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

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EMS1 Daily News

Deputy comforts infant at ambulance crash; photo goes viral

An ambulance, semitrailer and three cars crashed on Ala. Interstate with no serious injuries (Photo courtesy of Jefferson County Sheriff's Office)

Police rescue Ky. man from 125-pound python

One of the responding officers knew to uncurl the snake by grabbing its head

3 things you need to know to be a confident medic

There are three things every EMS provider needs to focus on to get the job done confidently and competently

Exceeding expectations as an EMS leader

As leaders we not only set expectations for others and ourselves, we must also exceed those expectations

Pediatric simulation training: Tips to make it effective for medics

Educators need to provide realistic simulation training to ensure pediatric patient clinical competence

Butt dials: 30 percent of 911 calls in San Francisco

A research project found that as the number of emergency calls increased in the past few years, the number of dispatches decreased

Guatemala mudslide kills 152; 300 still missing

There was no more hope of finding anyone alive as questions about the neighborhood safety arose

Emerging EMS technologies subject of EMS focus webinar

Experts to share insights about the innovative ways that prehospital care can be improved with new technologies, devices and software applications

Wis. fire, EMS consolidation saved millions, report says

The consolidation of fire and EMS services from seven municipalities reduced the number of stations, vehicles and firefighters

Doctors reattach toddler's head after internal decapitation

A head-on car accident broke the toddler’s C1 and C2 vertebrae and his collarbone

EMS1 Topic Articles

Deputy comforts infant at ambulance crash; photo goes viral

An ambulance, semitrailer and three cars crashed on Ala. Interstate with no serious injuries (Photo courtesy of Jefferson County Sheriff's Office)

Police rescue Ky. man from 125-pound python

One of the responding officers knew to uncurl the snake by grabbing its head

3 things you need to know to be a confident medic

There are three things every EMS provider needs to focus on to get the job done confidently and competently

Exceeding expectations as an EMS leader

As leaders we not only set expectations for others and ourselves, we must also exceed those expectations

Pediatric simulation training: Tips to make it effective for medics

Educators need to provide realistic simulation training to ensure pediatric patient clinical competence

Butt dials: 30 percent of 911 calls in San Francisco

A research project found that as the number of emergency calls increased in the past few years, the number of dispatches decreased

Guatemala mudslide kills 152; 300 still missing

There was no more hope of finding anyone alive as questions about the neighborhood safety arose

Emerging EMS technologies subject of EMS focus webinar

Experts to share insights about the innovative ways that prehospital care can be improved with new technologies, devices and software applications

Wis. fire, EMS consolidation saved millions, report says

The consolidation of fire and EMS services from seven municipalities reduced the number of stations, vehicles and firefighters

Doctors reattach toddler's head after internal decapitation

A head-on car accident broke the toddler’s C1 and C2 vertebrae and his collarbone

EMS1 Columnist Articles

3 things you need to know to be a confident medic

Early in my career I truly believed that everything was my responsibility, and without me the outcome of the emergency would be compromised. My incessant worrying about every aspect of the response: apparatus placement, crowd control, hazardous materials mitigation, the weather, the press and anything I could think of, was crippling my effectiveness as an EMT.

I even took my insecurities to the ER and when transferring care to the ER staff would obsess about every detail, giving a report full of unnecessary findings. Knowledge is useful, and gathering all of the information available is always a good idea. There is, however, a limit to what is needed for a good report. Passing the vital ingredients to the patient’s ultimate outcome on to the next person in the continuum of care is best done clearly and concisely.

Tension on the scene of an emergency or in the ER is nothing new in the emergency responder’s world. It seems everybody thinks that they are the ultimate authority. There is little I dislike more than arguing with a person from a different agency on an emergency scene or at the triage desk. I have finally found an answer to my problem of over-informing or over-controlling.

Do your job, and be excellent at it

Everybody has limits. As an EMT, I knew better than to confront an out-of-control person. I did not break up fights. I seldom ran into burning buildings. I never cracked a person’s chest. What I did do was to act within my scope of practice, following state protocols most of the time, thinking on my feet the rest.

Sometimes it’s those unexpected, unscripted moments when you need to act, and act quickly that define you as a first responder. Most of the time adherence to established practice is prudent. Knowing exactly what you are capable of helps when time to analyze a situation does not exist. Instinct is wonderful, but will not help if you have no idea how to accomplish what needs to be done. Wasting precious time on scene wrangling in your mind what you should, would or can do need not be your standard operating procedure.

Things you have to do as an EMT

  1. Be aware of scene safety.
  2. Assess and treat patients.
  3. Transport patients to appropriate facilities.

These three things seem so simple, yet somehow we manage to get caught up in awkward situations with fellow responders. Overbearing fire department paramedics are seldom shy about voicing their opinions concerning patient care. Police officers would rather not wait eight hours at the emergency room for their intoxicated driver with a seemingly minor head injury to be cleared. Even patients sometimes feel the need to take control.

By performing your job, and doing it well, everybody wins. There is no shame in delegation. Let the police handle the crowd. Allow the firefighters to stop the leaks, stabilize the vehicles or establish a safe zone. Give the patients as much control over their lives, injuries and conditions as prudent. Firmly inform the police that their prisoner needs to be taken to the ER for an evaluation, and briefly explain why.

Just make certain that you are capable of doing the job of the medic in such a fashion that everybody on scene is comfortable delegating the most important element to the scene to you. The patient is the reason for all of us being there, and the patient is ultimately EMS’ responsibility. By acting in a calm, professional and confident manner everything will fall into place.

Confidence is contagious

A confident medic has the ability to control the emergency scene far better that the arrogant medic. Emergencies have a tendency to increase a responder’s adrenaline level, and their actions often are a result of their emotional reaction to the emergency rather than a rational reaction to the scene.

