offshore helicopter ems operations · scott cravens, emt-b 800/547-7377 x1759 ... subscription...

EMS Compass Update

p. 24

ACE Inhibitor-Related

Angioedema p. 41

Community Paramedics and the Drug-Seeker

p. 56

Offshore HelicopterEMS OperationsCHI Aviation’s Sikorsky S-92 is a combination rescue truck and critical care transport ambulance p. 60

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EDITORIAL ADVISORY BOARD

4 JANUARY 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. 1

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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.

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FEATURES

24 How to Measure and Improve EMS Systems EMS Compass is setting the profession on a path toward performance measurement and improvementBy Michael Gerber, MPH, NRP

36 Evidence-Based EMS: Out-of-Hospital BiPAP vs. CPAP Is one any better than the other?By Hawnwan Philip Moy, MD, & Blake Bruton, MD

41 ACE Inhibitor-Related Angioedema ACEI-RA is a different beast, less than responsive to standard pharmacological agentsBy Kristin Spencer, MS, NRP

48 Oxygenate and Resuscitate Before You IntubateCommon pitfalls to avoid when managing the crashing airwayBy Russ Brown, NREMT-P

56 Community Paramedics and the Drug-Seeker Beyond pain, emotional and psychological needs can help drive pseudoaddictive behaviorsBy Jason R. Berman, EMT-P, & Dan Swayze, DrPH, MBA, MEMS

JANUARY 2016 VOL. 45 | ISSUE 1

COVER REPORT

60 When Size Matters: Offshore Helicopter EMS OperationsProviding medical and rescue services to the offshore oil industry is a massive missionBy Barry Smith

COLUMNS

14 GUEST EDITORIALThe Next Great TraditionBy Dan Swayze, DrPH, MBA, MEMS

18 CASES WITH A TWISTRepetitive RisksBy David Page, MS, NRP, & Will Krost, MBA, NRP

22 LUDWIG ON LEADERSHIPHow Will You Be Remembered?By Gary Ludwig

66 THE MIDLIFE MEDICFind Your “Next”By Tracey Loscar, NRP, FP-C

DEPARTMENTS10 EMS World Online

16 News Network

51 Ad Index

65 Classified Ads

On the CoverCHI SAR crews train an average of 85 flight hours per month. Photo by Barry Smith.

DOWNLOAD our FREE tablet edition app to access exclusive EMS World content.

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

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One of the most significant complaints among patients is being stuck too many times when a medical professional is trying to locate a vein to draw blood or start an IV. Thanks to Veinlite’s innovative product line, it does not have to be such a traumatic experience.

Venipuncture, or vein access, is one of the most routine invasive procedures medical professionals conduct every day. Sometimes, however, even the most experienced professionals have difficulty locating a suitable vein—due to age, especially with elderly and pediatric patients; obesity; or even skin color. This often results in sticking a patient several times, leading to patient discomfort, dissatisfaction and delayed treatment.

Veinlite solves that problem by illuminating and isolating a small portion of the vein for easy needle access. Veinlite deliv-ers vein imaging in a unique and innovative way that increases first-stick success while costing a fraction of other similar prod-ucts.

“I have been using the Veinlite in training nurses to start IVs, primarily in the elderly,” says Richard Johnston, of Lifeguard Ambulance in Texas. “Infants and the elderly typically are the most difficult to gain IV access in. The Veinlite also gives care providers who are not that experienced in starting IVs more confidence to attempt an IV.”

Johnston says there are several benefits to using the Veinlite. “In addition to reducing the number of attempts to gain IV

access on those with hard-to-access veins, it reduces pain and stress to the patient,” Johnston says. “Using the Veinlite can also reduce the amount of supplies used, thereby reducing costs.”

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“With dehydration being a major problem, the ability to start an IV is typically more difficult,” Johnston says. “The Veinlite can help us locate the vein more easily. The Veinlite can also help

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The Veinlite Vein Finder line of products is sold by TransLite LLC, a small high-tech company that designs, manufactures and sells medical devices to help reduce patient pain and trauma.

“Venipuncture is the most performed procedure in the country,” says TransLite President Nizar Mullani. “Yet one in five patients needs another nurse to come in and access the vein after two attempts at sticking the patient. And there’s just an 80% success rate after two sticks.”

Clinical Trials Demonstrate Veinlite’s Value Several clinical trials have been conducted to assess whether vein finder devices help improve vein access. The results show that Veinlite improves vein access, while near infrared light (NIR) devices are no better than the normal standard of care. In eight clinical trials of devices that use NIR, just one—on neo-nates—showed improvement in accuracy for sticking veins.

TransLite LLC funded a study at Boston Children’s Hospital to use Veinlite in a randomized clinical trial to access veins in the hard-to-find vein patients in the emergency department. The three-year trial showed that the use of the Veinlite improved the success rate for vein access from 74% to 83% after two attempts.

“In hospital exit surveys, the biggest complaint among patients is being stuck too many times for drawing blood or inserting an IV,” Mullani says. “With Veinlite the medical profes-sional can see the vein and put the needle right into it. If you don’t see the vein, you don’t stick it. We’re not a vein finder, we’re a vein access device.”

Mullani says Veinlite accesses veins without the need for a tourniquet, which can unnecessarily cut off circulation.

“The device accesses and helps hold the vein so it doesn’t roll,” Mullani says. “It anchors the vein. A whole bunch of devic-es use near-infrared light, which shines a light on the skin. Then they use a camera to get the image, but it only shows the vein

on the surface of the skin. The medical professional can’t get to the actual vein. Those devices are vein finders, but they don’t help access or sequester the vein.”

The Veinlite ring helps close off the vein, and traction can be applied to the skin by pushing the ring back from the opening. This secures the vein and makes it easier to access.

“Veinlite creates a local tourniquet that pops the vein up but doesn’t block the entire area of circulation,” Mullani says.

Mullani also sought to create a hand-held device that could operate on a battery. Research showed that orange/amber

light provided the highest contrast for imaging superficial blood vessels, while red light penetrated deepest for imaging deeper veins. The two colors of LEDs could produce reason-able images of veins using only two watts or less of power, and the portable Veinlite LED was created in 2004.

Three variations of the portable devices are available:• Veinlite EMS is a simpler, lower-cost device for use by

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Veinlite LED and effective for use on overweight patients and for sclerotherapy.

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And in 2015 the Veinlite EMS PRO was introduced. The Veinlite EMS PRO’s new, integrated exam light provides quick, one-button access to a built-in flashlight mode. Day or night, this aids in initial patient assessment and reduces the amount of gear required to deliver quality care. The device is suitable for use on adults and children, and for both light and dark skin tones.

For more information on TransLite LLC visit www.veinlite.com, e-mail [email protected] or call 281/240-3111.

EMSWORLD.com | JANUARY 2016 98 JANUARY 2016 | EMSWORLD.com

“Paramedics are out in the trucks by themselves. They have to have the IV access in the field and don’t

have backup of another nurse to access a vein. The paramedics love it because it makes their jobs easier.”

— Nizar Mullani

MOULAGE OF THE MONTH

NEW

PODCASTSWORD ON THE STREET: REPORT FROM ECCUHost Rob Lawrence reports from this year’s ECCU conference held in San Diego, December 8-11, 2015, just weeks after the release of the new Resuscitation Guidelines.

What will the science tell us about ways to improve survival? How will the new guidelines impact instruction and practice? What are the best practices in training and community programs? Listen to the resuscitation professionals— instructors, practitioners, survivors and researchers—discuss the latest in cardiac care. See EMSWorld.com/podcast.

BUILDING BIG DATAWith the acquisition of Rural/Metro Corp., AMR—and the larger world of EMS—is poised to learn a lot more about the effectiveness of a lot of the things we all do. The company’s already-substantial focus on data will encompass millions of additional points with the subsuming of Rural/Metro’s various operations and patient loads. That will tell all of us even more even faster about the impacts of interventions across the spectrum from 9-1-1 responses to transfers to community paramedicine and mobile integrated healthcare. Read more at EMSWorld.com/12146730.

QUICK TIMEWhat’s next for you in EMS? Catching up on your PCRs is certainly in the mix, but what about a year from now or 10 years from now? Maybe you’ll want to try something different. In this month’s Life Support column, Mike Rubin discusses career options. Read more at EMSWorld.com/12146735.

FEATURES

facebook.com/emsworldfans twitter.com/emsworldnews www.linkedin.com/groups?gid=1853412

Visit EMSWorld.com/webca sts to register for upcoming presentations:

FEB 10, 2 PM ET: RECOGNIZING AND REACTING TO THE LOST ADVANCED AIRWAYAll advanced airways are at risk of dislodgement and failing to recognize a dislodgement can lead to serious morbidity ranging from anoxic brain injury to death. This webinar offers best practices to prevent airway dislodgement and immediately recognize the lost airway, and offers five strategies for rapid and effective emergency airway intervention. Presented by Kevin Collopy, BA, FP-C, CCEMT-P, NREMT-P, WEMT, and sponsored by Physio-Control.

WEBCASTS

Bobbie Merica continues her guide to simulating injuries and illnesses through effective use of moulage. This month: Industrial response, steam burn, second degree. See EMSWorld.com/12146211.

THE MEDBOT EDUCATORHow many of you know what a mobile virtual presence device is? Of those who said yes, you probably first heard of them from an episode of the TV show The Big Bang Theory. Well, get ready to put your geek on, because we are about to look at how these devices might be used for prehospital education and even more. Read more at EMSWorld.com/12146983.


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55,300 new medics by 2022The Emergency Medical Services field is expected to grow more than 23% over the next decade, adding over 55,000 paramedic and EMT jobs. Are you ready?

Hire the right people based on science:

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The US Bureau of Labor Statistics expects the emergency medical services (EMS) field to grow by more than 23% over the next 10 years, adding over 55,000 paramedic and EMT jobs to the 235,000 skilled paramedics and EMTs already faithfully serving across the United States. The additional workforce needs are to due to increasing call volumes, aging populations, and a generally heavier reliance on governmental services. This presents additional challenges to an EMS community already grappling with the impact of the Affordable Care Act, shifts towards community-based care, value-based payments, and an aging workforce, especially in fire-based EMS organizations.

Consider the findings of the most recent report from the National Highway Transportation Safety Administration Office of Emergency Medical Services:

• Retaining workers is a challenge, with poor management practices, low wages and benefits, lack of career ladders, and disability contributing to turnover.

• Retention of older or more experienced workers [conserves] talent and experience within the EMS workforce and increases workforce supply.

• Developing strategies to accommodate older or more experienced workers and increasing successful recruitment and retention of older individuals would prove helpful for addressing the [workforce] issue.

It’s a complex proposition to hire the right candidates for roles that require highly technical medical skills and a willingness to put oneself in harm’s way for the benefit of a stranger. To help meet this challenge, the EMS community could benefit from science-based hiring practices.

Talent science, or science-based hiring practices, is a predictive and analytics-based approach to managing human resource processes, like candidate selection, medics’ development, and succession planning. This approach both objectively and statistically links specified performance metrics to behavioral characteristics of medics within an agency to help establish a model of “best fit” that is unique to each agency.

Here’s how talent science works. Custom profiles are built using large samples of incumbent medics and EMTs that reflect the behavioral makeup of the best-suited candidate for a specific organization. This is important because while nearly all medics and EMTs share a common sense of civic duty to help those in need, the behavioral characteristics of a successful medic in a large fire-based organization may be different from the behavioral characteristics of a medic or EMT in private agency or a quasi-governmental organization.

Next, job candidates are evaluated and ranked based on their responses to a comprehensive online assessment that is designed to measure 39 behavioral characteristics. The assessment compares each candidate’s behaviors to the custom profile corresponding to the position of medic or EMT within a specific organization. A report is then generated, visually describing how and where the candidate aligns and differs from the unique requirements of the profile and the defined needs of the organization.

This approach has proven to significantly reduce turnover and improve organizational performance in an industry with similar challenges to the EMS community—the nursing profession. A recent controlled study of over 1,000 newly hired nurses comparing the use of science-based hiring practices to traditional hiring practices demonstrated a turnover reduction of 47% and produced an annual savings of over $2.4 million. By employing a similar approach within EMS, agencies can become more effective at identifying the most qualified candidates from a skills perspective and can isolate those individuals whose characteristics make them the best fit for the organization at large.

The workforce crisis facing the EMS profession will not solve itself through procrastination and inaction. When medics leave, the loss in knowledge capital is substantial and the ability to serve the community is diminished. The community deserves the best from our agencies, and using science can help the EMS community deliver on those expectations.

Copyright 2015 © Infor. www.infor.com. All rights reserved.

Addressing the EMS workforce crisis with science Kurt A. Steward, Ph.D., Vice President, Infor Public Sector


GUEST EDITORIAL By Dan Swayze, DrPH, MBA, MEMS

Today more than 1,000 EMS providers have been trained to help save lives

differently than in the past.

The Next Great TraditionIt’s time to support the more than 1,000 EMS providers working as community paramedics and MIH practitioners

More than 200 years of tradition, uninterrupted by

progress. I’ve heard that phrase often to describe

how some firefighters hold strong to their rituals

and practices. But truth be told, the same could be

said of EMS.

Since the days of Napoleon, ambulance services

have existed primarily to transport the ill and injured

from where they fell to a hospital where they could

be treated.

More than 200 years ago, tradition dictated that

local townsfolk would transport injured soldiers to

the closest hospital in their hay wagons, but only

once the battle moved away. At the hospital, sur-

geons would begin their lifesaving interventions on

those who survived that long. But one surgeon, Dr.

Dominique Jean Larrey, was different. He believed the

surgeons should be deployed into combat to retrieve

the injured even while war raged around them. He

argued that by beginning care sooner, he could save

many more lives. Despite a belief that was undoubt-

edly unpopular with his peers, Larrey persevered and

invented the ambulance, the modern system of tri-

age and many other surgical innovations.

While you may have heard of Larrey’s contribu-

tion to our beginnings, think about this: He could

not have done it alone. He had to find colleagues

brave enough to risk breaking with tradition to join

him in his cause. Larrey’s followers undoubtedly

faced opposition but were courageous enough to

embrace the new role despite the personal risk they

encountered. As brilliant as Larrey was, he could not

have put his idea into motion without the help of oth-

ers willing to gamble on a new model to help save

more lives.

