1.JULY 2012Always En Route At

2. Choose 11 at www.jems.com/rs 3. Choose 13 at www.jems.com/rs 4. Choose 14 at www.jems.com/rs 5. The Conscience of EMS JOURNAL OF EMERGENCY MEDICAL SERVICES32I Rethinking Delivery Models IEMS industry may shift deployment methodsBy Johnathan D. Washko, BS-EMSA, NREMT-P, AEMD[July 2012]July 2012 Vol. 37 No. 7Contents I 5238 I Engulfed in an Instant I Lessons learned from Navy jet crash responsey Bruce Nedelka, NREMT-PA.J. Heightman, MPA, EMT-P B52 I No Need for Speed I Improving accuracy of nursing home response-level requestsy Lori L. Boland, MPH,Steve G. Hagstrom, NREMT-P BI 6060 I Silent Struggle I Drowning is a leading cause of unintentional injury deathy Justin Sempsrott, MD; Andrew Schmidt, DO, MPH; B Seth Hawkins, MD, FACEP, FAAEM, FAWM;Bryan Bledsoe, DO, FACEP, FAAEMI 38 Departmentscolumns 9 I Loadgo I Now on JEMS.com 14 I EMS in Action I Scene of the Month 16 I From the Editor I Return to Joplin y A.J. Heightman, MPA, EMT-P B 20 I Letters I In Your Words 22 I Priority Traffic I News You Can Use 26 I lEADERSHIP sECTOR I Discipline y Gary Ludwig, MS, EMT-P B 28 I Tricks OF the TRADE I Old Friends y Thom Dick B 30 I case of the month I More Than a Headache y Fred W. Wurster III, AAS, NREMT-P B 78 I employmentClassified Ads 82 I Ad Index 84 I Hands On I Product Reviews from Street Crews y Fran Hildwine B 88 I The Lighter Side I Youngns of EMSy Steve Berry B 90 I LAST WORD I The UpsDowns of EMSAbout models thatCoverand effective allow the prehospital industry to innovate, the are efficient Service deliveryimprove evidence-based clinical practice and make the shift to more immediate care in the field. Read more about service delivery models in Rethinking Delivery Models: EMS industry may shift deployment methods, p. 3236, and see how your service measures up. Photo iStockPhoto.comPremier Media Partner of the IAFC, the IAFC EMS SectionFire-Rescue Medwww.jems.comJuly 2012JEMS7 6. Choose 15 at www.jems.com/rs 7. LOADGOlog in for EXCLUSIVE CONTENT A Better Way to LearnJEMSCE.comonline continuing education programnus o followRescueResusitatePhoto Bryan E. BledsoeThe word summer is often synonymous with the word water. Unfortunately for EMS providers, it also means more awareness on how to treat drowning patients. Weve got you covered. Check out the bonus content for this months clinical education article, Silent Struggle: Drowning is a leading cause of unintentional injurydeath, pp. 6076. And for those of you who champion the cause, it also includes more information on the non-profit group Lifeguards Without Borders. s jems.com/journalJEMS.com offers you original content, jobs, products and resources. But were much more than that; we keep you in touch with your colleagues through our:Facebook fan page;JEMS Connect site;Twitter account;LinkedIn profile;Product Connect site; andFire EMS Blogs site.like us facebook.com /jemsfansFree online Learning Opportunities! We believe learning is a lifelong commitment. We also think theres a lot of knowledge to be had in EMS, and we bet most EMS professionals would agree. Thats why weve increased the number of free webcasts were offering. Make sure to register for one or all of them today. s jems.com/webcastsfollow us twitter.com /jemsconnectSponsored Product Focus Flow-Safe II CPAP SystemThe Flow-Safe II CPAP system with built-in manometer from Mercury Medical is now delivering more than 10 cm H2O at 15 LPM while using 50% less oxygen. Flow-Safe II has all of the benefits of the original CPAP system with superior safety features and performance, while consuming less oxygen. It doesnt require special high-flow equipment. Flow-Safe II also delivers consistent CPAP pressure on inhalation and exhalation. No extra partsit comes assembled with a deluxe mask, manometer and pressure-relief valve all in one disposable setup package. Clinicians can easily attach a nebulizer in-line for patients requiring aerosol inhalation medication with CPAP therapy. s Check out their JEMS.com ad and Hot Product listing!get connected linkedin.com/groups? about=gid=113182ems news alerts jems.com/enewsJune Poll ResultsHow long have you been in EMS?8%Less than one year.votesMore than 20 years.2224%25 years.Check it out26%% 1120years.20%610 years.jems.com/ems-productsThe mobile version s m.facebook.com/ questions/10150693378539794/best bloggers FireEMSBlogs.com www.jems.comJULY 2012 JEMS9 8. Conscience of EMS JOURNAL OF EMERGENCY MEDICAL SERVICESThe Conscience of EMS JOURNAL OF EMERGENCY MEDICAL SERVICES Editor-In-Chief I A.J. Heightman, MPA, EMT-P I a.j.heightman@elsevier.com MANAGING Editor I Jennifer Berry I je.berry@elsevier.com associate eDITOR I Lauren Hardcastle I l.hardcastle@elsevier.com assistant eDITOR I Allison Moen I a.moen@elsevier.com assistant eDITOR I Kindra Sclar I k.sclar@elsevier.com online news/blog manager I Bill Carey I bill@goforwardmedia.com Medical Editor I Edward T. Dickinson, MD, NREMT-P, FACEP Technical Editors Travis Kusman, MPH, NREMT-P; Fred W. Wurster III, NREMT-P, AAS Contributing Editor I Bryan Bledsoe, DO, FACEP, FAAEM Editorial Department I 800/266-5367 I editor.jems@elsevier.com art director I Liliana Estep I alildesign@me.com Contributing illustrators Steve Berry, NREMT-P; Paul Combs, NREMT-B Contributing Photographers Vu Banh, Glen Ellman, Craig Jackson, Kevin Link, Courtney McCain, Tom Page, Rick Roach, Steve Silverman, Michael Strauss, Chris Swabb Director of eProducts/Production I Tim Francis I t.francis@elsevier.com Production Coordinator I Matt Leatherman I m.leatherman@elsevier.com advertising director I Judi Leidiger I 619/795-9040 I j.leidiger@jems.com Western Account Representative I Cindi Richardson I 661-297-4027 I c.richardson@jems.com senior Sales coordinator I Elizabeth Zook I e.zook@elsevier.com SalesAdministrative Coordinator I Liz Coyle I l.coyle@elsevier.com SENIOR eMedia campaign manager I Lisa Bell I l.bell@elsevier.com advertising department I 800/266-5367 I Fax 619/699-6722 marketing director I Debbie Murray I d.l.murray@elsevier.com Marketing manager I Melanie Dowd I m.dowd@elsevier.com MarketingConference Program Coordinator I Vanessa Horne I v.horne@elsevier.com Director, Audience DevelopmentSales Support I Mike Shear I m.shear@elsevier.com Audience development coordinator I Marisa Collier I m.collier@elsevier.com SUBSCRIPTION DEPARTMENT I 888/456-5367 REprints, eprintsLicensing I Wrights Media I 877/652-5295 I reprints@jems.com eMedia Strategy I 410/872-9303 I Managing Director I Dave J. Iannone I dave@goforwardmedia.com Director of eMedia Sales I Paul Andrews I paul@goforwardmedia.com Director of eMedia Content I Chris Hebert I chris@goforwardmedia.com EMS Today ConferenceExposition reed exhibitions I Ed Several I 203/840-5932 I eseveral@reedexpo.com ems today exhibit sales I 203/840-5473 Kevin Kennedy I kkennedy@reedexpo.com elsevier public safety vice president/publisher I Jeff Berend I j.berend@elsevier.com founding editor I Keith Griffiths founding publisher James O. Page (19362004)Choose 16 at www.jems.com/rs 9. Choose 17 at www.jems.com/rs 10. JOURNAL OF EMERGENCY MEDICAL SERVICESThe Conscience of EMS JOURNAL OF EMERGENCY MEDICAL SERVICESEDITORIAL board William K. Atkinson II, PHD, MPH, MPA, EMT-P PresidentChief Executive Officer WakeMed HealthHospitals James J. Augustine, MD Medical Advisor, Washington Township (OH) Fire Department Director of Clinical Operations, EMP Management Clinical Associate Professor, Department of Emergency Medicine, Wright State University steve berry, NRemt-p ParamedicEMS Cartoonist, Woodland Park, Colo. Bryan E. Bledsoe, DO, FACEP, FAAEM Professor of Emergency Medicine, Director, EMS Fellowship University of Nevada School of Medicine Medical Director, MedicWest Ambulance Criss Brainard, EMT-P Deputy Chief of Operations, San Diego Fire-Rescue Chad Brocato, DHS, REMT-P Assistant Chief of Operations, Deerfield Beach Fire-Rescue Adjunct Professor of AnatomyPhysiology, Kaplan University J. Robert (Rob) Brown Jr., EFO Fire Chief, Stafford County, Va., Fire and Rescue Department Executive Board, EMS Section, International Association of Fire Chiefs carol a. cunningham, md, FACEP, FAAEM State Medical Director Ohio Department of Public Safety, Division of EMS Thom Dick, EMT-P Quality Care Coordinator Platte Valley Ambulance Marc Eckstein, MD, MPH, FACEP Director of Prehospital Care, Los Angeles County/ USC Medical Center Medical Director, Los Angeles Fire Department Professor, Emergency Medicine, University of Southern California Charlie Eisele, BS, NREMT-P Flight Paramedic, State Trooper, EMS Instructor Bruce Evans, MPA, EMT-P Deputy Chief, Upper Pine River Bayfield Fire Protection, Colorado District Jay Fitch, PhD PresidentFounding Partner, FitchAssociates Ray Fowler, MD, FACEP Associate Professor, University of Texas Southwestern SOM Chief of EMS, University of Texas Southwestern Medical Center Chief of Medical Operations, Dallas Metropolitan Area BioTel (EMS) System Adam D. Fox, DPM, DO Assistant Professor of Surgery, Division of Trauma SurgeryCritical Care, University of MedicineDentistry of New Jersey Former Advanced EMT-3 (AEMT-3) Gregory R. Frailey, DO, FACOEP, EMT-P Medical Director, Prehospital Services, Susquehanna Health Tactical Physician, Williamsport Bureau of Police Special Response Team12JEMSJULY 2012Jeffrey M. Goodloe, MD, FACEP, NREMT-P Associate ProfessorEMS Division Director, Emergency Medicine, University of Oklahoma School of Community Medicine Medical Director, EMS System for Metropolitan Oklahoma CityTulsaDavid E. Persse, MD, FACEP Physician Director, City of Houston Emergency Medical Services Public Health Authority, City of Houston Department. of HealthHuman Services Associate Professor, Emergency Medicine, University of Texas Health Science CenterHoustonKeith Griffiths President, RedFlash Group Founding Editor, JEMSJohn J. Peruggia Jr., BSHuS, EFO, EMT-P Assistant Chief, Logistics, FDNY OperationsDave Keseg, MD, FACEP Medical Director, Columbus Fire Department Clinical Instructor, Ohio State University W. Ann Maggiore, JD, NREMT-P Associate Attorney, Butt, ThorntonBaehr PC Clinical Instructor, University of New Mexico, School of Medicine Connie J. Mattera, MS, RN, EMT-P EMS Administrative DirectorEMS System Coordinator, Northwest (Illinois) Community Hospital Robert J. McCaughan Chair, IAEMSC Metro Chiefs Section Robin B. Mcfee, DO, MPH, FACPM, FAACT Medical Director, Threat Science ToxicologistProfessional Education Coordinator, Long Island Regional Poison Information Center Mark Meredith, MD Assistant Professor, Emergency Medicine and Pediatrics, Vanderbilt Medical Center Assistant EMS Medical Director for Pediatric Care, Nashville Fire Department Geoffrey T. Miller, EMT-P Director of Simulation Eastern Virginia Medical School, Office of Professional Development Brent Myers, MD, MPH, FACEP Medical Director, Wake County EMS System Emergency Physician, Wake Emergency Physicians PA Medical Director, WakeMed HealthHospitals Emergency Services Institute Mary M. Newman President, Sudden Cardiac Arrest Foundation Joseph P. Ornato, MD, FACP, FACC, FACEP ProfessorChairman, Department of Emergency Medicine, Virginia Commonwealth University Medical Center Operational Medical