visit us online at emsworld · supplied by hand pumps or a skedco field expedient bleeding...

The MCI IssueSan Bernardino Shooting Response p. 18

Preparing for an Airport Disaster p. 26

Inside the Gathering of Eagles: Part 1 p. 31» Field Amputations » Mass Gatherings » Chemical Spills

Visit us online at EMSWorld.com JULY 2016 | VOL. 45, NO. 7 $7.00

RANSOMWARE RISKS p. 12 » CE ARTICLE: RESPIRATORY PATIENTS p. 42 » LTE TECHNOLOGY p. 54

Fast set-up allows for more scenarios, more hands-on exercises and leads to increased trainee confidence.

Training time is valuable,

why WASTE it on SET UP and RESETS?

TECHLINE® TRAUMA WEARABLE WOUND SIMULATIONS allow instructors to swap out casualties and realistic, bleeding wounds faster than it takes to remove the used bandages. The anatomically correct wounds can be integrated into existing training, driving the students to practice life saving interventions on wounds that look and feel real. The extremely rugged wounds slip on or wrap around the patient, holding them in place during drags and evacuation. Bleeding can be supplied by hand pumps or a SKEDCO Field Expedient Bleeding Simulation System (FEBSS) Hydrasim® (Not included) for realistic training.

> Adapts to Actors or TOMManikin®

> Accepts Tourniquets and Packing for Hemorrhage Control

> No Make-up Necessary

> Choice of Light or Dark Skin Tone

> Clinically Accurate

> Realistic Textures

> Realistic Blood Flow

> Extremely Rugged

TECHLINE TECHNOLOGIES, INC. • 668 Davisville Rd. • Willow Grove, PA 19090 • Phone: 215.657.1909 • Fax: 215.657.4430American made TOMManikin® family of products are provided by TECHLINE® TECHNOLOGIES, INC. and INNOVATIVE TACTICAL TRAINING SOLUTIONS®

Patent No. 8,221,129 © 2016 Techline Technologies, Inc. All rights reserved. Equal Opportunity Employer

215.657.1909www.techlinetrauma.com

ASK ABOUT THE FULL LINE OF

TOMMANIKIN®, TAMIKIN®, Task Trainer, Wound-in-a-Box™, Wearable Wound Simulations© and Self Adhesive Moulage

1 In adult patients with cardiac arrest from cardiac etiology. ResQCPR System Summary of Safety and Effectiveness Data submitted to FDA.

2 Lurie et al. J Med Soc Toho Univ 2012;59(6):305-315.

The ResQCPR System is intended for use as a CPR adjunct to improve the likelihood of survival in adult patients with non-traumatic cardiac arrest. Risk information: Improper use of the ResQCPR System could cause ineffective chest

compressions and decompressions, leading to suboptimal circulation during CPR and possible serious injury to the patient. The ResQCPR System should only be used by personnel who have been trained in its use. The ResQPUMP

should not be used in patients who have had a recent sternotomy as this may potentially cause serious injury. Improper positioning of the ResQPUMP suction cup may result in possible injury to the rib cage and/or internal organs,

and may also result in suboptimal circulation during ACD-CPR.

49-0879-000, 01

The ResQCPRTM System is a CPR adjunct comprised of two synergistic devices – the ResQPOD® ITD 16

and the ResQPUMP® ACD-CPR Device. Used together, these devices increase blood flow to the brain

and vital organs, as well as increase the likelihood of survival.2

Better Blood Flow. Improved Survival.

For more information, please visit www.zoll.com or call 877-737-7763.

A major clinical study showed a

49%in one -year survival from

cardiac arrest.1

increase

For More Information Circle 10 on Reader Service Card For More Information Circle 11 on Reader Service Card

4 JULY 2016 | EMSWORLD.com

Standard Issue

800.533.0523 www.boundtree.com

The CAT Tourniquet is a one-handed tourniquet designed to completely stop blood flow of an extremity in the event of a traumatic wound with severe bleeding. The CAT features a new design from previous models for faster application, decreased blood loss, effective slack removal, fewer windlass turns, and simplified training with single protocol application standards.

• One-handed application tourniquet

• Official Tourniquet of the U.S. Army since 2005

• Proven to be 100% effective in occluding blood flow in both upper & lower extremities by the U.S. Army’s Institute of Surgical Research

• Recommended by the Committee on Tactical Combat Casualty Care

• Red Tip Technology® provides visual cue during application

• Designed to perform in all weather conditions

For more information contact your dedicated Account Manageror learn more at www.boundtree.com/cat.asp

PROUD SPONSOR OF:

PARTNERS

EDITORIAL ADVISORY BOARDPeter Antevy, MDCEO & Founder, Pediatric Emergency Standards

James J. Augustine, MD, FACEPMedical Advisor, Washington Township Fire Department, Dayton, OH; Clinical Associate Professor, Department of Emergency Medicine, Wright State University, Dayton, OH; Director of Clinical Operations, US Acute Care Solutions

Raphael M. Barishansky, MPH, MS, CPMEMS Consultant

Eric Beck, DO, NREMT-PAssociate Chief Medical Officer, American Medical Response

Bernard Beckerman, MD, FACEPAssociate Professor, School of Health and Behavioral Sciences, York College (CUNY), Jamaica, NY

Tom Bouthillet, NREMT-PCaptain, Town of Hilton Head Island (SC) Fire & Rescue Division

Kenneth Bouvier, NREMT-PDeputy Chief of Operations, New Orleans EMS; NAEMT President 2004–2006

Elliot Carhart, EdD, RRT, NRPEMS Performance & Research Coordinator, Pinellas County EMS & Fire Administration, Largo, FL

Chris Cebollero, NREMT-PSenior Partner, Cebollero & Associates, St Louis, MO

Will Chapleau, EMT-P, RN, TNSDirector of Performance Improvement, American College of Surgeons

Kevin T. Collopy, BA, FP-C, CCEMT-P, NREMT-P, WEMTClinical Education Coordinator, VitaLink/AirLink, Wilmington, NC; Lead Instructor, Wilderness Medical Associates

Michael W. Dailey, MDAssistant Professor, Dept. of Emergency Medicine, Albany Medical College, NY

Thom DickEMS Educator, Brighton, CO

William E. Gandy, JD, LPEMS Educator and Consultant, Tucson, AZ

Erik S. Gaull, NREMT-P, CEM, CPPMaster Firefighter/Paramedic, Cabin John Park (MD) Volunteer Fire Department

Troy M. Hagen, MBA, NREMT-PCEO, Care Ambulance, Orange, CA

Martin Hellman, MD, FAAP, FACEPAttending Physician, Children’s Hospital of Pittsburgh, Pittsburgh, PA

Tim Hillier, Advanced Care ParamedicDirector of Professional Development, M.D. Ambulance, Saskatoon, SK Canada

Lou Jordan PIO, Fire Police Officer, Union Bridge (MD) Fire Department

C.T. “Chuck” Kearns, MBA, EMT-PEMS Consultant

G. Christopher Kelly, JDAttorney at Law, Atlanta, GA; Chief Legal Officer, EMS Consultants, Ltd.

Skip Kirkwood, MS, JD, EMT-P, EFO, CMO Director, Durham County (NC) EMS

Sean M. Kivlehan, MD, MPH, NREMT-P International Emergency Medicine Fellow, Brigham & Women’s Hospital, Harvard Medical School

William S. Krost, MBA, NREMT-PAdjunct Assistant Professor of Emergency Medicine, The George Washington University

Ken Lavelle, MD, FACEP, NREMT-P Clinical Instructor and Attending Physician, Thomas Jefferson University Hospital, Philadelphia, PA

Rob Lawrence, MCMIChief Operating Officer, Richmond (VA)Ambulance Authority

Todd J. LeDuc, MS, CFO, CEMAssistant Fire Chief, Broward Sheriff Fire Rescue, Ft. Lauderdale, FL

Mark D. Levine, MD, FACEPAssistant Professor, Dept. of Emergency Medicine, Washington University School of Medicine; Medical Director, St. Louis (MO) Fire Dept.

Tracey Loscar, NRP, FP-CBattalion Chief, Matanuska-Susitna (Mat-Su) Borough EMS, Wasilla, AK

Craig Manifold, DOEMS Medical Director, San Antonio Fire Department and San Antonio AirLIFE; Assistant Professor, University of Texas Health Science Center at San Antonio

Paul M. Maniscalco, MPA, EMT-PSenior Research Scientist & Principal Investigator, The George Washington University Office of Homeland Security

David Page, MS, NRPDirector, Prehospital Care Research Forum at UCLA; Paramedic, Allina Health EMS; Senior Lecturer, PhD candidate, Monash University

Richard W. Patrick, MS, CFO, EMT-P, FFDirector, Medical First Responder Coordination, Office of Health Affairs–Medical Readiness, U.S. DHS

Tim Perkins, BS, EMT-PEMS Systems Planner, Virginia Office of EMS, Virginia DOH, Glen Allen, VA

Michael E. Poynter, EMT-PExecutive Director, Kentucky Board of Emergency Medical Services

Vincent D. RobbinsPresident & CEO, MONOC, Monmouth-Ocean Hospital Service Corporation, Neptune, NJ

Mike RubinParamedic, Nashville, TN

Angelo Salvucci Jr., MD, FACEPMedical Director, Santa Barbara County & Ventura County EMS, CA

Scott R. Snyder, BS, NREMT-PFaculty, Public Safety Training Center, Emergency Care Program, Santa Rosa Jr. College, CA

Matthew R. Streger, Esq., MPA, NRP Partner, Keavney & Streger, Princeton, NJ; Senior Consultant, Fitch and Associates, LLC, New Brunswick, NJ

Dan Swayze, DrPH, MBA, MEMS Vice President/COO, Center for Emergency Medicine of Western Pennsylvania, Inc.

Cindy Tait, MICP, RN, PHN, MPHPresident, Center for Healthcare Education, Inc., Riverside, CA

John Todaro, BA, NRP, RN, TNS, NCEEEMS/CME Academic Department Coordinator, St. Petersburg College, St. Petersburg, FL

William F. Toon, EdD, NREMT-P EMS Training Manager, Loudoun County (VA) Fire, Rescue and Emergency Management; Battalion Chief - Training (ret.), Johnson County (KS) EMS: MED-ACT

David Wampler, PhD, LPAssistant Professor, Emergency Health Sciences, University of Texas Health Science Center, San Antonio, TX

Paul A. Werfel, MS, NREMT-PDirector, Paramedic Program, Clinical Asst. Professor of Health Science, School of Health Technology & Management, Asst. Professor of Clinical Emergency Medicine, Dept. of Emergency Medicine, Health Science Center, Stony Brook University, NY

Katherine West, BSN, MSEd, CICInfection-Control Consultant, Infection Control/Emerging Concepts, VA

Gerald C. Wydro, MD, FAAEMChief, Division of EMS, Temple University School of Medicine, Philadelphia, PA

Matt Zavadsky, MS-HSA, EMTDirector of Public Affairs, MedStar Mobile Healthcare, Ft. Worth, TX

Published by SouthComm Business Media, Inc PO Box 803 • 1233 Janesville AveFort Atkinson WI 53538920-563-6388 • 800-547-7377Vol. 45, No. 7PUBLISHERScott Cravens, EMT800/547-7377 x1759 [email protected]

EDITORIAL DIRECTORNancy Perry800/547-7377 x1110 [email protected]

SENIOR EDITORJohn Erich800/547-7377 x1106 [email protected]

ASSOCIATE EDITORPepper Jeter800/547-7377 x1628 [email protected]

ASSISTANT EDITORLucas Wimmer800/547-7377 [email protected]

PRODUCTION MANAGERLuAnn Hausz 800/547-7377 [email protected]

ART DIRECTOR Julie Whitty 800/547-7377 [email protected]

AUDIENCE DEVELOPMENT MANAGERJackie Dandoy800/547-7377 [email protected]

ASSOCIATE PUBLISHER - CENTRAL & MIDWESTDeanna Morgan901/[email protected]

BUSINESS DEVELOPMENT MANAGER - WEST COAST John Heter 503/[email protected]

BUSINESS DEVELOPMENT MANAGER - SOUTHEASTAnn Romens800/547-7377 x1366 [email protected]

BUSINESS DEVELOPMENT MANAGER - NORTHEASTTom Greve201/358-0751 [email protected]

ADMINISTRATIVE ASSISTANTMichelle Lieffring 800/547-7377 x1612 [email protected]

LIST RENTALSElizabeth Jackson847/492-1350 [email protected]

Chris Ferrell, CEO Ed Tearman, CFO

Blair Johnson, C00Curt Pordes, VP, Production Operations

Eric Kammerzelt, VP, TechnologyScott Bieda, EVP, Public Safety & Security

Ed Nichols, VP, Public Safety Events

Subscription Customer Service877-382-9187; [email protected] Box 3257 • Northbrook IL 60065-3257

Article reprintsBrett PetilloWright’s Media 877-652-5295, ext. [email protected]

EMS World magazine® (USPS 947-780; ISSN 2158-7833 (print); ISSN 2159-3078 (online)) is published monthly by SouthComm Business Media, LLC. Periodicals postage paid at Fort Atkinson, WI 53538 and additional mailing offices. POSTMASTER: Send address changes to EMS World, PO Box 3257, Northbrook, IL 60065-3257. Canada Post PM40612608. Return undeliverable Canadian addresses to: EMS World, PO Box 25542, London, ON N6C 6B2.

Subscriptions: Individual subscriptions are available without charge in the U.S. to qualified subscribers. Publisher reserves the right to reject non-qualified subscriptions. Subscription prices: U.S. $52 per year, $98 two year; Canada/Mexico $72 per year, $139 two year; All other countries $103 per year, $196 two year. Student rate $19 per year. All subscriptions payable in U.S. funds, drawn on U.S. bank. Canadian GST#842773848. Back issue $10 prepaid, if available. Printed in the USA. Copyright 2016 SouthComm Business Media, LLC.

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recordings or any information storage or retrieval system, without permission from the publisher.

SouthComm Business Media, LLC does not assume and hereby disclaims any liability to any person or company for any loss or damage caused by errors or omissions in the material herein, regardless of whether such errors result from negligence, accident or any other cause whatsoever. The views and opinions in the articles herein are not to be taken as official expressions of the publishers, unless so stated. The publishers do not warrant, either expressly or by implication, the factual accuracy of the articles herein, nor do they so warrant any views or opinions offered by the authors of said articles.

For More Information Circle 12 on Reader Service Card

*For most tests. For Intended Use information, see CTI sheets at www.abbottpointofcare.com. For in vitro diagnostic use only. ©Abbott Point of Care Inc. 045792 Rev. A 04/16

®

To learn more, contact your Abbott Point of Care or Distribution Representative, or visit www.abbottpointofcare.com

• Portability—Compact analyzer goes wherever you go.• Insight—Make more informed treatment decisions quickly and confidently. • Accuracy—Lab-accurate results at the patient’s side.• Speed—Results in as little as 2 minutes.*

One Platform, Multiple Tests

TRANSFORM EMERGENCY CARE AND COMMUNITY PARAMEDICINE WITH FAST, LAB-ACCURATE TESTING.

THE TEST RESULTS YOU NEED TO PROVIDE BETTER CARE ANYWHERE.

POINT OF CARE

CHOOSE TRANSFORMATION™

See Inspiration in Action at abbottpointofcare.com

• Chemistries/Electrolytes• Cardiac Markers

• Lactate• Blood Gases

• Hematology• Coagulation

For More Information Circle 13 on Reader Service Card6 JULY 2016 | EMSWORLD.com

FEATURES

35 Motivational Interviewing for the Community Paramedic MIH-CP providers should master this valuable skill to get the most benefit from patient encountersBy Dan Swayze, DrPH, MBA, MEMS

54 Will a Smartphone Replace Your Mobile Radio?LTE technology, featured in most 4G-enabled smartphones, has some valuable properties for emergency needsBy Thom Dick

Getting the Most From Your History and Physical: Respiratory PatientsThere’s a big difference between pneumonia and CHF—here’s what you need to tell them apartBy Kenneth A. Scheppke, MD, & Keith Bryer, BBA, EMT-P

35

42

LETTERS TO THE EDITOR: Letters may be edited for clarity or space. E-mail [email protected].

SUBMISSIONS: E-mail queries, manuscripts, press releases and news items to [email protected].

PERMISSIONS: E-mail requests to [email protected].

CONTAC T USfacebook.com/emsworldfans twitter.com/emsworldnews

linkedin.com/groups/1853412 youtube.com/EMSWorld

JULY 2016 Vol. 45, No. 7

COVER REPORT: THE MCI ISSUE

COLUMNS

14 CASES WITH A TWISTBreaking the SealBy David Page, MS, NRP, & Will Krost, MD, MBA, NRP

16 LUDWIG ON LEADERSHIPManaging Your Ambulance Service 50 Years AgoBy Gary Ludwig, MS, EMT-P

58 THE MIDLIFE MEDICJust So We Are ClearBy Tracey Loscar, NRP, FP-C

DEPARTMENTS 8 EMS World Online

10 From the Editor

12 News Network

56 Ad Index

57 Classified Ads

18 Among the TargetsAt the San Bernardino mass shooting response, an IED and Twitter threats menaced emergency personnelBy John Erich

26 Preparing for an Airpor t Disa sterFAA mandate tests multi-agency response to airport emergenciesBy Rob Lawrence, MCMI

31 Inside the Gathering of Eagles: Part 1Limb-and-Life DecisionsAre you ready to perform a field amputation?

Preparing for the PopePapal visit was unchartered territory

New Orleans Primes for Chemical DisastersThe Crescent City gets ready for sudden spillsBy John Erich & Pepper Jeter

On the CoverSimulated casualties all wearing casualty cards describing their injuries await rescue and evacuation from the inside of the aircraft simulator.

Photo by Kenneth Smith

MOULAGE OF THE MONTH

NEW

Bobbie Merica continues her guide to simulating injuries and illnesses through effective use of moulage. This month: Industrial response, flying debris. See EMSWorld.com/12214033.

FEATURESStuck in Reverse >> EMSWorld.com/12205052 In this month’s Life Support Mike Rubin asks: What if paid EMS providers are encroaching on a service that’s meant to be all volunteer?

Month in Review >> EMSWorld.com/12217067 If you’re looking to catch up with the latest news, most popular articles and the EMS chatter on social media, check out EMS World’s Month in Review column.

