1. AUGUST 2012
Always En Route At

2. Choose 11 at www.jems.com/rs

4. Choose 13 at www.jems.com/rs

5. The
Conscience
of EMS
JOURNAL OF EMERGENCY MEDICAL SERVICES
34
I Primer Non Nocere I
Why EMS should be timely, thorough cautious in
implementing new approaches to patient care
B
y Paul E. Pepe, MD, MPH, Sandra M. Schneider, MD
August 2012 Vol. 37 No. 8
Contents
42 I It Takes a Village I
Are community health partnerships the wave of the future?
By Jennifer Berry
Integrated training simulation at the 2012 JEMS Games
By Chad Brocato, DHSC, CFO, JD; A.J. Heightman, MPA, EMT-P
Good science enthusiasm drive survival rates in Oklahoma
By Jeffrey M. Goodloe, MD, NREMT-P, FACEP; T.J. Reginald, NREMT-P; David S.
Howerton, NREMT-P; Jim O. Winham, RN, BSN, NREMT-P; Tammy
Appleby, NREMT-B
I 60
How we can influence the ‘ambulance driver’ media epidemic
By Rollin J. (Terry) Fairbanks, MD, MS
Be prepared to treat anaphylactic incidents before it’s too late
By Rick Rod, RN, CEN, NREMT-P
48 I Sim Success I
52 I Attacking Cardiac Arrest I
58 I More than Words I
Departments columns
7 I Load go I Now on JEMS.com
12 I EMS in Action I Scene of the Month
14 I From the Editor I Doubles Backups
60 I Sudden onset I
y A.J. Heightman, MPA, EMT-P
B
16 I Letters I In Your Words
18 I Priority Traffic I News You Can Use
22 I lEADERSHIP sECTOR I System Costs
y Gary Ludwig, MS, EMT-P
B
24 I HIGHER LEARNING I Old Dogs New Tricks
y William Raynovich, NREMTP, EdD, MPH, BS
B
28 I Tricks OF the TRADE I Psych Transfers
y Thom Dick
B
30 I case of the month I Risky Anticoagulants
y Patrick Harvey, MD
B
32 I RESEARCH REVIEW I What Current Studies Mean to EMS
y David Page, MS, NREMT-P
B
66 I employment Classified Ads
67 I Ad Index
68 I Hands On I Product Reviews from Street Crews
y Fran Hildwine
B
72 I The Lighter Side I EMS
y Steve Berry
B
74 I LAST WORD I The Ups Downs of EMS
I 48
About the Cover leadership article, “Primum Non Nocere: Why EMS should be
This month’s cover announces an important
timely, thorough and cautious in implementing new approaches to patient care,” pp. 34–40. This article by
Paul E. Pepe, MD, MPH, and Sandra M. Schneider, MD, points out that although many EMS therapies have
been implemented to diminish patient morbidity and discomfort through early intervention, we have also
inadvertently applied practices that may have been detrimental or ineffective. This article is a must-read
for all EMS providers, managers, researchers, educators and administrators who want to make sure they
“first do no harm.” Photo iStockPhoto.com
Premier Media Partner of the IAFC, the IAFC EMS Section Fire-Rescue Med
www.jems.com
August 2012
JEMS
5

6. Choose 14 at www.jems.com/rs

7. LOAD GO
log in for EXCLUSIVE CONTENT
A Better Way to Learn
JEMSCE.com
online continuing
education program
n
us o
follow
Most the country is in the hot grip of summer. We
asked our Facebook audience: Do all the ambulances at
your agency have air conditioning? The answers were all
over the map, but it seems some states and counties
require it, while providers in other areas have to hope
for the best.
Jon Kledzik: Not mine. Today was 104 in the cab :(
David Gaver: Well mine did ’till about 10 minutes ago
when it started blowing hot air.
C.J. Cornell: All of ours have 2/60 A/C: Two windows at 60 mph.
Amanda A Griffin: Yes. Most of the time. They get repaired pretty quickly in Alabama. :)
Eric Leland: The Texas heat and department of state health services require it.
Samantha Tucker: Yes. And if either A/C goes out, the unit is 10-7. Even our A Star has A/C. It’s Mississippi folks.
Bombero Rescate: Yep, except on those 90-plus degree days when the 88 year-old female patient says, “Can
you turn down the air? I’m freezing!”
Diana Ledford: The question should be: Does it work properly in the patient and crew compartments?
Jeff Schneider: Mandated by county policy. Plus this is the central valley of California. Average summer
temps of 90–95 degrees. Highs of 105–114.
Evan Basim Monaghan: I’m just thinking you would think all ambulances should have working A/C and heat.
I mean, we have hypothermic patients and patients who have heat stroke in the back of the ambulance.
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The Rescuer Emergency CPAP System from BLS Systems Limited was designed to offer
the maximal respiratory support to patients requiring positive pressure therapy. The newest device available to EMS services, this device offers easy to
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medication port, while having the lowest oxygen consumption of any comparable device. Available in two mask styles, this affordable CPAP system
offers more features than any similar disposable CPAP device.
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We believe learning is a lifelong commitment. We also think there’s a lot of
knowledge to be had in EMS, and we bet most EMS professionals would
agree. So join us for our upcoming webcasts on July 25 and August 22. At
1 p.m. Eastern on July 25, Doug Wolfberg, Esq., and Steve Wirth, Esq., will
focus on how you can reduce your documentation errors on
patient care reports in “Maximizing Your Revenue.” And at 1
p.m. Eastern on Aug. 22, Bryan E. Bledsoe, DO, FACEP, FAAEM,
will detail evolving changes in prehospital airway management in “Securing the Airway.” Register for one or both of
Doug Wolfberg them today.
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AUGUST 2012 JEMS
7

8. Conscience
of EMS
JOURNAL OF EMERGENCY MEDICAL SERVICES
The
Conscience
of EMS
JOURNAL OF EMERGENCY MEDICAL SERVICES
Editor-In-Chief I A.J. Heightman, MPA, EMT-P I a.j.heightman@elsevier.com
MANAGING Editor I Jennifer Berry I je.berry@elsevier.com
associate eDITOR I Lauren Hardcastle I l.hardcastle@elsevier.com
assistant eDITOR I Allison Moen I a.moen@elsevier.com
assistant eDITOR I Kindra Sclar I k.sclar@elsevier.com
online news/blog manager I Bill Carey I bill@goforwardmedia.com
Medical Editor I Edward T. Dickinson, MD, NREMT-P, FACEP
Technical Editors
Travis Kusman, MPH, NREMT-P; Fred W. Wurster III, NREMT-P, AAS
Contributing Editor I Bryan Bledsoe, DO, FACEP, FAAEM
Editorial Department I 800/266-5367 I editor.jems@elsevier.com
art director I Liliana Estep I alildesign@me.com
Contributing illustrators
Steve Berry, NREMT-P; Paul Combs, NREMT-B
Contributing Photographers
Vu Banh, Glen Ellman, Craig Jackson, Kevin Link, Courtney McCain, Tom Page, Rick Roach,
Steve Silverman, Michael Strauss, Chris Swabb
Director of eProducts/Production I Tim Francis I t.francis@elsevier.com
Production Coordinator I Matt Leatherman I m.leatherman@elsevier.com
advertising director I Judi Leidiger I 619/795-9040 I j.leidiger@jems.com
Western Account Representative I Cindi Richardson I 661-297-4027 I
c.richardson@jems.com
senior Sales coordinator I Elizabeth Zook I e.zook@elsevier.com
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SENIOR eMedia campaign manager I Lisa Bell I l.bell@elsevier.com
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Marketing manager I Melanie Dowd I m.dowd@elsevier.com
Marketing Conference Program Coordinator I
Vanessa Horne I v.horne@elsevier.com
Director, Audience Development Sales Support I Mike Shear I m.shear@elsevier.com
Audience development coordinator I Marisa Collier I m.collier@elsevier.com
SUBSCRIPTION DEPARTMENT I 888/456-5367
REprints, eprints Licensing I Wright’s Media I 877/652-5295 I reprints@jems.com
eMedia Strategy I 410/872-9303 I
Managing Director I Dave J. Iannone I dave@goforwardmedia.com
Director of eMedia Sales I Paul Andrews I paul@goforwardmedia.com
Director of eMedia Content I Chris Hebert I chris@goforwardmedia.com
elsevier public safety
vice president/publisher I Jeff Berend I j.berend@elsevier.com
founding editor I Keith Griffiths
founding publisher
James O. Page
(1936–2004)
Choose 16 at www.jems.com/rs
15