Director, Richmond Ambulance Authority Jerry Overton, MPA Chair, International Academies of Emergency Dispatch David Page, MS, NREMT-P Paramedic Instructor, Inver Hills (Minn.) Community College Paramedic, Allina Medical Transportation Member of the Board of Advisors, Prehospital Care Research Forum Paul E. Pepe, MD, MPH, MACP, FACEP, FCCM Professor, Surgery, University of Texas Southwestern Medical Center Head, Emergency Services, Parkland HealthHospital System Head, EMS Medical Direction Team, Dallas Area Biotel (EMS) SystemEdward M. Racht, MD Chief Medical Officer, American Medical Response Jeffrey P. Salomone, MD, FACS, NREMT-P Associate Professor of Surgery, Emory University School of Medicine Deputy Chief of Surgery, Grady Memorial Hospital Assistant Medical Director, Grady EMS Kathleen S. Schrank, MD Professor of Medicine and Chief, Division of Emergency Medicine, University of Miami School of Medicine Medical Director, City of Miami Fire Rescue Medical Director, Village of Key Biscayne Fire Rescue John Sinclair, EMT-P International Director, IAFC EMS Section Fire ChiefEmergency Manager, Kittitas Valley FireRescue Corey M. Slovis, MD, FACP, FACEP, FAAEM ProfessorChair, Emergency Medicine, Vanderbilt University Medical Center Professor, Medicine, Vanderbilt University Medical Center Medical Director, Metro Nashville Fire Department Medical Director, Nashville International Airport Barry Smith, EMT-P CQI Coordinator, Regional EMS Authority (REMSA), Reno, Nev. Walt A. Stoy, PhD, EMT-P, CCEMTP ProfessorDirector, Emergency Medicine, University of Pittsburgh Director, Office of Education, Center for Emergency Medicine Richard Vance, EMT-P Captain, Carlsbad Fire Department Jonathan D. Washko, BS-EMSA, NREMT-P, AEMD Assistant Vice President, North Shore-LIJ Center for EMS Co-Chairman, Professional Standards Committee, American Ambulance Association Ad-Hoc Finance Committee Member, NEMSAC keith wesley, MD, facep Medical Director, HealthEast Medical Transportation Katherine H. West, BSN, MED, CIC Infection Control Consultant, Infection Control/Emerging Concepts Inc. Stephen R. Wirth, Esq. Attorney, Page, WolfbergWirth LLC. Legal CommissionerChair, Panel of Commissioners, Commission on Accreditation of Ambulance Services (CAAS) Douglas M. Wolfberg, Esq. Attorney, Page, WolfbergWirth LLC Wayne M. Zygowicz, BA, EFO, EMT-P EMS Division Chief, Littleton Fire Rescue 11. Choose 18 at www.jems.com/rs 12. EMS INACTION Scene of the month14JEMSJULY 2012 Photo Bernie Deyo 13. Air TransportEmergency personnel place a patient into a medical helicopter for transport to a trauma center. The patient was ejected from his vehicle after it rolled several times in a remote area. Los Angeles County Fire Department (LACoFD) paramedics provided BLS and ALS care, including assessment, oxygen administration and C-spine precautions, to the patient prior to his airlift. LACoFD operates one of the most progressive, multi-functional helicopter systems in the country, with crews able to perform fire suppression, EMS, search and rescue, and extraction functions via their helicopters.www.jems.comJULY 2012JEMS15 14. from the editor putting issUes into perspective by A.J. HEIGHTMAN, MPA, EMT-PReturn to JoplinCrews rebound from the tornados horrible aftermathPhoto AP/Mark SchiefelbeinPhoto AP/Mark Schiefelbeinmeet with the crews and supervisors and speak at a staff picnic on the first anniversary of the tornado, I accepted immediately. METS and NCAD cover the Joplin area in a unique and cooperative response system (see Last Word, p. 90). Many of the regions EMS, fire personnel and emergency department nurses work for one or both agencies. I arrived in Joplin the day after President Barack Obamas speech at the Joplin Community College and was not at all surprised to learn that the elected officials, fire crews and law enforcement staff were allowed into the facility, but the EMS crews, the ones whoEMS crews were confronted by dead bodies and patients who ranged from having minor injuries to pieces of rebar sticking out of their skulls.16would be able to contribute the most if the president or another attendee collapsed during the ceremony, were stationed outside the auditorium at their nine ALS units. Its a common story that stinks and will probably only change when an elected official chokes to death on a martini olive and it takes 12 minutes for a crew to get to that persons obstructed airway. The community college, METS and NCAD are an important part of the Joplin tornado history because the tornado tore through the center point of their two primary response districts and dozens of the emergency personnel were at the community college instead of Joplin High School, which was not large enough to hold the high schools graduation, when the tornado tore through the high school, hospital and their homes minutes after graduation ceremonies had concluded. What follows are photos from that fateful day and my visit. I hope they show you the unimaginable obstacles the METS and NCAD EMS crews faced and how they have rebounded, physically and emotionally, in the year since that horrible day. Photo AP/Charlie RiedelThe tornado that tore through Joplin Mo., on May 22, 2011, killed 165 people and injured 1,500 others; it decimated thousands of homes, business, churches, nursing homes and St. Johns Mercy Hospitalone of the towns two hospitals. It received international attention for weeks. Much of the attention centered on the many lives lost at one of the nursing homes and St. Johns. Many of the media stories focused on heroic civilian efforts, including road crews that cleared the road early with chainsaws and assisted citizens and firefighters in finding and extricating trapped individuals. But like so many other disasters, the efforts of the local and mutual aid EMS agencies, which found, triaged, treated and transported scores of injured to medical facilities throughout a 12-hour period after the tornado, went largely ignored by the national media. So when Jason Smith, director of Metro Emergency Transport System (METS), and Rusty Tinney, director of the Newton County Ambulance District (NCAD), invited me toJEMSJULY 2012NCAD EMS Director Rusty Tinney and the first ambulance that arrived at E. 20th St.Range Line Road encountered more than a dozen dead bodies and people searching for relatives and friends who had been sucked out of the walk-in freezer at a fast food restaurant. Only four of the 12 people who tried to take refuge in the freezer survived. 15. Choose 19 at www.jems.com/rs 16. FROM THE EDITORThis is all that remained of the Greenbriar Nursing Home after the tornado ravaged the area. Eighteen were killed at this location.Photo AP/Charlie RiedelMETSNCAD crews established patient collection and treatment areas near the tornados path of destructiona path that traversed both ambulance service areas.Photo AP/Charlie RiedelA.J. Heightman (left)NCAD Director Rusty Tinney stand at the Pizza Hut one year after the incident. Many of the restaurants and stores have already been rebuilt, but the horrible sights seen by the EMS crews will always remain in their memories.Photo AP/Charlie RiedelPhoto Courtesy A.J. Heightman continued from page 16Photo AP/Mark SchiefelbeinThe remains of Joplin High School, where hundreds of lives would have been lost had the school been used for its graduation ceremony. The schools sign was modified and became a lasting symbol of hope for the community.Photo AP/Jeff RobersonPhoto A.J. HeightmanPhoto A.J. HeightmanSt. Johns Mercy Hospital, its emergency department and medical helicopter took a direct hit.Rusty Tinney (left)METS Director A Joplin City building was used as temporary hospi- Jason Smith stand in the temporary multi-section modular hospital tal after the tornado.Temporary trailers were erected after the tornado to house patients and equipment that survived the destruction of St. Johns.18JEMSJULY 2012Photo A.J. HeightmanPhoto A.J. HeightmanPhoto A.J. HeightmanMembers of Missouri Task Force One search-and-rescue team stand by as heavy equipment moves debris from a tornado-damaged Home Depot store.The spacious emergency department of the tempo- Crews from METSNCAD gather to rary prefab, modular, which is now named Mercy remember that fateful day in 2011 at the May 23, 2012, crew picnic. Hospital Joplin. 17. SaveDATE the NewLocation!March 5 March 9, 2013Washington, D.C.Advance Your Career at EMS Today Where People, Products and Ideas Connectwww.EMSToday.com 18. LETTERS in your wordsPhoto glen ellmanThis month, readers comment on a few recent JEMS articles. One reader discusses the information in an article on cultural sensitivity (Breaking Barriers: Practice cultural sensitivity to provide care to immigrant communities, May JEMS) by Emily Coffey, BA, NREMT-P, and Keith Widmeier, NREMT-P, CCEMT-P, EMS-I, and another had concerns with the type of care shown in an April EMS in Action photo spread (Active Assessment.) Finally, JEMS Facebook fans chime in on a quote by Thom Dick that reminds providers to take extra time to make all patients feel valued.Faith Practices I was mystified by the article Breaking Barriers, which had the following in a caption: Most Americans arent opposed to porcine insulin, but Jewish and Muslim patients might choose to accept the risks of hyperglycemia rather than receive this particular medication. I cannot speak for the Muslim faith, but as an Orthodox Jewish rabbi, my jaw dropped. The first law of Judaism commands us tobreak every law in order to save a life. There is no objection or law that prohibits the use of porcine insulin. Just the opposite is true: We are commanded to do whatever is necessary in order to save our lives and maintain our health. No person of the Jewish faith would ever accept the risks of hyperglycemia in order to avoid a medication coming from any animal source. Im extremely confused where the author got thisAnother day of death, mayhem and chaos over. Whacha watching?illustration steve berry1,000 Ways to Die20JEMSJULY 2011information, and its absolutely contrary to our faith. Rabbi Baruch Stone, NREMT-I Cambridge, Massachusetts Author Keith Widmeier, NREMT-P, CCEMT-P, EMS-I responds: According to the informational booklet, Informed Choice in Medicine Taking: Drugs of Porcine Origin and Clinical Alternatives (www.keele.ac.uk/ pharmacy/npcplus/medicinespartnershipprogramme/ medicinespartnershipprogrammepublications/ drugsofporcineoriginandclinicalalternatives/drugs-ofporcine-origin.pdf), porcine medications may be an issue for a number of faiths, but its more likely to be an issue for Judaism and Islam. The booklet goes into discussion about potential exemptions as well. However, I feel that this discussion is straying from the overall message of the article. Regardless of faithour patients or our ownit is imperative that we, as providers, respect the decisions made by our patients. Patients have the right to decide what treatment they choose to acceptor not acceptand providers should not attempt to downplay the importance of the patients faith for the desired medical treatment.Check the Basics In the April JEMS article, Active Assessment, paramedic Brian Pearce was doing what I call a double pulse