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

Huffington Post CHICAGO — A smooth, quick ambulance transport can be the difference between life and death for patients. Now, troubling questions are being raised about whether a Chicago Fire Department ambulance actually contributed to a man’s demise after it broke down on a city street while transporting a South Side gunshot victim to the hospital. The April 4 incident was the latest in ...

Daily Mail ORLANDO, Fla. — A little girl's trip to Disney World didn't turned out as magical as she expected when she was sent crashing to the ground after being hit by a dancer. Melissa Browning said her four-year-old daughter was dancing alongside Disney characters in a costumed parade at the Magical Kingdom theme park in Orlando, Florida, during a family trip. As her parents filmed ...

By Ray Henry The Associated Press COLLEGE PARK, Ga. — Eighteen people were taken to the hospital Friday, at least two in serious condition, after they were hurt in a crash between a hotel shuttle bus and a tractor-trailer near Atlanta's airport, officials said. At about 10 a.m. College Park police received calls about the crash on the road that loops around the world's busiest airport ...

Angel Flight is a nonprofit group that arranges free air transportation for sick patients from volunteer pilots

The Associated Press LONDON — British police say a zookeeper who was injured in a tiger attack at an animal park has died. Police say the woman, 24-year-old Sarah McClay, was in the big cats' enclosure at South Lakes Wild Animal Park in Cumbria when she was mauled by the Sumatran tiger on Friday. The park's owner, David Gill, told the BBC that he did not know why McClay entered the tiger ...

The Huffington Post BUSAN, South Korea — A 5-year-old girl was reportedly killed by a falling suicide jumper in a South Korean port city. The girl was crushed by the body of a 38-year-old man who leapt from the 11th story of his apartment building in the southeastern city of Busan on Wednesday night, CNN reports. The man died immediately, and the girl was pronounced dead from a skull fracture ...

News and Star CUMBRIA, UK — A motorcyclist who suffered severe brain injuries when he hit an ambulance parked too close to a race track near Whitehaven has been awarded a six-figure sum. Former mechanic Peter Corbett was unconscious for three months following the crash at Rowrah and needs daily help for life. He and his wife Anita, who gave up work to care for him, have now won a six-figure sum ...

DailyMail LOS ANGELES — A hospital in Los Angeles has become the first in the world to live-tweet a brain surgery using Vine, Twitter's new way to share videos online. Incredibly the footage shows the patient happily strumming away on his guitar while doctors operate. Patient Brad Carter, 39, was filmed while surgeons placed a pacemaker implant in his brain yesterday to counteract the effects ...

By Lee Filas Daily Hearld ANTIOCH, Ill. — A former Antioch-area volunteer firefighter and emergency medical technician already facing charges of having sex with an underage girl pleaded not guilty Thursday to charges involving a second victim. Matthew Bielecki, 40, of the 43000 block of Mary Avenue in Antioch, shook his head in shock as each of the new 29 counts of sex-related crimes — including ...

By Tiffany Rider Long Beach Business Journal LONG BEACH, Calif. — The Long Beach Fire Department can expect to begin receiving training on a new paramedic model known as rapid medic deployment (RMD) soon, according to Fire Chief Michael DuRee. Based on an 8-5 vote on May 15 by the Los Angeles County Emergency Medical Services (EMS) Commission, the proposed policy #407 that outlines requirements ...

Huffington Post CHICAGO — A smooth, quick ambulance transport can be the difference between life and death for patients. Now, troubling questions are being raised about whether a Chicago Fire Department ambulance actually contributed to a man’s demise after it broke down on a city street while transporting a South Side gunshot victim to the hospital. The April 4 incident was the latest in ...

Daily Mail ORLANDO, Fla. — A little girl's trip to Disney World didn't turned out as magical as she expected when she was sent crashing to the ground after being hit by a dancer. Melissa Browning said her four-year-old daughter was dancing alongside Disney characters in a costumed parade at the Magical Kingdom theme park in Orlando, Florida, during a family trip. As her parents filmed ...

By Ray Henry The Associated Press COLLEGE PARK, Ga. — Eighteen people were taken to the hospital Friday, at least two in serious condition, after they were hurt in a crash between a hotel shuttle bus and a tractor-trailer near Atlanta's airport, officials said. At about 10 a.m. College Park police received calls about the crash on the road that loops around the world's busiest airport ...

Angel Flight is a nonprofit group that arranges free air transportation for sick patients from volunteer pilots

The Associated Press LONDON — British police say a zookeeper who was injured in a tiger attack at an animal park has died. Police say the woman, 24-year-old Sarah McClay, was in the big cats' enclosure at South Lakes Wild Animal Park in Cumbria when she was mauled by the Sumatran tiger on Friday. The park's owner, David Gill, told the BBC that he did not know why McClay entered the tiger ...

The Huffington Post BUSAN, South Korea — A 5-year-old girl was reportedly killed by a falling suicide jumper in a South Korean port city. The girl was crushed by the body of a 38-year-old man who leapt from the 11th story of his apartment building in the southeastern city of Busan on Wednesday night, CNN reports. The man died immediately, and the girl was pronounced dead from a skull fracture ...