9. Choose 16 at www.jems.com/rs

10. JOURNAL OF EMERGENCY MEDICAL SERVICES
The
Conscience
of EMS
JOURNAL OF EMERGENCY MEDICAL SERVICES
EDITORIAL board
William K. Atkinson II, PHD, MPH, MPA, EMT-P
President Chief Executive Officer
WakeMed Health Hospitals
Keith Griffiths
President, RedFlash Group
Founding Editor, JEMS
James J. Augustine, MD
Medical Advisor, Washington Township (OH) Fire Department
Director of Clinical Operations, EMP Management
Clinical Associate Professor, Department of
Emergency Medicine, Wright State University
Dave Keseg, MD, FACEP
Medical Director, Columbus Fire Department
Clinical Instructor, Ohio State University
steve berry, NRemt-p
Paramedic EMS Cartoonist, Woodland Park, Colo.
Bryan E. Bledsoe, DO, FACEP, FAAEM
Professor of Emergency Medicine, Director, EMS Fellowship
University of Nevada School of Medicine
Medical Director, MedicWest Ambulance
Criss Brainard, EMT-P
Deputy Chief of Operations, San Diego Fire-Rescue
Chad Brocato, DHS, REMT-P
Assistant Chief of Operations, Deerfield Beach Fire-Rescue
Adjunct Professor of Anatomy Physiology, Kaplan University
J. Robert (Rob) Brown Jr., EFO
Fire Chief, Stafford County, Va., Fire and Rescue Department
Executive Board, EMS Section,
International Association of Fire Chiefs
carol a. cunningham, md, FACEP, FAAEM
State Medical Director
Ohio Department of Public Safety, Division of EMS
W. Ann Maggiore, JD, NREMT-P
Associate Attorney, Butt, Thornton Baehr PC
Clinical Instructor, University of New Mexico,
School of Medicine
Connie J. Mattera, MS, RN, EMT-P
EMS Administrative Director EMS System Coordinator,
Northwest (Illinois) Community Hospital
Robin B. Mcfee, DO, MPH, FACPM, FAACT
Medical Director, Threat Science
Toxicologist Professional Education Coordinator,
Long Island Regional Poison Information Center
Mark Meredith, MD
Assistant Professor, Emergency Medicine and Pediatrics,
Vanderbilt Medical Center
Assistant EMS Medical Director for Pediatric Care,
Nashville Fire Department
Geoffrey T. Miller, EMT-P
Director of Simulation Eastern Virginia Medical School,
Office of Professional Development
Thom Dick, EMT-P
Quality Care Coordinator
Platte Valley Ambulance
Brent Myers, MD, MPH, FACEP
Medical Director, Wake County EMS System
Emergency Physician, Wake Emergency Physicians PA
Medical Director, WakeMed Health Hospitals
Emergency Services Institute
Charlie Eisele, BS, NREMT-P
Flight Paramedic, State Trooper, EMS Instructor
Mary M. Newman
President, Sudden Cardiac Arrest Foundation
Bruce Evans, MPA, EMT-P
Deputy Chief, Upper Pine River Bayfield Fire Protection,
Colorado District
Joseph P. Ornato, MD, FACP, FACC, FACEP
Professor Chairman, Department of Emergency Medicine,
Virginia Commonwealth University Medical Center
Operational Medical Director,
Richmond Ambulance Authority
Jay Fitch, PhD
President Founding Partner, Fitch Associates
Ray Fowler, MD, FACEP
Associate Professor, University of Texas Southwestern SOM
Chief of EMS, University of Texas Southwestern Medical Center
Chief of Medical Operations,
Dallas Metropolitan Area BioTel (EMS) System
Adam D. Fox, DPM, DO
Assistant Professor of Surgery,
Division of Trauma Surgery Critical Care,
University of Medicine Dentistry of New Jersey
Former Advanced EMT-3 (AEMT-3)
Gregory R. Frailey, DO, FACOEP, EMT-P
Medical Director, Prehospital Services, Susquehanna Health
Tactical Physician, Williamsport Bureau of
Police Special Response Team
Jeffrey M. Goodloe, MD, FACEP, NREMT-P
Professor EMS Division Director,
Emergency Medicine, University of Oklahoma School of
Community Medicine
Medical Director, EMS System for Metropolitan
Oklahoma City Tulsa
10
JEMS
AUGUST 2012
Jerry Overton, MPA
Chair, International Academies of Emergency Dispatch
David Page, MS, NREMT-P
Paramedic Instructor, Inver Hills (Minn.) Community College
Paramedic, Allina Medical Transportation
Member of the Board of Advisors,
Prehospital Care Research Forum
Paul E. Pepe, MD, MPH, MACP, FACEP, FCCM
Professor, Surgery, University of Texas
Southwestern Medical Center
Head, Emergency Services, Parkland Health
Hospital System
Head, EMS Medical Direction Team,
Dallas Area Biotel (EMS) System
David E. Persse, MD, FACEP
Physician Director, City of Houston Emergency Medical Services
Public Health Authority, City of Houston Department.
of Health Human Services
Associate Professor, Emergency Medicine,
University of Texas Health Science Center—Houston
John J. Peruggia Jr., BSHuS, EFO, EMT-P
Assistant Chief, Logistics, FDNY Operations
Edward M. Racht, MD
Chief Medical Officer, American Medical Response
Jeffrey P. Salomone, MD, FACS, NREMT-P
Associate Professor of Surgery,
Emory University School of Medicine
Deputy Chief of Surgery, Grady Memorial Hospital
Assistant Medical Director, Grady EMS
Kathleen S. Schrank, MD
Professor of Medicine and Chief,
Division of Emergency Medicine,
University of Miami School of Medicine
Medical Director, City of Miami Fire Rescue
Medical Director, Village of Key Biscayne Fire Rescue
John Sinclair, EMT-P
International Director, IAFC EMS Section
Fire Chief Emergency Manager,
Kittitas Valley Fire Rescue
Corey M. Slovis, MD, FACP, FACEP, FAAEM
Professor Chair, Emergency Medicine,
Vanderbilt University Medical Center
Professor, Medicine, Vanderbilt University Medical Center
Medical Director, Metro Nashville Fire Department
Medical Director, Nashville International Airport
Walt A. Stoy, PhD, EMT-P, CCEMTP
Professor Director, Emergency Medicine,
University of Pittsburgh
Director, Office of Education,
Center for Emergency Medicine
Richard Vance, EMT-P
Captain, Carlsbad Fire Department
Jonathan D. Washko, BS-EMSA, NREMT-P, AEMD
Assistant Vice President, North Shore-LIJ Center for EMS
Co-Chairman, Professional Standards Committee,
American Ambulance Association
Ad-Hoc Finance Committee Member, NEMSAC
keith wesley, MD, facep
Medical Director, HealthEast Medical Transportation
Katherine H. West, BSN, MED, CIC
Infection Control Consultant,
Infection Control/Emerging Concepts Inc.
Stephen R. Wirth, Esq.
Attorney, Page, Wolfberg Wirth LLC.
Legal Commissioner Chair, Panel of Commissioners,
Commission on Accreditation of Ambulance Services (CAAS)
Douglas M. Wolfberg, Esq.
Attorney, Page, Wolfberg Wirth LLC
Wayne M. Zygowicz, BA, EFO, EMT-P
EMS Division Chief, Littleton Fire Rescue

11. Choose 17 at www.jems.com/rs

12. EMS IN ACTION
Scene of the month
12
JEMS
AUGUST 2012
Photo Glen Ellman

13. Extended Extrication
A
crew from the Fort Worth (Texas) Fire Department performs
an extrication of a male patient who was trapped in his vehicle
after a motor vehicle collision. The extrication process was extended
because the patient’s feet were pinned beneath the seat of the vehicle,
so the crew decided to use a bag-valve mask to ventilate him and then
perform endotracheal intubation on scene. The patient was extricated
successfully and transported by Careflight Air Ambulance to a hospital
center. MedStar EMS ground ambulance service provided ALS care to
the patient on scene and turned care over to Careflight.
www.jems.com
AUGUST 2012
JEMS
13

14. from the editor
putting issUes into perspective
by A.J. HEIGHTMAN, MPA, EMT-P
Doubles Backups
They can save your day
I
Photo A.J. Heightman
Photo A.J. Heightman
sources of carbon monoxide (CO), he
’ve written about my dad
told me that it made no sense to carry
many times in JEMS. He
just one oxygen (O2) tank equipped
wasn’t just a good care provider throughout his 40-plus
with a regulator and four spare O2
years as an “ambulance man”
tanks. He called these “naked soldiers,”
with the Scranton (Pa.) Fire
which was a reference to how useless
Department; he was also a great
a soldier would be in battle without
innovator and mentor to me and
his rifle. He noted how inadequate
many others in “first aid” and
it would be if an ambulance arrived
EMS circles. He always seemed
at the scene of a CO poisoning at a
to think things through to resohome, found a mother, father and two
lution of the worst-case scenario
children lying out on the front lawn
and paid close attention to risk
in need of oxygen, and EMS providers
management, resource manage- When you have multiple patients, you need multiples of your equipment.
had just one complete portable O2 unit
ment and disaster preparedness
and four spare bottles. Once again, he
petroleum jelly to grease up the ears of a child said, if it happened to him once, he would
long before it was fashionable to do so.
For example, he not only had all critically whose head was simply stuck between the never let it happen to him or his crews again.
needed tools and devices positioned where rails of a fence to “extricate” them but would,
My dad also carried two separate resuscitathey were easy to access, but he also had a instead, have a big rescue truck dispatched to tion devices (a bag-valve mask and a Robertprofessional sign painter outline the items so do it. Boy did he have that one correct!
shaw demand-valve system), as well as two
Another thing he ingrained in me was separate suction systems and two separate,
he could ensure they were returned and properly secured in their exact location and posi- that, “If one is good, two are better.” It was a identically-equipped trauma bags. He did so
tion after a call. This included non-traditional philosophy he carried over to his ambulances to be able to care for two separate patients
tools, such as Partner PryAxes, tin snips, Hal- and storage areas.
at the same scene and to ensure he had a
I remember asking him one day, way back “backup” in case one of the devices failed, or
ligan bars, hacksaws, ring cutters, hammers
and chisels, fire extinguishers, multi-purpose in 1970, why he insisted on the department’s so he was never delayed from immediately
fencing pliers and other “unusual” (not on the ambulance carrying two OB kits, two fire doing a “turnaround” and responding to a
ambulance essential equipment list) items (a extinguishers and liter flow regulators on every critical trauma case.
jar of petroleum jelly) that he found useful in oxygen tank in the ambulance. That question
His advice hit home for me recently when
got me a polite, but educational, 30-minute I heard a chief officer from Regional EMS
the field.
He had thousands of calls and field experi- lecture that I never forgot:
Authority (REMSA) present lessons learned
He told me he had delivered multiple sets from their management of the victims injured
ences under his belt. And he often remarked
that some of the people authoring the essen- of twins in his career and realized after the first at the Reno (Nev.) Air Races crash in 2012.
tial equipment lists “never rode on an ambu- set that if it could happen once, it could hap- Although each of the five ambulances stalance” or were what he called “windbags” pen many times. Thus came another famous tioned on site was equipped with one tourwho rode an ambulance for a year or two quote, “Find a problem; fix a problem.”
niquet, there were 15 amputated extremities
He pointed out that, in his experience, just at the scene. Crews were forced to improvise
and then got promoted, moved on to medical
school or off to some other administrative about the time a five-pound fire extinguisher with men’s belts on several patients.
achieved a 90% knockdown
position, only to surface later
The REMSA official was quick to point
of a car fire it ran out, so it out that almost immediately after the incion some high-powered comwas best to carry two to “fin- dent, his agency added multiple tourniquets
mittee where they could use
ish the job.”
their “extensive” EMS experito each REMSA unit so each unit was better
Living in the coal region prepared to manage multiple simultaneous
ence to change or influence
of Pennsylvania, and having amputations in the future. When I heard the
the industry.
provided emergency care fast action REMSA took to address this issue,
He pointed out that these
to many families overcome I had to pass my dad’s “If one is good, two are
self-proclaimed “experts”
by coal gas fumes and other better” advice on to you. JEMS
would never think to use Two are better than one.
14
JEMS
AUGUST 2012