check. I teach in a private paramedic college, and I notice all the students are trained to practice this, and I disagree with it. I understand the thought behind it, but we must consider that the American Heart Association (AHA), Heart and Stroke Foundation of Canada and Journal of the American Medical Association have referenced that 60% of healthcare providers cant adequately check for a carotid pulse. Ive taken a dozen students and had them access a carotid pulse, and all 12 couldnt find a pulse in a timely fashion. We live in a culture of fat necks, meaning many patients have lots of adipose tissue in their necks. Unless a provider uses a head tilt/chin lift to bring carotid artery closer to the surface, how can anyone truly feel a carotid 19. and radial at the same time? If a medic comes across an unconscious patient, they should assume theyre dead, check a carotid only first, then check a radial if theres a pulse to see if pressure is adequate. I dont care if Im perfusing the finger, but I do care if the brain is being perfused. Lets just follow AHA guidelines instead of changing what works. Assess responsiveness, open airway and check for breathing and pulse while using a head tilt/chin lift. This step still follows the current 2010 guidelines: If there is no breathing and no pulse, then get on the chest and start compressions. Lets get back to the basics. Arne Larsen Simcoe County, Ontario, CanadaWords of WisdomBelow are comments from the JEMS Facebook Fan page in response to the following quote by columnist Thom Dick:Next time you kneel in front of somebody you dont know or sit beside someone in that ambulance of yours, look them straight in the eye. While theyre with you, theyre important. Thom Dick Dennis Youngberg: Treat them as if they were your mother/father. Moe Altazan: Were all guilty of this at one time or another. It takes practice and compassion; we have to make it a natural habit. Marcia Chapman: Too many are paying more attention to their clipboard or computer than to their patients. Building a rapport with your patient is just as important as any of your other skillsit takes practice to develop and ongoing use to master. Smiley Rie: So very true. It might not be an emergency to us, but to most of them it is. And my other favorite saying is this: Its not about our egos; its about the patient. ohn Michael Fisher: I was taught this during school so now its second J nature for me, but I only sit in the jump seat if Im playing with the monitor, doing something airway, or if the patient falls asleep. I always sit on the bench and play to precept everyone. Sharon Cox: True words. I cant stand it when paramedics or EMTs dont talk to their patients or are too clinical with them. A kind word, a smile, a held hand and a little reassurance goes a long way. Curtiss Orde: Amen to Thoms quote. JEMSDo you have questions, comments or concerns about recent JEMS or JEMS.com articles? Wed love to hear from you. E-mail your letters to editor.jems@elsevier.com or send to 525 B St. Suite 1800, San Diego, CA 92101, Attn: Allison Moen. Choose 20 at www.jems.com/rswww.jems.comJULY 2012JEMS21 20. PRIORITYUSE TRAFFIC NEWS YOU CANZombie Drug Despite sanction, patients continue to use drug known as bath saltstlnors/istockphoto.comThe meteoric rise of the street drug called bath salts has taken a grip on prehospital providers and emergency departments (EDs) nationwide. Many experts say theyre most alarmed by the short amount of time it has taken for this drug to become so prominent. Bath salts is the most common street name for certain synthetic cathinones, including methylenedioxypyrovalerone (MDPV) and methedrone. Its a broadly available psychoactive drug that mimics the effects of other stimulants such as methamphetamine, ecstasy and cocaine. In 2010, there were 303 calls to poison control centers nationwide for probableBath salts are stimulants, and their symptoms are simliar to those from methamphetamine, ecstasy and cocaine use. bath salts complications. The first third of 2012 has already resulted in 1,007 calls. If this trend persists, this will equate to morePhotos Courtesy NEMSMBRQUICK TAKE During EMS Week, dozens of people from EMS systems all over the U.S. gathered to participate in the 2012 National EMS Memorial Bike Rides (NEMSMBR), with routes starting in both Boston, Mass., and Paintsville, Ky. Both routes ended in Alexandria, Va. The ride is held annually to honor EMS providers who have died in the line of duty and to advocate for safety in EMS and the wellness of EMS providers. Over the seven days, close to 100 riders, called Muddy Angels, participated per day on the East Coast route and seven riders on the Kentucky route. Another 2025, affectionately known as Wingmen, provided support. Twentytwo states were represented among the participants. For some, it was a return to the ride, but for others, it was their first ride. For both, many moments and emotions were experienced along the way. The 2012 ride was also especially meaningful for many, as the group rode to honor Lori Foster-Mayfield, a paramedic from Reno, Nev., who died unexpectedly in January. Due to our previous years accounts of the ride, as well as the outpouring of support for Lori and her passion for her profession, 14 people from the Reno area joined us on the ride, says Trish Hamilton, a flight nurse and Loris best friend. For me, [the decision to ride] was the best decision I could have made. My Muddy Angel family is like no other friendship or family out there. They are some of the best people I have ever known. Its a grueling journey, both mentally and physically. However, the spirit of the ride, those who are being honored and the feeling of family among the Muddy Angels heals muscles, hearts and souls. Tim PerkinsBeth Kirkland Davis and Trish Hamilton (above) read during a Memorial Service for Muddy Angel Lori Foster-Mayfield.More of the latest EMS news is at JEMS.com/news22JEMSJULY 2012than 3,000 calls in 2012; a tenfold increase from 2010. Common side effects include euphoria, anxiety, confusion, insatiable desire for more of the drug and paranoia. Hyperthermia, cardiovascular collapse, rhabdomyolysis and renal sequalae are more severe and potentially fatal consequences of use. Its crucial that prehospital providers understand the risk for these potentially fatal complications and that ED evaluation, monitoring and treatment is the appropriate definitive therapy. The news headlines continue to publicize the bizarre and severe actions of those abusing this new street drug. The latest shocking 21. Choose 21 at www.jems.com/rs 22. continued from page 22 headline reveals a crazed individual in Florida who is suspected of chewing off the face of another man after taking bath salts. The suspect has been repeatedly described as a Zombie, highlighting the severe psychoactive effects of this medication. Other headlines include suicides, strangulations and homicidal actions by those under the influence. One notable case in West Virginia involved a man who allegedly dressed in womens clothing and stabbed a stolen goat to deathall while under the influence of bath salts. Prehospital and ED personnel also report bizarre, unpredictable and very dangerous actions from individuals under the influence of bath salts. These patients exhibit dangerous, unpredictable, combative behavior that put bystanders and EMS providers in danger. Treatment modalities include restraining the individual as necessary, providing cardiovascular support, treating hyperthermia and administering benzodiazepine foragitation. This is to prevent harm to the patient, as well as preventing further hyperthermia and muscle activity that could result in rhabdomyolysis. Beta-blocker administration for hypertension is contraindicated because it causes a spike in blood pressure, which is attributed to unabated alpha-adrenergic stimulation.1 In response to the substantial rise in abuse and emergency department visits related to bath salts, the Drug Enforcement Agency (DEA) imposed an emergency sanction classifying MDPV as a Schedule I controlled substance. That puts it in the same category as heroin and lysergic acid diethylamide (LSD). Prior to this action, more than 30 individual states had criminalized the drug. For the short term, there are indications that the DEAs action may be blunting nationwide use of the drug. However, this sanction may have limited long-term consequences because chemists of synthetic drugs may be able to slightly alter thechemical compound so it isnt classified as the prohibited compound. Examples of alternative chemicals being manufactured to replace the now-illegal bath salts include naphyrone, which is sold as cosmic blast. Naphyrone is gaining popularity in Europe and is spreading to the US. Symptoms and dangers are nearly identical to bath salts. EMS providers need to remain vigilant for these potential patients and be aware of the various treatment modalities. They also need to maintain crew safety around these potentially violent patients. Jon Nevin, NREMT-P, BS, MBAReferences 1.Michigan Department of Community Health. (April 30, 2012). Bath Salts Health Care Provider Fact Sheet. In Michigan. Retrieved June 11, 2012, from www.michigan.gov/documents/mdch/Bath_ Salts_FAQ_Health_Care_Providers_April2012_ v2_384317_7.pdf.Patient Handling Errors The legal risks of gravity By Doug WolfbergSteve WirthOne of the areas of EMS operations that often seems to be taken for granted is patient handlingor lifting and moving, as we referred to it in EMT class. Oftentimes, this critical area might be given short shrift in training programs. Changes in technology can also lead to crew member unfamiliarity with the use of new equipment. And sometimes, simple mistakes can allow gravity to overtake our best efforts, resulting in patient drops and other patient handling errors. Although hard data on the number of patient drops is hard to come by, anecdotally, we usually receive a couple of calls a month with these types of cases. The legal defense of patient drop cases usually involves a mechanical evaluation of the stretcher and other equipment. But most of the time, this inspection (typically done by a mechanical engineer or other such expert) reveals no deficiencies with the equipment. Most of the time, these incidents are caused by human error. Good, old-fashioned negligence, as we like to call it. In cases that come down to unvarnished human error, little can be done to pull a rabbit out of a hat in court: Negligence is negligence. And negligence does not require the violation of a protocol or written policy to be actionable in court. (When was the last time you read an EMS protocol that said dont drop the patient?) Negligence is the failure to Get help when you need it. Lets face it. Ameriuphold the standard of care applicable to the circumstances (or, put another way, the failure to act cas obesity epidemic takes its toll on EMTs and medics as a reasonably, prudent EMT or paramedic would every day. Know your physical limitations when lifting under the circumstances). No violation of a written patients. If you need extra assistance, ask for it before protocol or policy is necessary