WEBCASTSVisit EMSWorld.com/webca sts to view previous presentations:

How to Prepare and Deliver High-Value EMS Simulation

Maximizing Your Revenue: The Critical Link Between Documentation, Reimbursement & Compliance

Recognizing and Reacting to the Lost Advanced Airway

Time Is Brain: The Need for Speed in Large Vessel Occlusion

twitter.com/emsworldnews www.linkedin.com/groups/1853412facebook.com/emsworldfans

ADVERTORIAL

Stopping the BleedWhen a patient is heavily bleeding, time is of the

essence. To help stop the bleeding quickly and

efficiently, Compression Works provides the

Abdominal Aortic and Junctional Tourniquet

(AAJT). The AAJT utilizes a belt, windlass

and pneumatic pressure to compress the

aorta or the arteries supplying the groin or axilla.

The AAJT can be used in the groin, the armpit

or the abdomen and is FDA cleared for all junctional hemorrhage

sites. The tourniquet can remain in position for up to four hours.

The AAJT is the only device to have an approved indication for

bleeding in the pelvis, and is the only device of its kind with inde-

pendent international validation of its effectiveness.

Brian Girard, vice president of marketing and sales with T1G, a

company that helps train EMS, military and other first responders,

says they have used the AAJT in training since about 2012.

Girard says in 2012, a group of pararescue jumpers came through

his training facility with the AAJT and left some as tourniquets for

his company to keep. Impressed with the product, Girard began

implementing it into training procedures.

Before fully implementing it, Girard ran an impromptu focus

group with a group of Marines who came through T1G for train-

ing. Girard said he wanted to see how easy the product was to use

for someone who hadn’t used it before.

“We mainly wanted to see the application times, because the

pararescue jumpers who brought us the product had already been

messing with it, so of course they were good at it,” Girard says.

They split the Marines into two groups, and showed one group

the general, two-minute crash course on how to use the AAJT. The

second group didn’t get to see the product

before being asked to use it. The first group

got the AAJT on and the hemorrhage con-

trolled in about 45 seconds, and the second

group was able to get the hemorrhage under control in

a little over two minutes while also using direct pressure to

the wound to help stop the bleeding. After the focus group, users

had nothing but positive things to say about the AAJT.

“Everyone liked it, thought it was easy to put on, and obviously

it worked,” Girard says.

Girard says a big reason why he likes to train people with the

AAJT is that junctional hemorrhage control is so important.

“At the time, junctional hemorrhage was one of the No. 1 killers

on the battlefield,” Girard says. “We had pretty much all known

someone who had died from junctional hemorrhage on the battle-

field, so it didn’t take any convincing for us to use the product.”

Girard says working with Compression Works has been a simple

process, and the company has been prompt and extremely respon-

sive to the limited number of issues T1G has brought to their atten-

tion. Girard says after hundreds of uses and cleanings (whereas

the average user only uses the AAJT a few times), a piece came

unglued. When this was brought to the attention of Compres-

sion Works, along with a few other minor tweaks T1G suggested

that might improve the functionality, changes were made almost

immediately.

Overall, Girard says he would gladly recommend the AAJT to

any agencies looking for a junctional tourniquet.

To learn more about the AAJT, visit compressionworks.com.

Circle 14 on the Product Information Card

ADVERTORIAL


Standardizing Safety: Do You Measure Up?

FOR MORE INFO: FERNOEMS.COM | 877.733.0911

July, 2016

All first responders are depended upon to do a job nobody else can do, at a time when nobody else can help. It is critically important that constant, hands-on training takes place with actual tools-of-the-trade to ensure positive patient outcomes. We remember the first time we used the “new” defibrillator on a patient. Either there were trepidations and butterflies in the stomach wondering if you could operate it, or there was confidence that you knew it like the back of your hand. And if you had the cooperation of the patient’s circulatory system, they would soon be walking out of the hospital.

Being creatures of habit, we are perhaps more resistant to change than the average civilian. Change, to us, could impact the life or death of a patient. However, some changes are long overdue.

The Society of Automotive Engineers (SAE) published their Recommended Practice J3027 for Patient Litter, Fastener and Restraint Systems in 2014, preceded by a multi-year scientific and peer-reviewed development and testing period. The purpose of this SAE document is to describe the conditions a cot, its floor fastener and the patient restraints (belts) have to meet in order to keep a patient on the cot and the cot fastened to the

floor during a 30-mph impact. The results of testing showed that a traditional “Antler and Rail” fastening system could not be expected to meet this criteria.

There are no “Federal Regulations” for ambulances operating within the fifty states and each state is now in a position of deciding whether or not to adopt SAE J3027 into their minimum requirements for ambulance certification. Fortunately, states have several options to help them with that process. The KKK-A1822-F (CN8) Federal Ambulance Purchasing Specification may be adopted by a state (around thirty have already, in whole or in part). Likewise, the state may adopt the NFPA-1917 Ambulance Standard or, when published, the new CAAS GVS v1.0 Standard. Both standards and the KKK specification include a requirement to meet SAE J3027.

If you operate a service in a state that has not adopted the SAE J3027 requirement into their MINIMUM requirements, remember you are able to specify an SAE J3027 compliant cot system as an addition or

improvement to your own purchasing documents.

Ferno has been helping lead the effort when it comes to the

EMS regulatory environment and has several of its own engineers who serve on committees that have overseen the new SAE and KKK standards. As a result of our partnerships with agencies such as NIOSH, NTEA and AMO, we have been at the forefront of innovating products that meet these new standards.

Ferno’s iN∫LINE™ and Stat Trac® Cot Fastening Systems have been dynamically tested and are fully compliant with new SAE ambulance safety standards. While the iN∫LINE Fastening System works exclusively with the iN∫X® Integrated Patient Transport & Loading System, the Stat Trac Fastening System achieves full SAE compliance when combined with the POWERFlexx®+ST or the 35XST PROFlexx®.

“Change, to us, could impact the life or death of a patient. However, some changes are long overdue.”


FROM THE EDITOR By Nancy Perry

You’re there �rst when emergencies arise,

putting your safety on the line to help those in

need. Listening to and working together with

medics, we built iN∫X, the only system PROVEN

TO EFFECTIVELY ELIMINATE LIFTING*. Add

the iN∫LINE Fastening System and you have

FULL SAE COMPLIANCE making your trip safer

for you and your patient.

*READ THE WHITEPAPER AT FERNOEMS.COM/INX/KNOWLEDGECENTER | 877.733.0911

© 20

16 FE

RNO,

INC.

iN∫X® INTEGRATED PATIENT TRANSPORT & LOADING SYSTEMiN∫LINE™ FASTENING SYSTEM

TOGETHERwe can Safely Deliver

Better care.

10 JULY 2016 | EMSWORLD.com For More Information Circle 16 on Reader Service Card

Building the Internet of Lifesaving ThingsFirstNet President TJ Kennedy talks technology

EMS is on the cusp of a revolution. Are you ready for

communication technologies that will turn the back

of your ambulance into a remote emergency room?

The newest generation of EMS practitioners will soon

hold high-definition two-way video dialogues with physicians

and specialists. This real-time relay of information will allow

hospitals to see what is coming in from the field ahead of

time. At this year’s EMS World Expo Opening Keynote, FirstNet

President TJ Kennedy will share how technology and con-

nectivity will bring about the “Internet of Lifesaving Things,”

making a monumental difference in the field and improving

the continuum of care.

I recently sat down with TJ to discuss the progress of FirstNet

and changes on the horizon.

EMS: For readers not familiar with FirstNet, can you give

us a brief description of the project?

TJ: FirstNet is a product of public safety’s advocacy efforts.

The entire community—including EMS—pushed for the cre-

ation of a nationwide public safety broadband network to

modernize communications and address challenges with

interoperability. Today we are well on our way to realizing

that network. FirstNet is developing an LTE network for first

responders with input from public safety agencies across the

country. Once operational, FirstNet’s nationwide public safety

broadband network will enable first responders to send and

receive text, voice, video, images, location information and

other data in real time to help increase situational awareness

and operational capability in the field.

EMS: As technology in healthcare advances, what chal-

lenges exist that could prevent EMS from taking full advan-

tage of these changes and how will FirstNet resolve those

challenges?

TJ: EMS does not have access to encrypted, prioritized and

preemptible networks. FirstNet is going to provide a new set

of tools to empower EMS. We will have priority and preemp-

tion built into the FirstNet network and FirstNet will deliver

a reliable network for all EMS entities. We will also have an

encrypted network that will support a secure network to

serve EMS.

Once the network is operational, it will be important for

responders to incorporate the nationwide public safety broad-

band network into their operating procedures. They will need

to be able to leverage prioritized public safety LTE broadband

services and technology in the field.

EMS: What key themes will you address during your keynote

presentation at EMS World Expo?

TJ: I believe that public safety broadband is going to revo-

lutionize emergency communications and bring about the

“Internet of Lifesaving Things.” Imagine if paramedics could

send a drone ahead of their arrival to an incident to gauge

the severity and even determine if

additional EMS resources will be

necessary. As they arrive, they use

connected tools to take the vitals

of an injured individual and send

the data to the nearest hospital in

real time before and during EMS

transport. In addition, a “smart”

ambulance has already calculated

the fastest route to the closest

hospital with the needed specialty

care and the responders are able

to hold a two-way video dialogue

with doctors and emergency room

staff who are standing by. The Internet of Lifesaving Things is

expected to provide new ways to identify medical issues and

save precious time when it counts. Another example of this is

allowing key patient information to be shared between EMS

and the hospital, which can improve the continuum of care

and patient outcomes.

EMS: This year is the 50th anniversary of the seminal

National Academy of Sciences White Paper, which gave

birth to the EMS system we have in place today. EMS has

changed dramatically during those five decades, what do

you think the next 50 years have in store?

TJ: As the nation’s overall public safety communications sys-

tems move to IP-based systems, we’ll begin to reap the ben-

efits of end-to-end next-generation communications. Informa-

tion will flow from PSAPs to providers in the field and to the

hospital, creating a 360-degree view of calls and incidents.

This will improve situational awareness, delivery of care, effi-

ciency of response and the safety of those on the front lines.

While FirstNet is just one critical part of a complete next-gen

public safety communications system—specifically, the pipe-

line that allows information to move quickly to and from first

responders in the field—I like to think FirstNet is a building block

for other public safety initiatives. I look forward to seeing the inno-

vation that is enabled by FirstNet over the next five decades—new

technologies that haven’t even been imagined yet.

EMSWorldExpo.com

TJ Kennedy

NEWS NETWORK By Matthew R. Streger, Esq., MPA, NRP

Ransomware: A Ticking Bomb for Public SafetyO

n February 5, 2016, Hollywood

Presbyterian Medical Center was

virtually shut down after its com-

puter systems were infected with

a virus that encrypted the hospital’s elec-

tronic medical records system. The hos-

pital was rendered operational again only

after paying a ransom of $17,000 in Bitcoin,

a virtually untraceable internet currency.

A little more than one month later, Med-

star Health was the target of a similar

attack that disabled the integrated com-

puter system across 10 hospitals in Mary-

land and Washington, D.C. Medstar even-

tually regained full operational capacity,

reportedly by restoring functionality from

backups and other internal processes.

Both of these events put patient care at

risk by disabling critical information sys-

tems, and both clearly cost the hospital

systems untold sums of money from busi-

ness interruption and lost productivity.

From January to March 2016, the FBI

reports a total of $209 million in ransom

payments from cybercrime events, up from

$25 million in 2015.

These types of incidents are becoming

more common. Police departments in Mas-

sachusetts, Maine and Illinois recently fell

victim, paying ransoms to re-enable their

computer systems. The high-level encryp-

tion used by these attacks makes it virtually

impossible to crack the systems and defeat

the ransom directly.

It is only a matter of time before EMS

agencies become victims of these attacks.

EMS systems continue to have greater

dependence on technology, with electronic

medical records systems, computer-aided

dispatch systems, other communications

systems and standard computer networks

accessed by a variety of devices from

handheld phones and tablets to dedicated

computers.

These systems are not always well-pro-

tected, updated and controlled, resulting in

soft targets for hackers. In fact, the inter-

connected nature of the systems presents

a cascading series of vulnerabilities, and

may place larger systems that EMS tech-

nology connects to at secondary risk.

Protecting Your AgencyThere are several best practices agencies

can follow to help reduce risk and mitigate

issues that might arise:

» Back up your system: Just like per-

sonal computing best practices, your

critical computer infrastructure should be

backed up. You should have multiple back-

ups in multiple places, and these backups

should include your operating system and

software, as well as your data. Test your

process for restoring from a backup to

regain operational capability. This single

factor, if properly employed, will reduce

ransomware exposure to almost zero.

The worst-case scenario, with a solid

backup methodology, would be to restore

your systems, patch your vulnerabilities

and continue to operate. This type of back-

up best practice also protects your system

from other disasters as well.

» Protect your passwords: The easiest

way to compromise a computer system is

simply by walking in through the front door,

so if your devices or login credentials are

not protected this is a critical vulnerability.

Do not fall for the false security of requiring

users to change passwords every 90 days,

as it will result in users simply writing their

credentials on a piece of paper next to the

computer. That being said, requiring users

to have complex passwords, disallowing

common words and requiring the password

to be different from those of other systems

are good practices for security.

» Get expert advice: Systems should

employ information systems specialists

to ensure system reliability and validate

those activities with an outside security

audit. Patch common application vulner-

abilities as soon as issues are identified and

ensure older known issues are patched as

well. Robust firewalls should control out-

bound communications, preventing some

problems and providing early identification

of others.

» Train your personnel: Training

should include device and password secu-

rity, as well as identifying phishing and

spearphishing attacks. Phishing attacks

involve e-mails that appear to be valid

requests for information, or requests to

reset a password or take a specific action

that results in negative action or vulner-

ability, and spearphishing attacks are

well-formed and directed to a specific

individual. Users should have awareness

of these types of attacks and what do to,

and what not to do, if they receive such an

e-mail. Awareness of these threats is the

most effective protection.

AB O U T THE AU TH O R Matthew R. Streger, Esq., MPA, NRP, is a partner at Keavney & Streger, LLC, in Princeton, NJ, and a senior consultant with Fitch and Associates. Matthew is a paramedic with over 30 years of healthcare experience, and is a member of the EMS World editorial advisory board.

BYOD PoliciesBring your own device (BYOD) policies are more common in the workplace, but present a set of vulnerabilities that may not be worth the costsavings or con-venience to personnel. Carrying two separate phones, for example, is annoying but that remains a small price to pay for ensuring that your employees’ inad-vertent actions do not compromise your system integrity. There are reports, for example, of malware that appear to be common games such as Candy Crush Saga that infect Android handsets so deeply that it may be necessary to replace the phone. The root-level access that these apps establish can grant access to a phone’s entire file system, and potentially your computer system as a result. This may happen as a result of an unsophisticated user who installs apps from outside the normal channels (Google Play, Apple App Store), or from a sophisticated user who “jailbreaks” an iPhone to remove security restrictions.

From January to March 2016, the FBI reports $209 million in ransom payments from cybercrime events, up from $25 million in 2015.


L E N O I R C O M M U N I T Y C O L L E G E

EMERGENCY MEDICAL SCIENCEEarn Your Degree Online!

231 Hwy. 58 South • Kinston, NC

www.lenoircc.edu

Paramedic Certifi cation (Hybrid Program)• Fully CAAHEP Accredited

• Different course options that allow currently credentialed EMTs, AEMTs, or individuals with no certifi cation to train

for their Paramedic certifi cation.

• Hybrid Paramedic program offered through LCC Continuing Education Department. Only four on-site visits required for skills training and evaluations. All coursework is done online. Tuition is $360.

• Clinicals can be completed in your area. Contact LCC regarding available areas.

• Graduates are eligible for the NCOEMS Paramedic exam and the National Registry Paramedic exam.

Associate Degree in EmergencyMedical Science — Bridging• All degree classes offered 100% online.

• Currently credentialed state and national Paramedics earn up to 45 credits toward their degree just for

being certifi ed!

• Designed for demanding EMS work schedules. Complete the degree at your own pace!

Contact a program specialist at

252-527-6223, ext. 115 or [email protected] More Information Circle 17 on Reader Service Card

CASES WITH A TWIST By David Page, MS, NRP, & Will Krost, MD, MBA, NRP

EMSWORLD.com | JULY 2016 1514 JULY 2016 | EMSWORLD.com

Breaking the SealWhat’s going on when a festival patron who should be dehydrated instead keeps peeing?

A 27-year-old male who had been drinking alco-

holic beverages presented with light-head-

edness and blurred vision after spending two

days at an outdoor summer music festival

where temperatures were constantly above 85ºF.

Initially the crew found the patient to be bellig-

erent, using profanity and refusing treatment. But

despite repeated offers by the police to take the

man to jail, the crew continued with a more thor-

ough medical assessment. The patient was unusu-

ally anxious and repeatedly said, “Molly is my friend,

she makes me glow in the dark!” and “I’m so hot!”

Vital signs were BP 70/40; pulse 120; respiratory rate

24; and blood glucose 108 mg/dL.

This crew appropriately began considering acute

alcohol intoxication and dehydration as the most

likely cause of the patient’s symptoms. While trying

to ignore the vulgarity, the crew also ignored some of

the apparently nonsensical sentences. They estab-

lished a large-bore IV and began giving a rapid fluid

bolus of normal saline. “I’m sure this will help your

hangover, my friend,” one of the crew told the man.

They also decided to transport him to the medical

tent, not directly to the emergency department.

Differential DiagnosisThe key to great decision making in the prehospital

setting is critical thinking. It is important to consider

all potential lethal conditions. In this case, merely

assuming (incorrectly) that the patient’s problem

was simply intoxication could have meant the dif-

ference between life and death. Once in the tent,

providers considered the patient’s presentation to

be a medical emergency and began treating him.

The twist in this case is that the patient, in his own

way, was trying to tell the crew a bit more about

what was happening to him. The patient was using

the term molly to describe taking MDMA, also known

as ecstasy or X. The fact that the man was hot was

also key. A bit more investigation by the crew would

have yielded valuable information about his hydra-

tion. In this case, the patient had been drinking large

quantities of neon-colored fruit punch and dancing.

