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

A panel of EMS leaders shares their top surprises, concerns and suggestions on how other leaders can apply the State of EMS findings to improve their agencies.

Guilford County EMS partners with the N.C. Harm Reduction Coalition to distribute naloxone to patients who refuse transport after an overdose.

To effectively manage jaundice and detect hyperbilirubinemia in newborn babies, healthcare policies are in urgent need of change.

Survivors of fallen first responders currently can get a one-time $25,000 payment.

The two teens followed the dispatcher's instructions in aiding their mother until paramedics arrived on the scene.

The business offers inter-facility transfers for Aberdeen and the surrounding area.

The TEMS team is familiar with the types of emergencies the SWAT team responds to, allowing them to respond more quickly to those situations.

New to EMS? Here are some flashcards to make learning medical abbreviations easier.

Colleagues found Sean McMullin, 46, unresponsive on Sept. 24; he worked 14 years with the department.

Tennessee and the 16 other states have led the way in emergency preparedness in academic settings by enacting laws that require the device be placed in all schools.

A panel of EMS leaders shares their top surprises, concerns and suggestions on how other leaders can apply the State of EMS findings to improve their agencies.

Guilford County EMS partners with the N.C. Harm Reduction Coalition to distribute naloxone to patients who refuse transport after an overdose.

To effectively manage jaundice and detect hyperbilirubinemia in newborn babies, healthcare policies are in urgent need of change.

Survivors of fallen first responders currently can get a one-time $25,000 payment.

The two teens followed the dispatcher's instructions in aiding their mother until paramedics arrived on the scene.

The business offers inter-facility transfers for Aberdeen and the surrounding area.

The TEMS team is familiar with the types of emergencies the SWAT team responds to, allowing them to respond more quickly to those situations.

New to EMS? Here are some flashcards to make learning medical abbreviations easier.

Colleagues found Sean McMullin, 46, unresponsive on Sept. 24; he worked 14 years with the department.

Tennessee and the 16 other states have led the way in emergency preparedness in academic settings by enacting laws that require the device be placed in all schools.

The first-year findings from the State of EMS report set a foundation to track change in EMS and ignite discussion among EMS leaders and field providers about our future. We asked EMS1 editorial advisors, columnists and contributors to review, react to and reflect on State of EMS 2016 data. The panel includes:

• Dr. James MacNeal, EMS physician
• Sean Caffrey, EMS manager/administrator
• Chris Cebollero, EMS consultant
• Rob Wylie, Fire Chief
• Catherine R. Counts, EMT, graduate student

1. Which State of EMS 2016 finding surprised or interested you most"

Dr. James MacNeal: It is interesting that such a large percentage of respondents think paramedics should have an associate’s degree as a minimum requirement. These same respondents reported an extremely low number of associate’s degree-prepared paramedics working for them.

It will be interesting to follow this trend over time as the next generation of paramedics enters the profession. While the associate’s degree may seem to be a surrogate for achieving professional status for paramedics, it causes me some concern. Is it fair to ask an entry-level paramedic to take on two years of college debt to enter a career that pays less than minimum wage in some areas"

The perpetual chicken-or-egg situation is occurring here. Do we get the degree to justify better pay, or offer better pay so providers get the degree" My guess is that it will be a slow combination of both that will ultimately lead to a larger proportion of associate’s degree-trained paramedics.

Sean Caffrey: I also found it most interesting that almost two-thirds (64 percent) of respondents believe that paramedics should hold at least an associate’s degree; however, less than 8 percent of organizations actually required that of their applicants. This is a clear disconnect that actually represents our own organizations holding us back as professionals.

It’s also interesting to note we’ve been concerned about 24-hour shifts, and longer, for many years. We also have recent evidence that 12-hour shifts may, however, be among the worst of all in terms of fatigue and recovery. Interestingly, almost 40 percent of services report shift lengths of 24 hours or more, while half of all services surveyed use 12-hour shifts.

We have much work to do to better understand shift length and fatigue, including the research published in Prehospital Emergency Care, " Recovery between work shifts among Emergency Medical Services clinicians."

Chris Cebollero: It was interesting to see the differences in how systems are conducting clinical care. More than half the agencies involved in the cohort are using an AutoPulse or LUCAS device. You can argue that these systems are trying to be on the cutting edge of care and trying to increase their cardiac arrest survival rates. But only a quarter of reporting agencies are using the impedance threshold device. This seems to be a disconnect in using resources in concert with each other to achieve a high rate of ROSC. If you decided to go with a mechanical CPR device, take the next steps and use the ITD to ensure maximum effectiveness.

Rob Wylie: The survey finding that surprised me the most was the lack of consistency in medical care practices. I realize that there is and always will be a significant divide in the service area types — for example, rural versus urban — but with the advent of available technology, such as software for patient tracking outcomes, along with increased grant availability and more professional certification and education requirements, I would have thought that the gaps would narrow. There will always be outliers, but I expected a more homogeneous prehospital health care system.

I was also surprised by the disparity in clinical measures being utilized by different agencies. With the widespread distribution of best practices, I expected more agreement on critical clinical measures that all agencies should track as a standard.

Catherine R. Counts: Two things stood out to me. First, almost half of the organizations were able to implement hypothermia protocols, which is a relatively quick uptake of a new clinical procedure versus other interventions. Note that the 2015 AHA guidelines do not recommend prehospital initiation of therapeutic hypothermia.

Second, I am surprised that nearly half of respondents are surveying patient satisfaction – although I think we need to define the word "survey" to better understand the effort to collect and analyze satisfaction data.