Today more than 1,000 EMS providers have been

trained to help save lives differently than in the

past: in new roles as community paramedics and

mobile integrated healthcare practitioners. That’s

a small portion of all EMS personnel, but enough to

convince the editors of EMS World that it is time to

support these brave new providers by dedicating a

series of articles over the coming year to this new

type of patient care. While articles on the finance

and administration of these programs remain criti-

cally important discussions, EMS World recognizes

that those serving in this new role also need articles

focused on the aspects of patient care they will

encounter that are different than those faced in their

traditional roles.

We start the new series this month on page 56

discussing substance abuse. Instead of describing

the traditional approach to treating an overdose, the

article focuses on the terminology and treatment

paths available to those who suffer from either

addiction or pseudoaddiction caused by their chronic

pain. While the topic may not be popular among

those holding strong to our EMS traditions, those

practicing in this new role will encounter patients

needing these treatments regularly.

I applaud EMS World Editorial Director Nancy Perry

and Senior Editor John Erich for dedicating time and

space to help these new providers. Thanks to their

efforts and the bravery of the 1,000-plus provid-

ers willing to break from their traditional roles, we

are looking at the start of the next great tradition

of EMS.

AB O U T THE AU TH O R Dan Swayze, DrPH, MBA, MEMS, is the vice president and COO of the Center for Emergency Medicine of Western Pennsylvania and is widely considered one of the pioneers of the emerging field of community paramedicine. Dan has been involved in EMS for more than 30 years.

14 JANUARY 2016 | EMSWORLD.comFor More Information Circle 17 on Reader Service Card

Heather Bogdon and David Dupra from the CONNECT Community Paramedic Program in Pittsburgh, PA, are part of the rapidly growing number of community paramedics in the United States.

Fla. Paramedic Elected to National Board PositionSunstar Paramedics’ Community Outreach Coordinator, Charlene

Cobb, has been elected to the Board of Directors for the National

Association of Emergency Medical Technicians (NAEMT). She

will serve as an at-large director.

During her two-year term, Cobb plans to work on creating

industry solutions for an easier transition for military medic vet-

erans who want to move into an EMS career. She also plans to develop strategies

to improve workplace safety and working with government representatives and

industry officials to pass the Field EMS Modernization and Innovation Act.

Cobb has been an active member of NAEMT since 2005. “I am extremely hon-

ored to have been elected by my fellow NAEMT members,” said Cobb. “Over the

last 30 years, I have watched this field evolve and am excited to take a larger role

in making a difference for EMTs around the country.”

For more on NAEMT, visit naemt.org.

Virginia Of fice of EMS Awards A gency of E xcellence DesignationAt a recent event, the City of

Manassas Fire and Rescue System

was among the first agencies to be

awarded with the Agency of Excel-

lence designation from the Virginia

Office of EMS.

This was the first year of a pilot

program that seeks to recognize

agencies that strive to operate

above the standards and require-

ments of Virginia EMS regulations.

Agencies were evaluated in

eight program areas: leadership/

management; emergency medical

dispatch; clinical care measures;

operational medical direction; life

safety; community support and

involvement; recruitment and retention; and performance and risk.

“I’m glad we could be part of this pilot program,” said Manassas Fire and Rescue

Chief Brett Bowman. “The men and women of the City of Manassas Fire and

Rescue team are exceptional, and I am proud that they have been recognized for

their service to the community.”

The designation as an Agency of Excellence lasts for three years, at which time

an agency must reapply for the certification. For more information, visit www.

vdh.state.va.us/OEMS.

EMS Supervisor Lt. Matt Fox (pictured), along with Battalion Chief Todd Lupton, helped steer the City of Manassas Fire and Rescue System through the pilot program.

Every two seconds someone in the

U.S. needs blood.

More than 41,000 blood donations

are needed every day.

The average red blood cell transfusion is approximately

3 pints.

The blood type most often

requested by hospitals is Type O.

The number of blood donations collected in the U.S. in a year is

15.7 million.

There are 9.2 million blood

donors in the U.S. each year.

JANUARY IS NATIONAL BLOOD DONOR MONTH

Cool/Not Cool

Happy Breathe-day!Jane Powers sure knows how to throw a party!

Three years after surviving a cardiac arrest, Pow-

ers has turned her own birthday celebrations into

annual CPR training events complete with EMS

instructors.

Powers, a longtime employee of the Arizona Dia-

mondbacks baseball team, collapsed in a tunnel

under the Diamondbacks’ stadium after a 2012

game, and was pulseless when found by umpire

Jim Joyce. Joyce used the CPR he’d learned as a

young man to help resuscitate Powers, who now

offers hands-only CPR familiarization to dozens

of volunteers each year. “You never know when

you could be in that situation (to use CPR),” says

Powers. “You want to be as prepared as Jim Joyce

was for me.” Cool!

A Barbaric RitualJason Waldeck, a former volunteer firefighter

in Ellis County, TX, says he put up with months

of hazing after joining the Waxahachie station.

According to Waldeck, though, none of that comes

close to the sadistic treatment he endured last

January at the hands of fellow firefighters.

Waldeck says he was pinned down and sexually

assaulted by five colleagues while the girlfriend of

one videotaped the incident.

Eight people, including the department’s chief

and assistant chief, have been indicted on charges

associated with the assault.

“I can’t get it out of my mind,” says Waldeck. “I’ve

had thoughts of suicide.”

It would be deplorable to classify the alleged

incident merely as hazing gone awry, or to link the

accused to a work-hard-play-hard characterization

of emergency services. This isn’t about firefight-

ing or volunteering; it’s about savage, sociopathic

behavior perpetrated by the strong against the

weak. Uncool!

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NEWS NETWORK


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


Remember, slow is smooth

and smooth is fast.

Repetitive Risk sFor this EMS crew, unloading the stretcher proved dangerous to both patient and provider

This inaugural column is dedicated to our peers

who risk their lives to serve others daily. In this

column we will explore cases in which things

didn’t quite go as planned. Sometimes this

means we were surprised by a clinical presentation,

while others involve near-misses or adverse events.

While we love EMS, the work we perform is often

conducted in unpredictable and harsh environments

with limited information and resources and high

stress. EMS personnel are 2½ times more likely to

be killed on duty, and five times more likely to suf-

fer a transportation-related injury, than the average

worker.1 We hope this column will help promote an

open, honest and timely process to communicate

potential mishaps and promote a culture of safety

in EMS operations.

This Month’s CaseAfter an emergent transport to the hospital, the crew

was unloading the stretcher loaded with a roughly

200-pound critical patient in congestive heart fail-

ure. Crew member #1 was at the foot of the stretcher,

operating the manual control, while crew member #2

was on the patient’s right side, watching and ready

to catch the wheels.

As expected, with ER staff watching as they met

the ambulance in the garage, the crew was moving

quickly to get the critical patient inside. Crew mem-

ber #1 began to give a quick report while starting to

pull back on the stretcher. The hospital has a slightly

uneven garage floor (to allow for drainage in the

center), and the vehicle and stretcher were slightly

tipped to the patient’s left side.

As the crew pulled the stretcher out, the safety

bar missed the safety hook. The stretcher came

out of the back of the ambulance rapidly, with its

wheels still retracted. Crew member #1 at the foot

of the stretcher tried to hold the weight. Unfortu-

nately the stretcher tipped toward the left, and the

patient reached out to the left side as crew member

#2 (on the patient’s right side) pulled up, trying to

help prevent the stretcher from hitting the ground.

Momentum shifted to the left side.

To complicate matters, this stretcher was

equipped with a canvas basket behind the head.

When the stretcher began tipping out of balance, a

worn and loose strap caught the safety hook, mak-

ing it harder for both crew members to maintain the

stretcher upright.

At this point the stretcher twisted and inverted,

almost completely falling to the ground. The patient

struck their head, face and upper left shoulder on

the jagged ambulance bumper first, then the floor.

Assisted by the ER staff, the patient was rolled and

placed on a long spine board with cervical precau-

tions and then quickly moved into the critical care

room.

Crew member #2, leaning while trying to lift,

immediately felt severe back pain and fell forward,

striking their head on the overturned stretcher and

sustaining an inch-long laceration to the forehead.

The patient died of heart failure shortly after

admission. On review the traumatic injuries, while

serious and possibly having delayed care, were not

found to be directly responsible for the patient’s

death. Crew member #2 sustained a herniated L5-S1

low-back injury that required a laminectomy and

extensive rehab, and continues on light duty with

the goal of returning to work in the field.

Root Cause AnalysisWhen analyzing adverse events, safety experts

talk about gaps or holes in safety practices lin-

ing up to cause a “perfect storm” that results in

injury. (See the “Swiss cheese model” explained

here: https://psnet.ahrq.gov/primers/primer/21/

systems-approach.)

In this case the crew, with a combined 14 years of

experience, acted like so many other crews would.

With a critical patient’s best interest in mind, they

moved quickly performing a routine task—unload-

ing the stretcher, a procedure they have completed

thousands of times without mishap. They were nei-

ther disregarding safety nor acting recklessly. In the

blink of an eye, they became distracted with reports

to the ER staff and relied on a safety hook that had

never failed them.

It is common for us to be complacent and disre-

gard risks during repetitive tasks that have never

caused us harm. Like our use of stretchers on every

call, pilots will take off and land an airplane on every

flight. And like aviation, where most crashes occur

on take-off and landing, we also know most injuries

to providers and patients will occur during stretcher

loads and unloads. Have you ever thought, I don’t

need to wear my seat belt, I’m just driving down the

block to the store? When “it hasn’t happened to us,”

we can think It doesn’t happen to me. Our compla-

cency leads us to slip, then trip.

Straps, oxygen bottles and special baskets can

catch on the safety latch, creating further danger.

Nonpreventable FactorsThe single hook, combined with a stretcher safety

bar that is curved, combined with a garage that

is tilted, combined with straps from equipment

baskets, combined with an unload procedure that

requires holding weight until wheels descend and

lock, is a system design disaster waiting to happen.

Preventable FactorsCrew distraction, lack of communication during a

critical task, moving too quickly and disregarding

risks are all elements that could have been mitigated

in this case.

LessonsThis event is as tragic as it is common. Clearly we

need systems that have improved safety design.

Help may be on the way from stretcher manufac-

turers offering no-lift systems. In the meantime,

what can you do to prevent this from happening on

your next call?

We are big fans of crew resource management

(see sidebar). In keeping with aviation’s “red rule”

when potential risks exist, it is essential that we stop

(or at least slow down enough to think about the

procedure), perform a cross-check with a partner,

follow a clear checklist, use clear verbalization of

keywords, and repeat back confirmation (closed

loop communication). Maintaining a sterile cockpit

CRM TipsTHIS COLUMN WILL FEATURE A MONTHLY TIP ON CREW RESOURCE Management (CRM) principles and techniques that apply to the cases we present.

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

In this inaugural column, patients and providers were injured in a stretch-er mishap. In aviation most crashes occur on take-off and landing. If we apply this principle to EMS, let’s imagine a systematic process to improve stretcher loading (take-off) and unloading (landing):

• Sterile cockpit—During take-offs and landings, crews are silent unless there is a concern for safety. In our EMS case, we do not want to create distractions until critical stretcher procedures are completed. These might include wheels being up and the stretcher being latched.

• Key words—The critical step in stretcher unloading is to ensure the wheels are down and locked.

• Checklists—For procedures we know might injure a patient or ourselves, we have to take additional steps to reduce risks. One of these is to pause, review key steps in a checklist, and read back these steps for a second person to confirm we have not missed anything. For procedures that carry excess risk— like aviation’s “red rule”—checklists force crews to stop, read back and ensure we have critical elements covered.


could also prevent unnecessary distraction. In this

case identifying an environmental hazard (tilted

garage floor) and waiting for a third person to help

is also possible.

Improving safety parameters, such as removing

loose straps, placing two safety hooks and ensur-

ing the stretcher bar is updated to be flat, will help

mitigate some risks.

Standardizing the process of loading and unload-

ing would be the single greatest mitigator of risk in

this case. Streamlined and vetted processes have

been proven to mitigate almost all errors.

From simple procedures such as ensuring a door is

locked before an airplane takes off to complex crash

landings into a river, cross-checks with a standard-

ized checklist have saved many lives. Remember,

slow is smooth, and smooth is fast.

Why Do We Need This Column?Recent studies report between 98,000 and 210,000

deaths each year are due to preventable medical

errors.2–4 We know that errors in areas like medica-

tion administration, airway management, assess-

ment errors and patient falls are not just happening

in hospitals. These same errors occur in ambulances,

but providers are afraid to report them for fear of

being dismissed, and agencies are afraid to report

them from fear of being sued. Unfortunately, without

reporting or tracking these errors, we cannot under-

stand the depth of the problem or create systems

to improve our safety.

In 2013, responding to a request from the Nation-

al EMS Advisory Council (NEMSAC), the National

Highway Traffic Safety Administration (NHTSA)

collaborated with the American College of Emer-

gency Physicians (ACEP) to publish the Strategy for

a National EMS Culture of Safety (www.emsculture-

ofsafety.org). This landmark document outlines the

need, framework and steps for EMS to implement

major operational changes that will lead to improved

safety.

To become more reliable we must implement just

culture. Learning from our mistakes so we do not

repeat them is a key component of this process. We

must make it safe to report errors without fear of

reprisals and analyze the root cause of the adverse

event. Like aviation, we need to focus on systems of

safety, not blaming individuals.

The Center for Leadership and Research (CLIR),

in collaboration with the National Association of

EMTs (NAEMT), has set up an international report-

ing website and database to track these errors at

www.emseventreport.com. The brainchild of para-

medic Gary Wingrove, this tool allows EMS providers

to anonymously report near-miss or actual adverse

events without fear of punishment.

In this column we intend to report on cases where

things simply didn’t go as planned. We will hide

details to protect the privacy of those who share

these events, but we want to help create a national

culture of safety that is not afraid to shed light on

near-miss or adverse events. We are committed to

facilitating honest and prompt reporting so that oth-

ers will learn from them and avoid them. Send com-

ments and feedback to [email protected].

RE FE RE N CE S

1. Braithwaite S, et al. Strategy for a National EMS Culture of Safety; p 6, www.emscultureofsafety.org.2. James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Safety, 2013 Sep; 9(3): 122–8. 3. Institute of Medicine. To Err is Human, https://iom.nationalacademies.org. 4. Department of Health and Human Services Office of Inspector General. Adverse Events in Hospitals: National Incidence Among Medical Beneficiaries, http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf.

