FEBRUARY 2013 | VOL. 42, NO. 2 $7.

00
Technology
Resource
Guide & Apps
Showcase p.40
September 812, 2013 | Las Vegas, NV
EMSWorldExpo.com
EMS RERUNS: SOCIAL SERVICES P. 18


|
DIFFICULT AIRWAY MANAGEMENT P. 27
VISIT US ONLINE AT EMSWORLD.COM AND ON THE IPAD
A CASE STUDIES APPROACH
Acute Altered
Mental Status
in Elderly
Patients p. 31
EMS 2020: How To
Manage Risk p. 21
When it comes to mechanical CPR,
make sure you do your homework.
AutoPulse

Lucas

2
4
2012 ZOLL Medical Corporation, Chelmsford, MA, USA. AutoPulse and ZOLL are trademarks or registered trademarks of ZOLL Medical Corporation
in the United States and/or other countries. All other trademarks are the property of their respective owners.
The above graphic illustrates relative volume of published comparative trials for the AutoPulse and Lucas 2 systems performed in humans.
It is not intended to portray any specic publications in which they appear.
*Select AutoPulse studies include:
Steinmetz J, et al. Acta Anaesthesiol Scand. 2008 Aug;52(7):90813.
Duchateau FX, et al. Intensive Care Med. 2010 Jul;36(7):125660.
Ong ME, et al. Crit Care. 2012 Aug 3;16(4):R144.
Timerman S, et al. Resuscitation. 2004;61(3):27380.
Casner M, et al. Prehosp Emerg Care. 2005;9(1):617.
Ong ME, et al. JAMA. 2006;295:22:262937.
The AutoPulse Non-invasive Cardiac Support Pump is
the only currently available mechanical CPR system that has shown
clinical benets in comparative human trials. Published in well-respected journals,
the results from these trials conrm how safe and effective the AutoPulse is for patients.*
Weve done the work for you. Get the facts.
TRUST
THE RESEARCH
To request an information kit, call 800-804-4356
or visit us at www.zoll.com/homework.
Enter to win a free AED by circling #10 on the Product Information Request Card,
or scan the QR code to the right. AED provided by EMS World.
Featured Products
Monitor for Web, iPhone

, iPad

,
Android, Blackberry

Mobile Data Terminal for Android

Chair Car for iPad

Visit www.eeteyes.com
Fleet management made simple
For More Information Circle 11 on Reader Service Card
Fleeteyes is an ambulance eet management solution
that offers a complete set of tools for fast, efcient vehicle
management. It seamlessly integrates with a variety of
CAD systems and devices, including Garmin

and AVL-
capable modems, to ensure real-time exchange of important
information between dispatch systems and vehicle crews.
The application provides rich visual data on vehicle location,
weather, and trafc, as well as turn-by-turn directions to any
incident location. Fleeteyes mobile applications give you
dispatch in your pocket capability by allowing access to your
eetanywhere, anytime.
Key Features:
y Google Maps Integration
y Loaded Mileage Calculation
y Compatibility with Garmin Devices
y Messages and Automatic Alerts
y Common Operating Picture
y CAD Integration
y Historical Data Reporting
y Geofencing and Speeding Alerts
y Secure Data Centers with 24/7 Access
For more information,
call 954-308-8700 or email
sales@eeteyes.com
For More Information Circle 32 on Reader Service Card
3tranded motorists depend on you. You depend on your truok. 1hat's why
the 2012 3uper Uuty