News and Star CUMBRIA, UK — A motorcyclist who suffered severe brain injuries when he hit an ambulance parked too close to a race track near Whitehaven has been awarded a six-figure sum. Former mechanic Peter Corbett was unconscious for three months following the crash at Rowrah and needs daily help for life. He and his wife Anita, who gave up work to care for him, have now won a six-figure sum ...

DailyMail LOS ANGELES — A hospital in Los Angeles has become the first in the world to live-tweet a brain surgery using Vine, Twitter's new way to share videos online. Incredibly the footage shows the patient happily strumming away on his guitar while doctors operate. Patient Brad Carter, 39, was filmed while surgeons placed a pacemaker implant in his brain yesterday to counteract the effects ...

By Lee Filas Daily Hearld ANTIOCH, Ill. — A former Antioch-area volunteer firefighter and emergency medical technician already facing charges of having sex with an underage girl pleaded not guilty Thursday to charges involving a second victim. Matthew Bielecki, 40, of the 43000 block of Mary Avenue in Antioch, shook his head in shock as each of the new 29 counts of sex-related crimes — including ...

By Tiffany Rider Long Beach Business Journal LONG BEACH, Calif. — The Long Beach Fire Department can expect to begin receiving training on a new paramedic model known as rapid medic deployment (RMD) soon, according to Fire Chief Michael DuRee. Based on an 8-5 vote on May 15 by the Los Angeles County Emergency Medical Services (EMS) Commission, the proposed policy #407 that outlines requirements ...

All right readers, time to chime in: What was your most ridiculous 911 call"

I'm sure that each one of us can recall an incident that left us shaking our heads in amazement, so utterly silly that it defies all common sense.

We are victims of our own success, sadly. Since the advent of a national emergency call number went into effect over 45 years ago, we have encouraged the public for its use. Except for sporadic efforts, we have done very little to curb its misuse.

The fact people are not stupid, combined with the fact that we are required to respond to emergency calls, simply sets the system up for misuse. Sealing the deal is the limitation of not being able to read caller's minds or visualize the scene.

Ultimately the issue goes much deeper for EMS response. We are not equipped or trained to truly manage many of the medical calls we are sent to; it's frustrating to know that the transport we provide is unnecessary in most of these situations, along with the wasted healthcare dollars being spent.

Encouraging signs that the healthcare system is beginning to change in response to issues like this makes me hopeful that the misuse rate will fall over time.

I can only hope that the EMS profession will adapt as well. Until then, system misuse will continue.

Successful EMS grant applications may occur more frequently if your EMS agency uses a stakeholder review process that engages community VIPs and other stakeholders (even end-users of your lifesaving services) to read and comment on your grant application before submission.

In some cases, these stakeholders might create a local solution for you because of their influence and access to local funds. Or, after reviewing your grant request, these stakeholders may give your agency a reality check for what they think will succeed or what seems too self-serving and unnecessary.

In any case, key communicators in your community will be able to advocate for you and/or dispel any myths about your agency and its needs.

Who is an EMS stakeholder"
In a broad sense, stakeholders can be defined as individuals with or without formal EMS training who have a strong personal interest in advancing the effort to improve access to high quality EMS personnel and equipment. They strive to offer better EMS clinical services in the field and to keep the costs to what many perceive to be peace of mind healthcare affordable.

This interest could stem from the stakeholder feeling a personal responsibility to ensure good EMS care for his/her friends and neighbors. The stakeholder may have had an intimate experience with EMS, such as a personal or family experience, or by being a caregiver at some level in healthcare.

As a result of participating in the review of an agency’s application, stakeholders may and will most likely become knowledgeable advocates for EMS’ role in their communities’ efforts to save lives.

Create an "elite" appointment for these stakeholders
The stakeholder review process should also carry some prestige in the community, be publicized and celebrated. To that end, a municipal government body (i.e. city council or county commission) might assist you in appointing influential stakeholders to review your agency’s grant application(s).

A stakeholder’s invitation might indicate that the invitee has been chosen because of his/her past willingness to embrace the need for grants to achieve optimum patient care services. These individuals might also be appointed based on their previous experience with peer review processes.

They may have demonstrated the ability to interact effectively within groups (i.e. a leadership or participatory experience in a managerial, professional, or educational capacity). And, in exchange for the prestige your agency will assign to the grant review process, your grant review stakeholders should be able to commit to a minimum period of two years of participation at the time of selection. They will also attend at least one grant review session per year with a willingness to review a list of equipment, personnel, research and training grant opportunities prior to reviewing your department’s applications.

Clinton, Miss. — In unanimous decisions, the Boards of the National Association of Emergency Medical Technicians (NAEMT) and the National Emergency Medical Services Management Association (NEMSMA) voted to establish a strategic relationship betweentheir two organizations to mutually support their respective missions and work collaboratively to advance the EMS
profession. Both organizations strongly believe that collaboration within the EMS profession is essential to addressing the key challenges facing EMS today and in the future.

The agreement calls for collaboration on a wide range of policy and programmatic activities in areas such as advocacy, public awareness, education, and clinical standards. "We are excited about the opportunities this new partnership will present. We know we can accomplish more for the EMS profession working collaboratively. Bringing together the providers and the administrators will improve communications for all and advance our common interests," says Troy Hagen, NEMSMA President.