Both of these made him sweat profusely and urinate

Central Pontine MyelinolysisCentral pontine myelinolysis, when severe, is known as locked-in syndrome. In locked-in syndrome, the patient loses function to all motor neurons except those that control vertical eye movements, blinking, breathing and alertness. In other words, the patient can see and is completely aware of everything going on but cannot speak or move.

The exact mechanism that causes a loss of myelin is unknown, but what is known is that rapidly corrected chronic hyponatremia results in edema of the pons, midbrain, thalamus, basal ganglia and cerebellum. This edema is believed to irreversibly (in the majority of cases) disrupt neuronal function. As a general rule, if sodium concentration is altered over a short period of time, then the sodium/fluid balance should be corrected rapidly. If the sodium concentration is altered over a prolonged period of time (greater than 48 hours), the sodium/fluid balance must be corrected slowly. The exception to this rule is the patient with severe neurologic symptoms such as seizures or severe neurologic dysfunction.

Help identify errors and near-miss events that affect the safety of EMS providers and patients by reporting anonymously at www.emseventreport.com. Data collected will be used to develop policies, procedures and training programs.

CRM Tips: Dig DeepIt is easy to get tunnel vision. As in

this case, not everything is black and white. We often talk to patients and use information presented on the surface to form our differential diag-noses. In EMS we are constantly mak-ing diagnoses and need to be well informed to make the best decision possible for our patients.

Myp

urga

tory

year

s/Th

inks

tock

so excessively that his friends started call-

ing him “the whiz kid.”

PathophysiologyIn hot conditions where dehydration is like-

ly, it is important to remember that people

will normally slow or stop their urinary out-

put. This forces reabsorption of water. This

mechanism is designed to prevent further

dehydration and ensure the kidneys do not

eliminate the much-needed fluid.

This mechanism is regulated by the renin-

angiotensin-aldosterone system. It works

by identifying the sodium (salt) level in the

blood and either activating the system when

the salt level is too high or turning it off if the

salt level is too low. This is a complex process

but can be simplified (not the most physio-

logically accurate statement but an example

that it is easy to understand) by saying that

high salt makes the blood thick, and low salt

will conversely make it thin. The body never

likes extremes and will do everything pos-

sible to exist in a perfectly balanced state.

The hormone that is primarily respon-

sible for regulating water in the kidneys

is antidiuretic hormone, more commonly

known as ADH. When ADH is present it will

stop diuresis (urinary excretion).

Alcohol EffectsThis is where things get really interesting.

Have you ever heard someone say, “Don’t

break the seal” when they have been drink-

ing alcohol? This is a metaphorical “seal”;

there is no physiologic basis for it. This

incessant need to continue to pee after

the seal is broken is a direct result of the

loss of control by ADH. Alcohol directly

blocks ADH release, and as a result ADH

no longer regulates urinary excretion.

Despite the fact that alcohol, by its nature,

dehydrates the blood, there is no hormon-

al protection from dehydration. Increases

in urinary output caused by ADH block-

ade and chemical dehydration caused by

alcohol will lead to less water available to

dilute the high salt content of the blood.

After further evaluating the patient in

the medical tent, the physician reported

an initial i-STAT POCT blood sodium

(salt) level of 118 milliequivalents per liter

(mEq/L). The normal blood sodium level

is between 135–145 mEq/L. This finding

in itself would be concerning and under

normal circumstances associated with

an increase in blood volume. An increase

in blood volume will cause dilution of the

sodium and ultimately lead to a relative

hyponatremia. However, this patient was

exhibiting clinical signs of decreased

blood volume.

There are a few steadfast rules of phys-

iology, and one of them is that sodium

always follows water. Wherever water

goes, it drags sodium with it. In this case

the patient was dangerously hyponatremic.

Continuing to give him more fluids without

managing his sodium was extremely risky.

The patient was transported to the

ED, and his clinical picture remained

unchanged despite conservative fluid

resuscitation strategies. Fluid resuscitation

was approached conservatively to ensure

that permanent neurologic damage was

not caused by the paramedics (see central

pontine myelinolysis sidebar).

The key lesson in this case with is to keep

a high index of suspicion and listen to the

patient. Many times prehospital care pro-

viders will be the only medically trained

providers to see the scene and talk to

bystanders. Being a good differential diag-

nosis “detective” will save many patients.

Editor’s note: Cases are obfuscated and

amalgamated to protect patient privacy

and provider anonymity. While staying

as true as possible to the actual event,

creative license is used to better explain

the lesson(s) in the case.

ABOUT THE AUTHORS David Page, MS, NRP, is director of the Prehospital Care Research Forum at UCLA. He is a senior lecturer and PhD candidate at Monash University. He has over 30 years of experience in EMS and continues to be active as a field paramedic for Allina Health EMS in the

Minneapolis/St. Paul area.

Will Krost, MD, MBA, NRP, is a faculty member at the George Washington University School of Medicine and Health Sciences in the Departments of Clinical Research and Leadership and Health Sciences. He has over 23 years of experience in EMS operations, critical care

transport and hospital administration.

David PageFEATURED SPEAKER

EMSWorldExpo.com

LUDWIG ON LEADERSHIP By Gary Ludwig, MS, EMT-P

Managing Your Ambulance Ser vice 50 Years A goWhat was being the boss like in the time before the white paper?

This year marks the 50th anniversa-

ry of the publication of Accidental

Death and Disability: The Neglected

Disease of Modern Society, the

landmark white paper from the National

Academy of Sciences that helped set the

stage for the development of modern-day

EMS. How far we have come in 50 years?

Although we still have a long way to go,

as a profession EMS has made tremendous

strides from the care we delivered some

five decades ago.

The statistics were staggering a year

before the white paper was published.

In 1965 there were 52 million accidental

injuries leading to 107,000 deaths, 10 mil-

lion people were temporarily

disabled, and 400,000 people

were permanently impaired, at

an estimated cost of $18 billion

(1965 dollars).

The white paper stated that

accidents were the leading

cause of death for persons

aged 1–37 and the fourth-leading cause

of death for all ages. For people under

75 motor vehicle accidents constituted

the leading cause of accidental death. In

1965 there were 47,089 traffic fatalities,

compared to 32,675 deaths in 2014. That

is a significant reduction in deaths during

a time when the U.S. population increased

by approximately 124 million people.

But what was it like to manage an ambu-

lance service 50 years ago?

Location, Location, LocationWell, it all depended on where you worked.

If you were the director of a funeral home,

you might also have to manage an ambu-

lance, since many funeral homes also

operated ambulance services. (I always

thought it was a conflict of interest, since

if you delivered poor care on the ambu-

lance, your funeral home was ultimately

rewarded in the end.)

Although not many fire departments

operated ambulance services, a fire chief

who found himself in this situation—unless

he was a visionary—probably saw operat-

ing an ambulance service as a necessary

evil, since the primary role of the fire service

back in the day was to fight fires.

There were some private ambulances,

but in talking to people who worked on

ambulances 50 years ago, the owner of

the ambulance service was in business to

make money and always looking to where

he could save costs.

Many government hospitals in large

cities also operated ambulance services

in the 1960s. If you found yourself run-

ning an ambulance service for a hospital,

chances are you were somewhere in the

hospital chain of management;

you might also have the clinics

under your responsibility, since

many hospitals had ambulanc-

es to move patients between

healthcare facilities.

There were even a few police

departments in the ambulance

business, and some of those still exist.

Even though the St. Louis Police Depart-

ment did not operate ambulances, I can

remember growing up in south St. Louis

and seeing police department prisoner

transport vans called “paddy wagons” into

which injured people were loaded on can-

vas stretchers before being raced as fast

as possible to the city hospital.

It did not matter if you were a funeral

home director, fire chief, business owner

or hospital executive, you probably tried to

do the best you could with what you knew.

It was not about medicine, it was about

staffing, dollars and maintenance of the

ambulance.

No StandardsBack in 1966 EMS did not really exist. Ambu-

lance services were mostly limited to trans-

porting people without really providing any

care. If you were lucky, there might be oxy-

gen in the back of the ambulance. Look at

old pictures of ambulances, and they might

have sign on them saying oxygen equipped,

as though this was some type of marketing

tool. Sometimes the people working on the

ambulance had advanced first aid training

from the American Red Cross, since no EMT

or paramedic curricula existed.

There were no standards on how ambu-

lances were built. Many were Cadillac

ambulances designed to give a smooth

ride, but not accommodating of patient

care. There was no headroom in the ambu-

lance to work on a patient—that is, even if

there was an attendant in the back, since

many services had none.

Other ambulances were panel trucks or

station wagons. I’ve even seen a picture

of an ambulance that was a large delivery

truck with a tailgate—the type that might

deliver your refrigerator or stove. States

usually had no laws on how to operate an

ambulance service, so many services made

it up as they went.

Personnel did not need a medical

license, and background checks usually

consisted of checking to see if there was

a driver’s license. Unfortunately we still

fight that stigma when some still call us

“ambulance drivers.”

As an ambulance manager you did not

have to worry about response time stan-

dards, advanced medical equipment, train-

ing, quality improvement programs, medi-

cal direction and many other facets today’s

leadership must deal with.

Although your job as the leader of EMS

organization may be more difficult these

days, with all the moving parts, there should

also be much more satisfaction than our

counterparts had five decades ago because

of the improved differences we make in our

systems and people’s lives.

ABOUT THE AUTHOR Gary Ludwig, MS, EMT-P, is chief of the Champaign (IL) Fire Department. He is a well-known author and lecturer who has managed award-winning metropolitan fire-based EMS systems in St. Louis and Memphis. He has a total of 37 years of fire and EMS experience and has been a paramedic for over 35 years. Contact him at garyludwig.com.

Gary LudwigFEATURED SPEAKER

EMSWorldExpo.com


EMS1607


MADE IN THE USA

QuikClot.com • 1-877-750-0504 • [email protected]

©2016 Z-MEDICA, LLC. All rights reserved.

Improve your ability to control bleeding and you improve your ability to save lives.Reduces Blood LossIn a pre-clinical model, QuikClot® had less blood loss when compared with standard packing.1

1. Sena MJ, Douglas G, Gerlach T, Grayson JK, Pichakron KO, Zierold D. A pilot study of the use of kaolin-impregnated gauze (Combat Gauze) for packing high-grade hepatic injuries in a hypothermic coagulopathic swine model. J Surg Res. 2013 Aug;183(2):704-9.

Maintains Robust ClotsIn numerous independent studies, QuikClot® products have demon-strated the ability to maintain a robust clot during movement 2,3,4 & improved time to hemostasis.2,5

2. Kheirabadi BS, Scherer MR, Estep JS, Dubick MA, Holcomb JB. Determination of efficacy of new hemostatic dressings in a model of extremity arterial hemorrhage in swine. J Trauma. 2009;67:450-460. 3. Gegel B, Burgert J, Gasko J, Campbell C, Martens M, Keck J, Reynolds H, Loughren M, Johnson D. The Ef-fects of QuikClot Combat Gauze and Movement on Hemorrhage Control in a Porcine Model. MILITARY MEDICINE. December 2012;177:1543-1547. 4. Garcia-Blanco J, Gegel B, Burgert J, Johnson S, Johnson D. The Effects of Movement on Hemorrhage When QuikClot® Combat Gauze™ Is Used in a Hypothermic Hemodiluted Porcine Model. Journal of Special Operations Medicine. 2015 Spring;15(1):57-60. 5. Trabattoni D, Montorsi P, Fabbiocchi F, Lualdi A, Gatto P, Bartorelli A. A new kaolin-based haemostatic bandage compared with manual compression for bleeding control after percutaneous coronary procedures. Eur Radiol. 2011;21:1687-1691.

By John Erich, Senior Editor

Among the Targets

At the San Bernardino mass shooting response, an IED and Twitter threats menaced emergency personnel

Ivan

Mila

dino

vic/

iSto

ck /T

hink

stoc

k

18 JULY 2016 | EMSWORLD.comFor More Information Circle 19 on Reader Service Card

“A large number of law enforcement officers started walking toward the triage area, and they said we had to move because they’d found an explosive device. They also said they didn’t know where the shooter was at that point. So I went from functioning in an oversight capacity and monitoring operations to worry-ing about the personnel who were on scene. We didn’t know where the shooter was, and the officer said there was an explosive, and we didn’t know what that meant—how many or how big. All he said was we had to move.”

—Dave Molloy

In last December’s terrorist attack at San Bernardino’s Inland Regional Center, shooters Syed Rizwan Farook and Tashfeen Malik killed 14 and wounded more than 20 at a workplace training

event-slash-holiday gathering. Answering such a call, with shooters

still on the loose, is unnerving enough for responders. In this case their anxiety was magnified by an explosive device found inside afterward and threats sent to emer-gency personnel.

Radicalized Muslims without known connections to terror groups, Farook and Malik were quickly killed in a shootout with police. Farook, a county health inspector, had initially attended the event at the IRC, then left following an argument before the pair returned in ski masks and tactical gear and opened fire. Their attack took less than four minutes.

Left behind was a bag containing three crude linked explosive devices rigged for remote detonation. This could have been meant to be exploded first and create easy targets as people ran from the building, a la Columbine—or could have been meant for responders. As they fled after the shooting, Farook and Malik drove back near the IRC and may have tried to detonate the bomb. An earlier unrealized plot, according to a criminal complaint against their associate Enrique Marquez, also would have targeted emergency personnel.1

The IRC IED didn’t work and was neu-tralized by police. But whether emergency personnel were targets of preference or just convenience, this was a case where many could have died.

“That was one of the things that plagued me in the weeks after and I had to work through,” says Carly Crews, RN, BSN, MICN, EMS coordinator for the San Bernardino City Fire Department. “I had employees in that building and many other people I cared about around there. It was terrifying. It was hard to face that we could

Editor’s note: As we were preparing to send this issue to press, the tragic events unfolded in Orlando, FL, on June 12. Our thoughts go out to all the victims’ families and the EMS, fire and law enforcement personnel who responded. We will cover the event in detail in a future issue.


were going into while we sat there staging or were en route didn’t allow chaos to form. We were very controlled on scene because we knew exactly what our objectives were and what needed to happen. I credit our battalion chief for thinking ahead and deter-mining those assignments ahead of time.”

It’s never a good day for a terror attack, but on this day department personnel were already stretched. Two stations had recently closed, and several leaders were busy else-where: The fire chief was in a meeting at city hall, and a deputy chief and two bat-talion chiefs were away in Rialto (ironically attending an educational event on terror-ism). Some equipment had been set aside for a forthcoming drill. Available were Crews, the EMS coordinator, and an engineer on light duty. More battalion chiefs came in to assist, and a SWAT medic who was training with police near the incident scene also got there quickly. A fortunate break was that the local EMS agencies, dispatch and hospitals all had meetings or training events going on that day, making extra personnel available.

With an MCI declared, triage, treat-ment and transport areas were quickly established outside the shooting site. The SWAT medic had begun initial triage, with officers dragging victims out and to care. More resources arrived with assignments in hand, averting duplication and delay. The IC assigned another battalion chief to unified command and oversaw operations himself.

At AMR Molloy had been on a conference call when his supervisor rang in with the news and a request for more hands. They quickly mustered 15 units and three super-visors toward the IRC.

As they approached, news helicopters hovered overhead, and “Are you OK?” texts from worried loved ones were already arriv-ing. The area was packed with cars, many unmarked law enforcement. Molloy looked up to see sheriff ’s deputies with automatic weapons moving up the street, followed by a fire chief with lights and siren. They trailed them to the scene. By now covered bodies lay on the roadside there. From a golf course across the street, a helicopter lifted off.

“It was the most intense scene I’ve seen in the 21 years I’ve been here,” Molloy says. “What was interesting, though, was that although it was chaotic, I felt like every-body who was there—EMS, fire, PD—was in control.”

The patients were coming. In all 33 were struck by gunfire. Their care generally consisted of hemorrhage control, occlu-

have lost them. I’m grateful we didn’t.”“It’s disheartening to think,” says Dave

Molloy, local operations manager for AMR, who responded that day and described the

abrupt forced relocation in the opening, “that there are people out there who would try to hurt us while we’re trying to help oth-ers. It’s very frustrating.”

Finding the IED wasn’t the only challeng-ing aspect to the San Bernardino incident. But a smooth and well-crafted response by the San Bernardino City Fire Department, AMR, law enforcement and other partners helped minimize casualties, aid the wound-ed quickly and distill some valuable lessons for when the next mass shooting occurs.

Controlled ChaosThe first report of shots fired that day came at 10:58 a.m. A paramedic engine from near-by fire station #231 was on scene and staged within nine minutes of initial reports and four of dispatch. Another 11 units rapidly joined it.

Crews arrived in that wave, having learned en route that the incident was an in-progress shooting with at least 20 patients. The FD’s on-scene incident commander, a battalion chief, began assigning ICS roles over the radio then.

“Having those predetermined assign-ments was really a key” to the response going well, says Crews. “Knowing what we

For More Information Circle 20 on Reader Service Card For More Information Circle 21 on Reader Service Card

TABLE 1: STAFFING

10 medic engines with 3 personnel

2 medic trucks with 3 personnel

1 battalion chief assigned to the city

2 battalion chiefs in an antiterrorist class in Rialto

Deputy chief in an antiterrorist class in Rialto

Fire chief in a meeting at city hall

EMS coordinator

Engineer on light duty

SWAT medic in training

2 battalion chiefs came in to assist


sive dressings for thoracic injuries and airway maintenance. The number of seriously wounded was popularly reported as 22, but that omitted one who turned up at a hospital by personal vehicle. A total of 20 were transported (including an officer injured in the shootout), and three others took themselves. Two of those had orthopedic injuries; the third presented some 30 hours later with shrapnel and bullet fragments in the chest.

Real-time hospital information communicated through the regional ReddiNet system helped guide destination decisions. Facili-ties relayed bed availability information to the comm center, and FD and AMR leaders collaborated on where to send whom.

Triage, treatment and transport moved rapidly. Police and air resources joined AMR in getting patients to initial care and on to hospitals. Thirteen fire agencies were ultimately represented, as well as multiple ambulance companies and law enforcement jurisdictions (to the tune of around 300 officers in 17 minutes). The feds showed up too; FBI personnel in flight from Los Angeles to Pomona for training were diverted and on scene within 26 minutes.

