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

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EMS1 Daily News

Ark. EMS to wear body armor on calls

Of the 275 bullet-resistant vests ordered, 30 are made of steel plates

ALS-related gene found with help from Ice Bucket Challenge

The viral sensation of 2014 raised $115 million for ALS research

6 EMS questions for the next U.S. president

Policy questions are coming at the presidential candidates from every direction; here are six questions EMS should want answered

1 killed, 2 injured in Va. ambulance crash

A patient was killed during a medical transport

What does it feel like to do CPR?

An ALS instructor shares her experiences performing CPR and what to expect

Woman who called ambulance 400 times receives prison time

The 54-year-old was prosecuted under an act meant to curb abuse of the emergency system

Overdoses continue spiking in Akron, surpass 200 in less than a month

By Nick Glunt The Akron Beacon Journal AKRON, Ohio — From January to June, Akron paramedics responded to about 320 drug overdose calls. In the three weeks between July 5 and July 26, paramedics logged 236. The dramatic spike, from two or fewer per day to 11 or more, is thought to be the result of the introduction of carfentanil to the Akron drug market. The heroin-like drug is so potent it's ...

IS suicide attack in Syria kills 44

Rescue workers searched for survivors under the rubble of buildings following the attack

SC rescue team receives $1.5M loan to purchase ambulances, radios

The purchase will allow the department to retire an older ambulance and ensure that it has an extra ambulance for special situations

4 Armenian medics taken hostage

Gunmen seized a police post on July 17, demanding freedom for a jailed opposition figure, and took those inside hostage
Top

EMS1 Topic Articles

Ark. EMS to wear body armor on calls

Of the 275 bullet-resistant vests ordered, 30 are made of steel plates

ALS-related gene found with help from Ice Bucket Challenge

The viral sensation of 2014 raised $115 million for ALS research

6 EMS questions for the next U.S. president

Policy questions are coming at the presidential candidates from every direction; here are six questions EMS should want answered

1 killed, 2 injured in Va. ambulance crash

A patient was killed during a medical transport

What does it feel like to do CPR?

An ALS instructor shares her experiences performing CPR and what to expect

Woman who called ambulance 400 times receives prison time

The 54-year-old was prosecuted under an act meant to curb abuse of the emergency system

Overdoses continue spiking in Akron, surpass 200 in less than a month

By Nick Glunt The Akron Beacon Journal AKRON, Ohio — From January to June, Akron paramedics responded to about 320 drug overdose calls. In the three weeks between July 5 and July 26, paramedics logged 236. The dramatic spike, from two or fewer per day to 11 or more, is thought to be the result of the introduction of carfentanil to the Akron drug market. The heroin-like drug is so potent it's ...

IS suicide attack in Syria kills 44

Rescue workers searched for survivors under the rubble of buildings following the attack

SC rescue team receives $1.5M loan to purchase ambulances, radios

The purchase will allow the department to retire an older ambulance and ensure that it has an extra ambulance for special situations

4 Armenian medics taken hostage

Gunmen seized a police post on July 17, demanding freedom for a jailed opposition figure, and took those inside hostage
Top

EMS1 Columnist Articles

6 EMS questions for the next U.S. president

Our two major political parties have officially nominated their candidates. Hillary Clinton and Donald Trump, mostly in broad brushstrokes, are painting their differences on policy and regulatory issues to voters.

Health care, one of the dominant political issues of the past eight years and likely a top issue for years to come, is of great interest to voters. The different facets of health care are a focus of lobbyists representing different groups like retirees and veterans, political action committees funded by mega-donors, and insurance, pharmaceutical and hospital conglomerates.

I don't expect EMS issues to be specifically addressed by either candidate in the final months of the campaign, but if I was given the opportunity to speak with either candidate one-on-one, these are the questions I would ask.

1. How will you permanently fix reimbursement for Medicare and Medicaid transports"
Ambulance services often lose money when transporting patients with Medicare or Medicaid, because the cost of transport can exceed what is actually reimbursed to them. In addition, no reimbursement is made for transporting patients to alternate destinations, such as mental health facilities or sobriety centers, which are better suited to treating certain sets of problems.

