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

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Video shows the jarring consequences of texting while driving

AT&T releases new 'It Can Wait' injury prevention video and launches virtual reality experience tour to increase awareness of the dangers of phone use behind the wheel

Jersey City launches citizen emergency response program to lower response times

Citizens will be trained to respond before EMTs arrive; the program is modeled after a successful community response program in Israel

Airway management with an algorithmic approach

EMS providers need to use a systematic method for airway assessment and management

Airway management: The equipment and technique debate continues

Understanding the three types of airway management errors can help EMS providers select the optimal equipment and technique for airway management

Vt. EMT killed in highway collision

Brendon Cousino, 30, was “heavily entrapped” in his car and had no pulse when emergency crews arrived

Impact of AMR buying Rural/Metro on EMS providers

EMS1 readers react to the acquisition announcement with optimism, questions and caution

Honolulu to extend 12-hour-shift pilot program

The program changed shifts from eight hours to 12 in an effort to resolve staffing issues

Tenn. mandates medic, advanced EMT on majority of calls

A basic EMT and paramedic were previously required, and the new regulation raises concerns about staffing

Pa. doctors amputate man's foot on train tracks

The doctors are trained in performing operations in the field, and crawled under the train to perform the surgery with limited tools

SUV crashes into W.Va. nursing home

Emergency crews arrived to find the SUV buried in the side of a room; four people were treated for minor injuries
Top

EMS1 Topic Articles

Video shows the jarring consequences of texting while driving

AT&T releases new 'It Can Wait' injury prevention video and launches virtual reality experience tour to increase awareness of the dangers of phone use behind the wheel

Jersey City launches citizen emergency response program to lower response times

Citizens will be trained to respond before EMTs arrive; the program is modeled after a successful community response program in Israel

Airway management with an algorithmic approach

EMS providers need to use a systematic method for airway assessment and management

Airway management: The equipment and technique debate continues

Understanding the three types of airway management errors can help EMS providers select the optimal equipment and technique for airway management

Vt. EMT killed in highway collision

Brendon Cousino, 30, was “heavily entrapped” in his car and had no pulse when emergency crews arrived

Impact of AMR buying Rural/Metro on EMS providers

EMS1 readers react to the acquisition announcement with optimism, questions and caution

Honolulu to extend 12-hour-shift pilot program

The program changed shifts from eight hours to 12 in an effort to resolve staffing issues

Tenn. mandates medic, advanced EMT on majority of calls

A basic EMT and paramedic were previously required, and the new regulation raises concerns about staffing

Pa. doctors amputate man's foot on train tracks

The doctors are trained in performing operations in the field, and crawled under the train to perform the surgery with limited tools

SUV crashes into W.Va. nursing home

Emergency crews arrived to find the SUV buried in the side of a room; four people were treated for minor injuries
Top

EMS1 Columnist Articles

Airway management with an algorithmic approach

By definition, an algorithm provides a step-by-step approach to solving a problem. Many tasks in EMS are managed using an algorithmic approach, and many local protocols are formatted in an algorithmic, "if you find this, then you do that" fashion.

Airway management is a task well suited to an algorithmic approach, as there are many options, maneuvers, and tools available for use by prehospital providers. The following factors, from simplest to most complex, may be helpful to consider when developing an algorithm for airway management.

First things first

The starting point for any airway management algorithm is an accurate assessment of the patient’s airway status and the identification of any potential airway complications. Identifying current and potential causes of airway compromise allows the provider to select the appropriate positioning, devices, and approach to managing the airway.

The assessment of the airway in a responsive patient can be as simple as listening to the patient speak. A patient who speaks with ease, in a normal sounding voice has an adequate airway. A patient who is conscious, but unable to speak may be choking and require immediate intervention to clear the airway of a foreign body.

For a patient who is conscious, but has a decreased mental status or respiratory difficulty, listen for abnormal sounds as the patient breathes. Stridor, gurgling, and a hoarse voice all indicate potential airway compromise. Unresponsive patients can be evaluated in a similar manner, by listening for any abnormal airway sounds as the patient breathes.

Factors to consider in airway management decisions

Another component of the initial airway assessment is the identification of potential airway management challenges. A quick assessment of the patient’s age, body size, and any special circumstances can allow for quicker management of life threatening airway issues.

For example, patients who are obese are significantly more difficult to ventilate, and may require different positioning and equipment than a normal-sized adult.[1] Pediatric patients require special positioning as well to ensure alignment of airway structures.

Special circumstances such as the presence of dentures, facial and oral trauma, stoma, or potential cervical spine injuries will also influence airway management techniques. Identifying factors that may complicate airway management allows the provider to be adequately prepared to effectively manage the airway.

Getting ready

The final component of the primary assessment is gathering and preparing appropriate equipment for airway management. Often this can be as simple as ensuring the airway bag is nearby. Oxygen delivery equipment, suction, simple adjuncts, and advanced airway equipment should all be quickly gathered and placed close to the patient. This task can often be delegated to another provider, allowing the EMT or paramedic to continue down the airway algorithm.

Identifying and correcting hypoxia

Occurring concurrently with the assessment of airway status is the evaluation of the need for supplemental oxygenation. Hypoxia must be identified quickly and steps taken to adequately oxygenate the patient.

The assessment of hypoxia and administration of oxygen can occur in a fluid and often-simultaneous fashion. For instance, during the initial assessment of the airway the provider may identify the need for supplemental oxygen and delegate the task of administering oxygen to another provider. If the patient is in respiratory failure and requires ventilation with a bag-mask device, or has other signs of airway compromise, the provider can quickly continue the algorithm as another responder is managing oxygen administration.

Positioning and manual maneuvers

Patient positioning is the most basic but perhaps the most important aspect of effective airway management. A properly positioned airway allows for maximum airflow into the lungs, while a poorly positioned airway can inhibit or completely obstruct air movement.

Many conscious patients will automatically assume the most efficient airway positioning on their own. For these patients, providing padding and support to maintain their position of best breathing can ease their work of breathing and keep an adequate airway for as long as possible.

Unresponsive patients require a more thoughtful approach when it comes to positioning. Often BLS providers are taught two options for a manual maneuver to open the airway; the head-tilt chin-lift and the jaw-thrust. Although these maneuvers are considered effective, providers should consider adding other maneuvers to their airway algorithm.

Since the 1940’s, the sniffing position has been considered the ideal position for advanced airway management in the unresponsive patient. [2] Studies have shown that the sniffing position also improves the ease of bag mask ventilations, especially when combined with a jaw thrust maneuver. By bringing the chin forward and tilting the head slightly back, the oral, pharyngeal, and laryngeal axes align to maximize airflow through the upper airway. The jaw thrust maneuver then lifts the tissue of the tongue and soft palate up and away from the back of the throat, providing an unobstructed path through the glottis and into the trachea.

Managing an airway in an obese patient

While the sniffing position aligns the airway structures in a patient of average size, its effectiveness for heavier patients is limited, especially ones who are supine.[3] Patients who are obese may have an excess of soft tissue in the airway and anatomical airway obstruction becomes more likely.

The ramp position may be more successful when positioning the airway of heavier patients in the supine position.[4] Placing padding under the shoulders and head of an obese patient can achieve the same airway alignment as the sniffing position does for a person of average size. The ideal position when using the ramp technique brings the outside of the ear canal forward to the level of the sternal notch. The amount of padding needed and exact angle of the ramp will vary depending on the size of the patient.

For all patients, taking a moment to consider patient positioning and manual maneuvers before beginning more active airway management can help ensure the best possible conditions to maintain the patency of every airway.

Fluid, blood, and mucous

The next step in airway management is identifying the need for suctioning by listening for gurgling sounds during breathing. Fluid, emesis, blood, and mucous are all possible causes of gurgling and should be suctioned from the airway when found. Oral suctioning can be accomplished using a Yankauer rigid catheter. Suctioning the nasopahrynx is accomplished in a similar fashion but is done using a French soft-tip catheter.