All emergency responders have one thing in common — the power of observation. Everybody is aware of what the other people are doing. We subconsciously judge our fellow responders, making mental notes for the next time. Focusing on what you know, and leaving the rest to what other people know relieves stress, improves patient care and sets the stage for future well run emergency scenes with the people we respond with. Establishing yourself as a go-to person takes a little time, but is never done by accident, or happenstance.

Exceeding expectations as an EMS leader

To effectively hold our workforce accountable, leaders need to set expectations. We expect our highest performers to not only meet expectations, but also exceed them and set the standards for others to follow. As a leader you are always on stage and in the spotlight. The workforce, your boss and peers are checking out how you conduct and handle your business.

As my good friend and retired EMS Chief Don Lundy says, "When you put the uniform on, it’s always Act 1, Scene 1, and Action!"

Ensuring you exceed the expectations of the audience — personnel, policy makers, and local media — is the crux of being a great leader. Let’s take a look at some components of how leaders can exceed expectations.

Setting the standards

Regardless of your position, set out to exceed expectations in all you do. Set the standard from the very beginning that you are a going to give 100 percent in everything you do. Your life is not about being mediocre.

Since your name and reputation is your calling card, always put yourself in the best position to succeed by setting these standards for yourself:

1. Always expect more from yourself than you expect from others, but also know your limitations.

Being the leader, it is natural that you always want to take on more and never say no to anyone. Do not be afraid to say no. Remember you are not saying no to the person, you are saying no to the task. It’s always better to be honest and upfront with your capacity than to miss an important deadline later.

2. Refuse to live off your past success.

Just because yesterday you won the big award from an industry association or made an outstanding presentation to the board does not mean you can bask in the limelight. Go out every day and conquer the next obstacle, achieve the next goal and take your leadership team on the same ride. Never allow yourself or your team to become complacent on yesterday’s successes or failures.

3. Earn respect daily.

Just because you wear the gold badge and make the final decisions does not mean you should take your position for granted. When we get the feeling we are the only person that can do the job, that’s when we are prime to be replaced. Always be humble, appreciate what you have achieved and set out like it was your first week in the position.

4. Ask for information, question challenges and give feedback.

When you are at the top of the organizational chart, folks are going to come to you for advice and for you to share your experience. It is easy to answer a question or give the information needed, but instead use your questioning techniques and allow the person asking the question to develop a solution. Guiding them will help them get to a solution. This is a great way to develop critical thinking skills. If you can set the expectations and teach your workforce to find solutions, productivity will increase and the organization will prosper.

5. Always travel the high road.

In business there always seems to be someone trying to do you in or make you look bad. Some people spend a lot of time keeping score and cannot wait to get revenge. This is a horrible waste of time and energy. When you are a high-performing leader and give 100 percent all the time, some average leaders will resent you. Someone will always feel they can do it better. Turn the other cheek and refuse to return the hurt.

6. You cannot offer excuses and exceed expectations.

One of my favorite sayings with my leadership teams is, "We are not here to point fingers, we are here to fix the problem." Be positive, smile in the face of adversity and remember my quote, "There are no problems, just solutions."

7. Value everyone on the team.

John Maxwell says, "Great leaders add value to people every day." Your job as a leader is to get the very best out of your workforce to deliver the best service they can. Set out to value the people on your team. Everyone is important regardless of the position. Once you believe that and value everyone; they deserve your very best. You asked them to follow you. Now that they are, give them 100 percent.

8. Choose a team that complements you.

When we hire personnel we have a tendency to hire people just like us. Do you want 10 of you as part of your leadership team" Hire people who are stronger than you in your weaker areas. It’s okay to defer to the individual with the most experience or knowledge. This will be seen as a great leadership attribute. You will be perceived as a confident leader who trusts the team.

You expect your workforce and team to be the very best they can be. As their leader it is up to you to set the standards of what exceeding expectations looks like. Demonstrate by exceptional leadership, give an excellent performance in every responsibility you undertake and empower team members to think beyond the details of the job. You will exceed expectations and create an environment and culture of exceeding expectations.

Quick Clip: Is it time to arm medics?

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

In this week’s Quick Clip, co-hosts Chris Cebollero and Kelly Grayson discuss EMS safety. After the school shooting at Umpqua Community College (Ore.) where nine people were killed, Chris and Kelly talk about the possibility of arming EMTs and paramedics.

Reality Training: Responders watch as bystander makes water rescue

Incident Date: July 2015

Department: Reno police, REMSA, and Reno Fire Department

What happened: A smartphone video shows a man, apparently in distress and possibly intoxicated, on a rock in the middle of a small river. Three emergency responders are standing on the shore when a bystander shouts, "You guys should be the ones going down to help. Really, you're going to let this guy go save him""

As the responders continue to watch from the shoreline and the bridge over the river a 71-year-old man wades into the river and helps the man in distress to shore. Police, fire and EMS responders followed their local protocol to wait for the water rescue team to make entry and extricate the man in distress.

Discussion points: hands-off patient assessment and water rescue hazards

As you watch the video, below, discuss these questions with your partner, company or squad.

  1. How can you assess the medical condition of the patient from a far and based on the video were there immediate life threats to the man on the rock"
  2. What are the risks associated with water rescue and how are those risks mitigated"
  3. As a responder, do have an obligation to inform bystanders of the go or no-go decision and why you are making that decision"
  4. Should responders attempt to restrain other bystanders from a rescue attempt"
  5. What are potential diagnoses for the patient and a treatment plan"

Water rescue

Drowning, worldwide, is the third leading cause of death and some of those deaths are secondary to a trained responder or untrained layperson making a rescue attempt. The unseen hazards of cold water temperature, rocks and other submerged objects, waves and currents make water rescue especially dangerous.