How will you ensure our nation's ambulance services, many run by volunteers or municipal fire departments, are properly reimbursed for the services they provide to citizens on Medicare or Medicaid"

2. What steps will you take to resolve the the fatal opioid overdose epidemic"
Opioid overdoses now kill as many or more Americans than motor vehicle collisions. In some areas of the United States, opioid addiction and deaths are at epidemic levels.

What is the role of the Federal government in reducing the availability of illegal narcotics, and better regulating the distribution of legal narcotics" Where can we find the resources to transport patients to facilities with addiction treatment expertise" What steps will you take to change the focus of EMS, law enforcement and public health efforts from reversing overdoses with naloxone — which has increased in price by 1000 percent — to preventing addiction from starting in the first place"

3. Will you call on congress to pass the Field EMS Bill in your first 100 days"
EMS does not have a specific home in the federal government. The Department of Health and Human Services, Department of Homeland Security, the National Highway Transportation Safety Administration, and the Centers for Disease Control and Prevention all have interests in and initiatives for EMS, but no single agency has the needs and interests of EMS as its core mission.

Where does EMS belong in the federal government, and will you call on the U.S. Congress to pass the Field EMS Modernization and Innovation Act as a priority accomplishment for your first 100 days in office"

4. What is your plan for Obamacare"
Though Obamacare has increased the number of Americans with health insurance, it does not seem to have addressed the underlying issues preventing millions from accessing primary care. Since many patients lack access to primary care physicians and are either unable or unwilling to find non-emergent care, emergency services are being tied up with patients requesting aid for minor aches, pains and maladies.

If you do intend to repeal Obamacare, what will you put in its place to ensure health care access for our seniors, our veterans, our disabled and our vulnerable children" Alternatively, if you plan to let Obamacare stand, what will you ask the Congress to revise or add"

5. What actions will you champion to reduce chronic disease care costs"
The costs of treating chronic diseases like obesity, diabetes, hypertension, COPD and heart failure are an enormous strain on our nation's economy, and often crushing to every model of ambulance transport. As you barnstorm the U.S. from now to election day, you will regularly see and hear from voters suffering from these illnesses, and observe firsthand how chronic diseases can be a tremendous obstacle between personal productivity and the pursuit of happiness.

As president, how will you lead our nation to better personal health, reduce the incidence of chronic disease and regulate tobacco, alcohol, sugar, sodium and other food additives known to directly worsen health"

6. How will you make sure EMS is ready for the next national disaster"
Paramedics, along with their firefighter and law enforcement officer colleagues, are on the frontlines responding to terrorist attacks, active shooters and natural disasters. Most EMS agencies, already operating at or near the capacity of their personnel and equipment, are hard-pressed to respond to an unexpected surge in service.

As we near the 15 th anniversary of the September 11 th attacks, we regularly receive news of departments who are unable to communicate with one another, chiefs who are unable to put political squabbles aside to develop regional response plans, a lack of equipment for paramedics responding to active shooter incidents, and failures to implement the incident command system and collaborate through a unified command. Most recently, the Ebola scare exposed our inability to transport highly infectious patients between the few hospitals actually capable of receiving those patients.

Billions of dollars have been spent on preparedness — equipment, training and staffing — but only a fraction of that money has been directed to EMS and disaster health care. What will you do to make sure our nation's first responders are equipped and trained to respond to disasters as significant or greater than 9/11 or Hurricane Katrina"

Exercise your right as a citizen to vote
In the final months of the campaign season, research each candidate's positions on EMS and health care issues, as well as the other policy issues important to you. Then make sure to cast your vote for national, state and local candidates this fall.

Many state and national EMS organizations, like the National Association of EMTs and the American Ambulance Association, have advocacy efforts to represent and lobby on the behalf of their members. Add your voice by becoming a member.

Finally, if you find yourself on ambulance standby for a political candidate's campaign stop in your response area this political season, perhaps you will have a chance to ask the candidate how they will support EMS. If you do, let me know what they have to say.

What does it feel like to do CPR?

Nearly everyone in EMS has thought about being thrust into a situation where they’re required to use their knowledge of CPR to save a life in dramatic fashion. A user on Quora recently asked, “ How does it feel to perform CPR on a real person"” A few answers stood out to us, especially one by an ALS instructor named Lou Davis. You can read her reply below:

It feels as though you are holding someone's life in your hands.

