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JOURNAL OF EMERGENCY MEDICAL SERVICES
TheConscience
of EMS
Contents
Premier media Partner of the iafC, the iafC emS SeCtion & fire-reSCue med www.jems.com oCtober 2012 JEMS 5
Departments & columns 7 i Load & go i now on JemS.com 12 i EMS in action i Scene of the month 14 i FroM thE Editor i Patches, Pride & Patients �by a.J. heightman, mPa, emt-P 16 i LEttErS i in Your Words 18 i Priority traFFic i news You Can use 24 i LEadErShiP SEctor i Closed door Policy �by Gary Ludwig, mS, emt-P 26 i trickS oF thE tradE i Warm enough for Ya? �by thom dick 28 i caSE oF thE Month i naked & unconscious �by Kimberly doran 74 i EMPLoyMEnt & cLaSSiFiEd adS 77 i ad indEx 78 i handS on i Product reviews from Street Crews 80 i LightEr SidE i Clenched teeth Verbiage �by Steve berry 82 i LaSt Word i the ups & downs of emS
About the CoverIn this year’s JEMS Salary Survey, we revisit Flowing Springs EMS from this past year’s survey in an effort to ana-lyze how the economy and the overall structure of U.S. healthcare is affecting typical EMS agencies across the country. And as the subtitle “The future is bright—but how bright?,” hints, we found the data to be (cau-tiously) optimistic. pp. 30–41. Photo Chris swabb
OCTOBER 2012 VOl. 37 NO. 10
i JEMS 2012 SaLary & WorkPLacE SurvEy i the future looks bright—but how bright? By�Michael�Greene,�MBA/MSHA
30
42 i hEaLthcarE rEForM i �Changes present an unparalleled opportunity for emS �By�Teresa�McCallion,�EMT-B
46 i MobiLE WarMing i �Lessons learned in hypothermia prevention under difficult
field conditions� � �By�2LT�Collin�Hu,�EMT-E,�&�James�Spotila,�PhD,�EMT-B
52 i a Study on SaFEty i �highlights from workshop on ambulance patient compartments� � �By�Jennifer�Marshall�&�Y.�Tina�Lee
60 i innovativE dESign i �Pumper/ambulance model takes service to a new level �By�Bob�Vaccaro
64 i vitaL PathWayS i �detect & treat symptoms related to hemorrhagic shock �By�Peter�Taillac,�MD,�FACEP,�&�Chad�Brocato,�DHSC,�CFO,�JD
i 46
i 60 i 64
®
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www.jems.com ocToBeR 2012 JEMS 7
Have you ever considered serving on the board of direc-tors for an EMS agency in your area? Before you consider it, you should be aware of what a director is—and isn’t. Unlike an operations position, which manages the day-to-day workings of an organization, the board of direc-tors is all about leadership and governance. In “View from the Top,” Allison J. Bloom, Esq., discusses what serving on a board of directors involves, including how to set the tone and direction for an organization by engaging in strategic thinking and planning, and providing oversight of corpo-ration management.
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everyday heroesThe Laerdal Everyday Heroes photo and video contest is your chance to nomi-nate an individual within your organization to be recognized for exemplary service toward helping save lives. Check out their ad on JEMS.com or visit their Everyday Heroes contest for submissions guidelines. All entries will receive an Everyday Heroes t-shirt and pin. s laerdal.com/EverdayHeroes
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Sponsored Product Focusems als appThe EMS Advanced Life Support (ALS) interactive application puts criti-cal information at your fingertips with rich content, detailed illus-trations, and pioneering features. It provides fast, easy access to vital assessment information, medications, and drug doses; quick interpretation of 12-lead ECGs; and the latest CPR and ACLS algo-rithms from the American Heart Association (AHA). This app is now available on the iPhone and Droid platforms. For more infor-mation call 888/624-8014 or visit informedguides.com.
s Check out their ad on JEMS.com!
s jems.com/article/view-from-the-top
View From the top
seeking ems innoVatorsWe’re looking for the EMS industry’s newest innovators, and we need your help identifying them. The 2012 EMS 10: Innovators in EMS award program, sponsored by JEMS and Physio-Control, Inc., seeks to recognize 10 people who have stepped outside the box, identi-fied a need and taken steps to advance the art and science of pre-hospital emergency care. If that sounds like someone you know, nominate them before the Dec. 14 deadline. s jems.com/ems10
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Editor-in-ChiEf I A.J. heightman, MPA, EMt-P I [email protected] Editor I Jennifer Berry I [email protected]
AssistAnt Editor I Allison Moen I [email protected] Editor I Kindra sclar I [email protected]
onlinE nEws/BloG MAnAGEr I Bill Carey I [email protected]
MEdiCAl Editor I Edward t. dickinson, Md, nrEMt-P, fACEP tEChniCAl Editors
travis Kusman, MPh, nrEMt-P; fred w. wurster iii, nrEMt-P, AAsContriButinG Editor I Bryan Bledsoe, do, fACEP, fAAEM
Art dirECtor I liliana Estep I [email protected] illustrAtors
steve Berry, nrEMt-P; Paul Combs, nrEMt-BContriButinG 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 [email protected] CoordinAtor I Matt leatherman I [email protected]
PUBLICATION OFFICE 800/266-5367 I fax 619/699-6396
ADVERTISING DEPARTMENT 800/266-5367 I fax 619/699-6722
AdVErtisinG dirECtor I Judi leidiger I 619/795-9040 I [email protected]
wEstErn ACCount rEPrEsEntAtiVE I Cindi richardson I 661-297-4027 I [email protected]
sEnior sAlEs CoordinAtor I Elizabeth Zook I [email protected], ePrints & liCEnsinG I wright’s Media I 877/652-5295 I [email protected]
eMEDIA STRATEGy I 410/872-9303 I MAnAGinG dirECtor I dave J. iannone I [email protected]
dirECtor of eMEdiA sAlEs I Paul Andrews I [email protected] dirECtor of eMEdiA ContEnt I Chris hebert I [email protected]
SUBSCRIPTION DEPARTMENT I 888/456-5367I dirECtor, AudiEnCE dEVEloPMEnt & sAlEs suPPort I Mike shear I [email protected]
AudiEnCE dEVEloPMEnt CoordinAtor I Marisa Collier I [email protected]
MArKEtinG dirECtor I debbie Murray I [email protected] & ConfErEnCE ProGrAM CoordinAtor I
Vanessa horne I [email protected]
ChAirMAn I frank t. lauingerPrEsidEnt & ChiEf ExECutiVE offiCEr I robert f. Biolchini
ChiEf finAnCiAl offiCEr I Mark C. wilmothsEnior ViCE PrEsidEnt & GrouP PuBlishEr I lyle hoyt I [email protected]
ViCE PrEsidEnt/PuBlishEr I Jeff Berend I [email protected]
foundinG Editor I Keith Griffiths
foundinG PuBlishErJames o. Page
(1936–2004)
Choose 16 at www.jems.com/rsChoose 15 at www.jems.com/rs
JOURNAL OF EMERGENCY MEDICAL SERVICES
The Conscience
of EMS
JOURNAL OF EMERGENCY MEDICAL SERVICES
TheConscience
of EMS
JOURNAL OF EMERGENCY MEDICAL SERVICES
The Conscience
of EMS ®
008_010_STAFFBOXES.indd 8 10/1/2012 2:17:57 PM
Choose 16 at www.jems.com/rs
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EDITORIAL bOARDWILLIAm K. ATKInsOn II, PHD, mPH, mPA, EmT-PPresident & Chief Executive Officer
WakeMed Health & Hospitals
JAmEs J. AugusTInE, mD, FACEPMedical Director, Washington Township (Ohio) Fire Department Associate Medical Director, North Naples (Fla.) Fire DepartmentDirector of Clinical Operations, EMP ManagementClinical Associate Professor, Department of
Emergency Medicine, Wright State University
sTEvE bERRy, nREmT-PParamedic & EMS Cartoonist, Woodland Park, Colo.
bRyAn E. bLEDsOE, DO, FACEP, FAAEmProfessor of Emergency Medicine, Director, EMS Fellowship
University of Nevada School of MedicineMedical Director, MedicWest Ambulance
CRIss bRAInARD, EmT-PDeputy Chief of Operations, San Diego Fire-Rescue
CHAD bROCATO, DHs, REmT-PAssistant Chief of Operations, Deerfield Beach Fire-Rescue Adjunct Professor of Anatomy & Physiology, Kaplan University
J. RObERT (ROb) bROWn JR., EFOFire Chief, Stafford County, Va., Fire and Rescue Department Executive Board, EMS Section,
International Association of Fire Chiefs
CAROL A. CunnIngHAm, mD, FACEP, FAAEmState Medical Director
Ohio Department of Public Safety, Division of EMS
THOm DICK, EmT-PQuality Care Coordinator
Platte Valley Ambulance
CHARLIE EIsELE, bs, nREmT-PFlight Paramedic, State Trooper, EMS Instructor
bRuCE EvAns, mPA, EmT-P Deputy Chief, Upper Pine River Bayfield Fire Protection, Colorado District
JAy FITCH, PHDPresident & Founding Partner, Fitch & Associates
RAy FOWLER, mD, FACEPAssociate Professor, University of Texas Southwestern SOMChief of EMS, University of Texas Southwestern Medical Center Chief of Medical Operations,
Dallas Metropolitan Area BioTel (EMS) System
ADAm D. FOx, DPm, DOAssistant Professor of Surgery,
Division of Trauma Surgery & Critical Care, University of Medicine & Dentistry of New Jersey
Former Advanced EMT-3 (AEMT-3)
gREgORy R. FRAILEy, DO, FACOEP, EmT-PMedical Director, Prehospital Services, Susquehanna HealthTactical Physician, Williamsport Bureau of
Police Special Response Team
JEFFREy m. gOODLOE, mD, FACEP, nREmT-PProfessor & EMS Section Chief
Emergency Medicine, University of Oklahoma School of Community Medicine
Medical Director, EMS System for Metropolitan Oklahoma City & Tulsa
KEITH gRIFFITHsPresident, RedFlash GroupFounding Editor, JEMS
DAvE KEsEg, mD, FACEPMedical Director, Columbus Fire Department Clinical Instructor, Ohio State University
W. Ann mAggIORE, JD, nREmT-PAssociate Attorney, Butt, Thornton & Baehr PCClinical Instructor, University of New Mexico,
School of Medicine
COnnIE J. mATTERA, ms, Rn, EmT-PEMS Administrative Director & EMS System Coordinator,
Northwest (Ill.) Community Hospital
RObIn b. mcFEE, DO, mPH, FACPm, FAACTMedical Director, Threat Science Toxicologist & Professional Education Coordinator,
Long Island Regional Poison Information Center
mARK mEREDITH, mDAssistant Professor, Emergency Medicine and Pediatrics,
Vanderbilt Medical Center Assistant EMS Medical Director for Pediatric Care,
Nashville Fire Department
gEOFFREy T. mILLER, EmT-PDirector of Simulation Eastern Virginia Medical School,
Office of Professional Development
bREnT myERs, mD, mPH, FACEPMedical Director, Wake County EMS SystemEmergency Physician, Wake Emergency Physicians PAMedical Director, WakeMed Health & Hospitals
Emergency Services Institute
mARy m. nEWmAnPresident, Sudden Cardiac Arrest Foundation
JOsEPH P. ORnATO, mD, FACP, FACC, FACEPProfessor & Chairman, Department of Emergency Medicine, Virginia
Commonwealth University Medical CenterOperational Medical Director,
Richmond Ambulance Authority
JERRy OvERTOn, mPAChair, International Academies of Emergency Dispatch
DAvID PAgE, ms, nREmT-PParamedic Instructor, Inver Hills (Minn.) Community CollegeParamedic, Allina Medical TransportationMember of the Board of Advisors,
Prehospital Care Research Forum
PAuL E. PEPE, mD, mPH, mACP, FACEP, FCCmProfessor, Surgery, University of Texas
Southwestern Medical CenterHead, Emergency Services, Parkland Health &
Hospital SystemHead, EMS Medical Direction Team,
Dallas Area Biotel (EMS) System
DAvID E. PERssE, mD, FACEPPhysician Director, City of Houston Emergency Medical Services Public Health Authority, City of Houston Department.
of Health & Human ServicesAssociate Professor, Emergency Medicine,
University of Texas Health Science Center—Houston
JOHn J. PERuggIA JR., bsHus, EFO, EmT-P Assistant Chief, Logistics, FDNY Operations
EDWARD m. RACHT, mDChief Medical Officer, American Medical Response
JEFFREy P. sALOmOnE, mD, FACs, nREmT-PAssociate Professor of Surgery,
Emory University School of MedicineDeputy Chief of Surgery, Grady Memorial HospitalAssistant Medical Director, Grady EMS
KATHLEEn s. sCHRAnK, mDProfessor of Medicine and Chief,
Division of Emergency Medicine, University of Miami School of Medicine
Medical Director, City of Miami Fire RescueMedical Director, Village of Key Biscayne Fire Rescue
JOHn sInCLAIR, EmT-PInternational Director, IAFC EMS SectionFire Chief & Emergency Manager,
Kittitas Valley Fire & Rescue
COREy m. sLOvIs, mD, FACP, FACEP, FAAEmProfessor & Chair, Emergency Medicine,
Vanderbilt University Medical CenterProfessor, Medicine, Vanderbilt University Medical CenterMedical Director, Metro Nashville Fire DepartmentMedical Director, Nashville International Airport
WALT A. sTOy, PHD, EmT-P, CCEmTPProfessor & Director, Emergency Medicine,
University of PittsburghDirector, Office of Education,
Center for Emergency Medicine
RICHARD vAnCE, EmT-PCaptain, Carlsbad Fire Department
JOnATHAn D. WAsHKO, bs-EmsA, nREmT-P, AEmDAssistant Vice President, North Shore-LIJ Center for EMSCo-Chairman, Professional Standards Committee,
American Ambulance AssociationAd-Hoc Finance Committee Member, NEMSAC
KEITH WEsLEy, mD, FACEPMedical Director, HealthEast Medical Transportation
KATHERInE H. WEsT, bsn, mED, CICInfection Control Consultant,
Infection Control/Emerging Concepts Inc.
sTEPHEn R. WIRTH, Esq.Attorney, Page, Wolfberg & Wirth LLC.Legal Commissioner & Chair, Panel of Commissioners,
Commission on Accreditation of Ambulance Services (CAAS)
DOugLAs m. WOLFbERg, Esq.Attorney, Page, Wolfberg & Wirth LLC
WAynE m. ZygOWICZ, bA, EFO, EmT-PEMS Division Chief, Littleton Fire Rescue
10 JEMS OCTOBER 2012
JOURNAL OF EMERGENCY MEDICAL SERVICES
The Conscience
of EMS
JOURNAL OF EMERGENCY MEDICAL SERVICES
TheConscience
of EMS
JOURNAL OF EMERGENCY MEDICAL SERVICES
The Conscience
of EMS ®
008_010_STAFFBOXES.indd 10 10/1/2012 2:18:02 PM
Choose 17 at www.jems.com/rs
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>> Photos Roland WebbEMS IN ACTIONscene of the month
12 JEMS OCTOBER 2012
R iders collide during the start of day six of the seven-day BC Bikerace, a rugged mountain bike course stretching from
Vancouver to Whistler, British Columbia, Canada. According to Roland Webb, course medical manager, the EMS team of approxi-mately 20 paid and volunteer paramedics and nurses treat nearly all of the approximately 520 participants at some point during the seven days, whether for minor or complex injuries. (Top right) A basecamp nurse cleans foreign bodies from a man’s eye after a day racing in heavy rainfall and mud. Performing effective care at the race presents many challenges for EMS, including re-locating daily and dealing with remote locations and potentially challenging extrications, Webb says. “In some places, access is a nightmare, and in others it’s easy, so you have to be flexible and get a clinic staff together for one week a year that can handle it.”
Off-ROAd caRe
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Have you noticed how well person-nel from different agencies—and those wearing different uniforms
and shoulder patches—get along and work together during a cardiac arrest or mass casu-alty incident?
Know why that is? It’s because they’re all focused on a common goal: the mitigation of a complex incident or resuscitation of a person whose life will slip away if they don’t focus on the most appropriate care, set aside personal biases about who’s in charge and fol-low the command system regardless of who’s “in charge.”
I’ve found this to be the case during most “big” calls. But when you get public, private, third service and hospital-based EMS system administrators together for a planning meet-ing or at a city council hearing on the best way to offer EMS in a region, their protec-tive attitudes, operational and staffing biases, and agency loyalties, will often surface like the teeth on a shark that smells blood in the water.
It shouldn’t be that way. We should check our egos and biases at the door whenever we leave home to head to work. We should simply focus on the patient and delivering optimal service to the community.
Wars have taught us invaluable lessons about strategy development, command and control, and the use of innovative tactics. They have also taught us many hidden lessons about group interaction, the use of limited resources and, most importantly, “blind” faith and cooperation between forces from differ-ent service branches without bias or preju-dice—particularly when it comes to combat casualty care.
The importance of this unbiased attitude and approach to patient care was never more evident to me than in the sad, but power-ful, story of the life and tragic death of Sgt. Eric E. Williams, an Army flight medic from Southern California who was killed on July 23 in Afghanistan.
At Williams’ funeral, Army Staff Sgt. Michael Constantine told of being on the receiving end of Williams’ care in 2008, and vividly recalled the battle that almost took his life. A bullet tore through Constantine’s ribs and collapsed his lung during a fierce battle in Afghanistan.
Sgt. Williams was the flight medic who rapidly arrived on an Army helicopter to attend to him as he gasped for breath, watch
his vision begin to fade and “tunnel,” and had a significant amount of blood filling his airway.
Constantine says, “I had started to give up and let the inevitable rush over me until, in a calm voice, I heard Williams’ voice say ‘Just breathe out.’ So I did.”1 He then felt Williams’ hands repairing his massive, open wound.
Constantine says he looked up and searched the medic’s face for some indication of how bad the wound was. He told those in attendance at his funeral that he was met with a reassuring smile and words of promise from Williams, who told him he would do all that he could to save him.
Williams and his flight crew members did, in fact, save Constantine, and he never saw Williams again.
In July, four years after Williams saved Constantine’s life, he learned that Williams was killed as his second deployment ended. Williams was in transit from his duty station in Ghazni Province, Afghanistan back to the U.S., and his forward operating base came under enemy fire.
He never made it home, but the stories of his heroic acts did.
The most important part of this story is that Williams grew up in civilian life serving with public and private emergency response agencies. He had served as president of the fire explorers while at Murrieta (Calif.) Valley
High School and later became an EMT for American Medical Response.
He did his job then based on what was in the best interest of his community and his patients. Later, while serving as a medic in the Army, he provided care indiscriminately to those in need whether they wore a patch from the Army, Marines, Air Force, Navy or Afghanistan military—or no patch at all.
During his memorial service, the last entry in Williams’ Internet blog entry titled “Coming Home” was read. In his short blog message, the dedicated, humble Army medic noted having witnessed “the atrocities of war” and
wrote words that sum up why we all work in the field of EMS:
“We have thrust ourselves into the midst of chaos in order to do something so important, so visceral, that few will ever understand what it means. We collectively have risked it all and put everything on the line to save our fellow man, regardless of nationality, race, religion or sex.”
Remember Sgt. Eric Williams’ ultimate sacrifice and never let personal bias or your agency affiliation stand in the way of patient care or decisions that are the best interest of your patient or the community you serve.
We all have to accept and embrace the fact that we will always wear different shoulder patches and have different employer-driven philosophies and service objectives. But we must work cooperatively together, particu-larly in the years ahead as new approaches to healthcare delivery require a more compre-hensive, integrated EMS delivery model. JEMS
RefeRence1. KabbanyJ.(Aug.4,2012).WILDOMAR:Regionremem-
bersslainMurrietasoldier.InNorthCountyTimes.RetrievedAug.4,2012,fromwww.nctimes.com/news/local/wildomar.
fRom the editoRputting issues into perspective
>> by A.J. HeigHtMAn, MpA, eMt-p
14 JEMS OCTOBER 2012
Read Sgt. Eric E. Williams’ last blog entry, “Coming Home,” at http://myfriendthemedic.
blogspot.com/2012/07/coming-home.html.
PatCHES, PRidE & PatiEntSConsistent cooperation should be the goal
He never made it home, but the stories of his heroic acts did.
014EDITOR.indd 14 9/12/2012 3:55:59 PM
Choose 18 at www.jems.com/rs
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LETTERSin your words
16 JEMS OCTOBER 2012
If you want to advance and improve our profession (and help make it a profession) then you will under-stand that a single, simple collective term of identity is necessary for the media to describe us and what we do. We have to make it easy for THEM to get it right. When I’ve had this conversation with media represen-tatives (and I have), they say, “Oh, OK.”
The Canadians and Australians have figured this out. Those who work on ambulances are all paramed-ics, just like those who work on fire trucks are fire-fighters, and those who work in police cars are police officers. It has worked well enough that they have a public identity in those countries that is substantial. How about we “real” paramedics get over it and share our “elite” (cough, cough) title with the others who work with us. We should all be paramedics. I don’t care; we can be called “BLS paramedic,” “ILS para-medic,” “ALS paramedic,” “critical care paramedic,” “tactical paramedic” or “flight paramedic,” etc., etc., ad nauseam infinitum amen. The bottom line: They’re all paramedics.
Skip KirkwoodVia jems.com
New Zealand still uses the generic term “ambulance officer” to describe those at all clinical levels, be they a technician, a paramedic or an intensive care para-medic. Technician level officers are overwhelmingly volunteers; they complete a six-month block course, perform a limited number of procedures and dispense a limited number of drugs (about 10). It’s not appropri-ate to call them a “paramedic,” and it’s certainly not appropriate to call an American EMT who, under the EMS Agenda for the Future, completes a course of less than 200 hours and has oxygen, aspirin and glucose, a “paramedic.” Elsewhere in the world, a paramedic must go to college for three years to earn the right to use the title. As much as I applaud Canada for its use of the titles, primary and advanced care paramedic,
JuST WoRdS?Perhaps it’s not surprising that JEMS readers had a lot to say about the August feature article by Rollin J. Fairbanks, MD, MS, that discussed how to combat the longstanding issue EMS providers have with being referred to as “ambulance drivers” in the media and elsewhere (“More
than Words: how we can influence the ‘ambulance driver’ media epidemic.”) Is there a solution, or will this continue to be a problem for the profession?
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I’m going to have to play devil’s advocate a little here. Sorry folks.
Ben HoffmanVia jems.com
We are ambulance drivers. We work with fire truck drivers and police car drivers to provide first aid and a ride to the hospital. Once we arrive there, the vital sign takers, bed makers and report takers help the prescription writers and test orderers take care of the medical services consumer. After all, it’s all about the words, isn’t it?
