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

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Mich. fire dept. gets grant for new ambulance

A $250,000 Community Development Block Grant allowed the purchase of a new ambulance

Md. volunteer fire depts. get grant for equipment

Howard County's West Friendship Volunteer Fire Department and Lisbon Volunteer Fire Co. received a combined total of $10,000 in grant funding

Software improves efficiency of pre-hospital treatment

By Michael Cayes Mooring Tech, Inc. This article is provided by Mooring Tech, Inc. and does not necessarily reflect the opinions of EMS1. When first responders show up at the scene of an accident, a heart attack, or crime scene, they are trained to begin immediately triaging all parties on site. Without knowledge of preexisting conditions and other important health factors, EMT’s rank the level ...

Meteorite might have killed man in India

Scientists will determine if the object that killed a man Saturday was a meteorite

Tech company helps fire dept. track emergency incidents during Super Bowl

With the system, the department also was able to track its crews and pinpoint hundreds of game-related events around the county

Alleged drunk driver crashes into ambulance

The paramedics were not transporting a patient and were not injured in the collision

2 medics injured in NC intersection collision

The ambulance was traveling with its lights and sirens activated when it was struck by a vehicle

NY medics train to treat K-9s

A new law allows medics to treat and transport police dogs injured in the line of duty

Doctor creates new device to replace EpiPens

AllergyStop is small enough to fit on a keychain; it’s currently awaiting FDA approval

Obama asks Congress for $1.8B in emergency funding to combat Zika

The money would be used to expand mosquito control programs and speed development of a vaccine, among other things
Top

EMS1 Topic Articles

Mich. fire dept. gets grant for new ambulance

A $250,000 Community Development Block Grant allowed the purchase of a new ambulance

Md. volunteer fire depts. get grant for equipment

Howard County's West Friendship Volunteer Fire Department and Lisbon Volunteer Fire Co. received a combined total of $10,000 in grant funding

Meteorite might have killed man in India

Scientists will determine if the object that killed a man Saturday was a meteorite

Tech company helps fire dept. track emergency incidents during Super Bowl

With the system, the department also was able to track its crews and pinpoint hundreds of game-related events around the county

Alleged drunk driver crashes into ambulance

The paramedics were not transporting a patient and were not injured in the collision

2 medics injured in NC intersection collision

The ambulance was traveling with its lights and sirens activated when it was struck by a vehicle

NY medics train to treat K-9s

A new law allows medics to treat and transport police dogs injured in the line of duty

Doctor creates new device to replace EpiPens

AllergyStop is small enough to fit on a keychain; it’s currently awaiting FDA approval

Obama asks Congress for $1.8B in emergency funding to combat Zika

The money would be used to expand mosquito control programs and speed development of a vaccine, among other things

Calif. firefighter/medic hit by car while helping crash victim

Eric Oviedo suffered moderate injuries, including some rib fractures, a head laceration, a concussion and several bumps and bruises
Top

EMS1 Columnist Articles

Frequent Flyers: Ambulance history with Capt. Salty

Prove It: Oxygen therapy improves outcomes following AMI

Medic 12 and Engine 46 receive a report of chest pain on the 12 th floor of a local office building. Engine 46 arrives on the scene first and finds a 42-year-old male sitting at his desk. The patient complains of an uncomfortable pressure in the center of the chest that started about 15 minutes ago. The patient rates the pain as a 7 on a 1 to 10 scale. The patient has no significant medical history, no allergies to medication, and no other complaints.

The patient’s heart rate is 96, the blood pressure is 132/84 mm Hg, the respiratory rate is 16 and the room-air pulse oximetry (RaSO 2) value is 97 percent. The patient’s lung sounds are clear and equal. The crew of Engine 46 delivers supplemental oxygen at a rate of 8 lpm via a non-rebreather oxygen mask. The patient's pulse oximetry value quickly increases to 100 percent. Because the patient has no allergies to medications, one member of the engine company hands the patient four baby aspirins and asks the patient to chew, rather than swallow the aspirin.

Paramedics from Medic 12 arrive a few minutes later and place the patient on an electrocardiogram (ECG) monitor, which reveals a sinus tachycardia, with no ectopy. Paramedic Davis begins her attempt at IV access while paramedic Garcia acquires a 12-lead ECG. There is ECG evidence of an anterior ST-segment elevation myocardial infarction (STEMI). After determining there are no contraindications, paramedic Davis begins nitroglycerin therapy and asks the crew from Engine 46 to remove the oxygen mask.

During transport, the patient receives 100 micrograms of fentanyl and rests comfortably. Since the medics activated a STEMI Alert before arriving in the emergency department, the team in the coronary catheterization lab was ready and accepted the stable patient directly from the back of the ambulance.

Later, the medics meet with the crew from Engine 46. The lieutenant asks why the medics removed the oxygen when the patient was clearly having a heart attack. Paramedic Davis explains that oxygen is not necessary for patients who are not hypoxemic.

Study review: Supplemental oxygen for MI
Researchers in Australia recently evaluated the effect of supplemental oxygen therapy on myocardial infarction (MI) size [1]. The trial involved paramedics with Ambulance Victoria in Australia and nine different hospitals all capable of performing 24-hour percutaneous coronary intervention services.