15. Choose 18 at www.jems.com/rs

16. LETTERS
in your words
Photo vu banh
A Thousand Words
As the saying goes, “a
picture is worth a thousand words.” One such
picture, an image featured on the cover of June
JEMS, struck a chord with
a reader concerned with
how the photograph represented an EMS culture
of safety. Read why he had
an issue with it, as well as
JEMS Editor-in-Chief A.J.
Heightman’s response.
I’m writing to ask for your assistance in adopting a culture of safety in EMS.
In your June issue, you have a great article on the Richmond Ambulance
Authority creating a comprehensive culture of safety model.
On the front cover of this particular issue, you have a photo of
CARE Ambulance providers and an Orange County Fire Authority firefighter/paramedic assessing a female patient in an ambulance.
Recognizing that a picture is worth a thousand words, I feel the cover
demonstrates the lack of embracing the culture of safety, although
not intentionally.
In the picture, one of the CARE personnel is standing unrestrained while
trying to take a patient’s blood pressure. The patient is also lacking the shoulder restraint belts that all major stretcher manufacturers say are necessary
for proper safety.
Through the windshield, you can see what appears to be a red stop light
centered, making me think that this is an ambulance that is in traffic and not
sitting at a scene. Even if stopped at a light, the medic should be securely
seated and restrained.
The help I am asking for is a simple request. Please have your staff review
photos, particularly those on the cover, from an “is this what we should be
doing?” perspective.
illustration steve berry
What?
Choose 19 at www.jems.com/rs
16
JEMS
AUGUST 2012

17. All the articles and seminars on safety will have a hard time convincing
the troops if major influential publications such as JEMS portray unsafe
operations as being how we operate. It may seem like a nit-picky point, but
if we are really going to change the fundamental thought process in EMS
to a culture of safety, we must all embrace it and demonstrate it from the
top down. Because JEMS has been the leader in EMS publications since the
beginning, I would challenge you and your staff to be the first to implement
a culture of safety in EMS publications.
Thank you for your consideration, and for providing the industry with a
state-of-the-art publication for so many years.
Ken Beers
Chief, Canandaigua Emergency Squad
Canandaigua, New York
JEMS Editor-in-Chief A.J. Heightman, MPA, EMT-P, responds:
We appreciate your comments and concern over the June JEMS cover photo.
This was a carefully pre-planned and executed static photo shoot conducted
in Orange County, Calif., under the watchful eyes of the medical director and
supervisors from the Orange County Fire Authority and CARE Ambulance, two
respected, professional EMS agencies.
This photo was taken in a stationary “at scene” ambulance positioned in
the ambulance bay at an Orange County fire station, not in a traffic area. We
should have presented that information on the “About the Cover” area on
the table of contents. We understand that without that information you and
others could have perceived this was an actual patient in an ambulance en
route to a hospital.
JEMS embraces a culture of safety in EMS. We make every effort to portray the “right ways” of performing EMS and admonishing the “wrong ways”
and simply did not give enough context to the photo for our readers.
We fully support the efforts underway by National Association of EMTs,
the EMS Safety Foundation, the International Association of Fire Fighters, the
International Association of Fire Chiefs, the National Highway Traffic Safety
Administration, and other industry leaders to change current behaviors and
create a comprehensive culture of safety throughout EMS. We will be more
careful in our captioning in the future.
Thanks for reading JEMS with a discerning eye.
CORRECTION
In June JEMS, “Hot Products” featured 50 of the top, innovative products at
this year’s EMS Today Conference and Exposition. Several product descriptions have incorrect photo listings. We’ll be running the correct product
photos and descriptions in September JEMS “Hands On.” JEMS
Do you have questions, comments or concerns
about recent JEMS or JEMS.com articles?
We’d love to hear from you. E-mail your letters to
editor.jems@elsevier.com or send to 525 B St. Suite
1800, San Diego, CA 92101, Attn: Allison Moen.
Choose 20 at www.jems.com/rs

18. PRIORITYUSE
TRAFFIC
NEWS YOU CAN
Federal Law Addresses
critical Drug issues
By Doug Wolfberg, Esq; Steve Wirth, Esq; Ken Brody, Esq; Franklin Banfer, RN, EMT-P
T
he Food and Drug Administration
Safety and Innovation Act (Senate
Bill 3187) was signed into law by
President Barack Obama on July 9. This
mammoth bill is designed to ensure both
the safety and adequacy of the nation’s
drug supply. Three parts of the law that will
affect EMS are Title IX: drug approval and
patient access, Title X: drug shortages and
Title XI: Subtitle D—synthetic drugs.
Drug Shortages
Nearly half of the drugs on the FDA’s shortage list are administered on ambulances.
Many of those drugs are used to treat seizures, cardiac arrests and other life-threatening conditions. Hampered by shortages, EMS
providers have used expired or alternative
medications, and have been forced to follow
modified treatment protocols that don’t represent best practices in patient care.
Title X of the new law is designed to
reduce drug shortages and improve information sharing regarding certain drugs,
including those used in emergency medical
care. Manufacturers will be required in most
cases to provide at least six months notice
to the government of the discontinuance
of the production of a drug or interruption
in its manufacture. And Health and Human
Services (HHS) will now be required to disclose both the discontinuation and manufacturing interruption of critical drugs to all
appropriate healthcare providers, including
EMS agencies.
Also, if HHS determines that there’s
likely to be a shortage of any critical drug, it
must expedite the review of new drug applications for which doing so would mitigate
or prevent the drug shortage. Moreover,
if HHS determines that an enforcement
action against a manufacturer—who has
notified HHS of a discontinuance or interruption in drug production—could reasonably cause or exacerbate a shortage of the
drug, HHS is to evaluate the risks associated with such shortage on patients before
determining what enforcement measures, if
any, to impose.
Additionally, the new law calls for a federal task force to develop and implement a
strategic plan to enhance HHS’s response to
preventing and mitigating drug shortages. A
component of the strategic plan will include
an evaluation of whether to establish a manufacturing partnership program through
which a qualified manufacturer would have
the capacity and capability to supply, within
a rapid time frame, drugs determined or
anticipated to be in short supply. Further,
within 18 months after the bill’s enactment,
the Comptroller General of the U.S. will be
required to conduct a study to examine the
cause of drug shortages and make recommendations on how to prevent and alleviate
such shortages.
Title IX addresses the need for expedited
drug approval while maintaining safety
and effectiveness standards. EMS providers will be primarily concerned with “fasttrack products” (i.e., a drug that is intended
for the treatment of a serious or life-threatening disease or condition) and accelerated
approval for such drugs.
It remains to be seen how effective this
legislation will be in addressing the drug
shortage dilemma. The problems can’t be
resolved overnight, and implementation of
some of the provisions in Title X may need
to await the adoption of regulations, which
the law requires within 18 months (although
many federal agencies often don’t complete
the task of issuing new regulations within
the time frames established by Congress).
Regardless, there’s no “quick fix” for drug
shortages that limit treatment options and
threaten patient care, but the enactment of
this bill is a move in the right direction.
Bath Salts
Bath salts have had serious implications
for EMS. Patients under the influence of
bath salts can present with altered mental
status, auditory and visual hallucinations,
agitation and violence.
Subtitle D of Title XI is the Synthetic
Drug Abuse Prevention Act of 2012. It
expands the list of Schedule I controlled
substances. Schedule I drugs include substances with high potential for abuse, no
currently accepted medical use in the U.S.,
and a lack of accepted safety for use of
the drug or other substance under medical
supervision. Unless specifically authorized,
the manufacturing, distribution, dispensing, possession or the intent to engage in
such conduct is illegal. The Synthetic Drug
Abuse Prevention Act adds bath salts as a
Schedule I controlled substance. This means
the possession of bath salts will be a violation of federal law. Of course, EMS providers encounter patients under the influence
of all sorts of drugs, both legal and illegal,
and merely classifying bath salts as illegal
drugs will not stop their use. Hopefully, the
act will reduce the frequency with which
they’re encountered in the field.
Like any new massive federal legislation,
the new federal drug law will have its share of
bureaucratic tangles. However, several provisions of this law promise a new beginning
in addressing drug supply problems that
have plagued EMS agencies across the U.S.
Pro Bono is written by attorneys Doug Wolfberg
and Steve Wirth of Page, Wolfberg Wirth LLC, a
national EMS industry law firm. This month’s column
was also written with the assistance of PWW attorney Ken Brody, Esq., and PWW clinical specialist
Franklin Banfer, RN, EMT-P. Visit the firm’s website
at www.pwwemslaw.com.
Supreme Court Ruling
Affordable Care Act intact
On June 28, the Supreme Court issued
its historic ruling on the constitutionality of the Affordable Care Act (ACA). This
ruling moves the country one step closer
to the full implementation of the healthcare reform that passed Congress and was
Conduct a keyword search for “drug shortage” at JEMS.com for more information
18
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AUGUST 2012