A rescue squad member died in the line of duty from injuries sustained when the rescue boat she was in capsized in an Alabama river during a search for a kayaker. Your recognition of the risks involved in water rescue is critical to your ability to carry out a life-saving rescue without compromising your own life.

Finally, civilians have high, often realistic expectations, for responders to act rapidly when someone is injured or in distress. A screaming bystander should not affect rescuer urgency or behavior to make a patient rescue, extrication or extraction.

Why EMS personnel need an off-duty bailout bag

I went to the movies with my wife a few hours after hearing about the shooting at Umpqua Community College in Oregon.

As we walked to the theater, I told my wife we had to sit near the back. If there was someone alone behind us, we may have to move or leave.

This wasn’t because of the events in Oregon. I routinely do that. I also watch people in the mall when I am there with my family. I maintain a heightened state of awareness.

Only couples and larger groups were at the theater and we had a seat near the back. Odds were squarely in my favor that nothing would have happened, but that wasn’t the case in a theater in Aurora, Colo., a mall in Salt Lake City and a school in Sandy Hook, Conn.

I can't completely let my guard down now, and I believe I am not alone. Here are some of my top tips for on- and off-the-job safety.

Off-the-job safety

  • Keep your head about you. Everyone else will be in a panic during an active shooter incident. Much like clinical situations, you will only survive if you think clearly and critically.
  • Understand the concept of cover. The simple act of getting behind something that will stop a bullet is the easiest and most life saving thing you can do.
  • Incorporate movement into your survival plan. Dropping to the floor and covering your head makes you a sitting duck. Know where your exits are. Move from position of cover to the next position of cover until you are safe.
  • Know alternative paths to safety. Malls, theaters and other large buildings may have delivery corridors. These hallways, accessible through the rear of the store, may be your fastest exits.

Personal bailout bag

I keep a personal bailout bag, also known as an individual first-aid kit (IFAK), in my truck, so I can provide immediate and relevant care at an active shooter incident, as well as help with my personal survival. You should have your own IFAK. The following patient care items are in my bailout bag:

  1. Combat tourniquets
  2. Hemostatic dressings
  3. Israeli battle dressings
  4. Chest seals

On-the-job safety

I have two predictions that are not in favor of EMS safety.

First, EMS providers are being deployed into warm zones. This is already happening and will continue to a greater extent. Our training will prepare us for this response. Tactic and new equipment — vests and other protective devices — will be designed to be EMS specific.

Secondly, I believe we will become bigger targets. It used to be that shooters would turn the gun on themselves and die by suicide as the police approached. Now it seems that shooters are increasingly being neutralized by the police.

We have always been looked at as the "good guys" in the emergency-response business and that has prevented us from being targeted. The next iteration of this will be the active shooter/sniper who targets responding emergency personnel. It has the potential to demoralize us and causes more terror.

Response considerations

Since EMS and fire stations are within the community, it is likely that first due apparatus will be close when an active shooter incident begins. Keep the following things in mind:

  • Expand the warm and hot zone. Consider the scene to extend past the physical location where the shooting is reported. Whether it is a sniper situation or a perpetrator who may have left the scene as part of a panicked crowd, the danger zone extends much farther than you would think.
  • Practice response with law enforcement. Drill with police and fire agencies to determine roles and responsibilities at an active shooter incident.
  • Equipment for real risks. Your department should match equipment and training with the realistic role you will play in a scene.

Today is the day to make a comprehensive plan and strategy for your personal safety, as well as the plan and role of your public safety agency in the next active shooter incident.

I am very interested in hearing your experiences, the equipment you carry, and your agency’s policies in the comments below.

How to become an excellent volunteer EMS service

For several months I have been raising awareness about the value and importance of volunteer ambulance services.

Shining a spotlight on services that demonstrate excellence in customer service and clinical competency helps to offset the frequent stories of failing volunteer agencies. Examination also helps identify the attributes and processes some agencies use to achieve their success.

Many readers, especially after reading this column on 6 cultural changes, have said that they find the information encouraging and informative. Some even proudly emailed to tell me their agency works just the way I describe.

Others felt discouraged and inadequate

This email captures the sentiments shared by several readers:

"Scheduled staff 24/7" Response from the station" Uniforms and education paid for" New equipment" What kind of rainbows and unicorns world do you live in lady" There is no way this is an average small town volunteer squad you speak of. Get real." Name withheld

I get it

I understand the frustration that comes with feeling that the solutions suggested to solve your issues are simply beyond your reach, unrealistic, or overwhelming.

I realize that it is a fight to affect change in an agency paralyzed by the desire to live in the past.

I know that there is sometimes a real animosity between the volunteer EMTs and their line officers, board of directors or town government, often based on personal differences, lack of understanding on both sides, and resentments over issues that should be long forgotten. I’ve been at those meetings, in different places, year after year.

There is no magic bullet

If your agency is broken beyond repair, you have three options: close, keep doing what you are doing and eventually close, or start over with new leadership and focus.

What if long-term members are offended" You should expect that.

What about rules, bylaws, tradition, and charters" Change them to build a stronger organization.

Realize now that no matter what, someone is not going to be happy or support change.

Y ou may lose people

Recognize that you won’t be able to persuade everyone that a cultural change as well as an operational change is needed. The people who have the most influence must be committed, or they need to get out.

Get started

Fix what you can now, and set realistic goals that are both achievable and measurable. Mark Twain said, "The secret to getting ahead is getting started."

You might not be able to change everything at once, but choose one or more of these to get started on change.