2. Which additional finding was either most affirming or most concerning"

Sean Caffrey: I was pleased to see a very diverse list of organizations surveyed, an uncommon occurrence. Overall it shows that while we often pride ourselves on variation, we are generally similar as organizations and as a profession, dealing with similar issues and seeing similar trends. Despite the variation in agency type and geography, little in the survey was particularly surprising.

James MacNeal: The funding issues continue to concern me. As health care becomes more integrated, are we placing increasing demand on some of the lowest-paid members of the health care team with the least amount of training in care management and long-term care"

This is unfortunate, but it might also prove a huge opportunity for EMS to step into a role that no other provider can assume in such a rapid fashion. Mobile integrated health care needs to be properly funded before we can expect our agencies to continue to pursue it as a viable care option. Expecting EMS to develop training programs, educate providers and provide care is a lot to ask when there is no dedicated funding stream.

Chris Cebollero: It was interesting that there is still so much reliance on response times as a component of an effective EMS system. This old way of measuring system effectiveness has to finally be debunked and replaced. The EMS systems of today need to also focus on outcome measures, including measurement of patient satisfaction.

First responders are getting on-scene on average in four minutes. Care is at the patient's side faster today than when response time compliance was put into place decades ago. The clock should then stop and the team needs to deliver the best patient care possible, focusing on outcomes, navigating the patient to the most appropriate treatment facility and ensuring that patients feel they received excellent care.

Rob Wylie: The most affirming finding was the overwhelming agreement by the respondents that EMS services are becoming more integrated with the overall health care system. The complexity of the regulatory environment, coupled with the pace of clinical change in medicine in general, dictates that we have a cohesive, comprehensive and symbiotic relationship between EMS response agencies, hospitals and the medical education system.

Catherine R. Counts: It is affirming that clinical measures are being used by agencies to measure appropriate application of care, but the amount of variation is worrisome.

3. How do the findings of the first year align with other trends in EMS and health care"

Catherine R. Counts: It makes sense to me that there is variation in how "success" and "good care" are measured. The U.S. health care system as a whole can’t agree on what constitutes good care, so it’s no surprise that EMS can’t either.

James MacNeal: The likely increase in patient satisfaction scores tied to EMS reimbursement is a very scary prospect. Patients are often most anxious and least likely to understand the care that is being provided to them in the first minutes of their emergency. Poor experiences in the emergency department and in the hospital may translate to lower patient satisfaction scores for EMS by the time the patient receives the survey. In a model where EMS providers must have pancake breakfasts, fish fry dinners and bingo night (to raise needed funds), it is very scary thinking that if their patient satisfaction isn’t good, their reimbursement might be lowered more than the barely afloat level it is at already.

Chris Cebollero: It seems to me that the status quo is alive and well in EMS. The adage, "that's the way we have always done it" comes to mind when looking at the first year of data. We now have the opportunity to challenge our processes, determine what the EMS systems of tomorrow will look like and transition to new models. Health care is changing daily. It is time for EMS to be in the forefront of change to help patients get healthier.

Rob Wylie: The findings of the first year point in a couple of directions. First, patient outcome-centered care. As we see the growth of community paramedicine to prevent patients who could otherwise be treated at home by highly trained medics — supervised by doctors, physician assistants or nurse practitioners/APRNs — from returning to the hospital.

Second, we have an opportunity to refocus more of the services we provide to be patient-centric. Why do we transport diabetics who return to a normal (blood sugar level) after treatment" Why are COPD patients transported when all they may need is an adjustment in their medications" Home-based care is less expensive, less invasive and in many instances more than adequate.

Sean Caffrey: The variation in clinical care was not particularly surprising. As with any medical practice, the level of care being provided and the adoption of new treatment modalities occur at various speeds throughout the health care system.

It was also interesting to see some clearly outdated items still around while some newer therapies had gained substantial adoption. This is comforting in the sense that it represents that we advance in a similar way to our colleagues throughout health care and that removing therapies is perhaps harder than adding them.

4. What specific actions, based on State of EMS 2016 findings, do you recommend to EMS leaders"

Chris Cebollero: It is always a best practice to benchmark your system, processes and clinical care with the career field. This project lets EMS leaders look into the EMS mirror and gauge how successful their EMS system truly is. As leaders, we need to meet, exceed or set the standards for others to follow and hopefully come to some consensus on how "gold standard" EMS systems should operate. This is going to be a long road, but it begins with the sharing of data.

James MacNeal: Engage with your local hospitals now. Mobile integrated health care is not a right of EMS. Many hospitals don’t even know EMS providers can do these things. By getting in on the front end of this, EMS will be in a better position to control their destiny. Engage your medical director for EMS activities as well as hospital liaison duties. Integration is paramount to all of our success, but if you are not a full partner, bundled billing will be your nemesis.

Catherine R. Counts: Recognize that no EMS organization is an island, while at the same time no two organizations are exactly alike. Protocols and procedures can have variation across organizations, but said variation must come from a place of good intentions.

EMS is a changing field, but different organizations have the capacity to change at various rates. Don’t try a new idea just because a famous EMS agency or service did it. Do your own research and come to a decision that is best for your organization’s economic and cultural situation.

Rob Wylie: I am reminded of the adage, the only two things emergency response agencies hate are change and the way things are. We need to focus on best practices, evidence-based medicine and clinical measurements that truly gauge the value of the service we provide. "We’re too small" or "We’ve always done it this way" are crutches and excuses that do not hold water.

Look around at those that are doing it right. Educate your community and its leaders as to the kind of service your customers deserve and that those services cost money. Adopt evidence-based clinical measures that show the great work you are doing, not just how fast you are leaving the station after a 911 call.