Any special circumstances identified in the initial airway assessment should be considered prior to selecting the appropriate suctioning device and technique. Facial trauma, septal defects, and the patient’s age may all influence suctioning decision-making. Significant facial trauma may cause bleeding into the airway, requiring repeated suctioning until an advanced airway is in place. The presence of a perforated or deviated septum may influence the decision to suction the nasal passages. Pediatric patients, especially infants, are at risk for vagal stimulation during oral suctioning, so episodes of suctioning should be performed as quickly and gently as possible.[5]

Fluid, blood, or mucus in the airway may prompt the paramedic to consider placing an advanced airway. BLS providers may wish to request an ALS resource when suctioning is required, as bag mask ventilations are difficult when fluid is present in the airway and the risk of aspiration is significant.[6]

BLS airway adjuncts

Once the patient is positioned appropriately and a patent airway has been achieved, a BLS airway adjunct can be inserted. Oropharyngeal airways (OPA) and nasopharyngeal airways (NPA) help maintain a passage for airflow through an airway opened by manual airway maneuvers. Insertion of an OPA or NPA is especially effective in keeping the tongue and soft tissues from completely obstructing the airway.

OPAs and NPAs are particularly well suited to certain airway scenarios. OPAs work well for patients who are unresponsive with no gag reflex, particularly those who require positive pressure ventilation. When used in combination with positioning and manual maneuvers OPAs increase the ease of bag mask ventilation in unresponsive patients.

An NPA performs a similar function as the oropharyngeal airway, but is designed for use in patients with an intact gag reflex. When inserted into the nare, an NPA creates a small passage for air to move past the tongue and any soft tissue that may be occluding the airway. NPAs must be measured prior to insertion to avoid stimulating a gag reflex or causing trauma to the nasal passages.

NPAs can be used in either nare, or both simultaneously. NPAs may also be an advisable choice in situations where the patient’s mental status is likely to improve quickly, as with diabetic emergencies and narcotic overdoses who receive dextrose or naloxone, respectively.

Considering an advanced airway

The placement of an advanced airway can occur after a BLS airway is established. Supraglottic devices do not require direct laryngoscopy. Endotracheal intubation continues to be the standard when a long-term airway is needed.

Other procedures such as nasal intubation and rapid sequence induction (RSI) also have their place in advanced airway management. Regardless of the advanced airway under consideration, establishing a viable BLS airway using an algorithmic approach ensures the best possible outcome for every patient.

Transport decision

Making an appropriate transport decision is critical when treating a patient with airway compromise. If initial attempts at establishing an airway have failed, the provider must immediately seek advanced resources. Emergent transport of a patient is necessary if an airway cannot be acquired or maintained and a more advanced provider is not immediately available to assist. If an adequate airway has been achieved, either through BLS or ALS procedures, it may be appropriate to transport the patient at a lower priority, assuming that the patient’s vital signs remain within acceptable limits.

Continued reassessment and evaluation

The final step in an airway management algorithm is continued reassessment and evaluation. Recognizing changes in airway status allows the provider to adapt and respond quickly and effectively to new airway challenges. This reassessment may be as simple as using continuous waveform capnography to monitor the placement of an endotracheal tube, or as complex as continually adjusting a mask seal, suctioning the airway, and adjusting patient positioning.

Managing an airway can be a complex and challenging process. Developing an algorithmic approach to airway management allows providers to move smoothly through the decision making process with each and every patient.

References

1. Kristensen, Michael S. "Airway management and morbid obesity." European Journal of Anaesthesiology (EJA) 27.11 (2010): 923-927.

2. Cattano, Davide. "Airway Management and Patient Positioning: A Clinical Perspective." Anesthesiology News (2011): 17-23. Anesthesiology News. Web. 10 July 2015.

3. Adnet F, Borron SW, Lapostolle F, Lapandry C. “The three axis alignment theory and the “sniffing position”: perpetuation of an anatomic myth"” Anesthesiology. 1999;91(6):1964-1965

4. Cattano D, Melnikov V, Khalil Y, Sridhar S, Hagberg CA. An evaluation of the Rapid Airway Management Positioner in obese patients undergoing gastric bypass or laparoscopic gastric banding surgery. Obes Surg. 2010;Oct20(10):1436-1441.

5. Walsh, Brian K., Kristen Hood, and Greg Merritt. "Pediatric airway maintenance and clearance in the acute care setting: how to stay out of trouble." Respiratory care 56.9 (2011): 1424-1444.

6. Nagao, Tomoyuki, et al. "Effects of bag-mask versus advanced airway ventilation for patients undergoing prolonged cardiopulmonary resuscitation in pre-hospital setting." The Journal of emergency medicine 42.2 (2012): 162-170.

Airway management: The equipment and technique debate continues

If polled, it is reasonable to expect EMS personnel to rank advanced airway management as one of the most important prehospital interventions. Despite this attitude, numerous studies and case reports highlight the complications associated with advanced airway management, especially when inexperienced providers attempt to perform endotracheal intubation.[1-4] The American Heart Association acknowledges the lack of adequate evidence to recommend a specific advanced airway or to recommend the optimal timing for device insertion relative to other advanced procedures.[5]

Airway error types

Researchers recently proposed a classification system for errors and complications created when attempting to use an advanced airway.[6] This system includes technical errors, cognitive errors, and adverse anatomic effects.

Technical errors associated with advanced airway placement include airway misplacement[7], multiple failed attempts[8], prolonged attempts[9], and accidental dislodgement after correct placement.[10] Technical errors may decrease ventilation effectiveness[11] and increase the frequency and duration of interruptions in chest compressions during a resuscitation attempt.[12]

Cognitive errors deal with the knowledge needed to perform a skill. EMS personnel must know the advantages and disadvantages of each of the different type of advanced airway devices, and well as the indication for use. Examples of cognitive errors in advanced airway management include patient assessment errors, failure to troubleshoot airway problems, and overcompensation for oxygenation and ventilation deficiencies. Overcompensation, in the form of hyperventilation is common in traumatic brain injury management[13] and during resuscitation attempts following cardiac arrest that occurs both in the out-of-hospital[14] and in-hospital settings.[15-17]

Post - ROSC arterial hyperoxia (a potential consequence of overcompensation) has also been shown to decrease survival to hospital discharge rates in adult patients who suffered cardiac arrest.[18] Although arterial hyperoxia increases oxygen content of the blood, it also reduces regional perfusion through vasoconstriction.[19] The net effect is decreased oxygen delivery to the organs and tissues.

The final category of errors and complications are those that produce anatomic abnormalities. For example, esophageal-tracheal tube insertion can result in tracheal injury, upper airway bleeding, tongue edema, or esophageal laceration or perforation.[20] Overinflation of the laryngeal tube cuffs can cause swelling in the tongue significant enough to produce life-threatening airway obstruction.[21] Complications related to the endotracheal intubation involving anatomic abnormalities include tongue perforation[22] and tracheal laceration.[23,24]

Although trauma related to the use of endotracheal tube introducers is rare, most complications result from railroading, whereby the healthcare provider aggressively and forcefully pushes the endotracheal tube over the bougie even after meeting resistance.[25] Use of the bougie has resulted in bronchial laceration[26], pharyngeal wall perforation[27], bleeding and blood clot formation in a mainstem bronchus[28], and tracheal perforation resulting in a complete intratracheal airway obstruction.[29]

Using the most appropriate device

Despite the problems associated with advanced airway placement, EMS personnel can improve patient ventilation by inserting a supraglottic airway when compared to ventilation with a bag-mask even when the EMS provider has only limited training in advanced airway management.[30] A recent investigation demonstrated that early insertion of a supraglottic airway significantly improved chest compression fraction when compared to bag-mask ventilation in patients who suffered an out-of-hospital cardiac arrest.[31] This study did not measure survival outcomes however; other studies have demonstrated improvements in clinical outcomes with higher chest compression fractions.[32-34] The increase in chest compression fraction observed in the study is likely due to the change in compression/ventilation ratios that followed advanced airway insertion.

KISS principle applies

EMS providers should strive to keep things simple when deciding which airway device to use in a specific situation. Specifically for the paramedic practitioner, the airway toolbox is filled with a multitude of devices and procedures for establishing and maintaining airway patency. Paramedics should consider the following:

  • the anatomic presentation of the airway
  • the environment in which the patient presents
  • the confidence of their ability to perform the procedure reliably and accurately
  • the ability of the device or procedure to preserve airway patency, and
  • the potential for complications and untoward outcomes with the device

In general, the simpler the device or procedure, the greater the reliability and accuracy of its use. However, not all anatomic presentations or environmental conditions are conducive to simpler devices. EMS providers should be not only well versed in how to use every device and procedure available, but also to critically decide when to use the appropriate method and what other choices need to be used in case of failure.