Fill the schedule

If you can only schedule full coverage three days a week now, set a goal to have coverage four days a week in three months, five days a week in six months, and weekend coverage in 12 months. Do not demand more shifts from your core providers. Causing resentment and burnout is counterproductive. Instead, use mutual aid agreements or paid staff as you rebuild your roster.

Issue and require uniforms

If funds are too tight for uniforms, adopt and enforce a dress code with professional ID tags, t-shirts and hi-vis jackets. Then budget for purchasing EMS pants, uniform shirts and boots.

Provide no- or low-cost education

Take advantage of free, online webinars and CEUs provided through local hospitals. Consider asking local business to sponsor "educational scholarships" for members to attend state or regional conferences. Provide every member with access to self-directed, online training.

New equipment

Many towns have a grant writer on staff who can help your agency. Be proactive and don’t wait until you are regularly breaking down to ask for help. Also check out the resources from

Don't keep your hard work as an EMS volunteer secret. Share your first steps and ask your questions in the comments.

Rapid Response: Clear and concise radio communication is key to MCI management

What we know: All hell broke loose in a sleepy Oregon community Thursday when a 26-year-old gunman opened fire on a community college campus killing nine and wounding seven.

What's significant: It would be excusable if dispatch and responding units were excited and incoherent over the radio. But the 30-minute audio recording of that traffic shows a much different scenario.

Police, fire, medic and central dispatch were calm, clear and concise in their communications. That says a lot for a low-crime area where responders don't get a lot of real-life practice.

Takeaways: Many of us have been on far less intense incidents yet had radio traffic that was far more rushed, garbled and unintelligible than what we saw out of Douglas County Fire District 2 responders, the police and the dispatcher. This incident is a reminder of the value of good radio communication skills. Here are some things to think about as we process the lessons from Roseburg, Ore.

Train them early: Spend more time in the fire academy training cadets on proper radio use. This includes training them to communicate in stressful situations.

Take control: For a successful outcome, fire and EMS must control the scene, not be controlled by it. This is much like dealing with an irate individual and not allowing your level of excitement to be dictated by their excitement. Be in control before keying the microphone.

Be simple: Humans are hardwired to be very vocal when stressed. That's bad for emergency scene radio communication. Self edit and deliver only the words needed to convey the message.

Further reading: Rapid Response: Mass murder at Ore. college shows challenge, importance of good PIO work

Rapid Response: EMS educators and providers must be ready for mass shootings

As an EMS educator at a community college, I feel the emotional pain and anger that surrounds these incidents. It strikes close to home and I am frustrated that these events happen, and with alarming frequency.

My greater angst is the apparent laissez faire attitude toward this development of sudden violence in society. It seems like we are "getting used to" the idea that this is acceptable behavior, part of American life.

This cannot happen.

Of course, I don’t have a solution. Hearing arguments on both sides of the gun control and gun ownership debate leaves me confused and fumbling for a solution that would work effectively.

In the absence of any rational decision, all I can do is look for the lessons being learned every time these events occur.

1. If you don’t think what happened in Oregon can happen in your community, get over it. It could happen everywhere.

2. Front-line EMS providers must be prepared to enter warm zones with the initial law enforcement entry teams. To wait for tactical medics is to be too late to save lives.

3. In these chaotic, dangerous scenes, being heroic is being reckless. Training is essential to instill discipline that executes successful tactics.

4) We also need to know how to protect ourselves when we are not on duty. “ RUN. HIDE. FIGHT.” is the current theory for self-survival: RUN away as soon as you realize your life is at risk. If you can’t run, HIDE or barricade yourself from the shooter. And ultimately, if you are confronted by the shooter, FIGHT — do anything you can to disable the assailant.

Public access hemorrhage control devices

It is increasingly clear that rapid hemorrhage control contributes to better outcomes in critically injured trauma patients. The American College of Surgeons Committee on Trauma (ACS-COT) has stated that bleeding must be controlled by prehospital providers as quickly as possible. Recent products to control external bleeding have been introduced into the EMS market by various manufacturers.

However, in cases of severe bleeding, it's possible that trained professionals may not arrive in time to stop it before the patient exsanguinates. The question becomes whether untrained laypersons could be the first part of the chain of survival, providing basic first aid before EMS arrives. Fortunately, there is precedence in this area of first response.

Lay person defibrillation

In the early 1980’s the first FDA-approved automated external defibrillator (AED) became available in the United States.[1] Soon, researchers demonstrated these devices in the hands of trained EMS personnel [2-6] and even trained non-medical personnel posed little risk and were effective at saving lives.[7-11] In fact, AEDs are so simple to use, sixth graders with no previous AED instruction were able to meet similar performance goals as trained emergency medical responders.[12]

Today, AEDs have become part of the landscape in many areas of the country. In 2000, under the direction of President Clinton, the Department of Health and Human Services [13] began preparing guidelines for establishing public access defibrillation (PAD) programs in federal facilities. In 2006, the American Heart Association recommended that States enact legislation in support of the lay public’s access to defibrillators.[14] To date, this legislation includes protection from liability when bystanders use the devices in good faith, and legislation to require certain business, schools, and public gathering areas to implement PAD programs.[15]

The argument for public access hemorrhage control

Hemorrhage is the second leading cause of death for patients injured in the prehospital environment, accounting for 30-40 percent of all mortality.[16] Many of the patients who hemorrhage do so after suffering vascular injuries in one or more extremities.

The annual incidence of extremity vascular injuries in the U.S. ranges from a low of 12.4 injuries at a rural trauma center in Missouri [17] to a high of 55 lower extremity injuries at a high-volume urban trauma center in Houston.[18] In a study of isolated penetrating injuries to the extremities, 57 percent of the patients who died had injuries that might have been amenable to tourniquet application.[19]

Current state of EMS care

A panel of experts in prehospital trauma care convened by the American College of Surgeons recently recommended the prehospital personnel, from emergency medical responders to paramedics incorporate the early application of tourniquets into clinical practice for controlling extremity hemorrhage when direct pressure is ineffective or not practical.[20] The panel further recommends tourniquets selected for use at a local level be a commercially produced windlass, pneumatic, or ratcheting type device with demonstrated efficacy at arterial flow occlusion.

