The Rural Community Paramedic Your History & Physical p ...€¦ · Thomas Jefferson University...

The Rural Community Paramedic

p. 17

Getting the Most from Your History & Physical

p. 30

Why Your Agency Needs a SWOT Analysis

p. 44The ABCs of Pediatric SepsisUnrecognized sepsis kills kids; don’t let it happen on your watch p. 38

Visit us online at EMSWorld.com FEBRUARY 2016 | VOL. 45, NO. 2 $7.00

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· Easy-to-Use Timing Light with Pull Tab for activation· Light blinks every 6 seconds/10 breaths per minute· Assists in Reduced Risk of Aspiration· Assists in Reduced Stacking of Breaths· · Variety of BVM configurations

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Delivering safe ventilation results in sufficient expiration time avoiding breath stacking.

a disposable, color-coded manometer with integrated timing light

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

PARTNERS

EDITORIAL ADVISORY BOARD

4 FEBRUARY 2016 | EMSWORLD.com

Peter Antevy, MDCEO & Founder, Pediatric Emergency Standards

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

Raphael M. Barishansky, MPH, MS, CPMDirector, Office of Emergency Medical Services, Conn. Dept. of Public Health

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

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

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

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

Elliot Carhart, EdD, RRT, NRPAssociate Professor, Emergency Services Program, Jefferson College of Health Sciences, Roanoke, VA

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

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

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

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

Thom DickEMS Educator, Brighton, CO

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

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

Troy M. Hagen, MBA, NREMT-PCEO, Care Ambulance, Orange, CA; President, National EMS Management Association

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Mike RubinParamedic, Nashville, TN

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

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

Matthew R. Streger, Esq. Executive Director, Mobile Health Services, Robert Wood Johnson University Hospital; Fitch and Associates, LLC, New Brunswick, NJ

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

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

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

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

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

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

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

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

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

Published by SouthComm Business Media, Inc PO Box 803 • 1233 Janesville AveFort Atkinson WI 53538920-563-6388 • 800-547-7377Vol. 45, No. 2PUBLISHERScott Cravens, EMT-B800/547-7377 x1759 [email protected]

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

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

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

20

38

17

44

FEATURES17 Community Paramedicine in a Rural

Setting Minnesota’s approach includes free clinics and a mobile unit that travels the communityBy Michael R. Wilcox, MD, FACEP, FAAFP

20 How To Make the Most of Your Dispatch CPR InstructionsThe makers and takers of 9-1-1 calls have a huge opportunity to help cardiac arrest victimsBy John Erich

24 2015 CPR/ECC Update Infographic details what you need to know about the new CPR/ECC guidelinesBy Teresa Chan, MD, BEd, Sarah Luckett-Gatopoulos, MD, MSc, Brent Thoma, MD, MA, & Blair Bigham, MD, MSc, ACPf

27 Cardiac Resuscitation Research Review Studies address the efficacy of continuous chest compressions and automated compression devicesBy Sean M. Kivlehan, MD, MPH, NREMT-P

30 Getting the Most From Your History and Physical: Chest Pain Patients Done correctly, they can point you toward the right diagnosisBy Ken Scheppke, MD, & Keith Bryer, BBA, EMT-P

44 Why You Need to SWOT Your Agency EMS agencies have never been in more need of such analysisBy Raphael M. Barishansky, MPH, MS, CPM

FEBRUARY 2016 VOL. 45 | ISSUE 2

COVER REPORT

38 The ABCs of Pediatric SepsisUnrecognized sepsis kills kids; don’t let it happen on your watchBy Rommie L. Duckworth, LP

COLUMNS

12 CASES WITH A TWISTCulinary ComplicationsBy David Page, MS, NRP, & Will Krost, MBA, NRP

14 LUDWIG ON LEADERSHIP5 Things Smart Managers Never SayBy Gary Ludwig, MS, EMT-P

50 THE MIDLIFE MEDICWhat I Wish I’d Known ThenBy Tracey Loscar, NRP, FP-C

DEPARTMENTS 8 EMS World Online

10 From the Editor

48 Ad Index

48 Classified Ads

On the CoverWhile intubation may be necessary for the septic pediatric patient, do not use Etomidate as it can increase the severity of sepsis. Photo by Patrick Holland.

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

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

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

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

linkedin.com/groups?gid=1853412 youtube.com/EMSWorld

FEATURES

Medics with Guns >> EMSWorld.com/12156825Should medics carry guns? Maybe, says Mike Rubin, who looks at the pros and cons, on duty and off, in this month’s Life Support.

The Community Paramedic Clinic >> EMSWorld.com/12157188Last fall Wisconsin’s Ryan Brothers Ambulance opened a pioneering community paramedic clinic to help bring care to underserved patients in Madison. This article looks at who they’re helping, what they’re doing, and how it’s improving outcomes and saving money.

Month in Review >> EMSWorld.com/12156848 If you’re looking to catch up with the latest news, most popular articles and the EMS chatter on social media, check out EMS World’s new Month in Review column for a handy roundup of the top headlines.

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HOSTED BYREGISTER FOR EMS ON THE HILL DAYApril 20, 2016 (briefing April 19), Washington, D.C. | naemt.org

It has never been more important for EMS professionals to speak out on behalf of our patients’ needs and on issues that impact our ability to provide quality medical care.

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A Public Display of Hands“CPR Saves Lives March” shines the spotlight on SCA survival

On December 7, 2015, more than 1,200 people marched through the

streets of downtown San Diego to show their support for a subject

very dear to their hearts: improving SCA survival.

The “CPR Saves Lives March” was organized by the Citizen CPR

Foundation in conjunction with the Emergency Cardiovascular Care Update

(ECCU) 2015 conference. Faculty members, resuscitation experts and health-

care providers joined SCA survivors on the march.

“Survival rates from cardiac arrest are not low because of the lack of effec-

tive treatment,” said Tom P. Aufderheide, MD, president of Citizen CPR Founda-

tion (CCPRF) and faculty member of the Medical College of Wisconsin. “Early

9-1-1, CPR and AED use, consistently provided throughout our communities,

would vastly improve survival, but these simple and lifesaving actions are

only as good as our communities’ implementation and comprehensive action

to provide them.”

This issue features several articles on cardiac care, including a report from

ECCU (see page 20). For more on the “CPR Saves Lives March,” including an

aerial video of the event, see EMSWorld.com/12146469.

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

EMSWORLD.com | FEBRUARY 2016 1312 FEBRUARY 2016 | EMSWORLD.com

Critical tasks require us to

stop and regain focus.

Culinar y ComplicationsA call becomes complicated by last night’s dinner, a warm floor and a medication mishap

It’s a hot summer day, and crews receive a call

for a patient on the eighth floor of an apartment

building where the elevator is out of service. As

the crew climbs the last few stairs, they hear the

rush of air from a bag-valve mask swooshing, and

someone counting, “One and two and three.”

On arrival the crew finds a morbidly obese (around

350 kg) female in cardiac arrest on the floor of her

kitchen. Their size-up notes a large quantity of “dark

red fluid surrounding and on top [of] the patient,” as

a first responder says, “We can’t find where she’s

bleeding from, but it looks like it’s inside the mouth.”

The crew notes extreme rigidity of the neck and

jaw when trying to open the airway, and food par-

ticles “everywhere,” clearly indicating large amounts

of red-bluish-violet emesis.

As the team continues the resuscitation, the

monitor shows asystole and the crew discovers the

patient is of Eastern European descent. Compres-

sions are difficult to perform due to size and slipperi-

ness of the chest. They place a supraglottic airway

after being unable to visualize the airway. Later they

report the “moisture never seemed to go away, and

we kept sliding off the sternum.”

An intraosseous line is placed, and one crew

member hands the other a syringe with 10 ml of

clear fluid. “Here’s your epi,” he says. “I had to draw

it up and dilute the 1:1 because the 1:10 in the bag

is broken.” The medication is administered quickly.

Soon thereafter medical control approves cessation

of efforts; however, during cleanup several twists

become evident.

Case DiscussionIt turns out that the fluid was not blood, but borscht,

a beet soup the patient had served her family the

evening before. Once a younger family member

arrived on scene to translate, the crew also discovers

the patient had probably collapsed the night before

after serving the family meal, but was not found

until this morning. While a language barrier certainly

confused this case, the family on scene could speak

enough English to communicate this, but was never

interviewed well enough by the responding crews to

convey this information.

Why was the patient warm enough that the crew

chose to begin resuscitation efforts? The floor of the

kitchen was very thin and easily heated due to the

downstairs neighbor’s hot water pipe. The ambient

temperature and warm wood floor gave the sense

the patient had not been down for long.

Last but not least, the crew discovered the mul-

tidose vial they used to draw up epinephrine was in

fact a vial of amiodarone. Drug shortages had forced

a change in supplier, and the

vials of multidose epinephrine

and amiodarone looked very

similar.

Preventable FactorsEMS providers are tested on

each case we respond to. Are

you capable of quickly climbing

eight floors and taking care of

a cardiac arrest patient with a

clear mind? Staying in shape is

certainly a job requirement, but

knowing when to slow down

enough to regain composure

is key. Practicing mental acu-

ity training while your heart rate

is near maximum can help keep

you stay sharp.

Recent research has pointed

to serious concerns with the

accuracy of medication admin-

istration in EMS. Medication

labeling, storage and inven-

tory are key to creating a sys-

tem that minimizes the chance

of error. The fewer calculations

needed on a scene, the better.

This crew did not notice the

broken epinephrine vial during

their initial checks. More impor-

tant, pausing to double-check

a medication with a partner

might have caught this error.

After promoting a culture

of safety, where errors can

be reported without fear of

repercussion, Sedgwick County

EMS, in Wichita, KS, has done

a great job creating a check-

list that helps crews double-

check with each other before

administering any medication.

The cross-check takes 20–30

seconds and should be done

during any case. Even during

a cardiac arrest, we can afford

to spend the time to ensure

the right medication is admin-

istered. You can see this cross-

check with accompanying

video at www.emsreference.

com/checklists.

ABOUT THE AUTHORS David Page, MS, NRP, is director of the Prehospital Care Research Forum at UCLA. He is a senior lecturer and PhD candidate at Monash University. He has over 30 years

of experience in EMS and continues to be active as a field paramedic for Allina Health EMS in the Minneapolis/St. Paul area.

Will Krost, MBA, NRP, is a fourth-year medical student and a faculty member at the George Washington University School of Medicine and Health Sciences in the Departments of

Clinical Research and Leadership and Health Sciences. He has over 23 years of experience in EMS operations, critical care transport and hospital administration.

Please help us identify errors and near-miss events that affect the safety of EMS providers and patients. Report events anonymously at www.emseventreport.com.

E.V.E.N.T. is an anonymous tool designed to improve the safety, quality and consistent delivery of EMS. The data collected will be used to develop policies, procedures and training programs.

REPORT EVENTS

Editor’s note: Cases

are obfuscated

and amalgamated

to protect patient

privacy and provider

anonymity. While

staying as true as

possible to the actual

event, creative license

is used to better

explain the lesson(s)

in the case.

CRM TipsCRM techniques have led to improved communication, teamwork and safety in the military, commercial aviation and now EMS/fire agencies.

• Task saturation—When multiple key processes are going on at once, EMS providers need to guard against becoming overwhelmed. Critical tasks require us to stop and regain focus. The first responder’s strong belief the patient was covered in blood led the crew to think that was the case, instead of interviewing the family.

• No-blame culture—In a culture of safety, who committed an error is not as important as what caused the error and how to fix it. In this case there were a number of potential blame recipients. The medic who drew up the wrong medication could be blamed for improperly verifying the medication, and the medic who pushed the drug could be blamed because he neglected to verify the medication, especially in light of the fact that there was a noted variance from the normal packaging and concentration. In addition, both crew members could receive some blame for attempting to resuscitate a dead person. It is easy to be a Monday-morning quarterback and assume we would have done something differently, but it is hard to know for sure.


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The higher you go up in an

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Things Smart Managers Never SayEffective leaders choose their words carefully

Leaders of EMS organizations are involved in

conversations all day. And the higher you go

in an organization, the more people listen to

every word you say.

They’ll analyze it, scrutinize it and finally interpret

what they think is the “true” meaning of what you

said. Some don’t forget. I’ve had people repeat to

me exact statements I made to them 10 years earlier.

This got me to thinking of the five things smart EMS

managers should never say.

You Should Never Say...1. “We have always done it that way.” This is a common saying in the fire service, and it

seems EMS has latched onto it also. Employees who

bring up an issue and want to change things for the

better do not want to hear you say you’re not willing

to look at improving a process.