BIB LIO G R APH Y

Hobgood C, XIe J, Winder B, Hooker J. Error Identification, Disclosure, and Reporting: Practice Patterns of Three Emergency Medicine Provider Types. Acad Emerg Med, 2004; 11: 196–9.Hubble MW, Paschal KR, Sanders TA. Medication calculation skills of practicing paramedics. Prehosp Emerg Care, 2000; 4: 253–60.Kothari R, Barsan W, Brott T, Broderick J, Ashbrock S. Frequency and accuracy of prehospital diagnosis of acute stroke. Stroke, 1995; 26: 937–41.Rittenberger JC, Beck PW, Paris PM. Errors of omission in the treatment of prehospital chest pain patients. Prehosp Emerg Care, 2005; 9: 2–7.Vilke GM, Tornabene SV, Stepanski B, et al. Paramedic self-reported medication errors. Prehosp Emerg Care, 2006; 10: 457–62.

AB O U T THE AU TH O RS 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 anony-mous 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. A similar system used by airline pilots has led to important system improvements based upon pilot-reported “near-miss” situations and errors.

REPORT EVENTS

CASES WITH A TWIST

Video ChallengeCAN YOU COME UP WITH A VIDEO THAT demonstrates sterile cockpit, key words and use of a checklist for safe loading and unload-ing of the stretcher? If you do, please send the link to [email protected]. Our partners at North Ambulance and Jones and Bartlett Learning filmed this “stretcher cross-check” seen here: EMSReference.com/checklists.

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.

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


When you accept a

leadership position,

it is not just a title.


How Will You Be Remembered?It is your responsibility to leave your EMS organization better than you found it

“Management is doing things right, leadership is doing

the right things.” —Peter Drucker

When you come to the end of your career in

whatever leadership role you retire from,

how will you be remembered? Will the

number of people who show up at your

retirement party not even fill a telephone booth,

or will it be a large hall overflowing with those who

want to wish you well and thank you for everything

you did to contribute to the organization?

I have worked with some chief fire officers in my

career for whom the only people who showed up at

the retirement party were the retiree’s family and

those working in the building so they could get the

free food. It is very sad that your subordinates could

think so little of you and that you made no contri-

butions to better the organization; in fact, you may

have made it worse. For these individuals, that will

be their legacy and how they will be remembered

for years to come.

Clean the CampsiteThe Boy Scouts have a saying: “Leave the campsite

better than you found it.” This means making sure

you clean up any mess you created. All your trash

should be picked up and all camp fires put out,

restoring the campsite to its natural state. Even if

you arrived and found cans and wrappers left by

someone else, it is your responsibility to clean it up.

This saying can also apply to leaders of EMS orga-

nizations. Whatever leadership role you find yourself

in, whether it is a supervisor, a middle-level man-

agement position or the head of the EMS organiza-

tion, one of your responsibilities is to move the EMS

organization forward and leave it better than you

found it. How do you do this? You become a leader

instead of a manager.

Leadership vs. ManagementWhat is the difference between leadership and

management? It is very simple: You lead employ-

ees and manage things. We manage budgets, fleets,

payroll, inventories and computer systems, but we

lead people.

Leaders who fail and whose staff cannot wait

until they retire lack vision of where the organization

should be and, since they have no vision, they cannot

share that vision with their subordinates.

Leaders who leave an organization better than

they found it learn to create a vision of where the

organization should be and then find that one ingre-

dient that motivates people to share in that vision.

Just because you create a vision of where the

organization should be does not mean your employ-

ees will rubberstamp your vision. You have to be

able to share your vision and find a way of getting

employees to buy into your vision.

Most leaders find a way to get employees to share

their vision by empowering them in the process. As

President Dwight Eisenhower said, “Leadership is the

art of getting someone else to do something you

want done because he wants to do it.” Eisenhower

certainly understood this concept. Who else could

command millions of troops in battle to conquer

Europe while he had never been in battle himself?

You may not care what your employees think

about you when you retire. You may just wish to walk

out the door on your last day, never to be seen again.

If that is the case, then you were not a leader and you

were probably not even a manager.

In a leadership position you have a responsibility

to lead your organization and your employees and

make your EMS organization successful. If you do not

accept this responsibility, you should have stepped

down from your position way before your retirement.

When you accept a leadership position, it is not just

a title. It is a responsibility that you should fully accept

and strive for the success of your EMS organization.

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 successfully managed large, award-winning metropolitan fire-based EMS systems in St. Louis and Memphis. He has a total of 37 years of fire, rescue and EMS experience and has been a paramedic for over 35 years.

erative agreement with NHTSA, publicly launched EMS Compass. Since then, the initiative has tackled difficult issues, from how to decide which measures to use to how to be inclusive of the entire EMS com-munity. But the focus of EMS Compass has been cre-ating a replicable process for identifying, designing and testing performance measures—a process that can be used well into the future by organizations hoping to develop measures that support improving prehospital medical care.

“In order to take the next step as a profession, EMS must embrace a culture of improvement—one where we measure the things that truly matter to patients and we work to improve the processes that result in the best possible patient care,” says Bob Bass, MD,

EMS Compass is setting the profession on a path toward performance measurement and improvement

When staff in the National Highway Traf-fic Safety Administration (NHTSA) Office of EMS decided to support EMS Compass, it made perfect sense. For decades, NHTSA has funded projects

that have helped make the nation’s EMS systems what they are today. Twenty years ago, the Agenda for the Future presented a vision of a data-driven EMS sys-tem; more recently, the National EMS Information System (NEMSIS) established data standards and the

Prehospital Evidence-Based Guidelines (EBG) project established treatment guidelines based on research findings. Each has built on those that came before it, and EMS Compass is no different.

It’s the logical next step—applying those stan-dard data elements and medical research to create performance measures that will help EMS agencies meaningfully use their data to improve patient care.

In December 2014 the National Association of State EMS Officials (NASEMSO), through a coop-

By Michael Gerber, MPH, NRP How EMS Leaders Use Data to Improve EMS Systems “If we have measures that are truly patient-centered…I believe

we’ll make much better decisions and make much more significant improvement,” said Mike Taigman, General Manager of AMR in Ventura County, CA, during one of a series of 10 webinars held in June 2015 by EMS Compass as part of the initiative’s effort to engage and receive input from the EMS community. Each webinar tackled one of the 9 domains of measures EMS Compass is addressing.

Taigman admitted that measuring patient outcomes is a struggle in EMS and medicine generally. But that doesn’t mean EMS shouldn’t strive to have performance measures that are as patient-centered as possible.

During the session on population and public health, Taigman described the process measures that he believes EMS can use when true patient outcome measures are difficult to assess. A process measure, EMS Compass Project Manager Nick Nudell explained, is one that evaluates a step in the process that is linked to outcomes but is not the outcome itself.

Taigman’s examples included measuring the time from the first 9-1-1 call to certain evidence-based procedures for time-sensitive conditions, such as:

• First chest compression for cardiac arrest;• Restoration of blood flow for STEMI;• First CT scan interpretation for stroke;• Infusion of two liters of fluid for sepsis. There are six domains of measures that correlate to the priorities in

the U.S. Department of Health and Human Services National Quality Strategy. Population and public health is one; the other five are patient and family engagement, patient safety, care coordination, efficient use of healthcare resources, and clinical process and effectiveness. In keeping with the project charter to address all aspects of an EMS system, the initiative added three other domains: workforce, fleet and data.

In the EMS workforce webinar, Daniel Patterson, PhD, a senior scientist with the Carolinas Healthcare System in Charlotte, NC, discussed ways to measure fatigue and the safety culture within an organization—all of which have been linked to safety outcomes by research, he said.

While in the past some of these measures have used questionnaires that can be time-consuming to administer to staff, Patterson and other researchers have been working to refine those surveys to make them shorter but still valid. Other ways of measuring these factors, such as using text messaging to assess fatigue, are currently being investigated.

Mike Ragone, director of system design for AMR, spoke about the difference between measuring “on scene” times and “at patient” times during the session on efficient use of healthcare resources. “On scene time versus at patient side, as we all know, can be a huge difference,” Ragone said, citing the example of responding to a casino where it may take 15 minutes to reach the patient after arriving. “If we do not separate them, we won’t be able to draw conclusions” about the clinical relevance of response times, he added.

Ragone discussed some of the different ways systems are trying to measure accurate at-patient times, from communicating via the radio in order to let dispatchers mark the time to using handheld devices, such as smart phones, that allow the practitioners in the field to accurately record the time.

Although EMS Compass aims to create performance measures around the data standards established by NEMSIS, it was clear that this effort to use data to assess system performance may also drive changes to how data is collected, as EMS systems determine which elements are most critical to analyze.

How to Measure and Improve EMS Systems

The use of analytics and data to save lives is at the heart of operations at The Richmond Ambulance Authority in Richmond, VA. Two of RAA’s leaders were featured in the EMS Compass webinar series, COO Rob Lawrence on the use of performance management in EMS and Fleet Manager Dan Fellows who discussed metric-led fleet management.


former director of the Maryland Institute for EMS Systems, who is serving as the EMS Compass steering committee chair.

On January 13 the EMS Compass steering committee meets in person for the third time to discuss the progress of the mea-sure development process. The committee, composed of several experts in performance measurement and improvement from both inside and outside the EMS community, is also expected to be reviewing and prioritiz-ing the first sets of performance measures.

Building MeasuresBut the bulk of the work for EMS Compass has occurred between those meetings, when dozens of volunteer members of the initia-tive’s working groups have spent countless hours designing, refining and testing the measures.

When the EMS Compass Measurement Design Group first gathered in Washing-ton nearly a year ago, its members knew they had a challenge before them. Since then, they have helped create a measure-

ment design process that is transparent and evidence-based, with opportunities for members of the public to participate.

In addition, they have sifted through hundreds of potential measures submitted by the EMS community and present in the literature, choosing the ones that EMS agen-cies can use to help them in their pursuit of providing high-quality care to patients and making a difference in their communities.

“Choosing the ‘vital few’ measures and making sure we specify clear operational definitions to know the data to include, what to exclude and how to calculate the measures are essential to ensuring EMS agencies can use the measures to sup-port improvement,” says David Williams, PhD, executive director at the Institute for Healthcare Improvement and chair of the EMS Compass Measurement Design Group. “Measurement is vital to knowing how an agency is reliably delivering results and whether efforts to improve processes are moving their dots on their charts, and EMS Compass will help provide a good place

for agencies to start to look at meaningful process and outcome measures that can enable them to focus on improvement and reliability.”

From the start, EMS Compass has focused on using NEMSIS data points in its measures when possible. Because NEM-SIS creates a standard for collecting EMS patient data, the vast majority of U.S. EMS agencies are gathering the same informa-tion on each patient. NEMSIS-compliant electronic patient care reports (ePCRs) also ensure that the data are stored in the same way, so they can be sent to state and national databases and used for research and analysis.

But for EMS Compass, the NEMSIS stan-dard also means that clinical performance measures can be designed so that any agency using NEMSIS-compliant PCRs can use the measures in the same way. They can even be built into software that automatically pulls the information from individual ePCRs and calculates how an agency is performing on a specific measure.

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To support EMS Compass’s efforts to design measures that can be automated when using NEMSIS data, the project has enlisted a group of volunteers from sev-eral leading EMS technology and software companies. Chaired by FirstWatch Product Strategist Debbie Gilligan, the EMS Com-pass Technology Developers Group has focused on matching the proposed perfor-mance measures to NEMSIS data points, and testing them to make sure EMS agen-cies could implement the measures with the EMS clinical data they already have.

“The possibilities created by having elec-tronic records, a uniform data standard, and performance measures using that data are pretty exciting,” Gilligan says. “It’s been fun to get in a room with people from all these innovative companies who are in many ways competitors, but who all have one goal in mind—finding ways to make it easier for people to get more out of their data.”

Building consensus around performance measures is not easy, as many other areas of healthcare have discovered. During the

EMS Compass process, the committee members and project leaders have navi-gated some complicated questions, from what level of evidence review was needed to which sources of data could be consid-ered. Early on, it became clear that many members of the initiative recognized some

key measures—clinical outcomes—would rely on EMS agencies being able to access data from outside sources, such as hospitals.

“Information should flow seamlessly from prehospital care to hospital care and back,” Bass says. “To me I see that as a really important part of what we’re doing—to say here’s the science, here are the measures, here’s the way it needs to be done.”

At the same time, he acknowledged, most EMS agencies continue to struggle to get access to outcome information from hos-pitals. Recognizing that, many of the mea-sures were designed to serve as surrogate measures that use data currently collected by providers when they complete patient care reports only until they are able to link with hospital data to collect the complete measures.

“Maybe you have to do that initially just so you get some baseline on the EMS pro-cesses and start measuring,” Bass says. “But we have to be willing to say that the right way to measure performance often includes patient outcomes, such as survival to dis-charge for cardiac arrest. And maybe having a measure that says that will help improve the state of data-sharing between hospitals and EMS systems.”

Establishing a Foundation Based on EvidenceEqually important to using available data is creating measures that are based on the


Building consensus around performance measures is not easy, as many other areas of healthcare have discovered.


EMS1507S


latest evidence and best practices in pre-hospital care. The ultimate purpose of per-formance measures is to improve patient care and EMS practice—and therefore the patient experience and outcomes. Perfor-mance measures often drive programmatic

changes, so it was essential to the EMS Compass leaders to only measure processes that have a demonstrated positive impact.

For example, while measuring IV success rates has long been a standard for many EMS performance management programs, there has never been a proven association between IV success rates and patient out-comes. While it is clearly important that paramedics can competently perform skills

they are expected to perform, EMS Com-pass leaders chose to focus on measures linked to patient outcomes, such as the abil-ity to accurately identify stroke patients, or administration of aspirin for heart attack victims. Members of the initiative looked to sources such as American Heart Asso-ciation guidelines and articles published in the peer-reviewed medical literature to ensure the EMS Compass measures would be assessing evidence-based practices.

“A key opportunity in improvement is to use measurement to support EMS sys-tems to reliably deliver evidence-based care,” Williams says. “Not measuring the care processes that matter will not improve outcomes.”

Focus on Local ImprovementEMS Compass leaders say the initiative is focused solely on creating measures that support systems to improve care, and the project has no ability or authority to require agencies to use or report the measures. But with changes to healthcare funding occur-

ring across the industry, many members of the EMS community and EMS Compass team have acknowledged that in the future, healthcare payers, local governments and other entities may look for additional mea-sures to use to assess EMS payments or hold systems accountable—in a sense, this is already happening in cities across the coun-try that have response time requirements tied to contract payments for EMS services. If insurance companies and the U.S. Centers for Medicare and Medicaid Services (CMS) later link payments to performance, some EMS leaders argue, it’d be better for them to use measures developed by the EMS com-munity and based on solid medical research.

