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

Mass layoff ruins Christmas for EMTs and their communities

His mother said the school wouldn’t allow her son to carry his own inhaler, and confiscated it on several occasions when he tried to use it

Dozens of vehicles — possibly as many as 90 — were involved in the chain-reaction crash that claimed the life of at least one driver

Only five of the 26 ladder trucks have passed, but some remain on the street

The victim had multiple wounds to her chest and neck; medics pronounced her dead at the scene

Victims' families are calling for privacy, and for people to mark the upcoming school shooting anniversary with acts of kindness or volunteerism

Doctors took an artery outside the skull and sewed it into the brain, making a new path for blood to flow for the 14-year-old boy

One of his goals is to more than double the number of volunteers serving the community and its almost 60 square miles

A couple and four children went to play in the snow in the remote mountains, and didn't return after a night of sub-zero temperatures

The medic was among emergency responders attempting to help a man who had fallen down an embankment on a highway

Mass layoff ruins Christmas for EMTs and their communities

His mother said the school wouldn’t allow her son to carry his own inhaler, and confiscated it on several occasions when he tried to use it

Dozens of vehicles — possibly as many as 90 — were involved in the chain-reaction crash that claimed the life of at least one driver

Only five of the 26 ladder trucks have passed, but some remain on the street

The victim had multiple wounds to her chest and neck; medics pronounced her dead at the scene

Victims' families are calling for privacy, and for people to mark the upcoming school shooting anniversary with acts of kindness or volunteerism

Doctors took an artery outside the skull and sewed it into the brain, making a new path for blood to flow for the 14-year-old boy

One of his goals is to more than double the number of volunteers serving the community and its almost 60 square miles

A couple and four children went to play in the snow in the remote mountains, and didn't return after a night of sub-zero temperatures

The medic was among emergency responders attempting to help a man who had fallen down an embankment on a highway

Ah, the holidays: they’re filled with fond memories of family, friends, gifts and gatherings. It should be the most joyous time of the year.

Unless of course you start your workday by finding out you’re out of a job. Right out of the Grinch playbook.

Closure with no notice

The abrupt closing of a major EMS and medical transportation company last Friday has rippled through our industry, putting hundreds of EMS providers out of work and causing major upheaval in local communities. Some cities found themselves without an emergency medical provider, while patients who relied upon dependable transportation scrambled to find new ways to get to their clinical visits, or to home.

“This is a terrible situation — dropping a bomb on all those employees right before Christmas,” said Skip Kirkwood, director and chief paramedic of Durham County EMS and the immediate past president of the National Association of EMS Administrators, and Director of Durham County EMS (N.C.). “This is the time of year when we should be taking extra care of our employees. IF this was an absolute business necessity, it would have been nice if some provision was made for employee welfare — severance, COBRA continuation of health care, etc.”

It’s a sad state of affairs when an organization simply rolls down the shutter and locks its doors with no warning to its members. While I’d like to think there was some deliberation among senior leadership in the days and hours leading up to the decision, it certainly doesn’t seem like it. No press release, no spokesperson, not even a website that says, “we’re sorry.” Really" Is that so difficult to do"

“It's hard to believe that nobody at corporate knew this was coming,” Kirkwood added.

Reshape EMS to face challenges

There are bigger issues afoot that we all need to take notice of: financial stability in EMS is fleeting and rare. Commercial ambulance services and municipalities alike are struggling to maintain quality levels of service in the face of dwindling reimbursements from federal and private insurance companies.

Other stories have pointed out the high cost of medical transportation. Meanwhile, volunteer systems struggle to simply keep the doors open with little or no financial support.

EMS needs a major reset. We are seeing some major changes, in the form of community paramedicine and mobile integrated health care initiatives. These new services will add great value in being community health providers, and will ultimately be a significant part of our profession, just as critical care transport, tactical medicine and flight medics have become.

However, it will not be the savior. At the end of the day, EMS will continue to perform a major function — providing emergency care and transportation of the sick and injured. Beyond the reimbursement issues, there must be national dialogue as to what that exactly means to the public. Is it important enough that it must be supported through taxation and community fees" Should the insured demand that their carriers provide greater reimbursement for sudden, catastrophic events"

For over 40 years, we have been hiding from the public the costs and demands of providing emergency health care and transportation. It’s time to pull back the curtain and reveal the issues that have plagued the industry.

In the meantime, visit the Facebook page hosting a toy drive for former First Med employees’ families and help out with the spirit of giving. As Kirkwood said, “Taking care of your people SHOULD be the most important priority.”

At least let’s try to keep the family spirit going for our members this holiday.

This year brought some exciting new technologies to EMS. Some are simple; often the small things are the most appreciated. But a few are real game-changers, big ideas with a potential huge impact on EMS and health care in general. Here are some of my favorites.

Infrascanner Model 2000

The new Infrascanner Model 2000 was developed in cooperation with the U.S. Marines. It is a compact handheld device for detection of life-threatening bleeding in the skull called intracranial hematomas. It uses near-infrared (NIR) technology to screen patients for intracranial bleeding.

NIR light can penetrate tissue and bone several centimeters deep into the skull. The scanner detects differences in light absorption and displays the information on an easy-to-read visual display.

B2 Paramedic Helmet

Medics die of head injuries in the back of an ambulance in MVAs. That is when a sudden impact becomes deadly, throwing EMS providers into cabinets and bulkheads.

The new B2 Paramedic Helmet, introduced this year, is available in multiple shell sizes for a low profile. (Full disclosure: This is a project I've been involved with for years.) The low profile is important to prevent bumping into the ceiling all the time, especially when working in confined spaces. Each size comes with different thickness head pads for a near custom fit.

It has a 3mm double curved polycarbonate visor with a nose cutout. The visor can be worn over regular prescription glasses and is compatible with respiratory protection. It rides close to the shell when raised, without being in the head strike zone. The quick-release padded chinstrap and suspension system permits use of communication equipment. It is the only EMS helmet built to a motor vehicle safety standard.

ClearCollar

The ClearCollar offers some new unique features for EMS. The first and most obvious is that you can see through it. Looking through an anterior hole is not the same thing as looking through the collar. The adjustable ClearCollar offers constant observation of the neck. Particularly when airway compromise is present, the ClearCollar will afford a whole new level of direct observation.

Even better, the latest version now has two separate anterior locking mechanisms. This offers three big advantages, with the first being that it is very secure. Second, you don't have to settle for a narrow range of specific locking detents. With most cervical collars, you have a limited choice of potential size adjustments. With the ClearCollar the size range is virtually infinite.