The last critical patient was taken from the scene at 11:47 a.m.—less than 50 minutes after the first report of shots fired.

Then the IED was found.

‘Something’s Going On’The ordered retreat to a safer distance (down Waterman Ave. and around a corner to fire station #231) was orderly. “The only way to describe it,” says Molloy, “is like having a bath or sink full of water, and you pull the plug and the water drains out. It’s like we drained down the street all in one motion. That’s something very specific I remember. I’d never seen anything like that in all the MCIs I’ve been on.”

By that point, however, the seriously hurt had been helped, and only a few minor patients showed up at the new site. But a large contingent of LEOs arrived for protection, and rooftop snipers underscored that things remained dangerous and dynamic.

The shooters were still on the loose. And someone was making threats.


TABLE 2: INITIAL RESPONSE/TIMELINE

10:58 Initial reports of shots fired

11:03 ME 231 dispatched to stage

11:07 ME 231 arrived on scene/staged

11:04–11:11 11 additional units dispatched/on scene

11:12 MCI declared by ME 231

11:15 MCI treatment area established

11:17 Comm center ReddiNet poll initiated

11:21 AMR responding with 15 units

11:24 Bed availability provided to med comm

11:36 3 AMR supervisors responding

11:47 Last critical patient transported off scene

11:54 2 ALS/8 BLS Symons units responding

11:59 Treatment area moved to 231

12:03 Possible explosive device in building“We’d started receiving these tweets on our fire department

Twitter account,” says Crews. “It looked like Arabic writing, and then there were pictures of carnage and messages like ‘Ha ha ha, we got you, San Bernardino City Fire Deparment!’ and things along those lines. We immediately went to homeland security and said, ‘Something’s going on.’ That’s when I realized this was a terrorist attack. Before that we didn’t know what it was, if it was workplace violence or something else.”

Authorities responded by sending extra security to all fire sta-tions. The culprit(s) behind the tweets has not been identified, though they came before Farook and Malik were killed.

That’s the kind of thing that makes you really appreciate some extra protection, and force protection and perimeter control were among the lessons culled from the IRC event.

“It could have been very easy,” notes Crews, “for the shooters to have obtained an unmarked car and come right back into the scene. CHP was watching the perimeter, but there were so many people coming in and out, and we weren’t sure who they were or what their role was. That was one of our biggest concerns.”

On the whole, though, things went smoothly, due in no small part to the training conducted and relationships developed among fire, EMS, law enforcement and other local players. In 2013, in fact, they’d all conducted an active-shooter drill over three days at a local high school. This prolonged exercise let them try different approaches and tweak details to make their MCI operations more efficient.

One of the things they tested during that time was having a tacti-cal medic enter the hot zone and start getting patients to a casualty collection point. Another was moving the triage and treatment area as close to the action as possible (its distance from the wounded created challenges at incidents like Columbine, Aurora and LAX). Both of those strategies were employed at the IRC. The triage/treatment area was placed by the law enforcement IC at the edge of the hot zone due to its easy access and visibility to the unified command location and casualty collection point.

“Training and trying different things is the key,” says Crews. “It will make a difference what type of building you’re in, what type of city you’re in, how many patients there are. So it’s important not to just rely on one thing in the toolbox, but to utilize many things.”

It remains true, if not new, that relationships matter. You don’t want to meet your FD/EMS/law enforcement peers for the first time at an evolving mass-casualty scene.

“Relationships played a huge role that day,” says Molloy. “We trust each other; there was no question about what needed to be done. We pulled up on scene, and my folks fully engaged by sim-ply asking, ‘What do you need?’ There were so many opportunities for things that could have gone wrong but didn’t, and I think it

was because we worked so well together and functioned in that capacity that it went as smoothly as it did.”

Takeaway PointsStill, there are always lessons to learn. To the end of force protection, one was potentially using vehicles to shield personnel at the scene.

“We’re so organized to line up our vehicles,” says Crews. “The police just show up on scene and park where they park, which we criticize at times. But what EMS does is pull into that scene and line up in these perfect little clean walls you see in all the pictures. And it looks beautiful, but it doesn’t really protect us. So we’ve talked about using those apparatus as a safety barrier around that treatment area and blocking ourselves a little bit more from the building.”

There were, as there often still seem to be at complex incidents like this, interoperability issues as well. San Bernardino has its own frequency for police, which isn’t interoperable with the CONFIRE (Consolidated Fire Agencies of San Bernardino County) system used by everyone else.

TABLE 3: PATIENT TYPE AND SEVERITY

Injury Severity Number

Death 14

Gunshot wound/critical 11

Gunshot wound/complex 5

Gunshot wound/soft tissue only 4

Orthopedic 8

Total 42

Death—Triaged on scene as dead. Gunshot wound/critical—Patient required emergency surgery. Gunshot wound/complex—Patient had wounds involving multiple systems, e.g., soft tissue with fractures or soft tissue with neurological deficit. Gunshot wound/soft tissue only—Did not require surgical repair or was not accompanied by life-threatening blood loss. Orthopedic—Non-life-threatening wounds not caused by gunshots, e.g., trip and fall.

Prehospital Trauma Life Support Promotes quality trauma care and improves patient outcomes / 16 hours of CECBEMS credit

PHTLS for First Responders Immediate trauma care for seriously injured patients / 8 hours of CECBEMS credit

Advanced Medical Life Support – NEW Edition!Rapid and accurate patient assessment with scenario-based learning / 16 hours of CECBEMS credit

EMS Safety – NEW Edition! Strategies to significantly lower workplace injuries and ensure responder resilience / 8 hours of CECBEMS credit

Geriatric Emergency Medical Services Addresses the unique challenges of older adults with content on fall prevention, disaster management, MIH-CP / 8 hours of CECBEMS credit

Emergency Pediatric Care Provides knowledge and critical-thinking skills for the full spectrum of pediatric emergency illnesses and injuries / 16 hours of CECBEMS credit

Principles of Ethics and Personal Leadership Teaches personal and professional core values and promotes ethical decision-making/ethical leadership skills / 8 hours of CECBEMS credit

NAEMT’s Continuing Education programs include the latest evidence-based knowledge and are developed by leading clinicians and respected EMS educators from around the world.

Consistent Quality. High Standards.

Tactical Combat Casualty Care Crucial training for MEDICAL military personnel and fully compliant with CoTCCC guidelines / 16 hours of CECBEMS credit

Tactical Emergency Casualty Care Based on CoTECC and TCCC guidelines, course takes an all-hazards approach to teaching civilian tactical EMS / 16 hours of CECBEMS credit

Law Enforcement and First Response Tactical Casualty Care Basic lifesaving interventions for all public safety first responders and based on TCCC and PHTLS principles / 8 hours of CECBEMS credit

Bleeding Control for the Injured Basic lifesaving medical interventions for first responders and civilians and follows Hartford Consensus recommendations / 2.5-hour course

LEARN MORE AT NAEMT.ORG/EDUCATION OR EMAIL [email protected] 1-800-34-NAEMT

EMER

GENCY PEDIATRIC CARE

Coming in early 2017! All Hazards Disaster ResponseEmpowers practitioners with knowledge and skills to manage patients during the initial stages of a disaster/mass casualty event / 8 hours of CECBEMS credit

All non-tactical NAEMT courses are designed for both ALS and BLS providers.

EMSWORLD.com | JULY 2016 25For More Information Circle 25 on Reader Service Card

AMR plans to enhance its internal communications at future incidents with a dedicated dispatcher pulled from other daily calls, and it may start tapping surrounding AMR operations for manag-ers, administrators and other personnel to backfill positions when its leaders are occupied at a big event.

A final point, Molloy notes, is to not let personnel get distracted by what they perceive an MCI should look like.

“People need to have an open mind and be adaptable to the situ-ation,” he says. “We had a lot of law enforcement presence, and it was a difficult thing for some of our folks because they were coming in unmarked vehicles, and we didn’t know who was who. It wasn’t until later that we figured out these were the good guys. But help can come in any shape and form during an incident.”

A lesson not unique to San Bernardino but that bears repeating is not to neglect the emotional and psychological well-being of those who respond to disasters. Responders to the IRC got mandatory group crisis team intervention starting the night of the incident and continuing into the next week. They were also offered and encouraged to accept individual sessions.

Even besides the IED and Twitter threats, there were aspects of the response that lingered for Crews.

“One of them was hearing ‘San Bernardino, California’ all over the news and coming out of the president’s mouth,” she says. “It was so real, I couldn’t handle it. I got mad at that, at hearing it over and over. I didn’t like watching the news; I didn’t want to connect the victims to those faces I saw at the scene. That was very hard.”

It was hard too for Molloy, whose family friend Robert Adams was among those killed.

“You’re frustrated and you’re mad, and what do you do with that?” he asks. “The shooters were dead, so I can’t even say justice was served. But in the days following, you almost have to be like a cheerleader for the troops. You have folks out there who are nervous. I had people come to me and ask, ‘What do we do if we go out on these calls?’ And while I’m thinking I hope this doesn’t happen, you have to rely on your training and say, ‘We’re gonna suit up and go out and take care of our citizens.’ But you’re definitely worrying about scene safety and the area around you.

“You can’t take the attitude that it’s never going to happen to you,” he adds. “Terrorism and IEDs and active shooters are a real-ity today, and people need to prepare for it. If you train for it and it never happens, then amen to that. But you have to be ready.”

RE FE RE N CE

1. www.washingtonpost.com/apps/g/page/world/read-the-criminal-complaint-against-enrique-marquez-friend-of-san-bernardino-shooter-who-provided-rifles/1917/?refresh&tid=a_inl.


Carly Crews and Dave Molloy will present “Terror in San Bernardino,” which focuses on the experiences of the two agencies and the lessons learned.

FEATURED SPEAKERS EMSWorldExpo.com


» RIC Airport Rescue and Fire Fighting and police departments;

» Airline representatives; » Virginia Department of Emergency Management; » Federal Aviation Administration (FAA); » American Red Cross; » FAA Air Traffic Control Tower (ATC/FAA); » Transportation Security Administration (TSA); » Virginia State Police; » Virginia Department of Health (including Medical

Examiner’s office); » Virginia Department of Fire Programs; » Virginia Department of Transportation (VDOT).

Fire, EMS and CERT teams from the metro Richmond area also converged to exercise their mutual aid com-mitment. The event itself tested a number of phases in the response to the major incident developing on the RIC runway.


By Rob Lawrence, MCMIFAA mandate tests multi-agency response to airport emergencies emergencies

The Federal Aviation Administration (FAA) mandates that airports conduct full-scale tests of their airport emergency plan (AEP) every three years.1 Such drills not only test the AEP, but also create a real-time prac-tice environment for multi-agency, multijurisdictional

response coordination that would be necessary in the event of an actual incident. In April 2016, the Richmond International Airport (RIC) in Virginia conducted its AEP exercise against the challenging scenario of an incoming plane that had a run-in with a flock of birds, causing engine failure

As with real incidents, drills such as this require considerable exter-nal resources in addition to onsite airport fire and rescue assets. “This gives us an opportunity to work together for our mutual aid agreement for the metro area and all of our partners to work together and implement the region’s MCI plan,” notes John Fitzgerald, aircraft, rescue & firefighter captain for the Richmond Fire Department.

The exercise itself represented a model of regional cooperation with attendees from:

Photos by Kenneth Smith


several hazards as responders must immediately ensure dis-oriented passengers are directed or led to a point of safety. In many aircraft incidents, passengers disperse across the airfield, creating further hazards.

For those unable to exit the aircraft and for firefighting pur-poses, an internal attack and patient extrication may be neces-sary, which again requires considerable knowledge, skill and coordination. All immediate functions are the sole responsibility of the airport’s fire and rescue services and occur before mutual aid arrives on scene in the seconds and minutes after an event. The opening phase of the RIC exercise put the airport’s own resources fully to the test with the realistic scenario including live flames to extinguish.

Establishing Command and ControlWith the declaration of an airfield major incident, as in the case of the RIC exercise, operational support and mutual aid began to roll in. A range of support reported to various locations on the airfield. Fire and EMS all reported to the designated air-field crash gate and were directed toward the staging area, while emergency management and law enforcement reported to the designated unified command. Roles and responsibilities and a common emergency language are contained within the National Incident Management System (NIMS).

Agencies within the metro Richmond area have an added advantage in that they exercise those processes and principles regularly at such events as the biannual NASCAR series, the Richmond Marathon or last year’s UCI World Cycling Champi-onships. The largest level of mutual support, providing position specific incident managers, was from Henrico County Division of Fire, the jurisdiction in which RIC sits. The division’s deputy coordinator of emergency management, Anna McRay, played a major role in the development of the exercise and the ultimate success of the day. McRay also brought many willing volunteers from her CERT team to act as passengers and simulated casual-ties. On the day, 150 moulaged volunteers participated.

TriageBack at the crash scene, with mutual aid units pulling in, casual-ties started to pass through triage areas and were loaded onto waiting ambulances or ambu-buses.

As with every major incident patient tracking is a vital task both to inform as to the location of passengers who have now become patients and maintain the tally of how many START tri-aged patients went to which hospital and level of trauma center.

The establishment of solid communications is a necessity, particularly to inform the organization providing hospital medi-cal control. In the RIC/Metro Richmond system, the medical control function is performed by the Virginia Commonwealth University, which identifies the destination hospital based on trauma level, bed state and overall capacity to accept patients.

FamiliesAn essential part of the exercise was the opening of a Family Assistance Center. This essential function is located away from

The Initial ResponseThe initial chaos of any aircraft crash landing requires a number of activities to occur simultaneously. Fire suppression involving copious amounts of foam layer the site, which in itself creates

hazards as seen in the Asiana Airlines tragedy in San Francisco when a responding engine hit and killed a foam-covered passenger. Once on the ground, the airplane crew will endeavor to deploy escape slides and evacuate able-bodied passengers. This poses

The Ambulance Child Restraint provides the safe and effective transport of infants and children in an ambulance, covering weight ranges from 4lbs to 99lbs.

T: 516.321.9494E: [email protected] W: www.quantum-ems.com

Thankfully the child I belong to was

wearing an ACR

NEXT GENERATION

Ambulance Child Restraint

• History - 7 years proven track record

• Open channel design allows complete patient access from the airway to the waist without un-restraining the child.

• The restraint tightens into the mattress of the stretcher not into the child preventing any additional injury to the patient.

• Compact packaging, the ACR-4 fits into its own 10 x 10 custom bag taking up less room in the back of an ambulance.

• ACR-4 replaces the need to carry multiple devices to accomplish the task of restraining all size patients

• Machine washable

L44-99lbs

M22-55lbs

S11-26lbs

XS4-11lbs

SAVE TIME, SAVE MONEY, SAVE LIVES

SOLUTIONS


A simulated casualty is removed from the aircraft simulator as evaluators look on.

Creating and simulating realistic conditions is a key to the

success of exercises.



the glare of the media and any other person armed with a cell phone.

The center operated in conjunction with the airline owning the aircraft in jeopar-dy, as well as the Red Cross. Families and friends can be made comfortable and receive situation briefings. The exercising of this center was seen as a necessary and integral part of the exercise.

Transition to InvestigationAfter the casualties are cleared and fires extinguished, the remains of both aircraft and passengers are considered a crime scene for the purposes of the initial inves-tigation. In a real incident, many agencies are required to investigate various facets of the scene from the FAA and NTSB through to the FBI and state police. Training and

live scenarios require the understanding as to when the phase changes from that of rescue to recovery. This is created by the effective use of liaison officers from each agency within the unified command that maintain information flow in their own discrete channels and with each other.

ConclusionIn the aftermath of the RIC exercise, a num-ber of after-action reviews took place. The assessors from each phase of the drill were content that the region has a robust plan and approach to an incident at RIC. The oppor-tunity for agencies to conduct interoper-ability training both cross discipline and by jurisdiction continued to develop good relationships.

RE FE RE N CE

1. Federal Aviation Regulations. Airport Emergency Plans (AEPs). www.risingup.com/fars/info/part139-325-FAR.shtml.

AB O U T THE AU TH O R Rob Lawrence, MCMI, is chief operating officer of the Richmond Ambulance Authority. Before coming to the USA in 2008 to work with RAA, he held the same position with the English county of Suffolk as part of the East of England Ambulance Service. He is a member of EMS World’s editorial advisory board and host of the Word on the Street podcast. Rob

is a featured speaker at EMS World Expo, October 3–7, in New Orleans, LA. Visit EMSWorldExpo.com for more information.

326 Industrial Park Lane, Orleans, VT 05860 888.546.8358 KIMTEKRESEARCH.com

KIMTEKCORPORATION

ProudMember

Scan our QR-CODE with your smart phone

Advanced LevelALL UNITS SHIPFULLY ASSEMBLED

MTS-102

MTB-101MTSTR-104

with seat belt forofficer or rescuer

9 cubic feet of fully enclosed storage for equipment and supplies

Easy slide out tray in thestorage areaLarge area able to carry large

duffle bags/equipment

Rescue area able to transportpatients/victims out of remote locationson long board or stokes basket

Be Prepared. Stay Protected.For safe, efficient evacuation the MEDLITE® Transport

will transform your UTV/Side by Side.

Over 3200+ units in serviceworldwide!

Call KIMTEK Today! • 1-888-546-8358

kimtekresearch.com

Upright retractable A safe extra seatutility pole

MTD-103

Upgrades your UTV cargo box into a professional EMS transport device.


Simulated casualties all wearing casualty cards describing their injuries await rescue and evacuation from the inside of the aircraft simulator.

EMSWORLD.com | JULY 2016 31

The 18th annual EMS State of the Sciences Confer-ence—more commonly referred to as the Gather-ing of Eagles—convened

in Dallas, TX, on February 19 and 20, 2016, hosted by Paul Pepe, MD, MPH.

In a perennially packed house, one meaty presentation followed another, providing EMS practitioners with a steady stream of ingenious “beyond state-of-the-art” material revolving around ways to provide better EMS patient care and operations.

In Part 1 of a multipart series, we highlight three presentations that focused on mass gathering and disas-ter management issues.

Visit http://gatheringofeagles.us/ for 2016 conference presentations, from which the accompanying articles are drawn, and preview information for the 2017 Gathering of Eagles.

Inside the Gathering of EaglesWhen top docs meet, the information comes fast and furious

Limb-and-Life DecisionsAre you ready to perform a field amputation?

