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

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EMS1 Daily News

Miss Tennessee discusses her life’s work, passion as an EMT

Page Glass posted a photo via Facebook revealing how thankful she is for being ‘Called to Care.’ (Photo courtesy Facebook)

Paramedic pay rate increase approved by Ala. county agency

The new paramedic starting pay, $12 per hour, is “in the ballpark” of nearby services

Man escapes police, steals ambulance

The Texas man’s escape from handcuffs and the patrol car ended after he crashed the ambulance

Man hit, killed by Amtrak train in Calif.

The man was one of three people hit by trains around the Bay Area on Monday morning and the second to die

EMT in wreck that killed 4 UGA students 'truly heartbroken'

Abby Short was driving home from work when a car filled with college students crossed the center line and crashed into her

UFC heavyweight champion credits firefighter-paramedic career for victory

CLEVELAND — After becoming the UFC heavyweight reigning champion, Stipe Miocic said his career as a firefighter was instrumental in his victory. Stipe, 33, beat reigning champion Fabricio Werdum earlier this month in Brazil after a knockout punch just two minutes into the match. “It definitely does help because it allows you to be calm, cool and collected under any situation,” Miocic ...

Synthetic opioid W-18 spiking overdoses in Philly

W-18 is a novel opioid, typically manufactured in China, purchased online and legal to possess in the United States

Skydiving tour plane crash kills 5

The crash on the Hawaiian island of Kauai killed the pilot, two skydive instructors and two tandem jumpers believed to be on the plane

'EMS Bingo' Facebook photo criticized

An EMS Week photo of the game was considered offensive and a 'black eye' on first responders

Investigation underway after ambulance hits, kills bicyclist

A Detroit ambulance was transporting a patient when it struck a man riding his bike
Top

EMS1 Topic Articles

Miss Tennessee discusses her life’s work, passion as an EMT

Page Glass posted a photo via Facebook revealing how thankful she is for being ‘Called to Care.’ (Photo courtesy Facebook)

Paramedic pay rate increase approved by Ala. county agency

The new paramedic starting pay, $12 per hour, is “in the ballpark” of nearby services

Man escapes police, steals ambulance

The Texas man’s escape from handcuffs and the patrol car ended after he crashed the ambulance

Man hit, killed by Amtrak train in Calif.

The man was one of three people hit by trains around the Bay Area on Monday morning and the second to die

EMT in wreck that killed 4 UGA students 'truly heartbroken'

Abby Short was driving home from work when a car filled with college students crossed the center line and crashed into her

UFC heavyweight champion credits firefighter-paramedic career for victory

CLEVELAND — After becoming the UFC heavyweight reigning champion, Stipe Miocic said his career as a firefighter was instrumental in his victory. Stipe, 33, beat reigning champion Fabricio Werdum earlier this month in Brazil after a knockout punch just two minutes into the match. “It definitely does help because it allows you to be calm, cool and collected under any situation,” Miocic ...

Synthetic opioid W-18 spiking overdoses in Philly

W-18 is a novel opioid, typically manufactured in China, purchased online and legal to possess in the United States

Skydiving tour plane crash kills 5

The crash on the Hawaiian island of Kauai killed the pilot, two skydive instructors and two tandem jumpers believed to be on the plane

'EMS Bingo' Facebook photo criticized

An EMS Week photo of the game was considered offensive and a 'black eye' on first responders

Investigation underway after ambulance hits, kills bicyclist

A Detroit ambulance was transporting a patient when it struck a man riding his bike
Top

EMS1 Columnist Articles

Community paramedic program cuts mental health patient call volume

The Grady EMS Upstream Crisis Intervention Group launched in January 2013 and is the brainchild of Michael Colman, vice president of EMS operations. While reviewing call volume data, Colman noticed that about 6 percent, or 6,410, of GEMS 911 calls were NAEMD triaged as category 25, which means psychiatric/suicide attempt.

Upon further analysis, Colman realized that an overwhelming portion of their frequent users — callers using EMS at least five times a month — suffered from a psychiatric illness. A financial analysis using a sample of 156 patients from this group determined that it cost Grady EMS over $100 more than they received in reimbursement for each of these transports.

In addition, the emergency department spent over $400 more on each patient than they received in reimbursement. It quickly became obvious to Colman that caring for these patients in the current manner was unsustainable.

A community paramedic project focusing on the care and transport of patients with a psychiatric complaint was launched. And room for improved patient care was quickly noticed.

Patients experiencing mental health crisis were routinely subject to unplanned physical restraint, chemical restraint, police restraint and even arrest. Grady EMS wanted to find a way to better meet the needs of this special group of patients.