Sean Caffrey: The IHI's "Triple Aim" will continue to be the rallying cry of health care moving forward. We know health care is too expensive, far less effective than it should be and very disconnected from the patient.

EMS leaders must do a better job of measuring from the customer’s perspective. Obscure metrics, such as measuring response time intervals from the time of dispatch, something no patient would care about or benefit from, puts us in a position of peddling self-serving nonsense that will likely come back to haunt us. We must also do a much better job of measuring and providing good customer service. It won’t be long until we can read about ourselves in a Yelp or similar-style review.

5. What else would you add to the discussion"

James MacNeal: EMS providers need to be active learners and participants in the EMS system. Encourage your medical directors, nurses, emergency physicians and law enforcement personnel to spend time with you. You need to carry the torch of your profession and spread the word of our undying commitment to saving lives and serving our communities.

Chris Cebollero: As EMS leaders we often talk about how splintered the EMS career field is, or we wonder when some person or agency is going to unite all of EMS so we finally get the recognition and respect our career field deserves. It is through efforts such as this that will bring recognition to common care and operational practices.

Sean Caffrey: An overwhelming majority of respondents want paramedics to have a degree, many EMS organizations invest over half their budgets on staff and we claim to be very concerned with their safety. Our actions, or perhaps our need to get trucks on the street at any cost, however, show that we are not yet aligning our practices with our preaching – issues which are squarely under our control as EMS leaders.

Catherine R. Counts: The fact that Fitch, EMS1 and NEMSMA teamed up to do this report is fantastic. Although prior attempts at surveying EMS organizations have been made, the long-term goals of this survey set it apart from those efforts. By committing to seek out responses from the same organizations year after year (and with such a large response rate), this survey will only become more valuable both within and outside the EMS industry.

Concepts like mobile integrated health care and community paramedicine, paired with the continued focus on ensuring that health care is effective while being patient-centered, noted in this report and subsequent surveys will ensure that EMS is able to keep pace with the trends, changes or alternative markets coming our way.

Rob Wylie: I would recommend that all EMS leaders become involved in professional associations and organizations such as the National EMS Management Association, the International Association of Fire Chiefs, and the National Association of EMS Physicians (you don’t have to be an MD to join!).

Most of all, I would encourage leaders and their personnel to look hard at what their communities expect from them now, and then educate them as to what is possible with a collaboration and support in the future.

Find the need and create the solution! Become the "agency of first resort" in your community.

The Panel
James MacNeal, MPH, DO, NRP, began his career in emergency medicine as a paramedic. He holds an American Board of Emergency Medicine/Emergency Medical Services certification and completed an EMS fellowship at Yale University. He is the MercyRockford Health System’s EMS medical director.

Chief Rob Wylie has been in the fire service for 29 years, serving first as a volunteer firefighter and then as a career firefighter, rising through the ranks to become the fire chief of the Cottleville FPD in St. Charles County, Missouri, in 2005. During his tenure, he has served as director of the St. Charles/Warren County Hazmat Team and as president of the Greater St. Louis Fire Chiefs Association. Wylie has served as a tactical medic and TEMS team leader with the St. Charles Regional SWAT team for the last 19 years and serves on the Committee for Tactical Casualty Care guidelines committee. Chief Wylie is a member of the Fire Chief/FireRescue1 Editorial Advisory Board.

Chris Cebollero is a nationally recognized emergency medical services leader, author and advocate. He is a member of the John Maxwell Team and available for speaking, coaching and mentoring. Currently he is the senior partner for Cebollero & Associates, a medical consulting firm, assisting organizations in meeting the challenges of tomorrow. Cebollero is a member of the EMS1 Editorial Advisory Board.

Catherine R. Counts is a doctoral candidate in the department of Global Health Management and Policy at Tulane University School of Public Health and Tropical Medicine, where she also previously earned her master’s degree in Health Administration. Counts has research interests in domestic health care policy, quality and patient safety, organizational culture and prehospital emergency medicine. She is a member of AcademyHealth, Academy of Management, the National Association of EMS Physicians and National Association of EMTs.

Sean Caffrey, MBA, CEMSO, NRP, currently serves as the EMS programs manager for the University of Colorado School of Medicine, Pediatric Emergency Medicine Section. He has been certified as a paramedic since 1991 and has worked in volunteer, private, hospital-based, fire-based and third service EMS systems in roles from provider through department head. Caffrey currently works in conjunction with the state EMS office in Colorado, is the vice president of the EMS Association of Colorado, is a board member of the National EMS Management Association and a member of NAEMT, NASEMSO and NAEMSP. His interests include EMS system design, pediatrics, public policy, professional development and research.

By Allison G. S. Knox, EMT-B, Faculty Member at American Military University

It isn’t rare for newborn babies to have trouble with jaundice in the days after their birth. The condition is usually recognizable by an orange coloring of the skin, which is caused by a high level of bilirubin in the blood. Most of the time the baby’s liver will rid the body of bilirubin, but in rare cases, the bilirubin level rises so quickly that their body simply cannot recover, resulting in devastating effects.

When the level is high enough, bilirubin crosses the blood-brain barrier and leaves a stain on the brain that causes brain damage, a condition called kernicterus. Untreated severe hyperbilirubinemia can also cause auditory neuropathy spectrum disorder, ranging from mild to complete hearing loss, and cerebral palsy, which leaves a child unable to walk. Many of these children are forced into wheelchairs for life. For some, severe hyperbilirubinemia can even result in death. Once caused, the damage from hyperbilirubinemia cannot be reversed, but the cognitive parts of the brain are often left intact. For the family of a child with kernicterus, it can be devastating to see their child who was perfectly healthy at birth suddenly suffer from a debilitating illness.