“NAEMT and NEMSMA share core values and represent EMS professionals working in all types of delivery models,” stated Don Lundy, NAEMT President. “There is tremendous synergy between our two organizations, and this agreement capitalizes on this synergy and our strengths to better support all of our members, and the industry at large. We are very excited about the
opportunities that this new relationship offers.”

About NAEMT
Formed in 1975 and today nearly 32,000 members strong, the National Association of Emergency Medical Technicians (NAEMT) is the only national association dedicated to representing the professional interests of all emergency medical services (EMS) practitioners, including paramedics, advanced emergency medical technicians, emergency medical
technicians, emergency medical responders and other professionals working in prehospital emergency medicine. NAEMT members work in all sectors of EMS, including government service agencies, fire departments, hospital-based ambulance services, private companies, industrial and special operations settings, and in the military.

About NEMSMA
With 1,500 members, NEMSMAis a professional association of EMS leaders dedicated to the discovery, development, and promotion of excellence in leadership and management in EMS systems, regardless of EMS system model, organizational structure or agency affiliation. For more information about NEMSMA initiatives, position papers and educational courses, go to nemsma.org

Sometimes the best part of an emergency response is the commentary en route or the critique when all is done. There is something special about the cab of an ambulance — it's our own little world where we can vent, be honest or simply crack each other up.

Usually, what is said in the ambulance stays in the ambulance, but every now and then some things just need to be shared.

1. Overheard in the back of Rescue 1, during a clean-up.

"Pi#$ isn't too bad."

"Puke is the worst."

"Nah, s@#!'s worse than puke, any day."

"Blood is easy, it doesn't stink."

"That's why pi#$ isn't bad, easy clean-up."

"Old piss is pretty bad."

"New s@#! is worse than old s@#!."

"It's still runny."

"Speaking of runny, snot's pretty bad."

"Yeah but you hardly ever wear it. "

"Yeah, puke wins that one."

"But s@#!'s still the worst."

"Yup. pi#$ is my favorite. Definitely."

"I guess."

2. Overheard in the front of Rescue 1. Very late at night.

"I wonder why we never get sick."

"Because we already are sick. There's only so much sickness to go around."

"Yeah, but we're surrounded with sick people all the time. We touch them, breathe their air and all that, you would think we would get sick more often."

"You think too much."

"And why do we carry people with back pain down three flights of stairs when our backs are worse that theirs""

"Because we can."

"So can they."

"The difference is, they know WE can."

"But we know THEY can."

"You think too much."

"I guess."

3. Overheard in the cab of Rescue 1 enroute to "man down."

"We're Cavemen, you know."

(From officer's seat, fiddling with the radio) "How so""

"The station is like our cave. It's dark, dreary and ugly."

"A man-cave."

"Right. Instead of wall paintings we have a big screen TV. Every now and then an emergency happens, we pile on our skins and forage into the wilderness to protect the women."

"Some of us are women."

"Right, there have always been strong women."

"Right. Remember Raquel Welch from 1,000,000 years BC""

"Who""

(Looks incredulously over at his man-boy driver) "Never mind."

"Anyway, when we get hungry we leave the cave to hunt for meat."

"The supermarket isn't exactly hunting."

"It is when you're looking for a deal."

"I guess."

"Then, we gather around the fire and eat."

"You do look like a bunch of Neanderthals at the table."

"Exactly. Cavemen."

"Right. (Keys the mike as driver stops the rescue in front of the "emergency.") "Rescue 1 on scene."

The cavemen load up their weapons and forage into the wilderness, looking for their victim.

4. Overheard on the Street:

Police officer: "Hey, were you guys there that day when that girl flashed us""

Firefighter 1: "Which girl""

Firefighter2: "What day""

Firefighter 3: "There have been so many, we forget."

The police officer walks back to his cruiser, shaking his head.

Police Officer: "I think I took the wrong test."

5. Overheard in the Cab of Rescue 1 after clearing Hasbro Children's Hospital:

"She was hot."

"She's fifteen, you pervert."

"Not her you idiot, her mother."

"Her mother is old enough to be your daughter."

"That means I'm old enough to be her mothers father."

"Right."

"She's still hot."

"And you're still old."

"Right."

"Rescue 1 in service."

6. Overheard in Rescue 1 after a visit to the Coffee Exchange where the crew was completely ignored by the college girls behind the counter.

Lt: "I don't get it. They don't give us the time of day. It wouldn't kill them to be nice to us. Jeez, girls aren't like they used to be. Why can't they even crack a smile""

Ryan: "Because I'm fat and you're 50."

Lt: "Oh, that. Carry on then."

7. Overheard at the ER

The ER was a madhouse, drunken street people, drunken college kids, drunken housewives, and drunken fools. Minor injuries, a few legitimate traumas, some sick old folks and a bunch of people vomiting. The wait was hours. In the middle of it all was a twenty something year old inmate from the ACI and two correctional officers.

The prisoner had a minor injury to his throat from an altercation and had been waiting for a long time. As I walked past them I overheard the inmate ask his guards, "Can I go back to my cell" Anywhere is better than here."

The International Association of Emergency Medical Services Chiefs (IAEMSC) today announced the selection of North Washington Fire Protection District (CO) EMS Chief Dave Baldwin and Oakland Fire Department (CA) EMS Coordinator Daniel Gerard as the 2013 INTERMEDIX / IAEMSC Harvard Fellow recipients.