for a jury to find that making the situation worse by attempting to move not dropping patients is firmly within the EMS stan- a patient who is too heavy for you and your partner. Asking for help is no admission of failure or defeat if it dard of care. Here are a few suggestions for preventing unneces- means a safer move for you and your patient.Work as a team. Ensure patients are moved in sary liability arising from the ill effects of gravity that a delicate dance of coordination by all members of result in patient drops:Train your people. Make sure your crews are your team. One team leader should provide a clear lift properly trained not only in proper lifting and mov- count, so that all personnel are exerting at the same ing techniques (which can also help reduce workplace time. If other crew members are needed to back up injuries), but also in the proper use of your agencys the carriers on stairs, on icy or snow-covered drivespecific equipment. Newer technologies, such as pow- ways or to help navigate other hazards when moving ered cots, assisted lift devices and locking systems, can the patient, ensure those conditions are addressed require a greater comfort level to operate than tradi- before or during the move to minimize risks. Move all obstacles ahead of time if they can be moved and may tional equipment.Maintain your equipment. Follow the manu- impede your path of movement. In this regard, a little facturers suggested policies regarding periodic inspec- preplanning goes a long way. Though some of this advice tion, maintenance and replacement Pro Bono is written by may seem elementary, focusof equipment and devices used to attorneys Doug Wolfberg ing on improving patient handling lift or move patients, such as stretchand Steve Wirth of Page, practices can help prevent injuries ers, stair chairs and backboards. This WolfbergWirth LLC, a to crew and patients, and it can stuff doesnt last forever, so dont try national EMS-industry law reduce the chances of legal liabilto squeeze more life out of a piece of firm. Visit the firms website at www.pwwemslaw.com for ity arising from these preventable equipment that has reached the end more EMS law information. types of human errors. of its life span just to save a few bucks.Conduct a keyword search for drug shortage at JEMS.com for more information.24JEMSJULY 2012 23. Choose 22 at www.jems.com/rs 24. LEADERSHIPSECTOR presented by the iafc ems section by gary ludwig, ms, emt-pDiscipline Picture this scenario: Two of your paramedics respond to a scene. Your patients wife called for you to treat her husband, whos threatening suicide. He has been drinking and admits he took some of his pain prescription drugs. Once the paramedics get to the scene, the husband is agitated and uncooperative. Hes adamant that he doesnt want to be transported to a hospital. The paramedics try to gain his cooperation and try to get some history and vital signs, but he tells them, You aint touching me and I aint going to no hospital. This is a difficult scenario for the paramedics because they have a patient who isnt cooperating. According to the medical directors protocols, however, anyone whos threatening suicide or cant pass a series of questions to verify theyre competent to deny treatment and transport must be transported to a hospital facility. Finding themselves in a quandary, the paramedics decide to call the police. Once the police arrive on the scene and find that the patient is refusing treatment and transport to a hospital, they tell the paramedics theres nothing they can do because the patient is refusing treatment and transport. The paramedics decide not to transport the patient to the hospital. The two paramedics on the scene are good employees. They always come to work, are never tardy and generally cause no problems. Several letters from citizens in their personnel file reflect excellent customer service skills over the years. The employees files lack disciplinary action. For the most part, these paramedics are excellent employees. On this particular day, they made a bad decision. The EMS providers decided not to transport the patient who was denying any treatment and transport, and the police officers said they werent going to intervene. The providers had the patient sign their standard refusal of care form, and they exited the scene with the patients wife protesting.26JEMSjuly 2012After the Call Several hours later, the 9-1-1 center receives another call from the patients wife. This time her husband is unconscious with labored breathing. When another ambulance arrives, they have to intubate the patient and transport him to the hospital. EMS management later discovers what happened, conducts an investigation and suspends each paramedic on the original call for 10 days. Is it the right decision to suspend both employees? Some would argue that the paramedics in this case should be suspended, and others would argue that they should receive further education to understand the protocols and refine their decision-making skills. Many would argue that discipline isnt about punishment for doing something wrong; instead, its to change the behavior of the employees who made the wrong decision. Others would argue that the paramedics in this situation shouldnt be suspended because theyre good employees who werent unwilling to do the job, rather they werent fully aware of all the options available to them in the decision-making process. They possibly could have called their supervisor and asked what they should do. Or they could have asked the police officers to call one of their supervisors and have them respond to the scene to assist with options to manage the patient who should go to the hospital but was refusing to go. Some would argue that when you suspend two employees who made a wrong decision, you will take two good paramedics who are generally excellent employees and destroy their motivation for the job. Some would argue that the suspensions would dampen the employees enthusiasm to come to work, never be tardy, and treat patients and family members with excellent customer service skills because the employee didnt act intentionally or believe they were making a poor decision.The final step should be to administer the discipline. This final step should come only after the EMS providers have been taught, coached and counseled and the desired results arent achieved. Remember, the purpose of discipline is to change behavior, not to punish the employee. The disciplinary phase should also include an assessment of the desired behavior youre trying to achieve. The severity of the disciplin- Punishing your ary action should employees be based on the unnecessarily may potential conse- lead them to quit. quences the behavior could cause to the department. During my years, Ive seen managers in fire and EMS organizations hand out discipline like they were handing out candy. I even worked for one manager who finished every department-wide memorandum with the statement, Failure to follow this memorandum will result in discipline. Of course, those memos went over like a lead balloon, and he couldnt figure out why there was such dissension in the organization or why he couldnt hold a job anywhere. Bottom line: Discipline isnt always the answer. JEMS Gary Ludwig, MS, EMT-P, is a deputy fire chief with the Memphis (Tenn.) Fire Department. He has 34 years of fire and rescue experience. Hes chair of the EMS Section for the International Association of Fire Chiefs and can be reached at www.garyludwig.com.Photo istockphoto.com.The difference between disciplinepunishment 25. Choose 23 at www.jems.com/rs 26. TRICKSour patientsourselves OF THE TRADE caring for by Thom Dick, EMT-POld Friends Harnessing peoples wheelchairsYPhotos Thom Dickhundred pounds. But fortuou ever think about nately, people who depend wheelchairs, Lifeon those devices also tend to Saver? We see them have one or more standard so often I reckon most of us wheelchairs, and they can get rarely give em much thought, by with them for a short time. but so many of the people My first EMS employer you meet every day are totally was affiliated with a medidependent on them. cal equipment supplier, and Some chairs are pretty I learned my lessons early sophisticated and weigh more about wheelchairs from than you can lift. And some them. You can expect a basic of their owners have had folding wheelchair to have names as big as Itzhak Perla mass of 20 kg. Its weight man, Christopher Reeve, and increases depending on its Stephen Hawking. Franklin D. optional attachments and the Roosevelt was often popularsize of the patient its designed ized with a wheelchair during to accommodate. WWII, and actor Raymond Types of attachments Burrs award-winning Ironmight include adjustable side character never appeared footrests, removable handwithout one. rails, reclining backrests, But famous or not, the head supports and oxygen U.S. Fire Administration has racks; and each of those estimated as recently as 1999 adds weight. Many attachthat 1.8 million Americans ments can be removed prior depend on wheelchairs.1 The to loading a wheelchair, and World Health Organization they should be. You can stow currently estimates that 1% them under the bench seat. of the worlds population Of course, if youre in a Type some 65 millionare in need I or Type III ambulance, the of wheelchairs.2 And to many outboard compartments of the people we transport in might be better. ambulances, their wheelchairs Before you handle any are absolutely essential. wheelchair, consider that So how do you load a wheelchairs can be dirty. wheelchair? Where do you Theyre subject to spills and stow one safely in an ambubathroom accidents, and lance, and what do you do if many of them arent cleaned you simply cant take one with often. I think its a you? You dont exactly know good idea to glove those things when you start Knowing how to handle a wheelchair is an important up before you handle out as a new EMT, do you? aspect of patient care. one, and clean your To be sure, you simply cant transport some kinds of chairs in an ambu- hands afterward. Also, make it a habit lance. A powered wheelchair or scooter is to lock the brakes every chance you non-collapsible, and its motor, batteries and get. Thats a must before you help heavy wheels can raise its weight to several someone into a wheelchair or out of one. Its28JEMSJULY 2012also necessary to lock the brakes before you lift a wheelchair because youll need to grip one of its main wheels to do so. Collapsing and expanding a wheelchair is easy if you know what youre doing, but you can look pretty silly otherwise. To collapse one, grip the front and rear edges of its seat and lift abruptly (thus the gloves). To expand it, push downward with both hands simultaneously on the rigid supports attached to the right and left edges of the seat. Any time you stow a chair, make sure its folded and firmly secured with a buckle strap (such as the safety harness on your captains chair, for instance). Even a lightweight wheelchair can turn deadly and bounce around the inside of your compartment. Finally, if youre transporting a chair from a patients home, theres a good chance its not