with the available 6.7L Power 3troke

1urbo Uiesel is
suoh a strong ohoioe. lt features the proven performanoe and dependability
of a lord-built engine. ou oan also depend on it being up to 20 peroent
more fuel-eftoient than the Ram 5500 Chassis Cab. Uon't get stuok with
a lesser truok. lind out more at ford.com/commercial-trucks.
*Based on Ford drive-cycle tests of comparably equipped 2011 models.
James J. Augustine, MD, FACEP
Medical Advisor, Washington Township
Fire Department, Dayton, OH; Clinical
Associate Professor, Department of
Emergency Medicine, Wright State
University, Dayton, OH; Director of
Clinical Operations, Emergency
Medicine Physicians, Canton, OH
Raphael M. Barishansky, MPH
Director, Office of Emergency Medical
Services, Connecticut Department of
Public Health
Bernard Beckerman, MD, FACEP
Associate Professor, School of Health
and Behavioral Sciences,York College
(CUNY), Jamaica, NY
Tom Bouthillet, NREMT-P
Lieutenant, Hilton Head Island (SC)
Fire & Rescue
Kenneth Bouvier, NREMT-P
D eputy Chief, New Orleans E.M.S.;
NAEMT President 20042006
Chris Cebollero, NREMT-P
Chief, EMS, Christian Hospital,
St Louis, MO
Will Chapleau, EMT-P, RN, TNS
Manager, ATLS Program, American
College of Surgeons
Kevin T. Collopy, BA, FP-C,
CCEMT-P, NREMT-P, WEMT
P erformance Improvement Coordinator,
Airlink/Vitalink, Wilmington, NC; Lead
Instructor, Wilderness Medical Associates
Alan R. Cowen, MA, EMT-P
Deputy Fire Chief (ret.), Los Angeles City
Fire Department, CA; Associate Professor
of Emergency Services, Los Angeles
Valley College
Michael W. Dailey, MD
Assistant Professor, Dept. of Emergency
Medicine, Albany Medical College, NY
Thom Dick
Quality Care Coordinator, Platte Valley
Ambulance Service, Brighton, CO
Greg Friese, MS, NREMT-P
Director of Education, CentreLearn
Solutions, LLC; Lead Instructor,
Wilderness Medical Associates
William E. Gandy, JD, LP
EMS Educator and Consultant,Tucson, AZ
Erik S. Gaull, NREMT-P, CEM, CPP
Director, Resiliency Operations, iJet
Intelligent Risk Systems, Inc.; Master
Firefighter/Paramedic, Cabin John Park
(MD) Volunteer Fire Department
Troy M. Hagen, MBA, NREMT-P
CEO, Care Ambulance, Orange,
CA; President Elect, National EMS
Management Association
Martin G. Hellman, MD, FAAP,
FACEP
Attending Physician, Emergency
Department, Childrens Hospital of
Pittsburgh, Pittsburgh, PA
Tim Hillier, Advanced Care
Paramedic
D irector 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-P
EMS Consultant
G. Christopher Kelly, JD
Attorney at Law, Atlanta, GA; Chief Legal
Officer, EMS Consultants, Ltd.
Skip Kirkwood, MS, JD,
EMT-P, EFO, CMO
Chief, Emergency Medical Services
Division, Wake County, NC
Sean M. Kivlehan, MD, MPH,
NREMT-P
E mergency Medicine Resident
University of California - San Francisco
William S. Krost, MBA, NREMT-P
A djunct Assistant Professor of Emergency
Medicine,The George Washington
University
Ken Lavelle, MD, FACEP, NREMT-P
Clinical Instructor and Attending
Physician, Department of Emergency
Medicine,Thomas Jefferson University
Hospital, Philadelphia, PA
Todd J. LeDuc, MS, CFO, CEM
Assistant Fire Chief, Broward Sheriff Fire
Rescue, Ft. Lauderdale, FL
Mark D. Levine, MD, FACEP
Assistant Professor, Dept. of Emergency
Medicine, Washington University School
of Medicine; Medical Director, St. Louis
(MO) Fire Dept.
Tracey Loscar, NREMT-P
Training Supervisor, UMDNJ - University
Hospital EMS, Newark, NJ
Paul M. Maniscalco, MPA, EMT-P
Senior Research Scientist & Principal
Investigator,The George Washington
University Office of Homeland Security
Grants and Training; Deputy Chief/
Paramedic (ret.), FDNY EMS; President,
International Association of EMS Chiefs
(IAEMSC)
Norman E. McSwain, Jr., MD
Department of Surgery,Tulane University
School of Medicine, New Orleans, LA
Richard W. Patrick, MS, CFO,
EMT-P, FF
D irector, Medical First Responder
Coordination, Office of Health
AffairsMedical Readiness,
U.S. DHS, Washington, DC
Tim Perkins, BS, EMT-P
E MS Systems Planner, Virginia Office
of EMS, Virginia DOH, Glen Allen, VA
Carl J. Post, PhD
EMS Consultant, Lawrenceville, NJ
Michael E. Poynter, EMT-P
Executive Director, Kentucky Board of
Emergency Medical Services
Mike Rubin, BS, NREMT-P
Paramedic, Gaylord Opryland,
Nashville,TN
Angelo Salvucci Jr., MD, FACEP
Medical Director, Santa Barbara County
& Ventura County EMS, CA
Mike Smith, BS, MICP
Director of Clinical Education,
Lead Instructor, Emergency Medical
& Health Services,Tacoma (WA)
Community College
Scott R. Snyder BS, NREMT-P
F aculty, Public Safety Training Center,
Emergency Care Program, Santa Rosa Jr.
College, CA
Matthew R. Streger, Esq.
Senior Associate, Law Offices Of David S.
Barmak, LLC, Princeton, NJ
Cindy Tait, MICP, RN, PHN, MPH
P resident, Center for Healthcare
Education, Inc., Riverside, CA
John Todaro, BA, REMT-P, RN, TNS,
NCEE
Executive Director, Lowcountry Regional
EMS Council, North Charleston, SC
William F. Toon, EdD, NREMT-P
Battalion Chief - Training, Johnson County
(KS) EMS: MED-ACT
David Wampler, PhD, LP
Assistant Professor, Emergency Health
Sciences, University of Texas Health
Science Center, San Antonio,TX
Paul A. Werfel, MS, NREMT-P
Director, 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, CIC
Infection-Control Consultant, Infection
Con trol/Emerging Concepts,
Manassas, VA
Gerald C. Wydro, MD, FAAEM
Chief, Division of EMS,Temple University
School of Medicine, Philadelphia, PA
Matt Zavadsky, MS-HSA, EMT
Director of Public Affairs, MedStar Mobile
Healthcare, Ft. Worth,TX
6 FEBRUARY 2013 | EMSWORLD.com
ADVISORY BOARD
Partners
STAFF
PUBLISHER
Scott Cravens, NREMT-B 800/547-7377 x1759
Scott.Cravens@emsworld.com
EDITORIAL DIRECTOR
Nancy Perry 800/547-7377 x1110
Nancy.Perry@emsworld.com
ASSOCIATE EDITORS
John Erich 800/547-7377 x1106
John.Erich@emsworld.com
Jason Busch 800/547-7377 x1397
Jason.Busch@emsworld.com
PRODUCTION SERVICES REPRESENTATIVE
LuAnn Hausz 800/547-7377 x1616
Luann.Hausz@emsworld.com
GRAPHIC DESIGNER
Carey Arneson 800/547-7377 x1585
Carey.Arneson@cygnus.com
AUDIENCE DEVELOPMENT MANAGER
Sharon Haberkorn 800/547-7377 x1648
Sharon.Haberkorn@cygnus.com
ACCOUNT MANAGER - WEST COAST
John Heter 503/889-8609 Fax 240/823-0243
john.heter@emsworld.com
ACCOUNT MANAGER - SOUTH EAST
Ann Romens 800/547-7377 x1366
Ann.Romens@emsworld.com
ACCOUNT MANAGER - NORTH CENTRAL
Deanna Morgan 901/759-1241
Deanna.Morgan@emsworld.com
ACCOUNT MANAGER - SOUTH CENTRAL
Jan Varnes 547-7377 x4423
Jan.Varnes@emsworld.com
ADMINISTRATIVE ASSISTANT
Michelle Endres 800/547-7377 x1612
Michelle.Endres@emsworld.com
CYGNUS REPRINT SERVICES
To purchase article reprints, please contact
Foster Printing Services at 800/875-3251,
or e-mail sales@fosterprinting.com
LIST RENTALS
Elizabeth Jackson 847/492-1350, x18
ejackson@meritdirect.com
EUROPEAN SALES REPRESENTATIVE, ITSL MEDIA
Julian Maddocks-Born, Sales Director
+44 (0)1442 230033 julian@itsluk.com
Benedict Hume, Sales Manager
+44 (0)1442 288287 benedict@itsluk.com
John French - CEO
Paul Bonaiuto - CFO
Ed Wood - VP, Human Resources
Julie Nachtigal - VP, Audience Development
Scott Bieda - EVP, Public Safety & Security
Ed Nichols - VP, Public Safety Events
Curt Pordes - VP, Production Operations
Mail: EMS World Magazine
1233 Janesville Ave., Ft. Atkinson, WI 53538
Phone: 800/547-7377 Fax: 818/360-0231
Website: EMSWorld.com
Facebook: Facebook.com/EMSWorldfans
Twitter: www.twitter.com/EMSWorldnews
HOW TO CONTACT US
Letters to the Editor: All
letters must include the
writers name, address and
daytime phone number,
and may be edited for
clarity or space. E-mail
editor@EMSWorld.com.
Submissions: Queries, manuscripts, story
suggestions, press releases and news items
are welcome. E-mail editor@EMSWorld.com.
Current or Back Issues: Select back issues
are available for $10.
Permissions: E-mail requests to editor@
EMSWorld.com.
Subscriptions/Address Changes:
Phone 877/382-9187 or 847/559-
7598, fax 800/543-5055, write
to EMS World, P.O. Box 3257,
Northbrook, IL 60065-3257, or
e-mail circ.EMSWorld@omeda.com.
800-533-0523 www.boundtree.com
M
a
k
i
n
g

P
r
e
c
i
o
u
s

M
i
n
u
t
e
s

C
o
u
n
t

For more information or a product demonstration,

contact your dedicated Account Manager or call 800.533.0523
Making Lifesaving Faster,
Easier, Better.
A sudden cardiac arrest (SCA) response is a stress-test for Emergency
Medical Providers because time matters. You need your equipment to be
rugged and to support you every step of the way.
Philips best professional-grade AED yet, the HeartStart FR3 is designed to
make lifesaving faster, easier, and better.
Fasterhelpingyoudoyourjobfasterasitsigniwcantlyreduces
deployment.IteliminatesstepstohelpyoustarttherighttherapyCPR
ordewbrillation.
Easierhelpingmakeyourjobeasierwiththesmallestandlightest
professional-grade AED among leading global manufacturers.* It is
designed to be rugged and reliable.
Betterhelpingyouimproveyourresponsebysupportingacultureof
continuousimprovement,includingoptimizingtrainingandwne-tuning
SCA response.

*DataonwlewithPhilipsHealthcare.
For More Information Circle 33 on Reader Service Card
LMA Supreme

the next generation airway.

LMA FAMILY
When Lives Depend on
You, Depend on LMA

For more information contact your

LMA

representative or visit www.LMAEMS.com.