Christopher BlackVia jems.com
I am an ambulance driver. I’m probably a decent EMT as well. I teach the Emergency Vehicle Operator Course (EVOC) after spending years of white knuckle driving. My primary focus when teaching a class is to impart the enormous responsibility involved in driving an emer-
gency vehicle. In addition to being an emergency room on wheels, that truck is a billboard for your service, and potentially an instrument of destruction. If I haven’t scared the crap (spark) out of my students before the road test, I haven’t done my job. When I stand in front of or behind the ambulance during the road practical, I make it clear that my life and that of those in the truck as well as on the road is in their hands. They are proud of that accomplish-ment when they receive their EVOC certificate. Yet some consider being called “ambulance driver” the equivalent of a racial slur? Get over yourself.
Nancy MageeVia jems.com
Thank you for a great article. The term also leads to a mis-conception about what the ambulance is used for. I can’t tell you how many times nurses or unit secretaries have asked us as we’re leaving to take someone home because we happen to be going “his way.” When I politely decline, they usually become irritated and say things to the effect of “what good is driving an ambulance if you don’t drive people places?” We in EMS have a long way to go, but I think we all collectively appreciate your effort and your article. Thanks again.
Geoffrey HorningVia jems.com
Nice article. After almost 30 years at this, I still don’t like being called an “ambulance driver.” However, I also wish the media would use a thesaurus: The only verb they have for us is “rush.” It doesn’t matter what we do, the standard line is, “And EMS rushed the victim to the hospital.” As long as all we do is “rush,” then I guess our primary job is driving. JEMS
Sam BensonVia jems.com
016_LETTERS.indd 16 9/13/2012 4:11:16 PM
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As Hurricane Isaac headed toward the Gulf Coast region in the end of August, residents were figuring
out to ways evacuate, and EMS operations were swinging into full gear in their efforts to receive for back-up assistance. With the potential of a major storm hitting a wide swath of land, officials initiated emergency plans and waited out the weather early on.
AcAdiAn AmbulAnceOn Aug. 26, with the storm just two days away, Acadian Ambulance in Lafayette, La., activated its Evacuation Response Operations Center (EROC), a system borne out of responses to previous storms, to specifically handle the evacuations of healthcare facilities.
“Compared to other storms of the past 10 to 15 years, it was not one of the most challenging we’ve had,” says Jerry Romero, senior vice president of operations at Aca-dian. “But, we had to execute our disaster plan.” Part of this plan included having 40 additional ambulances in service.
The EROC system was created after hur-ricanes Gustav, Katrina and Ike struck the regions Acadian serves. Evacuating health-care facilities and nursing homes is a major part in the storm preparation process. To meet that need, Acadian activates a separate communications center to handle only those types of evacuations, rather than have those calls bog down the normal 9-1-1 system.
For instance, during Hurricane Katrina, Acadian evacuated more than 2,000 patients. During the first day of the EROC opera-tion for Hurricane Isaac, the company trans-ported 150 people.
Hurricanes are challenging for EMS orga-nizations. Officials are faced with calling in extra staff at a time where the staffers’ families and homes may be in danger. This happens at the same time that government officials are asking residents to evacuate the area where first responders are being sent to wait. The result, however, can sometimes be a shortage
of employees physically unable or unwilling to return to work.
“Our employees are pretty hurricane savvy,” says Romero. “At the beginning of hurricane season, we put out our employee update to remind them of the points to have a family plan prepared, to know what you’re going to do, and have a three-day
supply of clothes and food in case you don’t get home. We get a lot of people who call in and volunteer.”
SunStAr emSOfficials at SunStar EMS in Pinellas County, Fla., like others, began altering their hurricane response plans in 2004 and have upgraded
PriOritY trAFFicNEWS YOU CAN USE
18 JEMS OCTOBER 2012
Crews Activate Response Plans Hurricane Isaac HITS
NIH creates Office of Emergency Care Research: www.jems.com/article/nih-creates-office-emergency-care-resear
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An uprooted tree lies across Poydras St. in New Orleans as Hurricane Isaac made landfall with 80 mph winds, making it a Category 1 storm.
Trevelle Bivalacqua, 12, at right, helps firefighters and other volunteers evacuate residents from the Riverbend Nursing Center as Hurricane Isaac makes landfall in Jesuit Bend, La.
018_022PT.indd 18 9/18/2012 9:02:30 AM
did you Miss a live webcast? Check out the archives at www.JEMS.com/webcasts. • May the G-Force Be With You
• ‘Posting’ Is Not a Dirty Word
• When You Leave a Patient Behind: Refusals, Non-Transports & Best Practices for Documentation
• Top 5 Ways an In-Vehicle Router Improves EMS Operations & Patient Care
• CPR Quality Improves Survival
• Breathe Deeply: How CPAP and Ventilation Can Help Your Patients
• Simulating Work: How to Effectively Incorporate Simulation into Prehospital Care
• CPAP: Filling The Sails to Respiratory Relief
• Securing the Airway: The expanding role of extraglottic devices
• Maximizing Your Revenue
• The Mobile Transformation
• EMS Strategies for Improving Cardiac Arrest Survival
• Are You Bagging the Life Out of Your Patients?
• Drug Shortage Action Plans for EMS
• Statewide Trauma System Enables Multi-Agency Coordination with Trauma Centers to Improve Patient Outcomes
• CPAP in EMS: The Standard of Care Argument
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JEMSFamilyofProductsFP_Oct12.indd 1 10/1/2012 2:21:03 PM
20 JEMS OCTOBER 2012
>> continued from page 18
Halloween safety tips: www.jems.com/article/don-t-get-spooked
them after every storm since then.SunStar’s current plan includes a man-
datory callback for all employees, and it also includes provisions to make sure employees’ family concerns are taken into consideration. For instance, six responders and an ambulance are placed in 20 hotels throughout SunStar’s response area—and geographically near the responders’ homes to assist families if needed.
Two must be on duty at all times, which gives the other pro-viders a chance to check on their families. Another 250 go to the company headquarters.
Bringing everyone in inevita-bly involves logistical challenges for managers, such as the feeding and housing of staff. And once a storm begins, there will ulti-mately come a point where the crews can’t go out.
“We’ve kind of learned from other hurricanes that have hap-pened,” says SunStar Vice Pres-
ident Mark Postma. “We’ve tried to be as flexible as we can.”
Early on, it appeared the region covered by SunStar might get hit by Hurricane Isaac. However, the storm track went further west. The plan has been tested several times, though it’s been activated only once since its imple-mentation, Postma says.
SunStar was prepared, however, says Richard Schomp, director of operations. The company had already activated special EMS coverage for an event staged for the Republican National Convention on the Sun-day before the storm. That coverage, says Schomp, included 14 additional ambulances, extra management and a mass casualty sup-ply vehicle.
“I’d already staffed up the system to handle an extreme amount of volume,” Schomp says. “With the storm coming, we maintained that high amount. It had very little impact, but we were ready.”
Typically, EMS operations experience a large influx of 9-1-1 calls after a storm when residents have no power. Romero says there’s often a jump in heat-related calls, chainsaw cuts and falls from roofs as homeowners work to rebuild.
Getting crews time to rest, especially when they’re stationed over a wide geographical location, is one of the largest challenges, Romero says. However, each storm, Romero says, helps the company prepare for the next one. Hurricane Isaac was no different.
“Katrina, Rita, Gustav and Ike taught us a lot,” says Romero. “We’ve gotten better every time. We can always improve and will con-tinue to improve after this one.”
—Richard Huff, EMT-P
RemembeRing an emS PioneeRRobert Forbuss was an EMS advocate, speaker, author, leader and pio-neer known for promot-ing EMS, EMS careers and high-quality private
and public ambulance services. He died in August after a long battle with amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease. He was 64.
Janet Smith, a former Mercy Ambulance employee and colleague of Forbuss’ says, “The Bob Forbuss story is about how a man in an emerging new healthcare service in the 1970s, leveraged his company’s posi-tion in a growing Nevada metropolis to open political and strategic access to the power structure of the city and county his company served.”
Co-founder and subsequent president of the American Ambulance Association (AAA), Forbuss presided over the National Showcase for EMS in Washington, D.C. He served on the AAA committee to institute the process for ambulance accreditation from which the Commission on Accredita-tion of Ambulance Services (CAAS) was formed.
Jay Fitch, PhD, founding partner of Fitch and Associates, LLC, reflects, “He was my second private client, the best thing that could happen to a young consultant. Ener-getic and passionate, I came to admire his leadership.”
Forbuss served as the industry’s spokes-person during the national Ford ambulance crisis and was named EMS administrator of the year at the EMS Today Conference & Exposition in 1988 for his work during that crisis. Forbuss coordinated the ambulance and walking wounded components at the 1980 MGM Grand and 1981 Hilton high-rise hotel fires, an effort JEMS founder James O. Page described as a “command performance.”
Smith reflects, “Who knows how many have lived to see another birthday, a gradu-ation or a grandchild’s first steps because of him, his influence, his care in count-less cities and towns throughout America and especially in those communities where CAAS Accreditation is the benchmark. He will be missed.” —Mike Ward, EMT-P
a WoRd of encouRagementEditor’s note: Jullette M. Saussy, MD, served with NOEMS during hurricanes Katrina and Gustav. She provided this message to EMS crews responding to Hurricane Issac.
It’s incredibly difficult to be so far away and yet to still feel the deep longing to be right beside each of you as this hurricane approaches. Katrina in 2005, Gustav in 2008, and now Isaac in 2012—all on or about the same day seems more than just statistically impossible.
For those of you who have been through this drill, I know it brings up all kinds of emotions. It has for me, and I’m not even there. For the new-est members of the team, take a few lessons from the seasoned men and women of New Orleans EMS (NOEMS.) If they seem on edge, it’s for a reason. Be patient. If they seem emotional, it’s for a reason. Be patient. If they tell you to do something, it’s for a reason. Do it.
You have capable leaders, and they need the team to pull together and perform at their high-est capacity. We have one mission and that is to stay safe and to keep our citizens and visitors safe. Stay focused on that, and you will succeed. Thank you for the work you do each day. —Jullette M. Saussy, MD
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SunStar EMS hurricane deployment units prepare and debrief during the Republican National Convention at Tropicana Field as they mobilize for Hurricane Isaac response.
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22 JEMS OCTOBER 2012
>> continued from page 20
For more of the latest EMS news, visit jems.com/news
When Patients Don’t Stay Put
We’ve seen some tragic headlines recently that should be a cause for concern:
>> aug. 19, 2012: “Woman Dies after Jumping from ambulance” (Calif.) >> March 12, 2012: “Patient Jumps from ambulance Only to be struck by
truck” (nev.) >> Dec. 23, 2011: “naked Man Jumps from ambulance, Dies on Freeway”
(Calif.) >> Oct. 13, 2011: “Patient Jumps Out of ambulance and into River” (Okla.) Is this a trend? How can these incidents happen in the first place? We don’t
know the statistics, but we do know that patients who unexpectedly leap from your ambulance—while you’re with them in the patient compartment—not only can get injured or killed, but can also present huge liability issues for you and your EMS agency.
Dealing with patients with psychological issues is a big challenge. They may appear “fine” and “calm” one moment and then they snap into another person the next second. They often don’t have any outward physical injury, so they almost appear “normal.” This is when we may let our guard down ever so slightly, and bang: The next thing you see is the rear door flapping open and no patient in your vehicle. Not a good scenario.
We need to always remember to strive to never let something bad happen to a patient while they’re under our care. We don’t want them to be worse off than when we first found them, because if they are, then the obvious question from a “fact-finder” will be: “Did the EMS crew do enough to prevent this unfortunate incident?” And if the answer is no, then you may be looking at a negligence or wrongful death action against your agency.
Follow these tips for reducing your risk when transporting patients who have a “questionable” mental state:
>> always be attentive: Keep your eye on the patient at all times in a face-to-face position. The first sign that the patient is about to escape may be a change in their facial expression. You can’t see that sitting in the captain’s chair texting a friend, staring out the side window, or chatting with the driver. We must be totally attentive to the patient every second they’re with us. Being com-placent or distracted leads to dead patients in these situations.
>> Follow your protocols: Most systems have a protocol for dealing with a patient who may have psychological issues or has exhibited signs they may hurt
themselves. Make sure you review that proto-col and follow it. Your protocol will usually be the patient care standard by which you will be judged in a negligence lawsuit.
>> Get good information at the scene: Ask lots of questions of the facility staff or family members concerning mental stability, suicidal ideations, and so forth. Document exactly what the patient, nursing staff and bystanders tell you. Never accept a patient who looks “fine” without a good explanation as to why you’re taking them.
>> Don’t hesitate to call law enforcement: True, police officers are not always helpful, but it’s best to err on the side of calling them, and then keep them there for the remainder of the transport or ask an officer to ride in the back if possible. Always consider the option of an involuntary mental health commitment in accordance with your state law, if you’re concerned.
>> Use two people in the back: If you question the mental stability of a patient, it’s always best to have two providers in the patient compartment—positioned strategically so that the patient can’t escape easily. Someone should definitely be between the patient and the rear door of the ambulance. Don’t make it easy for them to escape.
>> Use restraints when needed: We’re not talking about the cot straps, which by the way, should always be in your complete view so that you can see them if a patient is trying to get unbuckled; never cover buckles under a blanket. Chemical restraints may be the safer way to go and can reduce patient anxiety. Don’t hesitate to use them or ask your medical command physician.
Keep in mind from a risk management standpoint, it’s far better to get sued for false imprisonment for excessively restraining a patient, than to get sued for wrongful death if the patient jumps from your ambulance as you look up and it’s too late. There are only a few lawsuits where EMS providers were sued for tak-ing a patient involuntarily, but there have been hundreds of lawsuits against EMS for negligence when the patient is left worse off than when you found them —regardless of your defense.
The authors are all attorneys with Page, Wolfberg & Wirth, a national EMS law firm. Visit the firm’s website at www.pwwemslaw.com for more information on a variety of EMS law issues.
Pro Bono is written by attorneys Doug Wolfberg and steve Wirth of Page, Wolfberg & Wirth LLC, a national EMS-industry law firm. Visit the firm’s website at www.pwwemslaw.com for more EMS law information.
QUICK taKePennWell ACQUIres elsevIer PUblIC sAfety; Jbl ACQUIres eMs ProdUCt lIneOn Sept. 14, PennWell Corporation announced the acquisi-tion of Elsevier Public Safety, the publisher of JEMS, from Elsevier, Inc. The deal also includes JEMS.com, the EMS Today Conference & Exposition (the JEMS Conference), EMS Insider, FireRescue magazine, FirefighterNation.com, FireEMSblogs.com, Law Officer magazine, LawOfficer.com and the publishing contract for APCO’s Public Safety Com-munications magazine.
Elsevier Public Safety, a division of Elsevier, Inc., was founded in 1980 as JEMS Communications, with JEMS, one of the most iconic brands in the EMS market. During the past 32 years, Elsevier Public Safety expanded to become the
only media company serving all four key public safety seg-ments—EMS, fire/rescue, law enforcement and commu-nications. The management and staff will join PennWell, a diversified global media and information company, and will remain based in San Diego. PennWell conducts more than 50 conferences and exhibitions, including the Fire Depart-ment Instructors Conference (FDIC), and has an extensive line of trade publications, including Fire Engineering and Fire Apparatus magazines.
PennWell will bring its trade show management know-how to the EMS Today Conference & Expo, held annually each spring. EMS Today celebrated its 30th anniversary this year and in 2013 will be held March 5–9 at the Washington Convention Center in Washington, D.C.
For more information, visit www.jems.com/article/news/pennwell-acquires-elsevier-public-safety.
In other acquisition news, Jones & Bartlett Learning (JBL), a division of Ascend Learning, acquired the EMS product line from Elsevier, Inc., closing the deal in July, according to JBL Executive Publisher Kimberly Brophy. EMS education resources previously published under the Elsevier brand are now part of the JBL EMS product line, including those mar-keted under the Mosby, Saunders and Churchill Livingstone imprint. The added value, Brophy notes, is that customers can now order a large variety of titles from one publisher.
JBL is a provider of instructional, assessment and learn-ing-performance management solutions for the secondary, post-secondary and professional markets. JBL will continue to support and enhance EMS products, domestically and internationally. Customers should note that Elsevier will be responsible for accepting returns on any products pur-chased directly from Elsevier through April 30, 2013.
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LEADERSHIP SECTORpresented by the iafc ems section
>> by gary ludwig, ms, emt-p
24 JEMS OCTOBER 2012
I recently received an e-mail that told me of an innovative new management principle that most major business schools, such
as Wharton, Harvard and Yale, would soon be scampering to teach. The e-mail added that management books would need to be rewritten and this new management practice would set teaching of leadership and man-agement back 200 years.
Intrigued, I couldn’t resist reading further into the e-mail about this earth-shattering management principle. I was curious about what was so tremendous and incredible. Could I possibly be on the brink of some utterly fantastic discovery that maybe some-how I could share with fellow EMS managers?
CLOSIng THE DOORAs I read further, I discovered that the writer was being facetious. He was being tongue-in-cheek and not really writing about an earth-shaking innovative or unfounded management application. What the author wanted to share with me was what the man-agement at his EMS service had distributed to its employees; a memorandum appropriately called the “Closed Door Policy.”
The memorandum basically said that man-agers were too busy to deal with employees when they had an issue that needed address-ing. Here is what the memo said (with the names deleted).
To All Employees,During business hours (9–17), [name deleted]
and [name deleted] are being bombarded with opera-tional issues every five minutes. This makes it impos-sible to complete our tasks and work assignments. We are tired of answering the locked door that specifically says, “AUTHORIZED PERSONNEL ONLY” to find out that you need to talk about scheduling, supplies, etc.
Although we appreciate all your concerns, unless it’s on fire, please e-mail us. We will get back to you in a timely manner. You cooperation is much appre-ciated and no exceptions will be made nor tolerated. Please take this seriously. We have a larger work load and get seriously behind due to constant visitors.
Surprisingly, this wasn’t a large service where 1,000-plus employees would keep the head of an EMS organization from doing their job because they were inundated with employees knocking on the door. So when I read the memo, I was baffled.
LEADIng wITH YOuR FEETManagement does need to prioritize tasks. And, as I have always preached, management shouldn’t be bogged down in minutia and should focus on strategic issues. However, I have also advocated they can’t sit in their offices behind closed doors and not interact with their employees. They need to find a balance between staying focused on strategic issues and getting out of the ivory tower to find out what’s happening in the operation.
When you get out and talk with employ-ees, you find out what’s working and what’s not. As I’ve often said, you don’t want to wake up in the morning and read in the paper what’s happening in your operation.
A label for this practice is “Management by Walking Around,” or MBWA. I have always felt this concept was misnamed and would be better termed “Leadership by Walking Around.” After all, we manage budgets and inventories; we should be leading people.
Nonetheless, this spontaneous practice in an unstructured manner allows managers to randomly check with employees
or equipment to find out what is happening in the operation.
My favorite method to do MBWA is to stop by one of our busier hospitals in Mem-phis where I know I’m going to find three or more Memphis Fire Department ambu-lances dropping off patients. It gives me the opportunity to randomly and spontaneously meet with personnel. It allows me to talk with them, and it allows them to ask me questions, let me know about any issues that need addressing, and, my favorite—deny or confirm rumors they’ve heard.
This is probably one of the best tools I have to discover what’s wrong and needs to be fixed, build rapport with employees and receive feedback. I may hear things I don’t want to hear, but that comes with the job and I would prefer employees to be honest. Some-times it seems like it’s a small problem. But I’ve discovered if you don’t deal with the small problems, they can become big problems.
A BALAnCIng ACTIt’s important to point out that, if you’re going to use MBWA, you have to do it the proper way. You can’t just walk around to say “Good morning.” Don’t criticize. Don’t create an atmosphere of fear that causes your employees to get scared and “clam up” when they see you coming.
And, most importantly, EMS managers can’t just sit in locked offices and shelter themselves from what’s happening outside the confines of their office. Maintaining that careful balance between becoming a recluse and interacting with your employees can allow you to truly find out what’s happening within (and around) your operation. JEMS
Closed door PoliCyKeeping lines of communication open can help you & your staff
Gary ludwig, MS, EMT-P, has 35 years of
EMS, fire and rescue experience. He currently
serves as a deputy fire chief for the Memphis
Fire Department. He’s also Chair of the EMS
Section for the International Association of
Fire Chiefs. He can be reached through his website at
GaryLudwig.com.
024Leadership.indd 24 9/12/2012 3:56:33 PM
TRICKS OF THE TRADEcaring for our patients & ourselves
>> by thom Dick, emt-p
26 JEMS OCTOBER 2012
“I’m melting, I’m melting!”So said the Wicked Witch of
the West just before she magically shriveled her way into history. I’m begin-ning to sympathize with that cranky lady. At the time of this article’s writing, my state has had a record-breaking summer of wildfires after more than a month of tem-peratures in excess of 90° F and multiple strings of 100-plus days in the mix. And the calendar says our summer is still ahead.
We need rain.One of my duties is to oversee the
maintenance of a small fleet of six Type III Ford ambulances. They’re all 7.3-Liter PowerStroke Diesel chassies with LifeLine boxes. We’ve hung onto the 7.3s because we don’t generate a lot of miles, and those engines and their TorqShift transmissions have been bulletproof. Just as importantly, the quality of the boxes has supported our continued investments in chassis mainte-nance. In fact, so far we’ve sent two units back to the factory in Sumner, Iowa, to refurbish and return them to service.
When I was originally assigned to take care of this fleet, we were having two kinds of starting failures. One was an easy fix: We began replacing the batteries annually. The other, which had plagued us for years, was alternator failures—especially of the upper alternators. Of course, the easiest way to correct that would be to switch to Type I ambulances.
One of the disadvantages of a cutaway-based Type III chassis is its teeny engine compartment. There’s not enough room in there for an alternator big enough to supply the needs of an ambulance (or a leprechaun to service it). So Ford resorted to a pair of alternators: one mounted high and the other one low. A Type I chassis has a longer hood, like a pickup truck, that offers much more space. But our garage bays aren’t physicially deep enough to accommodate Type I ambulances. And Colorado’s range of temperatures can
reach 110 degrees winter to summer. So you pretty much have to keep an ambu-lance garaged.
Neither of those alternators is just a spare; if one fails (usually the upper one because of heat), the other will follow soon enough. You can minimize the load on them by switching your emergency light-ing from incandescent to high-intensity LEDs. LEDs produce a lot of light with a little energy. Decreasing the load on an alternator should lower its operating tem-perature, minimize the wear on its drive belt and improve its reliability. But LEDs require a lot of rewiring, and that’s pricey. You can’t just replace bulbs.
You can idle a diesel all day long, even on a hot summer day with a heavy electrical load (including both air conditionings on full-blast). But when you turn the motor off, the radiant heat of all that metal has nowhere to go. So your underhood tem-
peratures will rise. If the cooling system is in good shape and your coolant is mixed at the proper concentration, it should be OK up to a temperature of almost 300° F. But the underhood temperature won’t be constant. It’ll be hottest up high (like where the upper alternator is) and not so hot down low.