Because for the time that you are compressing the chest, you are the one thing that is, potentially, keeping that person's brain oxygenated.

You are standing between them and death.

I could tell you how it feels physically - but in truth it isn't markedly different from the mannequin.

You may feel ribs breaking - particularly in older patients where the ribs have lost the elasticity of youth.

But the overwhelming feeling is that of responsibility - it may be the most important thing you have ever done.

I have performed CPR many, many times, o n patients ranging in age from mere days, to those who have already had their 'four score years'. I have rhythmically compressed the chest of those who I know will be taken before their time. Each and every time it feels as hard as the first time.

Their life in your hands. That's what it feels like.

Do you remember the first time you performed CPR on a patient" Was it what you expected or how was it different" Let us know in the comments below, and be sure to check out our Facebook page.

3 ways to teach capnography with active learning

EMS tends to attract action-oriented people with short attention spans, which is a challenge when designing education programs. Whether for initial or continuing education, students are more likely to remember material if they are involved in lessons, and directed to analyze and apply what they learn. Active learning uses activities to engage learners in higher-order thinking tasks rather than passively receiving knowledge conferred by an instructor [1].

Capnography is a valuable assessment tool that many EMS providers do not utilize to its full potential. Here are three strategies that use active learning principles to teach about capnography use for respiratory compromise, sepsis and resuscitation:

1. Embrace mobile devices and media during lectures
Everyone has sat through torturous lectures driven by PowerPoint slides, and knowledge retention even from good lectures is notoriously poor. Students are more likely to remember material if they are involved in lessons and directed to analyze and apply what they learn, and lectures are more effective when students are given the opportunity to participate. Frequent recall of material, such as answering questions throughout chapters in a textbook, greatly improves knowledge retention [1].

Mobile devices allow review questions to be answered during a lecture, which keeps students thinking about the material and shows the instructor how well they are grasping it. Free polling programs such as Poll Everywhere and Kahoot allow you to insert multiple-choice questions into PowerPoint slides, and participants can see the poll results immediately. Polling can gamify a lecture.

Videos can also be embedded into slides that demonstrate content in action. Thousands of videos of real patient care on YouTube and Vimeo show abstract concepts being applied in practice. For example, in a lesson about respiratory compromise, present students with a case study about an 84-year-old female short of breath, with a history of CHF and COPD, speaking in two- or three-word phrases and with diminished breath sounds. Use an online polling program to give participants the choice to:

A. Apply supplemental oxygen

B. Administer albuterol

After the class sees their preferred treatment, follow up by asking why participants chose their answers. Both can be justified, and the real value is in the discussion about why they thought one choice was better.

Then show this video where paramedics apply capnography to a patient with that same presentation. After seeing the nearly-rectangular capnography waveform indicating no bronchospasm, ask the poll question again to see if the results are different. Show the rest of the video, which includes a lesson from well-known EMS educator Dave Page, about assessing respiratory patients and end with a discussion about how applying capnography early can affect critical treatment decisions.

Using mobile devices to answer questions and showing videos that demonstrate the concepts during a lecture will help students remember information and make the experience more meaningful.

2. Assign class work at home and homework in class
An alternative to a lecture is the flipped classroom model, in which learners watch a video, listen to a recorded lecture or podcast or complete a reading assignment before class. Students then do activities that apply material from those assignments in class. This allows class time to be used for higher-level thinking and problem solving.

For example, a service wants to use capnography to improve sepsis patient care. Instead of lecturing from slides in a classroom about how EMS recognition of severe sepsis, IV fluid administration and hospital notification can save lives, participants could watch a free online presentation from Mike McEvoy about capnography and sepsis before their face-to-face training meeting. After watching the video, ask participants to write an email or post on a discussion board completing the following sentences:

  • Now I understand _____ about sepsis.
  • I still don’t get _____ about sepsis.
  • EMS sepsis recognition is or is not important because _____.

This pre-class activity allows the instructor to plan the lesson and focus on the less-understood areas of sepsis and capnography in class, as well as learn if there will be any resistance to the idea. It also encourages learners to reflect on and process what they watched in their own words, which improves knowledge retention [1].