Photo credit PHI Air Medical
With precious few seconds available to choose
a rescue airway device, the decision is a critical
one. As the rst single-use LMA

with
a built-in drain tube, the LMA Supreme
is the airway of choice.
LMA Airway Management

| LMA EMS

| LMA Visualization | LMA Atomization | LMA Pain Management

Lma North america, Inc. 4660 La Jolla Village Drive, Suite 900 San Diego, CA 92122
800-788-7999 Fax 858-622-4130 www.LmaNa.com
2012 Teleex Incorporated. All rights reserved. LMA, LMA EMS, LMA Supreme and Better by Design
are trademarks or registered trademarks of Teleex Incorporated or its afliates. LMA North America is a
subsidiary of Teleex Medical, Inc.
For More Information Circle 50 on Reader Service Card
TABLE OF CONTENTS
Acute Altered
Mental Status in
Elderly Patients
What can cause geriatric
AMS and delirium?
By Kevin T. Collopy, BA, FP-C,
CCEMT-P, NREMT-P, WEMT, Sean
Kivlehan, MD, MPH, & Scott R.
Snyder, BS, NREMT-P
TECHNOLOGY RESOURCE GUIDE
FEATURE
10 EMS World Online
12 From the Editor
14 EMS News Network
VOL. 42
|
ISSUE 2
EMS World

ISSN 1946-9365 (print) and ISSN 1946-4967 (online) is published monthly by Cygnus Business Media, 1233 Janesville Ave., Fort Atkinson, WI 53538. For subscription information or change of address call: 877/382-9187
or 847/559-7598 or fax: 800/543-5055. The publisher reserves the right to reject nonqualified subscribers. One-year subscriptions for nonqualified individuals: U.S. $45; Canada and Mexico $65; all other countries $90. Payable in U.S.
funds drawn on a U.S. bank. EMS World is published monthly. POSTMASTER: Please send change of address to EMS World, P.O. 3257, Northbrook, IL 60065-3257. Canada Post PM40612608. Return undeliverable Canadian Addresses to:
EMS World, PO Box 25542, London, ON N6C 6B2. Printed in U.S.A. GST #131910168. CHANGE OF ADDRESS notices should be sent promptly. Provide old mailing label as well as new address; please include ZIP code. Allow 2 months for change to take effect.
PUBLICATION OFFICES: Address all communications to EMS World, P.O. Box 7248, Mission Hills, CA 91346-7248. Telephone: 800/547-7377. Internet: EMSWorld.com. The views and opinions in the articles herein are not to be taken as official expressions of the
publishers, unless so stated. The publishers do not warrant, either expressly or by implication, the factual accuracy of the articles herein, nor do they so warrant any views or opinions offered by the authors of said articles. Copyright 2013 by Cygnus Business
Media. All rights reserved. No part of this publication may be reproduced in any form or by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from EMS World. Periodicals postage paid at
Fort Atkinson, WI, and additional mailing offices.
COLUMNS
18 EMS RERUNS
Emergency Social Services
By Thom Dick
20 LEADERSHIP BEST PRACTICES
Stepping Up
By Troy M. Hagen, MBA, EMT-P
26 BEYOND THE BOOKS
Three Big-Money Questions
By Mike Smith, BS, MICP
27 FROM CLASSROOM TO STREET
Airway Management Strategies
By Steven Kelly Grayson, NREMT-P, CCEMT-P,
& William E. Gandy, JD, LP
58 LIFE SUPPORT
Talking Back
By Mike Rubin, BS, NREMT-P
DEPARTMENTS
Sponsored by
50 Umbilical Vein Catheterization
in the Critical Newborn
A review of anatomy and technique
By Scott Tomek, MA, EMT-P, & Susan Asch, PhD, MD
49 Advertiser Index
53 Product Showcase
56 Classied Ads
21 How to Manage
Your Risk
By John Erich
24 Tailoring Learning
to the Learner
By Greg Friese, MS, EMT-P
A Vision for the
Future of EMS
40 EMS Apps Make Life Easier
How to put your smartphone to better use
By James Careless
43 NISC Brings Together Thought Leaders
Group seeks to drive dialogue on technology best practices
By Jason Busch, Associate Editor
44 EMS World App Roundup
46 With RFID, Asset Management Has Never Been Easier
Tiny technology saves time and money
By Jason Busch, Associate Editor
48 Mobile Apps Showcase
31
COVER REPORT
EMSWORLD.com | FEBRUARY 2013 9
INDUSTRY SPOTLIGHT
An outside spotlight on
fatigue management consul-
tant Circadians work in the
transportation industries.
PODCAST
EMS World
editorial advisory
board member Chris
Cebollero discusses
how prioritizing calls
can help reduce risk.
Q&A
Peter Dworsky,
director of risk management
for the large New Jersey
service MONOC, discusses
how to evaluate and reduce
risk at your agency.
EMS WORLD ONLINE
EMS 2020 ONLINE
FOLLOW US ONLINE: EMS World offers many ways for you to follow us
online for breaking news alerts, educational updates and networking opportunities.
facebook.com/emsworldfans twitter.com/emsworldnews
www.linkedin.com/groups?gid=1853412
Check out EMS 2020 section starting on page 21 of this issue and find
exclusive EMS 2020 content online every month at www.emsworld.
com/2020. Well have regular bonus features and other materials each
month to help facilitate the transition to EMS radical new future, and
provide opportunities for you to sound off, ask questions and share your
own successes and wisdom. Content for February includes:
BEST PRACTICE
Best practices in patient
handling as taught by emer-
gency-services insurer VFIS.
NEW THIS MONTH:
Moulage: Bridging the Training Gap
When moulage is integrated
into simulated exercises, it
creates a powerful training
modality that enhances live
actor and human patient
simulator events. Check out
these top moulage training
tips. See EMSWorld.
com/10853920.
ONLINE PRODUCT GUIDE COMPANY SPOTLIGHT
Diamond Grip is ICEtrekkers top-of-the-line winter traction device,
designed for the most challenging
conditions. These slip-on ice
cleats put a rectangle of grip-
ping beads under the ball of
the foot and a triangle under
the heel, and attach them with
hardened steel chain and steel rivets
to a tough rubber sling that slips over the toe
and heel of the shoe. For more information, visit EMSWorld.
com/10815673.
Visit the EMS World Product Guide to check out the latest tech-
nologies and services, plus rate all your favorite products using
our 5-star system!
CONTINUING EDUCATION
After viewing this video,
visit Rapidce.com to take the
accompanying test and earn 1
hour of continuing education
for $6.95. This activity is
approved by EMS World, an
organization accredited by
the Continuing Education
Coordinating Board
for Emergency
Medical Services
(CECBEMS).
Mastering Airway Management: A Continuing Education Video Series
Sponsored by
Advanced Airway
Management Techniques
This educational video, recorded at
the 2012 EMS World Expo, covers
advanced airway management,
including, but not limited to,
proper laryngoscope techniques,
endotracheal intubations, use
of blind insertion airways, use of
bougies, video-assisted adjuncts,
etc. Visit EMSWorld.com/10840219
to view the video.
About Paragon Medical Education Group
The Paragon Medical Education Group is a premier provider of interactive emergency medical
education. Continuing education sessions include a variety of prehospital-based offerings utilizing
still photographs and video segments from Paragons high-fidelity simulation sessions and
interactive procedural cadaver labs that are offered across the United States. The goal of Paragon
Medical Education Groups continuing education modules is to improve the understanding of
human anatomy and physiology as they relate to procedures performed in emergency situations
and disaster settings. It is our pleasure to partner with EMS World and Setla Films to develop the
elements of critical thinking and decision-making required to manage prehospital incidents.
10 FEBRUARY 2013 | EMSWORLD.com
For More Information Circle 51 on Reader Service Card
Safety Vision
Planning for the future of EMS involves minimizing the risks you face
LAST MONTH SAW the debut of our
EMS 2020 project. This new section
addresses the critical issues currently
facing the prehospital profession and
the changes we need to make in order
to ensure that EMS evolves with the
healthcare system.
In January, we looked at how agencies
can create a culture of safety in order
to protect their most valuable assets:
their personnel. This issue our discus-
sion revolves around risk management:
What the risks are in this profession and
how to manage them for both staff and
patients.
We know you face dangers on a daily
basis. Stats show that the risk of trans-
portation-related injury to EMTs could
be as high as fve times the national
average. And every time you lift a patient
you risk injury to your back, which could
be career-ending. Check out Associate
Editor John Erichs article on page 21
for some key strategies to lower your
chances of injury or worse.
You can also visit EMSWorld.
com/2020 for additional content and
exclusive features. Last month we
discussed how to take the safety lessons
learned in the aviation industry and
apply them to EMS. Heres what one
reader had to say: I work at an EMS
agency that has implemented the Just
Culture process with some success.
We have expanded the program and
training across our entire hospital
system and required all leaders to take
the Just Culture training. It is very impor-
tant that leadership and staff are held
accountable for their decisionsnot in
a punitive manner, but rather such that
all understand the values of your orga-
nization. Once the values are under-
stood, making the right and just deci-
sions becomes much easier.
Share your thoughts on what we
should be doing to reduce our risks.
E-mail ems2020@emsworld.com.