Current and future studies

Researchers in France are currently investigating whether the use of an endotracheal tube improves 28-day survival with favorable neurological outcome following out-of-hospital cardiac arrest compared to use of bag-mask ventilation.[35] The study is expected to conclude mid-year 2017.

Researchers in the United Kingdom are studying out-of-hospital cardiac arrest and comparing outcomes between 9,000 adult patients whose airways were managed with an endotracheal tube and those managed with a second generation supraglottic airway. [36] The primary outcome for the study, known as the UK AIRWAYS-2 study, is neurological outcome (as measured by the modified Rankin scale) at hospital discharge. Enrollment began early this year and is expected to conclude in late 2017.

Later this year, the Resuscitation Outcomes Consortium will begin enrolling patients into the Pragmatic Airway Resuscitation Trial (PART [ClinicalTrials.gov Identifier: NCT02419573]). For adult patients who develop cardiac arrest in the out-of-hospital environment, researchers will randomly allocate those patients to receive early advanced airway management with either an endotracheal tube or laryngeal tube.[37] The primary outcome for the study will be 72-hour survival. By the time the study concludes in late 2020, the researchers expect to enroll 3,000 patients.

References

1. Cobas, M., De la Pena, M. A., Manning, A., & Varon, A. J. (2009). Prehospital intubations and mortality: A level one trauma center perspective. Anesthesia and Analgesia, 109(2), 489–493. doi:10.1213/ane.0b013e3181aa3063

2. Gausche, M., Lewis, R. J., Stratton, S. J., Haynes, B. E., Gunter, C. S., Goodrich, S. M., Poore, P. D., McCollough, M. D., Henderson, D. P., Pratt, F. D., & Seidel, J. S. (2000). Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: A controlled clinical trial. Journal of the American Medical Association, 283(6), 783–790. doi:10.1001/jama.283.6.783

3. Katz, S. H., & Falk, J. L. (2001). Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Annals of Emergency Medicine, 37(1), 32–37. doi:10.1067/mem.2001.112098

4. Wirtz, D. D., Ortiz, C., Newman, D. H., & Zhitomirsky, I. (2007). Unrecognized misplacement of endotracheal tubes by ground prehospital providers. Prehospital Emergency Care, 11(2), 213–218. doi:10.1080/10903120701205935

5. Neumar, R. W., Otto, C. W., Link, M. S., Kronick, S. L., Shuster, M., Callaway, C. W., Kudenchuk, P. J., Ornato, J. P., McNally, B., Silvers, S. M., Passman, R. S., White, R. D., Hess, E. P., Tang, W., Davis, D., Sinz, E., & Morrison, L. J. (2010). Part 8: Adult advanced cardiovascular life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 122[suppl 3], S729–S767. doi:10.1161/CIRCULATIONAHA.110.970988

6. Benoit, J. L., Prince, D. K., & Wang, H. E. (2015). Mechanisms linking advanced airway management and cardiac arrest outcomes. Resuscitation, 93, 124-127. doi: 10.1016/j.resuscitation.2015.06.005

7. Jones, J. H., Murphy, M. P., Dickson, R. L., Somerville, G. G., & Brizendine, E. J. (2004). Emergency physician-verified out-of-hospital intubation: Miss rates by paramedics. Academic Emergency Medicine, 11(6), 707–709. doi:10.1197/j.aem.2003.12.026

8. Studnek, J. R., Thestrup, L., Vandeventer, S., Ward, S. R., Staley, K., Garvey, L., & Blackwell, T. (2010). The association between prehospital endotracheal intubation attempts and survival to hospital discharge among out-of-hospital cardiac arrest patients. Academic Emergency Medicine, 17(9), 918-925. doi:10.1111/j.1553-2712.2010.00827.x

9. Wayne, M. A., & McDonnell, M. (2010). Comparison of traditional versus video laryngoscopy in out-of-hospital tracheal intubation. Prehospital Emergency Care, 14(2), 278-282. doi:10.3109/10903120903537189

10. Park, S. H., Han, S. H., Do, S. H., Kim, J. W., & Kim, J. H. (2009). The influence of head and neck position on the oropharyngeal leak pressure and cuff position of three supraglottic airway devices. Anesthesia and Analgesia, 108(1), 112-117. doi:10.1213/ane.0b013e318192376f

11. Davis, D. P., Hoyt, D. B., Ochs, M., Fortlage, D., Holbrook, T., Marshall, L. K., & Rosen, P. (2003). The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury. Journal of Trauma, 54(3), 444-453. doi:10.1097/01.TA.0000053396.02126.CD

12. Wang, H. E., Simeone, S. J., Weaver, M. D., & Callaway, C. W. (2009). Interruptions in cardiopulmonary resuscitation from paramedic endotracheal intubation. Annals of Emergency Medicine, 54(5), 645-652. doi:10.1016/j.annemergmed.2009.05.024

13. Davis, D. P., Dunford, J. V., Ochs, M., Park, K., & Hoyt, D. B. (2004). The use of quantitative end-tidal capnometry to avoid inadvertent severe hyperventilation in patients with head injury after paramedic rapid sequence intubation. Journal of Trauma, 56(4), 808-814. doi:10.1097/01.TA.0000100217.05066.87

14. Aufderheide, T. P., Sigurdsson, G., Pirrallo, R. G., Yannopoulos, D., McKnite, S., von Briesen, C., Sparks, C. W., Conrad, C. J., Provo, T. A., & Lurie, K. G. (2004). Hyperventilation-induced hypotension during cardiopulmonary resuscitation. Circulation, 109(16), 1960-1965. doi:10.1161/01.CIR.0000126594.79136.61)

15. (Abella, B. S., Alvarado, J. P., Myklebust, H., Edelson, D. P., Barry, A., O'Hearn, N., Vanden Hoek, T. L., & Becker, L. B. (2005). Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest. Journal of the American Medical Association, 293(3), 305-310. doi:10.1001/jama.293.3.305

16. Losert, H., Sterz, F., Köhler, K., Sodeck, G., Fleischhackl, R., Eisenburger, P., Kliegel, A., Herkner, H., Myklebust, H., Nysaether, J., & Laggner, A. N. (2006). Quality of cardiopulmonary resuscitation among highly trained staff in an emergency department setting. Archives of Internal Medicine, 166(21), 2375-2380. doi:10.1001/archinte.166.21.2375

17. O'Neill, J. F., & Deakin, C. D. (2007). Do we hyperventilate cardiac arrest patients" Resuscitation, 73(1), 82-85. doi:10.1016/j.resuscitation.2006.09.012

18. Kilgannon, J. H., Jones, A. E., Shapiro, N. I., Angelos, M. G., Milcarek, B., Hunter, K., Parrillo, J. E., & Trzeciak, S. (2010). Association between arterial hyperoxia following resuscitation from cardiac arrest and in-hospital mortality. Journal of the American Medical Association, 303(21), 2165-2171. doi:10.1001/jama.2010.707

19. Iscoe, S., Beasley, R., & Fisher, J. A. (2010). Arterial hyperoxia and in-hospital mortality after resuscitation from cardiac arrest. Journal of the American Medical Association, 304(13), 1440-1441. doi:10.1001/jama.2010.1397

20. V´ezina, M. C., Tr´epanier, C. A., Nicole, P. C., & Lessard, M. R. (2007). Complications associated with the esophageal–tracheal Combitube in the pre-hospital setting. Canadian Journal of Anaesthesia, 54(2), 124–128. doi:10.1007/BF03022008

21. Schalk, R., Seeger, F. H., Mutlak, H., Schweigkofler, U., Zacharowski, K., Peter, N., & Byhahn, C. (2014). Complications associated with the prehospital use of laryngeal tubes--a systematic analysis of risk factors and strategies for prevention. Resuscitation, 85(11), 1629-1632. doi:10.1016/j.resuscitation.2014.07.014

22. Lollo, L., Meyer, T. K., & Grabinsky, A. (2012). A rare complication of tracheal intubation: tongue perforation. Case Reports in Anesthesiology, 2012, 281791. doi:10.1155/2012/281791