Pilot community paramedic program
In late 2012, a pilot program was developed and began operation on Jan. 14, 2013. The Grady EMS crisis response team consists of a paramedic, a Grady Health System licensed counselor, a Behavioral Health Link clinical social worker and in some cases a third-year psychiatry resident.

During the pilot phase, the Grady EMS crisis group co-responded with ambulances, self-dispatched or responded at the request of Grady EMS caregivers on scene. The role of the team paramedic is to provide a medical evaluation and assessment. During the pilot phase, the GEMS crisis group did not respond as an independent unit and was only available during the day Monday through Friday.

Full program launches
The pilot phase concluded at the end of April and the Crisis Intervention Group began responding as the sole unit — without other co-responding ambulances or personnel — based on CAD data and proximity. The unit's hours changed to reflect the demand of EMD category 25 calls and were doubled from 40 to 80 hours per week.

All Grady EMS paramedics were provided in-service training on the Georgia Crisis Action Line system and were able to access that system from the field when the crisis unit was not available.

The paramedics would call the GCAL number and then hand the phone to the patient. The average time to determine a disposition for a patient was 7 to 10 minutes.

This process allows for a mental health professional to evaluate the patient and determine the level of risk over the phone. The mental health professional stays on the phone with the patient and completes a safety plan after the paramedic obtains a patient refusal.

The crisis action line professional can also dispatch a mobile crisis team to the location within one to two hours or inform the paramedic of the necessity to transport the patient to an emergency psychiatric receiving facility.

Grady EMS has been allowing crews in some cases to transport patients to places other than an emergency department for many years now. As an extension of this program, the crisis response team transports some patients directly to in-patient psychiatric facilities.

For the patient, this process completely avoids unnecessary emergency department visits as it is essentially a direct admit into an in-patient mental health facility. Online Grady EMS medical direction is consulted prior to patient transport in the crisis team's SUV.

In addition to on scene crisis team referring psychiatric patients to out-patient services, Grady EMS established an agreement to allow 911 call takers to directly transfer some callers who met NAEMD 25-alpha/omega criteria to the crisis action hotline. This transfer process is similar to the process used for the nurse advice and poison control lines. No ambulance responds unless GCAL calls Grady EMS back.

Aside from the program's process changes, training throughout EMS fire and police organizations has resulted in much better care for Atlanta residents with mental illness. Today, many patients who in the past would likely have been arrested are de-escalated and helped by the techniques learned from Behavioral Health Link and its staff.

When restraint or arrest are unavoidable, the joint training and relationships developed between the police and EMS providers helps remove stress from the process for all involved.

Cost savings of the community paramedic program
In 2013, Grady EMS dispatch transferred 175 calls directly to Behavioral Health Line saving Grady EMS about $13,000. The Grady EMS Upstream Crisis Intervention Group responded to 20 percent of EMD category 25 calls totaling 1,250 responses.

The team obtained 275 refusals/no transports. Many of those patients were provided with safety plans and outpatient appointments, which prevented unnecessary emergency department visits totaling about 1,925 bed hours.

Grady EMS Community Paramedicine

Paramedic Matt Thornton and DeAnn Bing, MD (Photo courtesy Grady EMS)

Colman reported the financial impact of these non-transports saved the emergency department and EMS system over $140,000. To put this in perspective, imagine a 24-bed ER being empty for more than 3 days.

Combined with these non-transport referrals, the group generated other cost savings totaling just over $248,000 for FY2013.

In 2014 the psych unit responded to 1,778 calls, potentially saving EMS over $100,000. In 2015, Grady EMS received 7,668 calls that were psychiatric in nature. Of those, the psych unit handled over 20 percent, again saving EMS over $100,000.

Increased job satisfaction for Grady EMS paramedics
Many EMTs and paramedics are initially attracted to EMS as a way to earn a living while helping people. Almost inevitably, that newness wears away and becomes a grim realization that EMS in its most common form does not typically offer a long-term solution to the patient’s underlying problem. When that happens, the patient becomes a frequent flyer that no one wants to hear from.

Program director Tina Wright describes members of Grady EMS Upstream Crisis Intervention Group as problem solvers. She makes no illusion that the work is easy. Wright reports that the providers working on this unit are normally busier than their colleagues on the transport units.

Grady EMS Community Paramedic

Paramedic Tennyson and mental health social worker Candace respond to patients with psychiatric illness (Photo courtesy Grady EMS)

Still the group members report higher-than-normal job satisfaction. In fact, some have even turned down promotion to field training officer in order to stay assigned to the crisis team.