Changing medical policies
To effectively manage jaundice and detect hyperbilirubinemia in newborn babies, healthcare policies are in urgent need of change. Because potentially devastating levels of bilirubin are so rare, many doctors don’t necessarily look out for the signs and symptoms that can arise in the first few days of a newborn’s life. As a result, a child who could be helped is often left untreated. If bilirubin levels were regularly checked through physician-ordered tests, fewer babies would suffer from kernicterus.

Full Story: Medical changes that could prevent brain damage in infants

Learning medical abbreviations may be a difficult hill for new EMTs to get over. We’ve all been there, and flashcards are probably one of the best tools at your disposal.

Getting a good grasp on these abbreviations will not only help you throughout class, they will also help you write patient care reports when you work in the field.

Here’s a free collection of medical abbreviation flashcards that students have used to ace their EMT program.

Follow these instructions to get the most out of the flashcards:

The best way to use this app is to change a setting in the options menu so that it shows the abbreviation first, and you guess what it means.

After that, you can navigate the flashcards using the arrow keys. Press the down arrow key to see what the term means, and use the left and right arrow keys to shift back and forth between terms.

You can also quiz yourself in other ways depending on the learning style that's best for you. Students may use the "Test" study mode to see how it might be presented on a real test.

Of course, you can check out the full list here.

Did we miss any words" Let us know on our Facebook page or reply in the comments section below.

Download this podcast on iTunes, SoundCloud or via RSS feed

​​In this Inside EMS Podcast episode, co-hosts Chris Cebollero and Kelly Grayson discuss what EMS professionals need to know when dealing with pipe bombs and small acts of terrorism.

They pose this question: You are in a mall and a guy has stabbed three people. One person has a gusher of a wound coming from the neck or femoral. How can you stop the bleeding without getting yourself grossly contaminated"

Chris and Kelly also take a seat at the Guest Table and are joined by EMS1 columnist Dan Limmer. Dan shares his experience and opinions on DNR's, the grieving process and what educational standards we need to prepare EMS for dealing with the families of terminally ill patients.

Depending on the service area covered by a particular EMS provider, most of us will respond to one or more gunshot victims a career.

These may range from drive-by shootings to accidental trauma to self-inflicted gunshots to hunting accidents. The locations of most gunshot victims have an element of scene safety to consider, but most incidents are usually limited in scope with enough resources to secure the scene and treat the presenting patient or patients.

An active shooter incident is loosely defined by law enforcement as one in which a shooting is in progress and the situation may require a response which is different from standard practice [1]. The active aspect is important because, unlike a homicide or other completed crime, law enforcement or other responders may have an opportunity to alter the outcome of the situation. These situations are more specifically described by the FBI as "an individual actively engaged in killing or attempting to kill people in a confined and populated area" [1].

The power of data
In 2014, the U.S. Department of Justice released an analysis of 160 active shooter incidents from 2000 until 2013. During that time frame, 1,043 casualties, including 486 fatalities, were the result of shootings in 40 states and the District of Columbia. The DOJ study found that active shooter incidents can occur in any size or type of community meaning that all emergency responders need to prepare for a scenario like this one [1].

As the report details, there are themes common to many of these incidents:

• Predominantly male shooters (96.25 percent of incidents)
• Predominantly a single shooter (98.75 percent of incidents)
• Often resolved in five minutes or less (70 percent of incidents where a length could be determined)

These themes have grown into data-driven recommendations for both law enforcement and EMS providers on how best to respond to active shooter incidents. Because these incidents are high profile and evolve quickly, standard responses — like waiting for SWAT and tactical EMS personnel to arrive — are likely to be ineffective and responding units need to take a more proactive role early on in the incident [2].

Changing roles for police, fire and EMS
The traditional response to a shooting with a barricaded suspect had law enforcement to establishing a perimeter with EMS staged outside and waiting for SWAT to respond before making entry. With the advent of data-driven recommendations, officers are now asked to immediately enter the scene and engage with a shooter as prior evidence shows that this action has an excellent chance of bringing the incident to a close [1].

Similarly, fire and EMS agencies are being asked to treat these incidents more like hazardous materials scenes with defined hot, warm and cold zones. Given that these incidents are often perpetrated by a single shooter, once law enforcement has neutralized the shooter the scene essentially becomes a warm zone. SWAT and tactical medic resources are still needed for a detailed search of the premises but first responders, under police cover, can now begin to triage, stabilize and extricate wounded individuals [2].

This is an important step forward as the injuries sustained by victims of an active shooter are often dependent on rapid application of bleeding control and surgical repair.

The acronym to remember for active shooter response is THREAT:

• Threat suppression (law enforcement)
• Hemorrhage control
• Rapid Extrication
• Assessment by medical providers
• Transport to definitive care

This acronym combines the best available evidence about active shooters with evidence-based practice for trauma care [2].

Treatment priorities
Wounds sustained by victims of an active shooter can be broadly characterized as extremity or core injuries. Penetrating wounds to the extremities are already known to be effectively treated by early application of a tourniquet. Provided that a tourniquet is correctly applied, patients with these injuries may be considered stable for a period of time.

Wounds to the head, chest and abdomen are largely considered surgical in nature. While hospital capabilities and available surgical suites may vary from system to system, transporting these patients rapidly to an appropriate trauma center is critical to their survival.