It had been 25 years since the Philadelphia Fire Department had last needed its physi-cian response team in the field, but when a train struck a pedestrian late one night last summer, it was time again. The 46-year-old

victim was not killed but entrapped, his left leg mangled beneath a wheel. Freeing him would require its amputation.

Such calls are rare, but the department can answer them with a plan that calls for bring-ing hospital-based physicians to the field when surgical extrications are required. On this night docs Megan Stobart-Gallagher, DO, and Melissa Kohn, MD, of Einstein Medical Center answered the call.

The doctors crawled under the train and, using a surgical saw and Gigli saw, removed the foot at the ankle. “It was the right thing to do at the right time,” Stobart-Gallagher later told the press, “and getting that patient out when we did probably saved his life.”1

‘Move the Process Forward’A 1996 survey found just 13% of responding systems had performed an in-field extremity amputation in the previous five years, and 96% said they had no training for it. Only two of 143 systems even had a protocol.2 That was 20

years ago, but there’s no reason to think things have changed much since.

“I don’t think there’s probably been much improvement,” says Craig Manifold, DO, chair of ACEP’s EMS Advisory Committee, who pre-sented on the subject with Philly Fire’s EMS medical director, Crawford Mechem, MD, at February’s Gathering of Eagles conference. “But we have seen improvements in protocol development, and now we have an EMS sub-specialty and are developing EMS fellows, so I think it’s a perfect time to include it in training and move the process forward.”

As one aspect of that, EMS World will host a special amputation lab for medical directors at this year’s EMS World Expo, October 3–7, in New Orleans. Visit EMSWorldExpo.com

Leave a flap of skin to suture over the amputation site.

PART 1

Paul PepeFEATURED SPEAKER

EMSWorldExpo.com


for more information. But even if you can’t make it to New Orleans, there’s plenty to learn from the Philadelphia train case and other field amputations.

Team ConsiderationsPhiladelphia’s team gets its medical supplies and medications through a local hospital and uses PPE from the PFD. It’s unfunded, however, and lacks ongoing training. What training should it be getting? It’s hard to know, because there’s not much literature to draw from or experience, for most people, beyond small exercises.

“We have no science to really help us determine that,” says Manifold. “I think any of our protocols, at a minimum, should be dusted off, reviewed and practiced on an annual basis, if not more frequently—even every six months. It depends on the empha-sis and interest of the agencies involved.”

Who should be on the team? Start with physician expertise—an emergency medi-cine physician, EMS medical director and/or trauma surgeon. Local hospital, trauma and orthopedic specialists should be involved, and the perspectives of front-line providers should inform all plans.

“We absolutely need input from the field providers who may be asked to do this—the leadership team will be responsible for the involvement of their personnel,” says Mani-fold. “I’d also include as potential ancillary personnel the chaplaincy and critical inci-dent stress management folks,” as these calls can be emotionally taxing.

As far as equipment, there are simple handheld tools and surgical instruments that can disarticulate an extremity fairly easily. Appropriate saws include electric and manual surgical saws and a Gigli saw; reciprocating saws are available on most res-

cue trucks. Hydrau-lic tools like a Hurst work effectively but can damage bone.

Complement these with basic surgical equipment such as scalpel, pickups and spreader. Include tourniquets and hem-orrhage-control dressings; a way to gain vascular access (IV or IO); and airway management options. Don’t forget suturing equipment and a way to secure tissue and transport any salvageable parts. Coordinate all this at the hospital level. Ketamine is an excellent anesthesia for these cases—“probably the safest and best medication to use,” says Manifold. Etomidate can be a good option too, and analgesia (of course) and antibiotics are called for as well.

With so little information on how often EMS performs field amputations, their out-comes and what impact team and equip-ment configurations might have, it sure would be nice if someone pulled together available cases and started trying to learn something from them. That’s a near-term goal of Manifold’s.

In the meanwhile, departments should at the least proceed with crafting protocols and conducting training.

“People often do a good job of sort of put-ting this kind of thing in place,” Manifold says, “but we’re not always good with the follow-through of exercising it and making sure folks at the ground level really know how to access it and perform it efficiently. It does no good if it takes us two hours to assemble our equipment and team and get them out to the scene.”

RE FE RE N CE S

1. Williams S. Doctors Amputate Man’s Foot on Philadelphia Train Tracks. WVPI-TV, http://6abc.com/news/doctors-amputate-mans-foot-on-philadelphia-train-tracks/892350/. 2. Kampen KE, Krohmer JR, Jones JS, Dougherty JM, Bonness RK. In-field extremity amputation: prevalence and protocols in emergency medical services. Prehosp Disaster Med, 1996 Jan–Mar; 11(1): 63–6.

—John Erich, Senior Editor

Orthopedic surgeon Joe Alderete, MD, a leading expert on field amputations, will help conduct the amputation lab at EMS World Expo.

Preparing for the PopePapal visit was unchartered territory

When EMS personnel learned in 2013 that Pope Francis had scheduled a visit to Philadelphia on his 10-day global tour in

2015, the command structure began plan-ning for the event—or, rather, speculating. How many people would attend the highly anticipated Vatican-sponsored outdoor mass? “The papal visit was unchartered ter-ritory,” admitted Crawford Mechem, MD, EMS medical director for the Philadelphia Fire Department, in his Gathering of Eagles presentation earlier this year, “Pontificating in Civitas Autem Fraternitatis Caritatem: Philadelphia Preps for a Peripatetic Papal Pass-Through.”

Crowds for previous masses around the world had reached nearly six million. “A papal event isn’t comparable to other events, so the crowd estimate was our most difficult challenge,” Mechem says.

Initially the crowd estimate was three million. As the event drew closer, that dropped to one million. “It was the best number we could come up with,” says Mechem. “There was little science to it.”

Based on that size crowd, Mechem began estimating the number of anticipated patients, while also planning staffing and first-aid tent and resource deployment. Papal visit activities would stretch from the Philadelphia Museum of Art to Indepen-dence Mall. A five-square-mile “traffic box” would close to private traffic. Among the unique challenges, mass attendees—includ-ing the elderly and infirm—would need to walk a good part of the way to the site. How many visitors would turn into patients? How sick would they be?

“In our primary planning for the event, we placed first-aid stations throughout the area and deployed foot patrols consisting of EMTs, paramedics and small all-terrain vehicles to navigate the crowd,” Mechem

New Orleans Primes for Chemical DisastersThe Crescent City gets ready for sudden spills

In the middle of the night on January 6, 2005, a freight train collided with a parked train in Graniteville, SC, result-ing in derailment and the puncturing of three chlorine tank cars adjacent

to the Avondale Textile Mill. In less than two minutes, an estimated 60 tons of liquid chlorine was released into the air, producing a thick cloud of chlorine gas that quickly spread throughout the unincorporated and medically underserved town. The incident resulted in nine immediate deaths, 72 hos-pitalizations for acute health effects, and some 850 people seeking medical attention.

The incident gave pause to EMS per-sonnel in New Orleans, who later that year endured the unprecedented devas-

tation from Hurricanes Katrina and Rita. Even though no significant chemical spills were reported from those disasters, leaders wanted to be better prepared to respond to chemical incidents, especially in the world’s largest port by tonnage—the lower Missis-sippi River’s combined six deep-water ports.

Dev D. Jani, chief of planning and pre-paredness for the Office of Homeland Secu-rity & Emergency Preparedness in New Orleans, spearheaded the city’s participa-tion in the Chemical Defense Demonstra-tion Project (CDDP), which followed two scenarios of chemical spills:

» What would happen if a river barge tank of 2,400 gallons of hydrogen fluoride was breached?

» How would the 9-1-1 community respond to 19,000 gallons of organophos-phate released via railcar on the tourist-laden riverfront?

“The organophosphate nerve agent was picked to test our countermeasures dis-tribution system,” says Jani, noting the Department of Homeland Security’s Office of Health Affairs approved New Orleans as one of only four Phase II CDDPs in 2014. “We definitely have a large burden of com-mon toxic inhalational chemicals. We also wanted to really hone in on our localized commodities flow in the port system.”

Best Practices to ShareJeffrey M. Elder, MD, FAAEM, director and medical director for New Orleans

explains. “We deployed medical sta-tions along the anticipated walking routes from public transportation terminals. We had tents at Benjamin Franklin Park, where Pope Francis was going to be, and also on the long walking routes from the major train stations and subway stops.”

Security ConcernsSecurity measures were a major con-sideration. The U.S. Secret Service (USSS), in charge of security for such special events, determined the location of security checkpoints. “To make our EMS plans, I had to customize them based on those determinations. It created considerable challenges, especially getting our personnel in and out, getting ambulances to patients and patients to ambulances, especially as some security measures were changed on a fairly frequent basis,” says Mechem.

Recruiting VolunteersMechem brought in a cadre of ambulances from various EMS agencies from Pennsyl-vania and out of state. He also recruited volunteers from local hospitals while the Philadelphia Department of Public Health helped coordinate Medical Reserve Corps volunteers.

As the event drew closer, Mechem was surprised to learn some hospitals were slow to free up staff to volunteer.

“It was an interesting phenomenon,” he says. “Any time an event of this sort is coming up, people are interested in volun-teering. As time progressed and security measures became more obvious, hospitals realized that freeing up staff to volunteer would impact their own in-house opera-tions. Until the hospital leaders had a better feel for it and ramped up their own internal planning, they were very hesitant to free up staff. In retrospect we probably could’ve been more aggressive securing outside vol-unteers earlier in the planning process.”

Mechem planned 24-hour coverage preceding the event, concerned that some

attendees would arrive the night before to save a good spot. “In retrospect, the thought process was valid at the time,” he says.

Patient tracking was somewhat problematic. “We used a barcode-based wristband with Knowledge Center software,” he explains. “We’d used it the year before at the city’s Fourth of July celebration. Few of us were familiar with the system. We had so many volunteers coming in from so many directions; they got very quick lessons on how to use the tracking sys-

tem. Allowing more time for that aspect is a lesson learned.”

ConclusionOn the day of Pope Francis’s visit, the city was blessed with good weather. Tempera-tures ranged from 60–72ºF while approxi-mately 800,000 people attended mass. Ten medical tents treated 199 patients, with 21 transports. In “the box,” EMS personnel had 423 responses, with 129 transports. Activ-ity for the entire citywide EMS system was “about normal,” Mechem notes: “Given the uncertainty of the event, our preparation was appropriate,” he says. “We had more than we needed [and were] ready for much more.”

—Pepper Jeter, Associate Editor

Crawford Mechem, MD


EMS, discussed lessons learned from both exercises in his presentation, “Taking a New Defensive Striving Course in the Crescent City: Enhanced Preparation for Chemical Disasters N’Awlins Style,” at the Gathering of Eagles.

For the chemical spill exercises, dubbed Crescent Shield, more than 150 participants from all levels of government converged at NASA’s Michoud Assembly Facility in New Orleans East to approach issues that would arise in the aftermath of a catastrophic chemical incident. Collaborators honed in on critical decisions post-incident that need to be made in the first half-hour. “We not only looked at the overall landscape of critical decisions; we also looked at the ones that, if discerned, would lead to a cascade of additional answers for detections and recognition,” says Jani.

Exercises focused on response via oper-ations, logistics and command control; protective action messaging and public information; tactical communications

and interoperability; and medical and public health surge capacity. “We had many moving parts to consider,” says Elder. “We learned we needed a better picture of the total traffic coming through New Orleans. Port traffic is fairly easy to count, but rail and interstate traffic is more difficult to calculate. For example, the Public Belt (Railroad) owns and operates nearly 100 miles of track (from Lake Pontchartrain to the Mississippi River waterfront). Pri-vate carriers may use the Belt’s track and pay for the service or go around it by using the ‘back belt,’ owned by Norfolk Southern. The traffic discussion led to a hazardous-commodities flow study for port and rail that’s in the works now.”

OutcomesThe exercises yielded outcomes such as critical decision support architecture and a concept of operations to complement city and regional crisis management frame-works. More specifically, these tools were

created: a robust concept of operations (CONOPS) to complement the city’s haz-ardous-materials release management plan; decision matrices for use by first respond-ers; EMS protocols and paramedic hazmat training. Also as a result of the project, New Orleans EMS now carries the Cyanokit for cyanide poisoning, and calcium gluconate (for hydrofluoric acid burns, among other uses) is on order, says Elder.

“We looked at both exercises as the eyes and ears for our health systems,” says Elder. “Our focus should be, as we’re get-ting people decontaminated in an event, to actually treat patients by having the medical knowledge to make the right decisions in the field. As a medical director, I think the biggest thing that keeps me up at night is making sure we have medics who have the training and knowledge and wherewithal to know where to go to get more informa-tion when they have to during an event.”

—Pepper Jeter, Associate Editor

THE FIRST CHOICE OF

FIRST RESPONDERS

TEXTBOOKSINCLUDED

Gainful employment information available at ColumbiaSouthern.edu/Disclosure.

Learn more about our online EMS degrees, workshops, and CEUs.

ColumbiaSouthern.edu/EMSworld or call 877.258.7153

With courses encompassing legal, political and regulatory frameworks in EMS administration, earning an online degree in emergency medical services administration with Columbia Southern University will provide you with the professional development needed for success.

Degrees offered include:

• B.S. Emergency Medical Services Administration

• B.S. Health Care Administration


EMSWORLD.com | JULY 2016 35

The initial assessment was uneventful. The patient had recently been discharged for CHF, and the community paramedic was visiting as part of a program to reduce the likelihood of a readmission. The visit

revealed the patient was taking medications for acid

reflux and gout in addition to the meds on his hospi-tal discharge list, but was otherwise unremarkable. The challenge came when the CP called the patient back with a message from the patient’s cardiologist.

The doctor said the patient could continue taking his stomach medication, but that he should stop tak-

By Dan Swayze, DrPH, MBA, MEMS

Spending a few moments socializing

can help lift a patient’s spirits.

Center for Emergency Medicine of Western

Pennsylvania

MIH-CP providers should master this valuable skill to get the most benefit from patient encounters

THE LARGEST EMS CONFERENCE AND TRADE SHOW IN NORTH AMERICA

• 140+ CEU-certifi ed educational sessions across 3 days and 8 tracks • World-class faculty and industry thought leaders presenting the

latest techniques and trends in prehospital clinical care• State-of-the-art technology, products and services from 350+

exhibitors• Hands-on workshops and interactive learning opportunities with

the most advanced simulators• More global networking opportunities than any other national

conference

EMS World Expo Covers the Most Critical Issues Impacting Our Profession Today

• Mobile integrated healthcare/community paramedicine

• New advances in prehospital technology

• Provider safety

• Active shooter/MCI response Featured Sessions

• A Multi-Disciplinary Approach to Tactical Training and Community Response

• Terror in San Bernardino

• EMS Ops Lightning Round: Threat Management & Response

• Applying the Joint Rescue Task Force Program

• Combating Violent Crime and The ATF Tactical Medic Progam

• Preparing Your Community to Survive an Active Shooter Event

• Active Shooter/MCI Response Workshop

#EMSWorldExpo

w/ Promo Code: EARLYJULYEMSWorldExpo.com

Register by 9/2 and save up to $85

WHERE THE WORLD OF EMS CONVERGES FOR EDUCATION AND INNOVATION

GROUP RATESAttending EMS World is

Extremely Affordable!For the largest savings, register

6 or more by 9/2 (do not have to be from same agency) and pay just $270 each for the 3-day conference program! No promo code needed.


priorities. We can introduce them to new resources but may be surprised when they turn down options we think would help. The practice of MI is built on the understanding that the patient is the only expert on their life. They are the only ones who can decide whether their quality of life (e.g., being free from gout pain) is more important than its potential quantity (e.g., avoiding premature death from a CHF exacerbation). They are the only ones who can choose which healthy behaviors to adopt or ignore. Our role is not to encourage them to do what we think is best but to help them make the best decision given their priorities in life.

Acceptance—Accepting that partnership, and the patient’s right to choose their own priorities, means we have to respect the person’s autonomy. In fact, Miller describes our new role as requiring a “radical accep-tance recognizing that ultimately whether change happens is each person’s own choice, an autonomy that cannot be taken away no matter how much one might wish to at times.”

Patience will be tested when the patient has a different value system that results in decisions that are illogical to us. CPs will be frustrated when their patient’s behav-iors lead directly to their poor health, but they refuse to change. When the patient engages in behaviors we consider immoral, unethical or illegal, we will wrestle with our own ethics and moral compasses. CPs have to understand that although we are trying to help these patients out of a tough spot, they may not choose the same destination we would. It is, however, their inalienable right to choose.

Compassion—The Dalai Lama defined compassion as the wish to see others free from suffering. If we accept that definition, then community paramedicine is compas-sion in action. A healthy amount of compas-sion for our patients is critical to the success of our CP interventions and the practice of MI. If we approach the patient with the same clinical detachment taught to our colleagues in medicine, we will likely have a hard time engaging them in the change process. With-out empathy and compassion, our desire to judge our patients will be stronger than our desire to continue to try to help.

Evocation—Whether it appears as paren-tal nagging or our boss’s micromanagement,

offering unsolicited advice seems to be an incredibly common but unwelcome behav-ior when it is directed at you and me. Despite the fact that we largely ignore those who offer us advice, giving advice under the guise of “patient education” is our default inter-vention when we try to help our patients as a CP. Patient education is an important component of CP programs, but one whose value is overestimated. MI is based on the

premise that the ideas most likely to succeed are those generated by the patient. Eliciting ideas from the patient is a different skill and role for EMS providers who are used to being problem solvers. Nonetheless, the practice of MI recognizes that the patient is most likely to try and maintain solutions they generate themselves.

Understanding these four guiding prin-ciples will help us approach the patient dif-

ing the medication for the gout, as it could cause fluid retention. The patient became irate when he heard the order. He explained that his gout caused severe pain and lim-ited his mobility. He adamantly refused to stop taking the medication. He would rather risk having another CHF attack, he said, than face a life of chronic debilitating pain. The CP tried to explain the man could die if he had another attack of CHF and even offered to talk to the patient’s doctor to find a replacement. The patient refused and abruptly ended the call, telling the CP there was no reason for her to return.

We use this case to introduce one of the most challenging aspects of commu-nity paramedicine: understanding that the patient has the right to decide their priorities in life, even when those choices could severely limit the quality or quantity of that life.