We talked to our friend Cap Unrein at Rocky Mountain Emergency Vehicles (EVMARS) of Denver, who does our main-tenance. Cap recommended the basis of the following hot-weather procedure. We leave an ambulance running when we park it out-doors for just a few minutes. Nobody wants to climb into a 120° F ambulance, right? EVMARS installed externally accessible secu-rity switches that either lock or unlock all of our doors simultaneously. So we can leave a locked vehicle idling, yet we can access it quickly for a call. Then, when we return to quarters, we turn off the engines and leave the hoods open.
Looks funny. Makes sense. Obviously, we try not to leave the hoods open in pub-lic. Our crews don’t post on street corners, and they’re mindful of the temperature-sensitive contents of their compartments, so they normally return to quarters between calls. And we don’t know yet if this will even work. But it makes sense for any vehicle, whatever its design. And in this heat, we’ve gotta do something.
I have to tell you, there’s one more com-ponent to this plan. The crews have to under-stand their instruments—and the mechanics of their vehicles—well enough to make it work. To my way of thinking, that requires training and experience.
Neither of which happens by magic. JEMS
Thom Dick has been involved in EMS for
41 years, 23 of them as a full-time EMT and
paramedic in San Diego County. He’s currently
the quality care coordinator for Platte Valley
Ambulance, a hospital-based 9-1-1 system in
Brighton, Colo. Contact him at boxcar414@
comcast.net.
Warm Enough for Ya? Preventing failures to start
maintaining proper vehicle temperature isn’t rocket science, but it does require proper training.
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26tricks.indd 26 9/12/2012 3:57:15 PM
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1012-FP_RT.indd 1 9/12/2012 3:19:44 PM
CASE OF THE MONTHDILEMMAS IN DAY-TO-DAY CARE
>> BY KIMBERLY DORAN
28 JEMS OCTOBER 2012
A call comes in to 9-1-1 dispatch. “Help” is all that’s spoken before the operator hears the phone hit the
floor. The 9-1-1 dispatcher calls back only to get a busy signal. Police and EMS are dis-patched for a well-being call.
On arrival, the front door is found to be slightly ajar. The crew knocks, but there’s no reply. Entering the home, the crew sees a young woman lying on the floor in a pool of vomit. A syringe with an unknown substance is on the ground nearby. Suspecting a drug overdose, the EMS crew begins treatment. The patient is unconscious with emesis about her head and face. Her vital signs are blood pressure 60/45, heart rate of 130 bpm and respiratory rate of 10.
The patient shows no signs of waking. The crew clears the airway and administers oxygen. An IV is established and the patient is readied for transport. As the crew leaves the scene, one of the medics turns to shut the door and sees a vial under a chair. He retrieves it and notes that the label says Solu-Cortef (a glucocorticoid). He bags it for the emergency department (ED). Following his instinct, he looks around the area for medications and finds two bottles. One is labeled dexametho-sone and the other is labeled fludrocortisone. He takes his findings and rushes out the door into the awaiting ambulance.
During transport the patient continues to deteriorate. The medic administers 0.5 mg of narcan and a 500mL bolus of normal saline with no response. He radios ahead to let the hospital know that they’re en route. Now questioning the original diagnosis of drug overdose, he reports the medications he found on the scene in hopes it will help the receiving physician determine the cause of the patient’s condition.
ArrivAl AT THE EDOn arrival to the ED, the medic hands over the loaded syringe containing 2mL of unidentified solution, as well as the empty vial of Solu-Cortef and the bottles of dexa-
methosone and fludrocortisones. As they arrive at the hospital, the ED phy-
sician meets the crew and informs them that he’s familiar with the medications and they’re all used for people who have various forms of adrenal insufficiency (AI). The symptoms seen in this patient coincide with life-threat-ening adrenal crisis. The physician adminis-ters 100mg of Solu-Cortef via IV and within minutes, the patient rouses. In 30 minutes, she can explain what happened in the desper-ate moments before her crisis.
ADrENAl iNSuFFiCiENCyThe adrenal medulla (inside of the adrenal gland) secretes epinephrine and norepineph-rine. The adrenal cortex (outer layer of the adrenal gland) secretes cortisol and aldo-sterone. Cortisol, a glucocorticoid, is often called the “stress” hormone. One of the things cortisol in the body is responsible for is ele-vating blood glucose levels in times of stress. It also functions as a mediator for several inflammatory pathways.
Absence of cortisol can result in hypoten-sion, hypoglycemia and death. Aldosterone, a mineralocorticoid, is responsible for the regulation of sodium and water. Absence of aldosterone can result in hypotension and electrolyte imbalance. AI is a life-threatening condition in which the body is unable to pro-duce enough cortisol to sustain life. In other words, their adrenal cortex is “asleep.” People suffering from AI take daily cortisol/gluco-corticoid steroid replacement because what-ever adrenal function they have is depleted.
These patients are glucocorticoid dependent. In times of injury, dehydration, illness or sur-gery, they require an injection of Solu-Cortef. Solu-Cortef contains both glucocorticoid and mineralocorticoid properties, helping the body to compensate during a stress event.
AI in the prehospital setting may be dif-ficult to recognize in the absence of a good history, including medications, to point pro-viders to the cause of the problem. Two conditions associated with AI include hypo-tension and hypoglycemia. If not managed, these two conditions are life threatening. Prehospital treatment should include man-agement of the patient’s airway, vascular access and fluid resuscitation. If blood glu-cose levels are low, the patient should receive dextrose per local protocol. It’s important to complete a thorough physical assess-ment and obtain a complete patient history. Providers may confuse patients having an adrenal crisis with drug overdose patients because of their similar symptoms. Although the condition is rare, it should still be consid-ered as a potential diagnosis.
Authors’ note: Parts of the above case are taken from a true story. However, the differ-ence is that there was no syringe on the floor, no vial under the chair and no one found the medications. The patient was diagnosed as a drug-overdose patient and treated with charcoal. She likely would have died, but her mother charged into the ED and expressed the need for Solu-Cortef. Security was called, but luckily someone listened, researched and called the patient’s treating physician. The patient was treated and released. JEMS
Kimberly Doran is medical liaison for Adrenal Insufficiency
United. She is committed to bringing about awareness and
proper medical care and treatment for all who suffer
from various forms of adrenal insufficiency. She can be
contacted at [email protected].
NaKeD & UNcoNscioUsCrew’s misdiagnosis could have cost patient her life
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For more information about this condition, go to www.aiUnited.org.
symptoms of adrenal insufficiency can mirror a drug overdose, so providers need to be wary.
28CASE.indd 28 9/12/2012 3:58:18 PM
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1012-FP_RT.indd 1 9/12/2012 3:21:15 PM
The fuTure looks brighT—buT how brighT?
30 jems | october 2011
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>> About the DAtAThe Web-based survey consisted of approximately 150 questions. It allowed participants to voluntarily “skip” sections they considered “not applicable.” Two hundred twenty-one organizations (N=221) initiated the survey - a return rate of 10% from a distribution of 2,411 invitations. Survey participation was open for a five-week period during May and June 2012. Figure 1, p. 32, shows the breakdown of provider types and their call volumes.
The median of respondents serves populations of 50,000 and responds to 5,000 calls annually. Total respondents are noted as “n =” for each dataset where possible. In some instances, data was limited, not available or not applicable for all respondents. For example, respondents may answer call volume but not provider type, which means that “n” can change from dataset to dataset.
A representative sample of participation from provider organizations in each region of the U.S. and across all system model designs (see Figure 2, p. 34) was achieved. All 10 federal regions are represented in this year’s data national salary rollup, however several job classes and regions did not reach required participation for reporting.
Salary reporting follows Department of Justice and Federal Trade Commission issued Statements of Antitrust Enforcement Policy in Health Care.1 The text of the guidelines as they relate to salary surveys can be accessed online; the following are the most relevant extracts:
The agencies will not challenge, absent extraordinary circumstances, provider participation in written surveys of a) prices for health care services, or b) wages, salaries or benefits of health care personnel, if the following conditions are satisfied:
>>The survey is managed by a third party (e.g., a purchaser, government agency, health care consultant, academic institution or trade association).
>> Information provided by survey participants is based on data more than three months old.
>>There are at least five providers reporting data on which each disseminated statistic is based, no individual provider’s data represents more than 25% on a weighted basis of that statistic, and any information disseminated is sufficiently aggregated such that it would not allow recipients to identify the prices charged or compensation paid by any particular provider. 1
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www.jems.com | october 2011 | jems 31
>> By Michael Greene, MBa/MSha
The “JEMS Salary & Workplace Survey” is a joint research project in collaboration with Fitch & Associates, LLC (www.fitchassoc.com). For 28 years, Fitch & Associates is the leading international emergency services consulting firm and serves a diverse range of clients.
>> short course >> The survey represents
all federal regions. But the individual states not responding were Massachusetts, New Hampshire, Vermont, Delaware, District of Columbia, Nevada and Wyoming.
>> In total, 221 survey participants resulted in a 10% response rate.
>> The median population of respondents is 50,000.
>> Median annual call volume is 5,000.
>> Nearly one-third (27.5%) of responses were from multi-role fire services.
>> In a 2011–2012 comparison, some salaries have declined. However, wage growth between 2006 and 2012, including the recession years of 2008–2009, ranks high among U.S. jobs (8%).
>> Word of mouth and electronic media were the top tools used to find potential job candidates.
>> New employees spend less time in orientation, 160 hours vs. 240 in 2011 and less time in field training, seven weeks down from 10 in 2011.
>> One-third of employees are cleared to work after training without ever meeting with a medical director, with more than 20% “never” meeting with a medical director.
>> Fourteen of 19 job categories experienced wage gains in 2012.
>> Of 25 employee benefit categories, 15 were reported as being “reduced” and 14 were “eliminated.”
>> Potential bias/limitationsThis year, participating EMS organizations were given the option to complete the survey anonymously. Thirty-six respondents selected this option. With this selection the author and research staff are “blinded” to the e-mail or IP address of the respondents. Regardless of how information is submitted, raw data is only available to the research staff and author, and only aggregate data is published.
Data accuracy is a primary objective. Survey results may be limited by the accuracy of respondent sub-mitted data, organizational selective participation and an inconsistent pool of respondents year-to-year. Ambiguous, unclear or incomplete answers were unilaterally excluded from the dataset, rather than interpreted by the author, thus creating a potential additional bias.
In the JEMS 2011 Salary & Workplace Survey, we followed a long day in the life of fictional character Duke Gracie, a field training officer and veteran
paramedic at Flowing Springs EMS (FSEMS). For 28 years, running the JEMS Salary and Workplace Survey, conducted in cooperation with
EMS consulting firm Fitch & Associates, provides insight and understanding on key human resource topics. Continuing
on the narrative from a year ago, we’ll check in not only on the fictional Duke Gracie, but also his boss Margaret Taylor and FSEMS.
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This year, we find Duke as a newly minted community paramedic, looking like a new man who is refreshed and self-assured. In a freshly pressed uniform, Duke steps out of a Flowing Springs EMS Community Paramedic rig and pulls his sunglasses down over eyes in the bright early morning sunlight. “Another day in paradise, saving lives and stomping out disease,” he thinks as he smiles to himself.
In EMS, the human element—be it patient or provider—is the driving force in the sys-tem. As Michael F. Staley wrote in Igniting the Leader Within, “Knowing how to motivate a person in emergency medical services requires that you understand the person, the passion and the pay-check—in that order.”2
After his internal struggle in this past year’s survey, Duke is now passionate about his work. “It’s not like building widgets in some factory,” he tells fam-ily and friends. “I save lives, and get paid for doing it. I can’t imag-ine doing anything else!” (Doing something else was exactly what Duke was pondering a year ago, but more on that later.)
RecRuitment, HiRing & Retention “I haven’t been ‘texted’ about open shifts in months now,” Duke comments as he walks into the FSEMS Communica-tions Center. “Maggie must have gotten my replacement hired.”
“Yup, you’ve been replaced,” replies Lyndy Grayson, the com-munications supervisor. “We got hundreds of hits on Monster and our Facebook page, tens of qual-ified candidates from Maggie’s Tweet and a huge response from the buzz on the streets. Your job was as hot as a software IPO [ini-tial public offering].”
“Tweet, Monster, Facebook, IPO … this sounds like ‘Maggie speak’ to me,” Duke responds with a snort. “Kids these days don’t use the same language as they used to.”
Although these terms might sound unfamiliar to Duke, Flow-ing Springs EMS Executive
Director Maggie Taylor leverages the same technology in her recruitment strategy as her industry colleagues. Recruitment via an “agency website” (31%) takes a narrow sec-ond to “employee referral” (32%) in this year’s survey results. Other job websites, such as Monster.com and CareerBuilder.com (10%), as well as electronic mailing/list-servs (7%), round out the technological approach to recruiting. Trade journal ads (4%) and confer-ence booth recruiting (6%) are the least-used tools to find new employees, while local EMS training programs (23%) continue to be fertile ground to fill job openings.
Seventy-six of 221 agencies reported vacancies within their organizations. They reported an average of three vacancies in 2012, down from five in 2011.3 Additionally, agencies continue to use part-time EMS per-sonnel (67%) with nearly 30% reporting an increased interest from applicants in part-time employment.
Of key frontline EMS positions, organiza-tions continue to report a shortage of para-medic staff (39% vs. 40% in 2011) with an increase in a shortage of emergency med-ical dispatchers (28%), which is up 10% from 2011. The EMT-Basic category contin-
ues to exhibit a low percentage of reported shortages (18%).
When positions are available, Flowing Springs EMS is able to hire qualified candidates that they recruit. Similarly, 83% of survey respondents report “hiring as usual” with a single-digit minority saying “hiring is on hold or frozen” (greater than 6%).
tRaining, education & medical contRol“Turn and burn,” quips Duke. “Those newbies are in and out of orienta-tion quickly; they’re in the field at breakneck speed.”
“It’s like a well-oiled machine,” Lyndy comments. “We’ve got the orientation process dialed in.”
Little has changed this year over last in the subject matter covered in new employee orientation (e.g., pol-icies, patient care guidelines and cus-tomer service). What has changed are the average hours the employee spends in orientation. In 2011, respondents indicated that 240 was the average number of hours of orientation training required for new EMS employees. The average number of hours in orientation has dropped to 160 hours for 2012. A concurrent drop in the “average length of time (weeks) an employee new to your organization spends in the clearance/probation process before they are considered a fully functional and independent mem-ber of field staff” is noted in 2012 data. This is down from 10 weeks in 2011 to seven in 2012.
JemS 2012 SalaRy & WoRkplace SuRvey>> continued from page 31
32 JEMS OCTOBER 2012
Figure 1: Participant DistributionSurvey Respondent Mix
Survey Responses n= 221
Regional Distribution
See Regional Map (Figure 2), p. 34
Provider Model Distribution
% NUM
City/county third-service governmental 21.7 49
Private, not-for-profit organization 15.9 36
Hospital-based 11.9 27
Private, for profit company 8.8 20
Fire department, single-role 0.9 2
Fire department, multi-role 26.5 60
Public utility model 1.8 4
Other 12.4 23
Total Population Served n=201
% NUM
Less than 5,000 7.5 15
5,001-10,000 5.5 11
10,0001-25,000 21.9 44
25,001-50,000 15.4 31
50,001-100,000 12.9 26
100,001-250,000 15.4 31
250,001-500,000 10.0 20
500,001-1,000,000 9.0 18
More than 1,000,000 2.5 5
Call Requests vs. Transports Responses n=199 Transports n=199
% NUM % NUM
Less than 1,000 15.1 30 22.6 45
1,001-5,000 37.2 74 36.7 73
5,001-15,000 17.6 35 17.6 35
15,001-30,000 12.6 25 9.5 19
30,001-50,000 7.0 14 8.5 17
50,001 - 70,000 5.5 11 2.0 4
70,001-90,000 2.5 5 2.0 4
Greater than 90,000 2.5 5 1.0 2
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34 JEMS OCTOBER 2012
Figure 2: Participant by Region
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Note: The number in parentheses is the number of respondents from that region. Standard Federal Regions established in 1974 by the Office of Emergency Management and Budget. The same regions are used by the federal Emergency Management Agency and the Centers for Medicare & Medicaid Services.
“What’s Dr. Mark’s stance on this ‘speed training’ process?” Duke asks Lyndy.
“I guess I don’t know,” she responds. “He’s been a bit over-committed to the new commu-nity paramedic (CP) training.
“Between that and trips to the rural health clinic, he hasn’t been as hands-on as in the past,” she adds, looking at a closed office door marked with “Mark Man-gus, MD—Medical Director.”
Duke thinks about how unusual that is, remembering the days when he and Mangus ran calls together.
“Maggie needs to talk to him,” Duke tells Lyndy. “Now that the CP program is up and running, he needs to get back in here.”
Only 30% of “new employees who have completed their probationary credentialing process must complete an interview with a medical control physician as the final step to clearance.”
Worse yet, following the probationary credentialing process, some field employees (22%) “never” meet one-on-one with the med-ical control physician. Furthermore, in 2012 organizations reported field staff only met with the medical director “when needed” (67%).
Although the American Col-lege of Emergency Physicians (ACEP) doesn’t specify how much face-to-face time a medi-cal director needs to spend with EMS caregivers, ACEP has stated
that it “believes that all aspects of the orga-nization and provision of basic (including first responder) and advanced life support emergency medical services (EMS) require the active involvement and participation of phy-sicians.”4 How much time does your medical director spend one-on-one with field staff?
Few organizations report that continu-ing education (CE) content is developed and delivered solely “in-house” (9%) or entirely “outsourced” (15%); in fact, most use “both” (76%). CE occurs in a “traditional classroom” at 40% of the agencies responding. Less than 2% use “distributive methods” (e.g., video and the Internet) exclusively; most, or 58%, use both methods. Monthly CE occurs at 49% of
organizations, more frequently than monthly at 27%, quarterly at 16% and on-demand at 13%.
Doing MoreDuke’s former partner and field trainee Dave stops as he’s walk-ing by. He leans in the door, “Hey old man, how’s it going with the new job?” Duke stands and they shake hands and exchange backslaps.
“Good,” Duke responds. “We’re always doing more; it’s job security, you know.”
“It’s not enough to be a paramedic and field training officer. No, Duke’s got to be a com-munity paramedic too,” mocks Dave. “Look-ing to the future’s not a bad thing,” responds Duke, “Do more, or someone else gives you more to do. Besides, if I can make the system work even better, then I’ve made a difference.”
“It’s all about productivity,” Lyndy chimes in. “I’d rather be in Duke’s shoes than handing out parking tickets.”
City managers in a Tennessee commu-nity may have found a win/win on produc-tivity and budget. Firefighters in Oak Ridge will be issuing parking tickets according to
one online publication.5 Whether it’s to generate revenue or boost pro-ductivity, doing more with less is the new norm.
As director of Flowing Springs EMS, Maggie knows it’s imperative that the service operates in an economically sustainable and accountable model.
JeMS 2012 Salary & Workplace Survey>> continued from page 32
Figure 3: Participant Unit Hour Utilization
Response Volume Avg Unit Hours/Week (A)
Avg Call Volume/Week (A)
Avg Unit Hour Utilization (B/A)
Less than 1,000 (999) 310 19 0.06
1,001–5,000 (4,999) 755 96 0.13
5,001–15,000 (14,999) 892 288 0.32
15,001–30,000 (29,999) 1,338 576 0.43
30,001–50,000 (49,999) 2,002 960 0.48
50,001–70,000 (69,999) 3,278 1,344 0.41
70,001–90,000 (89,999) 4,258 1,728 0.41
Greater than 90,000 (99,999) 4,541 1,920 0.42
Figure 4: Unit Hour Utilization CalculatorTotal Unit Hours per Week = (A)
(Total number of staffed hours per week)
Average Call Volume per Week = (B)
(Total number of responses per week including transports, refusals, no transports, etc.)
Unit Hour Utilization = (B/A)
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36 JEMS OCTOBER 2012
Mention productivity to staff, and you can see a visible shudder. If she mentions unit hour utilization (UHU), she can almost hear the chorus of moans. As a visionary leader, she sees great potential for a win/win in her new community paramedicine program.
As uncertainty over the financial impact of the Patient Protection and Affordable Care Act (PPACA) leads the media headlines and politi-cal campaigns, some EMS systems are looking to expand their role in healthcare. PPACA places increased priority on prevention, well-ness and improved outcomes within a healthcare system. Accord-ing to Wikipedia.com, “An accountable care organization [ACO] is a
JEMS 2012 Salary SurvEy>> continued from page 34
Emergency Medical Technician (EMT-B): This section inquires about your full-time emergency medical technicians with basic EMS skill lev-els that may include additional skills, such as defibrillation, assisting patients with medications, and first aid based on the current National Standard Curriculum.
Emergency Medical Technician-Intermediate (EMT-I): A full-time emergency medical technician–intermediate based on the current National Standard Curriculum.
Emergency Medical Technician-Paramedic (EMT-P): A full-time emer-gency medical technician at the paramedic level based on the current National Standard Curriculum.
Emergency Medical Dispatcher (EMD): A full-time emergency medi-cal dispatcher that includes frontline communications positions. Duties include call taking, dispatch, or both. This person may also be certified as an EMT or paramedic.
Communications/Dispatch Supervisor: A first-line supervisor of emer-gency medical dispatcher(s). Duties may include shift supervision, schedul-ing, performance evaluation as well as call taking, dispatch or both. This person may also be certified as an EMT or paramedic.
Communications Manager: A senior management position of the EMS communication center. This position may oversee all operations, budget-ing, hiring, quality and strategic planning.
Field Training Officer: A full-time field training officer whose duties include field training of new employees or EMT students at all levels. This may be a full-time position or performed as part of regular shift work.
Education Coordinator: An entry-level management position. This position may be charged with providing or coordinating continuing medi-cal education, overseeing field training and supporting recertification of staff. In some organizations, duties may be blended with the quality management functions.
Quality Coordinator/Manager: Traditionally, an entry-level management position that may be charged with coordinating and managing key clinical per-formance indicators (e.g., cardiac arrest survival) and quality assurance (e.g., run form review and complaint investigation). In some organizations, duties may be blended with the quality management functions.
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Job DEScriptionS for Salary Data
choose 28 at www.jems.com/rs
choose 27 at www.jems.com/rs
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healthcare organization characterized by a payment and care deliv-ery model that seeks to tie provider reimbursements to quality met-rics and reductions in the total cost of care for an assigned population of patients.”
Can EMS do more? For a UHU calculator, see Figure 3, p 34. Using this year’s respondent data, participant UHU is presented in Figure 4, p. 34. Reported annual response volume and average unit hours were distributed by 52 weeks per year to determine an average UHU. Comparing that UHU to several published benchmarks the con-clusion is clear.6–8 There’s capacity to do more within many EMS
JEMS 2012 Salary SurvEy>> continued from page 34
Financial Officer/Manager: A full-time management position focused on budget and finance that may also have blended duties related to the oversight of billing operations.
Billing/Reimbursement Clerk: A frontline position responsible for pro-cessing patient care records, billing payers and collecting reimbursement for services.