Last, you can more easily fit it to the patient's position of comfort. One of the oldest splinting principles is immobilizing a patient in position found. If a patient is holding his or her own neck at an angle, being able to affix it that way is a huge advantage. With the new dual locks, you can even lock the front in a twisted position. Normally, this is only possible with a two-piece collar.

O2Max Trio

CPAP has been shown to definitively manage serious respiratory emergencies such as congestive heart failure, chronic obstructive pulmonary disease and asthma. Pulmodyne introduced a new model of disposable CPAP called the O2Max Trio

This is a completely original design. Other disposable devices use the Bernoulli principle to generate the pressure necessary to maintain open airways. The O2Max Trio uses the oxygen tank pressure to function please.

ZICO QR-D-2

The ZICO QR-D-2 from Ziamatic Corporation is a snap-in oxygen bottle bracket that solves a big storage problem for EMS. It quickly secures your portable oxygen cylinder. They have models for both vertical and horizontal storage.

Most existing cylinder holders reply on thumbscrews or a fabric strap to keep your portable bottle in place. They take two hands, are slow, rattle and frankly scare me. The three most dangerous things in the back of an ambulance in an accident are the defibrillator, portable cylinders, and suction unit. In an accident they all become deadly flying missiles.

We have long needed better ways to securely store small oxygen cylinders in a moving vehicle. I see the ZICO QR-D-2 as an elegant and practical solution. For a simple bottle holder it has some really advanced features. These design elements indicate that a lot of work went into the engineering.

To secure your cylinder you just set the tank base inside and then push back until it snaps in. The ZICO bracket has a positive spring-loaded latch. You can do it one-handed and when it locks it, it locks in with real authority. It is an important part of any comprehensive effort to build a safer ambulance.

Tourniquets

2013 was a big year for the tourniquet. The Ratcheting Medical Tourniquet (RMT) is an evolved medical tourniquet that uses an innovative buckle system and a well thought-out design. It is the most advanced and rugged tourniquet I've seen.

Many lessons have been learned from being at war the past 10-plus years, particularly when it comes to how to better manage trauma. One of these lessons is that tourniquets save lives and don't often cause further disability. Many on the battlefield have been saved by the early application of a tourniquet.

Until now, most have been versions of the ancient windlass-style tourniquet. These have not changed much since I learned how to use a kerchief and a stick in the Boy Scouts. The RMT operates in a totally different way. It uses a custom made buckle and ladder strap with "teeth" to apply dynamic pressure around the entire limb.

The SAM Junctional Tourniquet or SJT does things no other tourniquet can; it occludes the femoral artery in the inguinal area at the junction of the torso and legs. When blast injuries take off legs like in the Boston bombing and every day in combat zones, it can easily be fatal. It is frequently difficult, if not impossible, to stop the bleeding in time. Sometimes there is just not enough leg left to get a tourniquet around.

The SAM Junctional Tourniquet puts pressure on the arteries feeding the legs with a sophisticated mechanism of action that is easy to use and fast to deploy. You can put it on in under 25 seconds with a little practice.

It also functions as a pelvic splint. It is not unusual for a bomb blast to also fracture the pelvis when it takes off a leg. Since the new SJT is based on the SAM Pelvic Splint, it will be instantly familiar to anyone already using these splints. It is always nice when an EMS product can be effectively used for more than one thing.

LifeBot 5

LifeBot 5 is a completely portable version telemedicine solution. All the components are integrated into a compact 15-pound package that costs under $20K. Unlike previous systems, the LifeBot 5 is modular in construction so it can be readily adapted to new technologies and be easily upgraded.

Most often the weakest link in the chain is the ability of a pre-hospital vehicle to maintain reliable wireless data connectivity, The LifeBot 5 operates on multiple cellular providers, such as Sprint, Verizon and AT&T, but it also integrates 3G, 4G, Wi-Fi, WiMAX, LTE, satellite, and military data radio. It automatically manages connectivity and bandwidth in totally transparent fashion. The system analyzes what works and uses it automatically.

Patient data with the LifeBot 5 is securely transmitted using AES encryption. Secure text messaging may also be used to send highly specific or sensitive information "silently." It offers not only direct transmission of voice and video but complete patient physiologic data, including ECG, 12-lead STEMI, blood gases, ultrasound, e-PCR, EHR, blood pressure, and a lot more.

One system does it all, without the need to cobble together separate products. You can make any ambulance a telemedicine ambulance with one portable device instantly. This can not only provide higher levels of care, but also save money, substantially lower the chance of errors, and save lives.

Leatherman Raptor

The new Leatherman Raptor is a pure EMS tool. It benefits from an enormous amount of design input from working EMS professionals. It probably helped that most EMS providers already own some kind of Leatherman.

The Raptor includes six different functions in a compact folding tool. It measures 5 inches folded and weighs less than six ounces. It combines 420HC stainless steel shears with a strap cutter, ring cutter, oxygen wrench, ruler and glass breaker. It also features an easily replaced pocket clip and rugged injection molded holster.

ThoraQuick Chest Decompression Device

The ThoraQuick Chest Decompression Device is for now only sold in Europe, but I expect to see it in the U.S. market very soon. Dr. Ian McNeil, a past chairman of the British Association for Immediate Care, invented it.

ThoraQuik has a large-bore 10cm needle to both improve success reaching the pleural space and minimizing the risk of catheter occlusion once it is reached. The internal diameter of the catheter is over 3mm.

ThoraQuick has an integrated one-way air valve already attached. It also has an innovative plastic hub that protects the catheter and helps to quickly secure it with integrated peel and stick adhesive. It also features a non-traumatic internal tip similar in function to the Turkel Needle. It appears to integrate all the best features of many earlier products in one slick kit.

This was a great year for innovation. These are just a handful of the best new EMS products for 2013. I'm confident many will wind up on your ambulance someday very soon.

Paying it forward isn’t just a hokey concept. Yes, it was popularized by a somewhat cheesy Hollywood movie back in 2000, but the concept works. In big and small ways, every day, you are paying it forward. This works for the good that we do as well as the bad. And it works because emotions are not conserved.

Allow me to explain that last part.

In the late 18th century, Antoine Lavoisier first proposed the law of conservation of mass. This revolutionary proposal suggested that mass, the stuff we handle every day, was neither created nor destroyed, it only changed forms.

Antoine’s observation applies to all matter, from hydrogen ions to jelly doughnuts. For example, if you show up to work with a hot cup of coffee and a jelly doughnut, your day is off to a good start. Let’s say you give away your jelly doughnut to a coworker. That was nice of you, but you no longer have a jelly doughnut to eat. You can’t give something away and still have it. Also note that, if your coworker then eats the jelly doughnut, it doesn’t cease to exist. It simply changes form – usually in some way that’s not flattering in their uniform.