Wright says that members of this team know they are having a huge long-term impact on the lives of virtually every patient they encounter. Critical thinking and solution driven decision-making are key abilities. All team members are empowered to do nearly whatever needs to be done to help meet the needs of their patients.

Wright reports that the 911 call volume generated by their mental health frequent users has decreased by well over 50 percent, which translates into thousands of calls.

For Grady EMS providers answering 911 calls, the success of the Upstream Crisis Intervention Group means they answer fewer calls generated by patients not necessarily experiencing a life-threatening emergency. It goes nearly without saying that the Upstream Crisis Intervention Group is well-loved by the paramedics and EMTs who prefer acute 911 calls from traumatic injury or medical illness.

Employee fulfillment is one of the most important keys to reducing turnover. Allowing paramedics to specialize and focus on their area of passion, like responding to patients with psychiatric illness, can have a huge impact on attrition rates. Allowing paramedics to grow and expand their area of interests while staying with the organization keeps experience and hard-earned knowledge from being lost.

Encouragement for other organizations
Wright, Colman, and Eric Eason of Behavioral Health Link want other organizations to know about the Upstream Crisis Intervention group. They also wanted to encourage other EMS organizations to evaluate the users in their system and learn what needs are not being met.

Wright challenged any organization to grow its services and personnel. "We stepped back and asked: Is there a different way of doing what we are doing," Wright said.

Eason encourages other organizations to reach out to potential mental health service providers near them. "If you don’t find anyone with the vision it takes to do what you want, have them call us here at BHL, we’ll gladly consult with them and see if there’s anything we can do to support their efforts." Eason said.

Colman regularly receives calls about the program. He is glad to help other organizations.

Rogue Capno Waves: Confirm and monitor alternative airway placement

A 56-year-old male collapsed at a restaurant and received several minutes of dispatcher-assisted CPR. A civilian responding to a mobile phone alerting system retrieved an AED from an adjacent business and administered one shock prior to arrival of EMS.

Initial assessment revealed the morbidly obese patient had a pulse and blood pressure but was unresponsive and apneic. Bag-valve-mask ventilations were difficult due to the patient’s size, so the ALS transport crew elected to intubate. After two unsuccessful oral endotracheal intubation attempts, a King LT-D supraglottic airway was inserted and manual ventilation was continued.

Consistent with protocol, waveform capnography was attached; the following tracing was obtained.

The ALS providers believed the supraglottic airway was placed properly. They theorized that the zero value ETCO2 and absence of a discernable capnography waveform resulted from the use of monitoring equipment designed for endotracheal tubes with an alternative (supraglottic) airway.

In fact, the supraglottic airway was not in place; the patient shortly thereafter became bradycardic, rearrested and subsequently died.

Comparing waveforms from different airway adjuncts
There are some studies that compare ETCO2 waveforms and measurements obtained from endotracheally intubated patients to those using supraglottic or other alternative airways. In the mid 1990s, supraglottic airways began to gain popularity as an alternative to endotracheal intubation for short duration surgical procedures requiring general anesthesia.

In that era, multiple papers were published comparing capnography waveforms and values obtained from multiple types of airways and using a wide variety of ventilation modes. It was during that same period when comparisons were made using nasal cannula derived end-tidal values.

Those studies established two findings unequivocally. First, ETCO2 values obtained from measurements made in-line with any airway device, including bag-valve-mask devices and nasal cannulas, are equivalent to those obtained from an endotracheal tube. Second, waveforms obtained from any airway device, including BVMs and nasal cannulas, are identical to those obtained from an endotracheal tube.

The implications of these earlier and innumerable studies from the anesthesia world were significant. Capnography was a safe and reliable means of assessing the adequacy of ventilation in endotracheally intubated patients, of patients being ventilated with all types of airways and of patients being ventilated with no airway adjuncts at all.

Research studies also demonstrated that capnographic waveforms could be used with alternative airways to evaluate a wide variety of conditions such as cuff leaks, ventilator dyssychrony, bronchospasm, air trapping and low cardiac output with equal efficacy regardless of the type of airway they were attached to. These findings should not be lost on EMS.

There are no differences
While there remain some questions about proper sampling and use of capnography in certain high-flow gas therapies such as jet ventilation in neonates and high-flow nasal cannula therapy for adults, neither of these therapies are currently used by EMS.

Continuous waveform capnography is an EMS standard of care and must be used to monitor placement and adequacy of ventilation with any artificial airway. The voluminous anesthesia and prehospital literature tells us that the waveforms and values obtained from any alternative airway will be identical to those obtained from an endotracheal tube.