clearly identified as their property. Do them a huge favor. Attach a piece of two-inch cloth tape to the rear-facing surface of the seat back, and print their name on it with a felt marker. Apply the tape at an oblique angle, so you attract more attention. Even manual wheelchairs are expensive (up to $500 a pop), and they can get lost in hospitals. You wouldnt want that to happen on your shift if you could so easily prevent it, would you? JEMSReferences 1. USFA. Oct. 1999. Fire Risks for the Mobility Impaired. In Ogilvy Public Relations Worldwide. Retrieved April 29, 2012, from www.usfa.fema.gov/downloads/pdf/ publications/fa-204-508.pdf. 2. Disabilities and Rehabilitation: Guidelines on the provision of wheelchairs in less-resourced settings. In World Health Organization. Retrieved April 29, 2012, from www.who.int/disabilities/publications/technology/wheelchairguidelines/en/. Thom Dick has been involved in EMS for 42 years, 23 of them as a full-time EMT and paramedic in San Diego County. Hes currently the quality care coordinator for Platte Valley Ambulance, a hospital-based 9-1-1 system in Brighton, Colo. Contact him at boxcar_414@yahoo.com. 27. Choose 24 at www.jems.com/rs 28. CASEOFTHEMONTH DILEMMAS IN DAY-TO-DAY CARE BY Fred W. Wurster, III, AAS, NREMT-PMore than a Headache Patients symptoms found to be much more seriousPatient Assessment The patient responds by whispering his name and saying he has a headache and that it hurts to open his eyes. You question the patient about his reasons for being treated at the facility, and he reports hes an alcoholic who drinks approximately one gallon of vodka a day and has since he was 14. He has been clean for six days. The patient denies any other medical conditions, reporting that he doesnt take any prescribed medications and has an allergy to Penicillin. According to the patients chart, hes taken several medications to aid in his detoxification process. You and your partner look at each and try not to pass judgment because youve encountered many patients here in the past who havent been truthful with their complaints. While you continue to question the patient, he suddenly grabs the back of his head and states, This is the worst headache Ive ever had; it feels like someone is cutting into my brain. You obtain a baseline set of vital signs that reveal the following: BP=168/118; HR=92 and regular; RR=18 and non-labored.Transport The patient begins to writhe in pain, complains about increasing pain in his head and vomits twice profusely. You secure the patient and stretcher and prepare for transport. You30JEMSJULY 2012hospital. The patient remains apply the ECG monitor and unresponsive with unchanged administer 4 LPM of oxygen. vitals. The emergency departYou establish an IV and adminment (ED) staff takes him to ister 4 mg of Zofran for nausea. radiology for a computed As you begin transport, you tomography scan. ask the patient how hes feeling, A few moments later, the but he doesnt answer. You ask ED physician informs you that again and note that he now has the patient is in extremely critisonorous respirations. cal condition. He tells you the Current vital signs are now: Be wary when responding BP=198/168; HR=110; RR=8 to a call at a familiar facility patient has a substantial suband are shallow and abnormal because the patient could arachnoid hemorrhage and has in pattern. You begin to assist have an unknown underly- just gone into cardiac arrest. Resuscitation attempts are the patient with ventilations ing condition. with a bag-valve mask and your partner noti- unsuccessful, and the patient is pronounced fies the hospital of the sudden change to the dead about 30 minutes later. patients condition. While you ventilate the patient, he Subarachnoid Hemorrhage becomes extremely agitated and begins to A subarachnoid hemorrhage occurs when thrash around. Although hes not seizing, blood enters the subarachnoid space because he becomes difficult to control. This contin- of a variety of reasons. It usually occurs ues for a few minutes, and then he suddenly from a ruptured cerebral aneurysm or as a becomes somewhat alert and says, some- result of a traumatic head injury. The classic thing is really wrong. or textbook symptoms of one are a rapid A repeat set of vital signs still shows a dra- onset of a thunder-clap headache, which matically elevated blood pressure at 218/176, is often reported to be the worst headache with a HR=118, and now the patients respira- someone has ever experienced. Other associtions seem more normal at 14 per minute. ated symptoms include vomiting, confusion, You conduct a blood glucose test, and its 86 decreased levels of consciousness and somemg/dL. The patients skin doesnt feel hot, and time seizure activity. all the other physical exam findings are within Subarachnoid hemorrhage has a 50% mornormal limits. tality rate, and of that 50%, about half the About five blocks away from the hospital, patients expire before reaching a hospital. the patient lets out a scream that startles you Patients who survive usually have some form and your partner. He clutches his head, and of lasting effects, and early recognition and then becomes unresponsive. You immedi- rapid transporting to an appropriate facility is ately start ventilating again, because his res- paramount to their survival. pirations are extremely shallow and irregular. Prehospital treatment should be supportive You notice he has extremely unequal pupils of symptoms (if allowable by your protocol) and that his pressure has increased substan- and should be initiated as soon as possible to tially to 276/224 with a HR of 126 and RR of 6. optimize the outcome for your patient. JEMS You continue to assist the patients ventilations and prepare for intubation. The patient Fred W. Wurster III, AAS, NREMT-P, is the director is successfully intubated with ease, as he has of training for the Good Fellowship Training Institute no gag reflex. Hes sedated with 5 mg of in West Chester, Pa. and a flight paramedic with Versed as part of your post-intubation seda- PennSTAR in Philadelphia, Pa. Hes also a JEMS techtion protocol, and then you arrive at the nical editor. Contact him at fred.wurster3@verizon.net. Photo Yuri Arcurs/Dreamstime.comIts a Thursday afternoon, and youre dispatched to a local substance abuse rehabilitation facility for a person complaining of a headache. While en route, you and your partner discuss how many times youve responded to this facility for calls that dont seem legitimate. Additional information is obtained from the 9-1-1 center that reveals youre responding to a 48-year-old male complaining of a headache and dizziness. You arrive and are escorted to the patient, whos located at the nursing station. The patient is seated and holding his head with his hands. You introduce yourself and ask whats wrong. 29. Choose 29 at www.jems.com/rs 30. istockphoto.comEMS industry may shift deployment methods By Johnathan D. Washko, BS-EMSA, NREMT-P, AEMDFor many outsiders, running an ambulance service can often appear to be an easy thing. Although EMS appears to be simple, it isnt. EMS first 30 years or so have been solely focused on proving to the medical community that it could perform tasks that, traditionally, only doctors could do. So few have stopped to ask the questions associated with how we should perform these tasks.How EMS Provides Care This is the same problem found in most of the healthcare industry today. The focus on providing the best medicine money can offer has generated exceptional clinical results for patients, but those results have tremendous costs with one of the most uncoordinated, stove-piped, expensive and32JEMSJULY 2012inefficient healthcare delivery systems on the planet. The same often holds true for much of EMS. The medicine we in EMS provide on a daily basis is the foundation of our existence (and the clinical outcomes from these efforts are widely unknown and/or debated), but the methodologies we employ to deliver this medicine to our patients drives 7080% of our costs, based on the delivery model used. Were talking about the procedures, practices, schedules and deployment methodologies that are used by your EMS system to get your clinicians, medicine and equipment to the patient within some sort of acceptable time frame (i.e., response time). The debate to define acceptable response times is finally coming to a head, with evidence-based research and customersatisfaction and expectations driving this definition; however, many EMS leaders are also pushing EMS delivery methods to the forefront because of the economic downturn and healthcare reform. Prehospital medicine across the U.S. is, for the most part, standardized, but the system designs used to deliver these services are as diverse and variable as the species on our planet. System designs range from inefficient and ineffective, to highly efficient and effective with many variables, including wages and benefit costs, accountability, response-time reliability and measured clinical outcomes from these efforts, separating the men from the boys. Some of the most efficient and effective EMS delivery systems today often provide better clinical outcomes and service reliabilities as their most expensive counterparts, proving that throwing money at a problem isnt always the answer. Anecdotally, when you look at cardiac arrest return of spontaneous circulation (ROSC) rates across the country and then look at the system delivery models used to achieve these results, you either see static deployment models (station-based systems) or dynamic deployment models (i.e., highperformance EMS) as the common delivery mechanisms. (Hybrids containing methodologies from both genres also exist.) Both these service-delivery models can produce excellent cardiac arrest survival outcomes, but at what cost? Some have attempted to correlate survival rates with the number of active paramedics used in the system, but I find this absurd. (I know the e-mail inbox will be filled after this one with those who disagree with this statement.)Response Times Whether dispatch life support through prearrival instructions, first responder, BLS or ALS, the bottom line is the response times count ... period. Response times ensure high-quality CPR is initiated. These factors are what the clinical research indicates we need to do to improve neurologically unimpaired walk-out-of-hospital survival rates. The importance of ALS is definitely heading toward the stabilization side of the equation, post ROSC, and not where we thought it made a difference, in the initial conversion into ROSC. Many would debate whether ROSC is the 31. Choose 26 at www.jems.com/rs 32. Delivery Models continued from page 32best way to measure an EMS systems clinical effectiveness. I would strongly agree it needs to be greatly diversified; however, ROSC is all we currently have to examine for comparative purposes.Cost of Success Now lets look at the costs to achieve these results. Statically deployed EMS systems are, by design, an expensive way to provide services, especially for urban and suburban population centers. Rural EMS systems are a different animal and arent included in this group. As EMS