“Our goal is to create evidence-based measures that support the improvement of the quality of care at the local level, period,” says Dia Gainor, executive director of NAS-EMSO. “If agencies, regulators or communi-ties choose to use the EMS Compass mea-sures, then they will be using measures that are good for patients and good for EMS.”

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and building consensus around measures was a priority for the initiative, regardless of potential other uses of the measures. From the start, EMS Compass has involved dozens of EMTs, paramedics, educators, adminis-trators, medical directors and other experts on its various committees. The steering committee also included several experts from outside EMS, including Kedar Mate, MD, a physician and improvement expert with the Institute for Healthcare Improve-ment (IHI); Patria de Lancer Julnes, PhD, a performance measurement expert and researcher at Penn State Harrisburg; Todd Olmsted, PhD, a health economist at the University of Texas; and Martha Hayward, a patient advocate with IHI.

A Community EffortBeyond the impressive roster directly asso-ciated with the project are the dozens of individuals and agencies who submitted measures during the public “call for mea-sures.” In order to be as open and inclusive as possible, EMS Compass began its mea-

surement design process by asking members of the public to submit ideas for measures. The response exceeded even the expecta-tions of the initiative’s leaders when they received more than 400 submissions.

“From the beginning, I’ve been receiving so many e-mails, seeing great turnout at meetings, hearing from so many different members of the EMS community,” says Nick

Nudell, the EMS Compass project manager. “It’s exciting to see so many people engaged and interested in contributing.”

Since then, EMS Compass has hosted several webinars and conference sessions to share information and receive feedback, and the proposed measures are all avail-able for public comment on the initiative’s website, emscompass.org, prior to review by

the steering committee. EMS Compass has also encouraged agencies to test the specific measures to ensure that agencies are able to access the data and calculate the measures as intended.

Even with a process that is so focused on inclusiveness and evidence and testing, it is clear that EMS performance measures cre-ated today cannot be thought of as perma-nent. As research reveals new findings and different data becomes available, the EMS community must be willing to adapt and re-evaluate performance measures. What EMS Compass has focused on, rather than specific measures, is a process for devel-oping and revisiting measures. The mem-bers of the EMS Compass team hope that the process they’ve created—based largely on the model used by the National Qual-ity Forum and the larger healthcare com-munity—will be used in the future by the EMS profession to develop new measures, to reassess old measures and ensure that EMS agencies continue to have the tools they need to support improvement.

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It is clear that EMS performance measures created today cannot be thought of as permanent.

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“The real legacy of EMS Compass, and our main measure for knowing it is a suc-cess, will be a culture of performance improvement across EMS, from volunteers in the smallest rural agencies to chiefs in the busiest urban departments,” Gainor says. “Everyone in EMS shares the same goal—providing the best care to our patients—and EMS Compass will help us do just that.”

In fact, creating a sustainable process for designing measures is only part of the EMS Compass initiative—a result of the project will be a guide to using performance mea-sures for improvement. Frequently in the past, efforts have focused solely on the mea-sures. While agencies have started collect-ing the data and even calculating measures, many struggle with implementing change based on what they learn.

A critically important part of that process will be a shift away from thinking of mea-surement for compliance, accountability or judgment. Measurement for improvement focuses less on people and errors and more on understanding process reliability that

enables outcomes. This is a major cultural shift for EMS, which has not had wide-spread experience of using measurement for improvement.

“Figuring out how to calculate the mea-sures might seem like the difficult part, but it’s just the first step,” Bass says. “What’s usually the real challenge is knowing what those numbers mean and recognizing when improvements can be made and figuring out the best way to drive that change.”

The EMS Compass LegacyOver the next several months, the EMS Compass team will also lead discussions about how to ensure the increased focus on measurement for improvement doesn’t end when the funding for the current initiative runs out. Some leaders in the EMS commu-nity hope that federal funding will be used to extend the EMS Compass process. Oth-ers have suggested that EMS stakeholder associations could work together to keep EMS Compass alive. Another possibility is that the EMS Compass process of designing

performance measures is used by different organizations looking to create measures.

While the exact future of EMS Compass beyond its initial funding is not decided, it is clear that the EMS profession is ready to move beyond simply measuring IV rates and response times. By using evidence-based and thoughtfully designed performance measures, EMS agencies have the oppor-tunity to improve the quality of patient care and enhance their service to their commu-nities. And that’s a goal every EMS provider can agree on.

Editor’s note: The EMS Compass steer-ing committee is scheduled to meet on Jan. 13 to review and prioritize several perfor-mance measures. For the latest update, visit emscompass.org.

AB O U T THE AU TH O R Michael Gerber, MPH, NRP, is an instructor, author and consultant in Washington, DC. E-mail him at [email protected].

EMS1601



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ox improves to 90%. On arrival at the hospital, the emergency department physician immediately orders the respiratory therapist to switch from your CPAP to biphasic positive airway pressure (BiPAP).

You’ve seen this switch occur on multiple occasions when you’ve brought in a patient on CPAP and won-der why the ED always switches to BiPAP. Is BiPAP really that much better than CPAP? If so, should we be using BiPAP in the EMS world?

BackgroundAs a quick review, patients in acute respiratory dis-tress have a problem with oxygenation, ventilation or both. Oxygenation is the process of providing oxy-gen to the patient. However, pathologies like COPD and CHF may require more than just oxygenation as a result of alveolar disease preventing appropriate diffusion of oxygen and carbon dioxide across the alveolar membranes (i.e., pulmonary edema and bron-choconstriction). This is when ventilation becomes important. Ventilation can be thought of as the actual physiologic process of breathing, which is inhalation, diffusion of gases and exhalation.

Ventilation and oxygenation are important for understanding the utility of noninvasive positive pressure ventiliaton (NIPPV). NIPPV is a form of mechanical ventilation delivered through the use of tight-fitting nasal or facial masks that does not require endotracheal intubation. It can be delivered in two forms: CPAP or BiPAP.7 CPAP provides a continuous pressure of oxygen to the alveoli. This constant pressure provides oxygen directly to the lungs, prevents alveolar collapse, and may even open up previously closed alveoli (alveolar recruitment). In essence, CPAP primarily provides oxygenation and may indirectly influence ventilation by allow-ing alveoli to remain or become available.7 As a result of this constant pressure throughout the respiratory cycle, the patient has to overcome this pressure dur-ing exhalation. Thus, CPAP is limited by the patient’s ability to overcome the very pressure CPAP provides.

Here is where BiPAP can help. BiPAP provides CPAP, but senses and adjusts the oxygen pressure to the patient’s breathing cycle. The oxygen pres-sure increases during inhalation to provide maximal alveolar recruitment but decreases during exhalation to ease breathing while keeping alveoli open with its adjustable CPAP function. In essence, BiPAP pro-vides greater control for acute respiratory distress and may provide better gas exchange to optimize cardiopulmonary performance. Thus, many hospitals use BiPAP for this very reason: better control.

The use of BiPAP is further supported by a 2004 Cochrane review in which the authors examined 14 randomized controlled trials in which standard medi-

cal therapy (SMT)—defined as supplemental oxygen, bronchodilators, steroids and antibiotics—was com-pared to BiPAP in patients with COPD. With a total of 758 patients analyzed, the authors found a 48% reduction in the risk of mortality for patients treated with BiPAP. This demonstrated a number needed to treat (NNT) of 10, meaning that for every 10 patients treated with BiPAP, one life was saved compared to SMT alone. This review also demonstrated a 60% decrease in the risk of intubation with a NNT of 4.8

Clearly this review supports the use of BiPAP as a first-line NIPPV therapy in treating COPD. Before we claim that BiPAP is superior, though, let’s remember that this review did not specifically compare the use of CPAP against the use of BiPAP. So let’s look at the evidence comparing the two before we throw our CPAP machines out the window.

In-Hospital EvidenceTo begin, there are studies that showed worse out-comes with BiPAP compared to CPAP. In 2012, Bra-zilian researcher Juliana Nalin de Souza Passarini demonstrated an increased need for endotracheal intubation in patients who received BiPAP compared to those who received CPAP in treatment of acute cardiogenic pulmonary edema (ACPE) and COPD exacerbation.10 However, this study was limited by a nonrandomization of subjects, leading to bias in

the patients who received BiPAP and CPAP. This was demonstrated when the authors concluded that the increased need for intubation was likely due to greater disease severity in those patients who received BiPAP. Despite these limitations, this study still dem-onstrated that a majority of patients managed with NIPPV avoided the need for endotracheal intubation.

In contrast, an older, more methodologically sound study stated that BiPAP may provide slightly better results than CPAP. These authors attempted to evalu-ate whether BiPAP improved ventilation, acidemia and dyspnea more rapidly than CPAP in patients with ACPE by measuring vital signs and specific blood lab values. What makes this manuscript method-ologically superior to the former study is that it was a randomized, controlled, double-blinded study, so bias was kept to a minimum. The authors conclud-ed that BiPAP improves ventilation and vital signs quicker than CPAP. However, they added a word of caution after discovering a relationship with having a myocardial infarction (MI) and the use of BiPAP.6

E v i d e n ce - B a s e d E M S :

Out-of-Hospital BiPAP vs. CPAPIs one any better than the other?

By Hawnwan Philip Moy, MD, & Blake Bruton, MD

VitaLink Transport teams of all levels apply CPAP early during the care of patients experiencing respiratory emergencies. Only critical care teams utilize BiPAP.

It’s that crazy weather again. One minute it’s a beautiful sunny day, and the next it’s freezing rain. As you bundle up for the cold weather, you get dispatched to a 75-year-old male with difficulty breathing. You arrive on scene to find a thin, frail

elderly man sitting in the kitchen, leaning forward with elbows propped on the table. He struggles to say, “I can’t breathe.”

On exam you note pursed-lip breathing with a pro-longed expiratory phase. He has intercostal retrac-tions, diffuse wheezing with rales bilaterally, with pitting edema in his lower extremities. Initial vital signs are a pulse of 130, blood pressure of 165/60, respiratory rate of 25, and a pulse oximetry reading of 85% on room air. His medical history is significant for severe COPD and congestive heart failure.

While you debate whether this is a COPD or CHF exacerbation, you decide to put the patient on continuous positive airway pressure (CPAP) while administering nebulized albuterol. The patient is still anxious with labored breathing, but his pulse

Some rural EMS systems may take the long-term effects of BiPAP into consideration given their longer transport times.


Fortunately, a meta-analysis nine years later demonstrated this relationship of new-onset MI and BiPAP utilization did not reach sta-tistical significance.5

However, many who support CPAP state that both interventions lack a difference in meaningful outcomes (i.e., the need for intubation and/or effect on mortality). One such study compared BiPAP to CPAP in 200 patients with ACPE. The authors dis-covered that BiPAP was associated with faster resolution of respiratory failure (159 vs. 210 mins.). However, there was no dif-ference in mortality or rate of intubation in BiPAP and CPAP patients. In essence, CPAP may be just as good as BiPAP in the long run.8

Furthermore, a recent article in the New England Journal of Medicine further sup-ported that CPAP is just as beneficial as BiPAP in terms of meaningful outcomes. The objective was to determine whether noninvasive ventilation reduced mortal-ity and whether there were important dif-ferences in outcomes associated with the

method of treatment (CPAP or BiPAP). The authors discovered that 11.7% of patients on CPAP and 11.1% of patients on BiPAP either died or were intubated. This small difference was not statistically significant, and the authors concluded CPAP can be just as effective as BiPAP in short-term (seven-day) mortality.4

Before we say that CPAP can be just as good as BiPAP, though, let’s look at the pre-hospital evidence.

Prehospital EvidenceAlthough limited in number of studies, the prehospital evidence for the utility of BiPAP and CPAP shows comparable results to the in-hospital research. The Univer-sity of Sheffield’s Steve Goodacre, et al., published a systematic review comparing OOH CPAP and BiPAP to SMT. There was an overall reduction in mortality and intu-bation rate when compared to SMT, but they found no statistical difference with the use of BiPAP and CPAP. While this review seems to be the most complete to

date, the authors noted, “The analysis of BiPAP in particular involved fewer studies and fewer patients (190 receiving BiPAP vs. 610 receiving CPAP).”3 Additionally, Sheffield’s Abdullah Pandor and colleagues provided a similar systematic review that showed a decrease in mortality and need for intubation in the CPAP group that was similar to the BiPAP group.9

Bottom LineAfter looking at the evidence of BiPAP against CPAP, the only advantage BiPAP appears to provide is a decreased time to resolution of respiratory symptoms, vital signs and improvement of laboratory values. However, keep in mind that this difference doesn’t occur until late in the treatment course. While this shouldn’t affect most EMS systems with short transport times, some rural EMS systems may take the long-term effects of BiPAP into consideration given their longer transport times. Other-wise, current evidence demonstrates mini-mal benefit to BiPAP over CPAP.

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What we do know is that BiPAP provides better outcomes in patients with COPD when compared to SMT, and CPAP may be better for ACPE. However, the studies reviewed in this article have not shown a clear or consistent advantage to BiPAP over CPAP in clinically significant out-comes such as decreased mortality, need for intubation, ICU admission and length of hospital stay.

As a prehospital provider, it is always a good to question yourself, broaden your differential impression for acute respira-tory failure and maintain that inquisitive mind. With the evidence reviewed here, the hospital changing your prehospital CPAP to BiPAP every time should not distress you. In the short run, CPAP is just as good as BiPAP. The next time you are faced with a patient with acute respiratory distress, the best thing you can do is relax, remember your training and think about what you can do to best help your patient. If you decide CPAP is the way to go, you now have the evidence to support your decision.