After a review of the webinar in class, participants could work on cases in small groups that apply capnography for suspected sepsis. Some example cases:

  • 80-year-old male with altered mental status and decreased urine output.
  • 70-year-old female with difficulty breathing and isolated wheezing.
  • 40-year old male with pain and redness around his knee three days after surgery.
  • 12-year old with pain and red streaks up his arm three days after being bitten by a dog.

Assign vital signs for each patient, including ETCO2 and temperature, and have the groups of students report to their classmates' answers to these questions:

  1. Is the patient in systemic inflammatory response syndrome, sepsis, severe sepsis or septic shock" How do you know"
  2. How would monitoring ETCO2 help determine which patients need IV fluid" (ETCO2 below 25 mm HG with signs of infection is correlated with severe sepsis) [2].
  3. How could reporting the patient’s ETCO2 and temperature affect the patient’s hospital course"

By recalling, analyzing and applying content while working out problems in class, learners have more tools to use that information in their practice.

3. Practice like you plan to play with simulation
Simulation allows learners to practice psychomotor skills, build pattern recognition and improve team dynamics in a safe environment. Simulators range from task trainers, such as an airway head or IV arm, to human actors and high-fidelity patient simulators that talk, generate cardiac rhythms and lung sounds and physiologically respond to medications.

Regardless of the tools used, applying a few active learning principles can make simulation a successful learning experience. Write learning objectives before the simulation. Make participants actually perform the steps of as many assessment and treatment tasks as possible. Finally, participants should reflect on the experience in a debriefing after the simulation.

For example, use a pit-crew resuscitation simulation focused on the use of capnography. An instructor with a CPR torso, airway head, IV arm and rhythm generator available will read vital signs and ETCO2 levels to the pit crew. The participants need to use ETCO2 levels to guide compression quality, change compressors, identify a spike and sustained ETCO2 after ROSC and recognize re-arrest after a loss of ETCO2.

Participants should carry gear the same way they would into someone’s home. Teams should practice performing chest compressions around other interventions (including placing an advanced airway, starting an IV, administering simulated medications, applying the capnography circuit and checking blood pressure before having one read to them by the facilitator) and rotating compressors every two minutes. The facilitator could read trends in the patient’s ETCO2 as feedback on the quality of compressions. Have participants work through problems together, even if mistakes are made, and discuss them during a debriefing.

The debriefing should likely last at least half as long as the scenario [3]. The facilitator should guide the discussion in a way that allows students to learn from each other. Instead of giving an American Idol-style critique of the simulation, the facilitator should ask what the participants thought went well and what could have gone better, and then ask how they feel about the learning points. For this scenario, the facilitator could ask what could cause a sudden drop in ETCO2 (hint: misplaced airway, secretions in the tube or a pneumothorax). Practice followed by reflection helps participants apply that experience later.

When developing an education program, think about ways to engage learners. Using mobile devices in lectures, flipping the classroom and simulation exercises are three ways to get students to analyze, apply and practice using capnography.

References:

1. Brown PC, Roediger HL, McDaniel MA. Making it stick: the science of successful learning. Belknap Press of Harvard University Press, Cambridge, MA: 2014.

2. Hunter CL, Silvestri S, Dean M, Falk JL, Papa L. End-tidal carbon dioxide is associated with mortality and lactate in patients with suspected sepsis. American Journal of Emergency Medicine. 2013 Jan; 31(1):64-71.

3. Kamerer J. Teaching healthcare professionals using simulation. Net CE; 2015.

Recovering from Orlando: The role of a critical incident stress team

By Leischen Stelter, editor of In Public Safety

The June 12 massacre inside an Orlando nightclub left 49 people dead and 53 wounded. After police killed the gunman, officers, firefighters and medical professionals entered the building to provide aid to the wounded. According to news reports, the scene inside was absolute carnage with bodies scattered across the dance floor and in the restrooms. The trauma of the event affected not only those who were in the nightclub that night, but also those who responded.

The Role of a Critical Incident Stress Team
American Military University’s criminal justice program director, Dr. Chuck Russo, lives in Central Florida and was a founding member of his agency’s Critical Incident Stress Team (CIST). He is also the team leader for Florida’s Regional Disaster Behavioral Health Assessment Team. In that role, he oversees psychologists, psychiatrists and social workers, as well as specially trained volunteers, who provide services to first responders following a traumatic incident. Russo was on call for several days following the Orlando incident, ready to provide support to the police officers, firefighters, medical personnel and other first responders who assisted with the gruesome scene.