Baldwin and Gerard were selected from a highly competitive pool of immensely qualified EMS chief officers. Being designated for this fellowship is one of the highest honors for leaders in the field of Emergency Medical Services. Both recipients have longstanding contributions to the discipline of EMS and unparalleled commitments to the advancement of the EMS profession.

William Sugiyama, IAEMSC President, said “Chief Baldwin and EMS Coordinator Gerard represent some of the best of EMS leadership in the United States today. Over the course of their distinguished careers, they have helped to advance the discipline here and abroad. Their active involvement in EMS organizations locally, regionally, nationally, and internationally has resulted in contributions that further refine and advanced the discipline. We are proud to recognize Dave and Daniel for their commitment and accomplishments.” James L. Robinson, IAEMSC President-Elect, noted: “We are truly gratified by the generous support of Intermedix that enables IAEMSC to provide this opportunity for its membership. Intermedix has graciously supported this professional development initiative on an annual basis since 2006.”

Intermedix CEO Doug Shamon added, “We sponsor this scholarship with the recognition that promoting the advancement of EMS management as a profession is a highly worthy endeavor. We extend our congratulations to Chief Baldwin and EMS Coordinator Gerard and expect they will find this program to be an exceptional opportunity.”

Baldwin and Gerard will participate in the Harvard University John F. Kennedy School of Government Senior Executives in State and Local Government program in Cambridge, Massachusetts. The program provides experiences for participants both inside and outside the classroom to ensure that public officials are equipped on a daily basis to manage and lead results-driven government agencies and non-profit organizations. In particular, this program provides an opportunity to:

• Develop new conceptual frameworks for addressing program and policy issues;
• Explore the relationship between citizens and their government; and
• Examine the ethical and professional responsibilities of leadership

This three-week program is designed specifically to challenge assumptions about how to exercise leadership in the public sector. During the course of this program, participants learn strategies for establishing meaningful, attainable organizational objectives. Program participants also investigate the process of developing and evaluating policy alternatives and consider options for organizing and deploying resources to achieve these objectives.

For additional information about the International Association of Emergency Medical Services Chiefs, see www.IAEMSC.org - 1-877-442-3672.

About Intermedix Corporation

Intermedix focuses on the highly fragmented US healthcare and emergency response industries by delivering information technology and business services to manage the revenue cycle, promote preparedness and interoperability, and support incident response management, documentation, and reporting. Intermedix provides practice management and revenue cycle management services for emergency physicians and hospital emergency departments, emergency medical services (ambulance) agencies, anesthesiologists, primary care physicians, urgent care centers, and fire departments throughout the US. The company also provides technology solutions for federal, state and local government agencies, emergency management professionals, healthcare providers, and corporations using the brand names WebEOC®, EMResource™, EMTrack™, CORES, TripTix®, and Fleeteyes™.

Haven't read the initial case presentation" Read: ECG Challenge: get to the point!

This is the solution to the ECG Challenge – The turning of the point!

Let's take another look at the 12-lead ECG.

This ECG shows sinus tachycardia with a prolonged QT-interval.

Some of you identified a tiny bit of ST-elevation in leads I and aVL. Good catch! This 12-lead ECG was captured with arm lead reversal. In other words, lead aVR is in the position of lead aVL. In this case it does not represent ACS.

The QT interval is measured from the beginning of the QRS complex to the end of the T-wave.

It is normalized for heart rate because the QT interval should become longer as the heart rate slows down and shorter as the heart rate speeds up.

That's why the QTc has a little "c" at the end. That stands for "corrected" with Bazett's formula (or another similar formula).

Tip: The QT interval should be less than ½ the R-R interval. In this example (A) shows a normal QT interval and (B) shows a prolonged QT-interval. You will note that in (B) the T-wave ends after the half way point of the R-R interval.

A QTc above 460 ms is considered prolonged in females. A QTc above 500 ms is considered to be clinically significant by most authors. In this case the QTc is 566 ms.

Now let's look at the rhythm strip recorded in back of the ambulance.

I often hear heart rhythms referred to as "Torsades de Pointes" when in reality it is just polymorphic VT. Although we do see "turning of the points" here, it's not a textbook perfect "streamer" effect, but that doesn't matter.

All that matters is the QTc of the underlying rhythm!

We call polymorphic VT in the presence of a prolonged QTc "Torsades de Pointes". It's that simple! So this is a true case of Torsades.

Incidentally, this is one of the reasons I'm always encouraging paramedics to perform a 12-lead ECG on syncope patients. A prolonged QT interval is cause for concern and may indicate that the patient has suffered a run of Torsades and may be at risk for VF.

Sometimes a prolonged QT interval is secondary to a reversible cause like hypokalemia (which was true in this case), hypomagnesemia or certain prescription medications. In fact, the number one reason for a "black box" warning from the FDA is QT prolongation. Other times it's a congenital condition called Long QT Syndrome (LQTS) in which case patients may be eligible for an implantable cardiverter-defibrillator (ICD).

This run of Torsades was self-limiting and required no medication. However, the treating paramedics might have considered 2 grams of magnesium sulfate slow IV push. Some drugs (like amiodarone) prolong the QT interval and others (like lidocaine) shorten the QT interval, so keep than in mind when selecting an antiarrhythmic for polymorphic VT!