Half of the EMS agencies in a California survey already incorporate tourniquet use into clinical practice for the control of severe extremity hemorrhage while the prehospital use of hemostatic gauze was extremely rare.[21] Half of the local regions that allowed EMS personnel to apply tourniquets allowed improvised tourniquets rather than commercially produced devices.

Three commonly cited reasons for failure to implement Tactical Casualty Combat Care recommendations were the differences in injury patterns between combat and civilian casualties, a perception of no proven benefit in the civilian arena and the perception of harm from prehospital application.

However, prehospital application of tourniquets appear safe even when the tourniquet remains in place for one or two hours [22], with a reported complication rate of about 2 percent.[23] Based on the past and continuing positive experiences from the military, it is likely that more and more EMS systems will implement treatment guidelines for the use of the prehospital tourniquets.[24]

For maximum efficacy, tourniquets must be applied before the patient has developed shock.[25] During Operation Iraqi Freedom, tourniquets applied in the prehospital environment and before the onset of shock were strongly associated with survival.[26] In this study, when field personnel applied the tourniquet before the onset of shock, rather than waiting for shock symptoms to develop mortality virtually disappeared (4 percent vs. 96 percent respectively).

Can the public help"

First aid courses often teach bystanders to compress a wound in an effort to control bleeding. Unfortunately, with severe injuries, compression may not be enough. However, an interesting question to consider is whether tourniquets applied before EMS arrival by ordinary citizens without medical training would provide additional morbidity and mortality advantages.

As you can well imagine, definitive evidence in favor of bystander application of tourniquets is sparse. Of the 243 patients injured during the Boston Marathon bombing, 66 had at least one extremity injury.[27] Of those sixty-six, 29 (44 percent) presented with life-threatening limb exsanguination including 15 patients with 17 traumatic amputations of the lower extremities and ten patients with 14 major vascular lower extremity injuries. Of the 29 patients with life-threatening limb exsanguination, 27 had improvised tourniquets applied in the field with one-third applied by EMS and the remainder applied by non-EMS personnel or by an unknown person.

In a ten-year evaluation of isolated penetrating or blunt extremity injury requiring either arterial revascularization or limb amputation, only 2 percent of patients had a tourniquet applied before arriving at the trauma center and all were improvised tourniquets applied by police officers or bystanders.[28] An additional 2 percent of patients had a tourniquet applied by emergency department staff within one hour of arrival. While a very small number of patients without a tourniquet exsanguinated, no patient with a tourniquet died.

During a seven-year period, researchers at Boston Medical Center identified 11 patients who had an improvised tourniquet applied in the field by EMS [29]. Only one patient died, however, that patient was in cardiac arrest when EMS arrived on the scene. Of the 10 patients who survived, all had complete neurologic function in the affected extremity despite having the tourniquet in place for as long as 167 minutes (mean 75 +\- 38 minutes).


The military experience has demonstrated that complications associated with tourniquet use are rare, even when the tourniquet is improvised. The limited civilian data supports the safety of the devices. With untrained bystanders as part of the definition of a first responder, the Office of Health Affairs at the Department of Homeland Security recommends the availability of both tourniquets and hemostatic agents in the early management of severe bleeding.[30]


