seen. That’s got to change.

Here’s another wrinkle – many EMS providers work "part-time" at more than one job. Unlike most other workplaces, part-time in EMS may mean putting in 40 hours or more a week – without accruing health insurance, vacation or sick time, and other benefits of a full-time worker. Frankly, it’s hard to find an incentive for employment agencies to have full-time staff, with the money saved from not having to provide benefits. Sadly, that in turn artificially depresses the true cost of providing EMS, and forces EMS providers to work a lot of hours for little pay. How does this promote a stable, long-term workforce"

As much as I want to be a cheerleader for all of the progress EMS has made in the past 30 years, we have yet to make significant progress in standing up for our own people and providing them with the ability to serve for as long as they want to. A lack of mental health services is really just the tip of the iceberg of what is not working in our business.

7 traits of great field supervisors

The best-run EMS organizations — those with high employee engagement and sterling customer care — have great field supervisors. Unfortunately, field supervision is one of the least-recognized areas of the EMS management structure.

Many EMS organizations with fine providers and bright leaders fail to excel because they have have the wrong people in field supervision. Field supervisors set the tone for what really goes on in an organization.

They are the number one ingredient in employee engagement. They translate organizational expectations for the workers. They determine how the upper management story is told on the street, listen to the stories from the field, then carry them up to the people controlling the resources. Supervisors see what goes on in the field and determine how recognition and criticism is passed along to workers.

One of the most important steps in creating great supervisors is selecting the right people up front. Too often, people are made supervisors simply because they are willing to do the job, want to move up, and are good at making upper management feel good. Those characteristics may work in the short term, but, ultimately, field providers will rebel against such supervision and derail the organization’s performance. The next time you’re looking for a supervisor, try testing candidates for the following seven characteristics:

1. They’re reluctant to take on the job

Field supervision is a hard and demanding position. It has all of the bad hours of field work without the satisfaction of simply running calls and then going home. Furthermore, it comes with more responsibility but often not much more pay.

Be wary of the worker who appears eager to jump into a supervisor spot. That person may just be looking for a way off the street and up the ladder. Instead, look for people who love running calls, taking care of people, and hanging out with other providers, and don’t be turned off it’s there’s an initial reluctance toward becoming a field supervisor. Of course, you may have to do some heavy recruiting to attract these street lovers, but it will be worth it. They will bring their passion into the position, keep you growing as a leader, and make sure that the right stuff is attended to.

2. They make good EMS partners

Being a good supervisor demands people skills, which are hard to identify in an interview or through testing. Even more, EMS is a quirky business, and you need to a supervisor who understands those quirks.

The best way to find someone with the right people skills is by finding the person others like to partner with. Your field providers will guide you to the best potential supervisor; the person who is not well liked as a partner will be hated as a supervisor.

3. They’re not a stickler for rules

Making and enforcing rules is not the way to solve day-to-day problems. It’s not rules that keep the operation flowing smoothly, nor do they inspire tired street providers to smile at the third or forth cranky patient on a night shift. Again, it’s people skills.

But because this is largely not emphasized in the supervisor job description, too many in this position see their job as monitoring and enforcing the rules. Beware of hiring supervisors who know all the rules, and instead, go for the person who cares about individuals and understands the value of relationships. Look for someone who knows what is right even if there is no rule or policy.

4. They take a stand

The worst kind of supervisor is one who rubber stamps upper management. Initially, these people seem to make management’s job easier, but in the long run cannot be trusted to accurately portray what’s happening with the troops.

Go for the supervisor who is willing to challenge you and argue for the people he or she supervises. Go for a supervisor who is hard to sell on change, dubious about management’s intention, and fiercely protective of medics. This person will keep the organization honest and prevent hordes of street providers from beating down your office door. It’s easier to deal with one tough supervisor than a crew of angry medics.

5. They listen

Time and again, street providers say no one listens to them. Watch how your potential supervisor behaves around others. Is he or she the main storyteller" Does this person have all the answers and tells others how to do things"

Go for the candidate who has enough self-confidence to let others have both the first and last words. Go for the one who holds back and hears more than squeaky wheels. Listeners will go much further in keeping your people enthused, excited, and committed.

6. They ‘get it’

EMS isn’t just about patient care. It’s about having a functional organizational structure that can buy ambulances and pay its workers. Street providers need to focus on,and fight for, good patient care. Leaders and upper management need to focus on the politics, the funding, and the strategic planning. The supervisor sits flat in the middle of both. The supervisor needs to understand the importance of both, and hire the ones who get that.