Billing/Reimbursement Manager: Traditionally a middle management position responsible for supervising the processing of patient care records, billing payers and collecting reimbursement for services.
Fleet Mechanic: A frontline mechanic in fleet services whose duties may include preventative maintenance, scheduled/unscheduled maintenance, vehicle remounting/replacement and purchase specifications.
Fleet Manager: A middle management position charged with lead-ing fleet services. Duties may include supervising mechanics, coordinat-ing preventative maintenance, vehicle remounting/replacement and purchase specifications.
Information Technology/Systems Manager: This position may or may not be a management position. Responsibilities may include maintain-ing technological infrastructure (e.g., e-mail, servers, networks, etc.) for the organization.
Logistics/Supply Manager: May be management position or not. Responsibilities may include supply purchasing, storage, distribution and tracking. This position may also manage restocking of stations or ambulances.
EMS Operations Manager/EMS Chief: A middle- to upper-management position responsible for managing day-to-day operations. This position may have field supervisors and other frontline leadership positions reporting directly to them.
Administrative Director/EMS Administrative Chief: A senior-level management position that traditionally includes oversight of all non-operations functions and may include finance, billing/reimbursement and human resources.
Executive Director/Highest-Ranking EMS Chief: A senior leader of all EMS functions whose duties include strategic planning, constituent relations and leading senior management team.
Choose 29 at www.jems.com/rs
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38 JEMS OCTOBER 2012
organizations, whether it be writing parking tickets or becoming more accountable for the health of your community. If you had to choose between the two, it doesn’t seem to be a difficult decision; EMS is at its best when it’s caring for patients.
Can CP programs make a dif-ference? According to the Agency for Healthcare Research and Qual-ity (AHRQ), they do.9 MedStar Health’s Community Health Pro-gram in Fort Worth, Texas, has saved millions in emergency room charges and reduced 9-1-1 use.10 The Centers for Medicare and Med-icaid Services (CMS) must think so as well. In July, the CMS Health Care Innovations Grant program awarded Prosser Memorial Hos-pital in Washington almost $1.5 million to develop and provide a community paramedic program.11
Which model for commu-nity paramedicine should you choose? It could be a “new niche for EMS,” according to the August JEMS article “It Takes a Village.”12 The article identifies the key com-ponent of the multiple CP mod-els as the needs of and resources in the community. “They all fea-ture aspects of home assessment, home care and patient follow-up. They all focus resources on target population, follow-up care and prevention,” the article states. The take-home message: “Com-munity need” should drive model development and implementa-tion, creating a partnership in the healthcare of the community.
With Less?In May 2012, the U.S. Bureau
of Labor Statistics (BLS) reported that the unemployment rate ticked up a tenth of percent to 8.2.13 Yet a February 2012 BLS report on employment projections opened with, “Industries and occupations related
to healthcare, personal care and social assistance … are projected to have the fastest job growth between 2010 and 2020.”14
Listed as one of the “top five indus-tries for salary growth,” health-care workers have gained the biggest changes in wages, 9.4%, since 2006.15
What does that mean to EMS work-ers? There’s reason for some optimism in EMS wages. Twelve job categories from the 2006 JEMS Salary and Work-
place Survey were compared to 2012 data (See Figure 5, at left).16 Despite losses in two individual categories, EMS salaries increased 8% over that timeframe. This increase places EMS with general healthcare as one of the
JeMs 2012 saLary & WorkpLace survey>> continued from page 37
EMT EMT-I EMT-P EM DispatcherEducation
Coordinator
Quality Assurance Manager
2006 Average (Max.) $39,143 $37,485 $51,537 $40,845 $63,444 $65,073
2012 Average (Max.) $45,179 $40,059 $55,696 $46,777 $58,342 $69,017
Loss/Gain (+/-) 15% 7% 8% 15% -8% 6%
Figure 5: Annual Salary Growth Index from 2006 to 2012
Not Applicable
Paid by Employer
Partially Paid by
Employer
Reduced this Year
Eliminated this Year N
New Employee Relocation Expenses 98% 1% 6% 0% 4% 112
Life Insurance 17% 58% 26% 0% 0% 113
Line-of-Duty-Death Insurance 41% 46% 13% 0% 0% 113
Major Medical (Employee) 5% 26% 68% 1% 0% 112
Major Medical (Employee’s Family) 14% 11% 73% 2% 1% 114
Short-term Disability 28% 42% 28% 1% 1% 111
Long-term Disability 31% 38% 29% 2% 0% 109
Employee Assistance Program 18% 72% 11% 0% 0% 113
Dental 17% 18% 65% 1% 0% 113
Optical/Vision 25% 15% 55% 3% 1% 110
Liability Insurance 36% 53% 9% 1% 1% 110
EMS Tuition Reimbursement 19% 40% 33% 3% 5% 113
College Tuition Reimbursement 43% 13% 35% 3% 6% 111
Scholarship Fund for Employee’s Children 97% 0% 2% 1% 0% 111
Retirement or Pension Plan 8% 13% 74% 3% 2% 115
Retirement or Pension Plan 86% 5% 5% 1% 1% 111
Profit Sharing 96% 1% 2% 0% 1% 113
Stock Purchase Program 74% 26% 0% 0% 0% 112
Shift Differential Pay 12% 73% 14% 0% 2% 113
Uniform Allowance 64% 16% 18% 1% 1% 110
Health Club Membership Reimbursement 27% 69% 4% 1% 0% 113
Paid Time Off (PTO) Combined Benefit Leave 97% 0% 2% 0% 1% 110
Daycare Reimbursement 94% 6% 0% 0% 1% 111
Dry-cleaning of Uniforms 95% 2% 3% 1% 0% 112
Meal Service 99% 1% 0% 0% 0% 110
Concierge Service 98% 1% 6% 0% 4% 112
Figure 6: Existing Employee Benefits
Note: Survey results for the following are available at jems.com: Communications supervisor, communications manager, chief financial officer, billing manger, fleet mechanic, information technology manager, operations manager, administrative director, executive director.
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best jobs for wage growth.Not all the news is good. Organi-
zational “belt tightening” is reflected in the 2012 Employee Benefits data (See Figure 6, below left.). Twenty of 25 benefits categories were reduced or eliminated this year. Taking the biggest hits, the categories of EMS reimburse-ment (5%) and college tuition reim-bursement (6%) and new employee relocation expenses (4%) were elimi-nated by organizations reporting.
Show Me the Money“Daylight is burning,” declares Duke as he ends the conversation and heads toward the Communications Center for a schedule of today’s community visits. During his workday Duke will visit a number of “frequent flyers” that have been identified within the health-care community as needing screening and help with chronic care.
One of Duke’s congestive heart fail-ure patients wrote in recent thank-you card to FSEMS that Duke saved him from an ambulance trip to the hospi-tal. “He listened to me breathe, took a blood pressure and made a complete assessment. Then he called my doctor, who adjusted my pills. He did all of this before I was really sick,” Mr. Write wrote, adding that Duke even stopped by later to check on him again that day, concluding with a thank you to both Duke and FSEMS for good com-munity service.
National salaries for 2012 are bro-ken down into several categories and stratified by region (see Figure 7, at right) and call volume (see Figure 8, p. 40). The job descriptions used in the survey are also presented in “Job Descriptions for Salary Data,” p. 36–37. Regional data is reported where antitrust guidelines were achieved. All wages are adjusted to reflect a 40-hour workweek for comparison. See Figure 9, p. 40, for instructions on calculat-ing wages for comparison to different shift lengths.
Author’s note: Comparing 2012 sal-ary data to 2011 appears unreliable due to a qualitative participation bias. Data reported for 2011 national average sala-ries was significantly higher than data
Figure 7: Salaries by Region
EMT EMT-I EMT-PField
Training Officer
EM Dispatcher
Education Coordinator
Quality Assurance Manager
Billing Clerk Supply Clerk
Nat
iona
l
n= 105 39 109 35 44 45 28 47 22Average $27,747 $29,542 $37,909 $45,055 $36,327 $55,570 $60,502 $33,397 $48,511
10th $10,400 $16,672 $21,174 $21,840 $20,096 $30,160 $29,719 $20,509 $18,72025th $18,342 $19,366 $26,000 $25,552 $23,036 $39,092 $45,608 $25,651 $25,27250th $20,800 $23,050 $29,000 $30,319 $29,900 $43,867 $52,894 $27,040 $35,26175th $26,398 $27,040 $35,818 $40,128 $35,770 $52,894 $58,016 $31,200 $44,02390th $32,885 $32,051 $43,867 $55,959 $42,583 $63,128 $66,919 $37,380 $64,067Max $66,789 $66,480 $79,040 $95,000 $61,714 $89,837 $91,243 $62,387 $97,850
Hourly Average $13.34 $14.20 $18.23 $21.66 $17.47 $26.72 $29.09 $16.06 $23.32
Regi
on I
n= 3 1 4 0 2 1 1 3 1Average N/A N/A N/A N/A N/A N/A N/A N/A N/A
10th N/A N/A N/A N/A N/A N/A N/A N/A N/A25th N/A N/A N/A N/A N/A N/A N/A N/A N/A50th N/A N/A N/A N/A N/A N/A N/A N/A N/A75th N/A N/A N/A N/A N/A N/A N/A N/A N/A90th N/A N/A N/A N/A N/A N/A N/A N/A N/A
Regi
on II
n= 6 0 4 2 3 1 1 1 0Average $25,441 N/A N/A N/A N/A N/A N/A N/A N/A
10th $17,520 N/A N/A N/A N/A N/A N/A N/A N/A25th $20,300 N/A N/A N/A N/A N/A N/A N/A N/A50th $29,443 N/A N/A N/A N/A N/A N/A N/A N/A75th $33,181 N/A N/A N/A N/A N/A N/A N/A N/A90th $33,852 N/A N/A N/A N/A N/A N/A N/A N/A
Regi
on II
I
n= 11 3 13 5 7 5 5 10 3Average $28,115 N/A $37,258 $35,784 $33,585 $52,537 $53,150 $31,801 N/A
10th $19,635 N/A $26,789 $28,392 $24,369 $47,520 $48,639 $25,097 N/A25th $21,226 N/A $27,851 $30,888 $27,872 $52,998 $52,582 $27,238 N/A50th $25,230 N/A $34,299 $39,175 $32,531 $60,008 $52,998 $31,325 N/A75th $33,134 N/A $44,286 $40,128 $34,029 $76,460 $56,160 $34,679 N/A90th $41,021 N/A $51,027 $41,251 $44,040 $79,718 $57,264 $37,502 N/A
Regi
on IV
n= 11 8 14 2 6 8 3 8 6Average $25,402 $23,965 $34,328 N/A $38,294 $58,405 N/A $29,463 $58,423
10th $17,977 $18,273 $24,425 N/A $29,204 $39,822 N/A $26,824 $32,00125th $19,559 $21,458 $26,242 N/A $36,006 $48,203 N/A $27,028 $41,24150th $22,763 $23,837 $31,986 N/A $38,480 $57,662 N/A $29,040 $61,84575th $26,731 $26,287 $41,776 N/A $41,922 $67,345 N/A $30,679 $64,59290th $35,547 $28,792 $53,400 N/A $47,199 $80,334 N/A $32,475 $81,425
Regi
on V
n= 23 7 22 9 10 7 5 9 3Average $27,685 $31,501 $37,185 $42,521 $32,662 $50,337 $51,134 $33,532 N/A
10th $21,062 $26,333 $28,291 $23,587 $25,228 $41,191 $36,177 $26,000 N/A25th $24,357 $27,872 $29,796 $25,520 $28,642 $46,500 $45,864 $26,624 N/A50th $26,499 $29,869 $33,966 $30,992 $31,934 $52,000 $53,227 $34,195 N/A75th $28,850 $36,090 $40,082 $58,032 $36,494 $53,040 $60,300 $38,813 N/A90th $38,759 $37,440 $46,413 $64,856 $41,292 $56,431 $64,056 $40,718 N/A
Regi
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n= 7 1 8 3 2 4 3 0 3Average $35.254 N/A $39,857 N/A N/A N/A N/A N/A N/A
10th $18,698 N/A $27,331 N/A N/A N/A N/A N/A N/A25th $23,000 N/A $33,704 N/A N/A N/A N/A N/A N/A50th $31,434 N/A $37,183 N/A N/A N/A N/A N/A N/A75th $42,127 N/A $48,607 N/A N/A N/A N/A N/A N/A90th $55,220 N/A $52,134 N/A N/A N/A N/A N/A N/A
Regi
on V
II
n= 17 5 15 2 5 6 2 4 3Average $25,824 $33,132 $38,950 N/A $37,325 $47,981 N/A N/A N/A
10th $19,215 $21,919 $26,525 N/A $28,445 $31,080 N/A N/A N/A25th $20,800 $22,880 $27,602 N/A $36,011 $34,497 N/A N/A N/A50th $25,938 $31,117 $33,342 N/A $40,000 $46,693 N/A N/A N/A75th $28,787 $35,657 $42,949 N/A $42,213 $57,849 N/A N/A N/A90th $32,349 $47,101 $61,113 N/A $43,885 $66,171 N/A N/A N/A
Regi
on V
III
n= 9 5 10 2 4 5 5 5 4Average $28,929 $28,615 $39,388 N/A N/A $66,083 $65,358 $37,417 N/A
10th $19,479 $22,010 $28,596 N/A N/A $55,371 $59,779 $30,716 N/A25th $22,693 $23,024 $31,767 N/A N/A $60,000 $62,400 $36,712 N/A50th $29,203 $23,400 $37,835 N/A N/A $66,560 $65,562 $40,685 N/A75th $33,301 $28,600 $47,060 N/A N/A $72,800 $67,995 $41,371 N/A90th $40,652 $39,470 $54,199 N/A N/A $76,382 $70,878 $41,508 N/A
Regi
on IX
n= 12 3 11 7 5 6 3 4 2Average $27,723 N/A $37,189 $45,424 $38,420 $51,549 N/A N/A N/A
10th $17,385 N/A $22,384 $24,111 $26,170 $37,482 N/A N/A N/A25th $20,592 N/A $33,280 $31,338 $35,280 $42,115 N/A N/A N/A50th $23,017 N/A $38,251 $37,272 $43,750 $50,397 N/A N/A N/A75th $31,808 N/A $43,212 $56,145 $45,136 $56,684 N/A N/A N/A90th $46,475 N/A $47,445 $71,633 $46,758 $66,768 N/A N/A N/A
Regi
on X
n= 5 6 7 3 0 2 0 0 0Average $28,418 $35,057 $41,438 N/A N/A N/A N/A N/A N/A
10th $20,202 $24,835 $29,993 N/A N/A N/A N/A N/A N/A25th $23,504 $26,559 $35,981 N/A N/A N/A N/A N/A N/A50th $26,578 $29,947 $39,000 N/A N/A N/A N/A N/A N/A75th $34,008 $34,887 $42,026 N/A N/A N/A N/A N/A N/A90th $37,603 $50,388 $54,134 N/A N/A N/A N/A N/A N/A No
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40 JEMS OCTOBER 2012
reported in 2010 and 2012. As previously noted, selective participation and a different pool of respondents year-to-year creates this situation out-side of survey and researcher control. Visit jems.com/jour-nal and click on the salary sur-vey for an extended figure with additional job categories not shown here as well as a com-plete comparison of 2011–2012 data.
Out of 19 job categories, 14 reported sal-ary growth in comparison to 2010 wages. The billing manager position showed no growth in wages between 2010 and 2012 (see bonus salary figure online at jems.com/journal).
EMTs and education coordinators demon-strated a moderate loss in wages, minus two and minus four percent respectively. Chief financial officers (CFO) and supply coordina-tors took the greatest wage losses at -9% and -14%, respectively.
See bonus salary figure online at jems.
com/journal.A just-released Pew
Research Center survey reports that a $70,000 annual income is needed for a fam-ily of four to lead a middle-class lifestyle in the U.S. Using the Pew study definition of
middle-class lifestyle, only three of the EMS job categories—operations manager, admin-istrative director and executive director—would allow a single-income family of four to live middle-class lifestyle .17 In comparison, a registered nurse receives an annual salary
JEMS 2012 Salary & WorkplacE SurvEy>> continued from page 39
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EMT EMT-I EMT-P Field Training Officer EM Dispatcher Education
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Less
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n= 14 5 17 5 6 5 5 6 5
Average
10th $19,917 $20,851 $25,578 $26,707 $31,429 $44,450 $48,805 $26,671 $34,212
25th $23,858 $24,003 $31,846 $30,888 $33,119 $52,998 $52,998 $26,996 43,410
50th $30,674 $30,659 $38,195 $40,128 $36,161 $60,000 $58,000 $28,915 $60,320
75th $35,957 $34,739 $40,976 $52,000 $42,173 $81,120 $62,400 $33,755 $69,00090th $44,993 $35,673 $46,883 $69,934 $43,846 $81,582 $79,706 $40,092 $72,112
1,001
- 5,0
00
n= 31 11 30 7 16 13 9 14 6Average
10th $18,699 $17,160 $26,169 $37,183 $21,934 $36,858 $52,308 $24,923 $32,760
25th $19,864 $22,151 27,945 $37,734 $29,250 $51,144 $55,994 $26,109 $37,700
50th $23,754 $23,442 $34,320 $39,175 $35,646 $52,285 $60,300 $31,325 $43,118
75th $28,694 $30,670 $41,481 $45,594 $41,259 $61,300 $65,000 $36,778 $59,38490th $34,545 $46,717 $54,199 $56,584 $42,401 $71,552 $67,009 $40,348 $66,387
5,001
- 15
,000
n= 27 8 25 7 9 15 6 15 5Average
10th $19,386 $21,996 $27,144 $24,048 $28,417 $40,782 $50,148 $27,040 $19,402
25th $23,601 $25,350 $29,709 $28,256 $35,528 $42,934 $54,573 $27,581 $20,426
50th $27,642 $29,132 $34,112 $45,302 $41,600 $52,894 $66,770 $31,200 $63,369
75th $31,317 $31,558 $42,308 $54,713 $45,000 $59,266 $85,868 $37,877 $65,00090th $35,260 $33,540 $46,263 $61,318 $45,294 $76,935 $89,655 $54,898 $84,710
15,0
01 -
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00
n= 13 7 17 9 7 5 5 5 2Average
10th $24,011 $22,233 $27,275 $34,924 $31,889 $40,230 $49,559 $32,292 N/A
25th $27,579 $23,335 $28,148 $37,088 $35,262 $40,455 $50,612 $32,967 N/A
50th $35,755 $25,506 $42,389 $44,822 $37,844 $41,126 $52,368 $34,592 N/A
75th $41,856 $28,808 $49,140 $51,019 $41,427 $44,871 $57,659 $36,242 N/A90th $46,432 $36,660 $62,519 $60,872 $43,704 $50,627 $60,834 $36,961 N/A
Grea
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n= 6 3 5 1 1 3 1 2 1Average
10th $17,091 N/A $22,425 N/A N/A N/A N/A N/A N/A
25th $17,328 N/A $22,823 N/A N/A N/A N/A N/A N/A
50th $17,723 N/A $23,486 N/A N/A N/A N/A N/A N/A
75th $19,822 N/A $24,149 N/A N/A N/A N/A N/A N/A90th $21,081 N/A $24,547 N/A N/A N/A N/A N/A N/A
Figure 8: Salaries by Call Volume
Figure 9: Calculating Alternative Shift Schedule Wages
Average Work Week Straight Hours x 52 weeks/year Annual Straight Hours40 hours 40 straight hours x 52 weeks 2,080 hours48 hours 52 straight hours x 52 weeks 2,704 hours56 hours 64 straight hours x 52 weeks 3,328 hours
All wages are calculated based on 2,080 hours annually (40-hour work week).To calculate alternative shift schedules, divide an annual wage for a position by 2,080 hours to find the hourly rate and then multiply the result by the annual number of straight hours for the shift type of interest. Below are examples for the three most common average weekly hours.
30_41salary.indd 40 9/12/2012 4:04:50 PM
www.jems.com ocToBeR 2012 JEMS 41
of approximately $70,000.18,19 It’s no wonder that EMS often experiences a migration of EMS personnel to nursing professions.
ConClusionDuke considers the opportunity that the community paramedicine program has pro-vided him to be a good one. “It’s not just a paycheck. I get to help people before they need an ambulance. I get to spend some time helping them stay out of the ambulance and hospital,” he thinks. “And it saves the system money. How great is that?”
Considering the current state of jobs and employment in the U.S. today, EMS is look-ing pretty good. Although the profession’s future might not quite be bright enough for “dark sunglasses,” wage growth has been a bright spot in an otherwise depressed U.S. job market. EMS innovation, aimed at serving the population and cutting costs, has demon-strated benefit and value to healthcare. Com-munity paramedicine is a key component in future ACO success.
Based on the quantitative reductions in education, training and tuition reimburse-ment, EMS leaders and providers in all sectors of the industry are cautioned that short-term economic gains may hinder future EMS capacity and capability. Further, a family-oriented EMS employer must con-sider that many EMS workers households are supported by two working adults in order to maintain a middle-class lifestyle. Flexible staffing, scheduling, childcare and sick child-care may be a key component of workforce recruitment, retention, employee satisfac-tion and loyalty.
Circling back to Staley’s motivational the-ory in EMS, it’s the person who brings the pas-sion that gives the “heart” to EMS. A paycheck is meaningless if you lack the understanding of those human components.
Michael Greene, MBA/MSHA, is a senior associate at Fitch & Associates. He has served in frontline and leadership posi-tions, including volunteer and paid search and rescue, as a paramedic, a county EMS director and an air medical/criti-cal care transport director. He’s the author of numerous arti-cles and chapters on EMS, air medical transport and safety. Contact him at [email protected] or 816/431-2600.
Acknowledgment: The author acknowledges the support and contributions of Fitch project team members Sharon Conroy, Melissa Addison and Cindy Jackson.
Disclosure: The author is an external, expert con-sultant with the consulting firm Fitch & Associates, LLC, which provides emergency service organizational and sys-tem audits for communities and individual organizations.
Note: If you’re an EMS service with paid staff that did not participate in this year’s survey but would like to include your agency data next year, please e-mail the author.
RefeRenCes1. DepartmentofJusticeandFederalTradeCommission.
(August1996).StatementsofAntitrustEnforcementPolicyinHealthCareStatement6:Enforcementpolicyonproviderparticipationinexchangesofpriceandcostinformation.InFederalTradeCommission.RetrievedJuly13,2012,fromwww.ftc.gov/bc/healthcare/industryguide/policy/statement6.pdf.
2. StaleyMF.IgnitingtheLeaderWithin:TheleadershiplegacyofBenFranklin,fatheroftheAmericanfireser-vice.FireEngineeringBooks:SaddleBrook,N.J.,120,1998.
3. GreeneM&WrightD.JEMS2011SalaryandWorkplaceSurvey.JEMS.2011;36(10):42–49.
4. ACEPBoardofDirectors.(April2012).MedicalDirectionofEMS.InAmericanCollegeofEmergencyPhysicians.RetrievedAug.10,2012,fromwww.acep.org.