This is the law of conservation at work. We don’t create matter and we don’t destroy it. It merely exists. We can possess it and pass it on and even change its form, but we have no say on its existence.

The same does not hold true for the way we feel.

Share kindness and keep it too

Sometimes we like to think of our emotional state as matter. We imagine that our emotions were not created by us, but were given to us by some outside source. We also convince ourselves that the best way to be happy is to hoard our positive emotions and give the bad ones away.

Our emotional state is not conserved like matter. It doesn’t follow the law of conservation. In the world of human emotion, what we share expands. Unlike our jelly doughnut, we can give away an emotion and still keep it. You can give away anger and bitterness all day and still have the same amount when you’re done. What is given is also kept; therefore, emotions spread faster and farther than hydrogen ions or jelly doughnuts.

If you greet your partner in the morning with a jelly doughnut, grateful as he or she may be, they will be hard-pressed to spread your generosity farther than their waiting stomach. Greet them with joy or laughter or anger or frustration and they will be apt to pass it on.

This is worth understanding in EMS because we have such amazing opportunities to pass on things like joy and happiness and understanding and patience and kindness (especially kindness). We also are afforded ample opportunity to pass on anger and frustration and resentment and so many other negative bits of attitude, if we choose.

Let go of anger and it disappears

Our business is a human business. We connect with hundreds of individuals each day, and with each connection exists the opportunity to pass on a little piece of our own emotional state. We rarely reflect on the impact of the emotional content that we dump into the world, but it can be far-reaching and profound.

The anger and frustration that you pass on to the local nursing home staff might get passed on to their coworkers or patients or families. The kindness that you show a homeless patient might get passed on to the emergency room staff or the social worker whom they encounter next.

Your dismissive shrug when a patient expresses fear or concern may be recalled months or years later in a moment of crisis, or while retelling the story to a friend, or while standing in a voting booth considering a funding measure. The ten seconds that you take to kneel down next to a scared child and say, “Hey little man, we’re going to take good care of your mom” may be remembered for a lifetime.

When we understand that there is no law of conservation for emotional states, we recognize how critical our role is in passing on only the best within us. We have no obligation to take or keep or pass on any of the anger, fear, frustration, hatred or despair that is so often heaped upon us. The moment we let it go of it, it ceases to exist. We can consciously become a dead end for all of those emotional states.

Get back what you give

We can also take responsibility for the emotional energy that we choose to create and pass on to others. Let go of the idea that your internal flow of emotions appear from some mysterious place within you and that you are helpless to control your own emotional state of mind. You are the creator of your own internal dialogue and your emotional state. Part of the privilege of wearing an EMS uniform should be choosing to create and pass on only the best within you.

I was thinking this all over recently during one of our EMT classes. One question I like to ask new EMT students is, “What made you want to become a part of emergency services"” I’m pleasantly surprised at how frequently the motivation to become an EMT stems from some childhood experience with emergency services. In EMS, our own goodwill is often amplified and carried forward in ways more far-reaching and profound than we can ever imagine.

Paying it forward works. And the best part is, much of what we pay forward comes right back to us.

Case review

Rescue 18 and Engine 3 respond to a reported unconscious person on a basketball court in a city park. En route, the mobile data terminal in both vehicles flashes a message that CPR is in progress. The engine arrives first, takes over CPR from bystanders, and delivers a countershock from the AED.

The rescue arrives, verifies effective compressions and bag-mask ventilation, and begins advanced life support procedures. Paramedic Martin inserts an intraosseous line into the patient’s right tibia. Paramedic Erikson, who has assumed the position of code commander, requests the administration of epinephrine.

Shortly after the epinephrine administration, the team leader informs Erikson that the next shock is due in 15 seconds. Erikson begins charging the defibrillator. At the mark, Erikson clears the team, verifies the presence of ventricular fibrillation, and delivers the shock.

After switching chest compressors, the team settles into their third CPR cycle. While CPR is ongoing, Erikson notices that the ECG monitor appears to display an organized rhythm. At the two-minute mark, Erikson and Martin both verify the presence of a femoral pulse. The patient remains comatose and does not respond to Erikson’s commands. Martin successfully intubates the patient’s trachea as the team prepares to move the patient to the ambulance.

Transport to the hospital was uneventful. On arrival in the emergency department, the patient had a blood pressure of 110/70, a pulse of 98, and an end-tidal carbon dioxide reading of 45 mm Hg. The medics complete their paperwork and return to their station.

During the next shift, Erikson and Martin transport a different patient to the same hospital and ask about the cardiac arrest survivor. An ED nurse informs the pair that the patient rearrested before they could get him to the catheterization lab and they could not restore a pulse.

Study review

Researchers in King County, Washington retrospectively examined whether lidocaine improved various patient outcome measures when administered to patients who achieved ROSC after suffering an out-of-hospital cardiac arrest.[1] The study included all patients over the age of 18 years who suffered a bystander- or EMS-witnessed, cardiac-related, out-of-hospital cardiac arrest during a 17-year period from 1992-2008.

During the study period, emergency medical dispatchers sent automated external defibrillator (AED) equipped and EMT-trained firefighters simultaneously with paramedics. All EMS responders provided care consistent with American Heart Association resuscitation guidelines current at the time.

Patients selected for the study had ventricular fibrillation or pulseless ventricular tachycardia as the initial arrest rhythm. If the shockable rhythm persisted after the first shock, paramedics generally administered a lidocaine bolus as the first-line antiarrhythmic. However, because the study period spanned several revisions of the AHA cardiac arrest treatment guidelines, some patients received bretylium or procainamide as the bolus antiarrhythmic. Amiodarone was not used in this system except during a brief investigation during the 1990s.

In order to qualify for the study, each patient had to achieve a transient or sustained return of spontaneous circulation (ROSC) during the resuscitation. The transient ROSC period had to last long enough for the paramedic to record a blood pressure or identify other evidence of adequate perfusion. In either case, paramedics had the option of administering lidocaine either as a bolus or a drip to try to prevent rearrests.

The researchers identified three outcome measures for this study. The first was the frequency of rearrest before arrival at the emergency department. The second was whether the patient lived long enough to be admitted to the hospital. The final outcome measure was whether the patient lived long enough for discharge from the hospital. Although many investigations into cardiac arrest include some measure of neurological outcome in the survivors discharged from the hospital, this study did not include that variable as an outcome measure because the information was not uniformly available over the study period.

One thousand seven hundred and twenty one (1721) patients met all of the eligibility criteria for this study. The overwhelming majority (75%) received a lidocaine bolus or a drip during the ROSC period. Both groups (those who received prophylactic lidocaine and those who did not) had similar clinical characteristics (EMS response interval, receipt of early CPR, age, and gender).