2. “I don’t agree with my boss/board of directors on this, but we need to do it.” You should never talk about your superior in a dispar-

aging way. How would you feel if your subordinates

said this after you told them to do something? While

what you’re being told to do by your boss or board

may be unpopular, and you may want to deflect the

criticism off of you, throwing your boss or board of

directors under the bus is completely unprofessional.

You should always present a united front with your

boss(es). Once a decision has been reached by your

superiors, it is your job as an EMS manager to sup-

port it and ensure your subordinates do the same.

3. “Because I said so!”When I was little I would ask my parents to do

something, and every so often, when I was told

no, I would ask why. Sometimes one of my parents

would answer, “Because I said so!” I would always

be confused, but I knew they meant business by the

way they said it.

if you say this to one of your employees after you

tell them to do something and they ask a question,

you will garner very little respect from the employee.

In my mind, they are trying to understand your rea-

soning and rationale for your decision. Obviously I’m

not advocating you take time to explain your deci-

sions to employees after you give them orders on

emergency scenes, but there is certainly time to dis-

cuss decision-making in an office environment when

an employee is trying to understand your thought

processes better.

4. “That’s a dumb idea.” This statement is especially damaging to make if

you say it in front of a bunch of EMTs and paramed-

ics after someone has made a suggestion. Sure,

not every idea is going to be of the same value, but

a good EMS manager knows that when someone

makes a recommendation or suggestion, they should

not fear being shot down in flames and insulted.

If you do this often enough, no one will ever make

suggestions or share problems with you. Improve-

ments in any EMS organization come about when

smart people are encouraged to brainstorm in an

environment where they will not be humiliated.

5. “I am too busy.”Your EMTs and paramedics want to feel they mat-

ter and their issues are important to you. Blowing

someone off can make them feel they have no value.

You may be busy, and you can tell them so, but let

them know that you will get back to them at the first

opportunity.

Communication is Key to SuccessWhat you say and how you say it to your employees

determines your success as an EMS manager.

Over my career I have worked for some chiefs who

had no communication skills and were despised by

their subordinates. Employees did nothing beyond

what they were expected or asked to do. Morale

under these chiefs was terrible, and sick-leave usage

was rampant.

Always be careful of what you say and how you

say it, as your words can have a significant impact

on your agency.

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

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In the future, access to healthcare in the rural setting will become increasingly problematic. Fewer and fewer primary care providers will be choosing to prac-tice in rural areas.

From 2010–2050, the U.S. population is expected to increase by 40% (from 310 to 439 million). One quarter of Americans will live in rural/remote areas, but only 10% of physicians will practice there. Also, there will be an increasing number of immigrant patients who live in rural settings. By 2042 diverse, racially aggregate minority popula-tions will become the American majority.

In addition, there will be a growing num-ber of elderly living in rural areas. By 2030 more than 20% of the U.S. population will be over 65 years of age. Many of these peo-ple will have chronic diseases with limited financial resources.

To partially address this lack of health-care access, the community paramedic can be used to provide some benefit for these groups. As a pioneer in the area of com-munity paramedicine, Minnesota has sub-stantial experience with rural CP programs and needs.

The Rural Community ParamedicTo prepare for their roles, the state’s CPs undergo standardized training developed by experts at Hennepin Technical College in partnership with the Minnesota Ambu-lance Association. The program includes 144 hours of classroom instruction (half live or via interactive TV; half online/distributed learning) followed by 196 hours of clinical training in their area. Rural CPs gain addi-tional skills by expanding their clinical hours while working with their rural mentors.

Areas of clinical focus include primary care, community health/hospice, wound care, behavioral health, cardiology and respiratory issues, pediatrics and geriatrics, and networking.

As a part of their training, the CP devel-ops a gap analysis of healthcare needs with-in their community. They then bring to the healthcare team options to assist in filling these gaps. They expand their role in pro-viding healthcare, but they do not change their scope of practice.

The state has operated rural programs in three counties.

Rice County—Rice County is located in southeastern Minnesota. It has a population of 65,000, of whom 14% are over age 65, 4% are African-American and 8% are Hispanic.

The CPs in this county work within a free clinic (the HealthFinders Collabora-tive) with the guidance of a case manager under the licensure of a medical director and in partnership with a community health worker to make home visits. They focus on shut-ins, the disabled, the mentally chal-lenged and the underinsured. Their tasks include home safety checks, nutritional counseling, medication review, patient assessment, interaction with support per-sonnel, and mental health monitoring. Col-laboration with other healthcare providers has been a key to the program’s success.

Wadena County—Wadena County is located in northwestern Minnesota. It has a population of 13,757, of whom 22% are over age 65 and 4% are Native American.

The CPs within this county are a part of the local hospital system and partner with the Wadena County public health program. They provide several procedural services, including lab draws for long-term, chemi-

By Michael R. Wilcox, MD, FACEP, FAAFP

Patient assessment and medication

reconciliation are key parts of the

CP’s role.Tri-County Health Care

Minnesota’s approach includes free clinics and a mobile unit that travels the community

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cal dependency and homebound patients; tracheal tube stoma care; ostomy care; bladder scans; medication administration to the mentally ill; medication education and review; EKG procurement, IV starts, laceration repair and simple extremity splinting for long-term care patients; wound care; home visits to patients pre-orthope-dic surgery to assess for fall hazards; and

postsurgical visits to ensure proper wound healing and prevent unnecessary ER visits.

Over a two-year period, this program has averaged 100 hours of service per month and 5-10 patient encounters per week. Their work heavily involves collaboration with other healthcare workers.

Scott County—Scott County is located in south-central Minnesota. It has a popula-tion of 140,000, of whom 9% are over age 65, 4% are African-American, 5% are Hispanic and 6% are Asian. Its program was the first in the state to use community paramedics, which began in 2009.

The CPs within this county work with the public health system in collaboration with the Mdewakanton Sioux community and local faith communities to provide a free clinic for the un- and underinsured. This clinic is mobile and travels within the county in a medical van provided by the Sioux com-munity, seeing 14–20 patients per session.

There is an additional clinic that pro-vides similar services and is station-ary. It is housed within the Community

Action Partnership Agency (CAP). This is a resource center for food access, job placement and public assistance resources. Through the clinic’s efforts, a “medical home” is established for the patient that includes provider services and reasonably priced prescriptions.

Over a five-year interval, 600 patients have been cared for through this venue. Collaboration is a key factor in the success of this program as well.

Problems EncounteredThere have been four major problems encountered in developing CP programs in Minnesota’s rural settings. Solutions to these problems remain an ongoing chal-lenge. These are:

1. The lack of an electronic medical record that is inexpensive, user-friendly and interactive with other systems in shar-ing data.

2. Funding sources to sustain the pro-grams: Third-party payers are just now realizing the cost savings their plans may

realize with CP-type programs using front-line healthcare workers (CPs, CHWs).

3. The lack of common data elements that support the quality of care provided by com-munity paramedics. This is being worked

upon by national EMS experts.4. Potential liability concerns on the

part of the CP medical director, especially in areas of increased procedural request and usage.

ConclusionAccess to healthcare in rural areas will be an increasing issue in the future. Especially problematic will be the management of chronic disease in the elderly, the manage-ment of immigrant health and the promotion of public health mandates (immunization updates, follow-up of sexually transmitted diseases, mass-casualty event preparation, mental health care and treatment).

The community paramedic, through his or her program’s gap analysis of healthcare needs and attention to complex, under-served and vulnerable populations, will become a valuable resource to assist in addressing these gaps.

AB O U T THE AU TH O R Michael R. Wilcox, MD, FACEP, FAAFP, is a clinical associate professor in the Department of Family Health and Emergency Medicine at the University of Minnesota Medical School in Minneapolis; a medical consultant for EMS educational programs with the Minnesota state college and university system; and medical director for community paramedic and EMS educational programs with Hennepin Technical College and South Central Technical College, Eden Prairie, Minn. Contact him at [email protected].


The CPs in Wadena County are a part of the local hospital system and partner with the county public health program.Tri-County Health Care

Universal Challenges, Local SolutionsWith fewer people spread out over greater distances, rural EMS agencies face a complex set of calculations in launching community paramedic programs. This month community paramedicine pioneer Dr. Mike Wilcox highlights three CP programs in Minnesota that may serve as models for other rural communities. While urban and suburban agencies may want to focus on programs to help hospitals and health plans reduce readmission rates, these three rural agencies have played a vital role in supplementing their communities’ primary care, public health and hospice services.

The challenges summarized by Dr. Wilcox are universal to community paramedic programs regardless of their geography. Integrating our medical record systems with other healthcare providers has been a challenge even for hospital-based EMS agencies. Finding appropriate measures to evaluate the quality of CP services and finding sustainable funding are still barriers for many agencies, but great progress on both fronts has been made in the past two years. Of the challenges Wilcox cites, obtaining liability coverage for physicians willing to push at the borders of our traditional scopes of practice is likely to be more daunting a challenge than that faced by programs that primarily focus on patient navigation and advocacy services. —Dan Swayze

the 9-1-1 call act as a mechanism to strengthen the bystander CPR link is incredibly important and is probably the underpinning of success in some of the communities across the country that have saved the most lives.”

If that’s so, what goes in to what they’re doing, and how can others emulate that success?

Aspects of ExcellenceTo be the best, learn from the best: Seattle and King County, WA, have long been among America’s leaders in cardiac arrest survival. While there are numerous reasons behind that, a prominent one is this: Cardiac arrest is a default assumption.

Not for all callers, of course. But if you collapse in those jurisdictions and aren’t conscious and breath-ing normally when a bystander calls 9-1-1, you will be getting compressions started.

“What they probably do better than anyone is con-sider every 9-1-1 call a cardiac arrest/potential CPR call until proven otherwise,” says Bobrow. “In most places, when 9-1-1 dispatchers answer the phone, they aren’t thinking, This is a CPR call. It sort of has to be proven to them that the person’s really in cardiac arrest. They have to ask about breathing, and the type of breathing, and often they’ll listen to the breathing, and still they’ll wonder, Do they

really have cardiac arrest? But in Seattle and King County, if you’re unconscious or unresponsive and not breathing normally, you’re getting CPR started right away, and they’ll figure the rest out later. That’s a big paradigm shift in the way this is done from most cities around the country.”

So compression instructions generally get started faster. But not all instructions are equal. Even when given fast, they can come with a wide disparity in quality based on aspects like the dispatcher’s experi-ence, confidence and ability to galvanize action from sometimes-reluctant rescuers.

The dispatch profession’s best can engage and calm jittery callers, establishing rapport and gain-ing the trust that helps get their directions followed. When compressions begin they’ll count along, help minimize pauses, remind to push hard and allow full recoil. They’ll keep spirits up through the compres-sor’s fatigue and gut-twisting wait for the pros. That ongoing coaching is also a component of success.

One key to it is experience.“Most dispatchers, when they go on duty, aren’t

thinking, Today I really want to take care of some-one in cardiac arrest and have to get someone to do bystander CPR,” notes Bobrow. “So of course they’re reticent to do it—they don’t want to hurt anybody. If you don’t do this a lot, you can have some indecision;

When a cardiac arrest happens, fast CPR can help save a life. That’s not in dispute, but the evidence still mounts: A 2015 New England Journal of Medicine review of more than 30,000 cases from Sweden, where around three million people are CPR-trained, found

that 30-day survival was 10.5% when CPR was performed before EMS arrival and just 4.0% when it wasn’t.1 “The positive correla-tion between early CPR and survival rate,” concluded the authors, “remained stable over the course of the study period.”

That’s not an isolated finding; other recent data from Denmark showed that after a sustained decade-long effort to improve bystand-er CPR rates (increasing the national rate from 21.1% to 44.9%), 30-day and one-year cardiac arrest survival tripled.2

So why don’t more than roughly a quarter of out-of-hospital SCA victims get bystander CPR? Generally we know those answers too; lack of knowledge and lack of confidence are large among them. And part of the remedy for both is a robust program of dispatch-assisted CPR instructions given to those who call 9-1-1 for cardiac arrest victims.

“We believe the earliest links in the chain of survival are most impactful for out-of-hospital arrest, and certainly bystander CPR is one of the most impactful interventions we can do to save lives,” says Ben Bobrow, MD, medical director for the Arizona Department of Health Services’ Bureau of Emergency Medicine and Trauma Services and past chair of the American Heart Association’s Basic Life Support Subcommittee. “What we now believe is that having

By John Erich, Senior Editor

“Bystander CPR is one of the most impactful interventions we can do to save lives.”