5. FowlerB.(July12,2012).Carparkednearhydrant?ORfirefightersmightwriteyouup.InKnoxvilleNewsSentinel.RetrievedJuly16,2012.fromhttp://www.knoxnews.com/news/2012/jul/12/car-parked-near-hydrant-or-firefighters-might-up/.
6. AndresonD.&OvertonJ.HighPerformanceandEMS:Marketstudy2006–2009.CoalitionofAdvancedEmergencyMedicalSystems.2007.
7. KuehlAE,editor.PrehospitalSystemsandMedicalOversight.Kendall/HuntPublishingCompany:Dubuque,Iowa.2002.
8. SchaltbergerHA.(n.d.).EmergencyMedicalServices:Aguidebookforfirebasedsystems.4thedition.InInternationalAssociationofFireFighters.Retrievedfromwww.iaff.org/tech/PDF/EMSGuideBk.pdf.
9. AgencyforHealthcareResearchandQuality.(Jan.18,2012).TrainedParamedicsProvideOngoingSup-porttoFrequent911Callers,ReducingUseofAmbu-lanceandEmergencyDepartmentServicesAgencyforHealthcareResearch.InU.S.DepartmentofHealthandHumanServices.RetrievedAug.112012fromwww.innovations.ahrq.gov/content.aspx?id=3343.
10. MedStarEMS.(2012).CommunityHealthProgram.RetrievedAug.14,2012,fromwww.medstar911.org/community-health-program.
11. PMHMedicalCenter.(2010).PMHAwardedCommunityParamedicGrant.InPMHMedicalCenter.RetrievedAug.14,2012fromhttp://pmhmedicalcenter.com/index.php/resources-for-you/latest-news/item/119-pmh-awarded-community-paramedic-grant.
12. BerryJ.ItTakesaVillage.JEMS.2012;37(8):42–47.13. U.S.DepartmentofLabor.(n.d.).Databases,Tables&
CalculatorsbySubject.InBureauofLaborStatistics.RetrievedJuly12,2012fromhttp://data.bls.gov.
14. U.S.DepartmentofLabor.(n.d.).Databases,Tables&CalculatorsbySubject:Employment.InBureauofLaborStatistics.RetrievedJuly12,2012fromhttp://data.bls.gov.
15. RitterT.(July16,2012).BestandWorstJobsforWageGrowth[infographic].InPayscale.RetrievedAug.2,2012,fromhttp://blogs.payscale.com/compensation/2012/07/prevailing-wage-rates.html.
16. WilliamsDM.2006JEMSSalaryandWorkplaceSurvey.JEMS.2006;31(10):38–49.
17. PewSocial&DemographicTrends.(Aug.22,2012).Fewer,Poorer,Gloomier:Thelostdecadeofthemiddleclass.InPewResearchCenter.RetrievedAug.22,2012,fromwww.pewsocialtrends.org/files/2012/08/pew-social-trends-lost-decade-of-the-middle-class.pdf.
18. BaconD.Resultsofthe2011AORNSalaryandCompensationSurvey.AORNJ.2011;94(6):536–553.
19. U.S.DepartmentofLabor.(May2011).OccupationalEmploymentandWages:2011;29-1111registerednurses.InBureauofLaborStatistics.RetrievedAug.5,2012,fromwww.bls.gov/oes/current/oes291111.htm.
Takeaway PoinTs: 2012 DaTa
Innovative EMS leaders and staff are looking at new ways to increase productivity, efficiency and economics within the industry. The future may be inherited by those agencies with a vision of healthcare over a population ‘without walls.’ Early results of community paramedicine programs demonstrate favorable outcomes especially in light of healthcare reforms.
> Motivation is more than a paycheck in EMS. EMS leaders and medical directors must leverage indi-vidual’s passions and talents through personal inter-actions and understanding that goes beyond policy and workplace compliance.
> EMS has provided excellent wage growth during
tough times. This fact is important as a recruitment tool and incentive to those in, and those considering, a career in EMS.
> Cutbacks in orientation, field training and education benefits may serve a short-term staffing and economic purpose but continued cuts may affect long-term work force performance, knowledge acquisition, succession and satisfaction.
> A middle-class lifestyle can’t be achieved by most EMS job categories on a single income. Family-oriented orga-nizations must be innovative in employee programs designed for two working adult families.
30_41salary.indd 41 9/12/2012 4:05:04 PM
The landmark decision by the U.S. Supreme Court to uphold the constitutionality of the Patient
Protection and Affordable Care Act (PPACA) could become a watershed moment for EMS, according to number of EMS leaders. The five-to-four decision by the justices may open the door for the kind of opportunities to deliver patient care outside the narrow confines of the traditional prehospital emergency system. The question now is: “How will we step up and define how our organizations move forward?”
The Supreme Court decision upheld the individual mandate with a twist. Although
the federal government doesn’t have the power to force citizens to purchase health insurance, it can impose a tax on those who choose to go without coverage. All other provisions of the healthcare law, often referred to as “Obamacare,” including the Medicaid provision (with modifications) and the section establishing accountable care organizations (ACOs), were upheld.
Although the legislation has passed a major judicial hurdle, it still faces politi-cal challenges. Even before the ruling was made public, Speaker of the House John Boehner pledged his party would launch an immediate effort to repeal the law. Still, EMS
leaders warn against taking a “wait-and-see” approach. “This is not the time to sit at home. This is the time to be engaged,” says Scott Bourn, PhD, EMT-P, vice president of clinical practices and research at American Medical Response, Inc. (AMR).
He and others believe that the opportu-nity exists for EMS to evolve beyond the con-ventional “load-and-go” model into a more sophisticated concept of caring for patients outside of a hospital, including transport to alternative facilities and the expansion of the scope and practice of paramedics. He describes integration into the healthcare system as a “therapeutic win-win” for the
The following article is part one of two in an EMS Insider exclusive series on healthcare changes. The Insider, the premier publication for EMS managers, supervisors, chiefs and medical directors, is a must-have resource for the critical, accurate information EMS leaders need. The monthly publication offers quality investigative reporting, exclusive articles, management tips and the very latest news on legislative issues, grants, current trends and controversies. For more about how to become an Insider, go to www.jems.com/ems-insider.
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42 JEMS OCTOBER 2012
Changes present an unparalleled opportunity for eMs >> By Teresa Mccallion, eMT-B
ManageMent Focus
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www.jems.com ocToBeR 2012 JEMS 43
patient, the hospital and EMS. James J. Augustine, MD, FACEP, director
of clinical operations at Emergency Medicine Physicians (EMP) in Canton, Ohio, says this is a chance for EMS to help design a better system of emergency care outside the tra-ditional role of transporting patients from site to site. “EMS has a very important role as a provider of unscheduled care,” he says. “This really is our opportunity to identify the issues and parts of our practice that need to be reformed.”
He notes that healthcare can benefit from the experience of both fire and EMS in the area of prevention measures. “Preventing premature deaths has been the mark of the prehospital emergency system for the past 40 years,” he says. He believes that EMS should promulgate its successes in preven-tion and allow those lessons learned to be used in the design of new healthcare preven-tion efforts, improving the overall delivery of healthcare. “I’m a big supporter of our emer-gency system, and there are opportunities ahead to demonstrate our expertise,” he says.
Insurance coverageOne thing is certain: The number of peo-ple with healthcare insurance will dra-matically increase. The U.S. Census Bureau estimates that currently, nearly 50 million Americans—including nearly one in four working-age adults—are without insurance.
Many lost their healthcare coverage when they lost their jobs. Those who kept their insurance have been faced with rising pre-miums that put a strain on employers and employees alike. According to the Kaiser Family Foundation, a nonprofit organization that focuses on healthcare policy and issues, the average health insurance premium for family coverage has more than doubled dur-ing the past decade to $13,770 a year.
To provide health insurance for those who can’t afford it, the PPACA calls for the expansion of the Medicaid program. After 2013, individuals who earn up to 133% of the Federal Poverty Level (approximately $14,856 annually) will become eligible for Medicaid, a state-run program that uses matching funds from the federal government.
Currently, the federal government pays 57% of the cost of Medicaid to the states. Under the new law, the federal government will fully fund Medicaid for the first three years, decreasing its support to 95% by
2017, then 90% by 2020. Twenty-six states have publicly balked at the idea of taking on that kind of debt. In the ruling, the Supreme Court said that the portion of PPACA allow-ing Congress to penalize states that opt out by withholding all or part of the state’s Medicaid funds was unconstitutional. It’s nearly certain that some states won’t add these additional Medicaid recipients to their rolls, although it’s unclear at this time which ones will participate and which ones will not—a factor that will certainly affect EMS. Providers operating in these states will face higher uncompensated care due to a larger uninsured population.
“For EMS leaders who are politically active, this is the time to start asking what your state plans to do,” says Bourn. As stakeholders, EMS has a say in whether the state accepts those funds.
Individuals not covered by the Medicaid expansion will be required by law to main-tain “minimum essential” healthcare cover-age beginning in January 2014, or they will pay a penalty when filing their income taxes in 2015. Because the penalty is expected to be lower than the cost of insurance, some peo-ple may simply choose to pay the penalty.
For those who aren’t covered by employer policies, the PPACA provides for health insur-ance exchanges. These exchanges, set to go into effect no later than Jan. 1, 2013, should drive down the cost of healthcare policies by allowing individuals, who previously had to purchase policies at a higher rate, to buy into a cheaper “group rate” policy.
However, many states have held off on implementing of these exchanges in antici-pation of the Supreme Court ruling and may not meet the deadline. The U.S. General Accounting Office has estimated that the net result of PPACA could be that approximately 30 million Americans currently without health insurance will be insured under the new law.
revenuesThe EMS leaders interviewed for this article all agreed that although Medicaid reim-burses below the cost of providing the ser-vice—6% below according to a 2007 report by the American Ambulance Association, based on 2004 data—some reimbursement is better than nothing. In Minnesota, Aaron Reinert, executive director of Lakes Region EMS, says the added revenue could mean an additional $2 billion in healthcare coverage
to his state. He sees this as a huge advantage to begin to receive reimbursement for ser-vices his agency already provides.
Increasing the number of patients whose service is paid for by a third party offers an added benefit of providing a certain level of fiscal stability for an organization. Agencies that can now count on a stable reimburse-ment rate in the 80–90% range can think about long-term fiscal planning and invest-ments in innovation, although a couple of bumpy years may be ahead until the new payor mix settles.
Although no one believes ambulance services will get rich transporting these potentially insured patients, EMS admin-istrators aren’t the only ones who see a promising opportunity. During the past year, private equity firms have been buy-ing ambulance providers, including the two largest ambulance companies in the U.S., Rural/Metro Corporation and AMR. They see potential revenues created by the conflu-ence of the baby boomers and the expanding market of those covered by Medicaid under healthcare reform.
They aren’t the only ones eyeing Medicaid money. Analysts say that Medicaid repre-sents a growth opportunity for U.S. insurers. In July, the nation’s second-largest health insurer, WellPoint Inc., acquired Amerigroup Corp., which runs Medicaid coverage in 13 states, for a reported purchase price of $4.46 billion.
HeatHcare IntegratIon EMS was hardly mentioned in the more than 2,600 pages of the healthcare reform act; however, the ability to test new payment and care delivery models through demon-stration projects funded by the Center for Medicare and Medicaid Innovation does exist. Enterprising providers ought to be seeking demonstration projects to authorize system changes that allow for treat-and-release, alter-nate destinations and in-home care.
“It isn’t the bill I would’ve written … but it provides needed access to insurance, espe-cially for chronically ill patients,” says Bourn. That, he says, will change the dynamics of patient care for EMS. With increased primary care, these patients’ conditions will be less likely to deteriorate to the point where they need EMS. The bill also creates an opportunity for EMS to become integrated into the health-care system in a way it never has been. “Right
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44 JEMS OCTOBER 2012
now, we operate on an island,” Bourn says. “We can’t be an island anymore.”
Using the core competencies of EMS, there are numerous opportunities to care for patients outside the traditional emer-gency room setting. “Sometimes the patient needs to be monitored at home,” Bourn says. He doesn’t advocate replacing home healthcare workers, but rather augmenting their responsibilities by using interventions within the paramedic’s skill set and expert assessment on who’s sick and not sick to make an informed decision on whether to go to the hospital or stay home. “We are the experts in remote care in EMS,” he says.
O.J. Doyle, a consultant for the Minnesota Ambulance Association and the American College of Emergency Physicians and the only full-time state EMS lobbyist, couldn’t agree more. “Healthcare reform creates a very fertile environment for the community paramedic,” he says. Doyle, a former para-medic, has been both an operations director
and the owner of an ambulance service. “As we move forward, innovation and creativity is going to be rewarded,” he says. The goal will be to keep people who don’t need to be in the hospital out of the emergency department.
Doyle warns EMS administrators to be aware of possible state statutes that prohibit EMTs and paramedics from providing this type of care. That will require becoming active on the state level and educating law-makers. “You are all ambulance drivers to your state-elected officials,” he says.
However, the path to passing EMS legisla-tion has been blazed by leaders, including Doyle, who know how to avoid opposition from other medical professionals who may feel threatened. “It’s all about the packaging,” Doyle hints.
EmployEr rEsponsibilitiEsFrom an employer perspective, beginning in 2014, employers with 50 or more full-time equivalent employees will need to
offer full-time workers affordable insur-ance options or incur annual penalties of $2,000–3,000 per employee. The rules are slightly different for public employers. Every agency should consult a competent counselor to ensure compliance.
If you provide health insurance to your employees, research what constitutes a “Cadillac” plan. Most immediately think of the firefighters—who were given a morato-rium on their plans, with a sunset clause—but this can also affect some “Mom and Pop” agencies that provide a certain level of coverage for employees, but a much higher level for themselves. The new law applies a 40% surcharge for these types of plans. The surcharge must be paid for by the employer. None of it can come out of the pockets of the employees. JEMS
Teresa McCallion, EMT-B, is the editor of EMS Insider and a freelance public safety writer living in Bonney Lake,
Wash. Contact her at [email protected].
HEaltHcarE rEform >> continued from page 43
From a billing, employee and systems perspective, EMS administrators should be prepared in the following ways:
>> Expect increased volume: People who previously did not call 9-1-1 because they feared they couldn’t pay for the cost of transport and hospital bill will now be able to call for service. At least initially, expect an increase in the number of transports. “I see this as a short-term step of a few years,” Bourn says. As patients begin receiving appropriate primary care, those numbers should level out.
>> Expect changes in flow patterns: Now that people have insurance, they may want to be transported to a hospital they perceive provides a higher quality of care than the one they previously frequented.
>> Meet a hospital administrator: Your local hospital administrator may be your new best friend. They’re probably already looking at pay-for-performance issues. Ask them how you can help. For most administra-tors, EMS is just hospital ride, and they don’t realize EMS’ competencies and capacity. It’s up to you to educate them.
>> Prepare your workforce: This is a cultural change in clinical practice unmatched since EMS was introduced. There are a million ways to be a nurse, but only one way to be a paramedic. That will change. As an EMS leader, you must prepare your workforce for these changes. Some peo-ple have no desire to do anything but 9-1-1 calls. However, some, maybe toward the end of their career, prefer something that looks more like a healthcare generalist with a tremendous emergency care capacity. What this means for the workforce is an opportunity for expanded career paths in EMS. For EMS administrators, paramedics will no longer be interchangeable, and administrators will have to be responsible for
more human resource management than they ever have before. >> Join an EMS organization: If you haven’t already, join national EMS
organizations or associations that support the industry. Many are already hard at work providing recommendations for their members. Several provided executive summaries within days of the Supreme Court ruling and have already scheduled webinars to assist members with understanding the possibilities and challenges presented by healthcare reform. These will be particularly helpful with compliance issues. “By paying dues, we are supporting people to be our voice at the regional, state and national level,” says Reinert, who chairs the National EMS Advisory Council (NEMSAC), an organization that provides critical advice to the National Highway Traffic Safety Administration (NHTSA) Office of EMS and the Department of Transportation and the Federal Interagency Committee on EMS (FICEMS).
>> Conduct a cost analysis: The PPACA will require a cost-analysis on a regular basis to justify billing.
>> Check third-party agreements: The new law strengthens anti-kickback standards. Check all agreements with third-party vendors to ensure compliance.
>> Validate certifications: By 2015, all EMS agencies will be required to conduct a re-validation of service. Make sure every provider’s certifica-tion is up to date.
>> Do research: Research opportunities will continue to exist for docu-menting the value of excellent emergency care. All EMS agencies need to contribute to research efforts that verify how EMS contributes to the overall healthcare system.
How Ems managErs can prEparE
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LessonsLearned in
hypothermia prevention
under difficuLt fieLd conditions
>> By 2LT CoLLin Hu, EMT-E, & JaMEs spoTiLa, pHD, EMT-B
Preventing the onset of hypo-thermia is difficult when ambient conditions can’t be
controlled. This is illustrated by a 2011 cave rescue in rural southwest Virginia. A man wedged in a fissure at the entrance of a cave was exposed to sub-freezing air temperatures for 12 hours until extricated. The rescue effort included up to 50 first respond-ers from Carilion Clinic LifeGuard, which was in charge of patient care; Blacksburg Volunteer Rescue Squad; the Virginia Tech Cave Club; the Newport Volunteer Rescue Squad; the Giles County Volunteer Rescue Squad; the Newport Volunteer Fire Department and the Virginia Tech Rescue Squad.
EMTs succeeded in keeping the patient warm by using chemical heat packs, an electric blanket and hair dryer, and by keeping the patient physically active. This article sum-marizes this event. It also presents the physiological aspects of hypother-mia, and the importance of a creative, flexible approach to complex rescue scenes in challenging environments.
Saved from the ColdOn a late winter afternoon in 2011, multiple fire, rescue and EMS units were dispatched to the edge of a farm in rural Virginia for a patient report-edly trapped at the entrance to a nat-ural limestone cave. The 26-year-old patient had been wedged in an irreg-ular rock fissure in a semi-standing position for more than two hours prior to 9-1-1 being called.
Initial concerns of a crush injury or related trauma were quickly replaced by fear of exposure-induced hypo-thermia. Though dry, the patient was clad in only a t-shirt and pants, and much of his body was in full con-tact with bedrock. The air tempera-ture dropped below freezing with the onset of nightfall.
The challenge posed to the EMTs was not one of assessment, but how to keep a nearly inaccessible patient warm for a scene time that would last almost 12 hours.
After initial efforts to pull the patient free failed, rescue specialists were called in. Extricating the patient was a long process that required the removal of small protruding rock edges from the walls of the fissure using handheld percussion hammers and then extricating the patient in an upward direction.
Members of a cave rescue team worked from within the cave, below the fissure, chiseling away rock and pushing the patient upward, while a heavy tactical rescue (HTR) team above the cave entrance removed rock from around the patient’s upper torso and pulled him upwards using ropes secured to his waist.
Progress was measured in inches per hour. The patient’s body was ini-tially pinned in several places, con-fining his left leg in a bent position beneath him. But as he was lifted, he became snagged by additional rock ledges that had to be removed, result-ing in a repetitive cycle of chiseling and lifting that went on for hours.
The patient remained alert and ori-ented throughout the ordeal. EMS ini-tially found his skin was cold and pale. He was uncomfortable, but was not showing signs of significant hypothermia. However, his condi-tion slowly worsened, reaching a low point seven hours after becoming stuck. At his worst, still four hours before being extricated, the patient was lethargic, shivering moderately, and without radial or pedal pulses. He exhibited a Glasgow Coma Scale (GCS) score of 14, a heart rate of 90 beats per minute, respirations of 20 on ambient air, and blood pressure of 76/54.
Through creative efforts under-taken to actively warm him (see below) and after his body was steadily shifted to a more comfortable posi-tion by the rescue efforts, the patient’s condition gradually improved over the course of an hour. His color improved, he became more vibrant, and vital signs improved to GCS of 15, heart rate of 64 beats per minute and blood pressure of 115/85.
The patient was ultimately freed in stable condition after almost 11 hours stuck in the cave. His vital signs after he was placed on a backboard and in the ambulance were: heart rate 118, respirations 18, blood pressure 175/121, and skin still pale and cold. Despite an air temperature of 14° F when he was extricated at 3 a.m., his core temperature had only dropped to 96.8° F. Active warming efforts by EMTs had been successful at pre-venting systemic hypothermia. The
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Keeping this nearly inaccessible patient warm during an extended rescue demanded creativity.
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48 JEMS OCTOBER 2012
patient was further assessed in the ambulance and then flown by Carilion Clinic LifeGuard to Carilion Roanoke Memorial Hospital, from which he was released the next day.
SyStemic HypotHermiaHypothermia is separated into three phases: mild, moderate and severe.1 Mild hypother-mia begins when the core body temperature, which normally varies among individuals from 98–100° F, drops below 95° F. 2
As core temperature drops, several physi-ologic changes occur as the body begins to conserve and attempt to generate heat. This process occurs through activation of the sym-pathetic nervous system and includes shiv-ering, hyperglycemia, tachycardia, vascular constriction and hypertension.3
When core body temperature drops below 89.6° F, moderate hypothermia sets in.2 It results in significant altered mental status including hallucinations, agitation, somno-lence and possible loss of pupillary reflex. Other findings include bradycardia, decreased cardiac output and hypoventilation.3 ECG abnormalities are also common, specifically a J or Osborn wave, which is specifically a dis-tortion of early membrane repolarization and indicative of moderate hypothermia.4
In severe hypothermia (when body tem-perature drops below 82.4° F), a patient will exhibit marked stupor and all shivering will cease.2 The patient will experience progres-sively worsening bradycardia, hypotension and hypoapnea, progressing to shock and multi-organ system failure.3
This patient exhibited signs of mild hypo-thermia throughout the incident. During the time when he had his lowest blood pressure readings and became increasingly lethargic, EMTs on scene were concerned about poten-tial onset of moderate hypothermia.
Although it was not possible to quantify the patient’s temperature by direct measurement due to his confined position, his rapid recov-ery suggests his condition never advanced beyond the mildest stage of hypothermia.
The rates at which a patient’s core tem-perature drops and stages of hypothermia are experienced are highly dependent on ambi-ent conditions. The timescale can vary from minutes (i.e., when submersed in cold water) to days (i.e., when exposed to freezing air tem-peratures with inadequate clothing).
During this cave rescue, onset of hypother-mia was slow because the patient was dry and
winds were calm, particularly due to shield-ing by rock formations. The bedrock he was in direct contact with initially lowered his temperature by conductive heat loss more rapidly than heat lost directly to the atmo-sphere. This is because the rock was colder than the afternoon air temperature. However, the rock walls eventually worked to insulate him, because the cooling of the rock surface lagged behind the plummeting temperature of the air. (Note: Had the patient been trapped inside the cave, as opposed to its entrance, the ambient temperature would have been a con-stant 54° F, the mean annual temperature for this location.) The patient’s large body mass of around 220 lbs. also contributed to relatively slow conductive heat loss.