providers, we see these system designs as the means to earn money sleeping, but these designs are often ineffective clinical delivery models because of poor response-time reliability. However, one thing is reasonably certain. Static deployment systems are the most inefficient and costly way for us to deliver EMS service. Clinically effective static deployment models exist, but theyre even more expensive to operate than their ineffective counterparts because these systems throw away tons of money or manpower to solve response-time problems. Dynamic deployment systems on the other hand (those that match supply with demandboth temporally and geospatially), are frequently effective clinical delivery models because of superior response-time reliability, and they are the most cost-efficient means to achieve services, because they use the appropriate amount of resources to meet patient-care needs. These models are the most unpopular with EMS providers because productivity and efficiency are balanced with good clinical care, sacrificing down time. Sitting in the front of an ambulance and being placed on a street corner is not as comfortable as responding from a warm bed in a stations bunk room, but it gets the medicine into a critically ill patients veins a lot quicker. So the proverbial EMS dichotomyto station or not to station, is the question. The answer depends on the size of your regions wallet, tolerance for change, politics and willingness to provide tax subsidies. Many urban and suburban dynamic deployment systems, with excellent clinical outcomes, have operated with little to no tax subsidies for decades. Few (if any) static deployment models exist in urban or suburban regions with excellent clinical outcomes that, accounting for all costs, operate without some sort of subsidy (and usually a big one). This can be an eye-opening observation for elected officials and the public alike.Resistance to Change So because we know how to do it better, faster and cheaper, why doesnt everyone pursue this? The answers lie in human nature, political pandering, an unwillingness to abandon tradition and the economy. Where do we go from here? Although our industry will continue the eternal debate on EMS system design issues, a storm of unparalleled magnitude is brewing. This storm, also known as healthcare reform, will change our lives in EMS as we know it. Having an efficient and effective service delivery model is the foundation by which innovation, evidence-based clinical practice and the shift from treating a majority of our patients in the hospital to treating the majority of our patients in the prehospital realm will evolve. This change should be a metamorphosis by which EMS Choose 27 at www.jems.com/rs www.jems.comJULY 2012JEMS35 33. Delivery Modelscontinued from page 35How is Your Oxygen Supply?will springboard itself from being a rounding error in the federal CMS budget to becoming a significant contributor and provider to the U.S. healthcare system.How to ChangeMOGS-100Benefits of an Oxygen System: Become Completely Self-Sufficient Fill High Pressure Oxygen Cylinders Transportable to Disaster Site Transfill Directly to a VehicleGenerate OXYGEN On -site 24/7.CFP-15MMOBILE OXYGEN TRAILEROxygen Generating Systems Intl. www.ogsi.com | Email: jems@ogsi.com Tel: (716) 564-5165 or (800) 414-6474 | Fax: (716) 564-5173 Choose 25 at www.jems.com/rs36JEMSJULY 2012How and why will this happen? It comes down to pure economics. Once reimbursements shift from a fee-for-service model into bundled and/or capitated payment models (whether it be from an accountable care organization or other capitated reimbursement methodology) that reward continuum of care coordination and service integration vs. the current model, which financially rewards uncoordinated and inefficient care based on the volume of patients we see, well see a shift emerge in how medicine is produced. More importantly, the service delivery models used by this medicine, will change for the better. EMS can play a significant role. My interpretation of this is that EMS will be at the forefront of this change because the prehospital realm is our oyster, and we know it well. When you break an EMS system into its component parts, you find four primary activities: public safety, public health, disaster preparedness, response and recovery, and healthcare. The proportions by which EMS performs these functions can be widely debated. The fact of the matter remains that for most EMS systems, reimbursement from healthcare-based insurance is the primary mechanism for funding and typically pays indirectly for non-healthcare related functions, such as public safety, public health and the various stages of disaster management. I envision a day not too far from now when someone will call 9-1-1 and the dispatcher (a clinician) will work through a clinicaldecision algorithm and help the patient determine the appropriate locus of care, which will become alternative methods of healthcare service delivery, including community based/expanded scope paramedics and self care, and not elicit the typical U.S. EMS response. In several innovative EMS systems, paramedics are already visiting patients in their homes (in some cases, in tandem with a nurse, nurse practitioner or physicians assistant) to perform diagnostic testing on site and come up with alternative treatment regimens that would include on-site treatment options, transportation to alternative (less expensive) modes of care (e.g., urgent care) or treatment and transportation to the emergency department for those patients who truly require it clinically. Cutting edge, high-performance EMS systems are already blazing a path. EMS system design innovators are at the forefront of the revolution and evolution of our industry. Theyre some of the ones taking the risks, creating something from nothingmany without additional reimbursementto help carve the path most of us will eventually follow once the storm has passed if we survive it. Those systems with the ability to embrace change will survive in the new normal. For the ones that dont, I suggest you build a storm shelter and stock it well. JEMS Jonathan D. Washko, BS-EMSA, NREMT-P, AEMD, is assistant vice president of operations for North ShoreLIJ Center for EMS located in NYC and Long Island, N.Y., and is president of WashkoAssociates, LLC, a leading EMS consultancy group dedicated to improving EMS agency performance around the globe. Hes also a member of the JEMS Editorial Board. He may be contacted at jwashko@nshs.edu or jwashko@washkoassoc.com. 34. Choose 34 at www.jems.com/rs 35. Lessons learned from Navy jet crash responseBy Bruce Nedelka, NREMT-PA.J. Heightman, MPA, EMT-PVirginia Beach, Va., is the largest city in the Commonwealth of Virginia and ranked No. 41 in the 2011 JEMS survey of the top 200 cities in the U.S. Its 310 square miles and 38 miles of shoreline is home to approximately 450,000 residents and more than a million daily guests during the summer resort season. The city is also home to several large corporations, including STIHL Inc. and LifeNET Health, and its the heart of a large military population in America, with Little Creek, Fort Story, Dam Neck, Naval Station Norfolk and Oceana bases. 38jemsJULY 2012 36. Antonio P. Turretto Ramos/APAn aerial view shows the damage caused when a military jet crashed into the Mayfair Mews retirement community apartments in Virginia Beach, Va.Lessons Learned 1. Scene tape should be deployed, and policed, asearly as possible into a major incident. This will establish and maintain a large, controlled scene perimeter and ensure security for personnel, patients and their assets.2. The onslaught of media attention is often too much for the one agencys public information officer (PIO) to handle, so a coordinated approach should be established early into an incident by all of the public safety PIOs and the city media communications manager (MCG).3. Use of established social media communicationsis often effective and should be explored.4. Multiple news releases; frequent, scheduled andCopyright (c) 2012, The Virginian-Pilot. Reprinted with permissionannounced media updates; and traffic message signs on the interstate roads should be used.www.jems.comJULY 2012JEMS39 37. Engulfed in an Instantcontinued from page 39 About VBEMS Virginia Beach Department of Emergency Medical Services (VBEMS) is a third-service volunteer-based department with more than 1,100 volunteer members staffing the citys 10 volunteer rescue squads, plus 28 full-time paramedics and four full-time brigade chief field supervisors to augment the volunteers. The department responded to approximately 39,000 calls for service in 2011. In addition to emergency care and ambulance transportation, VBEMS also operates an allvolunteer Marine rescue team, heavy rescue service, two mass casualty incident (MCI) vehicles, an all-volunteer search and rescue unit, and bike teams. VBEMS also supplies the paramedics for the Virginia Beach special weapons and tactics team and air medical unit; manages post-disaster, medically friendly shelters; and provides lifeguard service for the citys Sandbridge and Little Island Park beaches. The city doesnt own any ambulances; all 35 of the VBEMS ambulances and support vehicles are purchased and operatedby the 10 volunteer rescue squads. The rescue station buildings are in some cases solely owned by a volunteer rescue squad. In most cases, theyre a city-owned facility housing fire department and EMS resources together. The calm afternoon and the lives of those living in the retirement community of Mayfair Mews in Virginia Beach were forever changed just after noon on April 6. It was at that moment when a U.S. Navy F/A-18 jet with a student pilot and trainer on board experienced serious engine failure from nearby Naval Air Station (NAS) Oceana and plunged to the ground, crashlanding into the buildings and courtyard of an apartment complex. Instantly, several buildings were engulfed in flames fed by jet fuel. The dark black plumes of thick smoke could be seen miles away. The pager tones that sounded for the incident were just like the ones that had dispatched thousands of calls before. However, this alert announced a call that would test the Virginia Beach EMS, fire and police departments, dispatch center and the citysChoose 30 at www.jems.com/rs40JEMSJULY 2012entire Emergency Response System like theyd never been tested before. The Emergency Communications and Citizens Services Department 9-1-1 Center initially received a frantic cell phone call telling them about the crash and the fire. Almost instantly, the inbound queue was flooded with 80 calls.Scan here to listen to actual 9-1-1 radio transmissions from the incident. This number quickly escalated to 200. At the time of the initial call, 13 staffed ambulances, five staffed paramedic rapid response zone cars, one EMS duty supervisor (EMS-5) and two assistants (EMS-6 and 7) were on duty. However, within an hour, more than 170 volunteers were involved and 30 ambulances were staffed. During the first 90 minutes of the crash, more than 20 other 9-1-1 calls for ambu- 38. Choose 31 at www.jems.com/rsFleet Video Recorder Selected By One