—Ben Bobrow, MD, Medical Director, Arizona

Department of Health Services’ Bureau of

Emergency Medicine and Trauma Services

The makers and takers of 9-1-1 calls have a huge opportunity to help cardiac arrest victims

Voices of ECCUThe following comments from top physicians were excerpted from EMS World’s Word on the Street podcasts recorded by Rob Lawrence at December’s Emergency Cardiovascular Care Update Conference, hosted by the Citizen CPR Foundation. Find those at EMSWorld.com/podcast. For more information on ECCU, visit www.citizencpr.org.

Dispatch Life SupportDispatchers are clearly an emerg-ing and important link in the chain of survival. They have a critical task for identification and coaching of com-petent CPR. If you look at King County (WA), almost half our bystander CPR is a consequence of our dispatchers identifying the arrest and coaching CPR. So the reason bystander CPR is performed so often in Seattle and King County is in large part because our dispatchers take the bull by the horns and ask those two questions: Is the patient conscious, and are they breathing normally? If no and no, they start compressions. When we think about actually saving a life, [dispatch-ers] are perhaps the most important link in the chain of survival.

—Tom Rea, MD, MPH

Collaboration Is KeyThe lesson we have learned is that as we work together, more lives will be saved. The recently published Institute of Medicine report on car-diac arrest sets a national vision for the future that will save lives—but it takes action.

—Tom Aufderheide, MD

First Call, First ContactIf we can catch the arrest at the first call and have first contact with anyone who is trained in medical direction, once you get the logistics of dispatching the call out of the way, you can then use that as an opportunity to facilitate bystander CPR. That goes beyond whether the person knows CPR; the reality is you can give CPR instructions, very

basic chest compression instructions, in a very short period of time. You can have hands on the chest very quickly, and we all know that’s the fundamental principle of survival.

The most important thing a medical director for a PSAP can do is institute telephone CPR. You get the information you need to dispatch your folks, and simultaneously you give continuous chest compression CPR instruction, and that can be done in 20 seconds on the phone.

—Michael Kurz, MD, MS

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maybe you’re not as confident in what you’re saying and listening to. But confidence comes with practice and experience, and really confident telecommunicators can hear certain things: They listen for gasping on the telephone. They can tell by the tone of someone’s voice if a victim is in really bad shape and sounds like someone who really needs CPR. They get very skilled at these things and confident in their ability to get a caller calmed down. Because it’s very stressful, understandably, and if people are panicked, I think that’s the most common reason callers can’t get CPR started.”

Another component of CPR dispatch-instruction excellence is mea-surement. That means every aspect of the process: not only how often instructions are given and how often callers actually perform CPR, but metrics like time from call reception to recognition of potenial OHCA, and then to the start of instructions and then compressions.

Ultimately the most important measure is the duration from call reception to the start of actual compressions.

“You can look at two different cases in two different cities, and they may both have gotten CPR started,” says Bobrow. “But in one city maybe that took 90 seconds, and in the other maybe it took seven minutes. We think that’s part of the disparity in outcomes among communities.”

There’s more that goes into it beyond that, too; obviously the proper rate and depth of compressions are vital, as is minimizing pauses. A dispatcher that really gets it can help a caller can make a huge difference in all those areas.

Breathing NormallyAt December’s Emergency Cardiovascular Care Update show in San Diego, where Bobrow and other top docs spoke on this and related matters, there was a lot of talk about gasping—the agonal breaths that can lead a bystander/caller to give an incorrect answer to a dispatcher’s inquiry about whether a patient is breathing.

Abnormal breathing is something we can listen for, rather than just quiz the caller about. It’s usually not subtle and often discern-ible. And when we ask about it, how we do so matters a lot.

“If you ask a caller ‘Are they breathing?’ they’ll look down and see someone taking these agonal gasps, and they’ll say ‘Yeah, sort of,’” Bobrow says. “But if you ask them, ‘Are they breathing normally?’, they’ll look down and tell you, ‘No, that’s not normal breathing. I don’t know what that is, but that’s not normal breathing. That’s the way my fish breathes when he falls out of the fishbowl.’”

Normally is an important adverb, and recent changes to the American Heart Association’s CPR and Emergency Cardiovascu-lar Care guidelines underline it:

“To help bystanders recognize cardiac arrest, dispatchers should inquire about a victim’s absence of responsiveness and quality of breathing (normal versus not normal),” the AHA’s document highlighting the revisions says. “If the victim is unresponsive with absent or abnormal breathing, the rescuer and dispatcher should assume the victim is in cardiac arrest. Dispatchers should be educated to identify unresponsiveness with abnormal and agonal

“ REMEMBER: When crisis strikes, we don’t ‘rise to the occasion,’ we ‘sink to the level of our training.’”


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gasps across a range of clinical presentations and descriptions.”3 The why behind this further suggests dispatchers be specifi-

cally educated to help bystanders recognize that agonal gasps are a sign of cardiac arrest and ask “straightforward” questions about normal/abnormal breathing.

“Often, if you just ask whether they’re breathing, the caller will answer yes when they’re gasping,” says Bobrow. “Then the next move for some dispatchers is, ‘OK, turn them on their side in a recovery position, and help is on the way.’ We just missed an opportunity to help that person!

“I think that situation happens all the time. Hopefully less and less as we go along, but I still think a lot of times we miss the opportunity to give prearrival CPR instructions because we confuse gasping with breathing normally.”

It All MattersA final best practice is to harness the power of social media. A specific way is by use of something like the PulsePoint app, through which dispatch systems can alert CPR-trained bystand-ers to nearby cardiac arrests. This lets them get quickly to those victims’ sides and get compressions started. It also tells them where to find the closest AED.

“I really think there’s enormous potential to use social media to basically make the public become the first responders,” says Bobrow. “That’s really what we want, and certainly we can do it better than we have in the past. We know social media and using smartphones and things like the PulsePoint app can help us locate able and willing rescuers and connect them to cardiac arrest victims.”

We don’t know on a grand scale how beneficial that is or might become, though there seems potential. But it’s worth noting—and this is true of even the best dispatch CPR instructions as well—that there is no single magic bullet to improving survival from out-of-hospital cardiac arrest. Having such weapons in isolation isn’t likely to do much. But as part of a larger system—which includes aware citizens, lots of AEDs, short call intervals, fast EMS response and good hospital and post-arrest care—they can combine for a powerful difference.

“It all matters,” says Bobrow. “High-performance CPR by trained rescuers and public access defibrillation and high-quality post-arrest care are all important. But one thing I’ll say is, if you don’t get anyone to do bystander CPR for an out-of-hospital arrest, the odds of survival are very, very low. It’s not impossible, but one of the things most out-of-hospital cardiac arrest survivors have in common is that they had someone at the scene able and willing to do bystander CPR.”

RE FE RE N CE S

1. Hasselqvist-Ax I, Riva G, Herlitz J, et al. Early cardiopulmonary resuscitation in out-of-hospital cardiac arrest. N Engl J Med, 2015 Jun 11; 372(24): 2,307–15.2. Wissenberg M, Lippert FK, Folke F, et al. Association of national initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest. JAMA, 2013 Oct 2; 310(13): 1,377–84.3. American Heart Association. Highlights of the 2015 American Heart Association Guidelines Update for CPR and ECC, https://eccguidelines.heart.org/wp-content/uploads/2015/10/2015-AHA-Guidelines-Highlights-English.pdf.


Preamble: Blair Bigham, MD, MSc, ACPf

Coauthors of the infographic: Teresa Chan, MD, BEd, Sarah Luckett-Gatopoulos, MD, MSc,

Brent Thoma, MD, MA, & Blair Bigham, MD, MSc, ACPf

It’s the quintessential 9-1-1 call: Someone has collapsed, isn’t breathing, and has no pulse. Alarms ring, and we scramble to our ambulances, fire trucks and zoom cars. We hope that this call, unlike the others, will be the one we get back. Our heart rates accelerate and our minds rush. We think about all of the variables within our control: drug dosages, airway adjuncts, defibrillation. We chat about who will do what, and when it will be done. We try to bring order to the chaos that undoubtedly will ensue. Just as quickly as it all started, it will end; the end of an algorithm, the time on our watch, or a rote phone call. We will turn off the moni-tors, shut off the oxygen, and turn to face the family.

I can easily recall each resuscitation I’ve terminated. The memory is not always vivid, but each pronouncement is there, very real to me still. The “failed” codes I have run are many, and have often made me question why we bother to resuscitate those whose hearts have stopped. I can list the causes and describe the pathology. Like a mechanic who declares a car has driven its last mile, I know when the human body has given up. Still, the alarms go off and I don’t sink down in despair; I jump with excitement. This code could be the one! Even when we get that precious return of spontaneous circulation, we can’t help but wonder if our actions have been wise. Will our efforts result in a waste of resources and dollars, with death being postponed only a few hours? Will we add another member to the proverbial cabbage-patch? Will this person ever open their eyes, speak words to a loved one, or live a meaningful life?

Our perspective in these cases is brief, and often negative. That Baywatch moment of coughing, eye-blinking and a full return to consciousness is something I’ve never seen. Recovery from car-diac arrest takes hours, days, weeks, or even months. Despite our limited perspective, the numbers don’t lie; survival from out of hospital cardiac arrest has tripled in the last 10 years. The num-bers continue to rise as the science that guides our treatment evolves and is translated into action. Two in one hundred used to survive; now that number is ten. In some places overseas, it is 20. For patients in ventricular fibrillation, survival can be as high as 60%. That’s more than half. This is how far we have come. The science continues to improve, the guidelines continue to evolve, and we continue to get better at bringing back the dead.

In October 2015, the American Heart Association, in partnership with resuscitation organizations all over the world and the highly· regarded International Liaison Committee on Resuscitation, released the latest scientific statements, treatment recommen-dations and practice guidelines for the care of victims of cardiac arrest. This infographic summarizes what you need to know before you respond to your next arrest.

We know that the devil is in the details, and that strong lead-ership, teamwork and attention to detail make a difference. By studying the latest guidelines and applying them in earnest, we can all do our part to ensure survival rates from cardiac arrest continue to climb. How high can survival from cardiac arrest go? That’s one question science hasn’t yet answered.

This infographic highlights the changes in the American Heart Association/ Canadian Heart and Stroke Foundation CPR/ECC guidelines in 2015.

Full guidelines at: https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/


Other Interesting Updates

Once upon a ROSC...

Pediatrics Other

Return to walking through the ABCs. Aim your interventions to achieve:

Sp02>94%, EtC02 30–40,

SBP >90 (MAP > 65)

Post-arrest patients with STEMI should go directly to a PCI center if

one is close by. Other patients without ST elevation may also benefit from direct transport for angiography.

Cold saline boluses in the field may lead to heart failure, but in-hospital

temperatures should be 32–36ºC for 24 hours.

Focus on Basics To the Cath Lab! No pre-hosp ice!


Chest compressions have been the center of attention during cardiac resuscitation for the past few years, and for good reason. In its 2010 guidelines revision, the American Heart Association (AHA) rewrote the ABCs to the

now established CAB approach based on increasing data linking improved outcomes to effective com-pressions.1

Since then the science of chest compressions has developed rapidly. This article reviews two recently published papers on two of the most controversial subtopics: continuous chest compressions and auto-mated chest compression devices.

Continuous Chest CompressionsGraham N, et al. Trial of continuous or interrupted chest compressions during CPR. N Engl J Med, December 3, 2015.

This is a large study performed across eight of the Resuscitation Outcomes Consortium (ROC) sites in North America and 114 EMS systems.

A total of 23,711 adult patients with non-traumat-ic out-of-hospital cardiac arrest were enrolled and assigned to either the continuous compressions or

By Sean M. Kivlehan, MD, MPH, NREMT-P

interrupted compressions groups. The outcomes measured were survival to hospital discharge and favorable neurologic function at discharge. The results showed no significant difference in survival or favorable neurologic outcome between the two methods.

Table 1 lays out the numbers in the trial. Table 2 lists the patients who were excluded, which is impor-tant to be aware of as these findings do not necessarily apply to them. Table 3 explains the protocol used in each arm of the trial.

There has been a lot of discussion about whether compression-only CPR is superior to conventional CPR. Previous studies showed an improvement in outcomes for both bystander-provided compression-only CPR and EMS-provided minimally interrupted compressions.2,3 However, these studies were observa-tional, which is a lower-quality standard of evidence than this newer randomized trial. So what does this mean for EMS? Before drawing conclusions, let’s dis-cuss some interesting findings in the data.