Establishing a casualty collection point allows extrication teams to avoid extensively triaging patients in the warm zone and instead to bring all patients out of the scene to be triaged and readied for transport. Care of victims during extrication should be limited to rapid application of bleeding control and removal to a casualty collection point [2].

Recently the White House, in conjunction with the Department of Homeland Security, launched the Stop the Bleed campaign to educate the lay public about hemorrhage control for everyday emergencies and mass casualty incidents, including an active shooter. Consider adopting this program for community outreach events or pre-positioning bleeding control kits in high-risk venues or those where there are a number of trained lay people.

Case conclusion
You pull up on scene and the engine crew meets up with their law enforcement escort. After donning body armor — ballistic vests and helmets — the extrication team proceeds into the building with bags of tourniquets and hemostatic dressings.

You and your partner establish the casualty collection point and advise incoming ambulances of the ingress and egress routes to the scene. You open your agency’s active shooter handbook and notify both your local agency contacts as well as those from your mutual aid agencies and the area hospitals. Finally, you and your partner prepare to receive the first wounded victims as the extrication team comes out of the building.

References

1. Blair, J. P., & Schweit, K. W. (2014). A Study of Active Shooter Incidents, 2000 - 2013. Texas State University and Federal Bureau of Investigation, U.S. Department of Justice, Washington D.C. . Retrieved from https://www.fbi.gov/file-repository/active-shooter-study-2000-2013-1.pdf
2. US Fire Administration. (2013, September). Fire/Emergency Medical Services Department Operational Considerations and Guide for Active Shooter and Mass Casualty Incidents. Retrieved from https://www.usfa.fema.gov/downloads/pdf/publications/active_shooter_guide.pdf

Any firefighter, officer or medic worth their salt comes away from an incident with a better understanding of their own strengths and weaknesses. And when that incident is major, often the revelations are as well.

That was one of the lessons Dallas Fire-Rescue Battalion Chief Tami Kayea learned from her night commanding the fire and EMS resources sent to deal with "one of the worst tragedies in our history" when a sniper opened fire on police officers during a peaceful, planned protest.

Chief Kayea addressed the more than 200 who attended this month's annual Executive Fire Officers Graduate Symposium at the National Fire Academy about the night of July 7 when a lone sniper with a high-powered weapon took aim at police from a downtown parking garage during a Black Lives Matter march, killing five and injuring seven other officers and two civilians.

Chief Kayea was on duty at a station six blocks from the site when the shooting began. They set up a mobile command post and a 15-block perimeter around the site. They essentially had a small fire department operating inside the perimeter, she says.

Fire and EMS crews running calls within that perimeter did so without lights and sirens. And she instructed units coming in to don bunker gear and traffic vests to visually set them apart from police — Dallas Fire-Rescue wears a dark blue station uniform similar to that of police.

Looking back, Chief Kayea says she should have established the command post at the nearest fire station. That would have provided more space and better communication tools than what they had in the field. And, she says, they were so far removed from the actual incident that being in the field offered no advantage.

One problem that arose was that dispatch was updating information over the computer, which is located in the cab of the command vehicle. However, they had established command operations at the rear of the vehicle and eventually had to station one person in the cab to keep abreast of updates.

One of the more peculiar things to happen at their incident command post was a group of civilians Chief Kayea stopped from walking toward the hot zone. She told them to go back in the direction they came because the sniper had not yet been stopped. Two argued with her over if she had the authority to prohibit them from entering the hot zone.

What was learned
Chief Kayea says, "I made a lot of decisions that night, and using Engine 18 as command was the best." She specifically called for that unit to join her at command, knowing who was on shift at that time and knowing they were best suited to help her manage this large-scale incident.

The Engine 18 crew also had a fire explorer attached to it, which was certainly less than ideal. And the explorer's mother was a Dallas police officer. In addition to keeping the explorer safe, Chief Kayea set up communications to make sure both mother and explorer knew the other was safe.

And of course other emergencies, connected or unrelated, don't cease because there's an active shooter. Chief Kayea said they dealt with the expected medical emergencies, crowd injuries, an elevator emergency and a dumpster fire. They also had multiple reports of fires and bombs.

"Just because the shooting was going on, doesn't mean everything else stopped," she said. "Did they start the dumpster fire to draw us in" We didn't know."

There was a constant flow of information coming in, she said, and a lot of it was wrong. It was very difficult for dispatch.

Procedurally, the department had to choose between its active shooter plan and its civil disturbance plan, she said. They had both, but only about one-third of the department had been trained on the active shooter plan, and the civil disturbance plan had never been used.

They opted for the civil disturbance plan, which she says worked very well. Getting everybody trained up on the active shooter plan is a top post-incident priority, Chief Kayea said.

After the incident, Dallas Fire-Rescue treated it as though it were a firefighter line of duty death by waiting until after the officers' funerals to provide counseling and debriefings for firefighters and medics. She does advise chiefs to offer mental health services after the incident reports are done, because those writing the reports have to fully relive the event.

On a personal level, Chief Kayea says that she has struggled most of her career with self-confidence and doubt in her ability. But what that night taught her more than anything is that when it mattered, her years of training took over proving to herself that she's worthy of her bugles.

Your agency is dispatched to a cardiac arrest. First responders have started CPR and defibrillated the patient. Upon EMS arrival, the patient is still unconscious, unresponsive with agonal respirations and poor oxygenation.

The crew decides to intubate the patient in hopes of improving oxygenation and managing the airway. The paramedic places the endotracheal tube and confirms placement with auscultation of equal breath sounds, fogging of the tube and visualization of the chest rising and falling.