23. Chen, E. H., Logman, Z. M., Glass, P. S., & Bilfinger, T. V. (2001). A case of tracheal injury after emergent endotracheal intubation: A review of the literature and causalities. Anesthesia and Analgesia, 93(5), 1270-1271. doi:10.1097/00000539-200111000-00047

24. Üzümcügil, F., Babaoğlu, G., Denizci, E., Sarıcaoğlu, F., & Kanbak, M. (2015). Tracheal laceration as a complication of out-of-hospital emergency tracheal intubation in a patient with COPD. American Journal of Emergency Medicine, 33(1), 128.e1-3. doi:10.1016/j.ajem.2014.06.021

25. Phelan, M. P. (2004). Use of the endotracheal bougie introducer for difficult intubations. American Journal of Emergency Medicine, 22(6), 479-482. doi:10.1016/j.ajem.2004.07.017

26. Sahin, M., Anglade, D., Buchberger, M., Jankowski, A., Albaladejo, P., & Ferretti, G. R. (2012). Case reports: Iatrogenic bronchial rupture following the use of endotracheal tube introducers. Canadian Journal of Anesthesia, 59(10), 963-967. doi:10.1007/s12630-012-9763-z

27. Kadry, M., & Popat, M. (1999). Pharyngeal wall perforation – an unusual complication of blind intubation with a gum-elastic bougie. Anaesthesia, 54(4), 404-405. doi:10.1046/j.1365-2044.1999.00875.x

28. Prabhu, A., Pradhan, P., Sanaka, R., & Bilolikar, A. (2003). Bougie trauma – it is still possible. Anaesthesia, 58(8), 811-813.

29. Arndt, G. A., Cambray, A. J., & Tomasson, J. (2008). Intubation bougie dissection of tracheal mucosa and intratracheal airway obstruction. Anesthesia and Analgesia, 107(2), 603-604. doi:10.1213/ane.0b013e318176fe36)

30. Roth, D., Hafner, C., Aufmesser, W., Hudabiunigg, K., Wutti, C., Herkner, H., & Schreiber, W. (2015). Safety and feasibility of the laryngeal tube when used by EMTs during out-of-hospital cardiac arrest. American Journal of Emergency Medicine, 33(8), 1050-1055. doi:10.1016/j.ajem.2015.04.048

31. Maignan, M., Koch, F. X., Kraemer, M., Lehodey, B., Viglino, D., Monnet, M. F., Pham, D., Roux, C., Genty, C., Rolland, C., Bosson, J. L., Danel, V., & Debaty, G. (2015). Impact of laryngeal tube use on chest compression fraction during out-of-hospital cardiac arrest. A prospective alternate month study. Resuscitation, 93, 113-117. doi: 10.1016/j.resuscitation.2015.06.002

32. Bobrow, B. J., Vadeboncoeur, T. F., Stolz, U., Silver, A. E., Tobin, J. M., Crawford, S. A., Mason, T. K., Schirmer, J., Smith, G. A., & Spaite, D. W. (2013). The influence of scenario-based training and real-time audiovisual feedback on out-of-hospital cardiopulmonary resuscitation quality and survival from out-of-hospital cardiac arrest. Annals of Emergency Medicine, 62(1), 47-56. doi:10.1016/j.annemergmed.2012.12.020

33. Rea, T., Olsufka, M., Yin, L., Maynard, C., & Cobb, L. (2014). The relationship between chest compression fraction and outcome from ventricular fibrillation arrests in prolonged resuscitations. Resuscitation, 85(7), 879-884. doi: 10.1016/j.resuscitation.2014.02.026

34. Yannopoulos, D., Aufderheide, T. P., Abella, B. S., Duval, S., Frascone, R. J., Goodloe, J. M., Mahoney, B. D., Nadkarni, V. M., Halperin, H. R., O'Connor, R., Idris, A. H., Becker, L. B., & Pepe, P. E. (2015). Quality of CPR: An important effect modifier in cardiac arrest clinical outcomes and intervention effectiveness trials. Resuscitation, pii: S0300-9572(15)00248-8. doi:10.1016/j.resuscitation.2015.06.004

35. ClinicalTrials.gov. (2015). Tracheal intubation vs. bag-valve-mask ventilation in patients with out-of-hospital cardiac arrest - CAAM STUDY [ClinicalTrials.gov Identifier: NCT02327026]. Retrieved from https://clinicaltrials.gov/ct2/show/NCT02327026"term=%22endotracheal+intubation%22+AND+%22cardiac+arrest%22&rank=1

36. BioMed Central. (2015). Airway management in out of hospital cardiac arrest patients [ISRCTN08256118]. Retrieved from http://www.isrctn.com/ISRCTN08256118"q=ISRCTN08256118&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10&searchType=basic-search

37. ClinicalTrials.gov. (2015). Pragmatic airway resuscitation trial (PART). Retrieved from https://clinicaltrials.gov/ct2/show/NCT02419573"term=%22endotracheal+intubation%22+AND+%22cardiac+arrest%22&rank=2

Inside EMS Podcast: How to safely drive an ambulance with lights and sirens

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

In this week’s episode of Inside EMS, co-hosts Chris Cebollero and Kelly Grayson are joined by Phil Frenkel, who has been an EMT six months. He has some questions about how best to handle driving an ambulance with lights and sirens activated.

Chris and Kelly stress safety when talking about the many ambulance collisions in EMS, and discuss how to not become a crash statistic.

Questions for EMS chiefs about safety, careers and active-shooter incidents

EMS leaders regularly gather to discuss challenges, share solutions and exchange best practices. Part of my preparation for events like Pinnacle EMS Leadership Forum, EMS World Expo, and EMS Today includes thinking of questions to pose to EMS leaders. At past conferences I have sought out chiefs and managers to ask about the development of community paramedicine programs, how to improve cardiac arrest survival, innovations in ambulance design, and adoption of online training.

Though some change in EMS is driven by regulatory changes or evolving recertification standards, much of the change comes from individual agencies identifying a problem, prototyping and testing solutions, implementing the best results, and then diffusing their innovations. These are some of the current challenges facing EMS that I want to ask chiefs to find out which solutions are working (or not working) and how they are spreading their best practices to other departments.

Question 1: In-vehicle safety
"Chief, What is the rate of seatbelt use in your ambulances" How do you monitor seatbelt use in the driver and patient care compartments""

When I read a news report about an ambulance collision with injuries, I look for specific details about:

  • Seatbelt use in the driver compartment and patient care compartment
  • Driver distraction in the ambulance, as well as any other involved vehicles
  • Driver fatigue and clues about shift length

Most EMS providers are knowledgeable of the importance of seatbelt use, but I am increasingly suspicious that compliance with the actual behavior is low. Clips of the New Orleans cast of Nightwatch and Boston EMS showed medics not wearing seatbelts.

Other ambulance safety questions that warrant discussion include:

  • What changes are you making to shift length and staffing to minimize risks from fatigue-related collisions"
  • What are you doing to protect the driver from distractions caused by electronics, passengers, and patients"
  • What are the best practices for maintaining and replacing ambulances"

Question 2: Career growth and training
"Chief, what are the career opportunities for paramedics and non-clinical pathways for growth in your system""

For much of the short history of EMS, there have only been two career pathways. The first path is EMT or paramedic to entry-level supervisor (FTO, field supervisor) to middle-management to chief. The other pathway has been EMT or paramedic to a new career, possibly, but not often in health care.

Community paramedic is the most obvious new career pathway, especially for medics to further their clinical skills, but more pathways are necessary. EMS has a need for paramedics to become experts in data analysis and interpretation, computer and information science, digital storytelling and marketing and finance.

Question 3: Active-shooter incident response
"Chief, what actions has your department taken to train and practice active-shooter incident response with your law enforcement partners""

Active-shooter response, like improving cardiac arrest survival, requires a mindset shift from past practices. An important first step is identifying situations for a tactical medic versus situations where a rescue task force is indicated. More and more communities are creating protocols for and equipping EMS to respond with police support as a rescue task force, which rapidly responds to patients in the warm zone of an active-shooter incident.

An important, and possibly overlooked component of active-shooter incident preparedness, is EMS representatives taking the lead on communicating with the media. In the minutes and hours after the La. theater shooting numerous representatives from Acadian Ambulance did live stand-ups with national television.