There are no differences. If you place supraglottic airways and fail to see a four-phase capnographic waveform, the airway is not in place and ventilation is not occurring.

The incidence of misplaced supraglottic airways may not be low nor is the number of ALS providers who mistakenly attribute lack of a clearly observable capnography waveform to use of an alternative airway. An abstract presented in January by Vithalani et al, reported a 13.9 percent incidence of unrecognized misplaced King airways by paramedics in a large urban 911 EMS system.

ETCO2 is irrefutable indication of airway placement and ventilation
There are many reasons why an alternative airway may not be properly placed, some related to operator error and some to variations in patient anatomy.

Regardless of why, the absence of a clearly discernable four-phase capnography waveform and the presence of measureable CO2 is a clear and irrefutable indication that the airway is not in place and ventilation is not occurring.

Finally, EMS providers should use capnography waveforms obtained during ventilation — regardless of the type of airway in place — to assess the effectiveness of ventilation and troubleshoot airway and ventilatory issues such as cuff leaks, air trapping, airway resistance and dyssychrony.

References reviewed:

  1. Gottschalk A, Mirza N, Weinstein GS, Edwards MW. Capnography during jet ventilation for laryngoscopy. Anesth Analg. 1997;85:155-159.
  2. Chhibber AK, Kolano JW, Roberts WA. Relationship between end-tidal and arterial carbon dioxide with laryngeal mask airways and endotracheal tubes in children. Anesth Analg. 1996;82:247-250.
  3. Chhibber AK, Fickling K, Kolano JW, Roberts WA. Comparison of end-tidal and arterial carbon dioxide in infants using laryngeal mask airway and endotracheal tube. Anesth Analg. 1997;84:51-53.
  4. Fukuda K, Ichinohe T, Kaneko Y. Is measurement of end-tidal CO 2 through a nasal cannula reliable" Anesth Prog. 1997;44:23-26.
  5. Lee JS, Nam SB, Chang CH, Han DW, Lee YW, Shin CS. Relationship between arterial and end-tidal carbon dioxide pressures during anesthesia using a laryngeal tube. Acta Anaesthesiologica Scandinavica. 2005;49: 759-762.
  6. Casati A, Fanelli G, Cappelleri G, Albertin A, Anelati D, Magistris L, Torri G. Arterial to end-tidal carbon dioxide tension difference in anaesthetized adults mechanically ventilated via a laryngeal mask or a cuffed oropharyngeal airway. Eur J Anaesthesiol. 1999;16:534-538.
  7. Freeman JF, Ciarallo C, Rappaport L, Mandt M, Bajaj L. Use of capnographs to assess quality of pediatric ventilation with 3 different airway modalities.
  8. Vithalani VD, Richmond N, Davis SQ, Hejl L, Howerton D, Gleason W, Emergency Physicians Advisory Board, MedStar Mobile Healthcare. Unrecognized failed airway management using a blind-insertion supraglottic device. Abstracts for the 2016 NAEMSP Scientific Assembly. Prehospital Emergency Care. 2016;20:144.

Inside EMS Podcast: Autistic child's mom develops a tool to assist EMS

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Download this podcast on iTunes, SoundCloud or via RSS feed

In this week's Inside EMS Podcast, co-hosts Chris Cebollero and Kelly Grayson discussed the new training tool created by Kimberly Stanford. The objectives of the training are to give responders, including paramedics, EMTs and firefighters, a brief understanding of autism and how to identify it.

EMS lobbying efforts building momentum

I was surprised — actually dumbstruck — that the U.S. House of Representatives passed the Veterans EMT Support Act. Like most constituents, I have low expectations for the leaders we have elected to represent us in Congress.

The Veterans EMT Support Act, H.R. 1818, which has completed its first legislative hurdle, has been a long-term priority of the National Association of EMTs and many other state and national EMS organizations. The bill directs the Department of Health and Human Services to establish a demonstration program for states with a shortage of EMTs to develop a streamlined transition program for trained military medics to meet state EMT licensure requirements.

During my EMS career I have watched the advocacy and lobbying role of the EMS profession strengthen. As an NAEMT member, I am proud of their most recent accomplishment. I am pleased that they declared the Veterans EMT Support Act to be a priority and have led a sustained effort on the bill's behalf. I look forward to the day it is signed into law by the president.

There are other important national advocacy efforts for EMS. Three organizations — the National EMS Memorial Bike Ride, the National EMS Memorial Service, and the National EMS Memorial Foundation — have joined with the shared goal of a permanent National EMS Memorial. Those organizations, with the help of congressional supporters, have bills pending in Congress to set aside federal land to establish a National EMS Memorial.