19. Comprehensive, Credible, Educational...
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20. continued from page 18
signed into law by President Obama more program within broad federal guidelines.
than two years ago. Personal opinions aside, Eligibility for the Medicaid recipients is
this ruling will have broad implications for largely left up to the individual states, with
dramatic differences among them.
everyone in the healthcare industry.
The ACA required states to standardIn one of the most watched cases in
recent history, the court kept the law largely ize Medicaid eligibility to include everyintact. The most controversial issue was body who has income less than 133% of the
regarding the constitutionality of the indi- federal poverty level. For some states, this
vidual mandate provision that requires vir- would represent a large increase in covertually everybody who can afford health age, and costs. To ease the financial burden
insurance to buy it. In a 5 to 4 decision, the on the states, the federal government will
court ruled that the federal government has cover all the costs of the Medicaid expanthe authority to penalize individuals who sion for the first three years and 90% starting in 2020 and beyond.
choose not to purchase health insurance.*
The Supreme Court ruled that the fedOne of the main goals of the ACA is to
reduce the number of U.S. citizens with- eral government can’t withhold Medicaid
out health insurance. It does so primarily funding from states that don’t expand their
through a combination of requiring peo- coverage. Effectively, this enables states
ple who can afford health insurance to buy to decide whether they’ll expand Medicaid, and some have already
it, requiring more businesses
stated their reluctance to
to provide health insurance
* There is a nuanced
do so. Many experts believe
to their employees and dradistinction between whether
the penalty falls under the
that the Medicaid expansion
matically expanding Medicregulation of interstate comis a good deal for the states
aid coverage. Medicaid is the
merce or a taxing authority.
and that state legislatures
joint state-federal health covFor all practical purposes,
and governors will be under
erage for low-income and
the court upheld one of the
intense pressure from hospidisabled individuals. Each
lynch-pins of the ACA.
tals, healthcare providers and
state administers its Medicaid
constituents to use the generous federal
funds to cover more low-income people,
but politics and ideology are sure to play a
role as this plays out over the next few years.
Implications for EMS
Most experts feel that healthcare reform
offers many opportunities for expanded roles
for EMS in community healthcare. Reducing the uninsured will increase demand for
health services, especially for primary and
emergency care. Numerous innovative EMS
agencies in the U.S. are learning from international experiences and working to deliver
high-quality, cost-effective healthcare delivery models using EMS personnel in expanded
roles and unique deployment strategies.
For more on advanced practice
paramedic programs, read “It Takes a
Village,” p. 42.
Despite the fact that the Supreme Court ruling affirms the constitutionality of the ACA,
the federal and state elections in November are
sure to play an important role in how healthcare is delivered in this country for decades to
come. —Keith A. Monosky, PhD, MPM, EMT-P
QUICK TAKEs
photo istockPhoto.com
Heat Wave across the U.S.
As temperatures rise across the country, so
does concern over the effect of this ongoing
heat wave. The National Climatic Data Center
reported more than 4,500 record daily highs
nationwide in the past month. At least 30 heatrelated deaths have been reported across the
country, including 10 in Virginia, where many
homes have been without power due to thunder storms.
Laura Stokes, MPAS, EMT-P, with Maryland’s
Anne Arundel County Fire Department, says,
“Since January, we’ve had 51 heat-related calls. [In] June we had 26. And just in the
10 days starting July, we’ve had 19. So we’re already way above what we would
expect.” She advises her EMS colleagues to be aware that not all heat-related
problems have obvious symptoms and that heat can exacerbate such existing
conditions as chronic obstructive pulmonary disease and asthma.
David Miramontes, MD, FACEP, the EMS medical director and assistant chief of
fire and EMS for the D.C. Office of Fire and EMS, also offered recommendations
about dealing with hot temperatures and patient influx. He advises eating foods
high in carbohydrates and drinking plenty of fluids throughout one’s shift, but avoiding caffeine. Dehydration due to such diuretics as caffeine and certain medications
can be problematic for both EMS workers and patients alike. —Jackie Krah
CHICAGO put ems bus in service
When Chicago Fire Commissioner Raymond Orozco saw an EMS bus at a conference
in Washington, D.C. about four years ago, he knew it would be a helpful asset for
the Chicago Fire Department (CFD). And thanks to a grant from the Department of
Homeland Security and May’s North Atlantic Treaty Organization (NATO) Summit,
it’s now part of the fleet in the Windy City, potentially freeing up some seven to 13
units for major events.
Leslee Stein-Spencer, manager of medical administration and regulatory compliance for CFD, wrote the Urban Area Security Initiative grant, which was approved
because of (and rolled out for) the NATO Summit. It was officially unveiled to the
public on June 15.
“We can transport up to 13 non-critical patients to different hospitals,” she says.
“We staff it with four paramedics, and if someone took a turn for the worse, we can
provide critical care.”
Reaction to the approximately $500,000 vehicle has been positive. “Hospitals that
oversee our medical license love it. The Allied Department of Public Health, which is
our regulatory agency, thinks it is great,” she adds.
Medical Director Eric Beck, DO, EMT-P, says, “The bus has advantages beyond
transport and mass casualty events. It also has value at larger incidents where an air
conditioned base would be desired or for rehab at a large fire.”
In the future, Beck says the department is working on obtaining a similar vehicle
but with specific resources for burn patients and a large cache of burn supplies.
—Devin Greaney
For more of the latest EMS news, visit JEMS.com/news
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21. Choose 21 at www.jems.com/rs

22. LEADERSHIP SECTOR
presented by the iafc ems section
by gary ludwig, ms, emt-p
System Costs
What’s the average price tag for an EMS system?
W
hat does your EMS system
cost to operate? It seems like
everyone is chasing the golden
answer to that question.
I know it sounds simple. If you’ve got the
answer, e-mail me.
Now before you e-mail me, I need to
know what your “system” costs you to
operate—not just ground ambulances or
what your budget is. When I talk about a
“system,” I’m speaking about the whole system, which includes communications, first
response and transport, and whether it is
ground, air or both.
Defining EMS Systems
Even within my explanation of what an
EMS system is, there’s debate. Some think
an EMS system is just the ground ambulance costs. Others think it’s the ground
ambulance coupled with the first response
agency. Still others, like me, think an
EMS systems comprises dispatch, the first
response agency and ground ambulances.
So if we can’t even agree on what an EMS
system is, how can you determine its costs?
The quandary of trying to determine the
true cost of EMS system has evaded EMS
managers, consultants and city managers
for years.
Some of the problems related to determining what your EMS system costs vary
from place to place. As the saying goes, “If
you’ve seen one EMS system, you’ve seen
one EMS system.” Why? The theory is that
no two EMS systems are alike. Systems
may have the basic foundations of a third
service, fire-based, private, volunteer or
hospital-based, but they all have nuances.
Within those foundations, many systems
have such variations as the level of service
that might be provided, the size of the
service area, response time requirements
or the readiness of the EMS system and the
cost of compensating the personnel. (Or in
some cases, such as with volunteers, there’s
no compensation.)
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AUGUST 2012
Other Cost Factors
Other factors that can affect the cost of an
EMS system are its levels of clinical sophistication. Is it an all-BLS EMS system for which
first response (if first response is included)
is BLS and the ground ambulance transport is BLS also? Or is it an all-ALS system
for which every first-response vehicle and
ground ambulance has paramedics with
ALS equipment? Or is it a combination of
BLS and ALS?
If there’s ALS within the system, what’s
the clinical sophistication of your ALS
delivery? Are there aggressive ST-elevation
myocardial infarction programs, continuous positive airway pressure, mechanical
CPR devices, auto-ventilators, a wide-array
of drugs, intraosseous infusions and other
levels of clinical delivery?
Other things to consider are the population size and economic and poverty levels
of the community. Populations and economic conditions of a community affect
EMS call volume. Poverty of the community
is also a major factor that affects costs.
Traditionally, you’ll see higher call volumes in urban areas than in suburban and
rural areas. My experience has shown me
that an urban community of 800,000 may
have 100,000 EMS calls with one in eight
people calling for an ambulance during the
course of a year, whereas a rural community of 3,000 with only 250 EMS calls may
equate to one EMS call for every 12 people.
One major factor that makes it difficult to determine an EMS system’s costs
is first response. Traditionally, fire departments provide first response in a community regardless of whether the ground
ambulance is fire-based or not. But
some fire apparatus and firefighters
don’t handle medical calls, instead
responding only on fire calls, as
well as other service calls (e.g., child
locked in a car). So the process of
looking at a fire department budget and
trying to determine a cost-allocation model
to figure how much of the fire department
is allocated to EMS calls, fire calls and other
service type calls can be challenging.
Some would even argue that such government costs as the city manager, city attorney,
finance manager, human resource manager
and others add to the cost of the EMS system
because part of their time in government is
spent dealing with EMS issues.
Another component that makes it difficult to determine an EMS system’s costs
is volunteers. Although they generally
receive no compensation, their contributions should be factored into operating an
EMS system. If it wasn’t for their volunteer
status, the money needed to operate the
system would be much higher. This makes
it difficult to truly measure the labor cost of
an EMS system.
Conclusion
Attempts have been made to determine
an EMS system’s cost. An effort by the
National Association of EMS State Officials
and the Medical College of Wisconsin called
the EMS Cost Analysis Project (www.nasemso.org/Projects/EMSCostAnalysis/)is
designed to create a framework that would
determine the cost of providing EMS care
from a societal perspective. The framework includes a 12-step tool to determine
the cost of an EMS system. Some contend
that the framework isn’t complete and still
needs additional revisions, but it’s a start.
One thing we know for sure is that the
reimbursement many EMS agencies receive
from Medicare, Medicaid, private insurance
and from those who self-pay doesn’t come
close to matching the costs of operating an
EMS system. JEMS
Gary Ludwig, MS, EMT-P, is a deputy fire chief
with the Memphis (Tenn.) Fire Department.
He has 34 years of fire and rescue experience. He’s chair of the EMS Section for the
International Association of Fire Chiefs and can be
reached at www.garyludwig.com.