Studies address the efficacy of continuous chest compressions and automated compression devices

EMSWORLD.com | FEBRUARY 2016 27

TABLE 2: PATIENTS EXCLUDED FROM THE TRIAL

EMS-witnessed arrest

DNR

Traumatic Injury

Asphyxial arrest

Uncontrolled bleeding/exsanguination

Known pregnancy

Preexisting tracheostomy

Prisoners

CPR in progress on arrival by non-study provider

CPR with a mechanical device before manual CPR started

Advanced airway management before study agency arrival

TABLE 1: TRIAL NUMBERS

Continuous Compressions

Interrupted Compressions

Enrolled 12,613 11,035

Survived to Discharge 1,129 (9.0%) 1,072 (9.7%)

Favorable Neurologic Function (7.0%) (7.7%)

cal chest compression devices, five of which are randomized (high quality of evidence) and 15 that are observational (lower quality of evidence). Overall, the five randomized trials included 12,206 patients and showed no improvement in survival or neurologic outcome when mechanical compressions were compared to manual compressions.

Interestingly, the observational studies did show an improve-ment in survival to hospital admission when mechanical compres-sions were used. However these studies also showed no improve-ment for the other two outcome measures of survival to discharge and positive neurologic outcome. Why is this? In observational studies, responders had the ability to use their discretion in using the device. This creates risk of a phenomenon called “selection bias,” in which patients who were more likely to survive were pref-erentially given the device, which led to better outcomes. Using a randomized trial format mitigates this and other biases, which is why it is considered the gold standard for evidence-based medicine.

So why don’t the mechanical CPR devices work as well as we hoped? It depends on your perspective. Previous individual ran-domized trials suggested that devices may be equivalent, which in a resource-limited setting such as a scene or the back of an ambulance could actually be a plus. Using a device that is shown to be as effective as manual CPR can free up crew members to pursue other tasks and prevent standing in the back of a moving ambulance.

This article brings up some other important issues about mechanical CPR devices that are yet to be addressed, such as efficacy of incorporated defibrillation algorithms. Most notably, they draw attention to the lack of data on the safety of the devices and suggest that differing injury patterns between manual and mechanical CPR could affect survival.

Bottom LineThe authors conclude that “the cumulative evidence of high-quality randomized data does not support a routine strategy of mechanical CPR to improve clinical outcomes.” However, they do not seem to worsen outcomes either, so for now, it is reasonable to continue to use them in the field as an alternative to manual CPR.

RE FE RE N CE S

1. Berg RA, Hemphill R, Abella BS, et al. Part 5: adult basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122: Suppl 3: S685–705.2. Bobrow BJ, Clark LL, Ewy GA, et al. Minimally interrupted cardiac resuscitation by emergency medical services for out-of hospital cardiac arrest. JAMA, 2008; 299: 1158–65.3. Bobrow BJ, Spaite DW, Berg RA, et al. Chest compression-only CPR by lay rescuers and survival from out-of-hospital cardiac arrest. JAMA, 2010; 304: 1447–54.4. Kleinman ME, Brennan EE, Goldberger ZD, et al. Part 5: adult basic life support and cardiopulmonary resuscitation quality: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 2015; 132: Suppl 2: S414–35.5. Hallstrom A, Rea TD, Sayre MR, et al. Manual chest compression vs use of an automated chest compression device during resuscitation following out-of-hospital cardiac arrest: a randomized trial. JAMA, 2006;295:2620–2628.

AB O U T THE AU TH O R Sean M. Kivlehan, MD, MPH, NREMT-P, is an international emergency medicine fellow at Brigham & Women’s Hospital, Harvard Medical School. He is also a member of the EMS World Editorial Advisory Board. E-mail [email protected].

The chest-compression fraction is a measure of the proportion of each minute that compressions were actually being delivered. The 2015 AHA guidelines call for a minimum of 0.6, or 60%. Con-ventional CPR reduces the fraction by definition due to pauses for ventilations, while other pauses could occur in any setting. So one of the advantages that continuous compressions should have over conventional CPR is a better chest-compression fraction.

In this study, both arms had very high chest-compression frac-tions, 0.77 and 0.83. Why is this? This is likely the effect of well-trained and effective EMS teams providing high-quality CPR at baseline. CPR training has strongly advocated minimizing inter-ruptions in compressions for several years now, and it seems to be paying off. However, this already high fraction may have reduced much of the possible improvement to be gained from continuous compressions.

Another important point to note is that the continuous compres-sions protocol was not the same as the established cardio-cerebral CPR (CCR) that involves passive oxygenation and delayed advanced airway insertion while three cycles of 200 chest compressions are

given. Of note, that protocol was given a “reasonable alternative” recommendation in the 2015 AHA guidelines.4 This study does not support or refute the usefulness of that study, but there is a separate ongoing study evaluating this approach.

Bottom LineThis new study does not dramatically change our everyday prac-tice. It finds that continuous chest compressions with PPV do not improve outcomes when compared to conventional CPR, but it doesn’t worsen them either. For now, EMS providers should follow the 2015 AHA guidelines as built into their local protocols.

Automated Chest Compression DevicesBonnes J, et al. Manual cardiopulmonary resuscitation versus CPR including a mechanical chest compression device in out-of-hospital cardiac arrest: A comprehensive meta-analysis from randomized and observational studies. Ann Emerg Med, Nov 19, 2015, (Epub ahead of print).

The use of mechanical CPR devices has grown considerably over the past decade and continues to be implemented in an increasing number of EMS systems. Despite the promising early observational studies, several randomized trials have shown mechanical CPR devices to be at best equivalent, and at worst harmful. In fact, the first randomized trial had to be halted early due to safety concerns.5

This new meta-analysis looks at 20 published studies on mechani-

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TABLE 3: PROTOCOL USED IN EACH ARM OF TRIAL

Continuous Compressions

100 compressions per minute with asynchronous PPV at 10 per minute

Interrupted Compressions

30:2 with PPV

the sophisticated diagnostic tests available, the history and physical are still the gold standard for determining a diagnosis. Labo-ratory tests and imaging studies are largely ordered to confirm or in some cases exclude a diagnosis already determined through the information obtained from the history and physical exam.

Unfortunately, the history and physi-cal exam are probably the most neglected aspects of patient care in today’s prehospi-tal setting. Besides conducting improper or incomplete histories and physicals, many paramedics miss a diagnosis because they look only for its “classic” signs and symp-toms. As anyone who has been in the field for a while can attest, many patients don’t have “classic” presentations.

By understanding the etiology and patho-physiology of an illness and conducting the proper history and physical exam, the para-medic’s ability to make the correct prehos-pital diagnosis will significantly increase. Learning to assess and understand what is going on with your patient is a skill far more important to making a correct diagnosis than just remembering the classic presenta-tions of an illness. Making a correct prehos-pital diagnosis requires that knowledge and experience be combined with the subjec-tive/objective information obtained from the history and physical exam. Together this information will form the basis of the prehospital diagnosis.

As in the days of Osler, bedside expe-rience is emphasized. Much of medicine is pattern recognition. The authors feel strongly that paramedics should routinely follow up on the patients they transport to the hospital. It is critical to the development of accurate pattern recognition that para-medics discover the actual final diagnoses of the patients they have cared for and then compare each one to their prehospital diag-nosis to reinforce the recognized pattern or correct their misdiagnosis and thus adjust that recognition for future cases.

The value of establishing an accurate diagnosis is to provide a logical basis for treatment and transport destination. Seri-ously ill patients need prehospital interven-tion tailored for their particular diagnosis. Today paramedics are well trained and should be able to recognize, treat and/or stabilize most medical emergencies.

“Paramedics do not make diagnoses.”This is a quote uttered frequently in

prehospital emergency medicine, and it’s one of the larger myths that still exists. It is a throwback idea from a bygone era and a thought pattern that restrains the true potential of the field. It supports the errone-ous assumption that prehospital emergency medicine is not a true profession with highly skilled and knowledgeable person-nel who provide daily advanced assessment and treatment across our nation.

If paramedics never made a pre-liminary prehospital diagnosis, how would they know which protocol to follow or to which specialty destina-tion a patient must be transported? Indeed, both the National EMS Core Content and the National EMS Scope of Practice Model describe the need for paramedics to develop a differ-ential diagnosis, or field impression, based upon advanced assessment skills in order to provide correct treatment for the patient.1,2

Gone is the time when paramed-ics had limited training and skills. Paramedics are now routinely called upon to perform advanced emer-gency medicine skills such as rapid sequence intubation, interpreting 12-lead EKGs, intraosseous line insertion and many others that were once performed solely by physicians. It is time for prehospital healthcare workers to accept their role as professionals.

As professionals, it is important for EMS personnel to formalize and enhance skills in the area of obtaining history and physical examinations. It is the art of patient assess-ment that separates a technician who per-forms procedures from a true professional

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

Done correctly, they can point you toward the right diagnosis


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This is the first of a four-part series that will appear bimonthly.

equipped with the scientific knowledge and finely tuned assessment skills to make accurate prehospital diagnoses and deliver accurate high-quality medical care.

Dr. William Osler, often credited as the “father of modern medicine,” promoted the importance of patient history and physical examination. He is quoted as saying, “Listen to your patient, he is telling you the diagno-sis.”3 In this multipart series we will follow Osler’s example and stress the importance

of developing the art and skill of the patient history and physical assessment. We will attempt to impart an enhanced ability to skillfully obtain this vital information in order to formulate a differential diagnosis. These skills are essential to ascertaining the correct prehospital diagnosis and deter-mining the correct treatment and transport destination.

The intent of this series is to assist paramedics in developing a system-atic, targeted history and physical exam by focusing on the patient’s chief complaint and considering the differential diagnoses by using the inclusion and exclusion information provided by the patient. The goal is to quickly and accurately determine the prehospital diagnosis so immedi-ate lifesaving treatment can begin. This first installment will discuss the differential diagnosis of chest pain and the manner in which a targeted history and physical exam can nar-row down the prehospital diagnosis.

H&P BackgroundThe history and physical exam have long been the basis for determining a diagnosis. It is often said the diag-nosis is made 90% of the time by the history, 9% of the time by the physi-

cal exam and 1% of the time by laboratory examination. This has been found to be true: In at least two studies on the relative value of the history and physical exam in making the correct diagnosis, clinicians were found to use a combination of chief complaint and history to make the correct diagnosis in 74%–96% of cases, the physical exam added up to 12%, and the laboratory evaluation supplied the remaining minor amount of information needed.4,5 Even today, with all

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HistoryThe importance of obtaining a good his-tory cannot be overemphasized. The history combined with the physical exam provides the necessary subjective and objective infor-mation to make a prehospital diagnosis. A complete history includes history of present illness, past medical, social and family his-tory. Traditionally there is little emphasis on the family and social history in para-medicine. They are included because often they provide important clues in helping to determine a prehospital diagnosis.

History of the present illness (HPI)—If you only learn one thing from this article, understand that the single most important part of any history and physical exam is the history of the present illness. The sole purpose of the HPI is to get a clear picture of the events that led the patient to seek medical attention. Listen carefully to the patient—most of the information you need to make the prehospital diagnosis is in the history of the present illness. Keep in mind that the HPI is an evolving process, and as

you proceed use the inclusion and exclusion information supplied by the patient to nar-row the diagnostic possibilities.

As we are all aware, patients are not always the best historians. Paramedics will need to have a degree of investigative prowess to extract the information neces-sary to arrive at the correct diagnosis. A patient’s fear, confusion and denial can all be obstacles to overcome to obtain a good history. It’s important as a paramedic to have confidence in your history-taking ability.

Taking a history is a skill similar to start-ing an IV or intubating a patient. Skills take time to develop. Avoid histories that amount to nothing more than a series of random questions, as opposed to questions present-ed in a logical sequence. In addition, avoid confusing medical terminology or leading the patient with your questioning. Allow the patient to use their own words, but don’t be afraid to clarify vague answers. If neces-sary, use your resources; family, friends and healthcare workers can help fill in the gaps.

The history of the present illness is based on the chief complaint. Apply the acronym OPQRSTA to the chief complaint to ensure all necessary questions are asked. Avoid skipping around, as it is confusing, and you are more likely to forget a key question!

• Onset—When did symptoms begin? Was the onset gradual or sudden?

• Provoke—What makes the symptoms worse?

• Palliative—What makes symptoms better?

• Previous similar episodes—This ques-tion will often give you the diagnosis if pre-vious episodes have already been diagnosed.