The diagnosis for this case was, of course, sepsis.

Manual or mechanical" Either way, if you are managing the patient that requires artificial ventilation and oxygenation, you are the primary ventilator. And, it doesn't matter if you are using a simple facemask or a machine; your objective is the same: effectively move air into and out of the lungs to optimize the circulating oxygen content and carbon dioxide concentration.

Easy, right" But it does require a few basic skills, a couple of devices and some knowledge, all of which you have or should obtain.

Creating airway patency

First thing needed is a clear pathway to the lungs. If an obstruction is present it is most often due to the tongue and that can be moved out of the way with a head tilt/chin lift or jaw thrust. It may require insertion of an oral or nasal airway or a combination of techniques.

In a worse-case-scenario, think two nasal airways, one oral and your partner is pulling the jaw forward so you can get in a few breaths while planning your next move.

On the rare occasion when the obstruction is not the tongue, more invasive procedures may be required, such as cricothyroidotomy. Always keep suction handy to clear any blood, vomit or mucous you encounter.

Once the airway is open, you can begin to move air, but how much air" We know that providing too little or too much oxygen or leaving behind too much or too little carbon dioxide can be bad for the patient.

Managing oxygen levels

Pulse oximetry indirectly measures oxygen content in the blood and capnometry measures expired carbon dioxide; this combination will give you the information you need to keep your patient in the right air zone.

Pulse oximeters are cheap; there are no excuses for not having one.

With pulse oximetry you can determine if you need to dial down the oxygen level for your COPD patient whose usual O2 saturation is 90% ¹ or help maintain the post cardiac arrest patient's O2 saturation normal but less than 100% as too much oxygen decreases survival of injured cardiac cells ².

The pulse oximeter will also inform you if your patient's oxygen level is too low and you need to increase the percentage of delivered oxygen. If you haven't reached your target O2 saturation on 100% inspired oxygen, it's time to add or increase the PEEP.

Positive end expiratory pressure, PEEP ³, exists normally in your alveoli due to the column of air in the bronchioles, bronchi and trachea stacked above these air sacs. Without PEEP the alveoli would collapse with each breath and that would decrease the exchange of oxygen and carbon dioxide in the alveoli.

Patients with COPD learn to increase their personal PEEP by exhaling through pursed lips. This is the same mechanism used by a PEEP valve, a device that keeps extra back pressure on the expired air to increase the pressure in the air sacs. These devices come preset with a single pressure setting or with a range of pressures. Models are available to fit any ventilating mask or tube.

If your patient has persistent hypoxia despite administration of 100% oxygen, you can increase their PEEP to help push oxygen into the circulation. Just use the lowest pressure that accomplishes your oxygenation goals. Too much PEEP can cause the blood pressure to decline.

Be cautious with asthmatics or anyone with bronchospasm requiring manual or mechanical ventilation. Bronchospasm is like a partial one-way valve, it lets more air into the air sac then it lets out. The result is hyperinflation, a steady increase in air pressure in the air sacs that can adversely affect air exchange and potentially decrease the patient's blood pressure. Decrease the rate and volume of ventilation to allow extra time for expiration. If you use PEEP, monitor your patient closely and decrease or discontinue if the patient is not improving or gets worse.

Controlling carbon dioxide

Capnometry devices are more pricey but well worth the expense to improve your patient care. You can move a step up by using capnography which provides carbon dioxide numbers plus a waveform graph or picture of expired CO2. This waveform supplies information about lung conditions and about blood flow in general.

For example it will show you when bronchospasm is present. The normal CO2 waveform is a slightly upward sloping square. Bronchospasm changes the normal waveform to a shark fin shape. This will show up even if you don't hear wheezing with your stethoscope. That would be useful to know especially if you have a little albuterol handy.

With capnometry you can manage changes in CO2 by changing the minute volume (respiratory rate x tidal volume) just like your brain stem does normally. Carbon dioxide is an acidic waste product from normal cell metabolism that is continuously transported by the blood stream to the lungs for disposal.

Most of the time your goal for manual or mechanical ventilation is to maintain a normal exhaled CO2 level (35-45mmHg). One important exception is the ventilated asthmatic as it is critical to decrease the rate and volume of ventilation to allow for adequate alveolar emptying while maintaining sufficient oxygenation and accepting a rise in carbon dioxide ⁴. The patient will normalize the elevated blood CO2 over time, but may die if you over-ventilate.

Summary

Whether your fingers are on the bag or on the dials of a machine, you remain the primary ventilator. With the basic overview presented above you can begin to optimize your patient's respiratory status and keep yourself part of the solution, and not part of the problem.

References

1. O'Driscoll BR, Howard LS, Davison AG: BTS guideline for emergency oxygen use in adult patients. Thorax. 2008;63(Suppl VI):vi1–vi68.