[Related: Critical Incident Stress Management Interventions Help Heal First Responders]

While Russo’s team was not deployed to assist in Orlando, he has spoken with several colleagues who were involved. “Most people hadn’t seen anything like it before – the only ones who had seen anything similar had been in war,” he said. There’s no level of training as intense as actually responding to a mass casualty incident. “If you’re a police officer long enough, you’re going to come across bodies and the results of violence. Most officers can deal with a certain level of blood and gore, but this exceeded everyone’s normal,” he said. ​

Full story: Recovering from Orlando: The role of a critical incident stress team

Altered Mental Status: 6 reasons why a complete assessment is critical

Altered mental status is a simple yet definitive indicator that something is wrong with the patient. AMS is relatively easy to determine in the field, but getting to the root cause of AMS requires a complete patient assessment. Here are six reasons, from actual patient cases, that demonstrate why it is critical to perform a complete patient assessment with every AMS patient.

1. Anything can cause altered mental status.
One of the core duties of EMS practitioners is to determine the root cause of AMS in a patient. In practice, however, this can be a challenge because AMS can result from almost anything. Is the root cause hypoglycemia, an acute MI, sepsis, a head injury, stroke or hypoxia" The only way for the EMS practitioner to get to the root cause quickly and accurately is by performing a complete patient assessment.

2. The patient can’t always tell you what is wrong.
AMS patients are usually not alert and thus unable to give the EMS practitioner much reliable information. Even when the patient is somewhat conscious, they often find it difficult to describe what is wrong. This occurs because the AMS has made it difficult to communicate, or because the patient's signs and symptoms are odd, vague or difficult to describe. The patient only knows that something is wrong.

For example, a paramedic crew responded to a call at a business for a middle-aged male patient whose only complaint was that he could not stay awake. The patient was alert, oriented and able to answer all questions appropriately. In between questions, however, the patient would close his eyes and drift off, as if he were asleep.

The first responders on the scene conveyed to the paramedic their private opinion that the patient was just trying to get out of work, because he appeared to be fine. As a result, the first responder's initial assessment was incomplete and consisted of vital signs and a 3-lead ECG.

However, because this patient was so adamant that something was wrong, the paramedic did a complete assessment, including a full neurological evaluation. The patient's arm drift and unequal pupils clearly demonstrated that he was having an acute stroke. If the paramedic had not detected the stroke during his complete assessment, the patient would have been transported to his preferred hospital 20 miles away, rather than to the primary stroke center just four miles away.

3. What is wrong today isn’t necessarily what’s been wrong before.
Many providers make the faulty assumption that a patient’s problem today is the same issue that was affecting them before. This can cause important medical issues to be missed because a complete assessment was not performed — patients who are regular 911 callers are especially vulnerable to this problem. Regardless of what the EMS practitioner thinks is wrong, it is critical that they perform a complete assessment on every patient, every time.

A certain paramedic crew responded to a residence for a syncopal patient. The patient was unresponsive in a kitchen chair with agonal respirations. The crew placed the patient in the supine position, and the paramedic performed a complete assessment that revealed bradycardia.

Their interventions, following the ACLS bradycardia algorithm, woke the patient up. The patient was obviously surprised at first, and asked the crew, "Is my stroke acting up again""

The emergency department nurse and physician found it difficult to believe that the patient's problem was not a result of a previous condition because the patient was now fully alert and had a normal heart rate. The complete assessment ensured that the underlying problem was correctly identified.

4. The patient can have multiple issues at once.
Often, the patient can have multiple issues at once, and the EMS practitioner will focus only on the most visible problem and miss the true root cause of their AMS. Many paramedics have learned this lesson the hard way.

A rookie paramedic once responded to an AMS call. The patient was an older male with a history of insulin-dependent diabetes. The paramedic assumed that the patient was hypoglycemic, so the initial assessment consisted of vital signs and a glucose check. The patient was indeed hypoglycemic, so the paramedic administered dextrose in an attempt to wake the patient and obtain a refusal.