Compared to those who did not receive prophylactic lidocaine, patients who did

• Experienced significantly fewer rearrest episodes (first outcome variable);
• Were more likely to survive long enough to be admitted to the hospital (second outcome variable); and
• Were more likely to survive long enough to be discharged from the hospital (third outcome variable).

In a retrospective analysis such as this, researchers cannot control any of the variables that can alter the outcome of the study. However, researchers can use an analysis technique called logistic regression to study the independent effects of each of those variables. Compared to those who did not receive lidocaine, patients who received lidocaine during the immediate post-arrest period were

• Three times less likely to rearrest because of a shockable rhythm;
• Two times less likely to rearrest because of a nonshockable rhythm;
• Almost twice as likely to be admitted to the hospital alive; and
• One and one-half times more likely to survive to hospital discharge.

What this means for you

Almost a decade before publication of the first paper on modern CPR, clinicians in Maryland demonstrated the effective use of lidocaine in a prolonged resuscitation attempt of a patient who developed ventricular fibrillation during cardiac catheterization.[2] That same decade, researchers successfully used lidocaine in the resuscitation of canine cardiac arrest presenting in ventricular fibrillation.[3] The authors pointed out, however, that cardiac massage appeared to be an important component of lidocaine’s action. Later, researchers demonstrated the effectiveness of lidocaine in humans for the treatment of ventricular fibrillation that developed in an operating room.[4]

Lidocaine quickly became the antiarrhythmic most often administered during resuscitation attempts following cardiac arrest. Lidocaine, when used in combination with epinephrine, improved defibrillation success compared to epinephrine alone; however, the drug combination had a higher incidence of refibrillation.[5] Since refibrillation is associated with reduced survival,[6] any medication that reduces rearrest frequency without harmful effects has profound clinical significance.

In this study, lidocaine administered after achieving ROSC resulted in a lower frequency of rearrest from a shockable rhythm and a reduced need for additional shocks after achieving ROSC. This suggests that lidocaine may indeed have an antiarrhythmic effect during the post-cardiac arrest period similar to the effects seen with AMI patients in previous decades.[7-10]

Limitations

This study was retrospective and therefore can only establish an association between prophylactic lidocaine administration and improved outcome measures following out-of-hospital VF/pVT arrest. This study was not designed to prove, nor do the authors attempt to claim, that one variable causes the other.

This study only addressed the issue of whether lidocaine might be beneficial when administered during the post-cardiac arrest phase. The authors do not attempt to draw any conclusions on whether lidocaine (or any other antiarrhythmic) administered during the resuscitation attempt would improve outcome.

Patients in this study who received prophylactic lidocaine achieved ROSC significantly sooner after EMS dispatch and had higher systolic blood pressures at ROSC than those who did not receive prophylactic lidocaine. The prophylactic lidocaine obviously had nothing to do with these two variables, but could explain why the prophylactic lidocaine group had better outcomes.

Summary

This study suggests that lidocaine administered during the post-cardiac arrest phase may reduce the incidence of refibrillation in adult victims of witnessed out-of-hospital cardiac arrest presumed to be of cardiac nature. One must be careful not to conclude that the drug is the causative agent for the improved outcomes. The latest American Heart Association guidelines note that there is insufficient evidence to recommend or to refute the prophylactic administration of any antiarrhythmic during the post-cardiac arrest phase.[11] More research is needed to definitively determine the value of lidocaine administration during the post-cardiac period.

References

1. Kudenchuk, P. J., Newell, C., White, L., Fahrenbruch, C., Rea, T., & Eisenberg, M. (2013). Prophylactic lidocaine for post resuscitation care of patients with out-of-hospital ventricular fibrillation cardiac arrest. Resuscitation, 84(11), 1512-1518. doi:10.1016/j.resuscitation.2013.05.022
2. Southworth, J. L., McKusisk, V. A., Peirce, C. II., & Rawson, F. L. Jr. (1950). Ventricular fibrillation precipitated by cardiac catheterization: Complete recovery of the patient after forty-five minutes. Journal of the American Medical Association, 143(8), 717-720. doi:10.1001/jama.1950.02910430009003.
3. Carden, N. L., & Steinhaus, J. E. (1956). Lidocaine in cardiac resuscitation from ventricular fibrillation. Circulation Research, 4(6), 680-683. doi:10.1161/01.RES.4.6.680
4. Degerli, I. U. (1972). The treatment of sixteen cases of cardiac arrest. Resuscitation, 1(3), 247-253. doi:10.1016/0300-9572(72)90054-8
5. Duncan, T. D., McClusky, D. M., & Porter, J. K. (1982). Use of drugs during cardiopulmonary resuscitation: A review of the literature. Journal of the National Medical Association, 74(12), 1218–1222.
6. van Alem, A. P., Post, J., & Koster, R. W. (2003). VF recurrence: Characteristics and patient outcome in out-of-hospital cardiac arrest. Resuscitation, 59(2), 181–188. doi:10.1016/S0300-9572(03)00208-9
7. Koster, R. W., & Dunning, A. J. (1985). Intramuscular lidocaine for prevention of lethal arrhythmias in the prehospital phase of acute myocardial infarction. New England Journal of Medicine, 313(18), 1105–1110. doi:10.1056/NEJM198510313131801
8. Lie, K. I., Liem, K. L., Louridtz, W. J., Janse, M. J., Willebrands, A. F., & Durrer, D. (1978). Efficacy of lidocaine in preventing primary ventricular fibrillation within 1 hour after a 300 mg intramuscular injection. American Journal of Cardiology, 42(3), 486–488. doi:10.1016/0002-9149(78)90945-1
9. Lie, K. I., Wellens, H. J., van Capelle, F. J., & Durrer, D. (1974). Lidocaine in the prevention of primary ventricular fibrillation. New England Journal of Medicine, 291(25), 1324–1326. doi:10.1056/NEJM197412192912504
10. Valentine, P. A., Frew, J. L., Mashford, M. L., & Sloman, J. G. (1974). Lidocaine in the prevention of sudden death in the pre-hospital phase of acute infarction. New England Journal of Medicine, 291(25), 1327-1331. doi:10.1056/NEJM197412192912505
11. Peberdy, M. A., Callaway, C. W., Neumar, R. W., Geocadin, R. G., Zimmerman, J. L., Donnino, M., Gabrielli, A., Silvers, S. M., Zaritsky, A. L., Merchant, R., Vanden Hoek, T. L., & Kronick, S. L. (2010). Part 9: Post– cardiac arrest care: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 122(suppl 3), S768 –S786. doi:10.1161/CIRCULATIONAHA.110.971002

The author has no financial interest, arrangement, or direct affiliation with any corporation that has a direct interest in the subject matter of this presentation, including manufacturer(s) of any products or provider(s) of services mentioned.