7. They go on vacation

Supervisors burn out left and right, and I believe it’s the most difficult and stressful job in the organization. It’s largely more thankless than being a provider, so go for the person who stubbornly recognizes the need to recharge and take time away from the stress. He or she will enjoy other aspects of life, and return feeling refreshed. Workaholics need not apply.

It’s not easy to find someone with all of these charactersistcs, so focus on those with at least four of the seven, and work on helping them develop the rest. Strong supervision will demand an investment of time, patience and trust, but doing so will pay huge dividends when you discover that the day-to-day operation of the organization is running smoothly without you. Then you will be able to get on with truly leading, not just managing the organization.

Vary annual EMS events to keep media engaged

In preparing for my most recent wedding anniversary, one of my tasks was to pick out a card for my wife. Staring at the shelves there were lots of options, yet many of them seemed familiar. I found myself trying to make sure that I didn’t purchase a card that I had already given.

EMS organizations have many anniversary or annual events that we pitch to the media on an annual basis. It’s okay to do the same successful media event year-after-year, just like it is okay to give an anniversary card to your spouse every year. You simply don’t want to always give the exact same card.

Year 1: EMS week news event

Years ago I was the public information officer for an ambulance service provider. Every year we celebrated EMS Week. Paramedics and EMTs were acknowledged and thanked by the company and the public.

We received excellent media coverage by hosting an event where reporters and videographers got to drive an ambulance on a closed course. We had a bunch of drills like serpentine through cones and tire spotting for them to complete. During the driving demonstrations, we had the opportunity to talk about our amazing employees and to explain the extensive training each EMT driver completed before they were allowed to drive the ambulance on the road in emergency situations.

The media loved it, and several stations did stories. Some did multiple segments throughout the morning live newscasts. All the coverage talked about thanking employees during EMS Week and that driving an ambulance is harder than it appears and requires a lot of training.

Year 2: Same event different 'card'

The next year we wanted to offer the ambulance driving event again, but we made a minor change to the event. This time we invited mayors and elected officials. We even had an informal contest between some of the officials to see which municipality ran over the fewest cones. The elected officials loved it.

The media loved it even more, as the elected officials driving gave them excellent visuals and each interviewed politician thanked our crews on camera for all that we do for their local community and its residents.

Year 3: New variation for EMS week event

The third year we came up with yet another variation, inviting sports team mascots to drive the ambulances. Media enjoyed this too, even though most mascots literally couldn’t fit behind the wheel. Instead we had to make up an obstacle course and different types of games for them to do and interact. Reporters loved it — especially as the mascots wrapped up the reporter in gauze and other medical supplies on camera during her live stand-up

Slight variations keep annual events fresh and fun

My point is that it’s okay to do the same basic thing every year when it’s a crowd pleaser that gets the desired result. The key is making a slight tweak to the annual plan to keep it fresh and fun. It’s the thought that counts.

An exhausted medic’s mistake

We found him lying on the sidewalk, mumbling and semi-conscious.

Was he drunk or diabetic" Sometimes it’s hard to tell; sometimes they are both. We picked him up, put him on the stretcher and lifted him into the truck. A few tests later and we had a treatment plan.

Turns out he hadn’t taken his insulin, had a few drinks with his friends on the corner and then had a few more. When he became incoherent, his friends left him. We didn’t. Homeless alcoholics depend on us. They have far more problems than the obvious.

While establishing an IV he took a swing at me, and the needle ended up in my hand, just below my thumb.

My partner held him down while I sat on the bench, looking absently at my hand. I pulled the needle out, and wiped my blood with an alcohol swab. Then I put my hand on the guy’s chest, held him with one hand and drove a fresh catheter home with the other. We ran some D-50 and a few minutes later things returned to normal.

Lack of sleep leads to mistakes

I was nearly as unconscious as the patient.

The call came in at the end of a 38-hour shift, and near the end of a 23-year career. I was too tired to care about much of anything. So I went home, tried to forget about the needlestick and hoped for the best. But all the hoping in the world will never take away the nagging doubt that haunts me to this day, “am I a walking time bomb"”

There isn't much to do once the damage is done, so if at all possible, don't let it happen. Take care of yourselves first, and get enough sleep; otherwise you may do something you regret.

While the money that comes with overtime is great, but lack of sleep makes you a little crazy, which is the only way I can explain my lack of follow-up after the needlestick incident. Had I been alert, it never would have happened. I may have been stuck by the dirty needle, but I most definitely would have followed up with proper documentation and treatment.

And it’s not just me my poor judgment affected.