All politics are local
Once a year, during EMS Week, we see a flurry of local news coverage about EMS agencies and the important services they provide. But after the elected officials make their proclamations and the appreciation dinners are eaten, most EMS agencies disappear into local media obscurity.

There are only a handful of EMS agencies in the United States that have sustained local advocacy efforts that garner attention, while also winning hearts and minds. Those efforts, often engaging with local officials — some of whom go on to become state or federal politicians, are what prime the pump for national efforts to succeed.

Here is what you can do to keep and increase the current lobbying and advocacy momentum for important EMS initiatives:

  • Join or renew your membership to the National Association of EMTs and your state's EMS association.
  • Regularly give your department's PIO, public affairs liaison, or marketing/public relations staff story ideas to feed to local media. Make it a mix of stories with themes of success, challenges and opportunities.
  • Ask your congressional representatives to support the National EMS Memorial legislation.
  • Broaden your perspectives by learning about EMS outside of your jurisdiction's boundaries.

Usually decisions are made by the handful of people who show up. If you want a say in the future of EMS make your voice heard.

3 overlooked resources in EMS grant writing

Successful grant writers use clear, specific language to focus the reader’s attention and to persuade the reader to fund their proposal.

How do you learn to write a compelling grant requests" How can you improve on the applications you’ve already written"

Here are three seemingly obvious resources that all too often are overlooked by new and experienced grant writers.

Read full story on EMSGrantsHelp.com

EMS body armor: What providers need to know

Ballistic protection in the form of vests for EMS providers are becoming increasingly common as part of standard PPE. While law enforcement personnel are accustomed to various types of ballistic vests and their capabilities, many in EMS are not, and this knowledge deficit could lead to a false sense of security. It is important that all EMS personnel issued ballistic protection have a basic understanding of its design and optimal ways in which to use it.

Threat levels
The National Institute of Justice issued a publication entitled "Ballistic Resistance of Body Armor," which is used worldwide to establish minimum performance requirements and test methods for the ballistic resistance of personal body armor intended to protect against gunfire. When issued ballistic protection, take note of what is known as the "NIJ Threat Level" which should be noted somewhere on the product’s labeling.

In general, the type of projectile that the vest is designed to defeat can be surmised by having an understanding of the six basic classification types:

Type I. This armor is designed to protect the wearer against smaller and lower velocity rounds such as .22 LR or .380 ACP. Its main advantage is being lightweight and less cumbersome on the wearer. This comes at a cost, however, in that the level of protection is low. Most agencies opt for a higher level of protection.

Type II-A (9 mm; .40 S&W). This armor protects against jacketed bullets of slightly higher velocity and mass. Many law enforcement professionals consider this level to be the bare minimum required for full-time duty personnel.

Type II (9 mm; .357 Magnum). This armor is heavier and has more bulk but gives more protection for higher velocity rounds up to 1400 feet per second.

Type III-A (High Velocity 9 mm; .44 Magnum). At this level, the wearer begins to be afforded protection from jacketed hollow point rounds. This is considered the highest protection available for most handgun rounds and is about the highest level one can obtain while still maintaining a low profile that might be concealed underneath a uniform shirt. However, its main disadvantage is weight and bulk making it less attractive for hot and humid conditions.

Type III (Rifles). At this level, the user begins gaining protection from high velocity rifle rounds and is intended to be used by personnel in tactical situations, such as armed barricaded subjects with a rifle. It is not considered standard threat level for every day usage.

Type IV (Armor Piercing Rifle). While this is considered the highest level of standard protection, it would be uncommon for EMS personnel to be issued Level IV ballistic vests. It is designed to resist "armor piercing" bullets and often uses ceramic plates which can be quite heavy and limit motion.

Limitations of body armor
Standard ballistic vests are designed to trap the kinetic energy of a projectile and spread the energy over a larger surface area thereby preventing it from penetrating vital body cavities. Interestingly enough, it provides little, if any, protection from edged weapons and stabbing instruments.

Additionally, the remaining kinetic energy of the bullet must still be absorbed by the wearer. While the bullet may not have penetrated the vest, one can still suffer a great deal of blunt force trauma behind the vest.

The NIJ measures the backface deformation or backface signature of various vests to determine the depth of distortion that occurs on the rear face of a vest that sits against the user’s body. Because of this phenomenon, it is important for any medical provider to look for rib fractures, pneumothorax, solid organ rupture or any other blunt force injury when evaluating a patient shot while wearing body armor.

Also, while body armor may provide some protection from fragments in an explosion — secondary blast injury, it does not protect against primary blast injury from a high order explosion.