23. Choose 22 at www.jems.com/rs

24. Higher Learning Practice
Educational Theories Put into
by William Raynovich, NREMTP, EdD, MPH, BS
Old Dogs New Tricks
Teaching changes in traditional EMS practices
I
t’s easy to introduce a new drug, device or procedure. EMS
responders welcome innovations. It’s also easy to remove drugs,
devices or procedures that haven’t shown to be effective. In
most cases, you simply taking them off the rigs.
Bringing about more subtle changes in practice, however, can
result in resistance, resentment and outright rejection. This article
is about how to effectively anticipate and overcome resistance to
bringing about changes in practice. So let’s discuss how to effectively anticipate and overcome this resistance.
EMS has many “sacred cows”—practices that are almost universally considered to be the “gold standards” for care and have been
deeply ingrained as the standard of practice for many years. It’s
inconceivable to many EMS responders that there could be a better
way of delivering patient care. When reflecting on past practices,
however, many of the former standard practices that were once
thought to be critically important to good patient care were subsequently shown to be useless, or worse, more harmful than beneficial.
This article will focus on how an instructor can effectively teach
a change in practice that, in effect, reverses one of those “gold standards.” Instructors may face a great deal of skepticism, resistance
and, often, outright hostility. Still, it’s “the job” of the EMS instructor to effectively deliver the new practice recommendations.
The Theory
L
mastery as a provider, no matter how well
founded in theory and practice, can be
barriers to learning.4 For example, experienced practitioners or educators may have
accurate but insufficient prior knowledge.
This can occur if they’re technically excellent at performing the skills but they lack
theoretical understanding of the underlying
pathophysiology or mechanics of how the
procedure or medication works was never
learned at depth or was forgotten over several years. The experienced EMS responders
may also have inappropriate or erroneous
knowledge based on prior theories that
have evolved to newer thinking.
TBF began by developing a self-contained Train-the-Trainer course that would
be delivered in the traditional classroom
setting.6 The TBF instructors received a
comprehensive training manual, instruction provided by a nationally recognized
EMS educator and peer, a complete package
of the scientific evidence and rationale for
the change in ventilation, and lesson plans
and support materials (e.g., instructor notes
for slides and workshops, new algorithms,
guidelines for instruction to each EMS provider level, sample scenarios, quizzes and
cases, ventilation rate exercises, procedure
algorithms, and pre- and post-tests).
Such an impressive, well-designed and
expertly presented course provided instruc-
tors with convincing evidence of the benefit
of the new ventilation recommendations
and extensive resources to present the
instruction to their regional EMS communities. The change in thinking about care of
TBI patients moved quickly in the industry.
The TBF initiative, however, was supported by a respected national organization that had substantial federal funding.
Individual instructors who want to accomplish this type of change on their own are
unlikely to have that level of funding, nor
the capability of producing such comprehensive courses, evidence, experts and support materials. Thus, the instructional goal
at the local level is to deliver training on
the new protocol or procedure within the
Photo istockphoto.com
asting learning can’t
take place when
barriers are raised.1–3
Instructors must be
100% invested in the
instruction and prepared to convey the
information with authenticity and commitment. Half-hearted and begrudging deliveries, with facial gestures and wisecrack
comments, will only result in mockery and
wasted time.
Instructors should also understand that
extensive EMS experience, education and
How do you teach the old dogs in EMS new medical “tricks?”
The practice
I
n the early 2000s,
the Traumatic Brain
Foundation (TBF) started
a reversal in the way
patients with traumatic
brain injury (TBI) were
ventilated. The long-standing, “logical” and
universally established way of ventilating
patients with suspected herniation of the
brain was to hyperventilate them.5
The current recommendation is to limit
the depth and rate of ventilations in the
adult to no more than 20 breaths per minute to avoid hyperventilation. The TBF’s
approach to reversing the practice serves
as an effective model for bringing about a
revolutionary educational change.
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27. Higher Learning
continued from page 24
constraints of a refresher course, a routine
continuing education session or through
other some other medium.
Individual Approach
To teach changes in procedures that have
been thought to be highly effective for
years, the instructor needs to first become
thoroughly knowledgeable about the
changes and develop a deep rationale for
them.. This step is essential because the
skeptical learner will sense any doubt the
instructor has, and the instructional process
will be compromised.
The instructor doesn’t need to work in
isolation. It’s best to begin by assessing the
receptivity for the new recommendation
through casual conversations. The discussion should focus on the risks and benefits
of the new recommendation and the underlying rationale.
A major “prior knowledge” barrier to
overcome is the powerful anecdote. That’s
prime face evidence, or evidence which appears
so logical and obvious that it is undeniable.
In fact, prime face evidence underlies most
of the practices of prehospital care, as well
as most medical practices today. There will
likely be a number of instances for which
the well-established, “effective” procedure
has “saved patients.” Those anecdotes are
difficult to counter, especially when the recommendation is based on weak clinical trials with complex statistical analyses that are
difficult to comprehend. Still, the anecdote
can’t hold up as the “best evidence” when
compared with randomized and blinded
clinical trials that have been independently
validated by other respected researchers.
The point is that the statistical clinical
research evidence must be presented in a
clear and understandable way. One way
to overcome this barrier is to approach a
statistician at a local university, or even
correspond by e-mail or telephone with the
authors and researchers who published the
articles. They can help to explain the results
in clear language that will make sense to
everyone. Instructors should acknowledge
the beliefs in the effectiveness of the traditional practices and address them head on
with the new evidence (research studies),
analytic arguments (critical thinking) and
an appeal to keep an open mind.1
After the instructor has taken the initial
steps to gain thorough knowledge about
the new recommendations, they can begin
to plan ways to deliver the instruction effectively. EMS instructors can use several core
principles to deliver the recommended practice changes when anticipating resistance.
Consider using the following approaches:
reparation (nothing is more imporP
tant than solid preparation);
Expert presenters (e.g., having a
nationally recognized educator present in person, and when not available,
possibly presenting remotely by using
a DVD, YouTube or Skype);
vidence (e.g., handouts with source
E
citations, abstracts, original articles, and
expert interpretations and opinions);
resentation materials (e.g., videos,
P
PowerPoint presentations);
ase presentations (ideally, real cases
C
for which the proposed treatment
would have made a difference in the
outcome and the established method
was either ineffective or harmful);
orkshops (opportunities for applied
W
practice sessions, which are ideal for
reinforcing the theory and cognitive
learning); and
uizzes (having the learners acknowlQ
edge the new practice by marking the
“correct answers” on the quizzes will
not only validate the instruction, but
will also imprint the commitment to
the learner as the quiz is taken).
Instructors can use several other subtle
ways for instructors to make a lasting impact.
Silence. Learning is most effective when
the environment, the body and the mind are
silent. In this context, the “silence” is really
a state of mind. Outside distractions and
preconceived ideas are set aside, and the
collective minds are prepared to receive the
new information.
To clear the mental clutter, the instructor can begin by “resetting” the minds of
everyone in the room with an icebreaker or
an amusing anecdote or joke. Lighthearted
videos are especially effective introductory
approaches for resetting the minds in the
room to be ready to learn.
Von Restorff effect. Another way to lower
tension and open minds for learning is to
make it fun, new and dynamic.7 Instructors
should be imaginative and search for ways to
be innovative, engaging and amusing when
presenting the new recommendations. The
overall effect will be greater, and the students
will remember the material longer.
Poetzel effect. The instructor can use
subliminal influences to have instruction
taking place without direct mental engagement.8 In the Poetzel effect, the instructor
might “seed” the environment with posters
or displays that depict the procedure, drug
or device.
A video about the recommendation can
be playing as the students enter the classroom. The instructor can start with stimulating casual discussions about the changes.
Conclusion
It’s an honor and a privilege to teach EMS.
EMS is powerful because it makes a difference between life and death, recovery
and health or permanent disability after
illnesses and accidents. It’s disconcerting
when practices that were held to be highly
effective are proven to be harmful or ineffective. Worse, it seems that if one practices
EMS long enough, the “old ways” return
in cycles. Thus, the challenge of presenting new and radically different treatment
recommendations is one that must be met
with dedication, commitment, deep knowledge and understanding, and savvy educational mastery. JEMS
William Raynovich, NREMT-P, EdD, MPH, BS, is the associate professor for EMS education at Creighton University
in Omaha, Neb.
References
1. Bridges W: Managing Transitions: Making the Most
of Change. Harper-Collins: New York, 1991.
2. Newcomb T, Hartley E: Readings in Social Psychology.
Henry Holt and Company: Troy, Mo., 1947.
3. Schein E: Process Consultation, Vol. 2: Lessons for
Managers and Consultants. Addison-Wesley: Reading, Mass., 1987.
4. Ambrose S , Bridges M, DiPietro M, et al: How
Learning Works: Seven Research-Based Principles
for Smart Teaching. Jossey-Bass: San Francisco, 2010.
5. New York State Department of Health. (2008) Statewide Basic Life Support Adult Pediatric Treatment
Protocols EMT-B and AEMT. In Scribd. Retrieved July
5, 2012, from www.scribd.com/doc/24858578/NewYork-State-Department-of-Health.
6. TBF (2005). Prehospital Management of Traumatic
Brain Injury Instructor Course.
7. Smith A: Keys to Student Mastery of EMT Training.
National Association of EMS Educators: Pittsburgh,
2010.
www.jems.com
AUGUST 2012
JEMS
27

28. TRICKSour patients ourselves
OF THE TRADE
caring for
by Thom Dick, EMT-P
Psych Transfers
Know how to deal with these types of patients
28
JEMS
AUGUST 2012
Photo Thom Dick
W
hen was the last time you
attended a talk on psychological transfers? How about the last
time you ever even heard of such a talk?
I can’t even guess how many hundreds
of times I’ve personally transferred people
with behavioral issues between facilities in
the middle of the night. There was a raging
value conflict in those days between people
who had fought for their lives in World War
II and their children, who were being forced
to fight for something much more nebulous
in a faraway place called Vietnam. It was also
a time of widespread use of amphetamines,
barbiturates, narcotics, cocaine and a whole
array of psychogenic substances. When we
transferred those folks, it was standard practice for the discharging facility to seal the transcript before they gave it to us. And, standard
practice for us not to open it—or else.
You’ve probably heard there’s a recession, Life-Saver. I don’t know if you’re seeing
what we’re seeing, but we’re seeing a lot of
angry, scared and disoriented people, beset
by circumstances they didn’t necessarily create. Our little town’s behavioral emergencies
have increased 100% since 2008, while our
community hospital’s emergency department (ED) has one psych bed. One. So once
more, our crews are transferring lots of psych
patients. Behavioral emergencies can be simple, or they can be immensely complex. You
don’t have to be a genius to understand that
scared people can be very dangerous just
because they’re scared.
They can suffer from the effects of external
factors that have nothing to do with medicine, like the loss of a job, a home and a car.
Throw in a divorce, all in the span of a year,
and you can expect them to be devastated.
They’re the ones who need your kindness as
much as anything. Others suffer from internal
factors, such as imbalanced chemicals in their
brains. In the span of a one-hour transfer, you
likely don’t have the wherewithal to assess or
alleviate those kinds of problems.
I think you deserve to know everything the
Don’t hesitate to physically restrain anybody
who triggers your Spidey-sense. Restraints
don’t have to be painful or even uncomfortable.
When you use them, incorporate all the cot’s
safety straps.
discharging facility knows about any patient
for whom you accept responsibility. You
should definitely read the transcript before
you even meet the patient. It should describe
circumstances, suicidal risk, flight risk, medications and behavioral history prior to and
during their stay in the ED. (If it doesn’t, you
should ask and expect a straight answer.) You
also deserve to know whether they’ve been
treated with physical or chemical restraints
prior to your arrival.
One of the best things about being with
JEMS for some 30 years is I’ve met a lot of
wonderful people. Aside from having a fine
name and spelling it properly, Thom Dunn,
PhD, is one of them. Thom is not only a seasoned medic, but he’s also a licensed clinical
psychologist. A couple of years ago, he gave
the only talk I’ve ever heard on psych transfers
(and behavioral emergencies in general). You
may not have ready access to Thom’s work,
but you can access a great article he published on the subject in 2008 at www.
jems.com/article/handlewithcare. 1 It’s
full of practical suggestions that could
only have come from someone who
has handled his share of these potentially high-risk calls.
Thom’s suggestions include the following and numerous others:
Dispatchers and supervisors should
choose experienced crews, not neophytes, to transfer patients with
behavioral issues;
patient who presents in
A
physical restraints should stay in
physical restraints;
sk every patient in advance: Are you
A
planning to harm us or try to escape?
Warn every patient in advance:
Touching the buckles will be perceived
as an ominous behavior;
physically restrained patient’s hands
A
and feet should be kept visible during
transport;
et into the habit of turning your strap
G
buckles upside down on the cot. It gives
you a few seconds’ extra warning if a
patient acts to unbuckle them;
atch the patient’s eyes. If you notice
W
them sizing up your location in the
patient compartment, consider the possibility they’re considering an attack or
an escape;
f you’re wondering whether or not to
I
physically restrain, restrain;
Incorporate the cot’s buckle straps—
all of them—into every application of
physical restraints;
eware of physically restrained patients
B
who attempt to negotiate their way out
of restraints; and
xercise special caution any time an
E
ED staff seems especially anxious to
discharge a patient with a behavioral
issue. JEMS
References
1. Dunn TM. Handle with Care: The challenges of transporting suicidal patients. JEMS. 2008;33(10):86–92.
Thom Dick has been involved in EMS for
41 years, 23 of them as a full-time EMT and
paramedic in San Diego County. He’s currently
the quality care coordinator for Platte Valley
Ambulance, a hospital-based 9-1-1 system in
Brighton, Colo. Contact him at boxcar414@comcast.net.