2. Peberdy MA, Callaway CW, Neumar RW, Geocadin RG, Zimmerman JL, Donnino M, Gabrielli A, Silvers SM, Zaritsky AL, Merchant R, VandenHoek TL, Kronick SL: Part 9: Post-Cardiac Arrest Care : 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010; 122: S768-S78

3. Neligan P: Why do we use PEEP". Available at http://www.ccmtutorials.com/rs/PEEP/index.htm

4. Stather DR, Stewart TE: Clinical review: Mechanical ventilation in severe asthma. Critical Care. 2005; 9 :581-587. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1414026/pdf/cc3733.pdf

Have you heard" More than 4200 retired players are suing the NFL over concussions and head injury. The suit alleges the league didn't do enough to warn players that they risked permanent brain damage if they played too soon after a concussion and that it hid evidence about the risks for decades.

The players all wear helmets and the defense argues that the players all knew the risks.

For years, many in EMS have been aware that a leading cause of death and injury among medics following a collision is from a head injury. This is not really surprising as medics, while in the patient compartment, admittedly are often unrestrained and in a completely vulnerable state. Note the following quote:

"NIOSH crash tests also revealed the possibility of head injury if a worker's head strikes the cabinets immediately above or behind them, and noted that vehicle structural failures can be a contributing factor in adverse outcomes of EMS crashes."

Its an unfortunate truth that's been around way too long. Years ago I had the opportunity to watch several safety presentations. Prior to the presentation the presenter would ask the question, who among you would consider wearing a helmet while caring for a patient in the back of a moving ambulance. Very few hands went up.

Following the presentation wherein gruesome EMS collision images were presented the same question was asked. Following the presentation, the response was almost perfectly reversed; a very high number stated they would wear a helmet. I often wondered was this just a short-term response to an emotional event or did this represent a real desire" I have seen other safety-related items like safety vests embraced immediately, only to be later cast aside.

Following the presentation, I would also sometimes hear the question, "Where can I buy a suitable helmet"" From what I know, helmets are specialized based upon their intended use or the activity of the wearer. The needs of a firefighter inside a burning building and a rock climber are different, so the helmet, shape and function needs to be different. At the time there was no EMS intended helmet.

I was recently sent a model EMT-1 Paramedic Helmet made by B2 Helmets to evaluate. It is intended for use in a moving ambulance, as the ears are free so a stethoscope may be used. The B2 also has a half face shield to help protect against blood or other potentially infectious materials from getting into the eyes. The design allows the face shield to be worn over prescription glasses. There is also an optional lightweight LED light to help light up the rescuers field of vision.

The helmet is FMVSS 218 (Federal Motor Vehicle Safety Standards) certified. This safety standard covers wheeled large motor vehicle applications.

I wore the B2 for a couple of days while typing, walking and riding in a vehicle just to see how it felt. I definitely knew I was wearing it but it was not uncomfortable. I wore the helmet on a very mild weather day so was not exposed to extreme temperature or humidity.

From rock climbing, bike riding, car racing to motorcycle riding there is a growing body of evidence that helmets make a difference. To be fair, the literature also points out that improperly worn or fitted helmets reduce the ability to decrease the risk of head injury. Even when properly worn, helmets do not prevent all head injury and are not intended to reduce neck injury risk.

To get helmets into the mainstream a change in culture is needed. When I was a kid I would never have considered wearing a helmet while riding a bike. Times have changed. The culture has changed. The media has driven a lot of the change, by providing the statistics and by the desire to save those we love.

I began my EMS career in the early/mid 70s and would not have given any thought to wearing a helmet then either. Back then we barely had seatbelts, let alone complete shoulder restraints or helmets. We did not have gloves back then or know of AIDS. We did many things back then that by todays standards would be considered wrong. We didn't have the choices then that we have today.

Again, times and the culture have changed. Whether riding bikes, playing football or riding in the back of an ambulance, the media and the statistics suggest we need better head protection. The lives we need to save are our own, both for ourselves and for the ones who love us.

Until something else or better comes along, industry designed helmets may offer the best protection. Until something better comes along use your noggin to lead change within your organization not to just be another statistic on a chart- consider head protection, consider a helmet. Watch the video about Shoal Ambulance's decision to require helmets. A truly industry leading move.

For more information on the B2 helmet, visit www.arasan.us.

One of the biggest challenges in EMS is communicating with people and patients who do not speak English. A language barrier can be an enormous problem preventing accurate assessment and good quality care. Fortunately, we have some good solutions in three basic flavors.

We have basic graphic tools or text-based "book" solutions, new smartphone programs, and a new service solution that puts you in immediate contact with a live translator.

The simplest of these is the Emergency Medical Translator from Kwikpoint. It was originally developed with the FDNY. It uses graphics to facilitate basic communication to overcome language barriers when no translator is available.

Topics include car crashes, assaults, sex crimes, falls and other emergencies. Related topics include pain symptoms, medications, overdoses, allergic reactions and toxic ingestion.

It also includes critical words and phrases with phonetic pronunciations in nine languages. The compact pocket-sized laminated chart format makes it easy to carry and easy to wipe clean.

I've carried the Communimed in my personal kit for years. It helps you obtain answers to key medical questions from victims, bystanders, or care providers who don't speak English. A total of 46 questions are translated into the 20 most common languages.

You turn to the required language and on one side you have the questions and multiple-choice answers in English, and on the right you have this repeated in the required language. You just point at the question you want to ask, and the other person points to the answer.

I've used it many times. It can really help get the essential information. I'll never forget the time I did a pretty comprehensive cardiac workup in Portuguese. The ED was pretty impressed by the detailed history I was able to get from a patient I could not speak with.