DiScuSSionThis rescue illustrates the challenges when key factors that are normally taken for granted on calls are absent, namely patient access, a stable environment and limited scene time. Unlike most situations, it wasn’t possible to remove this patient to a safe ambient setting.
Because of his confinement, it was diffi-cult to even obtain vital signs. It wasn’t pos-sible to establish an IV or intraosseous access, given the limited access to his extremities and because of the rigorous motions involved in the rescue. EMTs couldn’t have placed defi-brillator pads on the patient had they been needed, and even oxygen by mask wasn’t feasible because of the amount of hammer-ing around the patient’s head and the motion required of him during the effort. Keeping the patient warm, which was the primary goal of the EMTs during the rescue effort, also required flexibility and creativity.
The orientation and confinement of the patient prevented wrapping him in blankets or additional clothing. The primary effort to warm him consisted of applying 20-minute duration chemical heat packs wherever acces-sible, including his hips, arms and neck. The responding units quickly depleted all of their heat packs and eventually drained the store-rooms of several neighboring EMS agencies, ultimately consuming about 175 packs.
Other means of warming included a propane space heater, but this couldn’t be brought close enough to be effective and posed a risk of fumes and fire to the rescu-ers inside the cave. An electric hair dryer borrowed from a local farmer was moder-ately successful at warming the air around the
patient’s upper body, while an electric blanket draped over the patient’s head and shoulders helped as well.
Perhaps the most important warming was from the patient himself. During the course of the extrication, particularly the final few hours after his spirit was buoyed by the steady gains main by removing rock, the patient was very active, almost frantic, in his efforts to wiggle free and pull himself up and out with the rescuers’ assistance. Although this auto-warming helped keep hypothermia at bay, the fear was that the patient would exhaust him-self or suffer further injuries and then quickly succumb to the cold. Fortunately, he was extricated in time.
concluSionThe lesson to take away is that some calls require creative, even ingenious efforts to keep patients alive and bring them to safety. In this case, first responder thinking had to evolve quickly and then continuously adjust and seek out alternatives as the rescue effort stretched on.
When hypothermia from exposure is a risk, anything that warms without harming should be considered. Prolonged wintertime rescues like this also require special attention to scene safety to avoid cold-related injury and exhaustion of the first responders themselves.
This rescue illustrates that in addition to standard qualities of first responders, particu-larly diligence, selflessness, calmness and pro-fessionalism, some complex rescue scenes demand creativity and flexibility as well. JEMS
Collin Hu, EMT-E, is second lieutenant in the U.S. Army, and
a fourth-year medical student at the Edward Via College of
Osteopathic Medicine. He is a member of the Blacksburg
(Va.) Volunteer Rescue Squad.
James A. Spotila, PhD, EMT-B, is associate professor of
geology at Virginia Polytechnic Institute and State University
and a member of the Blacksburg Volunteer Rescue Squad.
referenceS1. McSwainNE.“EnvironmentalTraumaI:HeatandCold”
inPHTLSPrehospitalTraumaLifeSupport,6thEdition.MosbyJems/Elsevier:St.Louis.424–437,2007.
2. StephenRL.“HypothermiaandFrostbite.”Emer-gencyMedicine.Saunders/Elsevier:Philadelphia.1445–1450,2008.
3. HananiaN&ZimmermanJL.Accidentalhypothermia.CritCareClin.1999;15(2):235–249.
4. NolanJ&SoarJ.TheECGinhypothermia.Resuscita-tion2005;64(2):133–134.
mobile Warming >> continued from page 47
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www.jems.com | october 2012 | jems 51
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Timely diagnosis and restoration of coronary artery flow remains the cor-nerstone of treatment for patients with ST-elevation myocardial infarction
(STEMI). During the past six years, enormous efforts by hospitals and medical professionals have focused on a specific phase of coronary reperfusion, namely the “door-to-balloon” process. As a result of this work, more than 90% of patients pre-senting to hospitals with percutaneous coronary intervention (PCI) facilities are now treated within 90 minutes of hospital arrival.1
However, despite the improvements in door-to-balloon time, the current emergency cardiac care system often performs well below its potential. In 2012, more than half of the STEMI patients who called 9-1-1, and those transferred from outside emergency departments (EDs), haven’t met the new guideline goals for reperfusion: EMS arrival to device deployment within 90 minutes for EMS-transported patients, and first hospital door-to-device within 120 minutes for transferred patients.2,3 Paramedics should play a pivotal role in coronary reperfu-sion. Pre-notification and laboratory activation can reduce door-to-balloon times below 30 minutes.
These time goals can only be achieved with the expansion of STEMI protocols beyond the 1,400 hospitals with PCI facilities to the 3,600 hospitals lacking such capability and to the more than 15,000 EMS agencies in the U.S. Emergency car-diac care systems must evolve beyond the PCI hospital door with implementation on a regional basis.
Following the examples of such models as Los Angeles County and North Carolina, every hospital and EMS agency within a region should have a pre-specified and coordinated plan in which healthcare professionals know their role in the identification, diagnosis and expediting treatment of patients experiencing acute myocardial infarction.4-7
In order to meet the full potential of emergency cardiac care, the Regional Systems of Care Demonstration Project: Mission: Lifeline STEMI System Accelerator Program, funded in part by two-year grants from Philips Healthcare, The MEDICINES Company and Abiomed, has selected 20 regions across the U.S. for sustained efforts to regionalize coronary reperfusion plans. These 20 sites were selected based on leadership, organization and facilities, and their likelihood of developing coordinated diagnosis and treatment plans in every hospital and EMS agency in their region.
The STEMI Accelerator Program is designed to build on the experience of successfully implemented regional systems. According to a national survey of 381 STEMI systems conducted by the American Heart Association (AHA), the single most commonly cited barriers to system implementation were hospital and physi-cian competition.8 The program’s interventions are led by national faculty and local AHA staff who will serve as neutral intermediaries between EMS agencies, hospitals and physicians within a region.
A number of tenets are central to this accelerator intervention. It’s designed to build or advance systems that are ultimately self-sustaining and use exist-ing regional and national resources whenever possible, such as the ACTION Registry®-GWTGTM data and regional system reports. The program focuses on supporting leaders within each region to design, implement and sustain the system.
The ultimate goal is to establish rapid diagnosis and treatment of STEMI as a uniformed standard of care across every EMS agency and hospital within a region. When it comes to building emergency cardiac systems, a number of key features are shared across regions, including implementing national guidelines, similar ECG equipment and protocols, and having hospital systems to support rapid PCI. Many issues are unique to specific regions, largely based on the interplay of geography, government and market forces. Thus, the project will be guided by EMS providers in each region regarding challenges and barriers.
The project’s intervention will follow an approach that was developed a num-ber of regional STEMI systems. The initial focus will be on the establishment of leadership, common data and funding. Funding is primarily required to support data collection and analysis, and to provide a neutral “feet on the ground” regional system coordinator/implementer. Next, all PCI hospitals in the region will be organized to provide rapid intervention on a systematic basis that includes single
call catheterization laboratory activation by paramedics and emergency physicians on a 24/7 basis, accepting all patients regardless of bed availability, participation in the regional data registry, and adoption of regional reperfusion protocols. In develop-ing these protocols, the focus has been directed toward three patient scenarios that have the most potential to save time and lives: patients presenting by EMS, patients transferred from hospitals lacking PCI facilities, and patients with early signs of cardiogenic shock.
With pre-specified and uniform protocols, paramedics, nurses and emergency physicians who first come into contact with patients can rapidly implement treatment plans without delay for consultation or need to identify the accepting facility.
Once PCI hospitals have adopted the above processes to rapidly provide coronary reperfusion, coordinators and leaders will work with EMS agencies and non-PCI hospitals to adopt a STEMI diagnosis and treatment plan consistent with regional protocols and local resources. A final step involves ongoing measure-ment and feedback through Mission: Lifeline™ regional system reports, targeting opportunities for continued improvement.
The Accelerator Program has a two-year time horizon from conception to implementation. In order to measure the effects of the intervention, data will be examined from all participating regions relative to changes in treatment times and outcomes. Involving EMS on a regional basis will result in improved treatment times and lower in-hospital mortality.
James Jollis, MD, is a cardiologist at Duke University Medical Center. He is co-medical director of the North Carolina RACE program. Con-tact him at [email protected].
Mayme Roettig, RN, MSN, is the Assistant Director of the Center for Educational Excellence (CEE), Duke Clini-cal Research Institute/Duke University. Contact her at [email protected].
RefeRences1. Krumholz HM, Herrin J, Miller LE, et al. Improvements in door-to-balloon
time in the United States, 2005 to 2010. Circulation. 2011;124(9):1,038–1,045.
2. American College of Cardiology National Cardiovascular Data Registry (ACCNCDR). The ACTION Registry-GWTG National slide set Quarter 3 2010-Quarter 2 2012. ACCNCDR. December, 2011.
3. Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Catheter Cardiovasc Interv. 2012;79(3):453–495.
4. Rokos IC, Larson DM, Henry TD, et al. Rational for establishing regional ST-elevation myocardial infarction receiving center (SRS) networks. Am Heart J. 2006;152(4):661–667.
5. Rokos IC, French WJ, Koenig WJ, et al. Integration of pre-hospital electro-cardiograms and ST-elevation myocardial infarction receiving centers (SRC) networks: Impact on door-to-balloon time across 10 independent regions. JACC Cardiovasc Interv. 2009;2(4):339–346.
6. Jollis JG, Roettig ML, Aluko AO, et al. Implementation of a Statewide Sys-tem for Coronary Reperfusion for ST-Segment Elevation Myocardial Infarc-tion. JAMA. 2007;298(20):2,371–2,380.
7. Jollis JG, Al-Khalidi HR, Monk L, et al.; on behalf of the Regional Approach to Cardiovascular Emergencies (RACE) Investigators. Expansion of a Regional ST-Segment-Elevation Myocardial Infarction System to an Entire State. Circulation. 2012;126(2):189-195. Epub 2012 Jun 4.
8. Jollis JG, Granger CB, Henry TD, et al. Systems of care for ST-segment-elevation myocardial infarction: A report from the American Heart Association’s Mission: Lifeline. Circ Cardiovasc Qual Outcomes. 2012;5(4):423–428.
SponSored clinical feature
This clinical feature is sponsored by Philips.
BY JAMES JOLLIS, MD & MAYME ROETTIG, RN, MSN
51Philips 3.indd 51 9/18/2012 9:03:26 AM
52 JEMS OCTOBER 2012
In 2010, more than 250 U.S. ambu-lance crashes were reported in the news media.1 During such crashes,
EMS providers riding in the ambulance patient compartment while caring for patients are at high risk of suffering inju-ries. An ideal internal patient compartment layout would facilitate efficient clinical care
and ensure the safety of both patients and EMTs. Such patient compartment layout should be based on needs and requirements addressed by the EMS community and ambulance manufacturing community.
This article describes the workshop, Design Requirements for Ambulance Patient Compartments, held on Feb. 29,
2012, during the EMS Today Conference & Exposition. The workshop was sponsored by the U.S. Department of Homeland Secu-rity Science and Technology (DHS S&T) Directorate and conducted by the National Institute of Standards Technology (NIST). The purpose of the workshop was to iden-tify gaps in current practice, establish
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HigHligHts from worksHop on ambulance patient compartments >> By Jennifer Marshall & y. Tina lee
Participants in a workshop held
at the EMS Today Exposition & Con-
ference noted that keeping
their employees safe from crashes
like this one is important.
www.jems.com ocToBeR 2012 JEMS 53
consensus on technical issues related to ambulance design, and review and priori-tize design needs and requirements. The workshop results will eventually help iden-tify key requirements to recommend for the next release of the National Fire Protection Association (NFPA) 1917 Standard for Auto-motive Ambulances.
Project tasksAchieving a balance between EMS crew safety and patient care in the ambulance is a significant challenge for the EMS com-munity. There are approximately 50,000 ambulances on the road every day.1 But there are currently no standards that address performance, ergonomics or safety
in ambulance patient compartments that can be used by EMS organizations when procuring ambulances.
The DHS S&T Human Factors/Behavioral Sciences Division and the First Responder Resource Group have teamed with NIST, the National Institute for Occupational Safety and Health (NIOSH), and the BMT designers
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and planners, to aid in the development of standards for the design of ambu-lance patient compartments.
The project, titled “Ambulance Patient Compartment Design,” will develop new crash-safety design stan-dards and improved user-interface guidance that will result in patient com-partments that are safer for EMS per-sonnel and patients, and that enable the effective delivery of patient care.
The project includes the following five major tasks:
Needs and requirements analysis: To iden-tify needs and requirements of future patient compartment design through structured and systematic approaches.
Design concepts evaluation: To validate requirements using a set of alternative design concepts and criteria.
Final requirements identification: To iden-tify critical and important requirements that would improve patient care and safety based on the results of the design concepts evaluation.
Industry review: To ensure that the selected requirements satisfy community needs.
Standard recommendation: To present the requirements document to the NFPA for incorporation into the next draft (2013) of the NFPA 1917 standard.
To understand ambulance design and cur-rent practices issues, the project team stud-ied documents that included the NFPA 1917 standard, the General Services Administra-tion (GSA) KKK-A-1822F standard, ASTM International Standard Guide for Training Emergency Medical Services Ambulance Operations, Alberta Ambulance Vehicle Standards Code, Australian/New Zealand Standard 4535 and British Standards Institu-tion BS EN 1789.2–8
The project team then performed needs and requirements analysis of patient com-partment design. Their approaches included practitioner interviews, ridealongs, patient care walkthroughs, focus group meetings, a Web-based survey, and a workshop. These approaches allowed the project team to gain firsthand experience with practicing EMTs and paramedics to better understand their work environment, constraints, and con-cerns and hence, understand the needs of those in the EMS community.
The interviews, ridealongs and patient care walkthroughs were carried out
throughout the country at a variety of vol-unteer, state, local, private and hospital-affili-ated EMS organizations.
The goal of conducting focus group meet-ings was to gain a broader understanding of the issues involved in ambulance safety, from a variety of stakeholder viewpoints. Three focus groups, including one manufacturers group and two groups of EMTs, were con-ducted in August 2011 in Las Vegas in con-junction with the 2011 EMS World EXPO. These groups identified several design chal-lenges and suggestions for the improve-ment of working the environment within the patient compartments.
The findings from these focus group meet-ings were used as the basis for developing a nationwide ambulance survey that was con-ducted in December 2011. The purpose of the survey was to aid in soliciting requirements for design standards for ambulance patient compartments and to measure customer sat-isfaction with current design standards. This Web-based survey received more than 2,500 responses from EMS personnel across the country. As the result of these efforts, a draft version of needs and requirements for patient compartment design was generated. The aforementioned efforts culminated in the EMS Today workshop to review, add to and prioritize the needs/requirements gathered.
Why the Workshop The purpose of the workshop was to work with practitioners and federal stakeholders to identify gaps in current practice, estab-lish consensus on technical issues related to ambulance design, and review and
prioritize design requirements. The workshop participants included prac-titioners, practitioner organization rep-resentatives and federal government agency representatives.
requirements AssessmentThe workshop was structured to pro-mote dialogue and knowledge sharing among a diverse group of practitio-ners and assess the collective priorities for the design requirements of patient compartments in ambulances. It used breakout sessions to initiate focused discussions. A set of needs and require-ments, which was developed by the project team based on the results of pre-vious project tasks, was provided to the participants of each breakout session.
They were instructed to assess the require-ments from the safety, functionality, and the combined safety and functionality points of view. The assessment used a three-point Lik-ert scale. (See Figure 1, above left.)
topics & Design neeDsParticipants were grouped into four break-out sessions in order to facilitate the dis-cussion of technical design issues, current practices, and needs and requirements in different topical domains. The topics of these sessions included:
Seating, restraints and communication systems: This covered two domains. The seating and restraints domain concerns the extent to which the patient compartment will enable EMTs and paramedics to provide safe and effective patient care from a seated and/or restrained position in the ambulance patient compartment. The participants focused on the needs/requirements that will help achieve a critical balance between safety and effec-tiveness—restraints vs. seating, adjustabil-ity of seating for better access to patient and equipment, being able to interact with the patient while seated, and ergonomic seating.
The communication systems domain concerns the extent to which the patient compartment shall 1) enable efficient and effective communications between the patient compartment, the driver, and oth-ers; 2) facilitate driver awareness of activity in the patient compartment; and 3) facilitate the EMS provider’s awareness of driver actions. The participants focused on ways to com-municate effectively within the patient
A stuDy on sAfety >> continued from page 53
Figure 1: Likert Scale
Essential
Would significantly improve patient and EMS crew safety if implemented.
Would significantly improve patient care if implemented.
Conditional
Would improve patient and EMS crew safety if implemented, but not to a significant degree.
Would improve patient care if implemented, but not to a significant degree.
Low
Could improve patient and EMS crew safety to some degree if implemented, but not an important requirement at this time.
Could make patient care somewhat easier if implemented, but not an important requirement at this time.
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compartment with patients and others in the back, the driver, dispatch and hospitals.
Work environment: This domain concerns the extent to which the patient compart-ment will 1) enable the provider to safely and effectively perform patient care; 2) enables easy cleaning and restocking after each trip; 3) enable quick and safe ingress/egress; 4) include safety mechanisms (e.g., padding and nets) to reduce hazard risks; and 5) provide space and accessibility for storage of disposal containers. The participants focused on overall space design, accessibility of power and lighting control, as well as flooring and the height of the patient compartment.
General equipment and storage: This domain concerns the extent to which the patient com-partment will 1) provide space and accessibil-ity of storage for equipment and controls; 2)
allow safe and effective use of patient care items; 3) facilitate the ability of providers to perform inventory management; and 4) allow safe and secure storage of the patient care items including equipment, supplies and medicines. The participants focused on the needs/requirements for accessibility and location of equipment/supplies.
Special equipment and storage: This topic covers the special equipment (e.g., cots and jump bags) and storage. This domain con-cerns the extent to which the patient com-partment will 1) allow cots to safely and effectively be secured/released or loaded/unloaded; 2) allow the prehospital profes-sional to securely restrain the patient in the cot and safely and effectively treat the patient; 3) facilitate the ability of the EMS provider to safely and effectively perform
CPR; 4) provide safe and secure storage and accessibility of jump bags; and 5) allow safe and secure storage of patient’s equipment/belongings. The participants focused on space around the cot, cot loading systems and jump bag locations.
Workshop resultsAt the end of each breakout session, the group identified the essential design requirements that are most important across both safety and functionality. The groups also identi-fied a small number of items that should not be included in the requirement list for a vari-ety of reasons, such as measurability, policy/regulatory or out of scope. The participants recommended that some requirements be merged. The following list includes essential design issues/requirements:
A study on sAfety >> continued from page 54
The workshop participants identified a number of concerns/issues during all four sessions. Several examples are listed here.
seAting requirements: Participants expressed concerns about the possibility that new seat designs could infringe on space for equipment and storage. Participants did not perceive that forward-facing or rear-facing seating arrangements were functional enough to address the patient’s needs. The group suggested investigating best practices and designs used in other countries. The group also suggested that the community needs to move away from legacy designs behind and be more innovative in patient compartment design.
restrAint systems: The ability to reach the patient is just as important as the ability to reach equipment. Comfort was identified as an important requirement for restraint systems, because the lack of comfort could hinder widespread use of new systems by practitioners. The group identified that existing retractable restraints do not work efficiently, and that there is a need to clarify the difference between restraint systems and seat belts. It was noted that restraint systems could differ according to specific needs; for example, an advanced restraint system would not be needed for “walking wounded,” but such patients would still need to be subjected to some form of restraint.
CommuniCAtion requirements: Participants expressed concern about the use of non-verbal communication systems, which could cause distractions. Hands-free verbal devices were perceived as safer options. The group noted that new technologies could be readily available before the next release of NFPA 1917. Participants also perceived that means of communicating between the EMS provider, the driver and third parties (e.g., hospitals) do not need to be provided in and accessible from all EMS provider workstations.
Air AmbulAnCe design: A useful model for ambulance design would be air ambulance design (i.e., helicopter and fixed wing). Participants noted that ambulance design is often viewed from the perspective of designing the inside of a large automobile. They suggested that the patient compartment be viewed more as a cockpit.
prioritizAtion: The NIOSH accident trend data and no-strike zones would help prioritize implementation (i.e., procurements).
trAnsport CApAbilities: The ability to transport more than one patient should be considered as a possible requirement.
ergonomiC storAge: Equipment storage locations should take into account ergonomic issues such as weight and lifting height.
proteCting our oWn: Participants indicated that they care about their employees, and that protecting them from injury is the primary concern.
lift injuries: The leading cause of EMS injury is lifting/loading injuries. Lifting heavy equipment is also a major cause of back and muscle strain.
Aggressive/unprediCtAble pAtients: Patients who are aggressive or move unpredictably represent a safety consideration.
A spACe of our oWn: There should be a space provided to accommodate EMS providers’ belongings.
Child sAfety seAting: Participants recommended not using the adult cot equipped with child restraints, noting that a child safety seat is a better option.
loAding of pAtients: Hospitals are increasingly prohibiting EMS providers from lifting patients, due to the rate of back injury claims and patient injuries. Reducing back injury to EMS providers should be emphasized.
lACk of dAtA: Participants expressed concern that there’s no available data on EMS provider injuries, or the causes, severity, etc. of those injuries.
proteCt the heAd: Participants recommended EMS providers wear helmets.
individuAl equipment stAndArds: There’s a need to address the items carried by EMS providers, and there is a need to address requirements for individual equipment items.
trAining: Participants suggested there is a need to address train-ing in the standard.
pArtiCipAnt Comments
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Seating/restraint and communications systems1. The provider is able to reach common and critical equipment/supplies from a restrained
and/or seated position.2. The provider is able to operate equipment controls from a seated and/or restrained position.3. The provider is able to reach and treat the patient from a restrained position.4. Communication systems support the provider’s ability to continue providing safe and
effective patient care. Means for communicating between the EMS provider, the driver and third parties are provided and accessible from all EMS provider workstations.
5. EMS providers in the patient compartment are able to establish communications quickly with the driver or other third party.
Work environment1. Workspace has appropriate space for secure and safe placement and use of equipment,
papers and supplies.2. Providers are able to exit the patient compartment with a patient loaded on a
transport device from the main patient loading and unloading doors and one other door.
3. Safety mechanisms (e.g., padding, nets and airbags) are included in the patient compart-ment to reduce the likelihood of injury to EMS providers and patients during crashes or evasive maneuvers. This priority was seen as also subsuming three additional items:
>> No head strike obstacles; >> Pathways clear of obstacles (no portable patient care equipment); and >> Doors do not intrude into workspace or provide strike risk.General equipment and storage1. The location of the equipment while in use in the patient compartment minimizes the like-
lihood of introducing additional risks to EMS provider and patient safety.2. Placement of equipment that requires EMS provider interac-
tion, including the monitor, allows EMS providers to complete this interaction from a restrained and/or seated position.