Nothing is bulletproof
No vest is truly bulletproof, and with the growing use of ballistic vests in EMS, providers must be familiar with the various levels of protection and the limitations inherent in this increasingly common form of PPE. It will be essential that EMS personnel familiarize themselves not only with these factors, but with the practical use of this piece of equipment by wearing it and practicing skills with it such as airway management, hemorrhage control, vascular access and lifting and moving patients.

Why every EMS provider needs to support legislation for a National EMS Memorial

Every year, 850,000 EMS providers respond to over 30 million calls for service, treating 22 million patients without regard to color, gender or socioeconomic status. Ironically, we don’t toot our own horns very often. We don’t consider ourselves to be heroes. It’s just the line of work we chose to perform.

The work though comes at a significant cost. From career-ending injuries, poor wages and short career ladders, to bearing witness to the worst of the human experience, EMS is not a job for most folks. And for at least 32 EMS providers this past year who died in the line of duty, the work came at the price of the ultimate sacrifice.

There have been different ways for EMS workers to honor their fallen comrades. The National EMS Memorial Bike Ride, also known as the Muddy Angels, sponsors several rides throughout the country to raise awareness and pay tribute to the fallen. The National EMS Memorial Service is an annual event where surviving family members and EMS professionals gather to pay tribute.

Over the past year, these two valuable organizations have joined forces with the National EMS Memorial Foundation to advocate for a national EMS memorial, located in the nation’s capital, to recognize EMS line of duty deaths.

Now you too can help with this effort!

There are two bills currently in the U.S. Congress that, if enacted, will set aside federal land for the establishment of a National EMS memorial. House Bill 2274 and Senate Bill 2628 need your support. The bills provide no federal funds for the construction of a memorial. That will come from a separate fundraising effort.

However, it’s crucial that the EMS memorial be constructed on federal land, to underscore the critical role of EMS providers to protect the health and safety of the nation’s citizens.

Now, more than ever, your help is critically needed.

Moreover, the cost of your help is a mere email or phone call to your representatives in the House and in the Senate. By spending a few minutes expressing your support for the National EMS Memorial bills, you can help secure the votes necessary to pass this legislation.

If you are not sure who your representatives are, simply go to WhoIsMyRepresentative.com and type in your home ZIP code. Your house representative and senators will appear, along with their contact information.

This is National EMS Week. Honor your profession and your colleagues by taking a few minutes to urge your federal representative to vote for the National EMS Memorial.

Finding my own EMS light in a black cloud

Growing up, the only bumper sticker allowed on my dad’s truck was his Texas Paramedic patch.

It was a rule I never understood, but begrudgingly learned to accept. As I saw the "My Kid is an Honor Student" stickers consistently go untouched on the kitchen counter, I stopped bringing them home. When it came time for high school extracurricular activities and club sports, I never even bothered to buy their respective window adhesive displays of parental pride.

I hated that damn paramedic sticker.

My dad’s been a paramedic since before I was born. When he was in high school he wanted to help the Red Cross, so he was given two options: make sandwiches or take a one-day first aid course. He’s been hooked ever since.

Growing up with an ambulance outside the house, I accepted the concept of EMS as part of my reality. Sometimes that meant celebrating Christmas morning at 3 p.m., other times it meant missed sporting events and a single parent cheer squad.

But it also meant that I had the coolest show-and-tell since I got to bring an ambulance to school. It meant for career day, while the other parents talked about working in Houston’s space or oil and gas industries, my father talked proudly about something he wasn’t even paid to do.

I idolized him, despite the sticker, and his commitment to serving others. So I followed in his footsteps and took an EMT-Basic course my freshmen year of college. Like half of my friends, I wanted to go to medical school and this course served two purposes: building my resume and calming my curiosity.

Being in EMS was everything I imagined: lights, sirens, blood and drama. All in one neat 12-hour package.

I started riding at night because that’s what my dad had done. I kept riding under the moonlight because I learned to appreciate the providers and patients I met during the city’s darkest hours.

Unsurprisingly, I fell for one paramedic in particular. He was quiet, yet self-assured; willing to take the time to explain simple concepts to an overly curious volunteer. He was the opposite that I needed.

One of his first calls was an amputation on the backroads of rural Ohio. A decade later, he moved to New Orleans and six months after that the city was underwater and in chaos. He was the kind of black cloud you hear about over a beer after a long shift, not the kind anyone expects to meet and definitely not who I expected to fall in love with.

But it worked, and we created a lasting relationship out of something I’m sure many would have blown off as a temporary arrangement.