When I woke up some hours later, at home and in my own bed, I had to face the very real possibility that my irresponsible actions had the potential to touch the very people I was working to provide for. A dirty needle comes with all kinds of problems – HIV/AIDS and Hepititis topping the list. The problem flows downhill; the patient has a disease, the provider sticks himself with an infected needle and becomes diseased, the diseased provider brings the disease home and potentially infects those he is closest to.

Post-exposure prophylaxis (PEP) with antiretroviral medications against human immunodeficiency virus (HIV) are indicated, but are not mandatory. At the very minimum proper documentation should have been done. In the unlikely chance that I develop HIV it would have been nice to point to a probable source.

There is no room for poor judgment when lives are at stake. Exhausted people make poor decisions, and there is absolutely no excuse for medics to be practicing without proper rest. I did it for years, and now I have years to regret doing so. Time spent in the streets ends abruptly, and there is the rest of your life to live when it's done.

Or not.

It is up to each and every one of us to know our limits, and how best to not exceed them. When overtime is available, try to think of how you felt after the last one, and decide whether or not it was worth it.

How to use stretchers and cots to their full potential

I recall my first shift as a green EMT looking to my experienced Field Training Officer (FTO) to teach me all about this ‘street medicine’ everyone had been talking about in school. Of course our very first call was to a skilled nursing facility.

My FTO instructed me to “go ahead and get into bed with the patient, on your knees so we can slide her over to the cot.” Responders, can we be honest with ourselves for a moment; are you really “helping” transfer the patient by kneeling in or standing on the bed" No, you are not helping.

My first career, 15 years working in the physical therapy and pain clinic world, was spent treating spine disorders and pain issues. I came into EMS late in the game, but I have come to realize my first career afforded me a unique perspective on how we do our job. I have come to look at EMS this way; we are in the moving business and happen to provide fantastic patient care in the process.

My other observation is that the manufacturers are not adequately conveying the message of how to properly use their products. Or maybe we are simply not listening" I see this in two types of equipment; flexible stretchers and patient cots.

Flexible stretchers: aka the lifting tarp

Call after call I was taught to move patients, handle equipment and do my job in ways that I knew doubled and sometimes tripled the load on my body. Let’s examine the techniques involved in the patient move you do every day: the lateral transfer.

Technique 1: The sheet drag

Many EMS providers use a bed sheet to move patients from bed to bed. Science tells us that a bed sheet is not an approved patient transportation or transfer device. A bed sheet does not have handles which alter grip and hand position.

If we follow the NIOSH lift equation recommendations we need to keep spinal compression forces below roughly 800 pounds. However, pulling a 105-pound patient with a bed sheet between two beds loads your spine with between 900 to 1,800 pounds of compression force. Most of our patients weigh much more. We probably average over 2,500 pounds of force on the spine each call. Alarmingly, injury begins to occur at 800 to 1000 pounds of force.

Technique 2: The frictionless transfer

A great benefit of my job is that I train well over 50 EMS departments per year across the country. I get to see every type of EMS system and patient transfer gear. In every department the one tool that most already have on the ambulance, but is thoroughly misused or unused is the flexible stretcher.

Flexible stretchers have been marketed to us as ‘bariatric tools,’ so they stay on the truck unused for most patients. To clarify, I am talking about normal person sized vinyl tarps such as a mega-mover or Taylor Titan.

By using the flexible stretcher, a tool you already have, we can do some cool things. First, both responders can stay on the same side of the bed. Two people pulling are much more efficient than one pulling from the bedside and one person kneeling in the bed pretending or attempting to help. The vinyl tarp also reduces the spinal load well below 800 pounds of compressive force. A dangerous move is instantly safer.

Plus, when you get to the hospital the patient is still on the tarp. Simply slide the patient over, with both of you on the same side and retrieve your tarp back.

Unlike a slide board, tarps can be used for slides, drags, lifts, and transfers. Tarps are also simple to clean and quickly refolding and placed under the head of the cot; ready to go for the next patient.

Stretchers: aka the cot or pram

The ambulance stretcher is one the most expensive and heaviest tools that EMS ‘movers’ use. It is also the tool that I see the greatest amount of operator error and personal interpretation of the manufacturer’s recommended usage guidelines.

Recently I was talking to a rural EMS chief and asked what type of stretchers they were considering:

Notice the spinal load and extension. (Image Bryan Fass)

EMS Chief: “We are about to buy brand new manual lift stretchers.”

My standard reply is, “as a rural EMS service with limited first responder support, why not invest in powered stretchers so that your small crews can lift as a team"”

EMS Chief: “Well that’s because the crews feel that they are too heavy to bring in the house, too heavy to pull across the lawn, and too heavy lift.”