FROM THE EDITOR
|
By Nancy Perry
For More Information Circle 52 on Reader Service Card
uninterrupted hands-free compressions
featuring comprehensive CPR analytics
with capnography and CPR Metronome
Get ready for a more responsive approach to CPR.
physio-control.com/CPR
2013 Physio-Control, Inc. Redmond, WA
The responsive
emergency team
delivers exceptional
CPR
Todays responsive emergency team is always looking to elevate the
level of care they deliver, and they rely on evidence and data to get
them there. With the CPR Solution from Physio-Control, they have the
science-based, guidelines-consistent tools they need to respond better
to patientsand the demands of constant performance improvement.
And they choose Physio-Control
to help make it happen.
For More Information Circle 53 on Reader Service Card
NEWS NETWORK
A BILL TO extend Public
Safety Offcers Benefts
(PSOB) funds to certain
EMS providers and reautho-
rizing the USFA and fre
grants was signed by Presi-
dent Obama.
It was part of the National
Defense Authorization Act.
In late December, the
House and Senate gave the
fnal nod to the legislation
following years of work on
the issues.
In addition to extending
PSOB, the bill also reautho-
rizes the USFA and the
FIRE Act grants through
2017.
The legislation also says
rescue personnel who suffer
vascular rupture within 24
hours of an emergency
response should be eligible
for PSOB benefts. Heart
attacks are already covered
in the Hometown Heroes
Act.
Sen. Patrick Leahy, D-Vt.,
started three years ago to
close the gap in PSOB
coverage.
He frst introduced the
Dale Long Emergency
Medical Service Providers
Protection Act in June 2009,
naming the bill in honor of
the Bennington EMT who
was tragically killed in an
ambulance crash.
Leahy had added his bill
to the Senates version of the
annual defense authoriza-
tion bill. Because it was not
also in the House version, he
convinced conferees to keep
it in the fnal bill.
The Senate Judiciary
Committee, which Leahy
chairs, had approved the
bill in 2010, but further
action on the legislation
had stalled due to a single
Republican senators objec-
tion, according to a state-
ment.
The PSOB program
was launched more than
three decades ago to
provide assistance to the
surviving families of police,
frefghters and medics who
died or became disabled in
the line of duty.
The measure also
includes provisions to lessen
the length of a currently
unwieldy appeals process for
claimants, clarify the list of
eligible survivor benefcia-
ries, and make those who
have been catastrophically
injured eligible for peer
support and counseling
programs.
From Bennington, Vt.,
to Newtown, Conn., frst
responders are fesh-and-
blood lifelines to all of us.
When tragedy strikes, they
lay their lives on the line
with a sense of duty, with
skill and with selfess-
ness. All frst responders
should be treated as profes-
sionals, whether paid, volun-
teer, municipal or private
nonprofts. We count on
them, and they need to be
able to count on us. This is
their law, Leahy said in a
statement.
Obama Signs Bill Extending PSOB, SAFER, Fire Grants
The National
Association of State
EMS Ofcials recently
signed three grant
and cooperative
agreements. The new
projects are:
Model EMS
Guidelines: Funded
by NHTSA, this two-
year project will be
completed by the
Medical Directors
Council. The purpose
of this project is to
develop national
model EMS guidelines
intended to help state
EMS systems ensure
a more standardized
approach to the practice
of patient care, and to
encompass evidence-
based guidelines as
they are developed.
Statewide
Implementation of
a Prehospital Care
Guideline: Funded by
NHTSA, this is a three-
year project with co-
principal investigators
Matt Sholl (Maine EMS
medical director) and
Peter Taillac (Utah EMS
medical director). The
objective of this grant is
to support the use and
further renement of
the National Evidence-
Based Guideline Model
Process, developed
under the auspices of
the Federal Interagency
Committee on EMS
and the National EMS
Advisory Council.
Model Interstate
Compact for EMS
Personnel Licensure
for State Adoption:
This project will initiate
a 20-month process
to develop a model
interstate compact for
states legislative use
to solve the problem
associated with day-
to-day emergency
deployment of EMS
personnel across state
boundaries.
Visit www.nasemso.org.
NASEMSO Awarded Grants
AMBULANCE CRASHES CLAIM NINE
RESPONDERS IN 2012
Ambulance crashes killed nine of the 21 EMS responders who died
last year.
Statistics, compiled by the National EMS Memorial Service, show
there were 19 deaths in 2011.
Cardiac events, which were the leading cause of deaths of EMS
personnel in 2011, are still the primary killer of reghters. Last year,
36 of the 83 who died suffered cardiac arrest, according to USFA statistics.
Three people were killed in a medevac helicopter crash in Illinois
last year, and a veteran search and rescue technician died when his
chopper went down.
Others who perished serving their communities last year included
a provider who was struck while assisting at the scene of a crash along
a highway, and another who died of traumatic injuries after he fell from
an overpass after climbing over a barrier.
Two FDNY EMS providers who worked at the World Trade Center site
in New York City died of exposure-related issues in 2012.
Two others suffered their own fatal medical emergencies while as-
sisting patients, while another responder died of a job-related spinal
injury. One person was killed in a wreck after leaving work.
Fallen heroes are remembered during an annual memorial service
in Colorado Springs.
The 21st Annual National EMS Memorial Service will take place
on June 22 at 6 p.m. MDT at the Pikes Peak Center in Colorado Springs,
CO. See www.nemsms.org. Susan Nicol
14 FEBRUARY 2013 | EMSWORLD.com
For More Information Circle 34 on Reader Service Card
NEWS NETWORK
Culture of Safety
Strategy
Achieving a national culture of safety
in EMS is a long process, says Sabina
Braithwaite, MD, chair of the National
EMS Culture of Safety Strategy Project
steering committee, but one that comes
with intermediate wins. What that means
is that stakeholders of all stripes can take
positive steps today, even unilaterally, that
contribute to a safer work environment.
See below to learn what you can do
as an individual (e.g., single provider,
physician/medical director, educator,
researcher, vendor) to enhance the safety
cause and help develop our much-needed
safety culture.
Be open to any team members raising
safety concerns, regardless of their tenure
and rank;
Be willing to report errors;
Collaborate with management;
Seek opportunities to expand
knowledge base on culture, patient safety,
latest info and research on clinical safety,
responder safety, personal protective
equipment, etc., and be willing to bring
these to the attention of management;
Ask medical director what can be done
to improve safety for responders, patients
and the public;
Report safety hazards;
Perform safety checks, vehicle
inventory and safety inspections
conscientiously;
Be willing to speak up when a partner
or other responder seems fatigued or
under mental or emotional stress;
Maintain personal physical well-being,
get enough sleep and exercise;
Take advantage of CE opportunities to
learn about your own physical and mental
wellness.
For more strategies, see EMSWorld.
com/10836988.
THE FIVE STAGES OF GRIEF
0415 hrs. The tone sounds in the station and the blow lights ll the space
with harsh uorescent light. Rescue 1, respond to 160 Broad Street at
Crossroads for a female with tooth pain.
1. DENIAL
Tooth pain? Surely they jest. This must be a mistake. Ill just lie here, pull the
blanket over my eyes, wait for the lights to go out and it will go away.
Thats Rescue 1, respond to 160 Broad Street for a 22-year-old female
complaining of tooth pain.
2. ANGER
The grumpy rescue offcer sits at the edge of the bunk, fnds his shoes, throws
his shirt over his head and shuffes toward the pole.
Tooth pain! This is bull! You have got to be kidding me! Call a cab! Get a bus!
Get over it! Tooth pain, shes going to have tooth pain I when get there all right.
No, she wont have any teeth when I get there! Tooth pain. 9-1-1 for tooth pain...
3. RESENTMENT
As our heroes roll toward their fate they commiserate.
Can you believe this bull? Toothache! Were the only truck in the city doing
anything. Must be nice to work in a normal city with normal people who dont
call at 4 in the morning for a toothache! Why do they even send us? Whats the
matter with those dopes at fre alarm? Toothache. Unbelievable!
4. ACCEPTANCE
Rescue 1 arrives on scene to fnd a 22-year-old girl standing alone outside of the
homeless shelter holding her chin with both hands, crying. She looks miserable.
Did you call for a rescue? You did? Whats the matter? Toothache. Come on,
well take you to the hospital.
They help her into the side door of the rescue, make her comfortable, get
some vitals and transport.
5. CLOSURE
At the hospital they bring their patient to the waiting room, say a few polite
hellos and get back into the truck and drive toward home.
Rescue 1 in service.
Michael Morse, EMT-C, is captain of Rescue 5 in Providence, RI, and has served on the citys busiest engine,
ladder and rescue squads as a reghter, rescue technician and lieutenant during his 21-year career. He
is author of the books Rescuing Providence and Responding, and the Stories from the Streets column on
EMSWorld.com.
EMS 2020 PODCAST:
A CONVERSATION
ABOUT SAFETY
EMS World editorial advisory
board member Chris Cebollero
chats with Glenn Luedtke about
NAEMTs landmark EMS safety
course, which is designed to
promote an EMS culture of safety
and help reduce the harm incurred
by EMS providers in performing
their work. See EMSWorld.com/
10845667.
First Person
T
O
-
D
O