Send correspondence concerning this article to Kenneth W. Navarro, The University of Texas Southwestern School of Health Professions, 5323 Harry Hines Blvd, MC 9134, Dallas, Texas 75390-9134. E-mail: kenneth.navarro@utsouthwestern.edu

When medical devices fail, you may be required to report it so manufacturers and regulators understand the consequences.

Reporting problems is the only way that manufacturers and regulators can understand the “big picture” consequences of medical equipment failures on users and patients. When medical devices fail, you or your service may be required to report it. This column will tell you how.

Case 1

In May 2004, paramedics in Clifton Park, New York used a biphasic monitor-defibrillator to shock a patient in cardiac arrest. They successfully achieved return of spontaneous circulation and began packaging for transport when the patient fibrillated again. While charging their defibrillator, the screen went blank and then displayed a message, “bridge test failed.” A defibrillator from another ALS unit on scene was retrieved to treat the patient. Was this an isolated incident"

Case 2

During 2006 at several Albany, New York hospitals, nurses noted frequent IV pump alarms suggesting the tubing had occluded. Their initial complaints resulted in a recommendation from clinical engineering personnel that users be more attentive to proper alignment of the tubing in the pump channel. When alarms persisted, a report was filed with the Food and Drug Administration (FDA). Investigators discovered that the manufacturer had recently outsourced production of the IV tubing. The new production plant had produced tubing with external diameters outside the contracted specification. The defect resulted in the recall of tens of thousands of IV tubing sets from across the United States.

Background

The United States Congress first decided to regulate medical devices in 1976 by placing them under the watchful eyes of the FDA. The Safe Medical Devices Act (SMDA) of 1990 expanded the authority of the FDA. In 1992 Medical Device Amendments to the Act established a single reporting standard for medical device user facilities, manufacturers, and importers.

While prehospital providers and services are largely ignored in federal legislation, EMS is specifically named as a medical device user facility under the category “Outpatient Treatment Facility” (21 C.F.R. 803.3(u)(1)). The law expressly refers to ambulance providers and rescue services, regardless of whether they are licensed or accredited and whether they are independent or under the control of a larger medical entity.

The law dictates that if an event meets certain criteria for reporting, the user facility must report it, regardless of where, when, or how it occurred. Adverse event reports are referred to as Medical Device Reports, or MDRs. Bottom line: If your department has any medical or patient care equipment, you are a user facility and mandated under federal law to report adverse events.

Changes to the reporting requirements have redefined manufacturers and importers to ensure that foreign manufacturers who ship devices into the United States are required reporters, but requirements for device users have not changed.

Definitions

So what is a medical device" The simplest definition of a medical device is any object used in patient care that is not a drug. The prehospital list of devices is seemingly endless: defibrillators, suctions units, stretchers, bandages, splints, and even patient care compartments of ambulances.

What constitutes an adverse event" By strict definition, an adverse event is any occurrence that a user facility becomes aware of that reasonably suggests a medical device has or may have caused or contributed to a death or serious injury. Operator error that may have contributed to an adverse event is inconsequential and may actually identify design flaws.

Serious injury also has a complex definition that can be simplified to any injury requiring medical treatment. It is important to note that adverse events do not have to involve patients. A paramedic or civilian injured or killed by a medical device would constitute a reportable adverse event.

The FDA is empowered to extend the reporting requirements to other adverse experiences beyond those involving deaths, serious injuries, and serious illnesses, but has not yet done so.

Since 1996 user facilities including fire and EMS departments, rescue services, and air medical and ground transport services have been required to file MDRs within 10 working days of learning about an adverse event. Deaths must be reported to both the FDA and the device manufacturer, while serious injuries need only be reported to the product manufacturer. If the manufacturer is unknown, serious injuries must be reported to the FDA.

Reporting device malfunctions that do not result in death or serious injury is encouraged, but not required. Any user facility submitting an MDR (to either the FDA or a manufacturer) in the 12 months prior to January 1 must also file an annual report with the FDA compiling all of the previous year’s MDRs. Copies of MDRs and annual reports must be maintained for 2 years. Fire/EMS departments are required to have written procedures in place to identify, evaluate, submit, and maintain MDR reports.

Reporting routes

Reporting adverse events can follow two tracks: voluntary and mandatory. Health care providers and consumers can voluntarily report any adverse event or safety issue by completing FDA form 3500 electronically at the FDA’s MedWatch website.

Mandatory reports, such as those required by fire/EMS departments and other user facilities, cannot be done online at the present time. FDA form 3500 is used to file mandatory reports, and can be downloaded with instructions from the FDA MedWatch website.

Both form 3500 and the annual user facility report (form 3419) must be mailed to the FDA, Medical Device Reporting, PO Box 3002, Rockville MD 20847-3002, an address not too easily located.

A slightly out of date, but otherwise excellent, instructional manual on Medical Device Reporting for User Facilities can be found online. A change from semi-annual to annual reporting came after the manual was published.

Why report"

Reporting adverse events brings important information to manufacturers and the FDA about serious problems with medical devices — if those required to report actually do. Numerous studies have documented significant under-reporting. A US government study in 1986 concluded that hospitals reported less than 1% of medical device problems, and the more serious the event, the less likely it was reported.

The FDA maintains two searchable databases, including MAUDE (Manufacturer, User facility, Distributor Experience network), that are invaluable resources for researching equipment histories and user experience. MAUDE contains all adverse device reports, both voluntary and mandatory, filed by users, manufacturers and distributors in recent years. The precursor to MAUDE maintains Medical Device Reports filed prior to 1996.

You can search the MDR Database using free text queries, while MAUDE lets you pick product types. EMS services should scrutinize these databases whenever considering equipment purchases or investigating safety records of equipment in use.

Reporting equipment failures assures the safety of patients and your EMS colleagues throughout the world. Required or not, it is a moral and ethical imperative you owe to those you care for, the manufacturing industry, regulators, and your colleagues.

Reference

U.S. Food and Drug Administration. Medical Device Reporting. April 2013. On-Line at: www.fda.gov/MedicalDevices/Safety/ReportaProblem/default.htm. Accessed October 26, 2013.

Chapter 5

It’s Friday night at midnight and all five of Providence’s rescues are busy at Rhode Island Hospital. Well over half of our runs tonight will be alcohol related. Rescue 2 has brought an intoxicated male in from Cranston Street. He was found lying in a doorway, unconscious. Rescue 3 has a drunken Providence College student with them. I prefer the seasoned drunks like Darryl and Leroy; they never puke in the back of the truck. College kids either want to kill you when they are drunk, or they throw up without warning, usually all over the equipment. We always place an emesis basin in quick reach on weekend nights. Rescue 4 has brought in an assault victim from one of the downtown clubs and Rescue 5 has a RISD student who may have overdosed.