RE FE RE N CE S

1. Baird JS, Ravindranath TM. Out-of-hospital noninvasive ventilation: epidemiology, technology and equipment. Pediatr Rep, 2012 Apr 2; 4(2): e17.2. Cross AM, Cameron P, Kierce M, Ragg M, Kelly AM. Non-invasive ventilation in acute respiratory failure: a randomised comparison of continuous positive airway pressure and bi-level positive airway pressure. Emerg Med J, 2003 Nov; 20(6): 531–4.3. Goodacre S, Stevens JW, Pandor A, et al. Prehospital noninvasive ventilation for acute respiratory failure: systematic review, network meta-analysis, and individual patient data meta-analysis. Acad Emerg Med, 2014 Sep; 21(9): 960–70.4. Gray A, Goodacre S, Newby D, et al. Noninvasive Ventilation in Acute Cardiogenic Pulmonary Edema. N Engl J Med, 2008; 359: 142–51.5. Ho KM, Wong K. A comparison of continuous and bi-level positive airway pressure non-invasive ventilation in patients with acute cardiogenic pulmonary oedema: a meta-analysis. Crit Care, 2006; 10(2): R49.6. Kollef M, Isakow W. The Washington Manual of Critical Care, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2012.7. Mehta S, Jay GD, Woolard RH, et al. Randomized, prospective trial of bilevel versus continuous positive airway pressure in acute pulmonary edema. Crit Care Med, 1997 Apr; 25(4): 620–8.8. Nouira S, Boukef R, Bouida W, et al. Non-invasive pressure support ventilation and CPAP in cardiogenic pulmonary edema: a multicenter randomized study in the emergency department. Intensive Care Med, 2011; 37(2): 249–56.9. Pandor A, Thokala P, Goodacre S, et al. Pre-hospital non-invasive ventilation for acute respiratory failure: a systematic review and cost-effectiveness evaluation. Health Technol Assess, 2015 Jun; 19(42): 1–102.

10. Passarini JN, Zambon L, Morcillo AM, et al. Use of non-invasive ventilation in acute pulmonary edema and chronic obstructive pulmonary disease exacerbation in emergency medicine: predictors of failure. Rev Bras Ter Intensiva, 2012 Sep; 24(3): 278–83.11. Ram FS, Picot J, Lightowler J, Wedzicha JA. Non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev, 2004; (1):CD004104

AB O U T THE AU TH O RS Hawnwan Philip Moy, MD, is an assistant medical director of the Saint Louis City Fire Department and emergency medicine clinical instructor and core faculty of the EMS Section of the Division of Emergency Medicine at Washington University in St. Louis, MO. He completed his emergency medicine residency at Barnes Jewish

Hospital/Washington University in St. Louis and his EMS fellowship at the University of North Carolina in Chapel Hill.

Blake Bruton, MD, earned his Doctor of Medicine degree from the University of Arkansas for Medical Sciences. He is currently in his second year of emergency medicine residency at Washington University in St. Louis. He is a certified Advanced Trauma Life Support instructor for the American College of Surgeons. His current

interests include prehospital care, trauma resuscitation, bedside ultrasound and pediatric emergency medicine.

EMS1601S



Angioedema of the lips and face

If I were to ask you to list the treatment modal-ity for angioedema, your list would probably include oxygen therapy, IV, cardiac monitoring, pulse oximetry, capnography, IM epinephrine, corticosteroids, diphenhydramine and, in some

cases, rapid sequence intubation. In most cases of an allergy-induced angioedema, your answer would be spot on. Angiotensin-converting enzyme inhibitor-related angioedema (ACEI-RA) is a different beast, however. Before we discuss why ACEI-RA is less than responsive to the standard pharmacological agents

listed above, we should cover its epidemiology and pathophysiology.

More than 40 million people worldwide are pre-scribed ACE inhibitors,1,2 and chances are several of your previous patients have been taking them for heart failure or hypertension. ACE inhibitors are the drugs that end in the familiar -pril: lisino-pril, captopril and enalapril, for example. Like any prescription medications, there are potential side effects from ACE inhibitors, angioedema being one of the most serious.

Angioedema is estimated to occur in 0.1%–0.7% of patients on ACE inhibitor therapy.3,4 Of those who present to an emergency department with angioede-ma, 35% of cases are attributed to ACEI.1 Addition-ally, one study concluded that African-Americans are three times more likely to develop ACEI-RA within six months of starting ACE inhibitor therapy.1,5

The most common signs and symptoms of ACEI-RA are mild and may not even be reported by the patient; in other cases the situation can be life-threat-ening. According to the Journal of Emergency Medicine (2011), the most common sign of ACEI-RA is asym-metric (and isolated) swelling of the lips and face, although cases of isolated swelling have been docu-mented in the small bowel, genitals, uvula, tongue and floor of the mouth.6 Urticaria is usually absent. Unlike other types of allergic reactions that can occur rapidly and aggressively, several studies have shown ACEI-RA can occur with those who have been tak-ing ACE inhibitors for weeks, months, even years.1,2,4

By Kristin Spencer, MS, NRP

ACEI-RA is a different beast, less than responsive to standard pharmacological agents

EMSWORLD.com | JANUARY 2016 41

Photos courtesy of Bechera Y. Ghorayeb, MD, www.ghorayeb.com.

Safety is one of the biggest concerns in EMS when handling a patient.

Making sure the patient is comfortable is another focal point.

Mangar International’s Elk Lifting Cushion helps providers cover both of those areas.

The compact, battery powered cushion inflates with the push of a button to help patients reach a seated position, making it easier for them to stand.

Chris Mulberry, assistant chief paramedic of Platte Valley Ambulance Service, says his agen-cy has been using the lifting cushion and is very satisfied with the results.

“The nice part is that it’s not big and it’s not heavy,” Mulberry says.

The cushion applicable for use on patients of any age.

Chris Lokits of Louisville Metro EMS says the lifting cushion is “a blessing.”

“Being by myself doing lift assist, I was con-fident that I could successfully get the patient up without hurting them or myself,” Lokits says.

Mulberry says the cushion is especially useful when handling older patients.

“With elderly people, some have more fragile skin because they’re on certain medications,” Mulberry says. “The cushion makes it more safe and more comfortable, and makes it so you’re not just grabbing or yanking.”

Lokits says some elderly patients had concerns at first that the cushion was not stable, but after some explanation and doing his best to keep the patient stable, those concerns subsided.

The lifting cushion also allows the provider to come in less contact with any bodily fluids or waster from a patient because it requires less contact, Lokits says.

Prior to using the Elk Lifting Cushion, Mulberry says his agency just lifted patients manually.

The cushion, designed for either indoor or outdoor use, makes it so providers can shimmy

or roll a patient onto the cushion.Lokits says that although some pushing, pull-

ing or lifting is still required to get the patient positioned correctly on the cushion, it prevents providers from having to deadlift patients, reduc-ing the risk for personal injury. Lokits says this is invaluable.

Even though some contact with the patient is still required, Lokits says the product increases

safety for both the patient and the provider.

“I believe this device will pay for itself in the long run with a

decrease in IODs and workman’s compensa-tion claims,” Lokits says. “The device provides

additional safety for the crews, not to mention the safety provided for the patient we are lifting.”

Mulberry also says the device is durable.“When you see the pictures, it doesn’t look

too rugged,” Mulberry says. “EMS people are hard on equipment, but this product stands up to any EMS use.”

Lokits says the majority of the device is easy to clean when using the appropriate cleaner.

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Most cases of angio-edema are mediated by IgE antibodies—the endog-enous antibodies that attack seemingly innocu-ous allergens (antigens) in those with type I sen-sitivity reactions. Insect stings, seafood, pollen and some medications are frequently associated with IgE-mediated aller-gic reactions. IgE antibod-ies have a high affinity for mast cells and basophils,

and when bonded together result in the formation and subsequent release of chemical mediators. Of course, the chemical mediator closely examined in the para-medic curriculum is histamine. Histamine causes its effects by binding to H1 and H2 receptors that cause contraction of smooth muscles of the airway and GI tract, increased vascular permeability, vasodilation, enhanced mucus production, pruritus and gastric acid secretion. Translated, a histaminergic-mediated

angioedema means your patient with allergy sensitivi-ties could present with a runny nose, conjunctivitis, nausea and vomiting, diarrhea, bronchoconstriction, increased bronchial mucus secretions, generalized swelling, urticaria/wheals and hypotension—a mul-tisystemic reaction. Again, angioedema induced by histamine will respond to conventional therapies like antihistamines and corticosteroids, pharmacologi-cal agents commonly emphasized in most paramedic curricula.

Interestingly, ACEI-RA is not IgE mediated; the physiology of the condition is caused by the levels of the blood vessel-dilating peptide bradykinin in the body.2,4 Bradykinin counterbalances the vasoconstric-tive workings of the renin-angiotensin-aldosterone system and is thought to be a primary mediator in nonallergic angioedemas. There are two kinds of bra-dykinin receptors: B1 and B2. When bradykinin binds with these receptors, increased vascular permeability and isolated, nonpitting edema occurs. Glossitis is frequently seen. Given the pathophysiology behind ACEI-RA, you can now understand why conventional interventions for angioedema probably will not work with these specific cases.3,4



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How to ProceedSo what do you do? Do you not treat the angioedema? Of course you do. Most cases of angioedema are not caused by ACE inhib-itors, and it may be difficult to make a pre-cise correlation between the two. If you’re a person who would prefer a specific treat-ment algorithm for ACEI-RA or a definitive diagnostic test, you will be disappointed.

When assessing a patient with upper air-way obstruction/edema, conduct a fastidi-ous yet rapid exam. Identification regard-ing its etiology is extremely time-sensitive, especially when dealing with ACEI-RA. For purposes of this discussion, the upper air-way is defined as the conduit from the nose and mouth to the larynx.

You’ve probably heard it, but it bears repeating: Avoid approaching your patient with tunnel vision. Not all cases of angioede-ma are secondary to shellfish, hymenoptera stings or penicillin, so keeping a broad list of differentials is important. You must weigh the likely causes of upper airway obstruc-tions considering age, medical history,

recent events and physical examination. For example, you would not diagnose a young patient with a history of fever, dysphagia, sore throat and drooling as ACEI-RA.

There are multiple causes for upper airway swelling—some are progressive and potentially lethal, some more benign. Through your physical examination and history-taking, you can rule out some of the more common differentials. See box.

Understanding the underlying causes of common upper airway obstructions and identifying life threats is paramount, as treatment modalities differ. You would not treat a patient with massive maxillofacial injuries as you would a patient present-ing with anaphylaxis, epiglottitis or croup. Although the endpoint may be the same in most airway management challenges (i.e., oral intubation), patients with ACEI-RA may be nonintubatable through the oral cavity; glossitis may be severe enough to make the mouth impenetrable with an OPA, endotra-cheal tube, LMA, Combitube or King. (As a side note, although glossitis may look out-

landish, the larynx may not be affected, and the patient can still move air.) If the patient needs ventilatory assistance, perform BVM ventilations while simultaneously watch-ing the rise and fall of your patient’s chest to ensure adequate tidal volume. Observe SpO2, the patient’s color, mental status, heart rate and EtCO2—your patient may respond surprisingly well. It would be difficult to justify performing, say, a surgical airway when assisted ventilations prove beneficial.

Causes of Upper Air way Swelling

• Burns;• Epiglottitis• Laryngotracheobronchitis

(croup);• Massive maxillofacial trauma;• Acute laryngeal injury;• Ludwig’s angina;• Laryngeal stenosis;• Laryngeal tumors.


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blockers (e.g., ranitidine, cimetidine; class indeterminate);

• Corticosteroids (e.g., prednisone, methylprednisolone; class indeterminate);

• Cardiac monitoring;• Racemic epinephrine;• Epinephrine 1:1,000, 0.3–0.5 IM,

repeat if needed.Examining the list above, you may ques-

tion why histaminic antagonists and epi-nephrine are included as part of the sug-gested treatment plan for ACEI-RA, given histamine release is not the triggering agent. Epinephrine is administered primarily for its alpha-1 properties; the vasoconstrictive actions may reduce swelling in the affected areas, although several case studies have shown less than impressive results when using epinephrine for bradykinin-mediated angioedema.1 Histamine blockers are gener-ally used if the source of the angioedema is either histaminic-induced or unknown. It is reasonable to administer H1 and H2 block-ers for angioedemas of unknown etiology because the side effects are relatively few and

benign.1 It is important to note that in a small study published in the New England Journal of Medicine, patients with ACE inhibitor-induced angioedema recovered nearly three times faster with the administration of a bra-dykinin blocker than those given a standard glucocorticoid/antihistamine treatment.3

ConclusionAlthough ACEI-RA is rarely examined in either initial or ongoing paramedic training, airway management is. If your patient shows signs of airway closure or indicators that airway compromise is imminent, be aggres-sive in securing the airway before it becomes impossible. Although basic maneuvers such as the insertion of an NPA and BVM ven-tilations may prove successful, watch your patient closely to determine how he/she is trending. Complete airway obstruction secondary to laryngeal edema may occur rapidly and unexpectedly. Immediate intu-bation, by either the oral or nasal route, RSI or, in extreme cases, cricothyrotomy, may be required. With those suspected of ACEI-

Sometimes the least invasive practices are preferred over invasive procedures that may have catastrophic consequences.

If you determine BVM ventilations are ineffectual, intubate through the orotra-cheal route. If you cannot insert an ETT through the orotracheal route, consider the nasotracheal route. Although it’s becoming a lost art and at times forgotten as a viable option, a scenario may arise where using the nasotracheal route may be your only option in securing a definitive airway.4

Arguably controversial and not instituted in some places, rapid sequence induction (RSI) is an option and should be included in every paramedic’s treatment toolbox. If nec-essary and viable, RSI can be very beneficial in cases of ACEI-RA when you have a con-scious patient showing signs of imminent airway closure (e.g., stridor, hoarse voice, reports of dysphagia) or respiratory fail-ure. If you anticipate a difficult intubation due to anatomic changes, prepare two or three different sizes of ETTs. If the larynx is edematous, you may not successfully pass a

tube normally appropriate for the stature of your patient. If you can visualize the glottic opening but are unsuccessful with direct laryngoscopy, consider using fiber-optic intubation if available.

In extreme cases, a cricothyroidotomy may be required when all other attempts have failed. According to physicians Jose Yataco and Atul Mehta (2008), orotracheal intubation is successful in 97% of airway management cases, leaving only 3% of patients requiring immediate cricothyroid-otomy.7 But don’t let these numbers lure you into thinking I will never get that patient. You may get “that” patient and should always be prepared to perform this proce-dure if the worst-case scenario falls in your lap. Practice surgical airways frequently.

Once you have determined, through rul-ing out various differentials, that ACEI-RA is the probable etiology for your patient’s angioedema, examine the airway and act accordingly based on the patient’s presenta-tion. Your ultimate treatment goal is more than managing the airway through basic or

advanced devices; attempts to abate airway swelling through pharmacological agents are also vital.