L
I
S
T
S
16 FEBRUARY 2013 | EMSWORLD.com
For the rst time ever, TRIVIAL PURSUIT

teams up with EMS World to make training

entertaining! Test yourself with 300 questions in 6 categories, or compete against
co-workers while preparing for that next refresher. Either way, everyone wins.
A n s w e r : P a t i e n t h o l d s c l e n c h e d f s t o v e r s t e r n u m ( i n d i c a t i n g c h e s t p a i n ) .
Q: WhAt iS LEvinES Sign?
A paramedic
looks into your
eyes and whispers,
Anisocoria. What
is she trying to tell
you?

H
o
w
m
a
n
y

u
m
b
ilic
a
l a
rte
rie
s
d
o
w
e
h
a
v
e
a
t b
irth
?

W
h
ere w
o
u
ld

yo
u
f
n
d
th
e h
eart
o
f a p
erso
n
w
ith

d
ex
tro
card
ia?
What disorder is
polyphagia?
Bubbling or
crackling in the
neck is a sign of
what condition?
Y o u r p u p i l s a r e
u n e q u a l .
T
w
o
( p
l u
s o
n
e

u
m
b
i l i c
a
l v
e
i n
) .
S u b c u t a n e o u s
e m p h y s e m a .
I n
t h
e r i g
h
t p
l a
c e
( r i g
h
t t h
o
r a
x

i n
s t e a
d
o
f l e f
) .
E x c e s s i v e e a t i n g .
USAOPOLY is a trademark of USAopoly, Inc. Copyright 2012 USAOPOLY. HASBRO and its logo, TRIVIAL PURSUIT

, the associated logo, the distinctive design of the game board, trivia cards, game
tokens, and scoring wedges are trademarks of Hasbro and are used with permission. 1981, 2012 Hasbro, Pawtucket, RI 02862 USA. All Rights Reserved. TM & denote U.S. Trademarks.
Scan here
to purchase
game!
Order at Emsworld.com/tp
OR
$29.95 +shipping
EMS RERUNS | By Thom Dick
ITS ALMOST 5 when your tones go off,
and youve just about reached your
maximum fun level. But when you hear
that address againfor the second time
tonightyoure sure. Something needs
to be done for this guy. You cant stand
this for one more shift.
550 East Browning is the address
of Paul Stevens, a 50-year-old invalid
whos gradually deteriorating with
multiple sclerosis. He falls on his way
to the bathroom, and when he does he
cant get up. During the day he has a
caretaker who helps him, but at night,
youre it. You change his diaper, clean
him up and put fresh linen on his bed.
Your crew has done that for him more
than 60 times in the past year, usually
between 10 p.m. and 6 a.m.
Nor is it just for falls. Paul chokes on
his food, and sometimes he has trouble
even managing his oral secretions. He
also has a transient visual impairment.
And sometimes his lack of neuromus-
cular coordination makes it simply
impossible for him to conduct his most
basic life functions. On top of it all,
his symptoms are completely unpre-
dictable. He can wake up feeling OK,
and an hour later be relegated to bed.
Q.

What can we possibly do for this
guy? Most of the time, we help
him up and hes as good as he gets.
Hes nice, and he always thanks us.
But were a small agency with 50,000
residents to take care of. Hes one
person. He accounts for 1% of our
annual 9-1-1 responses, and hes
getting worse. Weve explained his
circumstances to our director more
than once and nothing ever gets
done.
A. I feel your pain. I do. Were
responsible for what we know about
people, arent we? Our little system is
struggling too, with folks whose most
critical need for support is not medical,
but social. When they call us, very often
they know they dont specifcally need
us. But they need somebody, and they
just dont know whom else to call.
Fortunately, there are some things you
can do, and they depend on the answers
to two questions: Is this occurrence
an emergency? And are there family
members who could become advocates?
Q.

What do you mean, an
emergency? Theyve called
us; of course its an emergency. No
matter how hard we try to educate
them, callers will always define their
own emergencies.
A. I mean, if you resolve a callers
problem and then leave them home
alone, will their situation probably get
worse, or wont it? If it will, you need
to immediately involve your areas adult
(or child) protective services agency,
and possibly law enforcement. If their
situation will probably remain stable
or get better, I think a better goal is to
harness the family.
Q.

Yeah, well...a lot of families
are either too stupid to help
anybody, or they really dont care.
Or they live 2,000 miles away. How
does any of that help?
A. In those cases it doesnt, of course.
But you have to try. If a patient has a
home, one family advocate can make
it possible for them to stay there.
Their situation may not be ideal, but
sometimes its a lot better than being
institutionalized. And if the family is
not a viable resource, you can usually
detect the clues in a few minutes. Any
outside resource will want that infor-
mation as part of your frst conversa-
tion with them.
Q.

What outside resource? The
problem here is, there are no
outside resources.
A. Actually, there are many. Theres
a terrible shortage of public services,
but theres a long list of independent
nonproft ones. That list is different
in every community, and the best
time to familiarize yourself with them
is between calls, when youre not
frantically grappling with somebodys
emergency. Our agencys crews have
been facing these kinds of problems
for years, because the community we
serve was a poor one even before the
recession. We maintain a list of local,
county, state and national resources,
and we keep it up to date.
If youre new to this stuff, no matter
where you live, there are three options
you can try right away. One is the social
services coordinator at a hospital in or
near your service area. The second is
the community resource offcer at your
local police or sheriffs department. And
the third is your local adult (or child)
protective services agency. They all
tend to be very nice and very knowl-
edgeable. Theyre all likely to under-
stand just about any situation you can
describe to them.
Theres one more thing. Be patient;
these things can take time to fx. But
youre not alone. EMS agencies are
struggling with them everywhere.
Thom Dick has been involved in EMS
for more than 40 years. He is the
quality care coordinator for Platte
Valley Ambulance Service, a commu-
nity-owned, hospital-based 9-1-1
provider in Brighton, CO. Thom is also a member of
the EMS World editorial advisory board. E-mail
boxcar_414@yahoo.com.
EMS Reruns addresses
dilemmas in EMS.
If you think of an
example, send it to us.
If we choose to publish
your dilemma, well
pay you $50. E-mail
editor@EMSWorld.com.
Emergency Social Services
Did somebody change our name?
Our agencys crews have been facing these
kinds of problems for years.
18 FEBRUARY 2013 | EMSWORLD.com
Order tOday $17.95 plus s&H
To order, visiT emsworld.com/peoplecare
in this revised and expanded edition of People Care, Thom dick
invites you to consider the wisdom and experience of dozens of
great caregivers as he explores the art of serving people.
If you read the
original book,
youll immediately
appreciate at least
seven new features
of this one:
Death notication
skills, for people
whove always
been taught
to leave that
responsibility to
others;
suicide
intervention
strategies, for
people you
encounter in the
most vulnerable
moments of their
lives;
safe procedures
for defusing and,
when necessary,
restraining violent
people;
The addition of
dozens of photos
in a pleasing new
layout;
A new chapter full
of cases intended
to illustrate the
lessons of People
Care;
strategies for
reconceptualizing
burnout and
managing it as a
balance issue; and
Quotes Worth
Remembering,
a collection of
wisdom you can
use in your very
next encounter
with someone
who will never be
as fortunate as
you are.
people care
secOnd editiOn By tHOm dick
S
portswriter Walter Red Smith once said, There is nothing to writing. All you do is sit down at
a typewriter and open a vein. Well, after staying up all night reading, its clear to me that Thom
opened an artery for you. This is as raw, personal and powerful as anything youll ever read on
caring for others. For the sake of the vulnerable people under your care, I hope you take People Cares
lessons to heart. Mike Taigman, EMS Consultant
n
o
w