  1. Cummins, R.O., Eisenberg, M. S., Bergner, L., Hallstrom, A., Hearne, T., & Murray, J. A. (1984). Automatic external defibrillation: Evaluations of its role in the home and in emergency medical services. Annals of Emergency Medicine, 13(9 Pt. 2), 798-801. doi:10.1016/S0196-0644(84)80441-2
  2. Eisenberg, M. S., Hallstrom, A. P., Copass, M. K., Bergner, L., Short, F., & Pierce, J. (1984). Treatment of ventricular fibrillation: Emergency medical technicians and paramedic services. Journal of the American Medical Association, 251(13), 1723-1726. doi:10.1001/jama.1984.03340370055030
  3. Heber, M. (1983). Out-of-hospital cardiac arrest using the "Heart Aid," an automated external defibrillator-pacemaker. International Journal of Cardiology, 3(4), 456-458. doi:10.1016/0167-5273(83)90118-3
  4. Jaggarao, N. S., Heber, M., Grainger, R., Vincent, R., Chamberlain, D. A., & Aronson, A. L. (1982). Use of an automated external defibrillator pacemaker by ambulance staff. Lancet, 2(8289), 73-75. doi:10.1016/S0140-6736(82)91692-0
  5. Stults, K. R., Brown, D. D., Schug, V. L., & Bean, J. A. (1984). Prehospital defibrillation performed by emergency medical technicians in rural communities. New England Journal of Medicine, 310(4), 219-223. doi:10.1056/NEJM198401263100403
  6. Weaver, W. D., Copass, M. K., Bufi, D., Ray, R., Hallstrom, A. P., & Cobb, L. A. (1984). Improved neurologic recovery and survival after early defibrillation. Circulation, 69(5), 943-948. doi:10.1161/01.CIR.69.5.943
  7. MacDonald, R. D., Mottley, J. L., & Weinstein, C. (2002). Impact of prompt defibrillation on cardiac arrest at a major international airport. Prehospital Emergency Care, 6(1), 1-5. doi:10.1080/10903120290938689
  8. O’Rourke, M. F., Donaldson, E. E., & Geddes, J. S. (1997). An airline cardiac arrest program. Circulation, 96(9), 2849-2853. doi:10.1161/01.CIR.96.9.2849
  9. Page, R. L., Joglar, J. A., Kowal, R. C., Zagrodzky, J. D., Nelson, L. L., Ramaswamy, K., Barbera, S. J., Hamdan, M. H., & McKenas, D. K. (2000). Use of automated external defibrillators by a U.S. airline. New England Journal of Medicine, 343(17), 1210-1216. doi:10.1056/NEJM200010263431702
  10. Valenzuela, T. D., Roe, D. J., Nichol, G., Clark, L. L., Spaite, D. W., & Hardman, R. G. (2000). Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos. New England Journal of Medicine, 343(17), 1206-1209. doi:10.1056/NEJM200010263431701
  11. Wassertheil, J., Keane, G., Fisher, N., & Leditschke, J. F. (2000). Cardiac arrest outcomes at the Melbourne Cricket Ground and Shrine of Remembrance using a tiered response strategy — a forerunner to public access defibrillation. Resuscitation, 44(2), 97-104. doi:10.1016/S0300-9572(99)00168-9
  12. Gundry, J. W., Comess, K. A., DeRook, F. A., Jorgenson, D., & Bardy, G. H. (1999). Comparison of naïve sixth-grade children with trained professionals in the use of an automated external defibrillator. Circulation, 100(16), 1703-1707. doi:10.1161/01.CIR.100.16.1703
  13. Department of Health and Human Services. (2009) Guidelines for public access defibrillation programs in federal facilities. Federal Register. 74, 41133–41139. Retrieved from
  14. Aufderheide, T., Hazinski, M. F., Nichol, G., Steffens, S. S., Buroker, A., McCune, R., Stapleton, E., Nadkarni, V., Potts, J., Ramirez, R. R., Eigel, B., Epstein, A., Sayre, M., Halperin, H., & Cummins, R. O. (2006). Community lay rescuer automated external defibrillation programs: Key state legislative components and implementation strategies: A summary of a decade of experience for healthcare providers, policymakers, legislators, employers, and community leaders from the American Heart Association Emergency Cardiovascular Care Committee, Council on Clinical Cardiology, and Office of State Advocacy. Circulation, 113(9), 1260-1270. doi:10.1161/CIRCULATIONAHA.106.172289
  15. England, H., Weinberg, P. S., Estes, N. A. 3rd. (2006). The automated external defibrillator: Clinical benefits and legal liability. Journal of the American Medical Association, 295(6), 687-690. doi:10.1001/jama.295.6.687
  16. Kauvar, D. S., Lefering, R., & Wade, C. E. (2006). Impact of hemorrhage on trauma outcome: An overview of epidemiology, clinical presentations, and therapeutic considerations. The Journal of Trauma, Injury, Infection, and Critical Care, 60(6), S3-S11. doi:10.1097/01.ta.0000199961.02677.19
  17. Humphrey, P. W., Nichols, W. K., & Silver, D. (1994). Rural vascular trauma: A twenty-year review. Annals of Vascular Surgery, 8(2), 179-185.
  18. Feliciano, D. V., Herskowitz, K., O'Gorman, R. B., Cruse, P. A., Brandt, M. L., Burch, J. M., et al. (1988). Management of vascular injuries in the lower extremities. Journal of Trauma, 28(3), 319-328.
  19. Dorlac, W. C., DeBakey, M. E., Holcomb, J. B., Fagan, S. P., Kwong, K. L., Dorlac, G. R., Schreiber, M. A., Persse, D. E., Moore, F. A., & Mattox, K. L. (2005). Mortality from isolated civilian penetrating extremity injury. Journal of Trauma, 59(1), 217-222.
  20. Passos, E., Dingley, B., Smith, A., Engels, P. T., Ball, C. G., Faidi, S., Nathens, A., & Tien, H. (2014). Tourniquet use for peripheral vascular injuries in the civilian setting. Injury, 45(3), 573-577. doi:10.1016/j.injury.2013.11.031
  21. Galante, J. M., Smith, C. A., Sena, M. J., Scherer, L. A. & Tharratt, R. S. (2013). Identification of barriers to adaptation of battlefield technologies into civilian trauma in California. Military Medicine, 178(11), 1227-1230. doi:10.7205/MILMED-D-13-00127
  22. Inaba, K., Siboni, S., Resnick, S., Zhu, J., Wong, M. D., Haltmeier, T., Benjamin, E. & Demetriades, D. (2015). Tourniquet use for civilian extremity trauma. Journal of Trauma and Acute Care Surgery, 79(2), 232-237. doi:10.1097/TA.0000000000000747
  23. Kue, R. C., Temin, E. S., Weiner, S. G., Gates, J., Coleman, M. H., Fisher, J., & Dyer, S. (2015). Tourniquet use in a civilian emergency medical services: A descriptive analysis of the Boston EMS experience. Prehospital Emergency Care, 19(3), 399-404. doi:10.3109/10903127.2014.995842
  24. Feliciano, D. V. (2010). Management of peripheral arterial injury. Current Opinions in Critical Care, 16(6), 602-608. doi:10.1097/MCC.0b013e32833f3ee3
  25. Department of Homeland Security. (2015). First responder guide for improving survivability in improvised explosive device and/or active shooter incidents. Retrieved from
  26. Kragh, J. F. Jr., Walters, T. J., Baer, D. G., Fox, C. J., Wade, C. E., Salinas, J., & Holcomb, J. B. (2009). Survival with emergency tourniquet use to stop bleeding in major limb trauma. Annals of Surgery, 249(1), 1–7. doi:10.1097/SLA.0b013e31818842ba
  27. King, D. R., Larentzakis, A., & Ramly, E. P. (2015). Tourniquet use at the Boston Marathon bombing: Lost in translation. Journal of Trauma and Acute Care Surgery, 78(3), 594-599. doi:10.1097/TA.0000000000000561
  28. Kalish, J., Burke, P., Feldman, J., Agarwal, S., Glantz, A., Moyer, P., Serino, R., & Hirsch, E. (2008). The return of tourniquets. Original research evaluates the effectiveness of prehospital tourniquets for civilian penetrating extremity injuries. Journal of the Emergency Medical Services, 33(8), 44–54.
  29. Bulger, E. M., Snyder, D., Schoelles, K., Gotschall, C., Dawson, D., Lang, E., Sanddal, N. D., Butler, F. K., Fallat, M., Taillac, P., White, L., Salomone, J. P., Seifarth, W., Betzner, M. J., Johannigman, J., & McSwain, N. Jr. (2014). An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma. Prehospital Emergency Care, 18(2), 163-173. doi:10.3109/10903127.2014.896962
  30. Department of Homeland Security. (2015). First responder guide for improving survivability in improvised explosive device and/or active shooter incidents. Retrieved from