29. Choose 24 at www.jems.com/rs

30. CASE OF THE MONTH
DILEMMAS IN DAY-TO-DAY CARE
BY Patrick Harvey, MD
Risky Anticoagulants
Meds have the potential to turn minor trauma into a major disaster
Anticoagulants have been on the market for
more than 80 years. They’re used to treat a
variety of disorders, including atrial fibrillation, pulmonary embolism and acute
myocardial infarction. Until recently, the
mainstays of treatment have been heparins
and Vitamin K antagonists (e.g., warfarin).
30
JEMS
AUGUST 2012
heparin for deep venous thrombosis prophylaxis. Despite this variety, these medications
are prescribed disproportionately to geriatric
patients who are at the greatest risk for bleeding complications.2
Physiology
Different classes of anticoagulants target different parts of the body’s normal coagulation
pathways. Coagulation works as a cascade
Prehospital providers need to be familiar with comwith earlier parts of the system activating
monly used anticoagulants and their risk factors.
later parts, leading to a positive reinforceSide effects, dietary restrictions and expen- ment cycle.
sive monitoring have fueled a search for alterThe final common pathway for all the
native agents to these traditional treatments. enzymes is the enzyme thrombin. Once
In the past few years, novel anticoagulants activated, thrombin cleaves fibrinogen into
have started to enter the American market. fibrin, the main component in the fibrous
It’s important for EMS providers to be famil- mesh that makes up a clot. Warfarin and
iar with both old and new anticoagulants and other Vitamin K antagonists block function
their implications for triage and treatment of of upstream enzymes of the clotting cascade,
the injured patient.
preventing thrombin from becoming active.
Heparin activates a thrombin inhibitor, slowing fibrin formation. Newly developed agents
Patient Population
Anticoagulants have a large and increasing can bind to thrombin, directly decreasing its
presence in the American healthcare sys- activity. The mechanism of action has important implications for
tem. The number
Figure 1: Blood Thinner Card
the strategies of reversal
of dispensed outpaRed are high risk; patient should go to a
of these medications in
tient prescriptions for
trauma center.
the bleeding patient.
Warfarin increased
Trade Name
Generic
45%—from 21 million in 1998 to nearly
Implications
Coumadin
Warfarin
31 million in 2004.1 As
for EMS
Jantoven
Warfarin
the above case illusAs the case presenLovenox
Enoxaparin
trates, the presence
tation
illustrates,
Plavix
Clopidogrel
of an anticoagulant
anticoagulants can
Pradaxa
Dabigatran
on a patient’s medicaturn a low-risk injury
tion list can change a
into a life-threatening
Yellow are potential risk; consult with
medical command.
minor fall into serious
hemorrhagic event.
trauma. The patient
Anticoagulation is key
Trade Name
Generic
population that takes
in the treatment of
ASA w/
Aggrenox
Dipyridamole
these
medications
many conditions, but
Brilanta
Ticagrelor
varies from a young
the focus in prehospital
Effient
Prasugrel
woman on therapeutic
and emergency settings
anticoagulation for a
is often on reversing
Persantine
Dipyridamole
pulmonary embolism
these drug’s effects.
Plental
Cilostazol
to a nursing-home resiUnderstanding the
Ticlid
Ticlodipine
dent on subcutaneous
mechanisms of action
Figure Courtesy Victor Berg
Anticoagulants
Photo istockphoto.com
A
76-year-old woman slips and falls
while walking through her home.
She sustains a minor laceration to
her forehead. Her daughter, who is with her,
calls 9-1-1. At the scene, you find her alert,
reporting pain only at the site of the laceration. She and her daughter report no loss of
consciousness. Her medical history is significant for hypertension and atrial fibrillation. The daughter hands you the medication
list, which shows Toprol XL, Pradaxa and
Colace. Vital signs are unremarkable, and her
Glasgow Coma Scale (GCS) score is 15. Her
finger stick blood sugar is 98. An 18 g IV is
placed in her right anticubital vein.
You elect to take to her to a nearby community hospital. En route, she becomes agitated and attempts to pull out her IV. After
you arrive at the hospital, the staff gives her 1
mg of Ativan via IV to help with agitation. A
computed tomography (CT) scan of her head
shows a traumatic subarachnoid with an
overlying moderately sized subdural hematoma. After the patient is out of the CT scanner, she becomes more combative, and her
GCS deteriorates to an 8. She’s immediately
intubated for airway protection.
The patient is given fresh frozen plasma
(FFP), prothrombin complex concentrate
and activated Factor-VII in an attempt to
stop the bleeding. The community hospital
doesn’t have neurosurgical capabilities, so
the patient is transferred to a trauma center.
At the trauma center, she’s taken to the operating room. Unfortunately, a post-op head
CT scan shows brain herniation. She doesn’t
awaken, and her family withdraws her life
support two days later.

31. Types of Agents
Warfarin
Initially discovered in naturally occurring sweet clover, warfarin and other Vitamin
K antagonists inhibit the formation of Vitamin K-dependant clotting factors II, VII,
IX and X. As the first effective oral anticoagulant, warfarin has gained wide use and
popularity. Its narrow therapeutic window and many drug and dietary interactions
make it a cumbersome medication to manage.
Bleeding is a major concern with warfarin therapy. After insulin, warfarin is
the most common drug implicated in the U.S. emergency department visits for
adverse drug events.1 Its ability to inhibit all aspects of the coagulation cascade
can make relatively minor vascular injuries life-threatening bleeds. All bleeding
patients require source control and, if necessary, replacement of blood products. Patients who bleed while they’re on vitamin K antagonists also need to take
exogenous vitamin K and fresh frozen plasma (FFP) to reverse their coagulopathy.
Heparin
Used commercially since the 1920s, heparin is a naturally occurring sugar polymer.
Medical heparin ranges in size from 5,000 to more than 40,000 daltons. Heparin
activates antithrombin III, a potent inhibitor of thrombin and other coagulation
proteins. Low-molecular weight heparins (LMWHs) are purified polysaccharide
chains that weigh less than 8,000 daltons. They can be given subcutaneously
less frequently than traditional heparin, making them useful in bridging patients
to Coumadin or for patients who can’t tolerate oral agents.2 The most common
LMWHs in the U.S. are enoxaparin (Lovenox) and dalteparin (Fragmin).
Heparin can be reversed with the peptide molecule protamine sulfate. This
positively charged molecule will bind to and inactivate heparin. The protamineheparin complex is then removed from the body. Low molecular weight heparins are also typically reversed with protamine. This antidote is less effective for
LMWH, however. Protamine reverses only about 60% of the anticoagulant activity
of LMWH, leaving significant amounts of active agent in the body.3
Dibigatran
Marketed as Pradaxa, dibigatran etexilate is the first orally available direct thrombin inhibitor in the American market. It’s been investigated for use in prevention
of deep venous thrombosis (DVT) after orthopedic surgery, treatment of DVT and
prevention of stroke in patient with atrial fibrillation. It has predictable pharmacokinetics that allow for twice-daily dosing without regular lab monitoring.4
Despite the predictable dosing, bleeding has become a major concern with this
drug. Currently, no reversal agent for dibigatran exists, which raises concerns about
treating severe bleeding. Such traditional reversal agents as FFP or prothrombin
complex concentrates (PCC) aren’t thought to be effective at reversing this agent
for these agents is important because the
target of a particular anticoagulant will determine the best strategy for its reversal.
Caring for a bleeding patient who has been
anticoagulated can be complicated, often
requiring various blood products and reversal agents. In the case of some of the newer
anticoagulants, these reversal measures may
not be effective, placing increased emphasis
on early and effective source control and
adequate supportive measures.
It’s imperative that prehospital providers
be familiar with the commonly used antico-
because they don’t have sufficient amounts of thrombin to replace the depleted
stores. Dialysis has been discussed as a possibility to reverse bleeding complications. It’s estimated that up to 60% of the drug can be removed from the body
using hemodialysis.5,6 Currently, treatment of bleeding while on dibigatran focuses
on stopping the drug, source control and supportive care. The drug company that
makes dibigatran, Boehringer-Ingelheim, has confirmed that there were 260 fatal
bleeding events worldwide between March 2008 and October 31, 2011.7 The Food
Drug Administration is currently reviewing the safety concerns of Pradaxa in
light of these data.
Future Therapies
Based on proteins isolated from leeches, rivaroxaban and apixaban inhibit factor
Xa. Marketed as Xarelto and Eliquis respectively, these medications have been
approved for prophylaxis of DVT in Europe. Phase III clinical trials are currently
underway in the U.S. for prevention and treatment of DVT. In small studies, these
agents have been show to be effectively reversed by PCCs.8
References
1. U.S. Department of Health and Human Services. (Aug. 16, 2007). FDA Approves
Updated Warfarin (Coumadin) Prescribing Information Events. In U.S. Food Drug
Administration. Retrieved Feb. 2012, from www.fda.gov/NewsEvents/Newsroom/
PressAnnouncements/2007/ucm108967.htm.
2. Lee A, Levine M, Baker R, et al. Low-molecular-weight heparin versus vs. a coumarin for the prevention of recurrent venous thromboembolism in patients with
cancer. N Engl J Med. 349(2):146–153.
3. Warkentin T, Crowther M. Reversing anticoagulants both old and new. Can J
Anaesth. 2002;49(6):S11–S25.
4. Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients
with atrial fibrillation. N Engl J Med. 2009;361(12):1139–1151.
5. Lichtman M, Beutler E, Kaushansky K, et al. Williams Hematology, 7th Edition.
McGraw-Hill, New York: 261–271, 2006.
6. Eisert WG, Hauel N, Stangier J, et al. Dabigatran: An oral novel potent
reversible nonpeptide inhibitor of thrombin. Arterioscler Thromb Vasc Biol.
2010;30(10):1885–1889.
7. U.S. Department of Health and Human Services. (Dec, 7, 2011). Pradaxa (dabigatran
etexilate mesylate): Drug safety communication—Safety review of post-market
reports of serious bleeding events. In U.S. Food and Drug Administration. Retrieved
Dec. 7, 2011, from www.fda.gov/drugs/drugsafety/ucm282724.htm.
8. Eerenberg ES, Kamphuisen P, Slipkens M, et al. Reversal of rivaroxaban and dabigatran by prothrombin complex concentrate. Circulation. 2011;124(14):1573–1579.
agulants and their effects on bleeding. Some
EMS systems have developed quick reference
cards to assist providers in identifying drugs
that cause coagulopathy (see Figure 1, p. 30).
A bleeding or potentially bleeding patient
who’s taking these medications should be
routed to the nearest facility capable of giving
large volumes of blood products, performing
hemodialysis and surgically controlling a site
of bleeding. JEMS
Patrick Harvey, MD, is a senior resident in the University
of Pennsylvania’s emergency medicine program in
Philadelphia and is active in both prehospital and wilderness medicine. Contact him at Patrick.Harvey@uphs.
upenn.edu.
References
1. Wysowski D, Nourjah P, Swartz L. Bleeding complications with warfarin use: A prevalent adverse
effect resulting in regulatory action. Arch Intern Med.
2007;167(13):1414–1419.
2. Hylek E, Evans-Molina C, Shea C, et al. Major hemorrhage and tolerability of warfarin in the first year of
therapy among elderly patients with atrial fibrillation.
Circulation. 2007;115(21):2684–2686.
www.jems.com
AUGUST 2012
JEMS
31