The next day, less than 24 hours after the incident, the CEO and chairman of Acadian recorded a video which gave an unprecedented level of detail about the EMS response to an active-shooter incident. The detailed, personal, and authentic video was posted and widely shared on social media. The mix of compassion, empathy, and factual information is a great model for other EMS leaders to follow.

Every agency, as it plans for major incidents, needs to be thinking about how it can leverage internal assets for media production, like the Acadian video, and then use social channels, like a department Facebook page, to widely distribute the information to employees, stakeholders, policy makers, civilians and the media.

What are your top questions for the leaders of the EMS profession"

5 evidence-based countermeasures for EMS fatigue

By Daniel Patterson, Matthew Weaver, and Francis X. Guyette

Our first article, “ Studying sleep: Health and fatigue in EMS” provided a brief overview of sleep health and fatigue and called upon EMS clinicians and administrators to:

1. Recognize that poor sleep and fatigue are threats to safety

2. Get involved in research that can help us better define the problem and test solutions for the safety of our clinicians and patients

In this article, we discuss fatigue risk management and highlight some (not all) evidence-based countermeasures for fatigue mitigation in the workplace.

Fatigue risk management system

A fatigue risk management system (FRMS) or a fatigue risk management program (FRMP) is defined as “A scientifically based, data-driven, addition or alternative to prescriptive hours of work limitations which manage employee fatigue in a flexible manner appropriate to the level of risk exposure and the nature of the operation.”[1]

For a FRMS or FRMP to be successful, it must have a strong leader or senior manager who is accountable for day-to-day oversight, adaptation, and improvement of the program. There should be fatigue management policies developed collaboratively by employers, workers, and all stakeholders. Workers and administration should receive education and training in sleep health and self-recognition of fatigue.

Administration should adopt a process that promotes reporting fatigue without fear of penalty or reprisal. A process for investigation of events potentially related to fatigue is important for evaluation and improvement. It is optimal that individuals or groups outside the organization lead evaluation or audits of an agency’s FRMS or FRMP program. Both the organization’s leadership and workers (clinicians) must share responsibility for development, implementation, evaluation, and improvement of the FRMS or FRMP.[1]

Managing fatigue in the workplace – especially the EMS workplace – is a challenge. Our understanding of EMS work-related fatigue is limited.[2] We understand that EMS clinicians are vulnerable to fatigue, inadequate sleep, and poor recovery from shift work.[3]

Fatigue countermeasures

While the nature of EMS work is unique from many other occupations, fatigue can be mitigated with a number of evidence-based strategies. There is no “one-size fits all” approach to fatigue management and no single strategy will fully eliminate the threat of fatigue in the workplace.[4] Numerous individual-level, environmental factors, social factors, scheduling and work-related factors, as well as many other known or latent factors must be considered when developing an FRMS or FRMP.[4] What works for an air medical service in the northeastern U.S. may not work for a third-service, ground-based EMS system in the western or midwestern U.S.

1. Adequate sleep

Regardless of the components of an FRMS or FRMP adopted, the top strategy should be universal; adequate sleep. There is no substitute for adequate, good quality sleep. Insufficient sleep has been identified as a direct cause of vehicle crashes, errors that harm patients, worker injury and reduced productivity of the workforce.[5, 6] Adequate sleep is key to health and wellness. There is individual variability in how much sleep each worker may need, but at least seven hours per night should be encouraged.

Other person-level countermeasures supported by evidence include the following:

2. Naps and rest breaks

Taking naps or rest breaks during shift work. Numerous studies of shift workers support use of short-duration naps (e.g., 20-30 minutes) during scheduled shifts.[7-11] Actual sleep may not be needed, and the act of resting with one’s eyes closed in a quiet location can be beneficial.

Extended naps on duty may result in sleep inertia – that groggy feeling immediately after awakening.[12] Sleep inertia can last minutes or even hours after waking and impact cognition/performance.[12] Administrators and clinicians should discuss use of naps as part of an intra-shift countermeasure to fatigue.

3. Physical exercise

Alertness can be elevated with physical exercise such as stretching, walking, jogging in place, and other activities that increase the heart rate and body temperature.[13, 14] Clinicians should consider use of physical exercise when feeling sleepy on duty. Exercise can help thwart perceived feelings of sleepiness and help maintain alertness – to some degree.

Exercise is not a panacea for fatigue or sleepiness. Prior research shows that exercise may alleviate perceived sleepiness and improve wakefulness by increasing body temperature, yet cognitive performance may not return to levels associated with being well-rested.[15] In short, you may be more “awake” after a bout of exercise, but you may not perform at your best mentally or physically. Again, there is no substitute for adequate rest and sleep.

4. Caffeine consumption

There is considerable research linking improvements in alertness with consumption of caffeine.[16] Despite benefits, clinicians should exert caution and avoid over-consumption of caffeinated beverages – including energy drinks. Seizures and cardiac dysrhythmias have been linked to over-consumption of caffeinated energy drinks.[17, 18]

One approach to consider is to have a cup of coffee and immediately take a short nap (i.e., 20 minutes) – since caffeine takes about 30 minutes to kick in, and sleeping too long may lead to sleep inertia.[12] This two-pronged approach can work – especially for those working night shifts.[19] With anything, use caution, and don’t forget, your best strategy is to obtain adequate rest and sleep!

5. Mental exercise

Engaging in conversation (talking) with partners to stay awake and alert when feeling sleepy is a type of mental exercise. The simple act of talking with your partner while on duty can help support alertness.[20]

There is no question that individual EMS clinicians face numerous challenges managing their own sleep health. Employers also face challenges filling schedules and ensuring continuous availability of EMS care.

We offer these strategies for fatigue mitigation because the issues are complex, and as we have said before (and affirmed by others in different industries),[4] there is no single “one-size-fits-all” solution for fatigue risk management in the EMS setting. The mitigation of fatigue in the workplace must be a shared responsibility between the clinician and employer.[1] EMS must support a culture of safety where clinicians arrive to work well rested and employers support employees to report fatigue without hesitation.

About the Authors

Daniel Patterson, PhD, NRP, is a nationally registered paramedic, senior scientist and associate director of emergency clinician and patient safety research in the Department of Emergency Medicine at Carolinas HealthCare System Medical Center in Charlotte, N.C. His research focuses on fatigue, sleep, and other factors that affect the health, safety, and well-being of EMS clinicians and their patients.

Matthew Weaver, PhD, EMT-P, is a paramedic and an NIH T32 post-doctoral research fellow in the Division of Sleep Medicine at Harvard Medical School. His research focuses on the health and safety of the EMS workforce and the patients they treat.

Francis Guyette, MD, MS is an associate professor at the University of Pittsburgh, Department of Emergency Medicine and medical director of STAT MedEvac air-medical system. His research focuses on treatment of the acutely ill and injured in the prehospital setting and health and safety of EMS professionals.

References:

1. Lerman SE, Eskin E, Flower DJ, George EC, Gerson B, Hartenbaum N, Hursh SR, Moore-Ede M, ACOEM: Fatigue risk management in the workplace. J Occup Environ Med 2012, 54(2):231-258.

2. Patterson PD, Weaver MD, Hostler D, Guyette FX, Callaway CW, Yealy DM: The shift length, fatigue, and safety conundrum in EMS. Prehosp Emerg Care 2012, 16(4):572-576.

3. Patterson PD, Buysse DJ, Weaver MD, Callaway CW, Yealy DM: Recovery between work shifts among Emergency Medical Services clinicians. Prehosp Emerg Care 2015, 19(3):365-375.

4. Caldwell JA, Caldwell JL, Schmidt RM: Alertness management strategies for operational contexts. Sleep Med Rev 2008, 12(4):257-273.

5. Williamson A, Lombardi DA, Folkard S, Stutts J, Courtney TK, Connor JL: The link between fatigue and safety. Accid Anal Prev 2011, 43(2):498-515.

6. Lombardi DA, Folkard S, Willetts JL, Smith GS: Daily sleep, weekly working hours, and risk of work-related injury: US National Health Interview Survey (2004-2008). Chronobiol Int 2010, 27(5):1013-1030.

7. Bonnefond A, Muzet A, Winter-Dill AS, Bailloeuil C, Bitouze F, Bonneau A: Innovative working schedule: introducing one short nap during the night shift. Ergonomics 2001, 44(10):937-945.