3. Equipment stored outside of a cabinet is secured such that it does not become a hazard to the EMS provider or patient.
Special equipment and storage1. The cot guidance and securing mechanism allows for the cot to
be secured in a safe and efficient manner.2. The cot loading system allows for the patient to be loaded
or unloaded safely with minimal risk of injury to patient or EMS provider.
3. When being used for patient care, the placement of secured jump bags allows EMS providers to quickly and safely access them.
4. Secure storage is available for patient and staff belongings. 5. Cot allows for the patient (including aggressive/violent ones) to
be securely restrained without hindering the ability of the EMS provider to provide safe and effective patient care.
ConClusions & Future WorkThe results of the ambulance patient compartment workshop con-firmed and prioritized the needs and requirements the project team gathered from other research efforts. These results will be further reviewed, enhanced and evaluated.
The workshop participants were asked to continue sending any further needs, requirements and suggestions about future ambu-lance patient compartment design.
The next step is to focus on modeling potential designs for the patient compartment.9 These designs will be based on the prioritized requirements. The selected requirements will be used to develop a set of design concepts that represent three-dimensional graphical models. Clinical-care experiments with
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different designs, placement of equipment and supplies and providers will be simu-lated using a human modeling tool. The purpose of these simulation experiments is to validate the requirements.
With the experimental results, a final set of design requirements will be identified. The final set of requirements and the vali-dated crash safety standards from NIOSH will be input to the next open comment period for NFPA 1917, which is tentatively scheduled for spring. JEMS
Jennifer Marshall is the homeland security program man-
ager with the Law Enforcement Standards Office of the
National Institute of Standards and Technology and man-
ages the standards development efforts that support DHS
and first responders. She has more than 10 years of expe-
rience in technology and standards development for the
homeland security community— including EMS, fire ser-
vice and law enforcement. She can be contacted at jenni-
Y. Tina Lee is a computer scientist with the Engineer-
ing Laboratory at the National Institute of Standards and
Technology. She has participated in research and authored
more than 50 technical papers relating to homeland secu-
rity modeling and simulation and manufacturing systems
integration. She’s the co-editor of the Core Manufacturing
Simulation Data Standard (SISO-STD-008-2010). She can be
contacted at [email protected].
RefeRences1. Ballam E. (Feb. 9, 2011). Ambulance Crash Roundup. In
EMS World. Retrieved from www.emsworld.com/article/10225399/ambulance-crash-roundup.
2. National Fire Protection Association. (2012). NFPA 1917: Standard for automotive ambulances. In National Fire Protection Association. Retrieved from www.nfpa.org/aboutthecodes/AboutTheCodes.asp?DocNum=1917.
3. U.S. General Services Administration (2007). Federal Specification for the Star-of-Life Ambulance, KKK-A-1822F. In FedBizOpps. www.fbo.gov/index?s=opportunity&mode=form&tab=core&id=086075b28f43af8197f412423a1be230&_cview=1.
4. ASTM International. Standard Guide for Training Emergency Medical Services Ambulance Operations. F1705-96, 2007.
5. Emergency Health Services, Health Policy and Service Standards Development Branch. (2010). Ambulance Vehicle Standards Code January 2010. In Government of Alberta. Retrieved from www.health.alberta.ca/documents/ehs-ambulance-standards-code.pdf.
6. Standards Australia, Standards New Zealand. 1999. Australian/New Zealand Standard: Ambulance Restraint Systems, AS/NZS 4535:1999. http://infostore.saiglobal.com/store/Details.
aspx?ProductID=3848757. British Standards Institute. (June 29, 2007). BS EN
1789:2007, Medical Vehicles and their equipment: Road ambulances. European Committee for Standardization (CEN), Management Centre: rue Stassart, 36 B-1050 Brussels. http://shop.bsigroup.com/ProductDetail/?pid=000000000030209683.
8. Dadfarnia M, Lee YT & Kibira D. A Bibliography of Ambulance Patient Compartments and Related Issues, NISTIR 7835. National Institute of Standards and Technology: Gaithersburg, Md., 2011.
9. Kibira D, Lee YT & Dadfarnia M. “Modeling for Optimal Ambulance Patient Compartment
Layout,” Proceedings of the 2012 Spring Simulation Multiconference: Orlando, March 26–29, 2012.Acknowledgements: The U.S. Department of Home-
land Security Science and Technology Directorate (DHS S&T) Human Factors/Behavioral Sciences Division spon-sored the production of this material under Interagency Agreement HSHQDC-11-X-00049 with the National Insti-tute of Standards and Technology (NIST). The work described was funded by the United States Government and is not subject to copyright.
Disclaimer: The findings expressed or implied in this report do not necessarily reflect the official view or policy of the U.S. government.
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PumPer/ambulance model takes service to a new level
>> By BoB Vaccaro
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The Volusia County (Fla.) Department of Public Protectionrecently took delivery of four Braun Patriot pumper/ambu-lances built on Spartan MetroStar chassis.
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When Joe Pozzo was hired as the new chief of the Volusia County (Fla.) Department of Public Protection
(VCDPP) in June 2010, he was given a mandate: Build and create a new model of service for Volusia County.
“We had no funding to keep going with a model that used traditional engines, trucks and squads,” Pozzo says. “We had to come up with innovative technology and vehicles to get the job done.”
Like many other departments around the coun-try, the VCDPP needed to identify cost savings to make up for falling revenues. And that meant changes to the department’s fleet. “We had to come up with a way to reduce our fleet and cut costs and still provide the same services to our population,” Pozzo says. PumPer/AmbulAnce modelAfter a lot of brainstorming, the VCDPP came up with the idea for a pumper/ambulance that could provide more efficient firefighting capabilities and EMS transport in the rural areas of the county. “Some people in the organization doubted the idea, but we thought the concept was thinking outside of the box,” Pozzo says.
“When we began the design process, we decided that for it to work, it had to be as close to a tradi-tional fire engine body as possible, with a traditional ambulance body added.”
It took a while to work through the exact specs that would allow the vehicle to serve both firefighting and EMS needs efficiently. To start, the VCDPP contacted Ten-8 Fire Equipment, the local dealer for Braun, which manufactures the Patriot line of vehicles. “We looked at a Patriot that was recently delivered to the West Palm Beach Airport,” Pozzo says. “However, the airport unit had limited fire-suppression capabilities. We wanted a custom fire truck cab with an ambu-lance body.”
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After working with the salespeople and engineers at Ten-8 and Braun, the depart-ment settled on a limited water tank with a compressed air foam system (CAFS).
“We needed to expand the water capabil-ity as much as possible since the vehicle would be first-out in some areas, providing firefighting capabilities as well as EMS,” Pozzo says.
The VCDPP contracted with Waterous to design and build the pump module, which was connected to a 300-gallon water tank and a 30-gallon foam tank. In addition, Braun raised the height of the ambulance box.
The units are set up with two crosslays of 1¾” hose and a dead load of 2½” hose for a supply line if needed and they carry the new Hurst E-Draulic cutters and rams. For future units, the department will engineer a rear compartment with stronger shelving to
hold 300–400 feet of 3” supply line.“Braun and Ten-8 were great to work
with,” Pozzo says. “They listened to our ideas and worked together with us to make this new concept work for us and the resi-dents of the county.”
The four pumper/ambulances are rotated in the high-volume rural areas of the county; they don’t have permanent stations. Pozzo stresses that the set-up is working well. “We would like to order an additional unit this year,” he says. JEMS
Bob Vaccaro has more than 30 years of fire-service expe-
rience. He is a former chief of the Deer Park (N.Y.) Fire
Department. Vaccaro has also worked for the Insurance
Services Office, the New York Fire Patrol and several major
commercial insurance companies as a senior loss-control
consultant. He is a life member of the International Asso-
ciation of Fire Chiefs.
InnovatIve DesIgn >> continued from page 61
The ambulance module features custom all-aluminum interior cabinets with Meganite countertops and rounded edge corners. The units also feature Braun’s VitalMax lighting system for shadowless light to aid in patient care, the EZ Glide sliding side-entry door for enhanced crew safety, the MasterTech IV electrical system, and the SolidBody construction.
Most U.S. EMS and fire service leaders are familiar with the various target hazards that
they have in their respective jurisdictions. Some have adapted various standard operating procedures (SOPs) and purchased firefighting apparatus that gets the job done for their communities. The Broward County Sheriff’s Office Department of Fire Rescue, located in south Florida, is no exception.
When you hear the name Broward Sheriff’s Office Department of Fire Rescue (BSO DFR), you may get the impression that this department operates
as a public safety organization with police officers operating in dual roles as firefighters—but that’s a misconception.
The BSO DFR originated in October 2003 when all operational and administrative responsibilities were transferred from the Broward County Board of County Commissioners to the Broward Sheriff’s Office. The department’s more than 700 personnel provide fire suppression, fire protection, EMS and edu-cational programs for most unincorporated areas of Broward County and to the municipalities of Weston,
Pembroke Park, Cooper City, Lauderdale Lakes, Dania Beach and Deerfield Beach through contract agreements. Additionally, the department serves Ft. Lauderdale-Hollywood International Airport and Port Everglades.
a UnIqUe RIgRecently, the department purchased a vehicle designed for an area of the county with diverse operational needs: an engine stationed in an area that regionally services the Florida Everglades, a main thoroughfare known as Alligator Alley.
“We have one station located mid-way on this thoroughfare that services the eastern portion of this heavily trav-eled main highway,” says BSO DFR Chief Neal de Jesus. “Since this is pretty much a rural area and EMS response from the
next station is a great distance away, we decided to design an engine that could be used for fire suppres-sion as well as EMS response—if we can’t get another ambulance in a timely manner or launch Air Rescue, we can use this engine to transport.”
The majority of the calls in this area are single-vehicle rollovers with multiple victims, so the vehicle is designed with a longer wheelbase than a standard engine. Although it probably couldn’t be used easily in another urban setting, on a long stretch of high-way, the turning radius isn’t a problem.
“The local dealer, Ten-8 Fire Equipment, and the Pierce engineers who helped us design this vehicle, were great to deal with,” de Jesus says. “The rear of the cab is used for EMS transport. It is roomy and has a climate-controlled area for patient treatment. We chose the Velocity chassis because of the added room in the cab, front and rear, as well as having a greater amount of compartment space. It has really worked out well for us so far.”
Chief de Jesus and his apparatus committee painstakingly worked out every detail on both vehicles to make them work for the department—something you should be doing when you design any new vehicle.
Although your budget might not be as large as some departments’ budgets, you can take this into consideration when you spec out your next ambu-lance. If you need to work on a commercial chassis instead of a custom unit, then design around that concept. Just make sure the dealer and manufacturer you choose are on the same page.
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Detect & treat symptoms relateD to hemorrhagic shock
>> By Peter taillac, MD, FaceP; & chaD Brocato, DhSc, cFo, JD
Case PresentationOn a cold, rainy evening, the crew of Rescue 4 is jolted to attention by a dispatcher announcing, “Respond to a shooting at 7th Street and Main.” The lead paramedic recognizes the address as a location within a community with a long-standing history of violent crimes. Local police have already secured
the scene. The EMS crew arrives to note a young male lying in a pool of blood with a visible gunshot wound (GSW) to his right abdomen.
He’s conscious but slow to respond to question-ing. The crew quickly assesses his initial airway, breathing and circulation status. Although his skin is cool to the touch, he has a palpable radial pulse.
in March 2013, a patient suffering from hemorrhagic shock will be among the victims managed at the JeMS Games clinical competition at the eMS today conference & exposition. this comprehensive clinical article will assist participating teams,
attendees and readers in understanding this complex medical event and has been accredited by the continuing education coordinating Board for eMS (cecBeMS) for 1 hour of continuing education credit.
For a limited time only, readers of this article may obtain ce credit courtesy of laerdal Medical corp. the first 500 visitors to JeMS.com/Discover-Simulation who register using promo code JeMSoctce (not case sensitive) will receive ce credit free.
in addition, JeMS Games founding sponsor, laerdal will provide a special “Discover Simulation” tool kit to each person attending the JeMS Games finals on March 8, 2013. the tool kit offers a turn-key solution to rolling out the simulations featured at the JeMS Games complete with facilitation guide, checklists and other valuable resources to help make simulation training easier.
2 0 1 3 j e m s G a m e s
F o r M o r e , V I s I t j e M s . c o M / D I s c o V e r - s I M u l at I o n
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Patients with internal or external bleeding are at risk for developing shock, so EMS providers need to be able to identify the hallmark signs. Ph
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Serious hemorrhage from truncal wounds is internal and uncontrol-lable, and requires EMS providers to assist the body’s natural ability to form a clot.
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This clinical education feature appears as part of the JEMS Integrated Clinical Training & Simulation (ICTS) project sponsored by
Laerdal Medical Corp.’s Discover Simulation program, with support from JEMS and the Eagles Coalition.
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High-flow oxygen is applied while additional assessment is conducted. One crew member quickly performs a rapid head-to-toe exam to discover a second GSW to the left anterior thigh, which is actively hemorrhaging bright red blood. The EMS provider immediately places a tourniquet proximal to the wound and quickly stops the hemorrhage.
When the crew rolls the patient to assess his posterior surfaces and place him on a backboard, they note an exit wound just lat-eral to the spine at approximately the level of the eighth rib on the right posterior thorax. The exit wound is approximately the size of a quarter. Vital signs include a blood pres-sure of 108/74, respiration rate of 30 and a pulse rate of 128 beats per minute (bpm) His Glasgow Coma Scale score is 14, and he’s confused about the time and place.
Once inside the ambulance, the patient is quickly reassessed. The lead medic quickly places two peripheral IV lines while the unit is en route to the hospital. During the 15-min-ute ride, the patient rapidly deteriorates. His blood pressure drops to 74/50; his heart rate increases to 144 and respirations are 38. Sus-pecting a possible tension pneumothorax, the medic inserts a 14-gauge catheter into the patient’s chest, and a rush of air ensues. The lead medic then administers a 500 cc bolus of normal saline. The patient’s respiratory rate and pulse immediately decrease, and his blood pressure improves to 95/50. The lead medic provides a concise radio report to the hospital and arrives shortly thereafter, hav-ing stabilized this critical patient.
Patients with internal or external bleed-ing are at risk for developing shock. In some cases, such as the one illustrated above, the onset of shock will be rapid. EMS provid-ers need to be able to predict that shock will occur prior to discovering the hall-mark signs. This article will address key considerations related to determining the risk of developing shock, detecting shock when it’s present, and providing rapid assessments and interventions to improve patient outcomes.
AnAtomy & Physiology The body meets its metabolic demands through a series of anatomical features and physiological mechanisms. In the context of bleeding and shock, the EMS provider must have a keen awareness of the anatomy and physiology of the cardiovascular system. It’s
equally important to understand how the system attempts to compensate during times of injury.
the heArtThe heart is at the core of the cardiovascu-lar system. It’s a four-chambered organ that must constantly pump blood to the lungs and the body as a whole. Blood is received in the two superior chambers, known as the atria. The lower chambers are known as the ventricles. The right atrium gets its blood from the inferior and superior vena cava. The blood is then pumped past the tri-cuspid valve into the right ventricle, which then ejects blood through the pulmonary valve, into the pulmonary artery, where it’s delivered to the lungs to be oxygenated. The “fresh” blood will return to the left atrium via the pulmonary veins.
It will then pass through the mitral valve into the left ventricle, which is considered the high-pressure side of the heart. Blood is
ejected from the left ventricle past the aor-tic valve into the aorta. It’s then distributed throughout the body.
Blood distriBution & ComPositionThe body’s distribution system for blood includes all of the vessels. Arteries, with the exception of the pulmonary artery, deliver highly oxygenated blood throughout the body. These vessels are relatively thick and are composed of three layers: the tunic intima (innermost layer), the tunic media (middle layer), and the tunic adventitia (out-ermost layer).
The arteries branch off to become smaller vessels, known as arterioles. These smaller vessels bring blood to the capillaries, which are tiny, thin-walled vessels that allow the diffusion of oxygen and nutrients for the benefit of the body’s cells. Waste products are then diffused from the cells into the venous side of the capillaries. Smaller ves-sels, known as venules, carry this blood to the veins. The venous blood is lower in oxy-gen but not devoid of it. The veins eventually connect to the vena cava to return the blood to the heart for its next loop in the cycle.
The blood is composed of both fluid and formed elements. The fluid is known as plasma, which contains important pro-teins, including critical clotting factors. The formed elements include the red blood cells (erythrocytes), white blood cells (leuko-cytes) and platelets. The leukocytes work to fight off infections. However, more impor-tant to learn about in the context of bleeding and shock are the erythrocytes and platelets.
When the system works properly, the body’s cells, tissues and organs are properly perfused. Perfusion is a complicated process that can be simplified down to this critical point: in order for the cells to function prop-erly, they need an adequate flow of oxygen and nutrients coupled with the need to elim-inate harmful waste products. Perfusion is accomplished when the heart, blood vessels and blood are working in harmony. Thus, the heart must be functioning, the blood vessels must have proper tone (resistance), and an adequate amount of blood must be present. EMS providers roughly measure perfusion by assessing blood pressure. Mathematically, blood pressure is a product of heart rate multiplied by stroke volume multiplied by peripheral vascular resistance.
leArning Objectives>> Identify major anatomical components
of the cardiovascular system.>> Describe the physiological components
of blood pressure.>> Differentiate between compensated,
uncompensated, and irreversible shock.>> Use a comprehensive assessment to
formulate a treatment plan for a patient suffering from shock.
Key TermsHemorrhagic shock: Shock associated with the sudden and rapid loss of significant amounts of blood often caused by severe traumatic injuries. This results in inadequate perfusion to meet the metabolic demands of cellular function.Compensated shock: Category of shock that occurs early, while the body is still able to compensate for a shortfall in one or more of the three areas of perfusion.Uncompensated shock: Category of shock that occurs when the compensatory mechanisms fail and the patient’s condition deteriorates.Irreversible shock: The terminal category of shock that will lead to the patient’s demise because it can’t be reversed.Truncal injury: Injuries pertaining to the chest, abdomen, or pelvis, where hemorrhage can be difficult to detect and control for prehospital providers.
VitAl PAthwAys>> cOnTinued frOm page 65
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The heart rate must be adequate to ensure proper blood flow. The average adult heart rate is between 60–100 bpm while at rest. Significant decreases or increases in the heart rate have a direct impact on perfusion.
Stroke volume is the volume of blood pumped from each ventricle with each beat and is typically 70 mL for the average adult male. Stroke volume can be decreased by such factors as increased resistance, improper functioning of the heart or valves, and inadequate blood volume.
Peripheral vascular resistance is the tone in the blood vessels. Because our bodies must constantly fight the forces of gravity and pump the blood throughout the body, the vessels need to have some pressure or “squeeze.” If all of your vessels were to dilate, your blood pressure would plummet as the blood would pool to the areas where gravity pulled it. So the peripheral vessels maintain this tone in order to equalize the effects of position changes (gravity) and to “fine tune” the blood pressure second to second.
Under normal conditions, the entire system works in concert to ensure that the blood flows to all organs, tissues, and cells. When the body has been compromised, such as when hemorrhage from a gunshot wound occurs, it will attempt to compen-sate for any reductions.
For example, if the blood pressure falls, the heart will respond by pumping faster and with more force, and the vessels will constrict and reroute blood from periph-eral areas to the core in an effort to preserve the vital organs. Thus, prehospital caregiv-ers should consider any factors that would reduce the overall flow of blood as they relate to heart rate, stroke volume and peripheral vascular resistance.
If external or internal bleeding is present, the stroke volume will obviously be affected because of the lost blood. If the patient has a rapid heart rate, then the volume and resis-tance will need to increase to “compensate” for the change. If the blood vessels lack ade-quate tone, the heart rate will need to increase as will the force of contractions. It’s impor-tant to understand the interconnectedness of the heart rate (HR), stroke volume (SV) and peripheral vascular resistance (PVR).
PathoPhysiology Simply stated, shock is a state of inadequate
perfusion. Hemorrhagic shock occurs when, as a result of acute blood loss, cells are negatively impacted because they are inad-equately perfused. Therefore, they don’t receive an adequate supply of oxygen or removal of wastes.
Three types of shock exist: compensated, uncompensated, and irreversible. The pre-hospital provider can have the greatest effect if shock can be prevented, by preventing blood loss. If this isn’t possible because of factors beyond the provider’s control, then caregiv-ers should act quickly to keep compensated shock from becoming uncompensated shock. All efforts should be undertaken to avoid irreversible shock.
Compensated shock occurs early while the body is still able to compensate for a short-fall in one or more of the three areas of per-fusion (HR, SV, and/or PVR). The signs and symptoms of this stage of shock include tachycardia and tachypnea, as well as cool pale, and diaphoretic skin. The patient’s blood pressure may be within normal ranges during compensatory shock. Men-tal status may also be normal during this early stage.
Uncompensated shock occurs when the compensatory mechanisms fail, and the patient’s condition deteriorates. The hall-mark sign of uncompensated shock is a reduction in blood pressure. Other signs include decreased mental status, tachycar-dia, tachypnea, thirst, reduced body tem-perature and skin that is cool, sweaty and pale. If untreated or inadequately treated, the patient may lapse into irreversible shock. As its name implies, this latter category of shock will lead to the patient’s demise because it can’t be reversed.
New CoNCePts Now back to our gunshot victim. How do we prevent the cascade of physiologic events that leads to the irreversible shock state? The key is prevention of shock in the first place. EMS providers are in a critical posi-tion because their actions in the first hour after injury, often called the “Golden Hour” (or “Platinum 10 Minutes”) can mean the difference between a stable patient and one who rapidly develops an uncompensated and then irreversible shock state, resulting in death.
Research from trauma centers and experi-ence from the battlefields of Iraq and Afghan-
istan have suggested new approaches to both the avoidance and the management of shock in the prehospital environment. Extremity injuries are addressed with immediate con-trol of hemorrhage, with a pressure dressing or a tourniquet. For patients with a truncal injury (wound to chest, abdomen or pelvis) careful and judicious fluid administration in the field can help minimize hemorrhage and preserve critical blood volume, thus giving the patient a better chance to make it to the operating room where such internal bleed-ing can be directly controlled.
Aggressive and lifesaving EMS care for this shooting victim begins with a rapid but thorough assessment of his wounds. This requires visualization and palpa-tion of the entire torso and extremities for wounds. This patient in this example dem-onstrates a penetrating wound to abdomen with an exit wound posteriorly at approxi-mately the eighth rib level, which raises the possibility of a chest injury, such as a ten-sion pneumothorax.
Rolling the patient to evaluate posterior wounds is a critical step that can be easily missed in the evaluation of a shooting vic-tim. In this case, this revealed a wound that may compromise pulmonary and cardiac function. In addition, an actively bleeding thigh wound is noted as part of the head-to-toe exam.
The management of these wounds (extremity and torso) requires prompt action on the part of the medic to avoid the onset of shock, to minimize internal bleeding, and to address the rapid deterioration of the patient. The two torso wounds aren’t visibly bleeding; however, it’s assumed there may be significant internal hemorrhage.