The paramedic was very surprised when the patient did not regain consciousness after receiving the dextrose bolus. The paramedic, now forced to do a complete assessment, discovered that the patient actually had several simultaneous issues, including a stroke and significant cardiac dysrhythmias. What might have happened if the patient actually did wake up, and refused transport"

5. The big problem results in a little problem that gets all the attention.
Sometimes, the patient’s initial complaint is just a symptom of a much more serious medical condition. The EMS practitioner must take care not to let minor symptoms take up their full attention.

This is common when seeing patients who fell because of a syncopal episode. Often, the patient's complaints will mostly be about injuries caused by the fall, rather than about the condition that caused the syncope in the first place. More than once, an EMS practitioner has missed an acute MI or other life-threatening condition because they were too focused on the superficial problems.

6. Assumptions will get you in trouble.
Every EMS student is taught to never make assumptions, but even the most experienced veterans can forget this rule from time to time.

A veteran paramedic responded to a non-emergency call at an assisted living center. The facility nurse reported that an elderly female had experienced a sudden onset of dementia and was exhibiting "unacceptable behaviors." Though the nurse said she had already performed a complete assessment on the elderly patient, the physician wanted her transferred to the emergency department for a psychological evaluation.

En route to the hospital, the paramedic suddenly remembered that dementia is not an acute condition.

He decided, albeit a little bit late, to perform a glucose check as part of a complete assessment, which revealed that the patient was hypoglycemic. One ampule of dextrose later, the patient's 'dementia' was reversed. The patient was now alert, and a little confused as to why she was in an ambulance. A complete assessment spared the veteran paramedic from looking silly at the ED.

These reasons clearly demonstrate that EMS practitioners must perform a complete assessment on every AMS patient to get to the root cause of the problem and provide the correct treatment.

Is your paramedic career worth more than a Facebook post?

The recent spate of highly-publicized officer-involved shootings involving African-American men continues to polarize this country. The most recent fallout includes the termination of multiple EMS and fire personnel over social media remarks directed toward the protests being waged in the streets of many U.S. cities.

The remarks that were made in haste and frustration, while of a personal opinion, were not appropriate for public safety personnel who are held in the public trust and charged with protecting the community’s health and safety. The comments were unprofessional and frankly, crass.

Folks, let’s be abundantly clear: you risk losing your job and your livelihood if you aren’t able to separate your personal life from your professional one. It is certainly your right to express your opinion, to criticize, object or debate. Discourse is a founding principle of our country.

Ethically and morally it’s not your right to threaten and discriminate against those who disagree with your point of view. It doesn't matter if you are in person or using a medium that somehow has managed to erase civility and kindness from the national dialogue in a few short years.

Once upon a time, one had to carefully think before speaking at a community meeting, a public forum or in a letter to a newspaper. Words were chosen with consideration. Opinions could be checked and normalized when feedback was immediate and discourse happened in real time.

Now we can fire off a fusillade of insults and ill-conceived thoughts with a few strokes of a keyboard. Sending our missives into seemingly vast space where we imagine our emotional comments do no harm.

Nothing could be further from the truth.

Consider how quickly we have moved to the extremes of our society, simply because of the simplicity of saying things in the extreme. But I digress.

The bottom line is, many people are getting fired over what they say in social media, including law enforcement officers, prosecutors, journalists and hospital staff. Ask yourself the question: Is it really worth it"

Test your EMS knowledge: Odd patient presentations and complaints

Medicine is full of nooks and crannies. Many patients love to tell you about their medical conditions — sometimes in way more detail than we need.

How well do you know some of the conditions your patients share with you" This quiz will help you find out.

Inside EMS Podcast: What 'selfie wars,' Narcan price jump mean for EMS

Download this podcast on iTunes, SoundCloud or via RSS feed

In this week's episode, co-hosts Chris Cebollero and Kelly Grayson discuss the unauthorized selfie photos two Florida paramedics took of unconscious patients, and the rising cost of Narcan.

Tips for assessing and managing a patient with "general illness"

Based on Rebecca’s initial presentation and vital signs, it should be clear that her body is working, perhaps even struggling, to maintain homeostasis. With no pertinent medical history, a normal — or slightly low — blood pressure and rapid heart rate, in conjunction with complaints of dizziness when standing and general lethargy, orthostatic vital signs may be a beneficial assessment tool. Care should be taken, however, in a patient already reporting dizziness when standing to prevent a syncope or fall when testing for orthostatic vital signs.