Paramedics randomized patients with ECG evidence of ST-segment elevation MI (STEMI) and room-air pulse oximetry (RaSO 2) values of 94 percent or greater to receive either 8 lpm oxygen via facemask or no oxygen. However, in the event the RaSO 2 values of any patient in the no oxygen group fell below 94 percent, paramedics administered either 4 lpm via nasal cannula or 8 lpm via facemask. All oxygen therapy initiated in the field continued until the patient was admitted into the cardiac care unit (CCU).

The primary endpoints for this study were myocardial injury and infarct size. The researchers assessed myocardial injury by measuring cardiac troponin I (cTnI) and creatine kinase (CK) concentrations every six hours for the first 24 hours, then every 12 hours to 72 hours for the duration of the hospital stay. Cardiac troponin I is a protein released when heart muscle cells die and becomes detectable in the blood stream within 3-4 hours after symptoms begin [2]. CK is an enzyme released when all muscle cells are damaged, including skeletal and cardiac muscle.

To determine the extent of the MI six months after discharge, the research team offered free contrast-enhanced cardiac magnetic resonance (CMR) imaging to any patient willing to return to the research center. This test allowed the researchers to measure the amount of scar tissue present in heart muscle after the infarction.

Results for primary and secondary outcomes
During the 34-month study period, paramedics evaluated 836 patients with a chief complaint of chest pain; however, only randomized 626 patients into the trial. Of those 626 patients, 168 patients were excluded because of prehospital protocol violations, patient refusal to participate in the study, repeat patient, or the patient was determined not to be having a STEMI.

The remaining 470 patients all underwent emergent coronary angiography. By the time the statisticians began the analysis, outcome data was missing for 29 patients. This left 441 patients in the final analysis; 218 patients in the oxygen group and 223 patients in the no-oxygen group.

For secondary outcome measures (which are interesting but not the focus of the study), patients who received oxygen had an increased rate of recurrent MI when compared to the no-oxygen group (5.5% vs. 0.9%; p=0.006, respectively). Additionally, the oxygen group more frequently had arrhythmias after admission (defined as sustained or non-sustained ventricular or atrial tachyarrhythmia requiring medical intervention) than the no-oxygen group (40.4% vs. 31.4%; p=0.05, respectively).

For the primary outcome of myocardial injury, there was no significant difference in mean peak troponin levels between the oxygen and no-oxygen groups (57.4 µg/L vs. 48.0 µg/L; p=0.18, respectively). However, the oxygen group had significantly higher mean peak CK concentrations when compared to the no-oxygen group (1948 U/L vs. 1543 U/L, p=0.01, respectively).

Finally, six months after discharge from the hospital, patients who received oxygen had larger infarct sizes (measured in grams of infarcted heart muscle) when compared to the no-oxygen group (20.3 g vs. 13.1 g; p=0.04, respectively).

What this means for you
The practice of routinely administering oxygen to all patients with a complaint of chest pain is based on rational conjecture and research conducted before the era of coronary reperfusion therapy [3-5]. Oxygen administration increases the arterial oxygen levels and hemoglobin saturation. This in turn was thought to increase the amount of oxygen provided to the tissues and perhaps even to the injured heart muscle itself [6].

However, more recent evidence suggests that in the absence of hypoxemia, the administration of supplemental oxygen does not reduce infarct size or mortality when compared to no oxygen administration [7]. Although the Ranchord et al. study [7] seems to contradict the present study, it is important to note a major difference between the two. Ranchord et al. [7] did not randomize patients until they arrived at the hospital. Most of the patients had already received oxygen delivered by paramedics before arrival in the emergency department.

Other evidence suggests that attempts to keep oxygen saturations close to 100 percent may actually be harmful in the setting of acute coronary syndrome [8-10].

Oxygen administration produces a number of physiologic changes within the body that may help explain why some patients are harmed. Healthy individuals inhaling high concentrations of supplemental oxygen have reduced cardiac output and left ventricular perfusion [11]. Together, these effects reduce both systemic and coronary oxygen delivery. Hyperoxia also reduces coronary blood flow, along with an increase in coronary vascular resistance in patients with cardiac disease [12]. Further, during the reperfusion stage, oxygen has the potential to increases free radical production, which can damage myocardial tissue [13-15].

Study limitations
The methodology chosen for this investigation introduced several limitations that influence how one should interpret the results. For example, both the paramedics and the hospital team knew exactly who was getting oxygen and who was not. Ideally, one would chose to blind the care team to reduce any bias an individual might purposefully or accidently introduce into the investigation. Without blinding, anyone on the care team could treat the two groups differently, which could affect the results.

However, it appears unlikely the lack of blinding introduced significant bias into this investigation. Supplementary data provided by the research team showed that in the prehospital setting, the pain scores reported by patients in the two groups were not different, and there was no difference in nitroglycerin or opioid administration to patients in the two groups. Once at the hospital, there were differences between the two groups with respect to vital signs, pain scores, or the interval between hospital arrival and intervention.

Another limitation of the study is in the power analysis. A power analysis (conducted before the investigation begins) informs the researcher how many patients must be enrolled to detect a difference between the two groups, if a difference really exists. The study was only powered to detect whether oxygen administration altered myocardial injury or infarction size, not for clinical outcomes, such as major adverse cardiac events or mortality. Although the study did detect a 7-gram increase in infarct size associated with oxygen administration, the study could not determine the clinical significance of this increase.