Case studies show great promise in treat-ing ACEI patients with fresh frozen plasma (Class II) or bradykinin blockers (e.g., icati-bant, Class II). However, neither is carried in ambulances. Nor is there a precise antidote to treat ACEI-RA.6 Based on that harsh real-ity, paramedics are forced to rely on conven-tional therapies including epinephrine, cor-ticosteroids and antihistamines. According to some clinicians, evidence-based treatment recommendations for ACEI-RA are:

• Supplemental oxygen;• Securing the airway and assisting ven-

tilations if needed;• Pharmacologically assisted intubation

(RSI);• Nasotracheal intubation if orotracheal

intubation impossible;• Capnography, pulse oximetry;• IV and fluids, if necessary;• Although controversial, treatment

still involves consideration of H1 and H2

RA, this fundamental training may very well be the most important intervention we can make—after all, it always comes down to your ABCs.

RE FE RE N CE S

1. Flattery MP. When ACE inhibitors cause angioedema. American Nurse Today, http://www.americannursetoday.com/when-ace-inhibitors-cause-angioedema/.2. Winters M. Clinical Practice Guideline: Initial Evaluation and Management of Patients Presenting with Acute Urticaria or Angioedema. American Academy of Emergency Medicine, http://www.aaem.org/em-resources/position-statements/2006/clinical-practice-guidelines.3. Bas M, Greve J, Stelter K, et al. A randomized trial of icatibant in ACE-inhibitor-induced angioedema. N Engl J Med, 2015; 372: 418–25.4. Wilkerson RG. Angioedema in the Emergency Department: An Evidence-Based Review. Emerg Med Practice, https://umem.org/files/intl/Angioedema%20-%20Final%20copy.pdf.5. Busse PJ, Buckland MS. Non-histaminergic angioedema: focus on bradykinin-mediated angioedema. Clin Exp Allergy, 2013 Apr; 43(4): 385–94.6. Winters ME, et al. Emergency department management of patients with ACE-inhibitor angioedema. J Emerg Med, 2013 Nov; 45(5): 775–80.7. Yataco J, Mehta A. Upper Airway Obstruction, https://store.acponline.org/ebizatpro/images/ProductImages/books/sample%20chapters/CCM37.pdf.

AB O U T THE AU TH O R Kristin Spencer, MS, NRP, is program director for EMS education at Crowder College in Neosho, MO.



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Case #2You are dispatched to a call to your local nursing home for a 64-year-old patient with altered mental status. Upon arrival you find the patient lying supine in bed with a nasal cannula placed in her nares, set at a flow rate of 2 lpm. The patient is responsive to painful stimu-lus, and her skin is pale and hot to the touch.

The staff informs you she has had a recent diagnosis of pneumonia and has become increasingly altered since this morning. They report her temperature is 102.3ºF and that she is normally alert and oriented to person, place and time. You quickly obtain a set of vital signs, which reveals the patient is tachycardic at a rate of 108 and tachypneic at a rate of 30. Her oxygen saturation is 82% on 2 lpm of oxygen, and her blood pressure reads 82/56. You place a nonrebreather on the patient at 15 lpm and obtain IV access as well as a 12-lead ECG. The 12-lead shows a sinus tachycardia, and the oxygen saturation does not improve at all. You remember read-ing somewhere about using a high-flow nasal cannula to improve oxygenation, so you turn up the patient’s cannula to 15 lpm, along with the nonrebreather. This only improves the saturation to 84%, so along with the patient’s mental status, you decide to intubate.

Your equipment is prepped and ready, and IV access has been obtained. You instruct your partner to bag-mask ventilate the patient to improve the saturation as you administer your induction agent followed quickly by your paralytic. The patient’s oxygen saturation begins to fall rapidly as you attempt intubation, but you secure the airway with the help of a gum elastic bougie. Intubation is confirmed via waveform capnography and bilateral breath sounds. Soon after intubation the patient goes into a bradyasystolic arrest and cannot be revived. What happened? How could this have been prevented?

Oxygenation and VentilationProper airway management is a fundamental skill in which every emergency care practitioner must be proficient.

The two cases illustrated above, while different, occur in both hospital and prehospital arenas every day. Whether you are a paramedic, EMT, nurse or physician, it is imperative to have a firm understanding of both basic and advanced airway management.

Concepts such as delayed sequence intubation (DSI), apneic oxygenation and the use of supraglottic airways have broadened our medical armamentarium and helped improve patient outcomes. It is important to understand that not every airway case is the same, and there is no one treatment modality that works for every clinical situation.

If we are to truly “do no harm” for our patients, we have to understand the pathophysiology of those treat-ments as well as the end goal of oxygenation and ventila-

tion. Before exploring these common pitfalls sometimes associated with our interventions, we must first discuss the principles behind oxygenation and ventilation.

Oxygen is transported in the body in two ways. Approximately 97% of it is bound to hemoglobin, while the remaining 3% is dissolved in the blood plasma.

Ventilation is the process by which we move oxygen from the environment into the body and the process of exhaling the byproducts of cellular respiration, mainly carbon dioxide.

In the prehospital environment we can measure oxy-genation status via pulse oximetry. An acceptable range on the patient breathing room air is 95% or greater. Keep in mind that pulse oximetry only measures the amount of oxygen bound to the hemoglobin molecule and not the actual percentage of hemoglobin in the body. Anemic patients can show an oxygen saturation well above 95% and yet still be clinically hypoxemic due to the lack of hemoglobin that can carry oxygen molecules.

Increasing our FiO2 (fraction of inspired oxygen) typically is the fastest way to correct hypoxia. During procedures such as RSI, we preoxygenate our patient with 100% oxygen, ideally for three minutes, to increase the amount of oxygen in the lungs, thus building a reservoir. By filling every available functional alveoli in the lung with oxygen, we extend the time it takes before our patient becomes hypoxic.

As oxygen diffuses across the alveolar capillary mem-brane, it is bound to deoxygenated blood returning from the right side of the heart. This oxygen-rich blood can now be pumped out by the left side of the heart into the systemic circulation to diffuse into tissue cells and complete the process of cellular respiration.

One of the byproducts of cellular respiration is the production of carbon dioxide. Once again, blood returning to the right side of the heart is rich in car-bon dioxide. This CO2 now diffuses across the alveolar capillary membrane into the lungs, where it is exhaled to the external environment. Many factors, such as cardiac output, percentage of hemoglobin, and certain disease processes such as pneumonia and acute respi-ratory distress syndrome (ARDS), can influence this process of oxygenation and ventilation. It is beyond the scope of this article to discuss every possible factor that influences cellular respiration, but this simplified explanation given above lays a foundation as we further explore three pitfalls that providers sometimes make in regard to positive-pressure ventilation and how to correct them.

Three PitfallsOverzealous bag-mask ventilationBag-mask ventilation is a cornerstone of basic life sup-port. It is often one of the first airway skills we learn as

Case #1You are dispatched to a call for a 16-year-old female patient with a chief complaint of possible anaphylaxis. Upon arrival you find the patient lying supine in the front yard with a crowd of bystanders huddled around. The patient is not alert to even painful stimulus, and her breathing is shallow and labored at a rate of 34 a minute. Her skin is pale, and her lips appear cyanotic. Her initial oxygen saturation reads 75%.

You instruct your partner to bag-mask ventilate the patient as you quickly move her to the ambu-lance. As the engine crew obtains IV access and

places the ECG electrodes, you attempt to obtain a history from bystanders, but it is sketchy at best. All they can tell you is they think the patient is allergic to pistachios and they were in her meal at dinner.

Her initial oxygen saturation only increases to 80%, and administration of IM epinephrine does little to improve things. The patient’s respirations are now becoming shallow and agonal, and her oxy-gen saturation continues to decrease. Your partner increases ventilations in an attempt to improve the oxygen saturation. You attempt to intubate, but just as you are about to place the endotracheal tube, the patient vomits and aspirates. What now?

By Russ Brown, NREMT-P

Oxygenate and Resuscitate Before You IntubateCommon pitfalls to avoid when managing the crashing airway


Ensure adequate oxygenation and ventilation before any intubation by maximizing oxygen delivery with the use of a BVM with attached PEEP valve and 2-provider mask-ventilations.Courtesy of NHRMC AirLink/VitaLink Critical Care Transport

new EMTs. Proper mastery of this skill, as well as a thorough understanding of possible adverse events, can greatly influence the care we provide. Conversely, a lack of fundamentals in the skill’s proper use and lack of respect for the dangers imposed by it can have disas-trous consequences, as evidenced in the cases above.

Often we lose sight of how fast we are ventilating our patients due to the high-stress environment of a resuscitation. As a result, the patient can inadver-tently become hyperventilated.1

One study published in the Journal of Critical Care Medicine showed that with increased ventila-tions, survival rates decreased.2 The study design was a prospective clinical trial in adults intubated for out-of-hospital cardiac arrest, as well as a study using three groups of seven pigs with induced cardiac arrest. In the group of cardiac arrest patients being ventilated, the average ventilation rate was around 30 breaths a minute, with a range of 15 to 49! For the pig study group, ventilation rates were set at 12, 20 and 30 breaths/minute, and physiological parameters

were then assessed. In the group of pigs ventilated with the 12 bpm, 6 of 7 sur-vived. In the group of pigs that received 30 bpm, none sur-vived.3

Another study, although small, demonstrated that even in emergency department envi-ronments, nurses and doctors were ventilating at rates of up to 41 times per minute!4

Hy per vent i la-tion is known to

increase intrathoracic pressures, thus decreasing venous return and left ventricular filling pressures. This drop in preload and coronary filling pressures will also cause a resultant drop in cerebral perfusion pressures.5 This is exactly the opposite of what we want to do in a resuscitation!

As illustrated in Case #2 above, the patient was hypotensive to begin with. Any further drop in pre-load can cause a precipitous drop in blood pressure, resulting in an undesirable outcome.

Studies show that elderly patients are at an increased risk for adverse hypotensive events and cardiac arrest shortly after intubation and positive-pressure ventilation.6 The elderly are also on medica-

tions that can change their physiology and decrease preload. It is important to take this into consideration when attempting to intubate the hypotensive patient or the geriatric patient in general.

Another complication of overzealous bag-mask ventilation and positive-pressure ventilation is vomit-ing and aspiration.

When a patient is hyperventilated prior to intuba-tion, much of this ventilation is put into the stomach.7 This rapid insufflation of air distends the abdomen and pushes against the esophageal sphincter until the contents of the stomach are expelled upward. This is the exact place you did not want them to be!

One reason we perform rapid sequence intubation in the field is to decrease the risk of vomiting in the patient who is not NPO. Paralytics will paralyze all the muscles of the body, including the lower esopha-geal sphincter, thus mitigating this risk.

Prior to administration of our paralytic, though, we must be cognizant of our ventilation rate and tidal vol-ume. Pulmonary physiology studies have shown that on room air, it takes very few breaths to adequately ventilate our lungs.8 Adequate ventilation is defined as a PaO2 (partial pressure of oxygen in the alveoli) around 100, taking into account any dead space. This is the amount of oxygen that is in the alveoli of the lungs and can be used to diffuse across the capillary membrane and dissolved into deoxygenated blood coming in from the right side of the heart.

At room air, which is 21% oxygen, it only takes around 3 lpm to reach a PaO2 of 100. Assuming you are ventilating with a tidal volume of 500 ml, that would be around six breaths. If you were ventilating at a tidal volume of 700 ml, this would be around 4–5 breaths. At increased FiO2 (fraction of inspired oxygen), the number of breaths needed to maintain an acceptable PaO2 is decreased further (see Figure 1). While many other factors can influence oxygenation and cellular respiration, such as acid-base balance, physiological and anatomical shunts, and cardiac out-put, the take-home point is that faster ventilations are not necessarily better. In the next few paragraphs, we will explore simple maneuvers, such as proper mask seal in conjunction with an adequate rate and tidal volume, that can improve the oxygenation status of our patients before intubation and help to prevent adverse events.

Improper mask sealThe inability to obtain a proper mask seal can be the difference between oxygenating your patient or not.

Prehospital and emergency care providers are typically taught a variety of methods for obtaining a mask seal, including the E-C technique. Much of what we learn in terms of airway management comes

Alveolar ventilation (liters/min)0 2 4 6 8 10

21%

30%

25%

40%

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FIGURE 1


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from techniques used in the operating room. The difference between us and providers in the OR is that they perform this procedure many times daily over many years and develop mastery of it. We may go many shifts before we are called upon to mask-ventilate some-one, causing skill reten-tion to erode.

For the typical street paramedic or nurse in the ED, any break in the mask seal will negate any ben-efits to oxygenation due to entrainment of room air and a loss of high-flow oxygen. The addition of a high-flow nasal cannula under the mask can pro-vide a continuous source

of oxygen, even when the bag is not being squeezed.9

While there are many factors that can influence the oxygenation of your patient, collapsed and inefficient alveoli are one culprit when the administration of high-flow oxygen does not work. Positive-pressure ventilation can help achieve this, but only with a good mask seal.

An alternative way for obtaining a proper mask seal is called the thenar eminence technique or, more simply, the “two thumbs down” technique.10 This is done by placing your two thumbs down against the edge of the mask and performing a jaw thrust to lift the face into the mask (see Figure 2). A first provider

is designated to squeeze the mask, while the second holds the seal. This works well because it incorpo-rates the strongest parts of your hands to hold the seal while allowing you to detect the slightest mask leak and adjust accordingly.

Focus on intubation before resuscitationAnother possible pitfall that emergency providers can make is becoming fixated on securing an airway as fast as possible, while ignoring the physiological derangements the patient is showing.11

We should always take a step back and view the patient’s entire clinical picture before rushing in to place an endotracheal tube. The acutely decompen-sating patient with shock, whether from a hemor-rhagic or cardiac etiology, may need to be stabilized first. Hypotension due to volume depletion or a fail-ing pump only increases our possible adverse events from intubation.

As discussed before, intubation and positive-pressure ventilation increase intrathoracic pressures and will decrease preload. With decreased preload comes decreased left ventricular filling pressures. All of this sets the patient up for hypotension and possible cardiac arrest.

Many medications used in the practice of RSI can also decrease preload and cause respiratory depres-sion, further increasing our risk of an untoward event. BLS maneuvers such as the administration of high-flow oxygen and proper bag-mask ventilation should always be performed prior to intubation. Use slow, easy breaths, as discussed above, and administer a fluid bolus to increase volume status and stave off intubation-related hypotension. The administration of fluids will increase intravascular volume, thus increasing right ventricular preload to the heart. If the patient is in cardiogenic shock, vasopressors such


FIGURE 2

An alternative way for obtaining a proper mask seal is called the thenar eminence technique.

FIGURE 3

Expel 1ml of saline and then draw up 1ml of EPI 1:10’000


as norepinephrine or dobutamine can be started and the patient further stabilized before proceeding with your RSI.