The patient is then moved from the home to the ambulance for transport. While in the back of the ambulance, the crew notices an expanding abdomen, no breath sounds and poor oxygenation. The endotracheal tube has become dislodged. The decision is made to extubate the patient and reintubate.

EMS providers manage difficult and often complex airways every day. As pointed out in this example, esophageal intubations can occur and ET tubes can become displaced during the packaging and moving of a patient. This is one reason why capnography should be used to confirm and monitor placement of the endotracheal tube.

Airway adverse events
The Center for Patient Safety’s Patient Safety Organization receives regular reports of airway-related events. Some of these events reflect the complicated range of patients that EMS encounters, from trauma patients that require surgical airways, to respiratory distress patients requiring endotracheal intubation.

Regardless, EMS must often act quickly as patients frequently present in acute distress. To take immediate action, the provider must have the skills and experience to manage many types of airways. Because of the wide range of risks and airway complications, such as esophageal intubation, ET tube dislodgement, aspiration and failed attempt, CPS is including airway management as part of this report.

Lee Varner, BSEMS, EMT-P, Project Manager for the Center for Patient Safety’s EMS services states, "Provider experience and critical thinking skills are an important part in developing the best plan for airway management. These skills are often developed over time in the clinical setting. Experience will help the provider to know when to take action or monitor a suspicious airway. Every patient is different, therefore, managing an airway requires many skills and a strong degree of experience. This is even more important as EMS encounters patients often in the least desirable surroundings or situations."

CPS issued a Safety Watch "Cricothyrotomy, are you ready"" as analysis from PSO data raised concerns about this low frequency, high risk procedure. The Safety Watch was a reminder that having multiple types of cricothyrotomy kits can lead to confusion during an airway emergency. Specifically, this means know your equipment so the procedure can be performed with whatever kit your agency stocks. Utilize only one type of kit and remove older or other freelanced kits. It was also recommended that a regular skills refresher for this critical procedure occur on a frequent basis.

Furthermore, it was recommended that this training be performed with the equipment you would use on a daily basis. Your EMS medical director should have oversight of selecting the equipment as various kits are widely available from vendors. Your agency may also prepare a specialty cricothyrotomy kit under direct supervision of your medical director.

From complex ventilators to long distance transfers, medical transport teams are frequently dispatched to handle patients with some of the most difficult airways that require advanced airway management. These can be inter-facility transports or scene calls. Whatever the scenario, there is always risk. This creates the need for the best system design or processes as well as safety behaviors.

Discuss endotracheal intubation with your EMS medical director and explore options, alternatives and backup plans for airway management. One alternative is a supraglottic airway. It can be used as either a backup rescue device or a primary means for airway management. Implementing a review of the skill, simulation training and clinical time with actual patient placement will help improve proficiency.

By Michael Morse, EMS1 Contributor

Most of us begin a career in EMS not knowing what to expect. "Expect the unexpected," those who came before us would say with a knowing grin. It doesn't take long before the lies we believed about the job are unveiled by reality.

Here are nine things I thought I knew, that turned out to be not quite true.

1. EMS is easy. Anybody can do it.
Easy" Nothing is easy if you're doing it right. An EMT doing things incorrectly kills people. Very few people are willing to bear the weight of responsibility for somebody else’s life, especially a stranger. Put a patient in the truck, and it’s you and them, and fifty MPH of road beneath you. Don’t screw up.

2. “When ya save them with Narcan, they'll puke on ya, then they'll attack ya"
Bringing a person back from the dead is a pretty satisfying experience for even the most jaded EMS person. I’ve brought hundreds of people back from the brink. With very few exceptions, I’ve found the newly revived are polite, grateful, embarrassed and cooperative. Giving somebody a second chance; not just correcting a mistake they made, but actually being the person responsible for helping them stay alive for another day, should never be minimized. We got into this vocation for a reason, and that reason is staring you right in the face every time you successfully use Narcan. The start of their new life begins the second they lay eyes on you. Saying something stupid to them cheapens the experience. Saying something brilliant is usually lost in the confusion. Stick to something kind and non-judgmental.

3. A little CPR and presto
CPR is great, no doubt about it. However, the first twenty-five or so times I did it were failures. But when I was able to bring back that twenty-sixth guy three months later, I forgot all about the first twenty-five and was ready for the next one. With experience comes acceptance. A person in cardiac arrest needs CPR, and needs it quick. The event is typically fifteen minutes from onset before we arrive on scene. Bystander CPR and rapid defibrillation is the key. We do the best we can, and sometimes the outcome is truly miraculous.

4. Alcohol is a great way to relax and enjoy life.
When 70 percent of your EMS calls are somehow alcohol-related you see real quick just how obnoxious this myth is. The misery caused by people who shouldn’t drink far outweighs the fun to be had by those who can — at least in the eyes of the EMT who has to live with the memories of mangled teens, men in their forties dying from liver disease, assaults, rapes, and other mayhem. Add the risk of the EMT abusing alcohol to deal with the stress, disappointment, and disillusionment that can be a byproduct of an EMS career and the allure of the drink fades away. Be careful, alcohol is a wise and cunning substance waiting to pounce on those of us with addictive tendencies.

5. Every person drives like a moron when an ambulance is approaching.
Actually, the vast majority of people do everything and anything to get out of the way of an approaching emergency vehicle. There are hundreds of vehicles in your path on the way to and from an emergency scene. Try and focus on the vast majority of people who get out of the way, and deal with the few who don’t without doing anything ridiculous. You cannot control the actions of people, all you can control is yourself. When I learned that little secret, driving with lights and sirens became enjoyable, rather than torture.