First, the EMS provider immediately stops the rapid blood loss from the thigh wound by the prompt application of a tourniquet prox-imal to the wound. This rapid and simple intervention may be lifesaving by preventing the onset of shock. Research from battlefield injuries in Iraq demonstrates a nearly 25-fold (96% vs. 4%) improvement in survival when hemorrhage was controlled by tourniquets prior to the onset of shock.
Depending on the status of the patient and the transport time, this tourniquet can either be left in place until arrival at the emergency department (ED) or, if possible, replaced by an effective pressure dressing.
If a tourniquet is left in place, the EMS pro-
64_70CEhemorrshockv2.indd 67 9/18/2012 9:06:25 AM
68 JEMS OCTOBER 2012
Vital Pathways >> continued from page 67
vider must alert the ED personnel that a tour-niquet is in place, so it isn’t overlooked while the other, more obvious, wounds are man-aged. If a pressure dressing is placed, then the tourniquet should be left loosely in place and the thigh wound frequently re-evaluated by the EMS provider for continued bleeding. Then, if bleeding recurs, the tourniquet can then be simply re-tightened.
Once the thigh hemorrhage is stopped, the medics placed two large bore IVs. This has been a recommended practice in early trauma management for decades. However, although the placement of such “lifelines” is still recommended to provide access for medications and fluids, newer research indicates that less IV fluid may be better for truncal wounds. Serious hemorrhage from truncal wounds is internal and uncontrol-lable by the medic in contrast to extremity wounds, which present with external hem-orrhage and are controllable, with direct pres-sure or a tourniquet.
For internal hemorrhage, the medic must assist the body’s natural ability to form a clot.
Research indicates that this clot formation is disrupted by rapidly increasing the BP with crystalloid IV fluids, such as normal saline. In addition, crystalloid dilutes the clotting factors that are critical to formation and strengthening of these fragile clots. Based on this research, the new recommendation
is “don’t pop the clot” by the use of excessive IV fluid in the field. For patients with internal bleeding who aren’t in uncompensated shock (their systolic BP is greater than 80–90 mm/Hg, or a radial pulse is present and menta-tion is normal), IV fluids should be withheld until the patient can receive definitive con-trol of this internal hemorrhage in the oper-ating room.
Resuscitation studies demonstrate that this strategy minimizes hemorrhage and subsequent transfusion requirements. However, in the case of a patient who is demonstrating signs of uncompensated shock (systolic BP is less than 80–90, or the patient has a loss of radial pulse or decreas-ing mentation), administration of judicious boluses of crystalloid to support the blood pressure may be required to get the patient to the ED alive. Administration of boluses of 500–1,000 cc at a time, with reassess-ment after each bolus to keep the systolic BP above 80–90 mm/Hg is recommended. This strategy of minimizing IV fluid by such calibrated boluses is contrasted with
Tourniquets can be an effective treatment for hemorrhage control for extremity wounds, such as this one, which required amputation.
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our former practice of indiscriminately administering large volumes of IV fluid to all trauma patients.
Lastly, the patient initially had a systolic BP of 108, but then rapidly decompensated, demonstrated by worsening hypotension and increasing tachycardia and tachypnea. The astute medic realized that, with a pos-sible chest wound, this patient may be mani-festing a tension pneumothorax. In this condition, the pneumothorax enlarges pro-gressively, increasing pressure in the chest to the point that the return of blood to the heart is compromised, resulting in decreased SV, and a shock state ensues. The immediate and lifesaving treatment is to decompress the tension pneumothorax by placing a large-bore IV catheter in the second intercostal space in the mid-clavicular line.
This results in an immediate decrease in the intrathoracic pressure and improvement in venous blood refilling the heart, restor-ing SV and cardiac output. Our medics rec-ognized and treated this patient with chest decompression followed by a calibrated 500
cc bolus of crytalloid, with improved vital signs found on reassessment. These medics prevented the onset of irreversible shock and saved this patient’s life with their prompt and expert interventions.
ConClusionNew concepts in trauma management dif-ferentiate between controllable hemorrhage from extremities and uncontrollable internal hemorrhage from truncal injuries. The goal of trauma management is the prevention of uncompensated and irreversible shock.
Prompt control of blood loss from extremities with a pressure dressing or a tourniquet is an immediate priority and should be implemented during the primary survey of the trauma patient. Internal bleed-ing control from truncal injuries is facilitated by “not popping the clot.” These patients may be managed in their compensated shock state (BP above 80–90 mm/Hg) by avoiding excess prehospital IV fluids. Judicious and calibrated IV boluses are used to support the BP below this level.
Last, remember that a penetrating chest injury in the face of shock may represent a tension pneumothorax and require immedi-ate needle thoracostomy to restore cardiac output. JEMS
Peter P. Taillac, MD, FACEP, is an associate clinical professor
in the University of Utah Division of Emergency Medicine.
He serves as the medical director for the Utah Bureau of
EMS, the Utah Department of Health, and West Valley City
Fire and EMS. Contact him at [email protected].
Chad Brocato, DHSC, CFO, JD, is the Deerfield Beach
(Fla.) district fire chief for the Broward Sheriff’s Office
Department of Fire Rescue & Emergency Services in South
Florida. He’s also an adjunct professor at Kaplan University
as well as the coordinator for the JEMS Games. Contact him
This clinical education feature appears as part of the JEMS Integrated Clinical Training & Simulation (ICTS) project sponsored by Laerdal Medical Corp.’s Discover Simulation program, with support from JEMS and the Eagles Coalition.
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70 JEMS OCTOBER 2012
RefeRences1. Kragh J, Littrel M, Jones J, et al. Battle casualty survival
with emergency tourniquet use to stop limb bleed-ing. J Emerg Med. 2011;41(6):590.
2. Bickell W, Wall M, Pepe P, et al. Immediate ver-sus delayed fluid resuscitation for hypotensive
patients with penetrating torso injuries. N Eng J Med.1994;331(17):1,105.
3. Taillac P, Doyle G. Tourniquet first! Safe and ratio-nal protocols for prehospital tourniquet use. JEMS.2008(Oct Suppl);24.
4. Butler F, Holcomb J, Giebner S. Tactical combat
casualty care 2007: Evolving concepts and battlefield experience. Mil Med. 2007:172(suppl 1):1.
5. McSwain N, Champion H, Fabian T, et al. State of the art fluid resuscitation 2010: Prehospital and imme-diate transition to the hospital. J Trauma 2011;70(5)(supplement):S2.
Vital Pathways>> continued from page 69
Objective 1: Identify major anatomical components of the cardiovascular system. 1. Which heart chamber receives blood from the vena
cavae? a. Right atrium b. Left atrium c. Right ventricle d. Left ventricle
2. Which valve separates the right atrium from the right ventricle?
a. Mitral valve b. Aortic valve c. Tricuspid valve d. Pulmonary valve
3. Which valve separates the right ventricle from the pul-monary artery?
a. Mitral valve b. Aortic valve c. Tricuspid valve d. Pulmonary valve
4. Which valve separates the left atrium from the left ventricle?
a. Mitral valve b. Aortic valve c. Tricuspid valve d. Pulmonary valve
5. Which valve separates the left ventricle from the aorta?
a. Mitral valve b. Aortic valve c. Tricuspid valve d. Pulmonary valve
6. What is the name of the innermost layer of an artery? a. Tunica media 1. A; 2. C; 3. D; 4. A; 5. B; 6. B; 7. C; 8. A; 9. B; 10. A; 11.
B; 12. C; 13. B; 14. C; 15. B; 16. B; 17. D; 18. A
Test your comprehension with this post-article quiz. This article has been accredited by the Continuing Education Coordinating Board for EMS (CECBEMS) for 1 hour of continuing education credit. For a limited time only, readers of this article may obtain CE credit courtesy of Laerdal Medical Corp. The first 500 visitors to JEMS.com/Discover-Simulation who register using promo code JEMSOctCE (not case sensitive) will receive CE credit free.
REVIEW QUESTIONS b. Tunica intima c. Tunica externa d. Tunica adventitia
7. What is another name for the red blood cells? a. Luekocytes b. Hemocyctes c. Erythrocytes d. Thrombocytes
Objective 2: Describe the physiological components of blood pressure. 8. Blood pressure is the product of stroke volume,
peripheral vascular resistance, and _________? a. Heart rate b. Tidal volume c. Cardiac output d. Functional reserve
9. What term describes the amount of blood ejected from the ventricles with each contraction?
a. Tidal volume b. Stroke volume c. End-systolic volume d. End-diastolic volume
10. Without any homeostatic corrections, which event would lower the patient’s blood pressure?
a. Vasodilation b. Slight tachycardia c. Increased stroke volume d. Bolus of normal saline
Objective 3: Differentiate between compensated, uncompensated and irreversible shock.11. Which sign would you expect to see in a patient with
compensated shock? a. Bradypnea b. Tachycardia c. Hypotension d. Warm, dry skin
12. What is the hallmark sign of uncompensated shock? a. Tachypnea b. Tachycardia c. Hypotension d. Cool, pale skin
13. Which type of shock will result in the patient’s death regardless of any prehospital intervention?
a. Neurogenic shock b. Irreversible shock c. Hypovolemic shock d. Uncompensated shock
14. Your young male patient has a gunshot wound near the spine at the level of the eighth thoracic vertebra. The patient is pale and diaphoretic. The blood pressure is 90/50 mmHg, the heart rate is 128 beats per minute,
and the respiratory rate is 30 breaths per minute. How would you classify his hemodynamic status?
a. Tidal volume b. Irreversible shock c. Compensated shock d. Uncompensated shock
Objective 4: Use a comprehensive assessment to formulate a treatment plan for a patient suffering from shock.15. You arrive on scene to find a young male lying in a pool
of blood with a visible bullet wound to the right abdo-men. The patient is trying to speak, but his words do not make any sense. What should you do first?
a. Control the bleeding b. Rapidly assess his airway c. Administer high flow oxygen d. Attempt to establish IV access
16. You’re treating a 20-year-old male with an entrance wound to the left anterior thigh. The wound is actively hemorrhaging bright red blood. The bleeding stops with the application of a tourniquet proximal to the wound. After applying pressure dressings, you loosen the tourniquet and note no further bleeding. On the way to the hospital, you notice a sudden soaking of the dressing with bright red blood. What’s the quickest and most reliable way to immediately halt the rebleeding?
a. Elevate the leg b. Retighten the tourniquet c. Apply additional pressure dressings d. Compress the femoral pressure point
17. Your young male patient has a GSW to the right lower quadrant of the abdomen. There is little bleeding vis-ible and the abdomen is slightly distended. The patient is pale and diaphoretic. His blood pressure is 91/62 mmHg, his heart rate is 134 beats per minute, and his respiratory rate is 32 breaths per minute. What is the most appropriate crystalloid administration rate dur-ing transport?
a. Two liters at time b. Judicious fluid boluses c. Wide open through large bore IVs d. Minimal or no fluid administration
18. You’re treating a female patient with a single entrance GSW to the right anterior chest. No air is leaking from the wound although the patient is having some respira-tory distress. The patient is pale and diaphoretic. The blood pressure is 66/42 mmHg, the heart rate is 140 beats per minute, and the respiratory rate is 34 breaths per minute. What is the most appropriate initial treat-ment for this patient?
a. Needle thoracostomy for possible tension pneu-mothorax
b. Judicious fluid boluses (500–1,000 cc at a time) c. No fluid administration d. Wide open fluids through large bore IVs
64_70CEhemorrshockv2.indd 70 9/18/2012 9:13:15 AM
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the LIGhteR SIDewhat they didn’t tell you in medic school
>> by steve berry
80 JEMS OCTOBER 2012
Is it me or does everyone seem a lot more uptight and over-sensitive lately? Fine! Don’t answer the question. See if I give a
flying duck! Thank God there are monthly lighthearted articles like mine that allow the reader to kick back and take a break from the unrelenting drama of day-to-day life, which is why I have chosen the topic of politics to help you relax and free your mind of stress.
A co-worker recently asked me if I was a democrat or republican to which my response was, “That’s a question I will refer to my lawyer.” Not that I don’t stand by my con-victions mind you, but if there’s one thing I’ve learned as an EMS provider, it’s to never buy a suction unit with a reverse switch on it. The other thing I learned was to duck (as in flying) while discussing politics in the workplace. Every quadrennial year it seems, intelligence, integrity and selflessness are thrown out the window as divisive labeling and animosity rules the day.
My job is stressful enough when it comes to dealing with confrontational patients without having a colleague considering me vermin simply because he views my politi-cal pick as vermin. I’m all for meaningful dialogue that honors political diversity, but more often than not. I’ve seen these civil dis-cussions turn dicey with a resulting exchange of unsportsmanlike angiocath stab wounds rather than that of ideas.
Unlike most work environments, a 9–5 hour workday is considered part-time in the fire and EMS profession. We are therefore likely to engage in these types of political discussions whether we want to or not sim-ply because we literally sleep, eat and lounge in the same vicinity. It’s estimated that more
than $6 billion will be spent by both can-didates on mean-spirited, exaggerated and intimidating catchphrase advertising. Thus, voices from the lounge chairs are bound to give rise to political affiliation during these unceasing, polarizing TV political ads—whether you want to hear them or not.
So how can one avoid discoursing on one’s political association while at the same time chloroform a co-worker’s blowhard campaign rant that provokes political ideol-ogy without thought?
Non-confrontational attempt #1: “I am here and salaried to execute a set of commissioned duties—not campaign for your party.”
Non-confrontational attempt #2: “I’m not comfortable discussing politics and prefer not to participate in this discussion.”
Confrontational attempt: “%#@ off, you narrow minded, delusional, sanctimonious, rhetorical narcissistic baboon advocate of unsubstantiated generalizations and intoler-able dogmatic babble.”
Some eight years earlier in my career, while transporting a centurion-plus patient on November fourth to a hospital, the patient pointed to the “I voted” sticker on my uni-form and softly said with a introspective
smile, “Hoover, Roosevelt, Truman, Eisen-hower, Kennedy, Johnson, Nixon, Ford, Carter, Regan, Bush, Clinton and Bush.”
“Excuse me?” I asked, smiling back as I ripped the Velcro blood pressure cuff free from his bicep.
“I voted in all them elections,” he clarified.“Yeah? A true patriot to the voting process,
obviously,” I endorsed.“I suppose,” he said without conviction.
“All I know is diapers and politicians should be changed often and for the same reason.” As he said this, he pointed to his underlying Depends. Pausing only to readjust himself on the cot, he continued, “Of course, my two cents worth is worth only just that—two cents.”
Now totally engaged in the patient, I
ignored the cardiac monitor batteries telling me it was time for a change. “So what do you think of the candidates of today?”
Happy to know someone was actually listening to him, the patient pulled him-self up even higher on the cot. “It’s all bad comedy really,” he said. “‘Too many clowns and not enough circuses,’ my father would tell me when I was a boy, and he voted as far back as Theodore Roosevelt. Call me
CleNChed TeeTh VerbiageWhy labels should be left out of politics
heimlich: horrid elections instigate
Merciless laryngeal induced Constrictive hypoxia
looks like another choking call during the presidential debates. … Can’t swallow what they’re hearing.
Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly & applying the wrong remedies.
—Groucho Marx
Vote for me!
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an idealist, but everything in politics has always sucked.”
“But these are exceptionally hard times,” I interjected ignorantly.
“Are they now?” he smirked. “Well young fella,” (I cannot recall the last time anyone called me “young fella.”) “Every electoral pro-ponent of their party touts that this is the most critical time in our history with each partisan group trying to scare the bejesus out of everyone, lest the horrific prospect of the other guy becoming president actually comes true.
“Really? Well, guess what?” he continued with more impassioned fervor. “The world is still spinning. No matter who the presi-dent is, this country will continue to endure. Our democracy still governs the person in charge of it.”
As we approached downtown, we saw a crowd of people with signs on a street corner loudly advocating their candidate with the opposing view standing on the other side of the street. “See those people out there,” my patient grinned. “I laugh at folks who idiotically go crazy when their party member doesn’t get elected. One thing I can say after all these years is that I have mastered the gen-teel art of letting others rant on and on while sitting back and basking in the knowledge he or she is full of diaper dung. Speaking of, are we at the hospital yet?”
EMS is a profession that demands its pro-viders have a high degree of broad-minded-ness while working in an environment rich in cultural, ethnic, religious and political diver-sity. Regardless of a patient’s personal belief systems or social and economic standing, all of us cast our vote each day by what we do or don’t do in relation to patient care. When I see a medic quick to use incendiary words or labels toward a group of people simply because they do not agree with their own political standing, I cannot help but question their overall tolerance and ability to compro-mise or provide bipartisan patient care.
Or as Soren Kierkegaard once said, “Once you label me, you negate me.”
Until next time, remember labels are for diseases—not people. JEMS
Steve Berry is an active paramedic with Southwest Teller County EMS in Colorado. He’s the author of the cartoon book series I’m Not An Ambulance Driver. Visit his website at www.iamnotanambulancedriver.com to purchase his books or CDs.
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AED AccEssHennepin (Minn.) EMS has
announced the addition of a new informa-tion system that will assist 9-1-1 dispatchers in helping callers locate lifesaving automated external defibrillators (AEDs) available near sudden cardiac arrest victims.
“The problem is that until now, publicly available AEDs are rarely used in an emer-gency because people don’t know where they are, they can’t see them, and 9-1-1 dispatch-ers are unaware of the location,” said Chris Kummer, manager with Hennepin EMS, in a news report.
The new system from Atrus, Inc., known as AED Link, shows the location of regis-tered AEDs on 9-1-1 agency consoles. “AED Link lets us instantly see the location of all registered AEDs near a sudden cardiac arrest victim so we can send someone to get it in time to help save a life,” Kummer said. Both Hennepin EMS and Atrus officials anticipate the system to be available by this month, which is fittingly, National Sudden Cardiac Arrest Awareness Month.
In 2011, Hennepin EMS managed seven cardiac arrest cases in which a bystander used
an AED. In six of those cases, the patient was resuscitated and walked out of the hospital neurologically intact. “While there are many factors to survival, bystander intervention with CPR and an AED is clearly a key link,” said Brian Mahoney, MD, Hennepin EMS medical director, in a news release.
We tip our hat to Hennepin EMS for work-ing to improve the availability of AEDs and aiding in ongoing efforts to increase cardiac arrest survival rates.
EquinE ThErApyEquine-assisted psychotherapy (EAP)
is a specialized form of psychotherapy using horses as a therapeutic tool. This modality is designed to address self-esteem and per-sonal confidence, communication and inter-personal effectiveness, trust, boundaries and limit-setting, and group cohesion. It has been effective in the recovery of our wounded warriors.
MONOC Mobile Health Services in New Jersey has announced a partnership with the Chariot Riders Equestrian Academy and Horses for Heroes program to sup-port New Jersey veterans and active mil-
82 JEMS OCTOBER 2012
LAsT WOrDThe Ups & downs of eMs
JEMs (Journal of Emergency Medical Services), ISSN 0197-2510, USPS 858-060, is published 12 times a year (monthly) by PennWell Corporation, 1421 S. Sheridan Road, Tulsa, OK 74112; phone 918/835-3161. cOpyrighT © 2012 PennWell Corporation. subscripTiOns: Send $44 for one year (12 issues) or $74 for two years (24 issues) to JEMS, P.O. Box 17049, North Hollywood, CA 91615-9247, or call 888/456-5367. Canada: Please add $25 per year for postage. All other foreign subscriptions: Please add $35 per year for surface and $75 per year for airmail postage. Send $20 for one year (12 issues) or $35 for two years (24 issues) of digital edition. Single copy: $10.00. pOsTMAsTEr: Send address changes to JEMS (Journal of Emergency Medical Services), P.O. Box 17049, North Hollywood, CA 91615-9248. Claims of non-receipt or damaged issues must be filed within three months of cover date. Periodicals postage paid at Tulsa, Oklahoma and at additional mailing offices. ADvErTising infOrMATiOn: Rates are available at www.jems.com/about/advertise or by request from JEMS Advertising Department at 525 B Street, Suite 1800, San Diego, CA 92101-4495; 800/266-5367. EDiTOriAL infOrMATiOn: Direct manuscripts and queries to JEMS Editor, 525 B Street, Suite 1800, San Diego, CA 92101. No material may be reproduced or uploaded on computer network services without the expressed permission of the publisher. JEMS is printed in the United States. GST No. 1268113153.
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itary personnel with disabilities. Chariot Riders Academy is a non-profit organization accredited by the Professional Association of Therapeutic Horsemanship International. In addition to the services they offer to the pub-lic, they also operate the Horses for Heroes program in Ocean and Monmouth Counties.
The Horses for Heroes therapeutic rid-ing program includes mounted and non-mounted equestrian activities in either group or private settings at no cost to participants. Activities are tailored to the individual’s needs and have been proven to improve the physical balance, gait and morale of both active military personnel and veterans with a wide range of both physical and psycho-logical special needs.
We give MONOC Mobile Health Services a thumbs up for supporting such a great service for our veterans. For more informa-tion on the Horses for Heroes Program, visit www.chariotriders.org.
MOrE AccOunTAbiLiTyThe National Association of EMTs
(NAEMT) announced a position paper that encourages the establishment of a “just culture” environment within all EMS agencies.
The term “just culture” refers to a values-supportive system of shared responsibility in which healthcare organizations are accountable for responding to the behaviors of their staff in a fair and just manner. Staff, in turn, are accountable for the quality of their choices and for reporting both their errors and system vulnerabilities.
In the just culture program, employees’ behaviors are separated into three catego-ries: 1. “human error”; 2. “at-risk behavior”; and 3. “reckless behavior.” This helps create a formula for consistency for the evaluation of human behaviors, and instills a sense of confidence in the individuals involved.
Because mistakes don’t always result in an adverse event, acknowledgement of a mistake allows agencies to take action before an event occurs.
We give a thumbs up to the NAEMT for helping foster an environment of accountability and consistency across all EMS agencies. JEMS
‘siMuLAncE’ On ThE rOADA new and innovative “Simulance” recently went into service in western Virginia. The Blue Ridge
Volunteer Rescue Squad (BRVRS) and Botetourt County EMS refurbished an ambulance and added a high-fidelity patient simulator.
The rescue squad submitted a request through the state Rescue Squad Assistance Fund (RSAF) for $100,455.72 at the 80/20 state/agency funding level. The primary goal of RSAF is to financially assist govern-mental, volunteer and nonprofit EMS agencies to purchase EMS equipment and vehicles and provide needed EMS programs and projects.
BRVRS was awarded a grant on Jan. 1, 2012, which covered the patient simulator, HD camera, video recording tether-less and ruggedized automaton needed to create this ground-up approach to EMS training.
“It’s like real medicine. There’s the 99% of patients that act a particular way, but then there’s the 1% that’s going to act a little different,” BRVRS member Colt Hagmaier said in a news report.
We applaud BRVRS for enacting this effective and innovative approach to regional training—and making good use of a retired ambulance.
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