By loving him, I gained a new appreciation for the family members of those in EMS. I learned to listen for the sirens, knowing they represented a life being saved but also the reality that he wouldn’t be home until the sun started to shine. I learned how to get blood stains out of uniforms and which dinners could be most easily reheated in the microwaves of truck stops or hospital EDs.

I learned to accept that he wouldn’t always make it a friend’s party or be interested in going out the day after a long weekend spent fighting drunks and transporting gunshot victims. I learned to mirror his eating schedule, meaning dinner rarely happened before 10 p.m. and his lunch time was more likely to line up with my bed time than anything else.

But there’s a darker side to loving someone who has been exposed to what he has. It means recognizing that the most miniscule of circumstances can trigger flashbacks and nightmares. It means every day is a battle for sleep. Some days he’s able to conquer the demons keeping him awake, other days he isn’t so lucky. But any win is short-lived because there’s always tomorrow.

He’s on the path to making friends with ghosts, but I know it won’t be an easy journey. Few health care providers know how to advocate for their own health and wellness, and EMS is not immune. When providers spend their entire careers fighting to keep others alive, it feels alien to think that they too might be at risk.

I dream of the day that this is no longer the case.

In the meantime, I will stand by his side. Advocating for him, his comrades and for the advancement of this profession. Knowing that each time EMS is viewed as more than a launching pad to another industry, brings us one step closer to recognizing that the physical, mental and emotional tolls placed on EMS providers are no less real than those felt by their fellow public safety and health care counterparts.

Tips for assessing and treating stroke victims

Finding a patient unresponsive with no identification and no obvious medical history puts an EMS provider in a situation of having an extensive list of differential diagnoses to rule out. Traumatic, neurologic and metabolic causes should all be considered at the beginning of the patient assessment.

In the instance of the patient working out in the hotel, trauma was ruled out by surveying the scene around the patient and performing a physical assessment. Metabolic issues, like diabetes, can be excluded through evaluation of medical history, if available, and assessment findings, like blood glucose.

One additional differential diagnosis to consider for an unresponsive patient is narcotic overdose. With the broad adoption of naloxone administered by BLS providers, police officers and lay people, these rescuers now have a treatment option that does not require ALS to be on scene.

While naloxone is generally regarded as safe, administering it is not without consequence. As a result, providers should still make a specific decision to administer naloxone due to a suspicion of overdose rather than simply giving it to every unresponsive patient.

In this scenario, the patient has irregular respirations with periods of tachypnea and is hypertensive. Neither patient assessment finding is particularly associated with narcotic use and the scene size-up is not suggestive of overdose so naloxone should not be given in this case.

With trauma and metabolic concerns initially ruled out, providers can begin to evaluate neurologic causes. The patient’s symptoms are suspicious for hemorrhagic stroke; for instance posture — arms flexed and held tight against the body — and pupillary findings of dilated and minimally responsive to light.

Brain anatomy
The brain is the chief organ of the central nervous system and resides inside the cranium. The brain itself is covered by a series of membranes called meningeal layers. Immediately on top of the brain is the pia mater, then the arachnoid mater and finally the dura mater. The spaces between these layers contain cerebrospinal fluid or blood vessels.

Types of stroke
Strokes, or cerebrovascular accidents, fall into one of two categories. When a stroke is caused by a clot in the blood supply to the brain it is referred to as an occlusive stroke. Risk factors for occlusive stroke include atrial fibrillation and recent travel, surgery or pregnancy.

A stroke caused by bleeding in the brain is call a hemorrhagic stroke. These strokes can result from traumatic injury or rupture of a blood vessel in the brain. Risk factors for hemorrhagic stroke include a history of aneurysm — an out-pouching of an artery where the wall has weakened — and hypertension. Activities like weight lifting, which can cause blood pressure to spike during episodes of straining, can also cause a rupture of an existing aneurysm.

Pathophysiology of hemorrhagic stroke
There are essentially three varieties of hemorrhagic stroke depending on where in the brain the bleeding is located.

A subarachnoid hemorrhage occurs in the space below the arachnoid layer and may be the result of a traumatic injury or a spontaneous rupture of a blood vessel. A subdural hematoma is the collection of blood between the dura and arachnoid layers. Subdural bleeding is generally the result of tearing of the veins which bridge the space between the two layers and is often the result of a traumatic mechanism. An epidural hematoma occurs between the dura mater and the skull and can result from either a spontaneous rupture or from trauma.

In any case, as the amount of bleeding increases, more and more pressure is placed on the brain. Since the skull is an enclosed space, blood loss into that space increases the amount of pressure and can begin to press against the brain.