a
v
a
i
l
a
b
l
e
perspectives & practices for professional caregivers
The #1 book designed to teach you how to care for
patients, people and providers in EMS
is bigger and better than ever!
LEADERSHIP BEST PRACTICES | By Troy M. Hagen, MBA, EMT-P
MY YEARS AS a paramedic in the feld
were fantastic. I truly enjoyed helping
people, knowing I was making a differ-
ence in my patients lives and even
saving a few.
When I stepped into a management
position, I was concerned about losing
that one-on-one interaction with my
patients. Would I fnd supervision as
rewarding? What I found was I had an
even greater impact on patient care,
albeit indirect. As a paramedic in the
system, I impacted only the patients
I saw in a shift. A supervisor has the
ability to impact care for every patient
for the entire shift.
The supervisor ensures crews have
everything they need to care for patients
and holds the system accountable to the
performance expectations established
by management. Managers impact the
care the entire department provides by
developing an effective strategic direc-
tion; implementing sound policies and
procedures; hiring the right people;
ensuring clinical competence; and
managing the budget to purchase and
maintain the right vehicles, equipment
and supplies to do the job.
Each step you make from feld
provider to supervisor to manager
requires new competencies. All of
these skills help your agency accom-
plish department-specifc goals and
objectives within the environment we
live. But what is the next step? What
about changing the environment and
changing the rules? With more than
800,000 EMS professionals responding
to 36.6 million EMS responses each
year in the U.S., imagine the impact
your voice can have. Advocating for
EMS issues and the EMS profession
can be game-changing and improve
care across the board.
Getting involved in national EMS
associations can help elevate the
entire profession, improving the quality,
effectiveness and effciencies of EMS
systems. National associations estab-
lish standards, share innovations from
best practices, and develop and track
benchmarks you can use to measure
your agency.
On January 1, 2013, I became presi-
dent of the National EMS Manage-
ment Association (NEMSMA). Our
strategic plan describes NEMSMA
as a professional association of EMS
leaders dedicated to the discovery,
development and promotion of excel-
lence in leadership and management in
EMS systems. NEMSMA will research,
discover, develop and promote best
and most promising practices in EMS
leadership, management and admin-
istration through example, education
and advocacy. NEMSMAs vision
blends best management policies and
procedures with leadership character
and competencies. This approach
can educate new and seasoned EMS
leaders and advocate for continual
improvement by modeling excellence
and creating/adopting best practices.
As I take the reins, my plan is to build
upon the associations current success
and help NEMSMA make a difference
in the EMS profession. I plan to accom-
plish that in several ways:
Engage the membership. We
need active members to participate in
committees and projects and see them
through to fruition.
Partner with other associations.
Many other national associations are
doing great work. It makes sense to
partner with agencies to create syner-
gies and accomplish more and better
products rather than each organization
working in silos and performing dupli-
cative work.
Partner with EMS media outlets
to tell the EMS story, portray leadership
challenges and highlight best practice
solutions.
Engage our federal partners and
Congress in meaningful conversation
about the state of EMS, what help is
needed, and what they can do to help
EMS and the patients we serve.
Develop additional management
and leadership tools and products for
EMS leaders to use on a daily basis.
Offer educational opportunities in
management and leadership topics. The
leadership core competencies phase of
the NEMSMA EMS Leadership Agenda
for the Future will be completed in
2013 and will serve as the foundation
for educational offerings and manage-
ment tools.
With the healthcare reform
movement, EMS is facing a water-
shed moment. This is our opportunity
to better integrate EMS into the health-
care delivery system. As a paramedic,
I knew I was practicing medicine and
providing healthcare. I also knew I was
making a difference in my patients lives.
If you are concerned you may not have
the same level of gratifcation as you
move up within your organization, fear
not. There are many rewarding oppor-
tunities where you will have signifcant
impact on patient care and the poten-
tial to save many more lives than ever
possible seeing one patient at a time.
When the opportunity arises, step up in
your organization and join the national
conversation.
Troy M. Hagen, MBA, EMT-P, is CEO of
Care Ambulance Service in Orange,
CA, and a member of the EMS World
editorial advisory board.
Stepping Up
There are many ways you can impact the delivery of patient care
A supervisor has the ability to impact care
for every patient for the entire shift.
20 FEBRUARY 2013 | EMSWORLD.com
Welcome to the second installment of EMS 2020.
Building on last months discussion of forging an
EMS culture of safety (nd that and all January
content at www.emsworld.com/2020), this month
examines risks: what are the largest facing our
industry and what can we do about them, as well
as how you should evaluate yours. Future issues
will delve further into these concepts.
We accept without question that EMS is a dangerous
profession. But what exactly are the greatest threats to
providers lives and health? If we want to do something
about them and develop safer work environments in
our future, we need to break down how, precisely, our
people get hurt and killed.
And get killed they do: An oft-cited 2002 review of
three national databases calculated an annual EMS
fatality rate of 12.7 per 100,000 workers, vs. a national
average of 5.0 over the same period.
1
When our people
die, its largely in helicopter and ambulance crashes.
2,3

Being in transit is indisputably a major danger; the risk
of transportation-related injury to EMTs could be as
high as ve times the national average.
4
What doesnt kill us may make us miss work: A 2007
review of LEADS data determined EMS providers
incidence of injury with missed work days to be 8.1
per 100 workers,
5
vs. rates of 2.9 for nurses and 1.8
for all hospital workers. Another review that compiled
data differently reached an injury rate of 34.6 per 100
workers per year.
6
Our injuries have been linked to motion and overex-
ertion stress on particular body parts and encompass a
lot of the familiar sprains and strains.
2,6
Other threats
include violence/assaults and exposure to bloodborne
pathogens.
5
We have higher rates of missed time and
medical evaluations than reghters or police, most of
it due to minor trauma.
7
There are still many data limitations surrounding
EMS death and injury accounting, but its not a great
mystery where the biggest threats lie.
How to Manage Your Risk
The biggest threats to EMS providersand what we can do about them | By John Erich, Associate Editor
SPONSORED BY
Scan QR code to join the discussion at www.EMSWorld.com/2020.
The fatality rate is made up of two primary factors:
transportation-related cases and assaults.
Brian Maguire, DrPH
P
h
o
t
o