A trial is currently underway in Europe that is adequately powered to detect morbidity and mortality associated with oxygen administration in patients having an AMI [16]. The results of that trial will provide greater insight into the role that oxygen should play in treating these patients.

Additionally, only about one-third of the patients who survived for at least six-months after the infarction agreed to return to the hospital to undergo the CMR imaging, which was used to determine the infarct size. CMR imaging of the remaining two-thirds could have significantly altered the results.

Finally, this study only compared 8 lpm oxygen administration to no oxygen administration. It is possible that low-flow oxygen administration (2 lpm via nasal cannula) may provide some benefit of increased oxygen delivery to the tissues without the harm associated with higher oxygen flow rates.

Summary
This study is another that suggests it may be safe to withhold oxygen from normoxic patients who were suffering from AMI. Oxygen administration to patients with no evidence of hypoxemia did not improve the patient’s symptoms. However, oxygen administration was associated with increases in infarct size at six months post event.

The 2015 AHA guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care acknowledges uncertainty in the role that supplemental oxygen plays in the management of uncomplicated ACS [17]. Despite the uncertainty, the AHA recommends that health care providers consider withholding supplemental oxygen from normoxic patients.

References

  1. Stub, D., Smith, K., Bernard, S., Nehme, Z., Stephenson, M., Bray, J. E., Cameron, P., Barger, B., Ellims, A. H., Taylor, A. J., Meredith, I. T., & Kaye, D. M for the AVOID Investigators. (2015). Air versus oxygen in ST-segment-elevation myocardial infarction. Circulation, 131(24), 2143–2150. doi:10.1161/CIRCULATIONAHA.114.014494
  2. Burcu Bahadir, E., & Kemal Sezgintürk, M. (2015). Applications of electrochemical immunosensors for early clinical diagnostics. Talanta, 132, 162-174. doi:10.1016/j.talanta.2014.08.063
  3. Madias, J. E., Madias, N. E., & Hood, W. B. Jr. (1976). Precordial ST-segment mapping, 2: Effects of oxygen inhalation on ischemic injury in patients with acute myocardial infarction. Circulation, 53(3), 411–417. doi:10.1161/01.CIR.53.3.411
  4. Maroko, P. R., Radvany, P., Braunwald, E., & Hale, S. L. (1975). Reduction of infarct size by oxygen inhalation following acute coronary occlusion. Circulation, 52(3), 360–368. doi:10.1161/01.CIR.52.3.360
  5. Rawles, J. M., & Kenmure, A. C. (1976). Controlled trial of oxygen in uncomplicated myocardial infarction. British Medical Journal, 1(6018), 1121–1123. doi:10.1136/bmj.1.6018.1121
  6. Sukumalchantra, Y., Levy, S., Danzig, R., Rubins, S., Alpern, H., & Swan, H. J. C. (1969). Correcting arterial hypoxemia by oxygen therapy in patients with acute myocardial infarction. American Journal of Cardiology, 24(6), 838-852. doi:10.1016/0002-9149(69)90474-3
  7. Ranchord, A. M., Argyle, R., Beynon, R., Perrin, K., Sharma, V., Weatherall, M., Simmonds, M., Heatlie, G., Brooks, N., & Beasley, R. (2012). High-concentration versus titrated oxygen therapy in ST-elevation myocardial infarction: A pilot randomized controlled trial. American Heart Journal, 163(2), 168–175. doi:10.1016/j.ahj.2011.10.013
  8. Cabello, J. B., Burls, A., Emparanza, J. I., Bayliss, S., & Quinn, T. (2013). Oxygen therapy for acute myocardial infarction. Cochrane Database of Systematic Reviews, 8, CD007160. doi:10.1002/14651858.CD007160.pub3
  9. Moradkhan, R., & Sinoway, L. I. (2010). Revisiting the role of oxygen therapy in cardiac patients. Journal of the American College of Cardiology, 56(13), 1013-1016. doi:10.1016/j.jacc.2010.04.052
  10. Wijesinghe, M., Perrin, K., Ranchord, A., Simmonds, M., Weatherall, M., & Beasley, R. (2009). Routine use of oxygen in the treatment of myocardial infarction: Systematic review. Heart, 95(3), 198-202. doi:10.1136/hrt.2008.148742
  11. Bodetoft, S., Carlsson, M., Arheden, H., & Ekelund, U. (2011). Effects of oxygen inhalation on cardiac output, coronary blood flow and oxygen delivery in healthy individuals, assessed with MRI. European Journal of Emergency Medicine, 18(1), 25-30. doi:10.1097/MEJ.0b013e32833a295e
  12. Farquhar, H., Weatherall, M., Wijesinghe, M., Perrin, K., Ranchord, A., Simmonds, M., & Beasley, R. (2009). Systematic review of studies of the effect of hyperoxia on coronary blood flow. American Heart Journal, 158(3), 371-377. doi:10.1016/j.ahj.2009.05.037
  13. Mak, S., Azevedo, E. R., Liu, P. P., & Newton, G. E. (2001). Effect of hyperoxia on left ventricular function and filling pressures in patients with and without congestive heart failure. Chest, 120(2), 467–473. doi:10.1378/chest.120.2.467
  14. McNulty, P. H., Robertson, B. J., Tulli, M. A., Hess, J., Harach, L. A., Scott, S., & Sinoway, L. I. (2007). Effect of hyperoxia and vitamin C on coronary blood flow in patients with ischemic heart disease. Journal of Applied Physiology, 102(5), 2040–2045. doi:10.1152/japplphysiol.00595.2006
  15. Yellon, D. M., & Hausenloy, D. J. (2007). Myocardial reperfusion injury. New England Journal of Medicine, 357(11), 1121-1135. doi:10.1056/NEJMra07166
  16. Hofmann, R., James, S. K., Svensson, L., Witt, N., Frick, M., Lindahl, B., Östlund, O., Ekelund, U., Erlinge, D., Herlitz, J., Jernberg, T. (2014). Determination of the role of oxygen in suspected acute myocardial infarction trial. American Heart Journal, 167(3), 322–328. doi:10.1016/j.ahj.2013.09.022
  17. O'Connor, R. E., Al Ali, A. S., Brady, W. J., Ghaemmaghami, C. A., Menon, V., Welsford, M., & Shuster, M. (2015). Part 9: Acute coronary syndromes: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 132(18 Suppl 2), S483-S500. doi:10.1161/CIR.0000000000000263