Arterial bleeding, since it comes from the high-pressure side of the circulatory system, will fill that space faster than venous bleeding. The measurement of pressure within the skull is called intracranial pressure.

Effects of increased ICP on the life support chain
As ICP increases, the pressure against the brain increases as well. The cranium is an entirely closed space with the exception of the foramen magnum (large opening) at the bottom where the brainstem connects to the spinal cord.

Given enough increase in ICP, the brain can begin to push — or herniate — through the foramen magnum. Obviously the brain will not fit through this space and the increase in ICP creates pressure on the brainstem as the brain presses downward. The pressure, aside from exerting physical stress on the brainstem, may also collapse the blood vessels which supply parts of the brain.

The brainstem is responsible in part for regulating heart rate and breathing. As the pressure on the brainstem increases, patients will begin to exhibit symptoms consistent with Cushing reflex. These symptoms include increased systolic blood pressure, decreased heart rate and irregular respirations. These changes in both respiratory control and circulation can have an impact on the body’s ability to maintain the life support chain and, ultimately, homeostasis.

Time of onset
One final assessment finding which may have an impact on a stroke patient’s course of treatment is the time last know well. Particularly in the case of occlusive strokes, this time frame, along with severity of symptoms, will guide the decisions about which treatment modalities to consider.

While "time last known well" is often used interchangeably with "time of onset" this may not always be the case. In many cases of stroke the time of onset of symptoms is actually unknown. Additionally, symptoms may gradually begin and increase in severity over time. As a result, understanding when the patient was last at his baseline is of the upmost importance.

In the case of the patient who was working out, EMS providers have a reliable time last known well from the housekeeper who witnessed him working out. You should make careful notes about the timeline she helps to establish and obtain contact information for her in case the physician at the hospital has other questions.

Conclusion
Based on your patient’s vital signs, his posture and the relative speed of onset of his symptoms, you suspect he is suffering from increased ICP due to a hemorrhagic stroke. With manual airway positioning you are able to maintain an adequate airway and are assisting his ventilations with a BVM. You check a blood glucose and obtain a reading of 88 mg/dL. You alert the ALS unit responding and advise of your differential diagnosis.

The ALS truck arrives and concurs with your assessment of the patient. You assist in packaging the patient for transport taking care to elevate the head of the stretcher. The ALS unit leaves for the nearest stroke center.

Why patient hand-offs are important to successful care

A 67-year-old male patient, whose chief compliant is a fever, hypotension and weakness, is left at the emergency department by EMS. A verbal report is given by EMS to the nursing staff.

After the EMS team leaves, there are questions regarding the patient's history, allergies, medications and the events leading up to the illness as septic shock is suspected. The electronic EMS chart is not available, nor is there a copy of the verbal report from EMS.

The ED staff must track down the EMS crew for more information. This leads to wasted time and resources during a potentially critical situation.

Knowledge and information is said to be power, but for patient safety it is vital. Every day patient hand offs occur where valuable information is lost or not shared.

This has become even more of an issue as many health care organizations, EMS included, have transitioned from paper charts to electronic health records and there is a lack of interoperability. Therefore, the Center for Patient Safety is adding transitions of care to this report due to the potential for data/information to be lost or missing.

Standardize hand-off report
Patient hand-offs can be thought of as an intersection where critical information is shared about patients between providers. These transitions occur in a variety of settings and many times the actual hand-off/report is not viewed as a critical step.

However, as illustrated above, this is a vital piece of the patients’ care and can help determine the next steps. Anytime a transition of care takes place, EMS providers need to ensure all the information is shared in a succinct, standardized manner.

One such approach taken from TeamSTEPPS and endorsed by the Agency for Health Research and Quality is the SBAR approach:

Situation
What is going on with the patient"

Background
What is the clinical background/context"

Assessment
What do I think the problem is"

Recommendation
What would I recommend"

The SBAR approach provides a framework for team members to effectively communicate information to one another. It is an easy to remember and easy-to-use tool for framing any conversation requiring a clinician’s immediate attention and action in any setting. Standardizing the transition of care helps to ensure the patient's care is smooth, no data/information is lost and improves patient safety.

Eunice Halverson, MA, CPS Patient Safety Specialist, states, "Patient hand-offs from prehospital providers to the hospital providers is one of the most important elements of successful care for patients with serious injuries or illnesses. Use of a standardized communication structure is key to a successful hand-off. Effective and complete communication enhances patient safety!"

An EMS time out, using the MIST reporting format, is an example of a tool that can be used for a patient hand-off:

M: Age/sex, mechanism or medical complaint

I: Injuries or inspections

S: Vital signs

T: Treatment

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