of the Largest Ambulance Service Providers Digital Allys eet video systems are used by thousands of companies and governmental entities in all 50 states and around the world, including one of the largest ambulance service providers in the United States. Digital Allys Video Event Data Recorders (VEDRs) provide liability protection and savings through proof in vehicular accidents and against fraudulent claims; inspiring safe and professional behavior; incident review for training purposes; monitoring blind spots or separate vehicle compartments; etc. They do not require an ongoing contract or additional equipment and come with software at no cost.Digital Allys VEDRs are integrated into a rear-view mirror so that they do not interfere with the drivers line of site or take up valuable space. Their design allows for easy installation into any type of vehicle, including those that did not previously include a rear-view mirror. Specialized one-way mirror glass allows an optional monitor to remain invisible while not in use.The systems record video, optional audio and detailed information. Recordings may be started manually or set to automatically start by reaching specic speeds or areas and numerous other customizable options, including violent maneuvers, shifting the vehicle into reverse, emergency lights, door sensors, etc. A predetermined amount of time prior to the moment a recording is triggered is also captured, which is referred to as pre-event recording.For more information, contact Digital Ally at 800-440-4947, sales@digitalallyinc.com or visit www.digitalallyinc.comChoose 32 at www.jems.com/rs 39. Engulfed in an Instantcontinued from page 40lances were dispatched. These included a motor vehicle crash with entrapment, and several serious medical cases. Although the turnout of EMS volunteers was so great that none of the cases for ambulances in Virginia Beach required mutual aid, surrounding cities sent fire apparatus to backfill fire stations. Because of the heavy volume of calls received by 9-1-1, EMS Chief Bruce Edwards assigned an EMS division chief to the 9-1-1 center to assist in triaging calls and refining automatic response matrices and managing the EMS field resources. This was a helpful function because of the increased 9-1-1 call volume and communications. Some callers gave conflicting information regarding the location and what was unfolding. Some were more precise. All, however, were desperate for help. Cathy Fowler, a 24-year veteran Virginia Beach dispatcher, was on the EMS console that day. When it became clear that we had a major incident, we all got so focused on our jobs that the 9-1-1 center had an amaz-ing calmness. There was no idle talk; we all did what we have been trained to do, Fowler says. The first inbound call entered the system at 12:06:07 p.m. The initial simulcast dispatch was announced to EMS and fire units at 12:07:28 p.m. Although the dispatchers voice was calm, the message was clear: There was a confirmed plane crash. The initial assignment included the duty district chief, Battalion 1; Engines 11, 8 and 3; Navy engine 31; Ladder 11; Ladder 8; Safety 1; and Fire Squad 3. The EMS units dispatched were EMS-5 (duty field chief); EMS-3 (duty division chief); ambulances 1420, 1425 and 827; MCI-2; and rapid response medic zones 14 and 08. Virginia Beach public safety radio communications is all digital with multiple frequencies and banks. EMS and fire are separate departments, and each has its own primary dispatch channel and dispatchers. Calls are often simulcasted over both EMS and fire channels, by either dispatcher, to announce co-response calls. Doing soChoose 33 at www.jems.com/rs42JEMSJULY 2012serves several purposes, such as giving the same dispatch information about the location and the same incident nature to all units. Units then acknowledge the dispatcher via radio or on mobile data terminal (MDT) and respond to the call. Radio traffic and communications on the primary and tactical channels in the early minutes could have become uncontrollably chaotic with such a large response. However, primary channel radio traffic was controlled. This can be attributed to several key factors: First, the dispatchers voice was not frenzied. Had he sounded excited, field providers could have picked up on that emotion, and each individuals adrenaline rush could have escalated; Second, fire department and EMS personnel had been involved in numerous training exercises and drills to prepare them to handle this type of situation. During the years, more cooperative, multijurisdictional drills between VBEMS, Virginia Beach Fire Department (VBFD), 40. Choose 45 at www.jems.com/rs 41. Engulfed in an Instantcontinued from page 42military fire and EMS, Norfolk International Airport, and local hospitals, plus many large outdoor events in the citys resort areas, proved to be invaluable rehearsals for this incident. It made the development of on-scene unified incident command much smoother and familiar. Although the first 9-1-1 call was still being received, Virginia Beach police officers near the crash site advised dispatcher Tonya King that they heard the thunderous crash and could see the smoke. King says, My first thought was that what I was being told on the radio couldnt be real. But when I looked at my computer screen and saw 9-1-1 calls flooding in, I knew this was truly the real thing.Response Activates Within the first hour, the staff of 13 dispatchers increased to 34 as their preplanned emergency response team was activated, calling in off-duty dispatchers and supervisors. The additional personnel enabled multiple command and tacticalchannels to be staffed and allowed several personnel to make the required return calls to hundreds of 9-1-1 hang-ups. Close behind that officer were two other EMS members, one of which was an off-duty EMS volunteer Special Weapons and Tactics (SWAT) medic and the other was Jay Leach, an EMS Volunteer Brigade Chief who was an on-duty paramedic (Zone-14) at the time and was part of the initial dispatch assignment. Both were near Laskin Road and Birdneck Road when the crash occurred. Citizens joined forces with emergency responders to work feverishly to get residents out of the buildings, remove the injured and find the pilots. Initial reports indicated that only one pilot and parachute were seen. However, dozens of additional calls came in with unconfirmed and conflicting reports of a second pilot being involved. This led to several minutes of intense searching and confusion: Was there one pilot or were there two? Police officers and citizens quickly located one pilot and called for an EMSChoose 35 at www.jems.com/rs44JEMSJULY 2012team to treat his injuries. Although a few units and personnel were already staging near 24th Street and Birdneck, access to the pilot was south of Fleming Drive. An incoming ambulance was flagged down by police as they were driving north on Birdneck from the area of Interstate. That ambulance loaded the pilot, advised EMS-5 and continued on to the hospital. Confirmation was then received from citizens and Oceana Air Traffic Control that a second pilot had been on board. A radio message from Brigade Chief John Fusco, the Duty Shift Commander, advised inbound units to be vigilant in their search for signs of a parachute or pilot as they approached the scene. Crews knew the pilots had been ejected and thought they had a good chance of finding the missing pilot if they located a parachute.An Unexpected Find Pat Kavanaugh, a resident of Mayfair Mews and a retired Virginia Beach Volunteer Rescue Squad member, opened his sliding 42. photo courtesy jon kightphoto courtesy Bobby Hill/VBEMS FoundationCrews transport the second pilot after he landed in the front porch of a mans home. door after the crash to investigate. To his shock and amazement, he found the missing F/A-18 pilot lying on the patio with a parachute hanging on the side of the building. After Kavanaugh reached the pilots side, he heard the pilot utter, Im sorry I destroyed your home. Kavanaughs EMS training and experi-ence instinctively kicked in. He conducted a quick patient survey and found no lifethreatening injuries. He then elicited the help of several neighbors and police officers to drag the pilot away from the burning building. An EMS crew was then directed to the location, and the pilot was moved quickly to an awaiting ambulance to beChoose 36 at www.jems.com/rstransported to Sentara Virginia Beach General Hospital. As can be expected with so many calls flooding the 9-1-1 center and nearly 100 citizens and first responders on the scene, some erroneous information came in during the first hour or more. One of the more tense time periods for incident commanders and responding crews came when reports continued that the second pilot was missing.The Search It was then known that the two pilots had been ejected as the plane fell to the ground. The fighter jets canopy was found behind an undamaged building near the entranceway into the complex. EMS-5 radioed again to incoming units that the second pilot was still missing and that they should include trees, ditches and rooftops in their search. Bystander reports 43. Engulfed in an Instantcontinued from page 45of a pilot being in the burning rubble were proven wrong when the radio cracked that the second pilot was found conscious and alert. The fire units took up positions according to a fire pre-plan and recommended an immediate second alarm. That was closely followed by a third and then a fourth alarm. Available fire resources were quickly depleted citywide, so mutual aid from three neighboring cities were requested. Special-ized crash rescue units from NAS Oceana were dispatched along with one of their engines and ambulances.Location Details The Mayfair Mews apartments are located just north of Interstate I-264 at Birdneck Road and Fleming Drive. Northbound traffic on Birdneck Road quickly became jammed. As northbound traffic congestion grew increasingly worse, access by respond-ing emergency vehicles was also slowed. So when EMS-5 arrived, Fusco made a series of quick decisions, including a request for the dispatcher to assign a medical tactical channel and announce that any incoming units must approach from the northLaskin Roadnot from I-264 or south Birdneck Road (see map, p. 39). Laskin Road quickly became a controlled intersection by police and a good access point for emergency vehicles and first responders in private vehicles.Priority Cell PhoneVoIP Access Verizon Wireless is the wireless provider for the city of Virginia Beach. Its also a major Virginia wireless provider. With the crush of citizen cell phone use (for voice and data), the wireless towers quickly became overloaded, and many calls were not able to go through. This hindered operations for police, fire, EMS and other agencies at the scene and created a level of frustration among providers that needs to be addressed for future incidents. At a post-incident discussion with a representa-Choose 37 at www.jems.com/rs46JEMSJULY 2012tive of Verizon Wireless of Southeastern Virginia, VBEMS learned about Verizons emergency wireless public access (WPA) system, which allows authorized