10 components of the life support chain for patient survival

For a patient to survive an emergency condition their organs must survive and continue to function. In order for organs to survive and continue to function, cells must be preserved and continue to function. At the cellular level, there are 10 essential components of the life support chain.

Early in my paramedic education at Youngstown State University I was presented with an article authored by an emergency medicine physician, which explained those 10 components necessary to keep a patient alive. I have searched endlessly for this article to give due credit to the author, however, I have not been successful. This list, compiled from my handwritten notes from 1979, provides a foundation to understanding pathophysiology.

My primary professor and paramedic program director was William E. Brown Jr. If the name sounds familiar to you, it should. Brown went on to become the Advanced Level Coordinator and subsequently the Executive Director of the National Registry of EMTs until his retirement in 2013.

Most important though, is that Brown instilled in me as an incoming paramedic student the necessity to base my education in EMS on a foundation of anatomy, physiology and pathophysiology. Memorizing signs and symptoms was not an option. We were required to understand and explain why the signs and symptoms were occurring in emergency patient conditions.

Likewise, our understanding of treatment was not to regurgitate a set of protocols but to provide the why behind the emergency care we were administering. This was imperative to educating a paramedic who can think and not just react.

A large sign in Brown's office summed up his expectation for paramedic students. It read:

"If you don’t believe in excellence in emergency medicine, then you don’t belong in here."

10 components of life support
I use the 10 components of the life support chain to teach EMT and paramedic students to think about what it really takes to give a patient the best chance to survive a medical emergency or traumatic emergency.

The 10 components of the life support chain necessary to maintain adequate oxygenation, perfusion and cellular environment are:

  1. Composition of ambient air
  2. Patency of the airway
  3. Mechanics of ventilation
  4. Regulation of respiration
  5. Ventilation/perfusion ratio
  6. Transport of gas by the blood
  7. Blood volume
  8. Myocardial effectiveness
  9. Microcirculation and systemic vascular resistance
  10. Acid base balance

Possessing an understanding of how to assess these components and provide support to maintain normal function, is key to ensuring patient survival in prehospital care.

Treat each cell
Your treatment impacts the ability of a cell to survive. For example, stopping an external hemorrhage should not be thought of as simply as task to perform when you see blood, but as a necessity to keeping the patient’s cells alive.

The patient's blood is a transport medium for oxygen, glucose, other nutrients, carbon dioxide and waste products. Without an adequate amount of oxygen and glucose being delivered to the cells, the cells will shift from aerobic to anaerobic metabolism. If this is not reversed, the toxic byproducts of anaerobic metabolism will cause the cell membranes to eventually fail leading to cell death.

Thus, the emphasis on controlling hemorrhage early and in the most effective manner possible, takes on a new meaning. It is not simply a task, but an intervention to keeping cells alive.

Opening an airway is not something you do simply because it is part of your protocol or expected in your treatment. You are opening the airway so that an adequate amount of oxygen is continually delivered to the cells so that an aerobic metabolic state can be maintained and the cells continue to function. If you don’t open the airway, the lack of oxygen in the blood will eventually cause the patient's cells to shift to an anaerobic state, and if not corrected, will eventually lead to cell death.

Thus, opening an airway or clearing an obstruction is necessary for cell survival. You must identify an occluded airway as early as possible and perform the skill of opening the airway quickly and effectively. If not, cells die. And if cells die, organs die. And if organs die, patients die.

There are three fundamental elements to all emergency care to keep cells alive:

1. Continued adequate oxygenation of cells.

2. Adequate perfusion of cells necessary to continue to deliver oxygen, glucose and other nutrients and eliminate carbon dioxide and other waste products.

3. Maintaining a cellular environment (milieu) that is compatible with cell survival.

As an EMS provider, your goal should be to maintain or return these three elements through your assessment and emergency care.

A disruption in any one of 10 components of the life support chain will lead to either an inadequate delivery of oxygenation or perfusion to cells or create a cellular environment where the cell cannot survive. The most basic and fundamental emergency care can positively impact the 10 components. Ineffective and inefficient emergency care can just as easily negatively impact the 10 components.

Master your downtime for long-term EMS career success

Every major step and accomplishment in my EMS career began while sitting in the front seat of an ambulance or at a desk in the station. I learned to master my downtime from the medics I shared the ambulance cab with.