6. Emergency Room personnel are great looking, fun and love seeing EMS.
It doesn’t matter if you’re the best EMT in the word; we all wear out our welcome, fast. This is especially true if we do our job half-assed and don’t respect the people we bring our problems to. Imagine dealing with the public, many of whom are frequent flyers, abusive patients and good, hardworking people cut down in the prime of their life by accidents, medical emergencies and the unknown. Then imagine doing so under bright fluorescent lights without the luxury of leaving, grabbing a coffee on the way back to the station and catching a snooze.

7. EMS = earn money sleeping
If I had a dollar for every hour of uninterrupted sleep I managed in nearly twenty-five years of EMS work, I wouldn’t have many dollars.

As for earning money" Most EMTs work for private ambulance companies. The only people earning real money are the people who own them. Fire department-based EMS makes a career out of a job, in most cases. It is far more difficult to make ends meet working for a private company, but it's not impossible.

8. EMTs get hardened by what they see and can handle emotional trauma better than the general public.
Nobody gets used to seeing terrible things. Some people can hide their feelings better than others. Others have no idea that what they are feeling is slowly eating them alive; they think it’s normal to feel like the weight of the world is crushing them. It’s not normal, and the only “hard” EMT is in all probability more brittle than hard.

9. The most important word in Emergency Medical Services is “emergency.”
As long as we believe that our primary reason for being EMTs is responding to emergencies we will have difficulty with this profession. “Mobile” Medical Services is a far more fitting moniker. Every time we respond to a medical call, where we are disappointed at the non-emergent nature of the situation, resentment overtakes compassion.

The best way to find satisfaction with a career in EMS is to eliminate preconceived notions about what the job entails. Nothing is as exciting as we imagine it to be. EMS is real. EMS is mostly boring routine. But sprinkled among that day-to-day grind is people. By focusing on the people that cross our path, and connecting with those who depend on us, EMS becomes far more than a job, and ultimately can, and should be a satisfying experience. What is essential is to keep your expectations grounded in reality.

Collapsed concrete, smoke and screams greeted our triage team. Our team leader quickly surveyed the width of the rubble pile and pointed each of us to an area of the incident to begin patient triage, initiate control of life-threatening hemorrhage and manage compromised patient airways. I was directed to the furthest left side of the incident and told to work my way toward the middle of the clustered patient.

My first patient was supine and only responsive to verbal stimulus. His breathing was labored and blood was spurting from the pulsing end of his femoral artery. His right leg was fully amputated above the knee.

"Tourniquet, high and tight. Stop the bleeding," echoed in my head as I rummaged through the trauma kit around my waist.

I applied a tourniquet as tight as I could around the patient's leg and the bleeding slowed. I quickly swept the patient for other injuries. It was hard to leave him, but knew that my assignment was triage, not treatment.

Urban Shield MCI and tactical training
"Hey brother, that's a little tight," the patient whispered to me.

My patient, who really has a high right leg amputation, was one of more than 30 volunteers pretending to be injured in the first EMS exercise at Urban Shield 2016.

I loosened the tourniquet, called for firefighters to carry the patient to the casualty collection point and moved to the next patient. A woman, likely deafened from ear drum rupture from the explosions pressure wave, was attempting to console a catatonic, shell-shocked patient sitting in the rubble.

Urban Shield is a series of comprehensive, full-scale preparedness exercises to test the capabilities of SWAT, USAR, EMS, explosive ordinance disposal, field hospitals and other supporting agencies. During the Sept. 10-12, 2016 48-hour operational period, teams rotated through a series of exercises in and around Oakland which are planned and coordinated by the Bay Area Urban Areas Security Initiative.

My EMS Branch team started its six-hour rotation at 0600 on Sept. 11 in a dimly lit parking lot at the Alameda County Fire Department Training Division. The sprawling complex of classrooms, fire training towers and simulated disasters hosted two of the three exercises our team completed.

I had a few minutes to meet my teammates, all EMTs with the Berkeley Medical Reserve Corps, before our instructor/proctor lectured us on trauma patient assessment, triage and rapid treatment for hemorrhage and airway emergencies.

Our student to instructor pairing was perfect. The BMRC EMTs are all pre-med and our instructor, Justin Lemieux, is a Stanford Emergency Medicine clinical instructor and SWAT physician. He was eager to teach and we were just as eager to learn from him.

From MCI response to Rescue Task Force
We spent 40 minutes triaging and moving victims to the casualty collection point in our first exercise, the collapsed structure MCI. After we finished, we received a debrief from the exercise observers on what we did well — not much — and where we could improve — lots of areas. The debrief team's assessment was specific, helpful and challenged us to do better.

With only a few minutes to review the incident as a team, we quickly walked to our next exercise, a joint simulation with a tactical team. A briefing video quickly brought us up to speed on a group of terrorists holding hostages inside a three-story building. The terrorists were known to have an explosive device.

Our medical team listened in as the SWAT team received its briefing and asked questions about the terrorist threat and available law enforcement resources. The SWAT team leader and our medical team leader decided the medical personnel would respond as a rescue task force from an armored vehicle at the edge of the hot zone until the threat was neutralized.

For a few nervous minutes, we waited for the tactical team to make entry into the building. We tracked their progress by listening to the start of and quick end of gunfire.

Moments later, two officers threw open the doors of the armored vehicle and instructed us to make entry through a corridor of officers to reach the injured hostages. We moved through a rolling corridor of officers while doing our best to stay in physical contact — hand on the shoulder — with one another.