Many healthcare providers assume if they provide education on a disease or describe the risks involved in the patient’s behaviors, the patient will make a rational

choice and change their ways. If that were true, however, the prevalence of smoking, obesity and sedentary lifestyles in EMS pro-viders would be close to zero. A quick look at your EMS colleagues shows that is not the case. Many of our colleagues know the long-term consequences of their behaviors but choose unhealthy habits regardless. CPs who believe their job is to simply lecture their patients on the errors of their ways will likely find their patients disengaged from the program or frustrating in their lack of progress.

While education alone may not be suf-ficient to motivate a change, there are ways we can influence the patient’s choices. This article will introduce motivational inter-viewing (MI), an evidenced-based thera-peutic communication style that can influ-ence the decisions our patients make. Mas-tering these techniques can be challenging for CPs, who must learn to transition from being a quick-thinking problem solver to interacting with patients in a completely different role.

The Essence of MI: PACE YourselfBy far the hardest part of using MI is try-ing not to solve the patient’s problems. In your traditional EMS role, problem solving was a critically important skill. You needed to be able to quickly assess and prioritize the patient’s problems and stabilize those you could treat. While you will still assess the patient’s problems in the CP role, try-ing to rush your assessment or prioritize their problems could lead you astray. And unlike your role in traditional EMS as the expert problem-solver, the patient is the only expert on what solutions will work for them. To help understand the essence of MI, William Miller (the father of MI) describes four characteristics that help put our new role into perspective.1 They can be described using the mnemonic PACE.

Partnership—In our traditional EMS roles, the patient has a problem, and we offer the solution. However, MI is built on a more equal partnership. Our role is not only to assess patients’ problems but to elicit their


*For terms and conditions please visit www.buyemp.com/customer-service.htmlBuyEMP.com You order. We ship (free).* It’s that simple.

EMPower your savings by joining our Online Loyalty Rewards Program.

Join now and receive 250 loyalty points!

• Earn points, redeem for $ savings on future orders

• Exclusive promotional offers to double & triple your points

• First alerts on new product additions to our program

• Savings on everyday run items, more additions coming soon!

Visit www.BuyEMP.com today to get started!

EMPOWERJoin Earn Redeem It’s that simple



To stay engaged in CP pro-grams, patients must trust and respect their CPs. Overlooked, however, may be the fact that the CP must have the same feelings toward the patient to remain interested in helping. When the patient demonstrates feel-ings of entitlement, displays manipulative behaviors or expresses a profound sense of hopelessness, the community para-medic may not trust the patient to have their own self-interest at heart. Observing those feelings and behaviors makes it dif-ficult to want to continue to help and can lead to the CP disengaging from the patient. Conversely, patients who believe the CP’s visit is yet another futile interaction with the healthcare system, or who question the CP’s motives, or who don’t believe the CP is really listening, will also find it difficult to engage in the process. Mutual engagement is essential for the visits to be therapeutic.

Just as there as several ways for either party to become disengaged, there are sev-

eral things that can be done to help keep the interactions on course. The first is to manage the patient’s expectations. An explicit discussion about the types of services you can help with and defining their respon-sibilities in the process can help

the patient understand how this may differ from their previous healthcare encounters.

Similarly helpful is to do a periodic reas-sessment of the patient’s priorities. Patients who appear withdrawn or who have not fol-lowed through on an agreed-upon action may be distracted by the emergence of a new challenge that takes priority. Rather than assuming the patient has lost interest in your help, periodically make sure you are still working on the priority issues.

Last, maintaining a sincere positive atti-tude despite the patient’s current emotional state can help lift the patient’s spirits. While it may seem like a waste of time, spending a few moments during the visit to socialize can help recharge the patient’s mood and

remind them of how enjoyable life can be despite their current frustrations.

SummaryMotivational interviewing is both a philoso-phy and a set of communication skills that can help CPs better understand and help their patients. Recognizing that patients have the right to choose their own direction in life and are the best source of ideas for how to change will help the CP avoid trying to solve problems outside of their control. Using open-ended questions, affirmations, reflections and summary statements can facilitate those discussions and make it less likely that any patient ever tells a CP there is no reason to return.

RE FE RE N CE

1. Miller WR, Rollnick S. Motivational Interviewing: Helping People Change, 3rd ed. New York: The Guilford Press, 2013.

ABOUT THE AUTHOR Dan Swayze, DrPH, MBA, MEMS, is the vice president for the Center for Emergency Medicine in Pittsburgh, PA.

ferently than we have in our traditional EMS roles. To put these guidelines into practice, however, requires that we learn new com-munication skills.

Core SkillsNot only does MI involve a different way of thinking about how to help patients, it requires us to practice conversational tech-niques that are vastly different from those we’ve used in our traditional roles. Not unlike learning to perform a clinical intervention, CPs must learn and repeatedly practice the techniques described below to become more effective at helping their patients. The fol-lowing four conversational skills are the foundation for MI interventions.

Ask open questions—The time-sensitive nature of traditional EMS work means we have to sift through lots of information in a very short time frame. We don’t have time to listen to the patient explain all the major events in their life they believe led up to the call to 9-1-1; we just want to know what prompted them to call today. When the patient starts going off on a tangent, we redi-rect them using closed questions to which there is little opportunity for elaboration.

In community paramedicine we benefit from hearing the rest of the story. Under-standing adverse childhood experiences, a history of physical or emotional traumas and family support systems (or lack there-of) is critical for CPs. These stories help us understand not only why a patient is in their current predicament but what resources may be available to help them. This infor-mation is more likely to be obtained through an open question such as “Tell me about yourself,” rather than a closed question such as “Were you ever abused as a child?”

Provide affirmations—An affirmation is an expression of a sincere appreciation for some trait or behavior of the client. Shar-ing these observations with the patient can be a powerful tool in building a rapport and confidence in their ability to change behaviors. Miller describes an affirmation as finding what is right with the patient rather than constantly focusing on what’s wrong. However, finding these positive attributes can sometimes be challenging. We may not agree with the patient’s lifestyle choices, values or behaviors. At times providing an affirmation to the patient means we have to

reframe our view of the patient’s situation. Given the multiple challenges (self-imposed or otherwise) many patients face, it may be helpful to appreciate that your patient has not given up. In most cases even the most troubled patient can be considered a survivor.

Use reflection, not questions—If there is one skill that is critical to master to con-duct MI successfully, it would be the use of reflections. Rather than interrogating the patient with a series of questions to obtain the information we need, MI relies on the skillful use of reflective statements to gath-er the information. Reflective statements essentially repeat what the patient said as a way of allowing the patient to elaborate. The statements reassure the patient you’re listening while allowing you to confirm you understand what the patient is trying to say. Reflections come in two general categories, simple and complex. A simple reflection simply repeats verbatim or rephrases what the patient just said. Complex reflections are attempts to check the meanings or emo-tions behind the words.

Table 1 provides examples of how a sin-gle statement can be reflected back to the patient as an opportunity to explore what the patient really meant. While it seems counterintuitive at first, using reflective

statements can often elicit better informa-tion faster than direct questioning. More important, reflections allow the patient to tell their story without feelings of judgment or interrogation.

Use summary statements—The final skill for practicing MI is the use of summary statements. CP visits tend to be longer than traditional EMS patient encounters, and it can be useful for the patient and the CP to occasionally review what has been

discussed. For example, you might start a summary statement with, “Mr. Smith, you’ve mentioned several concerns about your medications, and I want to be sure I’m capturing all the important ones.” Then list the individual concerns the patient has mentioned and conclude with, “Tell me what other concerns you might have.”

Summary statements can be helpful to ensure the CP is capturing all the important information that has been shared. Summa-ries can also be helpful in redirecting the patient when they go off on an unproductive tangent to areas that are more relevant to the current discussion.

Getting EngagedMastering the conversational skills listed above will help the CP be better prepared to help patients help themselves. However, an all too common frustration is those patients who refuse to follow through. These patients may allow the CP to visit but refuse to take any actions between visits to accomplish what they have agreed to do. The result is that the patient fails to make any progress and the CP becomes frustrated with the patient for their apparent unwillingness to help them-selves. Using MI techniques may help correct or even avoid these types of impasses.

Miller describes successful MI interven-tions as a four-step process that includes engaging the patient in the partnership; focusing their time on the steps necessary to make progress; evoking ideas from the patient on how to change their behaviors; and planning to implement the changes once a direction has been determined. However, if the patient disengages from the CP or program, the rest of the steps in the process will not be successful.

TABLE 1: EXAMPLES OF THE TYPES AND INTENT OF USING REFLECTIVE STATEMENTS

The patient says…

“I don’t like taking that medication!”

Types of reflection

Simple reflection—repeat: “You don’t like taking that medication.”

Simple reflection—rephrase: “You don’t enjoy taking that particular drug.”

Complex reflection—explore the statement’s meaning: “You don’t like the side effects that medication causes.”

Complex reflection—explore the meaning and emotions behind the statement: “It’s frustrating to deal with the side effects of your prescriptions.”

Dan SwayzeFEATURED SPEAKER

EMSWorldExpo.com


NEW DESTINATIONNEW DISTINCTION

NASHVILLE, TENNESSEE OCTOBER 18-22, 2016

Firehouse Expo is the can’t-miss event for you. It’s a cost-effective, one-stop-shop to help you become a more knowledgeable and skilled firefighter. This year’s event features:

• More than 140 conference sessions from the nation’s most accomplished and respected instructors

• 28 Hands-on training classes including 8 LIVE FIRE classes, Fire Dynamics training, Meth Lab Response, High-Rise Fire Ops and more

• Larger exhibit floor highlighting everything you need to know about apparatus, personal protective equipment and fireground technology

• NEW Live Drone Demo Area

• NEW Nashville FD Ride-Along Program

• Networking events that will highlight the best in entertainment and dining that only Nashville can offer!

• Second annual Legends & Icons celebration featuring the 2016 Firehouse Hall of Fame Class induction ceremony

Check FirehouseExpo.com daily for conference and event updates

Hurry, hotels are filling up fast, book today!

®

Visit FirehouseExpo.comFirehouse is Headed to Nashville. And You're Invited.

#FHExpo16

CriticalCONVERSATIONS

NationallyRecognized SPEAKERS

Expanded HANDS-ONTRAINING

REGISTER BY AUGUST 1

and save $50

with early bird pricing.

leaf

/ iSt

ock

/Thi

nkst

ock


By Kenneth A. Scheppke, MD, & Keith Bryer, BBA, EMT-P

There’s a big difference between pneumonia and CHF—here’s what you need to tell them apart

This is the third of a four-part series that appears bimonthly. Find Part 1, dealing with chest pain patients, at www.emsworld.com/12149999 and Part 2, covering neurological patients, at www.emsworld.com/12171904. In addition, find a video to accompany this article at EMSWorld.com/12220374.

Y ou and your crew are called to a nursing home for a patient complaining of shortness of breath. You find the elderly female patient hypoxic and, after initial stabilization, perform a full history and physical examination. Your protocols offer

specific treatment guidelines depending upon the etiology of the shortness of breath. Is this pneumonia with sepsis that requires large boluses of IV fluids? Or is this CHF that requires CPAP, nitroglycerin and possibly diuretics? Are you dealing with COPD, pulmonary embolism or sponta-

This CE activity is approved by EMS World, an organization accredited by the Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS), for 1 CEU upon successful completion of the post-test available at EMSWorldCE.com. Test costs $6.95. Questions? E-mail [email protected].

Hosted by NAEMT’s PHTLS Committee and EMS World Expo

Presenting the latest research and information on prehospital trauma care from internationally recognized experts around the globe, this 1-day educational event will change the way you practice.

All attendees will receive 8 hours of CECBEMS-accredited CE, CME or nursing CE.

WorldTraumaSymposium.com

OCTOBER 4, 2016 NEW ORLEANS, LA ERNEST N. MORIAL CONVENTION CENTER

Register by 9/2 and save $50 w/ Promo

Code EARLYREG2

The premier education event for

ALL providers of out-of-hospital

trauma care.

#WorldTrauma16

This year’s symposium will examine several topics, including:

• Future directions in prehospital trauma care: ultrasound, lactate measurement, REBOA, injectable hemostatic agents

• TXA and thrombolysis in the trauma patient• The impact of legalized marijuana on Colorado trauma• Crime scene preservation for the medic• The EMS role in handling chemical weapons• TCCC from a trauma surgeon’s perspective• Asiana 214 crash response• New Orleans Mardi Gras response/disaster planning• Crush injury in the trauma patient & confined space rescue

Co-Located with


neous pneumothorax? What clues should you look for in your history and physical examination to help you arrive at the cor-rect prehospital diagnosis?

It is well known that differentiating between pneumonia and CHF can be dif-ficult in the prehospital arena.1 It is also known that giving a diuretic like furose-mide to a patient with pneumonia can potentially cause harm.2 While many

agencies have pulled diuretics off their rescue vehicles in recent years, many others continue to administer them for cases of suspected CHF. This means that accurately making the correct prehospital diagnosis of CHF is even more important. Both diagnoses can present with crackles on lung exam. How can they be accurately differentiated in the field without the use of an x-ray?

In this third installment of the series, we will review the simple strategies to accurately differentiate pneumonia from CHF in the field. In addition we’ll examine several deadly causes of dyspnea as well as some of the common but less dangerous etiologies of shortness of breath (SOB). By performing a focused, systematic history and physical examination, you can rapidly diagnose and treat life-threatening respira-tory emergencies.

However, as always, rapid stabilization and transport are top priorities. A focus on controlling the airway, correcting hypoxia, reversing bronchospasm and improving ventilatory rates and tidal volume comes first. After initial stabilization of the patient, gathering the necessary information will allow the skilled paramedic to refine the prehospital diagnosis and treatment.

CHF vs. PneumoniaBefore discussing the details of a history and physical examination for a chief com-plaint of SOB, let’s begin with the simple strategies and clues to assist the street medic in correctly differentiating CHF and pneumonia. Some of these strategies necessarily oversimplify complex physi-ological problems. However, when used in combination with a thorough history and physical exam, these tricks of the trade can often make obtaining the correct diagnosis much easier.

PneumoniaPneumonia can be thought of as a disease of the lung. Patients with underlying lung disease can be thought to be at risk for more lung disease. This means your patients with a history of COPD, asthma or other lung pathology, or who take respiratory medications such as albuterol, should be considered high-risk for pneumonia.

Since pneumonia is an infectious dis-ease, your patient is more likely to catch it from other people. Consider the patient’s address in your diagnosis: Patients who reside in high-population-density living arrangements, such as nursing homes, are at particular risk. In addition to residing with many potential infectious contacts, these patients are often debilitated, run down and chronically ill. Infections are common in this population, since this

Code #72657

Move with Speed & SafetyThe MegaMover® Select™ Goes Where Stretchers Can’t

800.558.6765GrahamMedical.com

• Transfer, transport, and rescue patients that can’t be reached by stretchers

• 14 multi-positioned handles provide ergonomic lifting

• Pull straps for situations when pulling a patient is safer than lifting

• Durable, nonwoven design holds up to 1000 lbs.

• Light, space-saving, and portable

NEW EMS Products from Graham Medical



“flash” pulmonary edema over a matter of minutes. The shorter the onset of illness, the less likely it is pneumonia.

Vital signs can give clues as well. Blood pressure values tend to be higher in CHF than pneumonia. Flash pulmonary edema cases typically have extremely high systolic pressures, often over 200.

Using these tricks of the trade can give paramedics a shortcut to the diagnosis, but only if CHF and pneumonia are the exclu-sive etiologies to consider. While both are common, there can be more to SOB than just these two problems. Therefore, the skilled medic will have a good understand-ing of how to perform a focused history and physical examination for the chief com-plaint of shortness of breath.

Respiratory H&PBecause the respiratory and cardiovascular systems are so closely related, chief com-plaints such as SOB, dyspnea on exertion (DOE), wheezing and coughing must be carefully assessed to determine the correct

body system responsible so that an accurate prehospital diagnosis can be made and the correct treatment administered.

To be proficient in conducting the H&P, your process must be organized and sys-tematic. Practice makes perfect. Utilize the following outline as a guide for short-ness of breath assessments and a template for writing patient care reports. Explore the following categories in patients with a complaint of SOB:

1. Chief complaint: the main reason 9-1-1 was called;

2. History (present illness, past medical, social, family);

3. Review of systems;4. Physical exam;5. Form the prehospital and differential

diagnosis.

HistoryChief complaint—The chief complaint sets up the framework for the rest of the ques-tions to discover the diagnosis. With a chief patient complaint of shortness of breath, the

paramedic should immediately consider the life threats associated with that complaint and organize questioning to help refine or narrow down the possible etiologies.

Information obtained from the chief complaint must be expanded to include the onset, palliative/provocative factors, quality, radiation, severity, timing and associated symptoms (OPQRSTA). This framework ensures a thorough explora-tion of the chief complaint and should be completed prior to moving on to the next section of the history. The answers obtained from this section will point to a more specific etiology as the cause of the shortness of breath.

Past medical history—Questions regard-ing past medical history are very important when it comes to a chief complaint of SOB. If the patient has any of these pre-existing conditions, the odds greatly increase that the current episode is an exacerbation of a prior disease process. Ask about the presence of:

» Asthma; » COPD/emphysema;

Automated Chest Compression System for Professionals

For use as an adjunct to manual CPR

1 Kleinman ME, et al. Circulation (2015); 132:S414.

• Provides victims of sudden cardiac arrest the precision needed for high-quality and continuous CPR associated with better survival1

• Removable Compression Module allows for quick deployment, enhanced usability

• A rigid backboard with a stiff frame of single-piece design facilitates operation without unwanted flex

Be it on the ground, in an ambulance cot, a moving vehicle, or intra-hospital transport, the Lifeline ARM is your solution for uninterrupted CPR.

4 3

B

C

D

-300

-350

-400

-450

www.defibtech.com

VISIT US AT EMS WORLD BOOTH #239

www.monumedical.com

MK

T-G

D15

4-1

20-E

N


background generally translates to a weak-ened immune system and large opportu-nity for infection to spread.