Annette and Jennifer may have been the first true masters of downtime that I encountered. As a new trainee riding the backseat of their medic unit, they began their Saturday shift digging through the newspaper for garage sale advertisements. (I’m sure there’ an app for that now.)

Before we had turned a wheel on our first assignment they had already mapped out the best garage sales near every posting location in our district. Saturdays, they explained, were for "garage sailing", their term for pouring over the junk that people sell from their driveways every weekend.

I was in awe. Between 911 calls and inter-facility transfers, each new posting assignment kick-started a new round of planning, driving and shopping. The day flew by.

Since that day I have encountered many other downtime masters who practice their craft of overcoming boredom with fun and productivity. Pam showed up to our first shift with a hand held GPS and introduced me to Geocaching.

Sparky liked sitting outside coffee houses so much, he often walked into one coffee shop still nursing a cup of coffee from another coffee house near our last posting assignment. Sparky enjoyed the conversations over coffee more than he enjoyed the coffee itself. He loved a good conversation. When he died unexpectedly a few days after one of our coffee chats, I thought about how glad I was that I hadn’t wasted my shift with him napping or staring out the windshield.

Travis and Julia eventually married, but their relationship started over their mutual love of movies which they would play on a portable DVD player balanced on the dashboard.

Amy and Jim went on a fitness kick. As their supervisor, I often arrived at a post to find them doing air-squats off the back bumper and sit ups on the bench seat with their feet tucked under a seatbelt.

Paramedic Derek Andrew writes and performs music from his station . Music, much like exercise, is a great way to relieve the stress from a busy day of calls while also building an audience for his concerts and albums.

I know a few medics who ran successful companies from the front seat of their rig. Troy was a real estate broker with a group of clients who were exceptionally tolerant of him saying, "Sorry, I need to hang up, I have to run a call." His clients may have been annoyed by the occasional interruption, but they also liked the added trust of dealing with a public safety professional. Ryan ran his father’s rental-property management business and Mike brokered used cars that he bought at auctions.

I learned something from each of them about breaking through the boredom and monotony that often accompanies sitting at a quiet station or street corner post. In their own way, each one of them was a master of slack time.

Built my career on downtime
I basically built my career on downtime. From my early days as an EMT, when my partner and I drove around with a stack of paramedic textbooks piled on the console between us, to my years as a bio-tech consultant typing out reports on a borrowed laptop.

As an EMT instructor, all of my PowerPoints were built during the time between calls. That’s also when the first article I ever wrote for an EMS publication was typed.

When I was assigned to a slow station in my district I decided to write a blog. Fifteen years after my first article was published, I still do most of my writing during station downtime. (I’m writing this article in an airport while waiting for a connecting flight. Downtime shows up on days off too.)

How do you find fulfillment between calls"
It makes me wonder just how much of our fulfillment, enjoyment and maybe even long-term success comes from the decisions we make, not while on calls, but in between. We’re all given the same 24 hours at the beginning of each day but we all choose to spend them differently.

What we do is important. The decisions we make while an EMS call is in motion are crucial. That part is obvious. But the decisions that we make about what we do when we have nothing to do might be just as critical in the long run, and much less obvious.

What do you do when you have nothing to do" How do you master the downtime between one call and the next" Leave me a comment and let me know your favorite between call activities.

Inside EMS Podcast: Every first responder should be entitled to LODD benefits

In this Inside EMS Podcast episode, co-hosts Chris Cebollero and Kelly Grayson discuss the week's news. The Kentucky House passed a bill on Monday that, if approved by the Senate, will grant benefits to the families of EMS providers who die in the line of duty. Listen to what our co-hosts' think about it, and what else they think should be done.

Chris and Kelly also comment on these stories:

Medical magnet high school prepares students for EMS careers

White House petition asks for national EMS minimum wage

A fire chief lawyer's take on public duty doctrine

5 things civilians need to know about EMS

After reading this story on nonpaying responses in Pennsylvania and another one about a "surprise bill" for a paramedic response in California, I am beginning to wonder whether EMS reimbursement is one of this country’s greatest secrets. It seems like every week, someone is shocked about EMS’ financial state of affairs.

So in the spirit of a public service announcement that you can share with your community, let me shine some light on this matter:

1. EMS is not free
There are fixed costs of readiness — personnel, stations, supplies, ambulances and training — and response costs — fuel, disposable supplies, and reporting. There is an important corollary; even if your community's 911 emergency response is provided by a volunteer organization, it still isn’t free. Guaranteeing an EMS response , volunteer or paid, costs money.

2. No, your property taxes don’t cover EMS call response
This may not be true in all jurisdictions, but it is certainly true in many. It’s painfully so in areas where government demands a private company to provide the service at no cost, for the privilege of billing the patient for its efforts.

3. No, your insurance doesn’t cover EMS calls
Some insurance programs will cover the entire cost of an EMS response, except for a co-pay. But most insurance companies don’t. Medicare reimbursement falls short of paying for the full cost. Medicaid reimbursement is even worse. Let’s say that Medicaid might cover the cost a fuel for the day. Maybe. And here’s the kicker. Some contractual agreements prohibit agencies from billing the balance of the bill to the patient and some volunteer agencies choose not to bill the patient.