8. Garbarino S, Mascialino B, Penco MA, Squarcia S, De Carli F, Nobili L, Beelke M, Cuomo G, Ferrillo F: Professional shift-work drivers who adopt prophylactic naps can reduce the risk of car accidents during night work. Sleep 2004, 27(7):1295-1302.

9. Petrie KJ, Powell D, Broadbent E: Fatigue self-management strategies and reported fatigue in international pilots. Ergonomics 2004, 47(5):461-468.

10. Sallinen M, Harma M, Akerstedt T, Rosa R, Lillqvist O: Promoting alertness with a short nap during a night shift. J Sleep Res 1998, 7(4):240-247.

11. Smith-Coggins R, Howard SK, Mac DT, Wang C, Kwan S, Rosekind MR, Sowb Y, Balise R, Levis J, Gaba DM: Improving alertness and performance in emergency department physicians and nurses: the use of planned naps. Ann Emerg Med 2006, 48(5):596-604.

12. Tassi P, Muzet A: Sleep inertia. Sleep Med Rev 2000, 4(4):341-353.

13. Harma MI, Llmarinen J, Knauth P, Rutenfranz J, Hanninen O: Physical training intervention in female shift workers: I. The effects of intervention on fitness, sleep, and psychomatic symptoms. Ergonomics 1988, 31(1):39-50.

14. Harma MI, Llmarinen J, Knauth P, Rutenfranz J, Hanninen O: Physical training intervention in female shift workers: II. The effects of intervention on the circadian rhythms of alertness, short-term memory, and body temperature. Ergonomics 1988, 31(1):51-63.

15. Matsumoto Y, Mishima K, Satoh K, Shimizu T, Hishikawa Y: Physical activity increases the dissociation between subjective sleepiness and objective performance levels during extended wakefulness in human. Neurosci Lett 2002, 326(2):133-136.

16. Ker K, Edwards PJ, Felix LM, Blackhall K, Roberts I: Caffeine for the prevention of injuries and errors in shift workers. Cochrane Database Syst Rev 2010, 12(5).

17. Trabulo D, Marques S, Pedroso E: Caffeinated energy drink intoxication. BMJ Case Rep 2011.

18. Seifert SM, Seifert SA, Schaechter JL, Bronstein AC, Benson BE, Hershorin ER, Arheart KL, Franco VI, Lipshultz SE: An analysis of energy-drink toxicity in the National Poison Data System. Clin Toxicol (Phila) 2013, 51(7):566-574.

19. Schweitzer PK, Randazzo AC, Stone K, Erman M, Walsh JK: Laboratory and field studies of naps and caffeine as practical countermeasures for sleep-wake problems associated with night work. Sleep 2006, 29(1):39-50.

20. Rosekind MR, Gander PH, Gregory KB, Smith RM, Miller DL, Oyung R, Webbon LL, Johnson JM: Managing fatigue in operational settings. 1: Physiological considerations and countermeasures. Behav Med 1996, 21(4):157-165.

6 cultural changes made by successful volunteer agencies

Volunteer EMT’s, who typically have primary careers outside the field, are usually dependent on their organization's part-time leadership to keep them up to date on the EMS profession. As a result, many volunteers may not be aware of the adaptations and improvements many EMS agencies are making.

The most successful volunteer organizations have made these cultural changes as part of their commitment to continuously raise the bar to maintain modern standards of care.

1. Every shift has a scheduled crew

The practice of scrambling ambulance crews is archaic, dangerous, and unprofessional. Having a dedicated crew ensures an immediate response and eliminates members "cherry picking" – only responding to the best calls.

If you do not currently have sufficient staff to do this, an effective recruitment and retention program is your first priority. If you have gaps in your coverage schedule, alert dispatch so that time is not wasted toning and re-toning for a crew that will never respond. Yes, you are admitting to a deficit by doing so, but you are doing the right thing for your patients.

2. Response is from the ambulance station

Responding from the station can be a huge cultural change for some agencies. Responding from home or work in a personal vehicle contributes to the risk factor for the crew, and often adds to response time.

Help your membership understand that there are many additional benefits to having an “in house” crew. The crew is mentally prepared, in uniform, and has the opportunity to conduct vehicle and equipment checks .By investing in a computer-based learning program, scheduled shifts can be used to refresh knowledge and complete training requirements.

Take the ambulance out into the community while on shift and interact with the public. Invite them into your ambulance, do vital sign wellness checks and talk to people about their medical issues. Interviewing and assessing people in a non-emergent environment is great practice which builds confidence in low-volume providers and develops a rapport with the community. Talk to people about the satisfaction volunteering brings you, ask for support and promote membership during these contacts.

3. Ambulance crews are uniformed and carry identification

Presenting a professional appearance as well as ensuring safety is the responsibility of the agency and needs to be part of the budget. Dress uniforms are a nice perk, but if there are budget limitations the working uniforms and safety gear need to be the priority, not parade uniforms.

4 Education and training are a priority

Access to required and elective continuing education is provided to members. Attendance at conferences and local CE opportunities is encouraged and funded by the agency. Outside educators can be brought in house to keep it convenient, and to keep content fresh and people interested and excited. All drivers are EVOC or CEVO certified.

Be careful about offering “Free EMT Classes” in an attempt to boost membership. "Free" creates a perception that the class has little value or importance. Instead, consider offering a scholarship to qualified applicants who are willing to make a contracted commitment to the agency for a predetermined length of time.

5. Volunteers need to be competent, not just nice

There is no denying that volunteers are altruistic providers, dedicated to serving the people of their community. But simply being “nice” is not enough. Knowledge and clinical skills matter too. The desire to cling to outdated ideas, practices and policies out of a misplaced sense of tradition or fear of change must be overcome. Define your operating policies based on a commitment to excellence in service, not by what is convenient for the membership.

6. The agency plays a significant role in the health of the community

To do their part in forwarding the progression of EMS, volunteers need to become an integral part of healthcare in the community. Volunteer EMS should be dedicated not only to emergency response, but also to providing support services. Prevention, education, patient advocacy, car seat safety, first aid classes, well-being checks on seniors, standby for local events - the possibilities are endless. For example, every town should be a Heart Safe Community. Provide frequent opportunities for 'Friends and Family’ CPR classes and make it happen in your community. Be ubiquitous.

According to the NAEMT 62 percent of EMS in the U.S. is provided by volunteers and hybrid volunteer/paid departments. The vast number of volunteers demands that they remain informed, engaged and involved in order to take their place at the table and have a voice in the EMS community.They have a responsibility to do their part to move what is still a young profession forward.

5 must-have ambulance features

EMS providers are frequently out of quarters posting and responding to calls for eight to 12 hours at a time. An ambulance, at an all-day assignment such as a sporting event, concert or festival, may use lots of small supplies like bandages or ice packs, or they might be busy maneuvering through traffic to transport patients.

On the road or at a post, the following are five features that will make long shifts in an ambulance a little bit easier on EMS providers:

1. Auxiliary heating and air conditioning

Air conditioning is as vital in Arizona in July as heating is in Illinois in January. Each state mandates the heating and cooling requirements of ground ambulances, so there are some variations in standards. In addition to the basics, auxiliary heating, ventilation and air conditioning (HVAC) units can save fuel, reduce emissions and maintain an ambient temperature in the ambulance cab and compartment. The type of chassis and compartment will determine the most appropriate system. It is also important to consider the regulatory environment, as some locations may not require all of the auxiliary features available.

2. Climate controlled storage

Studies have shown that storing medications outside recommended temperature ranges can impact their potency and stability.[1,2] Maintaining drugs in a stable environment can prolong their shelf life and effectiveness.

The Commission on Accreditation of Ambulance Services (CAAS) Standard 203.03.04 mandates that providers establish storage policies and procedures to protect medication from extreme temperature changes. The American Ambulance Association advocated this standard in a white paper in 2005.

Parking in climate-controlled locations, rotating stock, portable pharmaceutical cases, and coolers are options; however, electronic, climate-controlled storage maintains an appropriate, stable temperature with minimal user interface. In addition, some storage units are not only climate-controlled, but also have locked access, even individualized access, which increases the accountability for and security of controlled substances.