Patients who have lost their ability to swallow normally are generally given a feeding tube. While that tube solves the issue of nutrition, what happens to the saliva? They have to try to swallow it. Often they aspirate this infectious liquid into their lungs, which can cause aspiration pneumonia. Consider any patient you see with a feeding tube and a chief complaint of SOB to have aspiration pneumonia until proven otherwise.

While fevers do not last 24 hours a day or 7 days a week, and the absence of a fever does not rule out an infection. If a fever is present, consider the cause of shortness of breath to likely be an infection, and there-fore consider the diagnosis to be pneu-monia. However, do not be lulled into the false idea that an absence of fever means absence of pneumonia. Many chronically ill patients are too ill and their immune systems too weak to ever create a fever. If present, consider pneumonia. If not, don’t rule it out.

Patients who are not ambulatory are at high risk for infections. Look for evidence of poor ambulation. Are there wheelchairs present, walkers, special boots to prevent bedsores for bedridden patients? If so, con-sider pneumonia high on the list of possible causes of SOB.

Timing is important. Infections usual present gradually. Slowly increasing SOB over days is more likely to be pneumonia than CHF. This is especially true if there is also a history of recent viral upper respira-tory tract infection.

Vital signs give clues as well. Low sys-tolic BP, diastolic hypotension, wide pulse pressure and fever all favor pneumonia over CHF. The skin exam in pneumonia is often dry. If fever is present, the skin may feel hot as well.

CHFJust as pneumonia can be considered a dis-ease of the lungs, CHF should be considered

a disease of the heart. Patients with a history of heart disease are more likely to go on to have more heart disease. Look for signs of cardiac surgery (sternal scar) and evidence of cardiac medications such as beta block-ers and prior diuretic use like furosemide.

Unlike the often chronically debilitated pneumonia patients from the nursing homes, many of these patients are quite healthy between CHF exacerbations. They tend to

come from private residences. After they get treated for an episode of CHF, they usually get to go back to their home. If their residence has been converted to look like a nursing home or hospice care environment, strongly consider pneumonia, because the chronically ill patient is more likely to succumb to it. Otherwise, a normal private residence may indicate a generally healthy patient, which favors a diagnosis of CHF. Consider the address when deciding between these two diseases. The living environment can give clues to their baseline health.

Fever does not generally occur with CHF. If it is present, it likely means the SOB patient has pneumonia. Diuretics should generally be avoided in patients who pres-ent with a fever.

The physical exam in CHF is likely to reveal some combination of JVD, hepato-jugular reflux, ascites and pedal edema. The history may suggest orthopnea (SOB when supine) or paroxysmal nocturnal dys-pnea (SOB waking up after lying supine). All of these are evidence of fluid overload

and point to CHF. Their complete absence should make the para-medic doubt that CHF is the prob-lem, and therefore diuretics should likely be withheld.

Timing of the illness is impor-tant to consider. There is a subset of patients with chronic CHF who have weak hearts with chronically very low ejection fractions. These patients generally

live constantly with some degree of CHF. In this subset, a gradual worsening may occur. They typically will have several of the fluid overload signs noted above to assist in differentiating them from those with the characteristic gradual onset seen in pneumonia. More typically, CHF patients have a rather acute onset of worsening. The deterioration is faster than in pneumonia, and in extreme cases patients can have

TABLE 1: GENERAL CHARACTERISTICS OF PNEUMONIA VS. CHF

Pneumonia CHF

Fever Normal temperature

Low BP/wide pulse pressure High BP

History of lung disease History of heart disease

Pulmonary medications (e.g., albuterol) Cardiac medications (e.g., diuretics)

Nursing home Home

Aspiration risk Orthopnea/paroxysmal nocturnal dyspnea

Bedridden Edema

Altered LOC JVD/HJR

Gradual onset More rapid onset

Dry/hot skin Clammy skin

JVD is an indicator of CHF, not pneumonia.


both numbers. In this case 50 for a diastolic pressure is below nor-mal. Diastolic hypotension indicates the patient has low systemic vascular resistance, a condition known to occur in sepsis. If your patient also complains of shortness of breath, you are probably dealing with pneumonia and sepsis. In a case like this, the vital signs plus chief complaint can give you the entire diagnosis.

General impression/ventilatory effort » Evaluate the patient’s level of consciousness; look for respira-

tory distress. » Observe the patient’s position of comfort (tripod positioning:

COPD) or discomfort (CHF, COPD, asthma all worse when supine). » Conversational dyspnea: If the patient cannot speak a full sen-

tence, it indicates a moderate to severe degree of respiratory distress. » Prolonged exhalation: COPD, asthma. Both COPD and asthma

can result in air trapping. Air easily enters the lungs, but damaged or obstructed airways trap air, causing hyperinflation. When air is trapped, breathing transitions from passive exhalation to active exhalation with prolonged exhalation time. Observe the ratio of inspiration time to exhalation time; for patients with prolonged exhalation, consider the diagnoses of obstruction to outflow of air (i.e., COPD and asthma). Chronic air trapping is what is respon-sible for the barrel chest appearance (increased anterior/posterior diameter) of COPD patients.

» Pursed-lips breathing: Found to improve the sensation of dys-pnea and reduce the work of breathing, pursed-lips breathing is often used spontaneously by COPD patients during exhalation.3 It is possible this maneuver helps force airways to remain open during exhalation by creating an effect similar to the use of CPAP.

» Accessory muscle usage: This is a sign of respiratory distress and can be seen in several conditions, including COPD, asthma, pneumonia, pulmonary embolus and pneumothorax.

» Respiratory rate: Patients in general breathe fast for three reasons: They have inadequate oxygen levels, elevated blood acid levels or a psychiatric/pain reason for breathing fast. Discovering the cause for the rapid respiratory rate will aid in the diagnosis. Abnormally slow breathing can be an ominous sign of impending respiratory arrest and may be due, among other causes, to drugs or CO2 retention in severe COPD.

» Shallow respirations: Pleuritic pain will cause patients to breathe with a lower tidal volume in an effort to avoid the pain. Consider possible causes of pleuritic pain such as pneumothorax, pulmonary embolism and pneumonia.

Respiratory patterns—The pattern of breathing may give a clue as to the underlying etiology of the respiratory complaint.

» Normal respiration: Rate is 12–20. Most adults will have a respiratory rate of 12–16, with the upper end of normal at 20. It is important to take the first set of vital signs manually so you have a good baseline.

» Kussmaul respirations: Characterized by deep, rapid respira-tions. Commonly caused by diabetic ketoacidosis or other conditions with severe metabolic acidosis.

» Cheyne-Stokes respirations: Characterized by cycles of a gradual increase and decrease in respiratory depth and rate. As the respiratory rates decrease, there is a period of apnea which may

» CHF or any history of heart disease; » Pulmonary embolus or DVT.

Social history—Risk factor analysis helps to determine the like-lihood of a given prehospital diagnosis. Ask about the following:

» Smoking (increases risk of COPD and pneumonia); » ETOH (increases risk of aspiration pneumonia); » Recent travel (increases risk of pulmonary embolus); » Living conditions (patients in nursing homes and other high-

density living arrangements are frequently exposed to infections and are at higher risk of pneumonia).

Medications—The most commonly prescribed medications and their indications should be committed to memory. The skilled para-medic will find that the current emergency is often related to the patient’s prior underlying medical problems, and the medication list will give useful information regarding what should be considered in the list of potential prehospital diagnoses.

Diuretics such as furosemide, as well as hypertension and cardiac medications, are associated with CHF. Respiratory medications such as albuterol suggest asthma or COPD. Oral contraceptives increase the risk of DVT/pulmonary embolus.

Physical ExamOnce the history has been obtained, the paramedic should be able to formulate a list of likely prehospital diagnoses. The physical exam is then performed looking for evidence to support or refute each.

Vital signs—Looking at specific vital signs gives an enormous amount of information about the patient’s condition.

» Pulse rate: Normal is 60–100. A rapid rate occurs in response to several etiologies. However, as a simplification, tachycardia can be thought to occur in three general instances: 1) The tissues are not getting enough nutrients/oxygen, and the body is compensating for this (i.e., the patient is in shock/has high metabolic demand); 2) the patient is taking a medication or has a condition that causes tachycardia, such as a stimulant/anxiety/pain; 3) the patient has an arrhythmia.

» Respiratory rate: Normal is 12–20. Tachypnea, or a fast breath-ing rate, as a simplification, can be thought to occur for one of three main reasons: 1) The oxygen level is low; 2) the acid level is high (as in shock or high metabolic demand states); 3) pain, anxiety or certain drugs.

» Blood pressure: Normal is a systolic of 90–120 over a dia-stolic of 60–90. The top and bottom number both give significant information. Systolic BP depends on stroke volume and strength of myocardial contraction. It occurs during systole. The bottom number occurs while the heart is at rest during diastole and indicates the vascular tone of the patient’s arteries. The difference between the top and bottom number is known as the pulse pressure. A wide pulse pressure occurs in septic, anaphylactic and neurogenic shock. A narrow pulse pressure occurs in hypovolemic/hemorrhagic shock.

As an example, a patient with the vitals of pulse 110, RR 24 and BP 105/50 is likely in septic shock. The fast heart rate may be an indication of shock. The rapid respiratory rate indicates the patient is blowing off acid (which increases in shock) and/or compensating for a low oxygen level. While the systolic blood pressure of 105 is often falsely reassuring, the skilled paramedic will look closely at




» Stridor: Stridor is a high-pitched sound commonly heard on inspiration without a stethoscope that is indicative of an upper airway obstruction typically caused by infection, anaphylaxis or foreign body obstruction.

» Pleural rub: A pleural rub is the hallmark of pleurisy. It is best described as a creaking sound heard over the affected area of the lung.

Abdomen—A distended abdomen may indicate ascites. This finding can be associated with CHF.

Lower extremities—Routinely examine the lower extremities in patients with a chief complaint of SOB. Pitting edema bilaterally is common in CHF. A one-sided swollen leg can indicate DVT, which would raise the likelihood that pulmonary embolism is the cause of the dyspnea. In addition, the presence of pressure sores would indicate a patient who is nonambulatory. Both pneumonia and pulmonary embolism are more likely in nonambulatory patients.

Respiratory EmergenciesQuickly diagnosing respiratory emergencies can significantly impact a patient’s outcome. Life-threatening respiratory medical emergen-cies include pulmonary embolism, CHF, pneumonia, spontaneous pneumothorax, exacerbations of COPD and asthma.

Pulmonary embolism—Pulmonary embolism typically presents as a triad of sudden onset of shortness of breath, tachycardia and hypoxia. Pleuritic chest pain and hemoptysis can also occur. Large

pulmonary emboli can cause hypotension, syncope and cardiac arrest.The following patients are at increased risk for a pulmonary

embolus: patients with a previous DVT or PE, recent hip or knee surgery, leg pain/swelling, immobility (bedridden, long-distance travel via car or plane) or pregnancy, including up to 6 weeks postpartum.

Differential diagnosis: acute coronary syndromes, spontaneous pneumothorax, pneumonia and hyperventilation syndrome.

Spontaneous pneumothorax—Spontaneous pneumothorax pres-ents with a sudden onset of respiratory distress and/or pleuritic chest pain and dyspnea on exertion. Breath sounds are diminished or absent on the affected side. Because a collapsed lung cannot fully inflate, there may be a decrease in chest wall movement on the affected side depending on the size of the pneumothorax. Carefully monitor patients for the development of a tension pneumothorax: severe respiratory distress, hypotension, cyanosis, JVD, altered mental status and tracheal deviation.

Tall, thin adolescent males and activities with changes in altitude (e.g., scuba diving, flying, hiking in high altitudes) increase the risk for a spontaneous pneumothorax. Look for a history of previ-ous spontaneous pneumothorax, COPD, cystic fibrosis, asthma, tuberculosis, pneumonia, lung cancer and/or Marfan’s syndrome.

Differential diagnosis: Acute coronary syndromes, pulmonary embolus.

COPD—Emphysema is a chronic condition characterized by shortness of breath secondary to damage of the alveoli. Damaged

last up to 30 seconds. Cycles can last up to 2 minutes. Common causes include head trauma, stroke, hypoxia and brain tumors.

Neck exam—Observe for JVD and hepatojugular reflux (HJR). With the examiner on the right side of the patient, place the patient supine with the head up at about 30 degrees and turned away from the examiner. Then observe the exposed neck for JVD. With the patient in the same position, press down on the right upper quad-

rant of the abdomen over the liver. If the liver is engorged with blood due to right-sided CHF, the jugular vein will become more distended, making JVD more pronounced and obvious. These are both common signs of CHF. In addition, JVD may be present with tension pneumothorax.

Chest » Inspection: Inspecting the chest is often neglected in the pre-

hospital setting, but valuable information regarding the level of respiratory distress and the rate and quality of breathing can be determined this way. As you visualize the chest, look for intercostal muscle retractions, rate and depth of breathing, and equal expan-sion of the chest wall. Note whether the patient has a barrel chest (indicative of COPD).

» Palpation: Respiratory emergencies with associated chest pain should prompt palpation of the chest wall. Palpate over the affected area and note whether the pain can be reproduced. Chest pain asso-ciated with respirations or coughing is defined as pleuritic chest pain

and associated with pleurisy, costochondritis, pulmonary embolus, pneumothorax, pneumonia and pericarditis. Pneumothorax com-monly produces subcutaneous air that can be felt as a crackling sensation while palpating over the affected area of the chest wall.

» Auscultation: The ability to distinguish adventitious lung sounds is a necessary skill to diagnose respiratory emergencies. Too often lung sounds are omitted as part of the physical exam unless the chief complaint is respiratory in nature. As mentioned in earlier articles, lung sounds should be assessed on all patients as part of a limited prehospital physical exam.

Lungs sounds can be difficult to assess in the field. To improve auscultation, eliminate background noises whenever possible. Posi-tion the patient seated if they’re able. Ask patients not to speak during auscultation and to take slow, deep breaths with their mouth open. Place the stethoscope on the patient’s bare skin. Begin aus-cultation on the posterior thorax at the apex. Move from one side to the other, comparing lung sounds. Listen for a full respiratory cycle (one inhalation, one exhalation), continue moving inferiorly to the bases. Repeat on the anterior chest.

Abnormal lung sounds can be decreased or absent or adven-titious (e.g., crackles, rhonchi, wheezing, stridor or pleural rub). These sounds can be heard by themselves but often are heard in combination.

» Normal lung sounds: There are essentially two types of nor-mal lung sounds, vesicular and bronchovesicular. Vesicular lung sounds are soft and low-pitched and are auscultated over most of the peripheral lung tissue. Bronchovesicular lung sounds are heard anteriorly over at the sternal borders at the first and second inter-costal spaces and posteriorly between the scapulae. They have a medium pitch since they are auscultated over main-stem bronchi. It is important for the paramedic to listen to many normal patients in order to train the hearing skills to identify abnormal breath sounds.

» Decreased breath sounds: Decreased breath sounds may be caused by chronic conditions such as COPD (emphysema and chron-ic bronchitis) and asthma, or acute conditions (e.g., spontaneous pneumothorax). Other causes include hypoventilation or obesity.

» Crackles: Crackles can be described as fine or coarse. Crackles are associated with pulmonary edema secondary to left ventricular failure, COPD, pneumonia, bronchitis and asthma. Fine crackles have a sound similar to rubbing your hair between your index finger and thumb. There are subtle differences in the quality of the crackles depending upon the underlying etiology. It takes time and experience to learn to decipher those differences.

» Rhonchi: Rhonchi are gurgling, rattling type sounds and are indicative of secretions in the larger airways. Rhonchi can be gen-eralized as in bronchitis or localized as with pneumonia.

» Wheezing: Wheezing is a high-pitched whistling sound and occurs in response to bronchospasm. Asthma, COPD, bronchitis, pneumonia, CHF, pulmonary embolism and allergic reactions can all produce wheezing. Early wheezing is first heard on exhalation. As bronchospasm progresses, it can be heard on the inhalation phase as well. As it progresses even further, breath sounds may become significantly decreased or even absent. This is an ominous sign that the patient is not able to move air sufficiently to produce wheezing. This means respiratory failure is imminent.

Applying Traction Is EasyWhen you have the right splint

Use the Sager Traction Scale to set the amount of traction needed—Sager Splints do the rest. The Sager’s dynamic function permits traction to decrease automatically as the muscle spasm releases. Your patient will always have the correct amount of safe, secure, traction. It’s that easy!

One-person application. Safely treats Proximal Third and Mid-Shaft fractures. Ensures optimal patient care.

Learn how easy Sager Splints are to use / for details on Sager Splint models visit www.sagersplints.comEmail: [email protected] / Call 800.642.6468 for the name of Your Authorized Distributor.

20270 Charlanne Drive Redding, CA, 96002-9223


A common CHF finding is pitting edema in the lower extremities.


resides in a nursing home. After reading this article, you know that is a major risk factor for infections such as pneumonia. You hear crackles, but before you grab for the furosemide, which could potentially make a pneumonia case worse, you look at her list of medications. Nowhere is a cardiac medication or diuretic listed. This makes CHF less likely. However, you do see listed multiple pulmonary medica-tions such as albuterol. You realize that pre-existing lung disease is a major risk factor for pneumonia.

Next you look at the vital signs. You see the patient is tachycardic with a low dia-stolic BP, corresponding to possible sepsis. After going through the rest of your his-tory and physical exam, you conclude this patient likely has pneumonia with sepsis. You administer a fluid bolus and call a sep-sis alert to the nearest hospital. On arrival, an x-ray confirms the presence of pneumo-nia in the left lung. The ED staff applauds you for avoiding diuretics and giving the needed intravenous fluids. Congratula-tions—you and your team have raised the odds that this patient will survive.

RE FE RE N CE S

1. Dobson T, Jensen J, Karim S, Travers A. Correlation of paramedic administration of furosemide with emergency physician diagnosis of congestive heart failure. Australasian Journal of Paramedicine, 2009; 7(3).2. Jaronik J, Mikkelson P, Fales W, Overton DT. Evaluation of prehospital use of furosemide in patients with respiratory distress. Prehosp Emerg Care, 2006 Apr–Jun; 10(2): 194–7.3. Nield MA, Soo Hoo GW, Roper JM, Santiago S. Efficacy of pursed-lips breathing: a breathing pattern retraining strategy for dyspnea reduction. J Cardiopulm Rehabil Prev, 2007 Jul–Aug; 27(4): 237–44.4. Tsuyuki RT, McKelvie RS, Arnold JM, et al. Acute precipitants of congestive heart failure exacerbations. Arch Intern Med, 2001 Oct 22; 161(19): 2,337–42.