Rebecca’s history of abdominal pain is consistent with a ruptured appendix and appendicitis. The hallmark of this condition is worsening abdominal pain, which increases until the appendix ruptures. The patient may experience some pain relief and assume that her condition has resolved. Pain returns, however, when an infection in the abdomen results in peritonitis or inflammation of the lining of the organs and abdominal cavity. This infection can spread and may become life-threatening.

Systemic Inflammatory Response Syndrome
Systemic Inflammatory Response Syndrome is the term used to identify inflammation present throughout the body. SIRS is not necessarily linked to one particular pathophysiologic process, but rather is simply the extension of inflammation which occurs when the local insult from infection or trauma continues unchecked and results in the involvement of the entire body. Though historically associated with sepsis, SIRS may be present after traumatic injury.

Screening for SIRS is relatively simple and most assessments are in the scope of EMS providers. For a patient to qualify as having SIRS, two of following criteria must be true [1]:

  • Temperature of >38°C (100.4°F) or <36°C (96.8°F)
  • Heart rate >90/min
  • Respiratory rate >20/min
  • PaCO2 < 32 mm Hg
  • White cell count >12,000/mm 3

The original paper identifying SIRS —and its link to sepsis —is from 1992. Many hospitals and EMS agencies use the SIRS criteria as an indication that a patient’s infection has become severe enough to result in system-wide inflammation. Essentially, SIRS screening in the presence of a source of known or suspected infection has been used to include a patient in the treatment regimen for sepsis.

Interestingly, several critical care journals have reported that SIRS criteria may simply represent the normal course of the body’s immune response to an infection (increased temperature and heart rate among others) and may not necessarily be associated with organ dysfunction from an out-of-control infection (sepsis) [2]. As a result, SIRS may be too broad an inclusion criteria and not specific enough to determine if a patient has sepsis.

Sepsis
Sepsis is a syndrome — or collection of symptoms associated with a disease — that is caused by infection [2]. It is essentially an amplified, inappropriate response by the body to an infection and can result in significant organ dysfunction. The concern about using SIRS as an inclusion criteria for sepsis is two-fold: First, systemic inflammation may occur as a normal response to an infection and may not be associated with organ dysfunction and failure (sepsis). Second, sepsis can affect multiple pathways in the body and may not always result in systemic inflammation captured by SIRS.

While the usefulness of SIRS may be in question, it is still the standard initial screening tool for sepsis used by many EMS agencies. Refer to your local protocols or medical director for specific guidance on sepsis screening.

The task force convened by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine questioned the usefulness of SIRS in sepsis screening and recommended a sepsis-specific screening tool that evaluates the extent of organ dysfunction in the body called the Sequential [Sepsis-Related] Organ Failure Assessment Score (SOFA) [2]. Unfortunately for EMS providers, however, many of the screening elements used in SOFA require lab results and are out of scope for EMS providers. This recommendation places into question the ability of EMS providers to screen for sepsis which requires aggressive, timely treatment to reduce morbidity and mortality.

One additional screening tool, quick SOFA (qSOFA), has been found to have similar predictive power for poor patient outcome as the full SOFA screening. The qSOFA, which can be assessed in the prehospital setting, is positive when any two of three elements are true:

  • Respiratory rate ≥22/min
  • Altered mentation (GCS ≤13)
  • Systolic blood pressure ≤100 mm Hg

Once a potential source of infection is identified and before aggressive intervention to treat hypotension the qSOFA may be a more effective predictor of mortality from sepsis than SIRS for EMS providers [2].

Goals for treatment
Regardless of how sepsis is screened for, treatment recommendations center on ensuring adequate fluid resuscitation to help maintain organ function. Additionally, patients require blood cultures to be drawn and broad-spectrum antibiotics to be started until a pathogen-specific treatment plan is developed. ALS EMS providers should consult their local protocols and may be asked to draw labs or start fluid resuscitation.