4. When you pay your exorbitant ambulance bill, you are paying for those who aren’t paying
This isn’t just an EMS oddity. Welcome to the world of health care cost distribution. For every individual who cannot or will not pay their fair share, there are many others who need to cover that shortfall. Emergency medical response and emergency care is this country’s form of socialized medicine. It’s existed since EMTALA was enacted in 1986. We cannot withhold care from you, regardless of your ability to pay.

5. EMS will respond regardless of the situation
Because that’s what we do. EMS providers perform all sorts of non-emergency care ranging from a lift assist to making a cup of tea to simply listening to a lonely widow in the middle of the night.

Responding to these social service requests and well-being checks is an everyday event for EMS providers. And we mostly do it gladly and with compassion and respect. Most EMS providers frankly don’t care about the billing, even though we know it helps put food on our tables, puts a roof over our heads, and pays for our children’s education. We will be there when you need us, if we can keep the ambulance fueled and running.

Naloxone reversal: Turning helpers into haters

Few things have caused as much recent conversation in EMS as the use of naloxone (Narcan). This lifesaving medication is quickly losing its wonder drug status and many EMS providers now view the medication as an enabler of drug addiction rather than as a life saver.

A Weymouth, Massachusetts, firefighter recently posted a message on his Facebook page that gave the issue mainstream media attention:

"Narcan is the worst drug ever created, let the (expletive) bags die … I for one get no extra money for giving Narcan and these losers are out of the hospital and using again in hours. You use, you should lose!"

The firefighter was suspended for 90 days . IAFF local 1616 in Weymouth was forced to quickly issue a statement that called the comments "disappointing" and reminded residents that their safety is a top priority.

Some have called for the firefighter’s termination, while others cite his 90-day suspension as a violation of his first amendment rights.

This issue comes down to one simple fact, which rises above the first amendment:

Just because you can say something doesn’t mean you should.

Of course this statement can be applied to everyone, but especially to those of us in public safety. Police, fire and EMS personnel occasionally complain about being held to a higher standard than others, but we also cite that higher standard when seeking raises and respect from the community — the same community that expects us to save them without judgment in an emergency.

And the simple truth is:

True heroes don’t go around wishing death to anyone on their Facebook page. Ever.

At a time when firefighters and EMS providers are under increasing scrutiny for everything from driving apparatus to the supermarket to how they spend down time at the station, when unions in general are also under attack, a firefighter’s stating that he isn’t paid enough to administer a simple lifesaving medication is nothing short of absurd.

What’s next" Perhaps the target will be people who are obese and EMS providers will refuse to do CPR, saying these people deserve to die because of their lifelong consumption of saturated fats.

Or how about people who forget their epinephrine auto-injectors and then have the nerve to be exposed to an allergen — and a provider claims they’re too stupid to live" Or those careless people who crash after texting while driving. Should they be left on the side of the road to bleed to death or choke on their own vomit" Providers could claim they aren’t paid enough to do that either.

Regardless of your personal opinion on addiction and the use of naloxone , consider this. If you’re an EMS provider face to face with another human being who is two or three shallow breaths away from death and the choice is yours — would you really let the (expletive) addict die"

If your answer is really yes, and not just because you’re blowing off frustration after a series of bad calls, then a 90-day suspension isn't enough. You should no longer be allowed to put the word firefighter, EMT or paramedic before your name.

If you answered yes while blowing off steam and you later realize the error of your ways, you should apologize — immediately and publicly. Fall on the sword so your brothers and sisters in fire and EMS don’t have to take the brunt of your thoughtlessness.

And if the firefighter who posted that Facebook comment ever responds to another EMS call for an opioid overdose, he’d better race everyone to the naloxone kit and administer it like he intends to save a life.

Why striking down the Ill. Public Duty Doctrine is not an attack on EMS

EMS providers and firefighters across the Land O’ Lincoln are reacting to the Illinois Supreme Court decision that essentially abolishes the so-called "Public Duty Doctrine."

There is a difference between liability protection and immunity, just like there is a difference between incompetence and negligence. Liability protection recognizes that accidents happen; immunity does not care what you do. You must accept that, in EMS, those are some pretty important distinctions.

At issue here is the move by the Illinois Supreme Court to do away with the "Public Duty Doctrine." In Illinois, it was state that the government does not owe the general public a duty to render care. This doctrine has been applied to provide protection/immunity from litigation when the care 911 agencies provided did not meet the undefined standards or expectations of a fickle public. While intended to protect against claims stemming from errors of omission, as a matter of practice, the doctrine never expressly drew distinctions between negligence or incompetence or just simple human error and became something of a catch-all.

As you might imagine, the thought that there would be no duty to provide care does not compute with me. In my humble opinion, not only is there a duty to provide care, there is a duty to provide competent, efficient and compassionate emergency care to everyone and anyone in need, when they call and without exception.

The case at the center of this change is one in which a series of bizarre circumstances after a 911 call for service resulted in a 41-minute delay. The patient died. The family sued.

For the record, the case itself is a non-starter for me. Someone called 911; 911 responded; EMS arrived at the home and made what appears to be a good faith effort to gain entry. With no further information and no response to their knocking, they left. It happens. Not knowing anything else, I don’t see that they did anything wrong.

The EMS agency cited the "Public Duty Doctrine" as a defense. That’s where they lose me. That defense would maybe apply to an error of omission; if they did not respond at all. However, 911 did respond, so it appears there was no omission.