• Quality of pain—Sharp, dull, pressure, squeezing, aching, burning?

• Region—Where is the pain located? Is the pain localized or diffuse?

• Radiation—Does the pain radiate?• Severity—What is the severity of the

pain on a scale of 1–10?• Time—Duration, frequency, constant/

intermittent?

The following is an outline of a prehospi-tal history and physical exam. Although his-tories and physical exams vary depending on the chief complaint, all should follow this general outline. However, transport should never be delayed to conduct lengthy histo-ries and physical exams. Unstable patients cannot afford such delays, and stable patients don’t require such in-depth histo-ries and physical exams. Remember, stabi-lization and rapid transport are the goals of prehospital medicine, and the assessment skills outlined in this article are designed to enhance the success of that mission. We begin with the framework of what infor-mation will be gathered and then discuss how to apply it specifically to patients with a chief complaint of chest pain.

This article has two main objectives: first to develop a focused systematic approach to the history and physical exam, and second to develop a better understanding of the etiology, pathophysiology and signs and symptoms of specific diseases so a prehos-pital diagnosis can be quickly and accurately

determined. This concept is important because even patients with the same disease can have different clinical presentations. The process involves four steps, and each should be completed before advancing to the next. Once you become proficient with the process, you will be able to quickly and accurately determine a prehospital diagno-sis within 2–3 minutes.

1. Chief complaint;2. History:• History of the present illness;• Past medical;• Social;• Family history;3. Targeted physical exam;4. Prehospital diagnosis and differential

diagnosis.

Chief ComplaintThe chief complaint is the primary reason a patient seeks medical attention. It acts as the logical starting point for determining which emergency medical conditions poten-tially exist and which follow-up questions

will help narrow down those possibilities. Some patients will list multiple complaints, which can make it difficult to determine the actual chief complaint. When treating patients with multiple complaints, deter-mine the patient’s main reason for calling 9-1-1 by asking a question such as, “Of all of those problems, which one concerns you the most?” Consider the answer to be the patient’s chief complaint. This will give you a reference point to begin targeting your his-tory and physical exam.

However, don’t disregard the other com-plaints; unifying them will help determine the prehospital diagnosis. In patients with chronic illnesses, the “frequent fliers,” it’s easy to become complacent and forego the history and physical exam. Give your patient the benefit of conducting a history and phys-ical exam for every encounter so you can make an informed decision regarding their treatment. Patients with chronic illnesses are likely to develop new medical conditions and complications from their chronic condition or even from their medical treatment.

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adult medical patients. This exam should also include ECG and glucose testing if warranted based upon the chief complaint. Caution: This exam is not for trauma patients.

Vital Signs • Blood pressure;• Pulse rate and quality;• Respiratory rate and quality;• Skin: color, condition, temperature;• Pulse oximetry;General • Position (supine, tripod, etc.);• Level of distress;Chest• Heart: rate and rhythm;• Lung sounds;Abdomen • Soft or rigid;• Tender or nontender;• Distention;Neurological • Level of consciousness (AVPU);• Orientation;• Gross motor and sensory exam;Extremities• Lower extremity edema.Once the history and physical exam are com-

pleted, there will be enough information to make an informed decision regarding your patient’s care.

Prehospital and Differential DiagnosisNow let’s apply this template to a chief complaint of chest pain.

In the world of medicine, there exist nearly innumerable potential diagnoses for specific com-plaints. Memorizing the nuances of each one would be impractical. However, since we are in the field of emergency medicine, and since our major role is that of initial stabilization and transport to the correct facility, we can limit our evaluation to those conditions that fall into two major categories: the potentially deadly/disabling and the statistically most common etiologies. This list of possible diagnoses is termed a differential diagnosis.

Taking a look at the chief complaint of chest pain, there are several potential life threats that must be addressed. These include myocardial infarction/isch-emia, aortic dissection and pulmonary embolism. There are also several common etiologies that must be considered: pneumonia, pleurisy, spontaneous pneumothorax, acid reflux and costochondritis.

The reader is cautioned that laypersons may mis-interpret some questions and assume “heaviness” in their chest is not actually chest “pain.” It may be bet-

• Associated signs and symptoms—Review of related body systems.Past medical history (PMHx)—Because time is limited in the

prehospital setting, past medical histories are limited to significant illnesses or diseases. In general inquire about any recent surger-ies, cardiovascular disease (coronary artery disease, hypertension, congestive heart failure, arrhythmias), pulmonary disease (COPD, asthma), stroke, diabetes, kidney failure or past similar episodes of their chief complaint.

The past medical history also includes any prescription or over-the-counter medications the patient is taking. Pay particular atten-tion to medications the patient has been prescribed, as they will provide some insight into underlying conditions and general health. Memorizing the most common medications and what they are used for will often let you elicit a patient’s past medical history just by looking at the medications they take. It’s also important to inquire about any recent medication or dosage changes, as either could be responsible for the patient’s condition, as can adverse side effects from a medication or combination of medications.

Also included in the past medical history are allergies to any medications. A urticarial rash, angioedema or wheezing character-izes a true allergic reaction. What many patients consider an allergic reaction is really a sensitivity or side effect of the medication—e.g., many patients claim they are allergic to morphine because it makes them nauseous.

Social history (SHx)—As paramedics we tend to overlook a patient’s social history. A patient’s social habits can provide insight into their general health and potential medical conditions. Specifi-cally inquire about smoking, drug abuse and alcohol consumption. Smokers have an increased incidence of coronary artery disease, hypertension and stroke. Use of drugs, specifically cocaine and other stimulants, can cause ischemic chest pain, hypertension, arrhythmias and stroke. Always inquire about possible drug abuse in patients with ischemic chest pain, especially patients who would be considered too young for coronary artery disease. Alcohol abuse can cause neurological, cardiovascular and gastrointestinal problems.

Travel history is part of the social history. With the ever-prevalent risk of new transmissible illnesses spreading from one continent to another, this is an additional important piece of information to gather from patients who present with an infectious-disease problem.

Family history (FHx)—Family histories are limited in the prehos-pital setting, as a positive or negative family history cannot rule out a specific illness or disease. Include family histories as part of the big picture. Coronary artery disease, hypertension, diabetes and strokes all have a high incidence of running in families. A positive family history is relevant with immediate family members only (mother, father, brothers, sisters or adult children). Because coro-nary artery disease, hypertension, diabetes and strokes are more prevalent in the fifth, sixth and seventh decades, a family history provides little information for a patient 50 or older. However, a 35-year-old patient complaining of chest pain whose father died of a myocardial infarction at 38 is significant.

Limited Prehospital Physical ExamThe following outline is an example of a limited physical exam. This is the minimum acceptable physical exam and should be done on all

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TABLE 1: EXAMPLE FRAMEWORK FOR A CHIEF COMPLAINT OF CHEST PAIN

Myocardial Infarction/Ischemia

Onset: Gradual, may be intermittent in days preceding the MI.P rovokes/palliative/previous: Exacerbated by exertion, better with rest;

often previous history of coronary artery disease.Q uality: Tends to be described as pressure, squeezing, heavy or burning.R adiation/region: Radiation to jaw, neck, upper back and either arm is

common.S everity: Ranges from 0–10; more constant and severe is more consistent

with MI; lesser degrees more consistent with angina.Timing: Waxing and waning as angina; becoming constant as an MI.Associated: Shortness of breath, diaphoresis, nausea, weakness.

Aortic Dissection

O nset: Sudden, abrupt onset, usually will call for help the same day it starts.

Provokes/palliative/previous: No exacerbating or alleviating factors.Quality: Sharp, tearing, ripping and migrating (i.e., changes location).R adiation/region: May migrate from chest to upper back, then lower as

dissection progresses.Severity: Generally severe pain.Timing: Sudden onset, constant.A ssociated: As dissects into other arteries, may get neuro or abdominal

complaints.

Pulmonary Embolism

Onset: Sudden, abrupt.P rovokes/palliative/previous: Better with shallow breathing, worse with

deep breaths. May have history of prior PE or DVT.Q uality: Sharp, pleuritic pain; may also be painless, presenting only with

SOB and lightheadedness.Radiation/region: Nonradiating, localized to chest.S everity: Ranges from minor with shallow breathing to moderate sharp

inspiratory pain.Timing: Constant, varies with insipiration.A ssociated: Dyspnea, lightheadedness, fainting, leg swelling and pain

(DVT symptoms).

TABLE 2: EXAMPLE OF ITEMS TO LOOK FOR WITH A CHIEF COMPLAINT OF CHEST PAIN


P MHx: Coronary artery disease, HTN, prior MI, diabetes, hypercholesterolemia, obesity, lupus.

SocHx: Smoking, cocaine.FHx: FHx of MI increases risk, especially if at a young age.

Aortic Dissection

P MHx: Marfan syndrome, Turner’s syndrome, bicuspid aortic valve, HTN, male sex.

SocHx: Cocaine.FHx: FHx of aortic aneurysm or dissection increases risk.

Pulmonary Embolism

P MHx: Cancer, recent surgery or trauma, current pregnancy, CHF, immobilization, obesity, oral contraceptives, prior DVT or PE.

SocHx: Smoking.FHx: FHx of PE or DVT increases risk.


systematic search for clues from the his-tory and physical exam to enable them to accurately formulate a field impression or preliminary diagnosis. After transport to the appropriate facility, following up to learn what the patient’s final diagnosis is will help to either reinforce or correct a paramedic’s pattern recognition, and with it diagnostic accuracy, for future similar cases.

This process can be applied to most common chief complaints such as short-ness of breath, neurological complaints and abdominal pain. Like all skills, the history and physical exam require practice and rep-etition in order to become proficient. We encourage readers to apply this organized method to all medical patient encounters. As individual proficiency improves, so will

the ability to determine the correct prehos-pital diagnosis.

RE FE RE N CE S

1. National Highway Traffic Safety Administration. National EMS Core Content, www.nhtsa.gov/people/injury/ems/EMSCoreContent/.2. National Registry of Emergency Medical Technicians. National EMS Scope of Practice Model, www.nremt.org/nremt/about/scopeofpractice.asp.3. Tuteur A. Doctor, Listen to Your Patient. The Skeptical OB, www.skepticalob.com/2009/06/doctor-listen-to-your-patient.html.4. Gruppen LD, Woolliscroft JO, Wolf FM. The contribution of different components of the clinical encounter in generating and eliminating diagnostic hypotheses. Res Med Educ, 1988; 27: 242–7.5. Peterson MC, Holbrook JH, Von Hales D, Smith NL, Staker LV. Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses. West J Med, 1992; 156(2): 163–5.

AB O U T THE AU TH O RS Kenneth A. Scheppke, MD, is the EMS medical director for six fire-rescue agencies in Palm Beach County, FL. He is also the assistant medical director of the JFK Medical Center emergency department in Atlantis, FL.

Keith Bryer , BBA, EMT-P, is deputy chief of operations for Palm Beach Gardens Fire Rescue in Florida.

ter to ask if there is any chest “discomfort” to ensure you elicit the correct response.

Once the chief complaint of chest pain is elicited, the next step is to formulate a logical mental framework or algorithm to help distinguish the above list of differen-tial diagnoses from each other. Knowing the presentations expected with each and combining the information gathered from OPQRSTA will assist in arriving at the cor-rect prehospital diagnosis. Table 1 presents an example of how to set up this mental framework. For brevity’s sake we will limit the discussion to the deadly possibilities and defer discussion of the less severe causes of a chest pain chief complaint.

After the initial history, the paramedic should have a fair idea of which possible diagnoses are present. The next step is to add the past, social and family histories to the equation. Specifically look for risk factors (Table 2) to support or refute the suspected diagnosis.

For example, if the paramedic suspects ischemic heart disease, the past history may

show risk factors of hypercholesterolemia, the social history may reveal smoking or cocaine, and the family history may reveal history of MI at a young age. All of these would support the prehospital diagnosis of MI/ischemic heart disease.

Alternatively, a patient with a past medical history of Marfan syndrome and hypertension along with a social history of cocaine abuse and a negative family history of MI would favor aortic dissection.

Finally, a past history of DVT, cancer, recent surgery, birth control pills or current pregnancy plus a social history of smoking and a family history of coagulation disorder all favor PE.

The idea is these follow-up questions are not random. We are searching in a system-atic way for evidence for or against specific diagnoses the first part of our history sug-gests may be present.

As we move on to the physical exam, we again will be looking for evidence of a spe-cific diagnosis (Table 3). While we will in general be performing a rapid generalized

head-to-toe exam on most patients, we will in addition be performing a more focused detailed exam looking for evidence of the suspected diagnosis.