Case conclusion
Though all signs point to appendicitis and sepsis, a thoughtful clinician casts a wide net and considers other problems. In the initial scenario you were asked if you might consider an alternative diagnosis if Rebecca was 24- or 64-years -old. EMS providers should bear in mind that pregnancy, specifically ectopic pregnancy, should be considered as a possibility for any woman of child-bearing age, regardless of whether or not she is taking birth control medication. Even at 44-years-old, Rebecca is still in a high-risk category. If Rebecca were 64-years-old an EMS clinician may consider a bowel obstruction, which can be dangerous in older patients, or ischemia of the lining of the abdominal cavity and organs. Just as differential diagnoses change with assessment findings, they must also change based on a patient’s age and any other recognizable factors which influence the function of body systems.

Following a positive SIRS screening based on Rebecca’s vital signs and a possible history of a ruptured appendix, you call ahead to the responding ALS unit to provide an update. The ALS unit arrives and the paramedic places an IV following her initial assessment. The paramedic uses the newly-approved qSOFA screening tool and agrees that Rebecca likely has sepsis. The patient is transported to the emergency department where she is started on antibiotics before going to surgery. She is expected to make a full recovery.

For more information, check out SurvivingSepsis.org.

References

  1. Bone, R., Balk, R., Cerra, F., & et al. (1992). American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med, 20(6), 864–74.
  2. Singer, M., Deutschman, C., Seymour, C., & et al. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) . JAMA, 315(8), 801–810.

How mobile integrated health is evolving to meet a patient need

Mobile Integrated Health Care also known as Community Paramedicine is an evolving specialty of EMS. MIH began in order to fill the gaps and niches in a communities health needs by EMS providers.

The MIH programs developing today vary widely. However, there are some common denominators such as population health management, readmission avoidance and transportation to alternative destinations. These programs ultimately seek to bring about better management of specific patient populations that occur across the healthcare continuum. In addition, there is an emphasis in MIH regarding how EMS providers can partner with organizations to find savings in health care dollars.

According to the National Association of EMTs the goal is to lower costs, improve the lives of patients and enable EMS practitioners — including EMTs, paramedics and community paramedics — to use their skills and resources to help solve the problems facing healthcare systems and communities. Examples of MIH programs already implemented include:

  • Community Paramedicine programs, which send paramedics with additional training and education into patients’ homes or into the community to do patient education and extend primary care in areas that have a shortage of primary care and other basic health resources.
  • Nurse triage to provide non-urgent 911 callers with advice, or providing assistance connected with alternative health care resources such as primary care, urgent care or mental health services.
  • Post-hospital discharge follow-up by EMTs, paramedics or community paramedics to ensure patients with conditions such as congestive heart failure, COPD and diabetes have the tools and information they need to manage their condition at home and avoid preventable readmissions.
  • Transporting patients to alternative destinations — such as primary care offices, urgent care, and mental health or detox facilities — instead of the emergency department.

Available lessons from MIH programs
The Center for Patient Safety intends to work in partnership with MIH programs for greater safety as well as serve as a resource to minimize risk. One of the benefits of participating with a Patient Safety Organization is the ability to share adverse events, near misses and unsafe conditions. This sharing enables learning that benefits all providers.

There are many lessons we can learn from available, seasoned MIH programs. Over the past 10 years, CPS has supported patient safety across the healthcare continuum, including hospitals, physician offices and other providers. Some of this experience and data allows for many lessons learned about falls, infections, wound complications and medication reconciliation just to name a few.

According to the fact sheet from the California Emergency Medical Services Authority "Community Paramedics are not independent practitioners; they work under clear medical control of a physician, receiving direction and supervision to ensure patient safety. The Community Paramedic training program builds upon the training and skill sets of experienced paramedics. Additional training in patient assessment, clinical skills and familiarity with the other health care providers and social services available in a local community will all be a part of the required training, and will lead to a more integrated approach to health care delivery."

Kathy Wire, JD, MBA, CPHRM, Project Manager for CPS states, "Historically, EMS providers stabilized a patient for transport and moved them to a hospital, where Emergency Department staff took over the patient’s care. Even in that limited role, EMS services have struggled to get information about the quality and safety of their care — they didn’t have any knowledge of what happened after the transfer. With the growth of Mobile Integrated Health Care, they will be working as parts of teams, managing patients without transport in a physician or APN-managed framework or working with the patient’s broader medical support system to determine the right destination for care. Now, they need to address the safety of their own care and also function as part of a safe team. As reimbursement for all providers drives this transition, EMS must evaluate outcomes of care and avoid the injuries and unreliability that accompany weak safety systems."

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