AB O U T THE AU TH O RS Kenneth A. Scheppke,

MD, is board-certified in EMS and emergency medicine. He has been practicing emergency medicine for over 20 years and is the EMS medical director for six

fire-rescue agencies in Palm Beach County, FL, including Palm Beach Gardens, Palm Beach County, West Palm Beach, Boynton Beach, the Town of Palm Beach and Greenacres. For more than 15 years he has trained paramedics and EMTs as medical director for the Palm Beach State College EMS Academy. He also serves as the assistant medical director of the JFK Medical Center emergency department in Atlantis, FL.

Keith Bryer, BBA, EMT-P, has been employed with Palm Beach Gardens Fire Rescue for more than 25 years. He currently serves as the department’s deputy chief of operations.

alveoli lose their elasticity and the ability to exchange oxygen and CO2, which results in prolonged respiration, decreased oxygen saturations and CO2 retention. Chronic bronchitis is a type of COPD that causes inflammation of the bronchial tubes, which produces the classic triad of a chronic cough, increased mucus production and shortness of breath.

Some of the most difficult breath sounds to assess occur in patients with COPD. Due to the destruction of the alveoli, breath sounds are generally decreased. Additionally, wheezing, rales and rhonchi can also be pres-ent, especially if associated with pneumonia.

During COPD exacerbations, patients try to manage the increased workload of breath-ing by assuming a tripod position, utilizing their accessory muscles and breathing with pursed lips. As compensatory mechanisms fail, increased respiratory effort and CO2 retention can quickly exhaust a patient, causing a decreased level of consciousness.

Look for a history of increasing respira-tory distress, typically preceded by infec-tions such as pneumonia or upper respira-tory infections, or by exposure to irritants such as air pollution or chemicals.

Differential diagnosis: CHF, pulmonary embolus, pneumonia.

CHF—For the purposes of this article we will focus on left heart failure, as left

ventricular failure (LVF) can cause severe respiratory distress. Conditions such as myocardial infarction or cardiomyopathy can damage the left ventricle enough so that a person’s ejection fraction is significantly reduced. This reduction causes blood to back up into the pulmonary circulation, causing the pulmonary venous pressures to increase. The elevated pressure causes capillaries to leak fluid into the alveoli and interstitial space.

Dyspnea on exertion and weight gain may indicate fluid retention in CHF; that and orthopnea are early signs of LVF. They are typically pre-ceded by increased sodium intake, infec-tions and noncompliance with medica-tions.4 Symptoms may progress gradually over hours or days. In contrast, flash pulmo-nary edema occurs rapidly, often becoming extremely severe in minutes. It is often a result of severe hypertension, myocardial infarction or mitral valve dysfunction.

Signs of right heart failure may be pres-ent: JVD, HJR, weight gain due to fluid retention, pedal edema.

Differential diagnosis: pneumonia, pul-monary embolus, COPD.

Asthma—Asthma is characterized by bronchoconstriction, inflammation of the

airways and increased mucus production. As with emphysema, asthma patients have difficulty getting air out. Patients can quick-ly become exhausted due to the increased workload of breathing and retention of CO2.

History will include a rapid onset of wheezing and SOB, which may be preceded by a recent upper respiratory infection or exposure to irritants (chemicals, tobacco smoke, air pollution, etc.). Exercise, stress and noncompliance with medications may also cause exacerbations.

Differential diagnosis: COPD, CHF, pul-monary embolus, pneumonia.

Pneumonia—Pneumonia is an infection of the lung characterized by a productive cough, fever and malaise. Risk factors include weakened immune systems due to chemotherapy or HIV/AIDS, chronic ill-nesses such as COPD, asthma and diabetes, and age over 65.

Look for recent upper respiratory infec-tion or flu, productive cough, dyspnea on exertion, fever/chills and general malaise. Differential diagnosis: COPD, CHF, asthma.

ConclusionOne of the more difficult aspects of con-ducting a prehospital history and physical exam is deciding which questions need to be asked and what elements of the exam should

be done. In each article of this series, we have detailed a his-tory and physical exam based on the body system correlat-ing with the chief complaint. Paramedics are encouraged to develop their own pattern recognition in medicine. Pat-tern recognition is the ability

to see the similarities between several cases with the same diagnoses and medical con-ditions in order to more rapidly diagnose future similar cases. Over time, using final hospital diagnoses to reinforce correct deci-sions (or alternatively correct false diagnos-tic impressions), the skilled paramedic will gain clinical acumen that will help improve the accuracy of their prehospital diagnosis and assist in determining what clues to look for in their history and physical examina-tions.

With this information in hand, let’s take another look at the hypoxic elderly female patient from our opening. The patient



Additional degree programs and online shifts available

Boca Raton | Orlando | Sarasota | Tampa | Online888.854.8308

SCAN HERE

LEARN MORE

ARE YOU PREPARED?

BACHELORCrisis & Disaster Management

MASTERPublic Health AdministrationBusiness Administration– Aviation Management– Construction Management– Project Management

Aviation Science– Aviation Operations– Aviation Security

Vital Signs 2016EMS Conference

Syracuse, NYOctober 13-16

You’re Invited

New Look,Same GreatConference!

A Program of the Department of Health

Visit us on the web at www.vitalsignsconference.comor call 518-402-0996 for more information.

Hope tosee youthere!

A one-sided swollen leg can indicate DVT, which would raise the likelihood that pulmonary embolism is the cause of the dyspnea.

Ken Scheppke


From the ridge, it continues to accept and respond to commands while it transmits photos of the search-ers’ progress.

Now imagine you’re with a SWAT team on the scene of a live shooting at a multi-story urban ware-house where two police officers have gone silent during a drug bust. Using 3D mapping software, the SWAT team locates both officers in different rooms on the second and third floors. The software enables a responder using a laptop to communicate with small sensors attached to the individual officers’ uniforms. An incident commander can view a 3D line drawing of the warehouse, including the locations of its internal features and showing the locations of the officers. Additional software communicates with more sensors, this time attached to flexible plastic panels (resembling x-ray film) inserted in the officers’ body armor. The film sensors detect and map the officers’ penetrating torso wounds.

Finally, suppose you’re at the scene of a wildland fire in a remote area where there is no phone coverage. A state patrol officer opens the lid of a ruggedized suitcase and sets up a complete communications cen-ter. Within 10 minutes, you can communicate voice and data at will with any resources you might need, on scene or not, ranging from the closest trauma center to FEMA. Your field units can communicate with one another using assigned frequencies on their normal LMR (land mobile radio) handy-talkies, or via tough, highly ruggedized LTE-equipped smartphones. In fact, they can also use PTT (push-to-talk) software on their phones to communicate in whichever mode they choose.

Agencies operating on Band 14 will be using LTE devices with five times the transmission power of a commercial cell phone. The system’s design is intended to provide 97% geographic coverage, and offers to address challenges like:

» Incidents in densely populated ones featuring large crowds using hundreds of personal cell phones simultaneously;

» Interagency communication needs, including data such as real-time photos and some video; and

» Mission-critical need-to-know things like emerging weather patterns, flood threats, hydrant locations, hospital availability, routes of ingress and egress, vehicle locations, personnel tracking and overall scope of the incident.

Can LTE cellular technology supersede the need for current radio systems? Experts disagree.

Craig Scherer, a fire systems technical specialist at the Denver Fire Department’s Communications Center, thinks the system would be too vulnerable to interference from public cell phone use. He said latency, the delay between transmitting a signal and receiving a usable answer, would also impair critical communications.

Ed Mills, FirstNet’s Colorado outreach and educa-tion manager, who moderated the conference, said he thinks the technology could make LMR radios obsolete in as little as three years.

“LTE is fast,” says Mills. “It’s line-of-sight, and it happens at the speed of light. A transmission from the West Coast to the East Coast (of the United States) would happen in a fraction of a second. There’s no need for a signal to bounce off of a satellite.”

Mills said one variable of implemention time is that it depends on how promptly major commercial carriers like Verizon and AT&T could comply with the system’s growth.

Recent history clearly illustrates the importance and effectiveness of this technology. Sonim, Mutua-link, Parallel Wireless, Verizon and numerous other vendors partnered to help local public safety agen-cies provide Band 14 coverage for the Rose Parade on January 1, 2016, in Pasadena and at Super Bowl 50 on February 7, 2016, in San Francisco. Both of those

A sk 100 emergency responders who’ve been to a major event what their worst challenge was and every single one of them will surely tell you: communications.

Their lives are getting easier, thanks to a dedicated band of the 700 MHz radio spectrum located just above that of digital TV broadcast

channels. Band 14, as it’s called, was reserved for public safety providers by the Spectrum Act of 2012, using the LTE (Long-Term Evolution) technology featured in most 4G-enabled smartphones.

LTE has some valuable properties for emergency needs. It penetrates buildings and walls easily, and it covers large geographic areas with less infrastructure than higher frequencies. It’s also lightning-fast and highly reliable.

Eighteen vendors from around the United States gathered in Brighton, CO, on May 3 under the auspices of FirstNet Colorado to showcase evolving technolo-

gies for about 120 participating potential users.Participants carried functional samples of personnel tracking devices and ruggedized cell phones with them throughout the day, while they kicked the tires of technology that has been in develop-ment throughout the United States for the past three years. The tracking devices recorded their attendance and movements,

while the cell phones enabled them to communicate with one another, ushering them from room to room in response to a tight schedule.

FirstNet Colorado is coordinating the state’s efforts to prepare for a nationwide high-speed data and cellular voice network for public safety providers using LTE. Here’s how that might work, using technology that has been developed so far:

Imagine you’ve been called to a ski resort where skiers have reported a friend buried in an avalanche. The local ski patrol has called for a drone, and the drone patrols the avalanche area in search of the skier’s cell phone. (A cell phone emits a constant radio-frequency signal until its battery goes dead.) The drone’s operator uses a tablet to map a search area based on aerial pho-tos, using a predetermined search strategy. The drone quickly conducts the search, and provides the rescue team with a GPS location before land-ing on a nearby ridge to maximize its battery life.

By Thom Dick

Will a Smartphone Replace Your Mobile Radio?LTE technology, featured in most 4G-enabled smartphones, has some valuable properties for emergency needs

DataSoft’s Automatic Injury Detection system

ESChat provides a secure PTT (Push To Talk) utility

Unmanned Aircraft Systems unmanned quadcopter


events involved huge crowds of people (all using personal cell phones constantly), in atmospheres of heightened international security and massive media attention.

Vendors at the event included: » John Bohike demonstrated DataSoft’s AID or Automatic Injury

Detection system. This plastic panel is inserted in the carrier of a ballistic vest. The small black sender in the lower left corner of the panel is a cellular transmitter. Within seconds of the panel being pierced by a projectile, it can report up to four wounds per panel to a land mobile radio (via Bluetooth), a cellular phone or a military radio. Visit www.datasoft.com.

» ESChat provides a secure PTT utility and various other inci-dent management software for ruggedized phones like Sonim XP7 Android. (It’s also Mac and iOS-compatible.) ESChat was used on Band 14 to coordinate the 2016 Rose Bowl, and was used interoper-

The Sierra Wireless oMG Mobile Gateway creates a Wi-Fi “bubble” around a vehicle that connects it to the best available network.

ADVERTISER INDEX Request Free Information at www.emsworld.com/e-inquiry

COMPANY PAGE INQ #

Abbott Point of Care 7 13

Bound Tree Medical, LLC 5 12

Breathing Air Systems 39 30

Columbia Southern University 34 28

Compression Works LLC 8 14

Compression Works LLC 41 31

Disaster Management Systems 20 20

Disaster Management Systems 27 24

Emergency Medical Products, Inc. 38 29

EMS World EXPO 36-37

Everglades University 53 39

Ferno 9 15

Ferno 11 16

Firehouse Expo 43

Graham Professional Medical 44 32

Kimtek Corporation 30 27

Lenoir Community College 13 17

Minto Research and Development 51 38

COMPANY PAGE INQ #

Monumedical, LLC 47 35

NAEMT 24 25

Nasco 17 18

North American Rescue Products 22 22

North American Rescue Products 49 37

Quantum EMS 29 26

Rescue Essentials 21 21

Simulaids Inc 59 41

Skedco Inc. 25 23

Skedco Inc. 48 36

Taylor Healthcare Products 28 34

Techline Trauma 3 11

Vital Signs 53 40

World Trauma Symposium 45

Ziamatic Corporation 60 42

Z-Medica LLC 19 19

ZOLL 2 10

ably with the Los Angeles County Sheriff ’s Department’s P25 land radio system. Visit www.eschat.com.

» Sierra Wireless InMotion Solutions exhibited a number of hardware and software offerings, including a mobile communica-tions gateway the size of a book. Mountable in the trunk of a squad car or under the seat of an ambulance, it creates a Wi-Fi “bubble” around a vehicle that connects it to the best available network—LTE Band 14 for public safety, with fallback to commercial LTE networks. Visit www.sierrawireless.com/gatewaysolutions.

» TRX Systems provides NEON Personnel Tracker, an indoor 3D personnel locating system that uses pager-sized sensors, Windows-based command software and an Android app to dynamically map the movement of personnel once they enter a structure. Visit www.TRXsystems.com.

» Unmanned Aircraft Systems exhibited a 24-inch, $75,000 Canadian unmanned quadcopter as one of a number of poten-tial on-scene aircraft. Its (video and still) cameras, struts, motors, rotors, battery and electronics are all field-replaceable as individual modules. It can stay airborne for 45 minutes, has a functional line-of-sight range of 1 kilometer, and can be digitally controlled from a tablet. This device has been used at a range of up to seven miles. Visit www.unmannedexperts.com.

AB O U T THE AU TH O R Thom Dick has been a passionate advocate of sick people and the safety of their field caregivers since 1970. He has written hundreds of articles and three books on those subjects, including the People Care books. You can reach Thom via Facebook, or at [email protected].


EMS1607S

THE MIDLIFE MEDIC By Tracey Loscar, NRP, FP-C


It’s an ironic part of our profession

that we install

people into a system we

do not ourselves

trust.

Just So We Are ClearInteractions with healthcare providers require plain talking

My mother is dying. My relationship with her is

complex and painful due to drug and alcohol

addiction. My father’s sudden death in 2013

thrust us back together after many years of

self-imposed estrangement. My younger brother had

already drunk himself to death and the rest of her fam-

ily had distanced themselves long ago. I was the last

one left.

When I came to Alaska from New Jersey to start the

next chapter in my professional life, what we were going

to do with her provided a huge challenge. We decided to

bring her out here, as managing households on opposite

ends of a continent was just too much.

Two months after she arrived she started complaining

of a sore throat. With a two-pack-a-day habit, this is not

unusual. At first it was manageable with OTC pain meds.

Eventually it became painful to swallow, then difficult to

swallow mechanically. When she began losing weight,

we knew what we might be facing.

The last couple of weeks have been full of appoint-

ments and tests. This once-vibrant, brilliant nurse is now

tiny and frail, crying quietly as they insert needle after

needle into the mass in her neck. She tries to control

her shivering as they put her in the CT machine, as she’s

always so cold. She wants to eat, but cannot swallow.

Three days ago, we got the preliminary results—meta-

static squamous cell neck cancer. (Author’s note: As with

any cancer, Google is NOT your friend.) From there we

made plans for an ENT consult, and the very real fact

that my mother’s fragile health probably will not toler-

ate much in the way of surgical or medical intervention.

I asked for a hospice consult as soon as possible, the

doctor agreed.

It did not hit my mother until later that night just what

the doctor was saying, and her anxiety went off the

chart. She exacerbated to the point where we ended

up in the emergency room. I have a fear of hospitals and

so does she, for the same reason that I know a lot of

you do too—it’s an ironic part of our profession that we

install people into a system we do not ourselves trust.

Why was I afraid?

Because they do not listen.

They hear the report or the alarm on the monitor, but

they do not listen fully. Sometimes it takes extraordinary

measures to get caregivers to understand the depth and

breadth of the problem or the need.

A few hours after she’s in the emergency room the

phone rang; the intensivist initiating her care after they

admit her is alarmed about the CT results from her neck.

He was calling me to see if I was willing to transfer her

to Anchorage because of her precarious airway status. I

told him she’s a Comfort One patient and that won’t be

necessary, there’s no need to transfer her.

Doctor: “I just want to really highlight one line from

this CT report for you, ‘Impending airway obstruction.’”

Me: “No tube, no trach, no vent.”

Doctor: “Just so we are clear, if I transfer your mom to

the floor and say, five minutes later her airway closes,

you are OK with your mom suffocating to death?”

Me: “Of course I am not, but what I am OK with is

the fact that she is a Comfort One patient, which is in

accordance with her wishes. Trust me, she and I know

what ‘impending airway obstruction’ implies. Make her

comfortable. Just so we are clear—no tube, no trach and

no vent.”

My parents had advanced directives and medical

proxy orders drawn up before it was cool to do so. Once

we got her into the Alaska health system the first thing

we did was request “Comfort One” status, which is the

state’s DNR program and recognized statewide from

EMS to hospital.

This forced confrontation with mortality so close to

home is an excellent lesson. Midlife may not mean end-

of-life but it does put us at the generational range where

we must change our working relationship with death. Our

parents are aging, we are aging. If we do not make our

wishes known then we leave ourselves at the mercy of

the healthcare system and face the necessary brutality

of resuscitation. Is someone able to speak for you? Are

you strong enough to speak for someone else? Make a

plan, do it now.

As of this writing, my mother is still in the hospital and

we are waiting for a consult with hospice. Every shift

change I contact the oncoming nurse to make sure that

we are on the same page: “No tube, no trach, no vent.”

Just so we are clear.

AB O U T THE AU TH O R Tracey Loscar, NRP, FP-C, is a battalion chief for Matanuska-Susitna (Mat-Su) Borough EMS in Wasilla, AK. Her adventures started on the East Coast, where she spent the last 27 years serving as a paramedic, educator and supervisor in Newark, NJ. She is also a member of the EMS World editorial advisory board. Contact her at [email protected] or www.taloscar.com.

visit us online at emsworld · supplied by hand pumps or a skedco field expedient bleeding...

Documents