The radio chatter continues, sending out of town rescues into the city. While the revelers continue to party, real medical emergencies occur. An East Providence rescue heads to Wickenden Street for an elderly woman with chest pains, a Johnston rescue responds to Killingly Street for a 4-year-old having a seizure and Cranston Rescue 2 is on the way to Broad Street. From the sound of our dispatch, they’re going to get Darryl. Again.

The triage area is out of control. People with assorted injuries occupy twenty of the stretchers that fill the room, some on spine boards with cervical collars around their necks, others just lying on the stretchers. A few elderly people are nestled in among the drunks and injured. Some seem amused by the circus around them, others not so much. There, everybody waits until a spot in the treatment area opens up. The seriously injured are in trauma alley.

The night is young and already the hospital is overburdened. Tanya is working with Gary and they are doing their best to keep up with the steady flow of patients coming through the doors. They not only have to contend with the rescues, but are responsible for walk-ins as well.

Outside, the cool, evening air offers a welcome change from the stifling atmosphere of the ER. I join the rest of the rescue crews who have gathered around the trucks. Theresa and Tim from Rescue 5 sit on the rear bumper of their truck, Zack and Mike from Rescue 4, Isaac and Chris from Rescue 2 and Heidi and Al from Rescue 3 are all here, standing around swapping stories and having some laughs, waiting for the next call. This is our bonding time. The firefighters are back in the stations, all of the rescues are here. It is a nice diversion from a night full of stress and aggravation to get together and vent. Most of the talk is about the nitwits we have been taking to at the hospital, or how many runs we’ve had. It is an important and vital part of a busy night to get together and see that we are not alone. The ten people working the rescues will do seventy-five percent of the fire department’s work tonight.

Two by two our numbers dwindle. First Heidi and Al go to an accident on Branch Avenue. Tim and Theresa are next, off to another assault at a downtown club. Isaac and Chris get sent to Poccasset Avenue for an asthma attack and Zack and Mike head downtown for some hot wieners at Haven Brothers. Mike and I decline their invitation and head back to quarters, hoping to get some rest before things get busy again.

I consider calling Cheryl to say goodnight but decide to let it rest. Tomorrow we’ll try again.

0136 (1:36 a.m.)

“Rescue 1; respond to 1016 Babcock Street for a domestic disturbance, stage for police.”

I put the book I was reading down and head for the truck.

I nearly flunked my senior year of high school.

I had a propensity for skipping class and going hunting. I’d come to school feverish, coughing up a lung, preferring to bank my unexcused absences for something more important than a little illness: the opening day of duck season. Then I’d disappear for a month. My teachers didn’t much mind; my grades were good, even if I rarely showed.

Then, one day at the end of my first semester, I discovered I had miscounted my available unexcused absences, and was one over the limit. So I faked an illness and went to my pediatrician, and while his back was turned, I stole the top sheet from his prescription pad and carefully forged his signature on a doctor’s excuse for 48 hours.

Predictably, I got caught.

Sentenced to study

My senior English teacher was the only one who sniffed out the deception, and he confronted me in private. After I confessed, Marshall Halbrook made me a deal: If I met his terms, he’d keep quiet about the fake excuse, and I could graduate. Defy him, and he’d turn me in, and I’d have to repeat my senior year.

It was the kindest act of blackmail ever committed upon me, and to this day I am grateful for it. For the entire second semester, I had to work for an A in English, forced to develop a level of academic discipline I had never had before, and one that has served me well in the nearly 30 years since.

One of the books he forced me to read was Don Quixote, and it left quite an impression. For those of you unfamiliar with the story, a Spanish gentleman named Alonso Quijano read one too many fictional chivalric romances, and his cognitive cheese slid off his reality cracker. Convinced he was a knight-errant, he renamed himself Don Quixote and set out in search of the adventures he read about in his novels. In Quixote’s fevered imagination, windmills were fierce giants, flocks of sheep were armies, and humble farm girls were fair and noble ladies.

The book became such a part of the cultural lexicon that “tilting at windmills” became forever synonymous with hopeless quests, and “quixotic” was used to describe anyone who retained their idealism in the face of harsh reality.

There is a little Don Quixote in those of us who advocate for change in EMS. The reality is, most people in EMS are undereducated for the jobs we do. We value rote memorization of algorithms and protocols over critical thinking. We place greater precedence on what we do rather than what we know, placing us in a cage of our own making: a set of psychomotor skills a monkey could master, instead of a body of knowledge unique to out-of-hospital care. We prefer anecdote over evidence.

We bitch mightily, but few of us dare to dream.

The possible dream

Those of us who do dare to dream often see our dreams dashed by the reality of modern EMS. We become jaded and cynical, convinced that EMS will never become the profession we envisioned. We look around us and see little but the low-information voters of health care, and feel hopelessly outnumbered. In the book, Quixote died of despair when he could no longer reconcile his delusions with reality.

But it’s the dreamers who make things happen. Christopher Columbus. Orville and Wilbur Wright. Galileo. Martin Luther. Thomas Edison. Jonas Salk. The founding fathers of our country.

Every one of them dreamed up something radical, and was too naïve, stubborn or angry to realize that what they proposed was impossible according to the conventional wisdom of the day. Had they listened to the low-information voters of their time, what would our world look like today"

The key to retaining your idealism and continuing to advocate for change is the realization that just because an idea has been held by a lot of people for a long time doesn’t make it a good idea.

What you need is the stamina to outlast the naysayers.

Keep the faith

All too many dreamers get into EMS, see all that is wrong with the profession, and throw themselves headlong into their quest to reform EMS, as close to yesterday as possible. When they can’t sustain that passion, their careers die from the same despair that killed Don Quixote, and you will never find so bitter a burnout as a disillusioned idealist.

So when you feel outnumbered by the low-information voters, think of the changes we’ve already seen in EMS. In my career, I’ve seen wholesale shifts in clinical treatment. Twenty years ago, we immobilized everyone and let the radiologists sort ‘em out. Now, not only do most EMS systems practice selective immobilization, an increasing number are abandoning the practice altogether. Cardiopulmonary resuscitation has undergone radical a radical shift toward BLS, and for the better. Even our most sacred of cows, oxygen therapy, is undergoing serious scrutiny.

Elements of system design are no longer immune to scrutiny, either. Forty-eight and 72-hour shifts are becoming rarities. Lights-and-siren response is falling out of favor in many systems. Community paramedicine is gaining a foothold. Everywhere you look, EMS is changing and adapting.