If we suspect from our history that a patient may be suffering an aortic dissec-tion, we will pay special attention to bilat-eral pulses and blood pressure, looking for asymmetry. If there is a combination of severe chest pain and one-sided neuro-logical deficits, the exam findings support the diagnosis of dissection.

Alternatively, if we suspect the patient has a PE and we find them to be tachycardic, tachypneic and mildly hypoxic with a slight wheeze along with a unilateral swollen leg, then the exam is consistent with pulmonary embolism.

ConclusionFor as long as medicine has existed, the his-tory and physical exam have been the core information-gathering tool to develop a dif-ferential diagnosis. Paramedics can improve their diagnostic acumen by adopting this

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TABLE 3: COMMON PHYSICAL EXAM FINDINGS


Pallor, diaphoresis, tachycardia and hypertension early; later, hypotension may occur with pump failure. New-onset heart murmurs may occur.

Aortic Dissection

Presentation varies with location of dissection. Hypertension is common. New diastolic heart murmurs can appear. Hypotension is an ominous finding of cardiac tamponade or aortic rupture. Difference in blood pressure from one arm to the other of 20 mmHg may be present. Unequal pulses may occur. Focal neuro signs occur in 20% of cases. Abdominal pain may be present if dissection travels to abdominal aorta. Hoarse voice may occur with recurrent laryngeal nerve compression.

Pulmonary Embolism

Tachypnea, tachycardia, low-grade fever, evidence of DVT (lower extremity edema), wheezing and cough may be present.


Infection versus sepsis is the key determination in sick kids. Start by investigating if the patient has an acquired infection.

On January 29, 2007, 14-year-old Andrew John McDonough was brought to the hospital for what his parents thought was appendicitis. Andrew was a healthy teenager who, earlier that week, had

attended his high school dance, gone skiing and, less than 48 hours before his illness, helped his team win the Pennsylvania state soccer cham-pionship.1

Andrew did not have appendicitis. In the hos-pital his parents were told he had been diagnosed with leukemia and, before the day was out, Andrew had gone into cardiac arrest due to septic shock.

While leukemia was a terrible but familiar word, Andrew’s parents did not understand what “septic shock” was and how it could have hit Andrew so fast and so hard.

The Most Common Deadly Disease You’ve Never Heard OfGlobally, 6 million children die every year from sepsis.2 In the United States more than 750,000 cases of adult and pediatric sepsis are diagnosed

each year.3–6 Incidence of sepsis in pediatric patients has been rising in the past decades, growing to more than 75,000 hospitalizations for severe sepsis, with a mortality of greater than 10%, at a cost of $4.8 billion dollars.7–9

So why is pediatric sepsis the most common deadly disease you’ve never heard of? Even among advanced healthcare providers, understanding and documentation of sepsis as a primary disease are poor. Many EMS providers think sepsis is a rarely encountered and slowly progressing disease found in elderly patients. The truth is that sepsis is terribly common, affects all age groups and in pediatric patients, is often subtle, with deteriora-tion occurring suddenly and fatally.10

EMS Can Make the DifferenceWhile sepsis accounts for approximately one in five ICU admissions, it is not just an “in-hospital” problem.11 Not only does EMS see sepsis often, these patients are some of our sickest.12 In 2010 the EMS system in King County, WA, found an incidence rate of sepsis of 3.3%, yet the incidence

Signs & Symptoms of S E P S I SS hivering (or was)E xtreme pain or discomfortP ale or discolored skinS leepy or altered mental status

“I feel like I might die!”S hort of breath

rate for MI was only 2.3% and for stroke only 2.2%. 13

Studies have shown that when EMS transports sepsis patients, these patients receive IV fluids, antibiotics and in-hos-pital sepsis treatment much faster.14,15 Likewise, systems with designated sepsis alerts are shown to reduce overall sepsis mortality along with significant reductions in length of hospital stay, time in ICU and cost per stay.16,17

Unfortunately the research also shows that many EMS systems have a long way to go when it comes to identifying sepsis. One study showed that despite significant abnormalities in the vital signs of septic patients (25% had systolic BP <90 mmHg), serial vital signs were often not taken or were poorly documented, only 38% had an IV line started with average fluid delivered of 300ml, and cardiac monitoring was per-formed less than 50% of the time.13

Is it that we don’t care, or that we don’t know? A 2013 study evaluated over 200 EMS providers, 83% of whom were paramedics and 73% of whom had been in EMS for over 10 years. They were given four scenarios in which to identify septic shock. Only 10% of them got the scenarios correct.18

EMS providers may wonder where to begin. To help victims of sepsis overall and pediatric patients specifically, EMS provid-ers can follow the ABCs:

• Acquire knowledge about sepsis;• Be ready to give sepsis alerts;• Children with sepsis need an advocate.To start acquiring knowledge about

sepsis, we can use another set of ABCs to describe the pathology: the patient acquires infection, blood vessel problems develop, leading to circulatory collapse.

Acquire InfectionSepsis always begins with some kind of infection. Bacterial, viral, parasitic or fun-gal pathogens get inside the body and begin to reproduce in the area of infection. These pathogens release toxins called exotoxins and endotoxins that damage the local body tissue. Normally the body’s first line of defense—the innate immune response— senses these toxins and begins to act quickly to attack the pathogens producing them.19

The immune system’s first responders are local macrophages (“eating” white blood cells) that attempt to consume and destroy the pathogens. During this process macro-phages release a variety of cytokines (cell

signaling proteins) that activate additional immune responses to battle pathogens.

Among other actions, these cytokines trigger inflammation in the area of infection that causes blood vessels to dilate, capillar-ies to leak and tissue edema, all of which allow greater flow of immune responders into the area to attack pathogens.20 Neu-trophils (“fighting” white blood cells) and other immune factors respond to the area of infection to fight pathogens, harming some “good” body tissue along the way.19 This damage can result in even more blood vessel leakage and release of more cytokine signaling chemicals. Cytokines may now cause a temperature increase in the infected tissues and ultimately cue the hypothala-mus to reset the patient’s body temperature, which produces a fever.20

These temperature increases are a good thing as they help to both slow pathogen replication and improve immune system activation. Signaling chemicals also trigger increased clotting and decreased fibrinoly-sis (anti-clotting), causing the neutrophils, macrophages and other material to clump against blood vessel walls.20

All of these physiological responses have intrinsic limits and antagonistic fac-of Pediatric Sepsis

The

Unrecognized sepsis kills kids; don’t let it happen on your watch

Cover Report by Rommie L. Duckworth, LP

38 FEBRUARY 2016 | EMSWORLD.com EMSWORLD.com | FEBRUARY 2016 39

Infection

Acquired Blood Vessel Problems Circulatory Collapse

M O D SHealthy

Simple Sepsis

S I R SSevere Sepsis

Sepsis Shock Death

Pediatric patients in severe sepsis or septic shock will be expending much of their energy to breathe. Ventilations increase oxygenation while decreasing work of breathing”

tors to help the body rapidly restore bal-ance once the danger has passed. When the local infection has been overcome, the body will immediately begin to deac-tivate the response, repair the damage and clean up the debris to restore normal func-tion to the previously infected area.19

Blood Vessel ProblemsSystemic Inflammatory Response Syndrome (SIRS) and SepsisCytokines sometimes travel beyond the area of initial infection. This can trigger a domino effect of inflammation, immune response and coagulation that may allow the infection to journey throughout the body thanks to the dilated, leaky and damaged vessels that are now present in response to the overwhelming infection.20

As the infection and accompanying inflammatory, immune and coagulation responses spread, a condition known as Sys-temic Inflammatory Response Syndrome, or SIRS, occurs. While other events such as trauma, pancreatitis, pulmonary embolism and anaphylaxis can also trigger SIRS, when SIRS is caused by an infection it is called sepsis. Sepsis is a result of the cytokines spreading throughout the body triggering vasodilation (causing distributive shock) and leaky blood vessels (causing hypovo-lemic shock), and causing many smaller blood vessels to be blocked by clots (caus-ing obstructive shock) all at the same time.21

The clinical definition of SIRS22 is:• Body temperature: >100.4 or <98.6• White cell count: >12,000/mm3 or

<4,000/mm3 or >10% band cells• Tachycardia: HR >90 bpm• Tachypnea: RR >20 bpmBy using a slightly modified version of

this definition, we arrive at the Robson sep-sis criteria that, when used by EMS provid-

ers, has been shown to have a sensitivity of 75%, versus providers attempting to identify sepsis without using specific criteria and only finding 12%.23

Under the Robson sepsis criteria, a patient is considered septic if any two of the fol-lowing are met:

• Body temperature: >100.4 or <98.6• Altered mental status• Tachycardia: HR >90 bpm or high for

age range• Tachypnea: RR >20 bpm or high for

age range• Serum glucose: <120 mg/dL (some

protocols replace this with serum lactate >4 mmol/L)

One may think of an analogy between sepsis and anaphylaxis. If someone has an anaphylactic reaction to a bee sting, it isn’t the dose of honeybee toxin that’s going to kill them, it’s their body’s exaggerated immune response to that toxin. Sepsis is similar. The infection’s toxins will certainly do damage, but sepsis only occurs when the body’s reaction starts to go haywire and causes SIRS.

As if sepsis wasn’t challenging enough to deal with, the disruption of the inflamma-tion, immune and clotting responses can

lead to these systems being reversed or even shut down so that the body may not be able to mount an effective immune response or clot properly.20,21,24 This will often allow the infection to gain even further ground, accel-erating the downward spiral.

This complex interaction of inflamma-tion, immune and clotting pathologies can leave providers feeling, Something is wrong with this child, but I don’t know what. It can be helpful to take a step back and remember that, simply, infection + sick (signs of SIRS above) = sepsis. This is sometimes referred to as “simple sepsis,” as the body is forced to compensate for the shock, but no real dysfunction has yet occurred.

Yet while infection + SIRS = simple sep-sis, and simple sepsis is bad, severe sepsis and septic shock are far worse.

Circulatory CollapseSevere Sepsis, Septic Shock and Multiorgan Dysfunction Syndrome (MODS)As the patient progresses down the sepsis spiral, at some point the body will no longer be able to compensate without assistance. This is when organ dysfunction begins and is the beginning of septic shock. At this point the body may respond well to supportive treatment such as an initial (of possibly many) fluid bolus of 20cc/kg.

When two or more of the body’s organ systems are impacted it is called multior-gan dysfunction syndrome, or MODS.22 The most critical organ systems are, of course, the cardiac and respiratory systems, but many other systems can begin to fail.25,26 These systems include the kidneys, liver, GI tract and even the nervous system.27 While the exact timing varies from patient

to patient, when severe sepsis progresses far enough that it does not respond to fluid administration, multiorgan dysfunction syndrome is likely and we arrive at septic shock. 28,29

The clinical definition of MODS is: • Systolic BP <90• Mean arterial pressure (MAP) <65• ARDS• EtCO2 <32• Glucose <120• Lactate >4 mmol (Note: Many defi-

nitions and protocols use lactate, but it is important to remember that pediatric patients may have normal lactate levels despite being in severe sepsis or septic shock).

When the patient doesn’t respond to >60 cc/kg of fluids, septic shock is a very diffi-cult and dire situation in adults. In pediatric patients, it is even worse.22

Sepsis in Pediatric PatientsNeonatal SepsisBetween 1995 and 2005, the prevalence of severe sepsis in newborns in the U.S. more than doubled, from 4.52 to 9.7 cases per 1,000 births.9

While definitions vary, sepsis that develops within the first 72 hours of birth is generally considered early-onset neona-tal sepsis, while sepsis that develops more than 72 hours, but up to as many as 30 days after birth, is considered late-onset neonatal sepsis.

When you look to identify if your patient may have an acquired infection consider the following neonatal risk factors:

• Premature birth;• Mother’s water breaks >24 hours early;• Mother has any of the following com-

mon infections untreated at the time of delivery: group B strep, syphilis, herpes, rubella, cytomegalovirus (CMV), toxo-plasmosis.30

Keep in mind that any child less than 90 days old is already at particular risk as their immune systems are not yet fully developed and they are incapable of making many of the antibodies necessary to protect themselves.

Sepsis in InfantsIncidence of pediatric severe sepsis is high-est among infants (5.16 per 1,000), with the rate falling in older children (0.20 per 1,000 in 10 to 14 year olds). The rate in boys is 15%

higher than in girls.7 When faced with a sick infant, consider any of the infections listed above when looking to identify possible acquired infection, plus respiratory synctial virus (RSV), E. Coli, listeria monocytogenes and meningitis.