Two sides to the same coin
On the heads side of the coin we have the notion that providers must be protected from improper, frivolous or spiteful claims of damage. I could not agree more. The doctrine certainly accomplished that goal.

Moreover, I will be the first and loudest to argue that providers are way too vulnerable to litigious attack by immoral gold-diggers at the hands of the lowest of the bottom-feeding plaintiff’s lawyers looking more for money than justice. My disdain for them runs deep.

On the tails side of the coin we have abuse and exploitation; the ambiguity of the doctrine seems rife with opportunity for providers to breed and foster complacency and even malice; to hide misconduct behind a wall of no duty.

Clearly that is problematic and goes against everything EMS is supposed to represent.

Dispel the myth
Comments from EMS providers after the decision seem to suggest that a great many providers believe that this ruling is an affront to them, an attack. I assure you, it is not.

Then again, the only providers who need to be worried about this ruling are those who sought or plan to seek refuge in its protections . If that is the case, they probably don’t belong in EMS anyway.

In reality, EMS providers in Illinois have lost nothing. The Supreme Court essentially ruled that the doctrine is antiquated and specifically stated that "… application of the public duty rule is incompatible with the legislature’s grant of limited immunity in cases of willful and wanton misconduct…" and that logic holds true.

Blanket and vague protections don’t truly serve anyone — EMS providers, firefighters or civilians. There are simple ways to legislatively protect EMS providers while simultaneously protecting the public with established standards of care.

In California, for example, the Health and Safety Code protects both EMS providers and the public by declaring that so long as providers perform their duties in good faith and without gross negligence, they cannot be held liable for damages. Most states use similar language.

Gross negligence , of course, is a squishy concept and hard to prove. Good faith, however, is fairly easy concept. You either did the right thing for the right reasons or you did the wrong thing for the wrong reasons.

Applied to the case in Illinois, the family called 911 and EMS responded; the providers appeared to have made a good faith effort to gain access and were unable. The loss of life is both unfortunate and sad, but nothing in my reading suggests that their conduct was either grossly negligent or performed in bad faith.

To me the "Public Duty Doctrine" created a defense that is ill-placed in EMS. Effectively, the doctrine says to the public in any given situation, "Hey, what are you mad about" We did not have to respond at all…" and that, of course, is ludicrous.

That is not how I want to be perceived as an EMS provider. How about you"

Arkansas medic only manages to semi-retire from EMS

When paramedic Sharon King decided to leave EMS in December 2014, she knew it wouldn’t be easy to end her 35-year career.

"It’s hard to completely break away from that life," the 66-year-old Hot Springs native says. "Being a paramedic gets into your system. You don’t want to give it up."

King, who was profiled in EMS1’s first "EMS Pioneers" column a year ago, ultimately added "semi" to her "retired" status and continued to work PRN for LifeNet, a Hot Springs ambulance service.

"I’m doing call-in relief — mostly long distance transfers," King says. "I did sign up for one 911 shift, but I talked to the supervisor first to make sure he knew I was still adjusting to being back on the truck. It turned out fine."

Not as young as she used to be
After working as a dispatcher and administrator at LifeNet from 2010 through 2015, King realizes fieldwork will never feel quite as routine as it once did.

"I know my limitations. At 66, neither my brain nor my body work as well as they used to. I don’t want to take unnecessary chances; it wouldn’t be fair to my partners or patients."

King wishes less physical and more cerebral specialties like community paramedicine had been available to her earlier in her career.

"I think I really would have enjoyed community paramedicine, especially as I got older and had more experience," she says. "I would have had the patient interaction I wasn’t getting in the office without as many physical demands.

"If I’d just been born a little later … Oh well, at least it’s nice not to have to be at a specific place at a specific time anymore."

A time to plant and a time to reap
A surplus of discretionary time is a luxury King hasn’t had until now. She’s spending a lot of those hours outdoors.

"I go out and work on our 15 acres of land like a field hand for an hour or two a day. I think that’s making me healthier and stronger, although sometimes I overdo it.

"I have a trail I cut into the woods from my house. After a week of that, my right knee swelled up about twice the size of my left — just a little reminder that I’m not a kid anymore."

A less physical but more challenging activity is King’s missionary work. She’s been to Russia twice, the Czech Republic and most recently, St. Lawrence Island — a remote part of Alaska only 30 miles from the Siberian coast.

"The island is owned by the Yupik tribe," King says. "There are about 600 of them living there. It’s cold and windy, without a tree to be seen.

"The tribe gets government assistance, but they survive mostly by hunting whales, seals and walruses. In the spring, maybe they can gather some berries, too, but they really can’t grow much of anything.

"The accommodations are sparse; two flushing toilets in the whole community. Most people have something like an indoor outhouse."

King says life is particularly rough for female inhabitants.

"There’s a lot of domestic abuse. Alcohol is illegal, but you know how that works.

"We try to give moral support to the ladies, and maybe treat them a little special by bringing a hairdresser and someone who does facials and manicures.

"It was a good trip, but I’ll have to wait two or three years before I can take another. We pay our own way."

Play it again, Sharon
King’s first EMS Pioneers appearance was highlighted by a photo of her playing the French horn. Now the former music major has even more opportunities to indulge herself in her first passion.

"When I started retirement, I was stingy with my time," King recalls. "After five or six months, though, I knew I wanted to be more involved with music, so I got reacquainted with Sigma Alpha Iota, my old college music club, and I’ve been singing with them.