c
o
u
r
t
e
s
y

L
a
r
r
y

B
o
x
m
a
n
EMSWORLD.com | FEBRUARY 2013 21
The fatality rate is made up of two
primary factors: transportation-related
cases and assaults, says longtime EMS
safety researcher Brian Maguire, DrPH, a
professor at Central Queensland Univer-
sity in Australia. We have a new look at
injuries and fatalities [just] out in Prehos-
pital and Disaster Medicine, and were still
seeing a fatality a year in the United States
from assaults. Thats way too many. And
transportation-related cases are still very
high. Those are the two areas that need to
be addressed.
Crashes
The helicopter EMS environment has
unique characteristics and pertains to a
limited audience, so lets limit our discus-
sion of risk to ground operations.
We know risks in ambulances surround
things like restraint use, seating position
and how we travel.
8
Its no secret that
restrained occupants do better in
crashes.
8,9
What else has been shown to
reduce risk?
Organizationally, it starts with a culture
of safety that says, We believe in safety,
live safety and put safety out there from
a policy and procedure standpoint, says
David Bradley, BS, NREMT-P, an educa-
tion specialist with Pennsylvania-based
emergency-services insurer VFIS. Then
as you get down to the person driving
the ambulance, theres driver selection:
Are we selecting the right people? Do we
know what their driving records are? Do
we have policies in place and train them
appropriately?
That training should involve classroom
instruction in risks and best practices,
followed by closed-course time, compe-
tency testing and ongoing monitoring/
refreshing. Its truly a soup-to-nuts
approach, says Bradley. Somebody
walks in the door, we cant just say, Hey,
they have a card, theyre OK to drive!
For ensuring safe operation, driver-
feedback systems have demonstrated
results.
10,11
In the patient compartment,
designs that let providers stay seated
(forward- or rear-facing) and restrained
obviously improve their odds, as do
securing equipment and removing head-
strike hazards. Efforts to improve that
environment proceed at multiple levels
involving a range of governmental and
industry players. Well cover those more in
future issues of EMS 2020, but know there
are a lot of good minds working on this.
From a design standpoint, I think
were getting there, says Bradley. There
are services that have taken it personally
to design their own [safer] ambulances,
and people really seem to have the idea
now that we cant continue with the status
quo. Were heading in the right direction.
In the interim, as we strive toward
optimal operation and design, theres
much we can do on the way to reduce
our risk of death and injury on the roads.
We have a lot more control over our
fates than perhaps we realize, says
Maguire. The rst step is recognizing
that this is a pretty dangerous profes-
sion, and transportation-related factors
are a big part of the risk. But we have a
lot of control over our risks with things
like how we drive and wearing seat belts
and minimizing distractions. We have to
be conscious and determined to do every-
thing we can to minimize our risks.
Thats on an individual level. At an
organizational level, agencies are respon-
sible to collect reliable data surrounding
their accidents and close calls, scrutinize
it and intervene against discovered risk
factors in sound, scientic ways.
Other Injuries
Improving tools have done a lot to help
us lift and move patient loads, but EMS
remains a profession that often demands
more physically than those performing it
can give.
STRATEGY:
Evaluate risks within organizations; craft
interventions and measure their efectiveness.
POLICY:
Despite policies surrounding vehicle operations and patient movement, EMS injury and death rates remain high.
Table 1: Steps to Take
Now
Every agency is unique and should
collect fatality, injury and near-miss
data to analyze and better understand
its own risk prole. Meanwhile, the
largest threats industry-wide, as now
documented by years of study, are vehicle
crashes and injuries sustained in the
course of duty (lifting, moving patients,
etc.) Future 2020 content will examine
these areas in greater depth and look
at ways to mitigate their threat. In the
interim, try these steps now:
VEHICLE OPERATION
Approach with a culture of safety (see
www.emsworld.com/2020) and articulate
and enforce safe-driving policies.
Not everyone should drive your
rigs. Check employees personal driving
records and avoid those with problems
operating safely.
Training should include classroom
instruction and time behind the wheel in
a controlled setting.
Monitoring and feedback systems
improve the performance of individual
drivers and help managers keep better
views of their eets.
Distracted driving is dangerous in
any vehicle. Keep the driver focused on
driving.
In compartment layout, maximize
providers ability to say seated (forward-
and rear-facing) and restrained at all
times.
Reduce head-strike hazardsboth
things providers can y into, like
cabinetry, and things that can y into
providers, like oxygen tanks. Secure all
equipment.
PATIENT LIFTING & MOVING
Use the tools and technologies
available to reduce the forces experienced
during patient moves.
Encourage provider tness
(for instance, by facilitating gym
memberships, healthy diets, etc.) and
asking for help when needed.
Pre-employent physical abilities
testing can help ensure personnel are
capable of job demands.
EMS World
Reader Poll
(as of 12/21/2012):
HAVE YOU EVER
BEEN INJURED WHILE
PERFORMING YOUR
JOB DUTIES?
10%
18%
10%
40%
22%
Yes, 3 or more times, at least once severely
Yes, 3 or more times, but never severely
Yes, once or twice, at least once severely
Yes, once or twice, but never severely
No
22 FEBRUARY 2013 | EMSWORLD.com
VISION:
Fewer crashes and reduced rates of job-related injury and death from all causes.
The Bureau of Labor Statistics puts us,
from an injury standpoint, at three times
the national occupational injury rate,
says Bradley. Our worker comp rates are
high because we get injured more often.
Its repetition; we do a lot more bending,
lifting, things like that. At VFIS its our No.
1 patient healthcare claim.
Its a challenging phenomenon to
intervene against, as peoples body sizes,
musculature, work techniques and injury
thresholds vary. Against such risks services
should look for technological assistance,
but also work to help their personnel stay
strong and t. Many provide access to
gyms or workout equipment.
Pre-employment physical abilities testing
can also help eliminate candidates not up
to the physical rigors of EMS before they
try it and get hurt. (More on that in future
EMS 2020 content as well.) Says Bradley:
Personally I believe its something we
should do. We need to know whether
someones capable of doing the job.
A Word About Assaults
Violence against providers is likely the
most difcult threat to intervene against.
We enter many inherently unstable situa-
tions and deal with people with a range
of problems that can be emotional and
psychological as well as physical (not to
mention their families and friends). Its
very hard to reliably predict who might
punch or shoot you.
Some best practices to consider include:
Staging and waiting for law enforce-
ment at potentially dangerous scenes;
Having some panic button commu-
nications capability and crew code signals
for its time to get out of here.
Verbal de-escalation and connict-
avoidance training can help defuse incen-
diary situations.
Training in escape and self-defense
tactics for eld personnel.
Conclusion
Theres much more that can hurt and
kill EMS providers, of course, and work
continues to nesh out the specimcs. In the
meantime, leaders of individual services
and systems should assess their own
operations and look to craft their own
interventions for their own risks and
circumstances. There are lots of ways to
approach it.
You might say, well, the most impor-
tant part of the problem is how paramedics
are dying, Maguire says. Or you might
decide to look at the things that lead to
paramedics ending their careers. Or you
might want to look at whats causing
the most sick days lost. There are many
different ways of looking at the issue of
safety, and all those things have validity.
Every issue is local, adds Bradley.
Organizations should look at themselves
and ask, What are the issues affecting us?
Where are our losses? Is everything getting
reported? What affects other organiza-
tions, and could they happen to ours?
There are so many lessons out there we
could learn; we just have to take them and
apply them to what were doing.
Next month we profile the work of DHS
and its federal partners in setting ambu-
lance safety and ergonomic standards.
REFERENCES
1. Maguire BJ, Hunting KL, Smith GS, Levick NL. Occupational
fatalities in emergency medical services: a hidden crisis. Ann
Emerg Med, 2002 Dec; 40(6): 62532.
2. Reichard AA, Marsh SM, Moore PH. Fatal and nonfatal injuries
among emergency medical technicians and paramedics.
Prehosp Emerg Care, 2011 OctDec; 15(4): 51117.
3. Houser AN, Jackson BA, Bartis JT, Peterson DJ. Emergency
Responder Injuries and Fatalities. RAND Science and
Technology, 2004.
4. Maguire BJ.Transportation-related injuries and fatalities
among emergency medical technicians and paramedics.
Prehosp Disaster Med, 2011 Oct; 26(5): 34652.
5. Studnek JR, Ferketich A, Crawford JM. On the job illness and
injury resulting in lost work time among a national cohort of
emergency medical services professionals. Am J Ind Med,
2007 Dec; 50(12): 92131.
6. Maguire BJ, Hunting KL, Guidotti TL, Smith GS. Occupational