32. RESEARCH REVIEW ems
What current studies mean to
by David Page, MS, NREMT-P
Stay Protected
Studies measure safety of stretchers protective gear
I
n the coming years, as the culture of safety
in EMS project continues, we hope to hear
much more about patient and provider
safety initiatives, and more routine reporting of errors, adverse events and near misses
in all areas of EMS. This Oklahoma-based
study helps remind us how simple research
can be, and how important it is that all
EMS agencies participate in it and then
report their findings in a peer-reviewed
scientific publication.
I Stretcher Errors I
Goodloe J, Crowder C, Arthur A, et al. EMS stretcher
“misadventures” in a large, urban EMS system: A
descriptive analysis of contributing factors and
resultant injuries. Emerg Med Int. 2012;2012:745706.
his retrospective analysis of quality improvement data in a single
Oklahoma-based ambulance service covering two cities (Tulsa and Oklahoma City),
the Emergency Medical Services Authority
(EMSA), reports a low incidence of adverse
stretcher events: 23 events in a one-year
period when this urban EMS system transported more than 129,000 patients. The
authors randomly selected a year to review
and analyzed data with their existing error
reporting system. The primary reason for
adverse events was a failure of the stretcher
to “catch” on the hook in the process of
unloading a patient. No patients were
injured from stretcher errors during this
time period.
The intent of the project was to establish a good baseline, and I think this study
will help accomplish this for Oklahoma.
However, I’m not sure how generalizable
these results are to other services. Many factors contribute to accurate reporting and a
low instance of errors. The authors discuss
that a culture of safety and method of tracking errors already existed in this system.
Kudos to them for already implementing
these practices.
Although we have no reason to doubt
32
JEMS
AUGUST 2012
Photo courtesy FISDAP
T
Stretcher errors were analyzed in a recent study on provider safety.
their reporting, and this safety record
should be commended, I find myself wondering if all near-misses were actually documented. I hope they continue on this great
path of safety, documentation and publication of research so we can all learn more.
Who will join them in a prospective multicenter study?
For more from Jeff Goodloe, read
“Attacking Cardiac Arrest,” pp. 52–57.
I Protective Clothing? I
Bourlai T, Pryor R, Suyama J, et al. Use of thermal
imagery for estimation of core body temperature
during precooling, exertion and recovery in wildland
firefighter protective clothing. Prehosp Emerg Care.
2012;16(3):390–399.
A
ccurately measuring core body temperature in EMS is one of our industry’s
most challenging present day enigmas. As
we progress in our knowledge and treatment
of sepsis, therapeutic hypothermia and other
temperature-related conditions, determining core temperatures has become essential.
In this project, the authors report
on a tightly controlled, experimental
project with high-sensitivity thermal imaging machines.
Although this study was small (six wildland firefighters in turnout gear), it took
extra care to avoid some of the common
problems associated with temperature
research. The subjects ingested a pill with
a radio transmitter to accurately measure
core temperature, and they had skin sensors
placed around their faces and other locations. They were pre-tested for fitness ability, and their diets were controlled during
the day before the test. They were also precooled by drinking ice-cold slushies (my
kind of research). In full turnout gear, the
subjects walked at 4 mph for 45 minutes.
The authors found a high correlation
between thermal imaging temperature

33. readings from the face and core temperatures during active exercise. The study discussed the theory that the temperature of blood
passing along the facial arteries fed by the carotid artery in close
proximity of the aorta appear to mirror core temperatures.
However, before you run out and borrow a thermal imaging unit from the fire engine in the station, beware: The facial
temperatures while at rest and during recovery were not a good
match. The units used in the study were the highest sensitivity
possible (older units may not be as sensitive). This study had only
six subjects and was conducted indoors. I completely agree with
the authors when they suggest that larger studies, under more
realistic environments (outdoors), are needed before we can render judgment on this technique.
If this method of temperature measurement were to work, the
potential applications at large sporting events and other mass
gatherings, as well as for patients with other illnesses, could be
useful. I know someone reading this will be inspired to try it, so be
sure to get institutional review board approval and make it an official study you can publish. We want to know what you find. JEMS
I watch box I
Photo istockphoto.com
Fernandez A, Crawford J, Studnek J, et al. An investigation of the association between extended shift lengths, sleepiness, and occupational
injury and illness among nationally certified EMS professionals. 2012 SAEM
Abstracts;S66.
Stay tuned for the full paper from Fernandez and the co-authors. This
abstract was presented at the recent Society for Academic Emergency
Medicine meeting. The authors used the National Registry of EMTs Longitudinal EMT Attributes and Demographics Study to see if there is a
link between extended shift lengths, sleepiness and occupational injury.
Answer: Yes. In this large survey that included the Epwroth Sleepiness
Scale (ESS), ambulance crashes, missed work due to occupational injury or
illness and needle sticks, it appears that
17.5% of respondents (186 out of 1,078
surveyed) experienced an occupational
injury or illness within the past year.
Working less than or equal to 24-hour
shifts was more than one and a half (odd
radio of 1.72) times likely to be associated
with injury or illness. Sleepiness was also
a factor. Does this mean the death of the
24-hour shift? I'll wait for the full paper
to draw any dramatic conclusions, but
this should cause all of us to give serious
thought to how much rest we get and
how many hours we work in a row.
Visit www.pcrfpodcast.org for audio commentary.
David Page, MS, NREMT-P, is an educator at Inver Hills Community
College and a paramedic at Allina EMS in Minneapolis/St. Paul. He’s
a member of the Board of Advisors of the Prehospital Care Research
Forum. Send him feedback at dpage@ehs.net.
Choose 25 at www.jems.com/rs

34. By Paul E. Pepe, MD, MPH, Sandra M. Schneider, MD
Why EMS should should be timely, thorough cautious
in implementing new approaches to patient care
F
or the past four decades, the evolving medical discipline of EMS has
had its demonstrated successes in
many communities worldwide.1–7 Not only
has there been a documented lifesaving
effect, but many EMS therapies also have
been used to diminish morbidity and discomfort for our patients through earlier
intervention.8–10
At the same time, in our well-intended
attempts to provide prompt and aggressive
care for our patients, we have also applied
practices that, inadvertently, may have
been detrimental for our patients or simply
not effective.11–32 In some cases, many interventions that could clearly be lifesaving
have been used too zealously or have been
provided either too early, or simply too late,
leading to a negative effect.13,14,16–18,26
In other cases, we haven’t used the procedure properly. As a result, we were
unaware of the resulting ineffectiveness
and subsequent loss of a potential lifesaving outcome.12,16,33–39
In many circumstances, based on available data, these detrimental practices were
considered standards of care and accepted
by the majority of practitioners.17,22,27–31 In
other cases, it was a poor understanding of
how system configuration can lead to a lessthan-optimal result.12,29,30
Fortunately, the ever-evolving EMS
focus on “research” and the surrounding emphasis on scientific investigation
in the prehospital setting has led to a better understanding of what EMS can and
should do for our patients.32,40 The results
have saved thousands of lives, raised the
stature of the EMS practitioner in the
34
jems
AUGUST 2012
house of medicine and increased the value
of EMS in the public eye.31,32, 40–42
Most importantly, in many cases, the
research effort itself saved lives. Even when
the scientific investigations revealed that
seemingly logical practices were actually
harmful, the study process itself has generally led to improved survival chances over
the pre-study levels—for both study and
control groups.31,32
This article will provide historical (and
even some current) examples of detrimental EMS practices and how we’ve identified
and attempted to retool those practices. It
will also attempt to provide future considerations for EMS practices while also providing caveats and cautions regarding the
limitations of “gold standard” research and
how to temper “evidenced-based medicine” with an ever-watchful eye.
Revisiting the ABCs
Since the origins of EMS practice, airway,
breathing and circulation (the so-called
“ABCs” of resuscitation) have been heralded
as the basics of emergency care. For practitioners, both in the in- and out-of-hospital settings, endotracheal intubation (ETI)
is still considered the definitive airway.43
It’s provided not only to better ensure adequate oxygenation and ventilation (carbon
dioxide elimination), but also to protect the
airway from rapid edema formation (e.g., in
burns and inhalation injury) or aspiration
of blood or gastric contents.43
In that sense, ETI has traditionally been
part of the clinical portfolio for prehospital
care personnel.1,2,7,12,43,44 Although it should
correlate with a worse outcome (the sickest
or most injured patients are the usual recipients), some studies have correlated ETI
with good outcomes.7,44–46
However, research initiatives over the
past two decades have suggested a detrimental effect or, at the least, no significant
advantage, to prehospital ETI, including a
controlled clinical trial in a pediatric population.13,15,47–51 Growing sentiment, including standards for cardiac resuscitation,
have de-emphasized EMS use of ETI.34,47,52
Nevertheless, the problem may not be the
tube, but the way in which it’s used, including prehospital practitioners being facile at
placement and their ensuing techniques of
providing ventilatory support once ETI has
been performed.12–14,16,29,30,48,53–55
The earliest EMS ALS systems were
staffed by a core team of skilled physicians
or a limited cadre of paramedics whose
response deployments were triaged and
focused primarily on the relatively smaller
group of critically ill patients.1,2,12,29,30 In
turn, skill use was frequent and, accordingly, ETI was routinely successful and performed rapidly.2,12,29,30
In the U.S. and many other locales,
however, a popular philosophy evolved in
the 1970s: More paramedics in a system
would provide patients a closer proximity to “advanced” prehospital care. Unfortunately, this deployment strategy also
created a dilution of skill use for individual paramedics.29 With a larger pool of
advanced providers who must compete
for the opportunity to attempt ETI among
the relatively small number of patients
who require the procedure, skills experience is much less frequent. This dynamic