If it is imperative to intubate immediately and if your medical direction allows it, push-dose pressors may be an option.12 Push-dose pressors are a relatively new treatment modality in the prehospital realm but have been used in the operating room for years. Their

use consists of drawing up a small dose of a vasopressor such as epinephrine and administering small aliquots to increase blood pressure. One advantage of push-dose pressors is that they can be faster to administer then a drip, especially in time-sensitive settings such as with a hypotensive patient who is about to arrest.

For example, one popular option is to take a 10-ml saline syringe and expel 1 ml out. Then draw up 1 ml of cardiac-dose epi and mix by shaking (see Figure 3). This will give you a concentration of 100 mcg of epi in 10 ml of saline. You can now administer 5–10 mcg every 2–5 minutes as needed to increase blood pressure before or after intubation. Always make sure to follow your local protocols and discuss these treatment options with your medical director.

ConclusionNow we can apply what we’ve learned to the cases above. In Case #1 you recognize that your partner is ventilating too fast. You instruct him to slow down and squeeze the bag with slow, easy breaths. You also have an engine crew member assist your partner using a two-person BVM technique. The addition of a high-flow nasal cannula under the mask helps to improve oxygenation as well.

With the patient’s oxygenation status corrected, you can now proceed safely with intubation. As you intubate, you notice sub-stantial swelling of the oropharynx, but intubation is successful with the aid of a bougie. En route, you continue to monitor the airway and start the patient on an epinephrine drip. Upon arrival

at the hospital, it is determined the patient had a life-threatening anaphylactic reaction, and she is further stabilized.

In Case #2 you realize the patient may be septic and her hypo-tension needs to be further stabilized before proceeding with intubation. You administer a 500-ml fluid bolus as you maxi-mally oxygenate the patient with high-flow nasal cannula and a nonrebreather. As a precaution you draw up a push-dose pressor of epi in cause the patient’s blood pressure does not respond to the saline bolus.

Her saturation does not respond to high-flow oxygen, so you decide to quickly move to assisted ventilations with a BVM and a two-person mask seal. A nasopharyngeal airway and jaw thrust is also added to maintain airway patency. The patient’s blood pres-sure improves after administration of the fluid bolus and with the oxygen saturation. With the patient’s hypotension and oxygen-ation status corrected, you can now safely intubate. Intubation is successful, and the patient is transported to the emergency department, where a diagnosis of bilateral pneumonia and sepsis is confirmed. The patient spends several days in the ICU and is eventually extubated and discharged.

In conclusion, it is important to understand our patients’ physi-ological state and how it relates to the procedures we perform. We must first realize that oxygenation and ventilation are our main goals, not necessarily placing an endotracheal tube. We should under-stand that basic airway maneuvers such as bag-mask ventilation can sometimes be just as dangerous as advanced airway maneuvers and have a methodical plan in place to deal with these situations.

So remember, the next time you are faced with an airway emer-gency, think resuscitate and oxygenate before you intubate!

RE FE RE N CE S

1. Aufderheide TP, Lurie KG. Death by hyperventilation: a common and life-threatening problem during cardiopulmonary resuscitation. Crit Care Med, 2004 Sep; 32(9 Suppl): S345–51.2. Ibid.3. Ibid.4. O’Neill JF, Deakin CD. Do we hyperventilate cardiac arrest patients? Resuscitation, 2007 Apr; 73(1): 82–5.5. Manthous CA. Avoiding circulatory complications during endotracheal intubation and initiation of positive pressure ventilation. J Emerg Med, 2010 Jun; 38(5): 622–31.6. Hasegawa K, Hagiwara Y, Imamura T, et al. Increased incidence of hypotension in elderly patients who underwent emergency airway management: an analysis of a multi-centre prospective observational study. Int J Emerg Med, 2013 Apr 24; 6: 12.7. Weiler N, Heinrichs W, Dick W. Assessment of pulmonary mechanics and gastric inflation pressure during mask ventilation. Prehosp Disaster Med, 1995 Apr–Jun; 10(2): 101–5.8. Calder I, Pearce A, eds. Core Topics in Airway Management. Cambridge University Press, 2005.9. Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med, 2012 Mar; 59(3): 165–75.10. Jin Y, Lee BN, Park JR, Kim YM. Comparison of two mask holding techniques for two person bag-valve-mask ventilation: A cross-over simulation study. Resuscitation, 2010 Dec; 81(2).11. Dunford JV, Davis DP, Ochs M, Doney M, Hoyt DB. Incidence of transient hypoxia and pulse rate reactivity during paramedic rapid sequence intubation. Ann Emerg Med, 2003 Dec; 42(6): 721–8.12. Weingart S. Push-dose pressors for immediate blood pressure control. Clin Exp Emerg Med, 2015; 2(2): 131–2.

AB O U T THE AU TH O R Russ Brown, NREMT-P, is a firefighter/paramedic and EMS field training officer for Southlake Fire Department in Southlake, TX. He has worked for a variety of services including fire, private and hospital-based EMS systems. He has a particular interest in airway management and cardiac resuscitation science. Contact him at [email protected].


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Editor’s note: In 2015 EMS World published a series looking at key aspects of establishing mobile integrated healthcare and community paramedic programs in EMS. This series continues in 2016 with coverage of clinical issues and profiles of systems that have moved beyond the early stages and contended successfully with more advanced issues. Magazine articles will be supplemented by additional content on EMSWorld.com. If your system has an MIH-CP program, let us know your experiences at [email protected].

Margaret was a 74-year-old woman who lived alone in an apartment in a low-income senior high-rise. What little “help” she received was from a daughter who lived nearby but whom Margaret suspected of

stealing her medications and money. As with many of our patients, Margaret had been dealing with a his-tory of serious medical issues—high blood pressure, a dysfunctional thyroid and a heart bypass. She was simultaneously battling anxiety and depression that had been untreated for years. But it was the relentless

and excruciating back pain that began after a back surgery 10 years ago that kept bringing her back to the emergency department.

The only thing that killed the pain was opioids. Most days Margaret would lie in bed all day, only getting up to take another pain pill. When the pain wasn’t being anaesthetized by the pills (or if she ran out), she would head back into the emergency depart-ment to find comfort. At first we assumed she used the medications to control her back pain. However, the longer we worked with her, the more evident it became that the pain pills were also her only way of coping with her emotional pain.

Margaret told the community paramedics that she may have gone to the hospital two, maybe three times a month to seek relief for her pain. Different sources confirmed she was actually going to various local hospitals 2–3 times a week. Some days Margaret would be discharged home from one hospital in the morning, only to end up at a different hospital later in the day. Many of those same sources told us she had been labeled as a classic “drug-seeker.”

Opioid DependencyThe Substance Abuse and Mental Health Services Administration estimates that approximately 6.9 mil-lion people in the U.S. are dependent on or abusing prescription drugs.1 Community paramedics (CPs) working in programs designed to reduce 9-1-1 utiliza-tion or 30-day readmissions are likely to encounter this population of patients regularly, yet very little for-mal education is available to help CPs understand the nature of prescription drug dependency. This article will introduce the types of drug dependencies and the resources most likely to help patients suffering with addiction.

Common prescription opioids include hydrocodo-ne (Vicodin), oxycodone (OxyContin, Percocet), mor-phine (Kadian, Avinza), codeine and similar drugs. These drugs work in part by blocking certain pain receptors, activating the mesolimbic (reward) system of the brain and creating a sense of euphoria. Opioids not only control the physical pain associated with an injury, but also alleviate the mental stress that both acute and chronic pain can produce. Unfortunately the body soon develops a tolerance to opioids that requires the patient to take higher doses of the drug to achieve the same effect.2

Compounding the issue is the paradoxical effect opioids have on the perception of pain. Patients undergoing opioid therapy often suffer from opioid-induced hyperalgesia, which actually increases their sensitivity to pain.3 There are several theories about the molecular mechanisms involved, but the result is that the patient may require higher and more fre-quent doses of the opioid to achieve a pain-free state.

Escalating the dose of opioids to counter the patient’s increased tolerance or hyperalgesic state increases the risk the patient becomes physically dependent on the drugs to function. Opioid depen-dency occurs when the patient experiences symptoms of withdrawal when the opioid levels are reduced.4 However, having a high tolerance to the medication or being dependent on opioids does not necessar-ily mean a person is addicted to their prescriptions. According to a joint policy statement issued by the American Academy of Pain Medicine, American Pain Society and American Society of Addiction Medicine:

“Addiction is a primary, chronic, neurobiological disease, with genetic, psychosocial and environmental factors influencing its development and manifesta-tions. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.”4

The Diagnostic and Statistical Manual of Men-tal Disorders, fifth edition (DSM-5) characterizes a diagnosis of substance use disorder as a patient

who experiences two or more of the criteria listed in Table 1 within a 12-month period. The manual defines a continuum of substance use disorders as ranging from mild (patient demonstrates 2–3 criteria) to severe (6 or more).5

Compounding Margaret’s case was the potential that her chronic pain was being undertreated due to her recurrent use of the ED and lack of a primary

care physician. Physicians David Weissman and David Haddox coined the term pseudoaddiction to describe cases where the patient’s chronic pain is not adequately managed, the patient’s demand for opioids increases and there is growing mistrust between the patient and her healthcare providers.6 In those cases the patient may display signs of addiction, but their primary objective is pain relief, not the “high” of using the opioids. Once the pain is adequately controlled, the maladaptive behaviors disappear.

Plan of CareMargaret did not have a doctor whom she saw on a regular basis because the one who’d cared for her had died and she could not find another she liked. Furthermore, she hadn’t seen anybody for her depres-sion or anxiety for many years and lacked any type of

DSM-5 CRITERIA FOR SUBSTANCE USE DISORDER AND SEVERITY SCALE

1. Hazardous use;2. Social/interpersonal problems related to use;3. Neglected major roles to use;4. Withdrawal;5. Tolerance;6. Used larger amounts/longer;7. Repeated attempts to quit/control use;8. Much time spent using;9. Physical/psychological problems related

to use;10. Activities given up to use;11. Craving.

Substance use disorder severity:Mild: 2–3 criteriaModerate: 4–5 criteriaSevere: 6 or more criteria

Beyond pain, emotional and psychological needs can help drive pseudoaddictive behaviors

TABLE 1: By Jason R. Berman, EMT-P,

& Dan Swayze, DrPH, MBA,

MEMS


With a substance use disorder, patients will experience two or more of the criteria listed in Table 1 within a 12-month period.

CPs who work in programs to reduce 9-1-1 use or hospital readmissions may encounter patients who are dependent on, or even abuse, prescription drugs.

Center for Emergency Medicine of Western Pennsylvania

mental health support. The patient’s ultimate goal was to be completely pain free. Our objective was to have her utilize the healthcare system more effectively to achieve her goal. To develop our plan of care, we needed to build the medical and psychosocial support system

she lacked. After conducting our initial assessment of Margaret’s situation, we developed a plan of care with input from other community paramedic team members, our medical command physician and, most important, Margaret.

The first priority was mak-ing sure she was being seen by a primary care physician and a therapist for her anxiety and depression. We began by search-ing for local doctors using cri-teria Margaret provided, then ultimately helped her choose one she was comfortable seeing. Next we worked together to find a therapist to help her manage her anxiety and depression. Ulti-mately she reconnected with a psychiatrist who’d treated her in

the past. Fortunately the psychiatrist also specialized in geriatric mental health.

Rather than asking her therapist to address her poten-tial substance use disorder, we worked with Margaret to enroll her in a pain clinic to better manage her pain. As is often the case, pain management at the local pain clinic was directed by a physician, but included both traditional and alternative medicine options to create an individualized treatment plan uniquely tailored for each patient. To increase the chances of success with this approach, we explained how pain clinics work, helped her enroll in a nearby clinic and provided encourage-ment to help Margaret adhere to the program while her therapy began.

To provide a more sustainable solution for her social support needs, we evaluated Margaret’s existing social network, which consisted of a small circle of friends who were neighbors in her apartment building. While they fulfilled some of her social needs, Margaret complained she still experienced times of loneliness. She reported that she would often sit alone in the lobby of her com-plex. We offered to connect her with local resources such as a nearby senior center, but she ultimately refused help accessing those programs.

ResultsLacking an alternative social support system, Margaret relied heavily on the community paramedic program

for her emotional support. Telephonic and in-person follow-up conversations included conducting medica-tion reconciliation and education, helping her complete various paperwork and applications for her care teams, and providing positive encouragement and social sup-port.

As the patient began utilizing her new medical and mental health providers, her dependence on the ED for pain control decreased dramatically. Her utilization of the ED dropped from 15-25 times a month in the months before she was enrolled in our program to 2–3 visits in the 4–5 months after our intervention. She instead relied on the healthcare system we helped her build to continuously evaluate and manage her chronic back pain as well as her depression and anxiety.

ConclusionThis case illustrates a patient who was likely displaying pseudoaddictive behaviors rather than having a more severe substance abuse disorder. Had the patient refused care from the pain clinic, displayed more symptoms of substance abuse disorder or been “fired” from the pain clinic for a breach of contract, substance abuse counseling would have been a more appropriate rec-ommendation. Chronic pain patients are particularly vulnerable to undertreatment for their pain, as care-givers fear making the patient addicted to pain control medication. Lacking relief from other venues, those patients frequently turn to the ED for pain control. Rather than just dismissing them as “drug-seekers,” community paramedics can play a vital role in helping these patients find more appropriate sources of care for their physical and psychological needs.

RE FE RE N CE S

1. Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, www.samhsa.gov/data/sites/default/files/NSDUHresults2012/NSDUHresults2012.pdf.2. Dumas EO, Pollack GM. Opioid Tolerance Development: A Pharmacokinetic/Pharmacodynamic Perspective. AAPS J, 2008 Dec; 10(4): 537–51.3. Lee M, et al. A comprehensive review of opioid-induced hyperalgesia. Pain Physician, 2011; 14(2): 145–61.4. American Academy of Pain Medicine, the American Pain Society and the American Society of Addiction Medicine. Definitions related to the use of opioids for the treatment of pain. WMJ, 2001; 100(5): 28–9.5. Hasin DS, et al. DSM-5 Criteria for Substance Use Disorders: Recommendations and Rationale. Am J Psychiatry, 2013; 170(8): 834–51.6. Weissman DE, Haddox JD. Opioid pseudoaddiction—an iatrogenic syndrome. Pain, 1989; 36(3): 363–6.

AB O U T THE AU TH O RS Jason R. Berman, EMT-P, is a community paramedic with the CONNECT Community Paramedic Program at the Center for Emergency Medicine of Western Pennsylvania.