The EMS Translator Field Guide, Spanish Edition is designed to facilitate communication between English-speaking providers and Spanish-speaking patients. It works a lot like Communimed, but replies more on simple yes or no responses.

There are quite a few translator programs available for smart phones. Here are two that have been favorably reviewed.

The Palm OS Medical Translator contains a list of basic phrases that a first responder commonly uses, with the English and foreign language translations. The program currently supports English and Spanish, and there is a phonetic version to help you pronounce the words.

iTranslate is an award winning translation tool for iPad or iPhone that helps you break down language barriers. It can translate between more than 60 languages. It combines machine translation with a custom built technology to serve you the most accurate translation results in the blink of an eye.

You can use iTranslate as a translation dictionary for many languages. The best part: you can even help improve the dictionary database by rating or suggesting translations.

iTranslate offers Text-to-Speech implementation powered by iSpeech. You can select between lots of different dialects, choose a male or female voice and even control the speaking rate.

By upgrading to the premium version for 5$/year you can speak instead of type. No training needed. Just start speaking and it transforms what you said into text and translates it into another language. Voice recognition is powered by Nuance, the most accurate voice recognition technology currently available on this planet.

Do Chinese characters look like hieroglyphs to you" With romanization you can turn ?? into this Ni hao! Transform non-Latin languages into Latin characters. This feature is available for many languages including Chinese, Japanese, Korean, Greek, Hindi, Russian and Thai.

iTranslate is optimized for fast text input. Get suggestions while you're typing, turn your phone to the side and use both hands for typing with the bigger landscape keyboard or use our popular swipe gestures for quick copying & pasting.

You can send or store translations via Email, or simply copy a translation and use it in any App you like. Browse through recent translations or save a translation for offline access.

The ELSA (Enabling Language Services Anywhere) is a best in class translation service solution. It combines a wearable hands free autodialing cell phone with a sophisticated back end support network.

You push one button on ELSA and you are immediately connected through their operating center to a live interpreter. It is a cost-effective, anytime and anywhere interpretation service.

ELSA provides immediate communication in 180 languages. It is ideal for emergency medical services. The device is durable and can be worn on a belt, shirt or around the user's neck.

Once connected you ask your question, and the operators translates to the patient. When the patient replies, the operator translates into English. It is easy to use and unlimited in application. It is just like having a translator with you.

Each of the interpreters are thoroughly screened and have situation-related experience. They are proficient in English and one or more of 180 languages and dialects,

ELSA provides low-cost, real-time communication between people who speak different languages in virtually any situation or environment.

All conversations are recorded and stored on their servers for retrieval anytime. They maintain these audio records for five years. Check out the videos here.

Once we only had only hand gestures. Now we have some excellent tools available. These products can turn a frustrating situation into just another run. Especially in urban areas with many different languages being spoken, they can be invaluable.

I recently had an opportunity to submit proposals to my state's annual symposium. It gave me an opportunity to present the concept of "Naked EMT Teaching." The idea was inspired by The Naked Presenter: Delivering Powerful Presentations With or Without Slides ¹ by Garr Reynolds.

I wanted to convey the idea that we are too wedded to powerpoints and/or rigid curriculum, which keeps us from doing the best job we can in teaching students our trade. To improve our abilities, we need to develop and embed new concepts in our teaching practice.

Medical critical thinking

The physician model for critical thinking is a three part activity:

• Medical inquiry – history, physical exam and diagnostic testing
• Clinical decision-making – a cognitive process that evaluates information to diagnose or manage a patient's condition
• Clinical reasoning – combining medical inquiry with clinical decision making and physician knowledge ²

Dan Limmer, Tim Miscovitch and William Krost wrote about critical thinking for EMTs in a two-part article published in EMS Magazine. ^3,4 Phrases such as "differential diagnosis," "active, inquisitive, aggressive assessment" and "develop strategic and dynamic care plans" are found in the article. These concepts were not part of the 1994 EMT-Basic National Standard Curriculum (NSC).

The take-home concept is that EMTs should function as clinicians not technicians. "An EMT who is a thinking clinician is able to identify patients who are stable or unstable and require prompt transport. The EMT clinician also makes decisions such as when to call for advanced life support or air-medical evacuation, when to perform rapid extrication and when to immobilize the patient before removing him from the vehicle." ³

Effective clinical learning

Critical thinking is evaluating patient assessment results against past patient encounters and the caregiver's knowledge of the disease process. Application of pathophysiology is a new element in the Educational Standards. Teaching pathophysiology and using it as part of a critical thinking process are new learning outcomes.

These learning outcomes change the role of instructors from vocational trainers to clinical educators. How can dedicated, experienced vocational trainers become clinical educators" It requires a combination of knowledge and teaching techniques beyond an updated PowerPoint presentation.

Pathophysiology resources

There are two EMT transition textbooks ^5,6 that provide essential anatomy, physiology and pathophysiology of the knowledge areas covered in an Education Standard program. Publishers have textbooks to support community college paramedic anatomy, physiology and pathophysiology courses ^7,8,9.

It would be great if EMT instructors could attend a course providing ems-focused anatomy, physiology and pathophysiology that would include teaching techniques and examples. Lacking that, here are two concepts that may help experienced EMT instructors.