Integrating new methods and products into trauma care

According to the Centers for Disease Control and Prevention (CDC), the leading cause of civilian death from age 1 to 44 in the United States is traumatic "unintentional injury."[1] EMS providers have to diligently stay up to date with the latest procedures and products in trauma care, as manufacturers continue to develop better ways to manage critically injured patients in the field.

Field triage

Field triage remains a vital initial component of prehospital care with the general goal of "Getting the right patient to the right place at the right time."[1] The CDC (2011) published guidance on the field triage process in "Guidelines for Field Triage of Injured Patients, Recommendations of the National Expert Panel on Field Triage."[2] Download the latest triage guidelines, visual flowchart, and numerous portable triage resources from the CDC website.

Daily field triage decisions made by prehospital professionals are supported by research and require effective critical thinking. Upon arrival at the scene of an injury, EMS professionals identify the severity and type of injury. Considering the evidence-based guidelines, prehospital professionals then determine which hospital or specialty care center would be most appropriate to improve patient outcome. CDC research supports the sound triage decisions of EMS professionals. Research demonstrates that the overall risk of death is 25 percent lower when care is provided at a Level I trauma center than when it is provided by a non-trauma center.[1]

Putting new products to the test

Treatment of the severely injured trauma patient in the prehospital setting should consist of assessment, extrication, initiation of resuscitation and stabilization, and safe, timely transport to the most appropriate trauma center whose capabilities match the patient’s needs.[3] Virtually all essential trauma skills are BLS in nature: hemorrhage control, airway and ventilation support, stabilization of fractures and spinal protection. Time-consuming field interventions should generally be avoided so as not to delay definitive care.[3,4]

An increased influx of military research affords civilian EMS an effective means to incorporate new evidence-based practice toward leading causes of trauma mortality. Many of the new trauma care products in the civilian market made their debut during military operations in the Middle East and Afghanistan. With the emergence of a plethora of new products that have flooded the market, EMS providers have a wide variety of equipment and supply choices to apply to trauma care.

Hemorrhage control bandages

These bandages are elastic in nature so they can be applied as a pressure bandage. Some of these are in a convenient roll format for easy packing and wrapping wounds. A few bandages combine the Celox™ hemostatic agent to better control life-threatening blood loss directly at the source of bleeding. It is suggested that when placed directly into a bleeding wound and subjected to pressure, Celox™ absorbs blood and forms an adhesive gel that seals the wound to stop hemorrhage. According to the manufacturer, Celox™ does not set off the normal clotting cascade and does not set off a blood clotting response which would lead to clots being formed at a distance from the product.

Some of these products on the market are represented by QuikClot® EMS Rolled Gauze™, QuikClot® EMS 4x4 Dressing, Dynarex Dyna-Stopper Trauma Bandage, Cederroth BloodStopper, and BioStat LLC Celox™ Z-Fold Gauze. The SWAT-T™ offers the combination of a tourniquet with a multipurpose-pressure dressing, and elastic bandage.

Israeli bandages

The Emergency Israeli Abdominal Bandage is a valued combat first-aid device for controlling traumatic hemorrhage. This abdominal bandage consolidates multiple first-aid devices such as a primary dressing, pressure applicator, secondary dressing, and a quick closure apparatus to secure the bandage in place. It is suggested that the non-adherent pad applies pressure to any site, can be easily wrapped and secured, and has an additional application similar to a tourniquet to further constrict blood flow. Some combat wounded veterans have reported that an injured person can self-apply the bandage with one hand.

Multi-trauma dressings

These bulky dressings can be utilized for major trauma and wound bleeding control. Most are constructed of a soft, nonwoven facing with highly-absorbent fillings in the material. It is suggested that these dressings are designed to provide effective padding and protection for major wounds. The GAM Multi Trauma Dressing comes as large as 12-inch x 30-inch. Other dressings include the Dynarex Dyna-Stopper Trauma Bandage, Dynarex Multi-Trauma Dressing, and Medstorm Multi-Trauma Dressing.

Hemostatic agents

Hemostatic agents are commonly in the form of powder, gel or granules and are used with dressings and bandages to control life-threatening hemorrhage. They come in a wide variety of applications—sponges, packets, syringes/plunger applicators, and impregnated in gauze. BioStat LLC Celox-A is applied by a plunger system so that the hemostatic agent can be delivered deep into small traumatic wounds. QuikClot 1st Response™ Hemostatic Agent is activated by applying the sponges into and over the wound. BioStat LLC Celox™ Granules are applied by sprinkling the granules over the wound then a dressing and bandage is applied.