Sepsis in ChildrenNiranjan “Tex” Kissoon, MD, FRCP(C), FAAP, MCCM, FACPE, vice president of medical affairs at BC Children’s Hospital and Sunny Hill Health Center in Canada, says that prehospital healthcare providers don’t need blood tests or pediatric critical care specialists to begin to identify and treat sepsis in children.

He stresses the importance of looking for signs early on and not waiting until a child is obviously crashing. “Providers have to have the mind-set that if the kid already looks sick, the danger signs are already there,” he says.31

He says that this medical truth has been known for so long that he quotes Macchia-velli on the subject: “The physicians say it happens in hectic fever, that in the begin-ning of the malady it is easy to cure but difficult to detect, but in the course of time, not having been either detected or treated in the beginning, it becomes easy to detect but difficult to cure.”32

What Can EMS Do On A Call?To manage pediatric sepsis EMS providers can follow the progression of sepsis pathol-ogy to identify, assess and treat sepsis:

• Acquired infection? Ask about infec-tion history;

• Blood vessel problems? Assessment and sepsis alert criteria;

• Circulatory collapse? Aggressively treat severe sepsis and septic shock.

Acquired Infection? Check Their HistoryPediatric patients should be assessed

using the Pediatric Assessment Triangle (see Figure 1) to identify and begin treat-ment of immediate life threats.33

The first step in recognizing sepsis is attempting to identify if the patient has an

Thermometr yWhen using a thermometer on a pediatric patient it is important to keep the following items in mind to obtain a clinically relevant and accurate temperature:

» Gold standard for kids is a rectal temperature; » Oral temperature is fine for older children and adults; » Axillary temps are not reliable; » Accuracy of tympanic thermometers is highly technique-dependent; » Accuracy of newer infrared temporal artery (TA) thermometry is also

technique-dependent.

What Is MAP?Mean arterial pressure (MAP) is a measurement of cardiac output superior to blood pressure, yet is not frequently used by many EMS providers.

Normal MAP is between 70–110 mmHg and target MAP (treatment goal) is MAP >65 mmHg. There are advanced ways to calculate MAP that involve different mathematical formulas depending on the patient’s heart rate, but a simple rule of thumb is [(2x diastolic BP)+systolic BP]/3.

Thus, if your patient had a BP of 100/70 it would be 70x2=140, plus the sys-tolic of 100=240. 240 divided by 3=80 which is a perfectly normal MAP.

Of course, in many systems there is an even easier way of calculating MAP. On most monitors that take NIBP measurements, the MAP is displayed right next to the blood pressure.

Breath soundsPositioningRetractions

Nasal flaring

ToneInteractiveness

GazeCry

Consolability

PallorMottlingCyanosis

Circulation

AppearanceWork of

Breathing

Figure 1: Pediatric Assessment Triangle

Phot

o by

Pat

rick

Holla

nd


Rapid vascular access is crucial in beginning treatment of severe sepsis and septic shock.

Initial fluid administration is 20ml/kg boluses until signs and symptoms improve, signs of fluid overload appear, or the limits of local protocols are reached.

Following theOn A Call

cquired Infection? Ask about infection history;

lood Vessel Problems? Assessment and sepsis alert criteria;

irculatory Collapse? Aggressively treat severe sepsis and septic shock.

Overall

cquire knowledge about sepsis;

e ready to give sepsis alerts;

hildren with sepsis need an advocate.

infection. Sometimes it will be obvious if a child has an infection, but many times the signs of the infection will be subtle.34

Consider the following clues and cues for infection: Is the child either febrile or hypothermic (possible in circulatory col-lapse: severe sepsis and septic shock)? Does the child have a recent history of vomiting or diarrhea? Burns? Abscesses? Blotches? Have they recently been on antibiotics? Have they had regular childhood immu-nizations withheld?

Immunocompromised children are at high risk for sepsis. Is the child on immu-notherapy, chemotherapy, steroid adminis-tration or other therapy that will decrease or disrupt their immune response?

Medical history or comorbidities that put pediatric patients at risk for sepsis include:35

• Acquired Immune Deficiency Syn-drome (AIDS)

• Developmental delay• Sickle cell disease

• Cystic fibrosis• Cancer• Premature birth• Poor respiratory function• Poor cardiac reserves• Liver or splenic dysfunction• Recent surgery• Indwelling devices• Transplant organs• Any B or T cell deficiency.Remember that not every infection a

child gets will lead to sepsis, nor will a definite diagnosis of sepsis mean that the patient cannot have other medical problems that EMS may also need to treat.35

Blood Vessel Problems? Assessment and Sepsis Alert CriteriaIf you believe your young patient has an infection, the next step is to identify if SIRS is present. The question you should ask yourself is, “Is this patient hypoperfus-ing?” Remember, an infection resulting in SIRS = sepsis.

Different assessment tools, techniques and checklists are available to providers in different systems, but signs of pediatric hypoperfusion include the following:28,36–39

• Altered mental status (GCS <12 or a change >3)

• Significantly increased or decreased pulse rate for age

• Significantly decreased blood pressure for age (late sign)

• Mean arterial pressure (MAP) <65• Difference between central and

peripheral pulses• SpO2 <94%• etCO2 <32• Temperature >100.0 or <96.0• Glucometry >180 mg/dl• Lactate >4 mmol/L• Ultrasound shows IVC decreases in

diameter >50% on inspiration• Urine output <1 ml/kg/hr (dry diapers).EMS sepsis alerts have been shown to

significantly decrease time to treatment for sepsis patients and reduce mortality rates. However, even if you don’t currently work in a system that uses sepsis alerts, knowing the criteria will help you better recognize pediatric victims of sepsis, allowing you to make better clinical decisions and be a better patient advocate.40, 41 While many system-specific adult and pediatric sepsis

alert criteria are available—some simple and some complex—it is critical for EMS providers to understand that not having a local alert protocol does not mean there is nothing you can do.

While defined sepsis alerts are help-ful, there are ways every EMS provider can make a difference for pediatric sepsis patients even if their system does not cur-rently use specific sepsis alert criteria. If you have identified a pediatric patient with an acquired infection who has blood ves-sel problems (shock) you can still make a tremendous difference for your patient by simply telling the emergency department staff, “I suspect sepsis.”42

Circulatory Collapse? Rapidly And Aggressively Treat Severe Sepsis and Septic ShockWhen evidence (or strong suspicion) of acquired infection is accompanied by find-ings of cardiovascular dysfunction such as systolic BP <100 after administration of a 20cc/kg fluid bolus, acute respiratory dis-tress syndrome (ARDS), or two or more other organ dysfunctions, it is considered severe sepsis.22

If the patient is allowed to move further down the sepsis spiral without intervention, multiorgan dysfunction syndrome (MODS) is likely to begin.

If your patient does not respond to initial fluid administration after 60 cc/kg, signifi-cant dysfunction is occurring and the con-dition is now considered septic shock, the final stage of sepsis.

TreatmentThe biggest challenge is making sure you recognize your pediatric patient is suffering from sepsis in the first place. Once that has been accomplished, treatment follows the typical ABCD (airway, breathing, circula-tion, drugs) pathway, along with activation of a sepsis alert and a good patient hand-off with advocacy.

AirwayPediatric patients experiencing severe sepsis or septic shock may require placement of an advanced airway. While rapid sequence intubation or med-facilitated intubation may be appropriate, it is important that advanced providers do not use etomidate on septic pediatric patients. Etomidate inhib-its 11-β-hydroxylase, an enzyme necessary for cortisol production. This can block the body’s normal stress response and increase the severity of septic illness.43, 44

BreathingThe primary goals are to reduce the work of breathing and increase oxygenation for your pediatric patient. A distressed pediat-ric patient will be working hard to breathe. This, along with the increased metabo-lism producing fever, will increase oxygen demand even further. An appropriately sized continuous positive airway pressure (CPAP) or bag mask (BVM) can be used to reduce work of breathing or provide ventila-tions completely.12,36,45

CirculationRapid and large-bore IV or IO access is important not only for initial fluid resus-citation, but also for possible blood product administration. As previously mentioned, recommended fluid administration is the standard 20cc/kg until any of the follow-ing occur:43

• Signs/symptoms improve• Rales• Hepatomegaly• MAP >65.Fluid administration may continue up to

60cc/kg. This does not mean that no more fluid will be administered beyond 60cc/kg, but most offline EMS protocols stop at that point (septic shock). In some cases fluid administration in excess of 200cc/kg may be necessary.12, 36, 45

Drugs/DifferentialIn some cases of severe sepsis or septic shock, pressor medications may be neces-sary to maintain the patient’s circulatory status. The following pressor agents are recommended for pediatric sepsis:46, 47

• Cold shock (compensating, cool extrem-ities, delayed capillary refill): Epi 0.1–1 mcg/kg/min IV/IO infusion, titrate to effect

• Warm shock (decompensated, warm extremities, flash capillary refill): Norepi 0.1–2 mcg/kg/min IV/IO infusion, titrate to effect

While hyperglycemia is a common find-ing in pediatric septic patients, EMS pro-viders should be alert for low blood sugar as well:44

• Neonates <45 mg/dL: Administer glu-cose 0.5–1 g/kg IV/IO of D5%;

• Infants/children <60 mg/dL: Adminis-ter glucose 0.5–1 g/kg IV/IO of D10%.

Antipyretics such as Tylenol or Motrin may be considered according to local proto-col to reduce fever both for patient comfort, as well as to reduce the physical demands the fever is placing on a body in shock.

When we consider that for every hour administration of antibiotics is delayed, patient mortality increases 7%, it seems only reasonable that antibiotics should be administered as early as possible, even outside of the hospital.48–50 Kevin T. Col-lopy, BA, FP-C, NRP, CMTE, clinical edu-cation coordinator for AirLink/VitaLink Critical Care Transport in North Carolina says, “Antibiotic treatment is important especially with patients who will undergo extended transport times. In these patients we can make a real difference in the amount of time it takes to get those antibiotics on board to begin fighting back the infection and its effects.”51

Not every EMS system can be equipped to provide adult or pediatric sepsis patients with antibiotics. Selection of proper anti-biotics to administer before blood cultures can be obtained is only one challenge. The agreement of destination hospitals to con-tinue this antibiotic therapy is another. EMS services seeking this level of service must be working in true “sepsis systems of care.”

EMS providers must also keep in mind other possible concurrent medical or trau-ma issues with sepsis patients. Especially when dealing with septic shock (refractory to fluids), remember to keep issues such as pneumothorax, pericardial tamponade and endocrine emergencies in your differential diagnosis.

ConclusionAfter nearly 50 surgical procedures and numerous complications Andrew McDonough passed away on July 14, 2007. The primary cause of death was sepsis trig-gered by a fungal infection.

Andrew’s story, along with the many oth-ers, can be found through the Sepsis Alli-ance (www.sepsisalliance.org), a charitable organization dedicated to raise awareness of sepsis among healthcare providers and the public.

Sepsis is a complex and deadly mixture of inflammatory, immune and coagula-tion responses resulting in a combination of distributive, hypovolemic and obstruc-tive shock that often goes unrecognized by healthcare providers until it is too late. EMS providers can do plenty for pediatric victims of sepsis by simply following the ABCs.

For Andrew McDonough and the many children like him, EMS providers need to be heard and spread the word: Unrecognized sepsis kills kids.

RE FE RE N CE S

Available online at EMSWorld.com/12156059.

AB O U T THE AU TH O R Rommie L. Duckworth, LP, is a dedicated emergency responder and award-winning educator with more than 25 years working in career and volunteer fire departments, hospital healthcare systems, and public and private emergency medical services. Currently a career fire captain and paramedic EMS coordinator, Rom is an emergency

services advocate, a frequent speaker at conferences around the world, and a contributor to emergency services research, textbooks, and print and online media.

EMS sepsis alerts have been shown to significantly decrease time to treatment for sepsis patients and reduce mortality rates.


EMS agencies have never been in more need of such analysis

Your Agency

Strategic planning is traditionally thought of as an evaluation of the strengths, weaknesses, opportunities and threats—known as a SWOT analysis—facing any company or organization, then mapping a path forward that addresses

those areas. EMS agencies have never been in more need of such analysis, as they attempt to survive in a world where operations and the delivery of clinical care are redefined on a near-daily basis.