emergency responders to have priority access to cell phone sites. That priority service is part of post-9/11 legislation to improve first responder communications during emergencies. It relies on local jurisdictions to determine the users and policies. Although WPA may sound like a solution, it also has its limitations. Regardless of the carrier, only aspecific capacity can be used, and when that capacity reaches its maximum, no other access is possible. A better alternative is to use pushto-talk or other technologies, such as texting or tweeting on a pre-established emergency Twitter account. Each uses voice over Internet protocol (VoIP) and sends digital packets in a way that allows far more users to access it at once. It was also learned through a post-incident review that although the user of a cell phoneChoose 38 at www.jems.com/rs 44. photo courtesy Bobby Hill/VBEMS FoundationTen ambulances were staged on Birdneck Road facing north for clear egress if transportation to a hospital was needed.may feel as though their call didnt go through, its possible that the individuals call was in a queue and would have eventually connected when a wireless cell became available. Despite this knowledge, first responders will not hold on indefinitely without any indication as to when the call will ultimately connect. The lesson learned from this is that VoIP alternatives need to be established and practiced before a major incident occurs.With that problem resolved, emergency units could then travel northbound in the southbound lanes from I-264 to access the scene.Use of Tactical Channels The Virginia Beach EMS and fire computeraided dispatch (CAD) system has eight shared tactical channels. The initial tactical channel assigned to EMS operations was changed twice as the fire department expanded itsChoose 39 at www.jems.com/rsoperations. That led to some radio communications confusion in the first hour or so of the incident. In the after-action meeting, senior EMS command staff decided to consider altering the EMS medical command tactical channel allocation on any future incidents of this magnitude and consider assigning the lesser used, but universally accessible, EMSadmin channel as its initial working tactical channel. This pre-planned EMS tactical channel would provide a clear channel forwww.jems.comJULY 2012JEMS47 45. Engulfed in an Instantphotos courtesy Bobby Hill/VBEMS Foundation continued from page 47EMS crews readied their equipment for triage at a staging area, and a special MCI unit (far right) was waiting in preparation for news of any wounded patients. EMS operations and is highly unlikely to be overtaken by expanding fire operations. EMS day-shift captain Earnie Delp (radio designation EMS-6) arrived on scene and became the incidents medical branch director. He established a staging area for arriving ambulances, personnel, EMS crash trucks and the EMS MCI unit early, a lesson learnedin training and from past incidents. Almost all units followed the directive to arrive at the scene by traveling south from Laskin Road. The few that did not, or could not, were delayed in traffic congestion. During the quickly unfolding incident, multiple proper vehicle staging and positioning was critical, and leaving adequate spaceChoose 40 at www.jems.com/rs48JEMSJULY 2012for ingress and egress of units was essential. Within a few minutes of arrival, Delp communicated by cell phone with the charge nurse at Sentara Virginia Beach General Hospital, the primary destination for the first patients. He provided a preliminary size up of the incident and a warning about potential mass casualties. This early alert provided ample opportunity for hospital administration to activate the hospitals external disaster plan, mobilize its personnel, call in off-duty staff and prepare for the worst. At this point, more units were beginning to arrive in rapid succession. When EMS Division Chief Ed Brazle (EMS-22) arrived, his collateral responsibility as the departments emergency management coordinator helped define the forward triage area. Brazle directed the on-scene crews to bring stretchers and other specified equipment to the corner of Fleming and Birdneck and be ready to receive patients. This was a good location for staging equipment and personnel because it allowed for rapid ingress and egress by crews in the event that a patient required a stretcher. In addition, there was a UPS store with a parking lot at that corner. The parking lot ultimately served as the location for command post tent for unified command. EMS officers participated in the unified command in key leadership positions, including area command, medical branch director and liaison officer. Triage, treatment and transportation sector officers were also appointed early, and EMS area command director EMS-5 was advised. The system was gearing up for what was logically expected to be 46. heavy casualties. Deputy EMS Chief William Kiley and Operations Medical Director Stewart Martin were now on scene. After completing an initial scene walkaround, Brigade Chief Joseph Corley established a rehab location at the southeast corner of Fleming and Birdneck. He assigned a rehab officer and assisted in deploying equipment and personnel. Within about 10 minutes of establishing that rehab location, the first wave of firefighters began to arrive after mounting the initial, aggressive fire attack and evacuations. The EMS team attended to them and documented each encounter as they awaited recall into the scene. This reinforces the need for rehab to be established and announced to all personnel as early as possible. The initial incident commander followed the fire departments pre-plan for the apartment complex and located the command post where the first-in district chief and battalion chiefs parked near the fire buildings with easy access through the parking lot from Birdneck Road. However, one of the initial 5 feeder hoses laid by the first-in apparatus, which caused problems for emergency vehicles and equipment by blocking access to several areas. After realizing this, fire crews enlisted the assistance of several citizens to help move the heavy hose and resolve the problem. Some 45 minutes into the call, it was believed that few, if any, civilian injuries would be coming to the waiting triage teams. Thoughts then began to shift to establishing a temporary morgue because of the multiple buildings heavily engulfed in flames.tion operations was selected on a side street in front of the initial on-site morgue location. The plan called for the deceased to be brought to the decontamination area to be thoroughly decontaminated. They were then to be placed into a body bag with a second body bag over the first one to ensure any contaminants from the first bag were encased in the second. It was initially believed that there would be a significant number of deceased as the building searches continued. Therefore, it was felt that the local medical examinersoffice wouldnt be suitable because of its limited capacity. During a subsequent discussion at the command post, the police commander decided that the anticipated volume of fatalities would be better staged at the Law Enforcement Training Academy (LETA) located less than a mile south on Birdneck Road. Commanders felt that facility would be more secure and private than the initial open location on the side street. LETA was readied as the collection point for any fatalities but wasnt actually used for itsExpecting the Worst The initial location selected for the morgue was on one of the side streets of the complex. This proved to be an inappropriate location because command wanted all bodies to be decontaminated before they were placed in body bags and delivered to the morgue. This is because of the significant presence of airborne carbon-fibers and fuel created by the burning plane and buildings. Therefore, fatalities couldnt simply be bagged and transported. Therefore, an alternative location that was more suitable for the decontaminaChoose 41 at www.jems.com/rs www.jems.comJULY 2012JEMS49 47. Engulfed in an Instantcontinued from page 49converted purpose because no fatalities were discovered.Personnel Accountability One issue that arose at the scene was the proper accountability of personnel. Many volunteers and other first responders selfdispatched to the scene. Some didnt have proper identification and some werent appropriately dressed. Identification became an issue because law enforcement officers who were under orders to allow only authorized personnel into the area began to refuse access for some. The decision was made to announce over radio systems and other communication means that enough personnel were available at the site and no additional personnel were needed. In addition, for the purpose of uniformity and security, law enforcement personnel were advised that any member claiming to be with EMS who failed to present proper identification was to be turned away. Although some were unhappy they werent allowed to become a part of the big one, restricting access to only those with proper identification was for the best. Personnel management issues stemmed from having so many members on scene and still arriving with no assignments, coupled with a lack of patients. To solve the personnel management issues, Virginia Beach Volunteer Rescue Squad Chief Roy White, Jr. was assigned to manage the EMS personnel. Within 15 minutes, White established a meeting place for all on-scene and arriving personnel, assigned an assistant and got EMS personnel accountability under control. Accountability and identification wasnt limited to first responders. Support personnel, such as utility workers and civilian contractors called in by the Navy, also didnt always have proper identification. This posed a challenge for the incident liaison officer, EMS Division Chief Tom Green, who was responsible for their accountability. At large-scale incidents such as this, personnel management and accountability needs to be established early in the incident to account for and manage responding on-duty and off-duty staff, as well as contracted or requested support personnel. Incoming first responders and activated support personnel need to be advised of the scenes restricted access and that proper identification will be Choose 42 at www.jems.com/rs50JEMSJULY 2012required. The maximum number of EMS personnel needed at the scene must be determined early in the incidentwith overflow personnel advised to report to a rescue station. This will better control on scene and back-up resources and ensure the availability of relief personnel should extended operations be needed.The Media Rush From the moment the incident was a confirmed plane crash and, more specifically, a Navy F/A-18 fighter jet crash, incident managers knew it was going to be a huge media event. Although its important to get the news out, its more important to get correct information out. Rumors and misinformation often run rampant during large incidents, and this case was no different. A media staging area was established early on in the parking lot at 24th Street and Birdneck Road. Initially, that designation actually meant little or nothin