3. Internet connectivity

Establishing wireless communication at an all-day posting is the most efficient way to communicate with the department's intranet, dispatch information, and complete electronic patient care reports (PCRs). Deploying a unit to a location without a way to connect to the internet means more work at the end of a shift to submit PCRs and review emails sent during the day.

Take advantage of the increasing capabilities of devices to connect and synchronize through the internet. Bluetooth and internet connectivity, integrated into patient care equipment like cardiac monitors, can efficiently transfer information to other health care providers and synch to patient records.

4. Portable power

Radios, cell phones, tablets, cardiac monitors and more require batteries. You may be connected, but you are not very useful with low battery power. An option for the mobile devices is storing a portable AC power supply in each unit. Battery chargers are now available that allow a user to connect multiple devices from different manufacturers to one source.

Just like medication, electronics are susceptible to extreme temperatures. There may need to be some discussion on where to store chargers when ambulances are not in service.

5. Space where you want it most

EMTs and paramedics are clear in this final need; more room in the cab, please. They want more legroom and a place to store a cooler with water and snacks and a bag with extra hand warmers, gloves, and other cold weather gear. Remember your crews might spend the equivalent of a transcontinental flight in the ambulance every day. Give them more space than they get in a coach airplane seat.

There are other challenging factors to evaluate in ambulance design. Certain specifications increase cost. Incorporating additional equipment affects gross vehicle weight, which affects fuel consumption. And all the safety standards must be met or exceeded.

Add your must-have ambulance features in the comments.

References

1. De Winter S, Vanbrabant P, Gillet J, et al. Emergency medical services/original research: Impact of temperature exposure on stability of drugs in a real-world out-of-hospital setting. Ann Emerg Med. 2013; 62:380-387.

2. McMullan J, Jones E, Silbergleit R, et al. Degradation of benzodiazepines after 120 days of EMS deployment. Prehosp Emerg Care. 2014; 18(3):368.

After 30 years in EMS, Harry Murphy is still a student

In July of 1985, Harry Murphy was hanging out in Virginia Beach when a friend urged him to check out the EMS squad.

“Dave and I were truck drivers,” says Murphy, now 51. “Dave was also a member of the Ocean Park Volunteer Rescue Squad. He suggested I do a ride-along with them just to get an idea of what was involved. I told him, nah, it’s not something I’d ever want to do. So Dave said to just come down to headquarters for some barbecue or something.”

“Something” turned out to be a head-on collision on the Chesapeake Bay Bridge-Tunnel, an 18-mile crossing between Virginia Beach and the state’s eastern shore. Murphy hopped on a rig.

“We got to the scene – there was a fatality and several other patients,” Murphy says. “I had no training. I started working with the guys out there because they needed all hands. I was basically a gofer.

“The dead body didn’t bother me. After the call was over I realized, hey, I can do this.”

Driving a different kind of truck

Murphy took a first-aid class and joined Ocean Park Rescue. By the end of 1986 he was an EMT.

“That meant I could drive the ambulance and be what Ocean Park called an ‘attendant in charge.’”

EMT certification also meant Murphy could work in the field. He got his first EMS job in 1987 with “a little mom-and-pop ambulance service” in Tidewater.

In 1992, one year before Med-Trans acquired his agency, Murphy became a paramedic.

“The company offered me a transfer to Evansville, Indiana as a field supervisor in 1996,” he says. “I ran the night shift there for three years, but my wife and I didn’t fit in real well in Evansville. It had nothing to do with work. We went back to Virginia Beach in ’99, and I got a job as a medic right across the border in Currituck County, North Carolina.”

Although Harry’s career was moving forward, his marriage was not.

Murphy's 1986 ride.

New home, new life

The Murphys divorced in 2004. Harry says EMS wasn’t to blame.

“My wife had been in EMS, too,” he says. “She volunteered on and off at Virginia Beach, then became an LPN. We just grew apart.

“That was a time in my life when my job was defining me. I was wrapped up in trying to make a career for myself and trying to control all the things around me.

“I had some growing up to do.”

After his divorce, Murphy began dating an EMT from Virginia. Soon they were a couple.

“We decided to move back to her hometown of Slidell, Louisiana,” Murphy says. ”We got married as soon as we settled in there.

“We were both hired by Acadian Ambulance in the Covington area, right across from New Orleans. I also started volunteering again at one of the local fire departments.

“Then we ran into a little bad weather.”

A career-defining event

Hurricane Katrina made landfall over southeastern Louisiana on the morning of August 29, 2005. The western eye wall passed right over Pearl River, where Murphy was stationed.

“We were at a fire department about 10 miles inland on Lake Pontchartrain’s northeast shore,” Murphy says. “It was me, my wife and another crew, with two ambulances.

“Our trailer wasn’t damaged – we had some elevation – but the Slidell station just a few miles south of us was flooded. The telephone lines were down and there was no cell service. We couldn’t talk to headquarters for two-and-a-half days.”

The communications outage was an even bigger problem for the population.

“The way the public would reach us is that they’d send someone to the fire station. Then we’d follow a fire truck to wherever the patient was, cutting our way through fallen trees, and see what we could do to help.

“There’d be people getting dehydrated trying to clear their property. We’d rehydrate them with IV fluid, tell them not to do that anymore, then leave them. The hospitals were crippled; we didn’t want to transport too many patients.

“Sometimes I feel my entire career was about preparing for that storm and its aftermath.”

Medic, heal thyself

After Katrina, Murphy and his second wife continued to ride as partners until she became a medic in 2008.

“We were forced onto different shifts,” Harry says. “I was doing nights while she was doing days and vice versa. I definitely noticed a strain between us. It required a lot more active work on both our parts to plan time together.”

That effort fell short. By 2010 the marriage was over. Once again, Murphy tried putting distance between himself and his problematic personal life. He joined the National EMS Academy, Acadian’s training division, 150 miles away in Lafayette. It was there that he met Kara, a paramedic who had worked at Acadian’s dispatch center for eight years, and had coincidentally handled many of Murphy’s calls while he was still in Covington.

“She joked that I’d known her as a disembodied voice on the radio for two or three years,” Murphy says. “We just kind of struck up a relationship.”

Their relationship became much more; in 2012 they were married. Murphy says he still tries extra hard not to make the same mistakes he did in his earlier marriages.

“It’s difficult to balance home life and the demands some EMS agencies put on you. I used to work 48 hours a week full time, 24 hours part time, then volunteer on top of that.

“I don’t let my work define me anymore. I try to bring my principles and my ethics to work and shape the job around that, rather than have the job shape me and my lifestyle.

“I don’t imagine there are too many people who lie on their deathbed and wish they’d spent more time working.”

Student-teacher

These days you’ll find Murphy more often in a classroom than on the streets. He’s on the faculty of South Louisiana Community College’s paramedic program while completing the final year of his Bachelor’s degree in Public Safety Administration. And he’s still happily married to Kara.

“Now that my personal life is finally working out, I’ve become a big advocate of education,” says Murphy. “That’s the route to professionalism. To become educated and share that knowledge with others is the highest calling.”

Sounds like Harry has learned a lot.

Is an ambulance the right vehicle for psych patient transfers?

Why do we use ambulances to transport medically-stable psychiatric patients from a community hospital to an in-patient psychiatric care or mental health facility"

This questionable practice has troubled me for many years and is again at the front of my mind after an incident where an ambulance in Utah is reported to have rolled after a “psych patient” grabbed the wheel as the vehicle was moving down the highway.

In some states the transfer of psychiatric patients by ambulance is common and it presents real issues for field personnel and EMS managers. About 10 years ago I was the executive director for a hospital-operated ambulance service in a small upper-Midwest city. Our peak ambulance staffing was five units and the state mental health facility (MHF) was three hours away. When either of the local hospitals wanted a psychiatric patient moved to the MHF and the local interfacility service declined to provide care we were called. To complete the transfer our unit was out of service for at least six hours.

Does a psych patient need an ambulance"

The time out of service was not the concern. Instead, my greatest concerns were the safety of the crew and the appropriateness of using an ambulance.

The patient needed a ride. They did not require oxygen, resuscitation, medications that paramedics carry, bandaging, splinting, or any type of prehospital care. They needed a ride.