The Four Pillars of SWOTStrengths and weak-nesses review internal factors that impact the ability to obtain a goal. In EMS this could include recruit-ing more volunteers, adding non-emergen-

cy services or managing the operating expenses.Strengths might be:• Solid community support;

• Meeting response time standards on a consistent basis (time period of 3 or 6 months);

• Collaboration with other stakeholders.Weaknesses can include:• Lack of a consistent funding stream that isn’t

dependent on billing;• Lack of volunteers/other staff;• Antiquated equipment/trucks;• Poor relationship with acute care facilities resulting

in backups of resources at EDs.Opportunities and threats focus more on exter-

nal factors impacting an EMS agency and its future development.

Opportunities can include:• A mobile integrated healthcare initiative based on

conversation with other stakeholders in the healthcare arena to fill perceived gaps in service;

• Transition from an all-volunteer unit to paying personnel for specific shifts when necessary;

• Better integration with the existing healthcare system to address gaps (e.g., mental health resources);

• Analysis of regionalization efforts in conjunction with surrounding EMS agencies.

Threats can include:

By Raphael M. Barishansky, MPH, MS, CPM

“The Tennessee Fire Chiefs Association is excited for the opportunity to partner with Firehouse Expo. Firehouse has a long history of supporting firefighter education, training and safety, which aligns with the mission of the Tennessee Fire

Chiefs Association and the Tennessee fire service.”– James Fountain,

President, Tennessee Fire Chiefs Association

“I am elated that Firehouse has chosen Music City as its location for Firehouse Expo in 2016. The State Fire

Marshal’s Office and the Tennessee fire service are proud to host such an elite conference and exposition. Nashville is an exciting city to visit and will provide an outstanding

atmosphere for a successful conference next year.” – Gary West,

Tennessee State Fire Marshal

Firehouse and Nashville – A Strong Partnership Begins!

#FHExpo1644 FEBRUARY 2016 | EMSWORLD.com

Why You Need to

Riverside County EMS system’s vision is to be the exceptional, outcome-focused EMS leader in the nation.”3 A vision statement is a declaration that conveys the image of how the organization wants its future to look

Phase 3The third phase is operational planning. This is when your strategic planning team takes a 30,000-foot view of previously discussed concepts to make them as practical and specific as possible.

This entails reviewing the issues discussed and realistically deter-mining what your EMS agency can afford to do without overreach-ing. For those things your agency commits to, now is the time to develop your plan for implementing and executing on those issues, which includes understanding who is responsible for what, what guidelines they’re going to be functioning under, what resources they’re going to have available to them, and what milestones or review points you need to have along the way to make sure every-one is staying on schedule. These are your agency goals and their defining objectives.

An example of a goal would be “to ensure the long-term financial solvency, stability and cost-effectiveness of the EMS system” and the objectives that support this goal could include:

• Establish methodologies to identify the baseline costs of the current system;

• Identify current funding sources for first response, ambulance transportation, education/training, disaster medical preparedness and response and other EMS-related services;

• Develop a mechanism that identifies funding that can sustain system improvements implemented under this strategic plan;

• Define and quantify the potential funding changes driven by the Affordable Care Act for traditional EMS delivery models.

ConclusionEvery day we read news of fire departments taking over EMS opera-tions, private EMS services going out of business due to an inability to weather economic downturns, or a volunteer ambulance squad failing to recruit or retain sufficient numbers of volunteers to staff its operation. Rarely is it considered that one of the significant contributing factors may have been the organization’s lack of focus and direction. Perhaps such events would not occur if an agency had a well-thought-out, long-term strategic plan.

RE FE RE N CE S

1. Virginia Department of Health, Office of Emergency Medical Services (OEMS). EMS Agency Management Series. EMS Strategic Planning. June 2001.2. http://www.sandiegocounty.gov/hhsa/programs/phs/emergency_medical_services/.3. http://remsa.us/documents/plans/140923FINALEMSSystemStratPlan.pdf.The author would like to thank the Riverside County (CA) EMS Agency for making its comprehensive EMS System Strategic Plan available online. See reference 3.

AB O U T THE AU TH O R Raphael M. Barishansky, MPH, MS, CPM, is a solutions-driven consultant working with EMS agencies, emergency management and public health organizations on complex issues including leadership development, strategic planning, policy implementation and regulatory compliance. He is a member of the EMS World Editorial Advisory Board. E-mail him at [email protected].

• An unclear understanding of how healthcare changes like the Affordable Care Act will impact the EMS system;

• Neighboring EMS agencies being more proactive in their efforts than your agency;

• Other stakeholders not understanding the unique-ness of the EMS system and not utilizing your agency to its fullest potential;

• Lack of a complete integrated approach to the healthcare system (i.e., political challenges, priorities, resistance to change, competing interests, silos, dif-ferent views).

A SWOT analysis is not a static process but some-thing re-examined on a regular basis in light of potential changes in the EMS system. Strategic planning is rooted in future-oriented, proactive thinking that anticipates change and adopts long-term strategies to meet the demands of that change. In other terms, a strategic plan is a “master plan” for your EMS agency. It is a management tool that will assist your organization in focusing its energy.

Where To BeginSuccessful strategic planning effort is predicated on an agency’s ability to approach it in three distinct phases.

Phase 1The first phase is “intuitive thinking.” This seeks to answer questions such as: Why are we in business? Who are our customers? What do they want from us? What

do they get from us? What matters most to us? Where do we see our company going in the future?

These are big-picture questions. At the beginning of the strategic planning process, people need to deliber-ately and thoughtfully think about how to respond to these questions. This is where you can take the oppor-tunity to craft your agency mission statement, which, optimally, answers the questions posed above.

A good example of am EMS-specific mission state-ment comes from the San Diego (CA) Health and Human Services agency, which states: “To ensure that all residents of and visitors to San Diego County receive timely and high-quality emergency medical services, specialty care, prevention services, disaster prepared-ness and response.”2

Phase 2The second phase is long-range planning. Instead of being intuitive, this is very analytical. This phase is about understanding such things as where your com-pany fits in the marketplace, what your strengths are as an organization, where your limitations are, and how you relate to customers and competitors. It also includes understanding the regulatory environment and how major trends in the EMS world affect you.

This is also where you would want to take the oppor-tunity to craft your agency vision statement so that it conveys how your organization wants its future to look. A good example of a vision statement comes from the Riverside County (CA) EMS Agency and states: “The

Understanding Current ChallengesThe world of EMS is in a constant state of flux. Currently we are looking at changes as a result of the Affordable Care Act (ACA), potential reimbursement changes based on value-added payments, staffing issues, clinical modifications based on peer-reviewed research and a dearth of volunteers.

Forward-thinking EMS agencies will examine the issues confronting them in the immediate, short and long term and, reflecting back on their SWOT analysis, draw up goals and objectives to decide where they want to be and how to address those issues.

Here are examples of such activities: » Mobile Integrated Healthcare/Community

Paramedicine: In order to ensure your agency is in compliance with the Affordable Care Act and continues to get paid for the services it provides, you may be thinking about developing an MIH-CP program. Have you done a SWOT analysis? Do you know what the weaknesses are, e.g. finding a reliable, consistent funding stream? Have you thought about home health agencies not wanting to partner with your EMS agency to deliver a service they may feel they have been already delivering? Is this a strength, since your EMS agency already employs

healthcare providers and has a fleet ready to deliver mobile services?

» Volunteer recruitment and retention: Judging by the number of headlines in the media regarding a dwindling volunteer pool and many EMS volunteer agencies becoming partially, or fully, paid, it’s clear the nature of volunteer EMS is changing. Does your agency have a plan for when the number of available staff no longer allows for effective, timely response? Have you met with neighboring towns/municipalities to explore regionalization? If funds are needed for personnel, where will you get those funds from?

» Regionalization of efforts: A logical next move for agencies experiencing staffing issues may be the development of a regional EMS entity comprised of multiple EMS agencies with similar missions. Although this may sound simple, a SWOT analysis is a necessity. Are there strengths that all of the EMS agencies share? What are the threats? Could one be a less-than-clear understanding of how leadership of the regional entity will be handled? Will a stipend be needed from the municipalities shared and, if so, will the stipend be the same for each municipality?

Tips for Successful Strategic PlanningHere are some key practices to follow during the strategic planning process:

» Ensure all voices are heard during the planning process. It is key to include field providers, line supervisors, managers and executive-level personnel in the planning process, as each will have a different perspective to offer. This will also ensure that personnel from all levels will go back to their peers and make the plan understandable.

» Do not let the strategic plan become just another document kept in an office or on a bookshelf somewhere. This document should be given to new employees during

orientation, as well as regularly referenced at senior-level management meetings. If the plan is going to be effective, it needs to be used and updated constantly.

» Keep your feet on the ground. Make sure that your goals and objectives are as realistic as possible. One of the primary reasons a strategic plan fails is that it has too many goals and objectives, creating a plan that is, as a whole, unfocused. It is also critical to ensure adequate resources are available to accomplish those goals and objectives outlined in the plan.

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


Overtime is nice, time over with family or friends is

nicer.

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What I Wish I’d Known Then Survival tips for making it midway through your career

“The years teach much which the days never knew.”

—Ralph Waldo Emerson

In the movie Terms of Endearment, there is a great

scene where Emma (Debra Winger) tells her moth-

er Aurora (Shirley MacLaine) that she is pregnant. In

response to the happy news Aurora grits out, “Why

should I be happy about being a GRANDMOTHER?!?”

Her not-so-thinly veiled outrage at the notion of being

bumped up a generation is hilarious and hits home.

It is one of thousands of movie references I can make

that a growing percentage of you will simply not “get.”

My favorite pop culture references and song lyrics mov-

ing into obscurity is an early and painful symptom of my

inevitable transition to the next phase of my life.

When working out the theme I wanted for this column,

I came up with the concept of the “Midlife Medic.” After

all, that’s what I am—a career paramedic who has made

it just a few miles south of the big 5-0. My experience

officially spans a generation. I am proud to have made

it this far, and to have had some wonderful opportuni-

ties along the way. I recognize that this field is different

for the older provider and believe that together we can

open conversations about unavoidable transitions. It’s

honest and it’s who I am.

I hate it.

I hate it because it’s true and I can’t change it. It is

somewhere nobody ever believes they will be until it is

too late. I mentally flinch at the term just as quickly as

I avert my gaze from the increasing ratio of silver in my

hair. I say it aloud and dreams of bifocals and enteric-

coated aspirin dance in my head.

I love it.

I love it because I’m still here, and my fear of the

unknown is less and my confidence is more. I love it

because all those years of interacting with people

has made me a patient-whisperer. All those different

calls have honed my situational awareness and ability

to interpret a scene to an edge so sharp I may appear

psychic to you. I love it because medicine is dynamic

and our field is evolving, so there is always something

new to challenge myself with. I am not the Midlife Medic

because I am old, but because I am still here and I still

love my job.

Here are some tips I would give my 20-year-old self to

make the long haul easier:

1. Everything comes with recovery time. Enjoy going out

until all hours and then pulling a double shift, because 10

years from now that will make you cry. Seriously.

2. Stop eating garbage. Make proper diet and exercise

a lifestyle habit now. It is SO much harder when you’re

older. Skip the fast food and dump the coffee…wait, what

am I saying? Life is short, always drink the coffee.

3. Stay current. Read journals, use the Internet, go to

conferences or find classes that offer more than the min-

imum. Don’t reject innovation, leave your comfort zone.

4. Own your age. It’s all right if you do not like the music

or speak the slang, just maintain a base knowledge. (Like

hazmat awareness, instead of the DOT manual you use

“Urban Dictionary” from a non-work Internet source.)

5. Get glasses. If you are having trouble reading dos-

ages and expiration dates, then get it corrected before

the next thing you have trouble seeing is vocal cords.

6. Overtime is nice, time over with family or friends

is nicer.

7. Diversify. Pursue the topics that interest you, find

your passion. Finish that degree! Continuing education

gives you professional mobility.

8. If you are struggling, ask for help. Whether that

help is figuring out a complicated medical call, lifting

a heavy patient, or because you are considering ending

your life, there is always someone out there willing to

help. Always.

9. Your experience has value, share it. Every encounter

gives you the ability to either learn or teach something.

Use it wisely.

10. Stop carrying your equipment on the same shoul-

der! (Don’t lie and say that you don’t, I know you do.)

Someday you will be where I am. I hope you will remain

true to yourself and still love the work, because those are

the things that will resonate to the younger providers

around you. Work together to learn from each other and

help move the industry forward in the spirit of mentor-

ship. Traditions are made by integrating the past, not

ignoring it.

My name is Tracey, and I am a Midlife Medic.

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

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