If you are already a user of powered stretchers you know what is wrong with those concerns. If you are a manual stretcher user, let’s dial this in.

1. Powered cots are only to be loaded and unloaded from the ambulance, patient or not, with two responders at the end.

2. Powered cots are never to be carried up stairs. They need to be married to a tracked stair chair. Use the stair chair to move the patient up or down stairs.

Powered cots drastically reduce the error of moving patients from point A to point B at LOAD height, which is the full up position that is only for loading and unloading the cot. The rest of the time the cot is designed to be in transport height. Transport height is roughly ¾ of the way raised, but not all the way up.

Major insurance companies track moving a patient at load height as the number one cause of dropped and tipped cots. Manual cots are not designed to be lifted from the floor to the full up position (load height) in one motion. Manual cots are two-stage lift stretchers; lift it halfway and move to the truck then raise the cot to load height.

Train: aka read and watch

When I ask EMS providers if they have read the user manuals or watched the how-to videos for their cots and tarps, I usually get a blank stare. We need to do a much better job ofutilizing our resources. Sales professionals need to become better educators on product use, not just product features.

For all patient lifts this is my mantra for you to live and lift by, “All hands working and every single lift counts.”

Stop handing down dangerous habits and use the tools we have with purpose and direction.

Which artery do you choose for taking a pulse in a medical emergency?

In a conscious adult, the radial artery is the preferred pulse point, for a number of reasons:

1. It's less invasive. Before you put your hands on someone's neck, you need to establish trust and rapport. It's awfully disquieting and just a bit awkward to assess a carotid pulse while talking to someone. They're already under considerable stress, so reaching out and putting a hand near their throat doesn't help ... it's downright alarming. Reaching for the femoral artery on the inner thigh, doubly so.

2. As a general rule, you should always choose the least aggressive, least invasive, least distressing option that accomplishes the task before moving onto the more aggressive choices.

3. If they're conscious and upright, I already know they have a carotid pulse. I don't know the rate, rhythm, or quality, but I definitely know they have one. Those unknowns can all be learned from the radial.

4. In nearly all cases, the conscious adult has a palpable pulse in their radial arteries that is not materially different than the carotid. In the unusual cases where the radial pulse was not palpable, it can tell you something relevant to your assessment.

5. A person with a radial pulse has a systolic blood pressure of at least 80. If you went right for the carotid, you wouldn't know that, only that the systolic pressure is at least 60. You would therefore learn more in the same amount of time using the radial. Better to start at the radial and switch to the carotid in the 1 or 2 out of 1000 cases where the conscious adult with no obvious arm circulation issues lacked a radial pulse.

6. It is easier to maintain contact with a person's wrist for an extended period than it is to keep your hand on their neck. There are a variety of circumstances where you might wish to do this. If they have an irregular heart rate, ensuring accuracy demands more time. If the pulse is bounding and you're trying to calm them down, you may opt for an extended or more frequent pulse assessment, at least for rhythm and quality if not rate.

In an unconscious/unresponsive adult, the preferred pulse point is the carotid artery.

There are several reasons for this, some of which are complementary points to those of the conscious patient:

1. Unlike a conscious patient, the chief question we're trying to answer when checking the pulse is if they have one. Someone that's awake and talking obviously does, but that can't be assumed in an unconscious person, so it makes sense to go for the strongest point first. The absence of a pulse at any other point would not indicate the absence of a heart beat, only that it isn't strong enough to reach those more distal points.

2. Unlike a conscious patient, we aren't concerned with alarming them or building rapport, so there's no downside to going right to the most reliable pulse point.

3. An unconscious person is at greater risk of an immediately life threatening situation, so a more aggressive approach is justified.

In summary, there are pluses and minuses for each pulse and some of these are more relevant in some situations than others. With any medical procedure, the benefits and efficacy of different options must be weighed against their risks. The level of invasiveness, ease or difficulty and necessity of frequent or extended checks, the emotional effect, and the level of urgency must all be considered. There's not much to be gained from initially checking the carotid pulse of a conscious adult in most circumstances, but there are several downsides noted above. Conversely, there are no downsides to going right to the carotid on an unconscious adult.

As in other areas, there are many things in medicine that are merely a matter of preference or style. I don’t think this is one of those things. I think it's a clear enough choice, a logical decision with a right answer and a wrong answer that dictate what the standard operating procedure should be, and I would correct any trainee I was precepting who did otherwise. Absent special circumstances, conscious adults should get a radial pulse check and unconscious adults should get a carotid check.

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