"I also got invited to play in a brass quintet — two trumpets, a trombone, a tuba and me on the French horn. Sometimes I feel like I’m way out of my league, but they’ve been very kind, and apparently happy enough with me to keep me."

Not the retiring type
What advice would King offer colleagues contemplating retirement"

"Develop some interests. Don’t waste your time lounging around the house.

"I’ve heard some retired people talk about being bored. I can’t imagine letting myself get that way. I feel like I have this new, wonderful gift of time. I’m determined not to waste it.

"I’m planning to ride more, too. I know EMS won’t last forever. At some point I’ll just have to say I can’t do it anymore.

"But not yet."

8 ways to cope with the stress of EMS work

Working in EMS can be mentally exhausting. Finding ways to cope with stress can be highly subjective. We asked EMS1’s readers their tips for dealing with the stress of emergency work. Here are some of the best answers and add what works for you in the comments:

1. Talk it out
"Everyone tells you "you must have friends outside of ems" but I have found my coworkers are now my best friends. We are a different kind of creature, us EMS folk; we are some of the most sporadic, hilarious and fun loving people alive and it's a side we rarely get to see while on duty. To relieve work stress we all go out often for karaoke, pool and drinks. We even have been on vacations together. I think it's important to see our biggest stress relievers are sometimes there when the stress is being produced. After all who else is going to appreciate the "inside jokes" we use to conceal our heartache after a bad call." — Raimey Davis

"Having friends in similar jobs helps. I had friends who were nurses, firefighters, police and other EMTs. I couldn't talk to others because they couldn't handle the details or even try to understand. It sounds cruel but we joked a lot about our experiences." Brian Fox

"Recognize the symptoms and have a great support team. Whether it is co-workers or your spouse, you need a support team to know and understand what you are going through." — Jana Richardson Montgomery

2. Live a balanced life
"Workout frequently, have a social life outside of work, have a few drinks to relax without getting annihilated every time, and any personal hobbies like hunting, fishing or whatever works. I will say that having friends that are not in the field helps but it's hard for them to understand the stresses of the job, so hanging out with co-workers or others in the field outside of work is good too." — Josh Smith

"As much as we feel the "need" to work, it has been my experience that management will eat their young (field employees). Never work to the point of physical, psychological or emotional breaking point. Force management to hire enough people to keep you safe. Management is responsible for the system you work in. If there are inadequate resources (field staff) that is management's problem. Recreation is founded in the roots of re-creating one's self. Find something outside of EMS to help decompress." — David Swarner

"Live within "straight time." If you must work overtime in order to stay afloat then you're living like a hamster in a wheel. Getting off the wheel doesn't happen in a minute but you can get free if you commit to it. Here are two pictures that could possibly be your future: A. 10 years from now you're burnt out and stuck in a profession that you can't afford to leave. It sucks to be your partner. B. 10 years from now with a balanced life, you're enjoying this very same, rewarding profession but it's much more fun when you're free to enjoy it rather than being trapped. You get to focus on your patients and your teammates so they're happier too. Your choice." — Randy Hilton

3. Sweat it out
"1.Separate yourself from work as soon as you punch out of work. 2.Work it and not be a lazy couch potato on your days off. 3.Meditate 4. Take a trip into nature whether it's a walk in your local trails and nature reserve or out to the real back country. 5. Do arts and crafts. 6. Do some exciting new things that take you it of your comfort zone." — Rikki Archemedis Rebello

"Hit the gym after a stressful day. Sweat It out." — Thela Cordero

4. Don’t be afraid to seek help
"Don't be afraid to find a good counselor or therapist to talk things through with. We learn how to compartmentalize very well in this job, but we need to remember to clean out those compartments every so often." — Polly McCaul

"Professional Stress Management MUST become and remain an ongoing process in both your professional and personal life." — Thomas Landers

"First and foremost, take care of yourself and those around you. We are far from above reactions to the insanely challenging scenes we are thrust into day in and day out. There is ABSOLUTELY no shame in reaching out for help even long before things get too tough to cope with on your own. Talk to each other, look out for each other, take care of one another as though they are your own. And don't be afraid to ask the tough questions if you are concerned about a coworker! That concern may make the difference in someone who's on the fence of making one of those decisions none of us want to see made." — Scott Gay

5. Have a laugh
"I have a morbid sense of humor. That always helps me." — Jonatan Cuevas

"Having a sense of humor, but also enjoying the good calls. Never be embarrassed to laugh at yourself when you do make a mistake (as long as it's not a deadly one). Don't be so hard on yourself. Recognize when you have had enough or too much and take a break and talk it out." — Melissa Morrison

6. Relax
"Knitting!" — Laura Schappert

"Take a day. Focus on your goals outside of EMS." — Jason Kinneen

7. Lead a healthy life
"Recognize the stress and what it is doing to your body. Each person is different and has different ways of dealing. For me, I have found exercising and eating healthier has been a big plus. I have also found those that understand me and understand the world I work in and they are my sounding board. Being surrounded by family and friends even if it is a brief time has helped greatly." — Marcy Wolf

8. Keep a journal
"I found that having a journal and writing it down can really help because the thoughts kind of lose their power after that. Plus understand that you won’t save everybody. It's an unfortunate truth about this job because you want to save everyone." — Sean Novak

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