Embrace ambiguity

Two summers ago I taught our first Educational Standard course with a brand-new edition of a popular EMT textbook. I provided this feedback to the editor:

"A frustration is the vagueness of some numbers. For example on page xxx, Table xx-x 'Vital Signs'. Need to read through two paragraphs to parse out what would qualify as a blood pressure reading that would be hypertensive or hypotensive."

I was channeling my vocational instructor need to have the "right" number to define a "normal" blood pressure. In medicine there is no absolutely correct number for blood pressure determination.

Clinicians appreciate that no patient presents like a textbook case. The goal is to determine what assessment and clinical findings are important to develop a patient care plan and determine transport priority. This requires a willingness on the instructor's part to teach more of the "grey" and less of the "black and white." Yes, it will take longer, and may be more frustrating to students. But the result will be a student who is more willing to look at the big picture, rather than just a number.

Case-based learning through concept mapping

Richard Beebe uses this technique in his paramedic textbook to get the students to visualize the patient's problem: "Concept Maps offer a way for instructors to help students conceptualize ideas in the classroom and help them develop the critical-thinking skills necessary for determining a field diagnosis. Each Concept Map, utilizing a typical emergency scenario, walks students through the critical thinking steps used during an EMS response." ¹⁰

Start with boxes, each representing a component of the patient's condition. Each box will have a sign, symptom, pertinent negative, general EMT impression of patient or other data. You will have six to twenty boxes. ¹¹

Consider how the boxes are related to each other, and make connections between each box. Use descriptions, such as FEELING LIGHTHEADED "may be due to" BLOOD PRESSURE 86/52. This process facilitates differential diagnosis and can guide inquisitive assessment, identifying areas for focused assessment. Once all of the boxes are connected, the student has a better understanding of what is happening to the patient and can develop a strategic and dynamic care plan.

REFERENCES

1. Reynolds, G. (2010) The Naked Presenter: Delivering Powerful Presentations With or Without Slides. New Riders. ISBN 978-0-321-70445-0.

2. Marx, J (ed), et al. (2009) Rosen's Emergency Medicine – Concepts and Clinical Practice, 7 ^th edition. Mosby. ISBN 978-0323054720

3. Limmer, D. D., et al. (2008) Beyond the basics, the art of critical thinking, Part 1. EMS Magazine 37(4) p. 87.

4. Limmer, D. D., et al. (2008) Beyond the basics, the art of critical thinking, Part 2. EMS Magazine 37(5) p. 76.

5. American Academy of Orthopaedic Surgeons (AAOS). (2013) Emergency Medical Technician Transition Manual: Bridging the Gap to the National EMS Standards. Jones and Bartlett, ISBN 978-1-4496-0915-3.

6. Limmer, D. D. and J. J. Miscovitch (2011) Transition Series: Topics for the EMT. Pearson Education/Brady, ISBN 978-0-13-511351-6.

7. Bledsoe, B. E., et al. (2007) Anatomy & Physiology for Emergency Care, 2 ^nd edition. Prentice Hall. ISBN 978-0132342988

8. Elling, B., el al. (2006) Paramedic: Pathophysiology. American Academy of Orthopaedic Surgeons/Jones and Bartlett, ISBN 978-0763737658.

9. Elling, B., el al. (2005) Anatomy & Physiology Paramedic. American Academy of Orthopaedic Surgeons/Jones and Bartlett, ISBN 978-076373925.

10. Beebe, R. and J. Myers. (2011) Professional Paramedic, Volume III: Trauma Care & EMS Operations. Cengage Learning. ISBN 978-1428323483.

11. Cañas, A. J. and J. D. Novak (2009) Constructing your First Concept Map. Institute for Human and Machine Cognition. Accesses May 14, 2013 from: http://cmap.ihmc.us/docs/ConstructingAConceptMap.html

Normally, I am strong believer that paramedics are at their best when they saunter into a scene, slowly walking and looking for clues and risks. But an active shooter incident is going to require repetitive bursts of significant physical activity.

Earth Day 2012 takes place this Sunday, with events planned held worldwide to increase awareness and appreciation of the Earth's natural environment. So, it's a good time to see what you can do at your agency to save both resources and money.

Consider using this PPE safety video in your EMT Basic or Refresher Class.

My most recent healthcare provider recertification was memorable for all of the things the instructors did well.

Substantial cajoling and adult guidance from mom in a Santa hat was required to initiate an orderly process of taking turns, appreciating a gift after it was opened, and taking occasional pauses for a meal or to welcome additional relatives.

On a skill sheet, patient assessment is presented as a linear process: First size up the scene, then complete the primary assessment followed by the secondary assessment.

One of the things I'm most often asked by students and rookie EMTs is, "Kelly, how am I supposed to hear a blood pressure in the back of the rig?"

Slideshare is an online community and tool for sharing presentations.

The batteries in your wireless cell phone, tablet or laptop are probably not the same old Duracells you used in your childhood walky-talkies.

If you have an OB patient about to deliver, do a U-Turn and put the patient backwards on the gurney. By placing their head at the "foot" of the gurney, this allows you to work out of the captain's chair and gives you more room. The hardest part of doing this is getting your partner to place the patient in this position. Old habits are hard to break and it may feel odd, but once in the truck ...