Dan Swayze, DrPH, MBA, MEMS, is the vice president and COO of the Center for Emergency Medicine of Western Pennsylvania and is widely considered one of the pioneers of the field of community paramedicine.


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Patients with chronic pain are vulnerable to undertreatment, as providers fear promoting an addiction.Center for Emergency Medicine of Western Pennsylvania

Providing medical and rescue services to the

offshore oil industry is a massive mission

It is licensed in the state of Louisiana as an air ambulance, but this is not your typical air ambu-lance—not in its size or the scope of its mission. Its fuselage is 56 feet long with a rotor diameter of 56 feet. Its maximum weight is 26,000 lbs. The

cabin is 20 feet long, six feet wide and six feet high. It has a maximum speed of 190 mph. Its mission is to provide medical and rescue services to the offshore oil industry in the Gulf of Mexico.

Vital StatisticsThe helicopter is a Sikorsky S-92, and it’s crewed by five people: a pilot, copilot, flight medic and two

rescue specialists. It is based in Galliano, LA, and operated by CHI Aviation. The operation is run on a subscription basis for oil companies with platforms in the Gulf of Mexico. CHI also has an AgustaWestland AW139 helicopter it uses for the same mission on an ad hoc basis for customers without subscription contracts for the S-92. They also get rescue assign-ments from the U.S. Coast Guard. Both ships are crewed 24/7.

Cover Report by Barry D. Smith

Photos by Barry Smith


CHI SAR crews train to hoist from land, open water and ships.

The contract covers personnel on oil platforms, the ships that supply the platforms and the helicopters that transport the workers to and from the platforms. Containing one of the world’s largest oil fields, the Gulf of Mexico has about 5,000 oil-related structures, supported by dozens of supply ships and a fleet of over 400 helicopters. In 2014 these helicopters made 740,000 flights over the gulf and transported two million passengers.

“We use the S-92 because of its range, speed and payload capabilities,” explains David Jacob, CHI’s director of offshore operations and a longtime para-medic. “Some of the platforms are 200 miles or more offshore. We can carry a huge amount of rescue gear. Our rescue specialists are certified in vertical rope, confined-space and hazardous-atmosphere rescue. We can also rescue all of the passengers of the largest helicopters used for offshore transport if one ditches in the gulf.”

The S-92 is one of the newest helicopter designs. It has an all-glass electronic display instrument panel that incorporates the latest flight control, navigation, communication and engine systems. The helicopter can perform rescue missions day or night and in bad weather. It has a color weather radar that can also detect the oil platforms. It has dual GPS systems for navigation.

It also has forward-looking infrared (FLIR) and low-light television cameras in a gyrostabilized tur-ret under the nose. The helicopter can be used as an airborne command post for an incident on an oil platform. Its crew can record and transmit imagery, and an oil company representative can be on board and talk with his personnel via the satellite phone in the cabin. They can also use it to see hot spots on an oil platform in case of a fire.

Another feature is a sophisticated autopilot system customized for search and rescue missions. It can automatically come to a 50-foot hover at any loca-tion specified by the pilot. Search patterns can be programmed and flown by the autopilot coupled to the GPS system to maximize search coverage. It is also equipped with dual rescue hoists in case one fails.

The facilities at Galliano are high-tech. The hangar is climate-controlled, which is especially important in the summer, with its high temperatures and humidity. The base has its own power supply, and the hangar is rated for a Category 3 hurricane.

Staffing and Training“Acadian Ambulance provides the paramedics for our operation,” Jacob says. “They also provide all the medical equipment, protocols, 24-hour online medical control, and dispatching and flight-follow-ing services. We can use Acadian’s aircraft to back

us up, and we may handle a local call for them with our AW139. Acadian ground operations span from Missis-sippi to Texas, so if we need additional equipment or personnel for an MCI, we can get them from Acadian ground ambulances.”

“The flight medics do not go through the rope and confined-space res-cue training,” says flight paramedic Anthony Cramer, Jr., who is also an RN. “We do go through hoist training. In water rescues, the rescue swimmer would deploy and bring the patient into the helicopter, where the flight medic would then begin treatment. If the patient is on land, a vessel or an oil platform, the flight medic would be hoisted down to the victim, as well as a rescue specialist. There are always two people going down to the patient.

“The flight medics have a good working relationship with the res-cue specialists. We pretty much live together when we’re on duty. The res-cue specialists have a varied amount of medical training. The minimum is EMR, but many are EMTs and para-medics. They can work on the patient under the direction of the flight medic. Since we work so much together, they can anticipate the flight medics’ needs. It is just like a crew in the back of an ambulance.

“The flight medics work under the same protocols as the Acadian Air Med flight crews, which are pretty exten-sive. We can do RSI, CPAP and 12-lead ECG, and we carry a ventilator. We can initiate a lot of treatment before arriv-al at the hospital because of our long transport times. They have a protocol for what they call chemical extrication. They use it in case they have a patient who is trapped by machinery or has a difficult extrication from where they fell. They use etomidate as a hypnotic sedative. The patient isn’t aware and has no memory of the event afterward.

“Our calls run the gamut from trauma to medical,” explains Cramer. “There is a lot of heavy machinery and moving heavy equipment on oil plat-forms. We have all the medical-type calls found in any community. One of

our biggest complaints is chest pain. We do 12-leads and can send them to the hospital while we’re en route. We also carry beta blockers and IV nitrates for STEMI patients. Once the hospi-tal has the 12-lead, the ED doctor and cardiologist decide whether to bypass the ER and send the patient directly to the cath lab when we land. We have done that several times with very good results. If we need to talk with medi-cal control for orders or to contact the receiving facility, we have a satellite phone as part of the communications suite on the helicopter.

“Acadian Air Med has a QA/QI pro-cess, and we are part of that as well. Our charts get reviewed like any other Air Med chart. We can also use the Air Med quality improvement coordina-tor for advice and opinions on patient care issues that occur. Our flight med-ics are all very experienced, and most have come from the Air Med side of Acadian. We work seven-on, seven-off, and many work shifts for Air Med to keep their skills fresh.

“An MCI is a real possibility on oil platforms. Do people just need to be moved off a platform because it is on fire or in danger of sinking? Or was there an event that created a large num-ber of casualties? If there is a medic stationed on the platform, he or she will have done the initial triage by the time the helicopter arrives. If not, we can begin to do the triage and packaging for transport. We might move victims to another close platform with medics


C

A. The hoist operator at the FLIR station on the S-92.

B. Hoisting from vessels underway and adrift must be accomplished on a regular basis to maintain proficiency.

C. The S-92 uses an electronic LCD instrument panel system to integrate sensors, communications and navigation.

D. CHI employs former U.S. Navy and U.S. Coast Guard rescue swimmers and U.S. Air Force pararescuemen as rescue specialists.

E. Overland SAR is practiced in case a transport helicopter crashes in a bayou.

D

E

A

B

on it and transport the more serious patients to shore. We can also use our AW139, and Air Med might be able to send some of their helicopters offshore to platforms. We can also pick up some Acadian Air Med crews and their gear on the way out to a known MCI.”

Due to the size and weight of the S-92, the crew may have to land at an airport near the hospital and have a ground ambulance transport the patient and flight medic from there. They’ll go to the most appropriate facility for the patient’s condition—STEMI center, stroke center, trauma center, burn center, etc. The dispatch center, which is Acadian’s, finds the closest, most appropri-

ate destination so the crew doesn’t have to “shop” for a receiving facility.

“Almost 100% of our pilots and rescue specialists have military search and rescue experience,” says Jacob. “We have U.S. Air Force pararescuemen and rescue pilots, U.S. Coast Guard rescue swimmers and pilots, and U.S. Navy pilots and rescue swimmers. There is a large amount of trust among the crews because of that. We know we will revert to our military training when things get challenging. The crews rely on their crew resource management training, which they all had in the military. We all know how to communicate effectively in stressful situations.”

ConclusionCHI’s S-92 helicopter is a combination rescue truck and critical care transport ambulance. It can handle rescue and med-ical incidents on ships, oil platforms and in the bayous and open water of the Gulf of Mexico. All of the people interviewed by EMS World said there is no better air ambulance and rescue helicopter anywhere in the world.

AB O U T THE AU TH O R Barry D. Smith is an instructor in the Education Department at the Regional Emergency Medical Services Authority (REMSA) in Reno, NV. E-mail bsmith@ remsa-cf.com.

A Ha zardous EnvironmentOIL PLATFORMS ARE BUILT LIKE ships, with compartments, verti-cal ladders and complex machinery. Dangerous chemicals and gases like methane and hydrogen sulfide are common, so the rescue specialists can extricate people from hazardous atmospheres with low oxygen using air tanks. They can also do vertical rope rescue for victims of falls or oth-ers who cannot use the ladders inside the platforms.

Hoist missions in the water and bayous have their own set of unique hazards. “In addition to looking for the normal hazards for a helicopter hoist operation, we are also looking for natural hazards such as sharks and alligators,” says Mike Fout, a rescue specialist instructor and former U.S. Navy rescue swimmer. “We also look for debris or con-taminants in the water. In addition, we have to think about the sea state and water temperature. For contaminants, we will minimize our time in the water and use a direct-deployment rescue method where we’re never unhooked from the hoist cable. We also have dry suits we put on to minimize skin exposure.”

Many of the rescue specialists had this training in the military, but all of them are current with the necessary civilian certifications for these skills. They have to recer-tify every two years on all of them. They also adhere to international standardized training and hold internation-ally recognized certifications for their rescue skills. All the paramedics are nationally registered and certified by the states of Louisiana and Texas.

“When we’re first hired, we get qualified in one position on the team, and then we get dual-qualified with time as both hoist operators and rescue swimmers,” Fout says. “The goal is to have all rescue specialists dual-qualified.

“In addition to main-taining currency with the different helicopter deployment methods, day and night, we also have confined-space and verti-cal rope rescue training to stay current with. We do a lot of training. We try not to be idle. We will pull out our confined-space and rope rescue gear a couple times a week and train. Our hangar is about three stories high inside, and we can practice vertical rope rescue techniques in there.

“A new person gets qualified on the aircraft first and then is sent to different rescue schools. We work with Roco Rescue, which specializes in industrial rescue train-ing, for high-angle rope and confined-space rescue train-ing. Medical training is done by Acadian Ambulance.”

There is an instructor cadre that includes hoist opera-tors and rescue swimmers who meet regularly to discuss new gear and new procedures they might want to adopt. If a new piece of equipment looks promising, they will get it and test it both in a static environment in the hangar and then with the aircraft.

The instructor cadre also meets to decide on future training needs, updates that might be needed in the pro-cess, and any improvements to the operation they might be able to make. They also look at how other civilian and military rescue units do things to see if they might want to add to or adjust their program.

“We are fortunate enough to have a large cross-section of military rescue experience,” says Fout. “Each brings their own experiences we can look at to see if something would be a good fit here.”


The CHI SAR S-92 is equipped with an autohover

feature that can bring the helicopter to a 50-foot hover.

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


Today the world of EMS is more than

taking the patient to

the hospital.

EMS1601B


Find Your “Next”What would you do if you could no longer work in the field?

If you woke up tomorrow and found your job was no

longer there, or that you could not do the work, what

would you do?

I cannot remember the last time I considered a

role outside of EMS, or even different from what I have

been doing. All my marketable skills tie back to EMS and

the work I’ve done there. My options are limited. I have

no “next.” The reality is that my strongest days may be

behind me and one can only climb in and out of ambu-

lances for so long.

As young providers we are resilient, enthusiastic and,

with that patch on, we come dangerously close to believ-

ing ourselves invincible. Time and circumstance teach us

otherwise on all counts. If you are careful and fortunate

enough to escape injury, age remains the great equal-

izer. At some point double shifts are no longer a minor

thing and a night of posting in an ambulance has you

reaching for the Advil.

Adventures for the midlife medic come with recovery

time and the realization that this is not a job that you

can do forever.

Today the world of EMS is more than taking the patient

to the hospital. Taking care of the sick and injured

remains at its core, but as this still-young career field

evolves there are new paths and opportunities that play

an integral role in the effective delivery of care on a much

broader scope.

What are you going to do when you cannot lift that

stretcher anymore? Are you prepared to work outside of

an operational role? Do you have a secondary skill set or

an interest in areas outside of patient care?

Many of us began and remain in the field because we

love the work. We should think ahead and understand

our importance to the new providers that will come after.

There is an absolute need for mentorship in this field

that revolves around the human experience, things

that have nothing to do with algorithms or dosages.

Yet we lose priceless providers every year to injury or

age, because there was either no mechanism in place

for them to change their role or they were unwilling to

consider it because they felt it was boring or beneath

them—that it made them “less” than what they were.

Today’s EMS has avenues in leadership, emergency

management, education and communication. If you

have ever had an interest in any of those areas, did you

pursue it? Everything from awareness level classes to

certifications to college degrees are available in each of

these arenas. A few hours out of your week might pique

your interest and help you find an inroad into another

component of the work you already love. Do not assume

that because you are a good provider you are good at

anything else, it takes work.

Communication is both an art and a science. Just

because you can’t lift a stretcher does not mean you

can lift a mic. Dispatching requires training, patience and

the ability to multitask on a different level.

“Those who can’t do, teach.” There is some nonsense

right there, because the reality is that, “Most that can

do can’t teach very well.” Learning how to educate is as

important as the material you’re providing.

Emergency management in today’s world leads peo-

ple to experience disaster planning, grant writing and

public health. These are not small skills and can carry

you effectively through to a lifelong career in this field

that you love. Look at the clock, look in the mirror and

ask yourself what you have done to prepare for the next

phase of your life or career.

Me? I talked to my husband, reworked my budget,

quit my part-time job and enrolled in school to finish

my bachelor’s. I looked ahead, beyond the next class

or next shift, and realized that the only thing that could

change was me.

It is one year later, and I am four terms shy of my bach-

elor’s degree. I spent time on myself and looked outside

of my box and confronted unique midlife fears about

becoming obsolete and feeling past my value. Now I

am about to embark on the biggest adventure of my

life and career as I take my family and my experience

across the continent to try my hand at EMS in America’s

last great frontier, Alaska, working as a battalion chief for

Matanuska-Susitna (Mat-Su) Borough EMS in Wasilla.

I am far from where I started when I was 18 years old

and as invincible as my patch. However, I’ve also learned

that I am far from being done—there is an entire field out

there with room for growth and maturity.

What’s your “next”?

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, and a member of the EMS World editorial advisory board. Contact her at [email protected] or www.taloscar.com.

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