Moreover, EMS had no legal authority from the state to detain anyone against their will. (Yes, in a few states EMS has that authority, such as under Florida’s Baker Act.) If the patient changed their mind about going to the MHF and wanted to exit the vehicle on the side of the interstate the right of EMS to do anything except let them out was legally unclear. Patients were not restrained (nor was it appropriate to do so), they were not sedated, and if they were medicated it was with oral medications that they had taken for a long period of time. Again, these were medically-stable patients who needed a ride.

Several times there were difficulties on these transports. As you know the back of an ambulance is a dangerous place, filled with sharp corners, cabinets, objects that can be used as weapons, and minimal opportunity for escape. Medics who attempted to restrain patients who decided to leave the ambulance would get into combat, for which they were not trained. The crew size was insufficient to restrain the patient. Most hospital guidelines call for a minimum of five caregivers to restrain a violent patient. Even a radio call for help might not see five or more responders arrive for 30-60 minutes, if ever.

What are alternatives to ambulance transport"

From the outside, it appeared clear that the local 911 service was the only entity that the hospitals could “bully” into performing unnecessary and probably uncompensated service. I wondered, how did these transfers meet “medical necessity” for payment by Medicare, Medicaid, or other payors"

Retrospective review of the transfers to the MHF showed that some were paid for, most were not. We had some discussions about the hospital assuming responsibility for payment for these transfers.

This led to a series of discussions about the appropriateness of this practice and it was ultimately agreed by the involved hospitals that this was not the best way to handle “psych transfers.” The practice used in other states - transport by law enforcement - was adapted for the hospitals. A sedan with a security barrier to protect the driver, as well as secure seat belts, was procured, and hospital personnel handled the transfers.

A good bit of money was saved. Ambulances remained in service in the community that needed them. Ambulances were used only for psych patients that had medical needs that could be cared for in an ambulance and two or three extra attendants were provided.

Is the scene safe during transport"

Remember that “scene safety” includes the interior of the ambulance as it moves down the road. It is time for the practice of transporting an unrestrained psychiatric patient in standard ambulances with a crew of two to come to an end. The patient should NEVER be allowed to ride in the cab of the ambulance. Another shortcut practice, allowing a psych patient to sit on the bench seat, is dangerous for the patient and the provider and illustrates that there is no medical necessity for the ambulance.

It is time for EMS chiefs and executives to look closely at the clinical, safety, and economic rationale for unnecessary psych patient transports by ambulance and work to devise a better way.

Active shooter: Rescue task force medics get to victims faster

There have been two major shifts in doctrine related to law enforcement operations in the last 10 years. The first shift is the aggressive pursuit of an active shooter with whatever assets happen to be on hand instead of waiting for a SWAT team.

The second major change is recognizing the need for emergency medical contingency planning. This includes training all tactical personnel and line officers in the basics of self-care and buddy care with the focus on bleeding control and the addition of a dedicated tactical medic.

An aspect of this doctrine shift is SWAT teams are increasingly including a dedicated tactical medical component and medical threat assessment as part of their organizational structure. The result is a tactical medic being assigned to the law enforcement team using one of several models.

In addition, law enforcement is at minimum notifying — or ideally involving — local EMS and hospitals about planned or developing law enforcement operations that have a high risk for injuries, like an active shooter incident. This change has given rise to the rescue task force.

Tactical medic vs. rescue task force

Tactical medics are attached to and considered part of a tactical law enforcement team. Whereas a rescue task force is a trained, but hastily formed group of EMS medical providers (private and/or fire based) that partner with law enforcement on scene. They will enter a newly secured area, such as an active shooter incident, to provide triage, emergent care and casualty extrication.

Both tactical medics and rescue task force (RTF) personnel provide emergent care in less than ideal situations, often under significant stress and in chaotic, sometimes hostile environments. Both work very closely with law enforcement during planning, training and actual events.

Most RTF members are outfitted with ballistic vests and helmets, and likewise, almost without exception, tactical medics are protected with body armor and helmets. Both are specifically trained and equipped to deal with ballistic, blast and other violence-induced trauma.

RTF members wear their usual daily uniform (Fire/ EMS/ law enforcement) and are typically dispatched during their normal shift. Tactical medics wear the uniform of the tactical team they are attached to and are physically located with the team, or just outside of the hot zone.

Rescue task force medics

Historically, EMS providers staged a safe distance away until police methodically secured the scene before permitting EMS to access victims. This practice is being phased out and replaced by the rescue task force, a more patient-centric and life-saving approach.

A rescue task force - compromised of cops and medics - assesses and treats patients during an Urban Shield simulation. (Image courtesy Josh Kennedy)

The RTF should have access to the wounded casualties when the threat has been eliminated, when the shooter is confined to another area, or when the scene has been deemed relatively secure. In the RTF model, providing life-saving interventions is done as soon as possible and is everyone's responsibility. There are four ways to render medical aid in these types of situations.

  1. Bystanders and victims provide care to one another prior to any responder arrival.
  2. Police rapidly extricate and escort victims to a safe area where awaiting EMS provides medical aid.
  3. Police secure the area and provide life-saving interventions at the point of wounding.
  4. Police secure or clear the area and bring in RTF medics under a force protection model.

The RTF focus should be on quick initial medical assessments and to provide life-saving interventions on scene, at the point of wounding or injury. Finding and treating patients should

be done in concert with efforts to extricate victims to a casualty collection point where a secondary triage, treatment and transport can be provided.

The RTF should use a pre-entry checklist to ensure important issues are addressed. The law enforcement job with the RTF is focused on escorting and protecting the medical members.

The RTF concept is becoming more widespread and adopted nationwide. However, fire departments, local EMS providers and law enforcement need to collaboratively train, drill and develop procedures and protocols for this concept to be effective.

Tactical medics

A tactical medic is somewhat analogous to a professional sports team trainer who travels with the team and is there primarily to provide medical aid to the team, whether the injury or ailment is serious or not.

On a typical planned SWAT operation there are several phases and steps that take place well before the hit. Most often, the mission is a planned high-risk search or arrest warrant. After getting a warning order, the SWAT team operators and all of the support elements (medical, communications, negotiators, etc.) typically convene at a forward staging area.

A briefing will occur, where mission goals, subjects and target location layouts are reviewed. Depending on the nature of the mission and operations security issues, the tactical medic may coordinate with the local EMS transport provider to have an ALS ambulance stage close to the location.

The tactical medic is the logical liaison to the on-scene EMS assets that support law enforcement operations. Typically, the tactical medic will have a face-to-face meeting with EMS units.

The most common items dispensed by a tactical medic is bandages and over-the-counter pain relievers. However, the tactical medic must also be prepared to provide life-saving interventions to team members and other on-scene law enforcement officers.

The tactical medic will also provide initial medical care as needed to victims, bystanders, and perpetrators once the scene is secured. They will transfer patient care to a standard EMS unit if further care and transportation to the hospital is needed.

Tactical EMS models

Some law enforcement agencies send personnel to EMT school or other comprehensive tactical medical classes. Those officers may become the default tactical medic for the team. That may be a workable solution; however, it is unlikely those individuals have the medical experience and patient-assessment skills needed to be the best medical practitioner in high-risk, high-stress situations.

There are countless workable models for the incorporation of a medical contingency plan for law enforcement operations. These are some of the more common models.

Officer, agent or trooper medic

A sworn law enforcement officer has dual roles as an operator and medic; they have law enforcement powers and can certainly protect themselves from potential threats.

Agency contract

The law enforcement agency has a contract or memorandum of understanding with a local EMS agency to provide up-close medical care. Some agencies put these contracted medics through a reserve officer school so that they can be armed as police.

Individual contract

An individual or a team are under contract or memorandum of understanding with the law enforcement agency for providing medical coverage for SWAT missions and training.

ALS stand by

In this outdated model, there are no tactical medics attached to the law enforcement team, but police will stage a standard ambulance some distance away to respond to the scene after the scene is secured by law enforcement.

Learning about tactical EMS
Many in the EMS field have demonstrated an interest in getting into the field of tactical medicine. In addition to the pre-existing medical training, it is highly recommended to procure specific tactical medical education.

Programs such as NAEMT Tactical Combat Casualty Care (TCCC), Tactical Life Saver and others like have been well received by the EMS and LE community. The International School of Tactical Medicine offers a two-week intensive program aimed at medical practitioners who need basic training on law enforcement operations and how to work within a law enforcement team as the medic.

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