If you don’t see improvements at your agency, perhaps you’re just not casting your gaze broadly enough. And if you can’t affect some degree of change at your agency, perhaps it’s time to leave your comfort zone and seek a place that challenges and inspires you.

And next time someone calls you a malcontent, don’t view it as an epithet. Consider it a badge of honor, and keep on tilting at windmills. Eventually, we’ll knock ‘em down.

CLINTON, Miss. — The National Association of Emergency Medical Technicians (NAEMT) announced the results of the NAEMT Board of Directors election for volunteer positions in the 2014-2015 term:

• Region I Director (re-elect): Scott Matin, New Jersey
• Region II Director: Cory Richter, Florida
• Region III Director: Aimee Binning, Wyoming
• Region IV Director (re-elect): Bruce Evans, Colorado
• At-Large Director (re-elect): Ben Chlapek, Missouri

All NAEMT Active members had the opportunity to vote in this election from October 15-28. The 2014 Board of Directors takes office on January 1. Joining President Don Lundy in continuing on the Board are: Chuck Kearns, President-Elect; Jim Judge, Secretary; Dennis Rowe, Treasurer; Connie Meyer, Immediate Past President; Jim Slattery, Region I Director; Chad McIntyre, Region II Director; Chris Cebollero, Region III Director; Rod Barrett, Region IV Director; Matt Zavadsky, At-Large Director; and Paul Hinchey, Medical Director.

“Please join me in congratulating our new Board members, and thanks to the members who voted in the election,” said NAEMT President Don Lundy. “Our gratitude goes out to all of the candidates for their interest in serving as leaders of NAEMT and their dedication to our Association and all of the EMS practitioners we represent.”

About the Newly Elected Board Members

Scott Matin is Vice President of Clinical & Business Services at MONOC Mobile Health Services, Wall, N.J.— New Jersey’s largest provider of EMS, ambulance and aeromedical services. Over the past year, Matin chaired the NAEMT Membership Committee and lead the Principles of Ethics and Personal Leadership (PEPL) Committee to develop a 16-hour CEU program for EMTs and Paramedics. He also serves on NAEMT’s Community Paramedicine and Advocacy Committees, and is a liaison to the American Ambulance Association and the Association of Air Medical Services. Matin hopes to “strengthen our profession — which I have dedicated my life to — because it is among the most honorable and respectable professions a person can have.”

Cory Richter is a Paramedic for Indian River Fire Rescue in Florida. He also is active in NAEMT as State Advocacy Coordinator, Advanced Medical Life Support (AMLS) State Coordinator, Affiliate Faculty and Instructor, PreHospital Trauma Life Support (PHTLS) Affiliate Faculty and Instructor, and Emergency Pediatric Care (EPC) Instructor. Richter has devoted years to state-level EMS issues, one being the creation of the Florida Drug Shortage Committee. He hopes to “continue to address the needs of EMS and push for better standards and organization at the national level, and push to take EMS to the next level and beyond. EMS is at a pivotal time and we need board members with big aspirations and the tenacity to see them through,” says Richter.

Amy Binning is a full-time practitioner for Sublette County EMS (SCEMS) in Pinedale, Wyo., where she was formerly Educational Coordinator, Secretary, Special Events Coordinator, and volunteer. Binning has served NAEMT as Region III Director, Health and Safety Committee member, Membership Committee chair, course educator, and an NAEMT Foundation Trustee. She was also a recipient of the NAEMT Presidential Leadership Award, and has been an advocate for EMS at the federal level by participating in various meetings and collaborations with EMS related groups. Binning states, “I will represent each of you to achieve our goals and realize our full potential as the Nation’s voice for EMS practitioners.”

Bruce Evans is the Deputy Chief at the Upper Pine River Fire Protection District, outside of Durango, Colo. He is a retired EMS Chief from the North Las Vegas, Nev., Fire Department, after serving 27 years in the Southern Nevada EMS system. He is an adjunct faculty member of the National Fire Academy in the EMS, Incident Management, and Terrorism Training programs. Bruce was also a recipient of the prestigious James O. Page EMS Achievement Award. “I have served in almost every aspect of EMS — hospital, fire, police, third-service, helicopter, and private ambulance, volunteer, and paid services — which helps bring a well-rounded perspective to NAEMT, as it strives to meet the needs of our membership,” says Evans.

Ben Chlapek is Chair of the NAEMT Military Relations Committee. Involved in NAEMT for more than 30 years, Chlapek has served as the Missouri representative to the NAEMT Board of Governors and Deputy Chief of the Central Jackson County Fire Protection District in Blue Springs, Mo. He also holds an A.A. in Fire Science, a B.A. degree in Chemistry, an M.P.A. degree in Public Affairs, as well as an M.S. in Homeland Security Studies. He retired as Lieutenant Colonel from the U.S. Army after 36 years of proud service. Wounded in Afghanistan, Chlapek works to help veterans. He states, “I believe that serving our profession is an honor — an opportunity to serve the people in our profession — and a duty."

A question posted recently on Quora asked, “Without violating patient confidentiality, what are some ridiculous ER stories" You know ... those crazy cases you tell your colleagues about. The ones you'll never forget ..." Lou Davis, and emergency nurse and clinical nurse educator, determined that "the constant source of interest and amusement can be divided into various categoires." Among her personal favorites:

Stuff Where it Shouldn't Be
The man with an apple inserted into his rectum, apparently by accident after an unfortunate fall onto a fruit basket whilst vacuuming. Naked! Now, I may be naive, but I'm not stupid and this is not believable. The public also present with vibrators, toothpaste pump dispensers and various items of cutlery.

These things are fairly amusing. The stories they tell about how the item got there, funnier still.

Creatures and Creepy Crawlies
One memorable day, a young lady arrived in the department weeping bitterly. She had, she told me, something in her bottom. Expecting a minor lump or spot, I asked her to lower her trousers. As I bent down to peer at the offending object, the offending object reared up to look back at me (it was a very large worm!) I vomited, Dr. Dan (I have spoken of him previously) fainted!

We have also had people attempting to insert small rodent-like creatures into various bodily oriffii (not sure if that's a word but I think you get my gist!)

Priapism
Look it up! This is a persistent erection of the male organ. It can be caused by a spinal injury. One patient arrived with a history suggestive of such an injury. There was a large 'bulge' in his undergarments. We were worried; this was not a good thing.

Sometimes 'it was there' sometimes 'it wasn't!' A colleague was suspicious, she tapped it, a suspiciously solid noise was heard. The patient had a large, false, member pushed into his pants. He had placed it there to 'impress the girls'.

You Can't Park There
Some people don't like to walk; some people don't like to walk so much that they want to park the car as close as they possibly can to the ED. One such person also clearly didn't want to get cold and/or wet and so drove their car through the automatic doors into the department!