On the third story of the building, we found our patients huddled in a room designated as a hasty casualty collection point. Our focus, as the rescue task force, was patient triage, treatment of life threats and rapid movement of casualties out of the building and to the armored vehicle, which we had identified as the casualty collection point. The tactical team leader quickly reassigned some of his officers to assist with bleeding control and patient movement, while the remainder provided continuing threat protection.

The exercise was over in minutes. We had made some improvements as a team completing our medical mission.

High-fidelity training
The final exercise, another joint simulation for SWAT and EMS, was at a massive shipping container storage yard. Rusting, once brightly colored shipping containers, were stacked four or five high with a few open lanes and lots of dark, narrow passages.

The scenario was dignitary protection in a four-vehicle convoy traveling to a public venue. A car for private security and a mini-van for the dignitary and his family were followed by an armored vehicle containing the tactical team and an ambulance for our medical team.

As the security car and minivan rounded a corner, BOOM! An explosion echoed through the canyons of containers.

We strained to see through the dust and smoke as the SWAT officers ran towards the explosion and eruption of gunfire. After a few minutes of nervously waiting, we were called to the incident over the radio.

A high-fidelity simulation of overturned vehicles, flames, smoke and multiple blast victims greeted us as we rounded the corner. Even though multiple attackers had been killed this was a very unstable scene and every patient was critical. Only the most minimal care was provided before patients were carried to the casualty collection point.

​Video courtesy of Jim Morrissey, Alameda County

Afterwards, Jim Morrissey, paramedic and Urban Shield planner, emphasized the two top priorities. "Tactical stops the killing. And then everyone — tactical and medical — stops the dying."

Morrissey, along with Alameda County Sheriff Gregory Ahern, emphasized the changing emphasis for SWAT once the active threat is neutralized. Not every officer needs to be pointing a rifle down range, in a security stance. Instead, some SWAT officers need to assist with hemorrhage control, patient movement and other lifesaving treatments.

This affirmed my experience just a few minutes earlier. I had looked up from a severely injured casualty and directed two officers to move the patient to the casualty collection point. They readily and willingly moved the patient so I could move to another patient.

Top takeaways from Urban Shield
Our medical team ended its day with a debrief. Lemieux went above and beyond by presenting a bonus trauma resuscitation case review.

I was able to return to the container yard to watch another EMS and tactical team run the dignitary protection scenario. I also had a chance to watch a tactical team complete an active shooter and hostage rescue scenario in a massive airline hangar at the airport.

Urban Shield was an immersive, high-fidelity and full-scale training exercise for individuals and teams. For me it brought MCI response challenges to life. Here are my top takeaways from Urban Shield:

1. Sense of urgency
Everything we did had to be done with urgency. We were pushed by the proctors and observers to spend minimal time on triage, only treat true life threats and rapidly sweep patients for wounds. Other than hemorrhage control, airway positioning and attempting to seal open chest wounds additional treatments were provided in the warm zone casualty collection point, cold zone treatment areas, ambulances or at a field hospital.

Part of working with urgency is being aware of time. It is really hard to triage a patient, quickly assess for life threats and begin lifesaving treatments in less than a minute. It takes regular on-the-clock practice to be ready for this type of work. It wasn't until the third exercise that I felt like I had adjusted my internal motor to work efficiently and with a real sense of urgency.

2. Transport is a treatment
For the walking wounded, the first treatment they receive is "If you can get up and walk, go" with a specific location identified. Any other assessment or treatment is withheld until the walking wounded patient self-transports to the casualty collection point.

The other patients, especially the red tags, have injuries and illnesses that are likely time sensitive. Movement is a treatment and moving a patient towards definitive care is critical to their survival.

Movement might happen in increments. First to a casualty collection point, then to an on-scene treatment area, then into an ambulance, additional triage at the receiving hospital and finally transport into an operating room.

3. SWAT willing and able to help
The SWAT officers we were partnered with and the others I observed were eager and willing to assist with medical. Officers divided patients into injured and not injured, applied tourniquets and carried patients to casualty collection points.

If you want SWAT to help, tell them how with direct and specific instructions. Their mission is to stop the killing. Once that mission is completed they are full partners in the next mission — to stop the dying.

4. Watch and learn from others
I learned a lot by listening to my teammates, our instructor and watching other EMS teams. Our medical team leader divided the triage area into sectors and directed each of us to a sector and to triage towards the middle. A casualty collection point keeps the medical team closer to additional victims and is an intermediary step between the area of injury and the treatment area or ambulance.

EMS Branch Team 19

Consider participating in Urban Shield 2017 or sending personnel from your agency to participate. I am sure anyone who participates is able to have a unique training experience and will bring valuable skills and knowledge back to their agency. Learn more at UrbanShield.org.

As of April 10, 2014 fire departments and EMS agencies are able to apply for grant funding through the Homeland Security Grant Program and Tribal Homeland Security Grant Program to purchase ballistic protective equipment for fire/rescue and EMS personnel.

Ballistic protective equipment is for response to active shooter and mass casualty incidents to support the entry of EMS personnel into a warm zone for triage, treatment and extrication of the wounded. However, like many federal grants, the HSGP is extremely competitive, especially since fire and EMS agencies are competing against police departments for a limited amount of funding.

To mitigate the funding limitations and competitiveness of the HSGP, the Assistance to Firefighters Grant has made Ballistic Protective Equipment eligible as a new mission under personal protective equipment. BPE is to include one vest, one helmet, one triage bag and one pair of goggles. This is considered specialized PPE and of medium priority.

Read full story on EMSGrantsHelp.com

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