QuikClot Combat Gauze® LE is a 3-inch x 4-yard strip of folded soft, white, nonwoven, hydrophilic gauze impregnated with kaolin. Kaolin is an inorganic mineral that is both safe and effective in accelerating the body’s natural clotting cascade.[6] ActCel Hemostatic Gauze created from regenerated cellulose is reported to be an effective, U.S. patent pending hemostatic agent. Recently approved by the FDA, the XStat® is a pill tablet-sized sponge hemostatic device for the treatment of gunshot and shrapnel wounds. When applied it rapidly expands making it effective for irregular wounds and junctional wounds in the groin or axilla that are not amenable to tourniquet application.

Chest seals

Development of a tension pneumothorax is a common life-threatening complication of an open chest wound. All open chest wounds should be treated by immediate application of a vented chest seal to cover the defect. If a vented chest seal is not available, use a non-vented chest seal.

Monitor the patient for the potential complication of a tension pneumothorax. If the patient develops increasing hypoxia, respiratory distress, or hypotension due to a tension pneumothorax, treat the by removing or "burping" the dressing or by performing a needle decompression.[11] Recent studies demonstrated that a vented chest seal prevents the subsequent development of a tension pneumothorax, whereas use of a nonvented chest seal does not.[5]

The Curaplex Halo Occlusive Seal is a non-vented design that is a choice for managing penetrating chest trauma. Asherman Chest Seal, Curaplex HALO Vent, and SAM® Chest Seal are vented devices that offer a self-adherent occlusive dressing designed for treating open chest wounds.

Pelvic binders and immobilizers

The SAM Pelvic Sling™ II, Hip Wrap™ Hip Immobilizer and Pelvic Stabilizer, and Morrison Spectrum Pelvic Immobilizer offer reduced movement of the hip and pelvis with a force-controlled circumferential pelvic belt. They are designed to safely and effectively reduce and stabilize open-book pelvic ring fractures.

Tourniquets innovations

Tourniquets simply work by drastically reducing or completely obstructing distal blood flow to the vascular injury of the affected extremity. Optimal use of a limb tourniquet must result in both controlling of hemorrhage and cessation of the distal pulses in the affected extremity.

Many commercial limb tourniquets feature a wider compression pattern than older tourniquets, improving circumferential and arterial compression. Some of these products include the SOF® Tactical Tourniquet-Wide (SOF®TT-W) and the m2 Inc Ratcheting Medical Tourniquet™. The SWAT-Tourniquet™ (SWAT-T™) suggests a more rapid means to control extremity bleeding and allows application higher into the groin and axilla than other tourniquets.

Junctional bleeding occurs between the trunk and the limbs (high level amputations) and between the pelvic area and legs. The most common type of junctional bleeding is groin hemorrhage. Traditional tourniquets are unable to be placed in these areas. Junctional tourniquets (also called truncal tourniquets or combat clamps) are fitted with target compression devices that can be specifically positioned over the injury site and pumped up until the bleeding stops. Common uses of junctional tourniquets include controlling inguinal and axilla hemorrhage, and stabilizing pelvic fractures.

Junctional tourniquets available on the market include the Combat Application Tourniquet® (C-A-T®), the Special Operations Forces® Tourniquet-Tactical (SOF®TT), the Emergency and Military Tourniquet, Combat Ready Clamp® (CroC®), Junctional Emergency Treatment Tool™ (JETT™), and the SAM® Junctional Tourniquet.

Special immobilization equipment

New immobilization products continue to launch into the market despite the growing body of evidence questioning the efficacy or necessity of spinal immobilization.

The Hartwell Combicarrier II reports reduced "unnecessary movement" and a concave patient surface, making it a choice for patients with suspected hip, pelvic, and spinal injuries. This device can be used as a scoop stretcher or full backboard.

The MedSource Pediatric Immobilization Board allows for the securing of each leg separately and is MRI compatible. The Ferno Scoop™ EXL Stretcher offers two hinged, interlocking pieces that allow operators to bring the two halves together beneath the patient which reduces the need to log roll the patient.

There are many new products and devices on the market to be considered for prehospital trauma care. EMS providers should carefully weigh the pros and cons of each device, and how it can be used most effectively in their system. The results on trauma patient morbidity and mortality from civilian field of these products will determine its success in the marketplace.


1. Centers for Disease Control & Prevention (CDC). Ten Leading Causes of Death and Injury. (2014, November 14). Retrieved from

2. CDC. Guidelines for Field Triage of Injured Patients, Recommendations of the National Expert Panel on Field Triage. (2015, March 04). Retrieved from

3. American College of Surgeons Committee on Trauma (ASC-COT). (2014). Resources for the optimal care of the injured trauma patient. Retrieved from FACS

4. Sanddal, T. L., Esposito, T. J., Whitney, J. R., Hartford, D., Taillac, P. P., Mann, N. C., & Sanddal, N. D. (2011). Analysis of Preventable Trauma Deaths and Opportunities for Trauma Care Improvement in Utah. The Journal of Trauma: Injury, Infection, and Critical Care, 70(4), 970-977. doi:10.1097/ta.0b013e3181fec9ba

5. Butler, F. K., Dubose, J. J., Otten, E. J., Bennett, D. R., Gerhardt, R. T., & Kheirabadi, B. S. (2013). Management of open pneumothorax in tactical combat casualty care: TCCC guidelines change 13-02. Journal of Special Operations Medicine, 13(3), 81-86.

6. Sena, M. J., Douglas, G., Gerlach, T., Grayson, J. K., Pichakron, K. O., & Zierold, D. (2013). A pilot study of the use of kaolin-impregnated gauze (Combat Gauze) for packing high-grade hepatic injuries in a hypothermic coagulopathic swine model. Journal of Surgical Research, 183(2), 704-709. doi:10.1016/j.jss.2013.02.039


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