Pranks
Emergency Department staff like to joke. And we are very good at it. You may think that you can play pranks on one another; I'm fairly sure that we are better.

Sandwiches sellotaped to the ceiling - done that. Wrapping colleague's cars in cling food wrap - done that.
The raising of the 'dead' (obviously a colleague) - done that!
Gluing colleague's shoes to the floor (that was funny!)

Noxious Substances
We like to think that we are moderately intelligent in the ED. However, that 'intellect' seemed to desert one of our number when a patient arrived in the department after having collapsed shortly after drinking from a cola bottle. The partially filled bottle was handed over. My esteemed colleague opened the bottle, inhaled deeply and stated 'does anyone think that this smells like almonds"'
(yes, for those Agatha Christie fans, it was cyanide!! As punishment, he spent the next few hours dressed in a chemical protection suit!)

Bad Folks
Occasionally, people arrive in the ED who have committed, or been victims of, crime (and on occasion have confessed to murder - but that's another story). On one memorable evening, a less than savoury character arrived having been involved in a violent incident. Forgive us for stepping aside when we were warned 'you've seen nothing' as he was carried out of the department later.

Giving Birth
For various reasons, some women arrive in the ED to give birth. Occasionally, these women (often young girls) claim to be unaware that they are 'with child'. We in the ED love 'having a baby'. It makes us feel all warm and fluffy. And it can be fairly amusing. On many occasions, I have been the bearer of good news.

A large number of these new parents are delighted.

Most amazement is reserved for those poor girls who, when the baby is being delivered, claim it isn't 'theirs' and it needs to go back.

Stake
We received a 'red phone' pre-alert that we would be receiving the victim of a road accident who had collided with a fence. Sure enough, he arrived. Unfortunately, so did the fence. there was a fence post, probably 5 inches across, which entered his body just below the right side ribs and exited through the left shoulder. All well and good had he been unconscious. He looked at us, we looked at him. In a very English way he said, 'I seem to have a splinter, I think that you might need to remove it'. He spent 3-4 weeks on the Intensive Care Unit but lived to tell the tale.

Farmers
We were sitting around, chatting idly one day when a big, red-faced farming type hoved into view. We asked if he needed help as he appeared to be a little 'lost'. He gestured to his left hand side, 'I seem to have lopped me arm off,'' he said. We looked at one another. This was clearly (to use the vernacular) Bollox as he was standing in front of us. So we removed the grubby blanket he was clutching around his shoulder. As we pulled it away, his left arm came with it. He looked at each of us in turn, 'Told you' he said.

I am really humbled to be a part of the movement to change the culture of safety within EMS and the fire service. When a police officer is assaulted, the assailant pays the price. When EMS providers are attacked, very little happens.

As a medic, when I was attacked, it seemed that no one cared. So I decided to do something about it. Change happens when it is personal to you. The stories that many other providers have shared about being victims of violence only strengthened my resolve to change the culture of safety as we know it.

A personal mission

Those who know me know this is a personal mission. It’s my passion, almost an obsession. Almost every day, I hear or read about one of us being assaulted. Many of the stories are worse than my personal experience. I have cried with you, got angry for you, and have grown better and stronger because of you. There is tremendous momentum now to change.

It’s OK to press criminal charges against a person who assaults you on the job. It is not just part of the job, and there are laws that prove that. Yes, it can be a pain to press charges, but do it. If not for you, do it so the rest of us can benefit. Make it a better and safer career for all those new providers who will eventually replace us.

I’ve been teaching techniques to defuse and defend against hostile behavior for some time. People laughed at me at first; they said there was no need to train EMS providers for violent encounters. Well, studies and surveys have proven there is a need, and the violence we face is real. According to the NAEMT, 4 out of 5 medics have been injured on the job — the leading cause of which (52%) is violence.[1]

According to Dr. Brian Maguire, EMS providers are 22 times more likely to be assaulted on the job than any other private sector profession.[2]

I have traveled all over the country. To date, I haven’t been at a station where there haven’t been tons of stories about being kicked, punched, stabbed by people we thought were patients. None of that behavior would be accepted in any other profession, yet some of us believe it is just “part of the job.”

It’s not. It’s simply not acceptable.

Definition of terms

When it comes to the subject of changing the safety culture within EMS regarding violence, we will have to address what I have found to be the most fundamental problem: the difference between a patient and an attacker.

This is not as simple as it sounds. Not being able to tell the difference between the two causes a conflict of mission, during and following a violent encounter. For example: An EMS provider is assaulted. Since the provider has no clear understanding of “patient” versus “attacker,” he believes that the assailant is a “patient.” So, any act of aggression is believed to be “part of the job.” The provider feels obligated to continue to engage the patient, even after being assaulted.

If the provider wished to pursue criminal charges against the assailant, they may be mocked by other staff because of the “part of the job” mentality. No criminal charges are filed, which leads to a lack of criminal prosecution. The act is essentially condoned by us.

Patient versus attacker

Let’s clarify the difference between a patient and an attacker. In order to be mentally better prepared for scene safety “tactics” while maintaining good customer service, EMS providers must have a clear separation between an uncooperative patient and an aggressive attacker.

An uncooperative patient is confused due to a true medical emergency. Examples would include postictal seizure patients, a hypoglycemic patient, a hypoxic patient, or a TBI/CVA patient.

An aggressive attacker is an intoxicated/drugged individual who uses verbal threats; attempts to grab, strike, spit or otherwise assault a provider; and places the provider in apprehension/fear for their own safety.

What doesn’t exist is the “combative patient.” Let’s define each part of the phrase.

• Patient: a person who is under medical care or treatment.
• Combative: eager or ready to fight, argue; aggressive.[3]

If EMS providers think “combative patient,” the “patient” part is what sticks in their minds. Therefore they remain connected, so to speak. Role confusion begins, which creates a dangerous environment for the provider to operate in. Is there any wonder why EMS providers wind up getting assaulted"

Once we are clear about who we are dealing with by definition, it becomes easier to manage the patient care approach. I’ll talk about that in the next article.

References

1. “NAEMT: Four in Five Medics Injured on the Job,” Fire Chief, Nov. 18, 2005. http://firechief.com/ems/naemtsurvey111805 Accessed 10/28/13

2. “EMS Occupational Risks,” Brian J. Maguire, Dr.PH, MSA, EMT-P, National Association of State EMS Officials 2009 Mid Year Meeting, http://www.nasemso.org/meetings/midyear/documents/maguire-ems-occ-risks-jun09.pdf Accessed 10/28/13

3. http://dictionary.reference.com/ Accessed 10/28/13

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 ...