35. www.jems.com
AUGUST 2012
JEMS
35

36. Primum Non Nocere
continued from page 35
predictably has been associated with less facile, failed intubation attempts in the majority
of EMS systems.12,29,50
Nevertheless, even when prehospital
practitioner performance of ETI is facile
and they can rapidly achieve successful tube
placement, the procedure may actually lead
to more harm if the practitioners’ ventilatory
practices are improper.12–14,16
In many venues, prehospital providers
have been demonstrated to overzealously
ventilate the patient once an ETI has been
placed.13,37 Even relatively controlled ventilation (tidal volume and rate) with positive-pressure breaths can have a profound
deleterious effect, especially in the bleeding patient who has experienced significant
IV volume loss.13,14,16,37,48,54,55 Even if provided
infrequently (i.e., five or six per minute), positive-pressure breaths can maintain adequate oxygenation and ventilation in such
fragile patients—and even be correlated
with improved outcomes.14,16,44,56 However,
even so-called “normal” rates of ventilation
can be relatively harmful and are likely to be
lethal in extremis conditions.7,13,14,16,54–56
Normal breathing is generated by the
diaphragm and other respiratory muscles.
The lungs are “pulled open” by creation of
a relative vacuum in the thorax. This “negative” intra-thoracic pressure sucks air into
the chest and enhances venous return to
the heart by also drawing more blood into
the chest.16,57 In contrast, providing breaths
delivers positive pressure to “push” the lungs
open. This creates higher than normal intrathoracic pressure, inhibiting venous blood
return back into the heart.12,14,16,54,57In most
normovolemic adults with normal blood
pressure and lung function, this intermittent
positive pressure, if not given too frequently,
is tolerated without observable clinical effect.
However, if the patient has a significant
degree of relative hypovolemia (e.g., severe
hemorrhage, dehydration and sepsis) or
obstructive lung disease impairing the outflow of air, the effect of positive pressure can
be dramatic and likely detrimental to outcome if breaths are delivered frequently (e.g.,
greater than five to six per minute).12,14,16,54,57
Also, in general terms, in low-flow
states, “ventilation should match perfusion”
(impaired blood flow should be matched
with constrained ventilation and CPR is
certainly a very low-flow state until normal
blood pressure is restored.
36
JEMS
AUGUST 2012
Therefore, although ETI may often be an
appropriate intervention in the prehospital
setting, it also can be detrimental if the system
isn’t designed to enhance skills for the practitioners and if the EMS providers aren’t controlling the ventilations properly.12,16.29,30,53
For similar reasons, more current consensus guidelines have supported a renewed
focus on minimally interrupted chest
compressions and de-emphasized rescuer
ventilation altogether in sudden-onset
(non-traumatic) cardiac arrest cases.34,35,52,57
In addition to inhibition of circulation by
positive-pressure ventilation, there’s another
concept of concern.
therapies are discovered that require deliberate and controlled CPR interruptions (e.g.,
stutter re-perfusion concepts) to diminish
reperfusion injury.59
The key determinant for return of spontaneous circulation (ROSC) is adequate coronary artery perfusion pressure (CPP) without
interruption.16,17,34,35,38,39,57 Current studies
show that CPP rapidly falls off when hands
come off the chest, and it takes many seconds
to build up the pressure head again.35,36
Accordingly, if one stops for too long an
interval (and too often) to provide rescue
breaths, pulse assessments or a shock, the
average CPP calculated over a minute (aka,
the “minute CPP”) is dramatically diminished
and, thus, the resuscitation efforts generally
become incompatible with ROSC.35,36,57,58
On the other hand, if compressions are
maintained without interruption, a reasonable minute CPP may be maintained,
increasing the chances of ROSC and survival
with intact neurological status.17,35,36,57,58
In short, the well intentioned and intuitive concept of providing lots of oxygen to a
patient who isn’t breathing normally may be
more harmful than helpful.16,17,35,37,57,58
At the same time, following our latest
mantras with chest compressions, such as
“push hard, push fast” and “don’t interrupt,”
may also be detrimental if compressions are
applied much too fast or if new promising
load, but the relatively slower expulsion of
the delivered tidal volume in patients with
obstructive lung disease also leads to residual positive-pressure retention at end expiration (i.e., throughout the entire respiratory
cycle).52,54,55
The resulting intrinsic positive end-expiratory pressure (PEEP) can impair successful resuscitation, particularly when ROSC
would have occurred had ventilations been
markedly reduced in frequency.55 Likewise, as previously noted, the effect of even
“normal” respiratory rates can be detrimental to those with severe intravascular hypovolemia, such as a hemorrhaging
trauma patient.14,16,48
EMS providers have also faced problems with well-intended and intuitively
logical attempts to return systemic blood
pressure (SBP) to “normal levels” in trauma
patients.11,20,22,60–62 Following the publication
of improvements in outcomes using experimental hemorrhage models in the 1950s and
’60s, it became standard of care to reverse
systemic hypotension, usually through the
use of IV isotonic fluid resuscitation and by
starting that fluid infusion in the prehospital setting.60,62
Revisiting Trauma Resuscitation
The problems with ETI are more pronounced with certain subpopulations of
patients, including those with obstructive lung disease, such as chronic bronchitis, emphysema and asthma, and, as noted
above, relative hypovolemia.14,16,52,54,55 Not
only does the positive-pressure ventilation have a detrimental effect in terms of
inhibiting venous return and cardiac pre-

37. Another attractive modality to raise blood
pressure in hypotensive injury patients was
the use of the so-called military (or medical)
anti-shock trousers (MAST), also known as
the pneumatic anti-shock garment (PASG)—
a device that was adopted from military aviation experience with G-suits.20,22
The PASG resembled a large blood-pressure cuff that surrounded both legs and the
abdomen. It was definitively shown to raise
SBP and was also touted to provide a tamponade effect to underlying bleeding and
stabilization of possible pelvic fractures.20,22
By the 1980s, considering its use as a noninvasive blood-pressure elevating device
that basic EMTs could employ, the PASG
became required by state law in two-thirds
of the U.S. as required EMS equipment.20,22
However, no clinical trials had ever
proven its effectiveness in saving lives.
Empirically, it made sense to use the PASG,
but subsequent prospective controlled trials
not only disproved the ability of the PASG
to save lives, but also suggested the devices
were actually detrimental.
The well-designed studies showed the elevation of SBP, but there was a pronounced
trend toward worse outcomes—particularly
in patients with distinct vascular injuries.20,22
This later led to a revisiting of the use of IV
fluids to raise SBP in trauma patients.23,27,28
The first controlled trials of preoperative
administration of isotonic IV fluids for both
hypotensive penetrating and blunt trauma
patients (with presumed internal hemorrhage) also showed no distinct advantage
and a likely detrimental effect, particularly
in those with penetrating injuries.20,27,28,62
In retrospect, the original experimental studies that showed a positive effect of
fluid infusion and SBP elevation were conducted in models that had a “fixed” hemorrhage.23,60–62 In other words, the severe
hemorrhage had been induced but was then
controlled (stopped) before the fluid infusion.
In contrast, it’s presumed that internal
hemorrhage in trauma patients isn’t yet controlled when fluid infusions are provided
in the prehospital setting.20,27,28,62 Based on
experimental models of “uncontrolled hemorrhage,” it’s now believed that the provision
of IV fluids (or SBP elevation with the PASG)
leads to hydraulic worsening of the bleeding, dislodging of early soft blood clots that
haven’t yet become fibrinous and perhaps
a dilution of residual clotting factors with
early fluid administration.23–26 The data suggest that delayed, slower infusions are more
optimal, even in head-injured models.26
Well Intentioned but often
Disadvantageous
Therefore, based on the most current data,
many well-intended interventions that were
originally thought to be lifesaving in given
situations are actually disadvantageous
under those specified conditions.20,22,23,24,27,63
These interventions were the standard of
care in EMS and were also zealously pursued
as critical therapeutic modalities.20,22,61,62
Sometimes the revelation that the interventions could be harmful came through a
better understanding of the physiology. In
some cases, however, it was also the circumstances or the timing of the intervention that
needed closer scrutiny.26,62,63
In essence, the story is more complicated
than a simplified question such as, “Are fluid
infusions, the PASG, ventilations or ETI ‘elemental’ or ‘detrimental?’” They’re all double-edged swords that can be tremendously
advantageous or even outright lifesaving if
used properly or at the right time.
At the same time, certain beneficial interventions can be deleterious if used improperly or in the wrong settings. In addition,
their value may not be appreciated if other
confounding variables obscure or mask
their effectiveness.16,43
For example, some “gold standard” clinical trials haven’t demonstrated a clear lifesaving effect of interventions that work well
in experimental settings.18,19,22,32,65,66
At first glance, these studies may be seen
as “definitive trials” and the conclusion
drawn that the expense of the device or therapeutic modality isn’t indicated, especially
after all the time, money and effort that went
into their implementation and eventual publication of the studies.19,65,66 However, it has
now been suggested that many so-called
definitive trials may have been obscured by
unrecognized confounding variables.19,32,67
A good example is the original prehospital trial of “high-dose” epinephrine (HDE)
conducted in the prehospital setting.19 HDE
worked dramatically well in the laboratory.
But no overall clear advantage was found in
controlled clinical trials. In retrospect, there
was no control for ventilation parameters as
part of the protocol.16,37
Also, the protocol didn’t follow the timing of drug administration set in the lab
because the HDE was given before defibrillation in the laboratory vs. after defibrillation in the trial.18,19
Subsequently, some of the participating EMS agencies were shown to have
previously unrecognized excessive ventilation.16,37 Some now speculate that this confounding variable may have overpowered
and masked the effect of the HDE.16
Similar concerns have been raised by
some when considering the recent trials
of the impedance threshold device (ITD)
in cardiac arrest.66,67 The ITD wasn’t demonstrated to be effective in one seemingly
well-designed, multi-center trial, whereas
a parallel study demonstrated a markedly
improved outcome when the ITD was used
in conjunction with another device.66,67
It’s unclear whether the ITD required use
of the other device (e.g., the active compression-decompression pump) to be effective,
or whether it simply was a neutral accompanying modality to the pump’s effectiveness.66–68 As alluded to before, however,
other unrecognized variables may have
obscured the true effect of the ITD and its
actual effectiveness including control of the
rate and quality of CPR performed.58,64,65,67,68
Again, timing, proper use and other clinical and system factors need to be considered
when judging the value of the devices.32,64,65,68
Regardless of the clinical trials’ results,
and even the negative outcomes in some
studies, it’s clear that the implementation
of clinical trials lead to a lifesaving effect
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