injuries among emergency medical services personnel.
Prehosp Emerg Care, 2005 OctDec; 9(4): 40511.
7. Suyama J, Rittenberger JC, Patterson PD, Hostler D.
Comparison of public safety provider injury rates. Prehosp
Emerg Care, 2009 OctDec; 13(4): 4515.
8. Becker LR, Zaloshnja F, Levick N, Li G, Miller TR. Relative risk
of injury and death in ambulances and other emergency
vehicles. Accid Anal Prev, 2003 Nov; 35(6): 9418.
9. Kahn CA, Pirrallo RG, Kuhn EM. Characteristics of fatal
ambulance crashes in the United States: an 11-year
retrospective analysis. Prehosp Emerg Care, 2001JulSep;
5(3): 2619.
10. Levick NR, Swanson J. An optimal solution for enhancing
ambulance safety: implementing a driver performance
feedback and monitoring device in ground emergency
medical service vehicles. Annu Proc Assoc Adv Automot Med,
2005; 49: 3550.
11. Myers LA, Russi CS, Will MD, Hankins DG. Effect of an
onboard event recorder and a formal review process on
ambulance driving behaviour. Emerg Med J, 2012 Feb; 29(2):
1335.
EMS Risk Management Measures: A Roundup of
Mitigation Strategies
Here are some novel EMS risk
management measures taken by services
in the U.S. and elsewhere.
Ambulance services in the U.K. have
red-agged thousands of addresses
where crews are to exercise caution or not
respond without a police escort. The sites
are where people have acted aggressively
toward providers in the past, are known
to have weapons or dangerous animals, or
have alcohol-related, psychiatric or mental
health disorders.
Certain British ambulance services
have issued stab-proof vests to front-line
providers.
Medics in Israel carry rearms. Some in
the U.S. are starting to as well.
In the U.S. the rise of violence against
providers has led to companies such as
DT4EMS (Defensive Tactics for EMS/
Fire, http://dt4ems.com), Paramedic Self
Defense.com (www.paramedicselfdefense.
com) and others that ofer EMS self-
defense training.
Services increasingly conduct pre-hire
physical agility testing to ensure applicants
can meet job demands. The Richmond
Ambulance Authoritys computer-based
evaluation of candidates musculoskeletal
strength and likelihood of failure appears
successful in screening out injury risks and
has reduced claims by almost 45%. (Read
about RAAs error self-reporting program at
EMSWorld.com/10845222.)
When health evaluations found many
personnel overweight and out of shape, the
Albuquerque Ambulance Service worked
with a local hospital and gym chain on a
year-long Biggest Winner program that
entailed regular exercise with free gym
memberships, food/diet journals and
monthly physical assessments. Participants
saw big decreases in their cholesterol levels,
blood pressures and weight.
Worried about fatigue and sleep
deprivation among providers a few years
ago, Austin-Travis County EMS worked
with a consultant to measure the problem
(employees wore activity monitors and
tracked their sleep, food intake and other
activities to provide detailed biodata) and
crafted solutions such as shorter shifts
and minimum not-at-work times to reduce
fatigue and the potential for error.
When patients refuse transport, St.
Louis Christian Hospital EMS leaves
them with Against Medical Advice
informational pamphlets that explain who
responded to their call, what they did, what
to look for in coming hours and days, and
what symptoms might prompt another
9-1-1 call or doctor visit. The pamphlets are
available for 11 chief complaints. Christian
Hospitals infection control ofcer also
rides ambulances to ensure adherence to IC
policies and procedures.
EMSWORLD.com | FEBRUARY 2013 23
Tailoring Learning to the Learner
How individual plans can improve EMS education and reduce errors | By Greg Friese, MS, NREMT-P
There is a growing concern about the
state of EMS refresher and recertica-
tion education. Many worry its too basic,
inadequately meets the needs of profes-
sionals across diverse work environments,
and discourages our people from pursuing
education opportunities beyond minimum
requirements. A greater tailoring of EMS
education to individual needs can address
these concerns and help us realize many
of the new opportunities facing us. We
can achieve this through individual
paramedic learning plans based on three
central pillars.
Pillar 1: Data-Driven Education
EMS agencies now collect an enormous
amount of dispatch and patient care data
in sophisticated programs that can intel-
ligently analyze it for patient care trends,
protocol adherence and community
events. I envision automated analysis
based on specic biological events or
patient outcome measures.
For example, many EMS agencies
provide annual training about innuenza
and droplet precautions. Because we dont
know exactly when innuenza will arrive,
we usually deliver the training in early
fall, well before its actually needed. By the
time innuenza arrives, if at all, the training
is forgotten or poorly remembered.
In a data-driven education system, an
automated analysis of CAD and PCR data
would recognize the arrival of innuenza
based on patient complaints, symptoms
reported and provider diagnoses. That
surveillance marker, when triggered,
would automatically assign an innu-
enza training program to all system
paramedics. That program would be
immediately relevant and useful, and
could be completed before the peak of
innuenza patients.
Other potential uses for data-driven
education include:
Protocol adherence
EtCO
2
monitoring is the standard for
any intubated patient, but we know it is
often not used. Rapid analysis of PCR
data could immediately check for intuba-
tions performed and EtCO
2
monitoring.
If capnography was not performed, a
series of automated actions might include
a template e-mail from the medical
director with a link to a form asking the
paramedic to explain why EtCO
2
was
not used and how airway placement was
conrmed. The same e-mail could include
a link to a PDF of the airway management
protocol, an instructional video of adding
EtCO
2
monitoring to the airway circuit,
and an assignment to complete an online
CE module on interpreting capnography
waveforms.
Skills competency
Weve all heard complaints that certain
providers seems to always magically have
patients with blood pressures of 120/80
regardless of the patients age, condition or
medical history. An automated analysis of
PCR data could search for documentation
anomalies by analyzing the last 100 blood
pressures measured by each provider and
then alert a QI manager of providers who
have 90% of documented systolic blood
pressures between 115125 mmHg. Suspi-
cion and time-consuming investigation are
removed from the process because the data
is always being analyzed for every provider.
Correct diagnosis and treatment
Correctly assessed heart failure treated
with CPAP and nitroglycerin is known to
reduce the need for intubation, length
of hospitalization and risk of hospital-
acquired infections. Ongoing data analysis
could always be looking for the proper
assessment and treatment steps for heart
failure. If, on the last ve heart failure
encounters, a paramedic only applied
CPAP two times, that could be a trigger
for automatic assignment of a CE module
on heart failure, an invitation to skills lab
to practice assembling the CPAP device,
and an appointment at the simulator lab
to practice and be checked off on assess-
ment and treatment of heart failure.
Conversely, if a paramedic has correctly
assessed and treated all their recent heart
failure patients, continuing education on
heart failure, at least at the same level as
the underperformer, is not only unneces-
sary but a waste of time and resources.
Instead, help high performers continue to
broaden and deepen their knowledge of
heart failure and other problems.
Low-frequency encounters
Depending on your service area, there
is likely a known subset of low-frequency
encounters. In a heavily geriatric commu-
nity, for instance, a paramedic could go
months without encountering a pediatric
patient. A simple automated analysis
of CAD data could determine which
paramedics have not had pediatric patient
encounters and then assign appropriate
CE modules, case reviews and observa-
tion opportunities.
Pillar 2: Development of Expertise
I believe paramedics are most effec-
tive when they develop niche expertise or
specialization within the broader eld of
paramedicine. Part of individual learning
plans would be annually or semiannu-
ally outlining self-study plans based on
individual interests and career goals.
Each paramedic would present this plan
to their training director to receive afr-
mation and support of their goals, as well
as to create accountability.
There are plenty of opportunities for
specialization within paramedicine, a eld
where we generally know a little about
a lot. For example, a paramedic could
outline a plan to learn more about 12-lead
ECG interpretation, airway management,
environmental emergency assessment,
pediatric trauma pathophysiology or any
number of clinical topics through activi-
CAD data can determine which para-
medics have not had pediatric patient
encounters.
Photo by Dan Limmer
24 FEBRUARY 2013 | EMSWORLD.com
Find EMS 2020 bonus
content online at www.
EMSWorld.com/2020:
EMS 2020 podcast host Chris
Cebollero discusses how prioritizing
calls can help reduce risk;
Best practices in patient handling
as taught by emergency-services
insurer VFIS;
A Q&A with Peter Dworsky,
director of risk management for the
large New Jersey service MONOC, on
how to evaluate and reduce risk at
your agency;
An outside spotlight on fatigue
management consultant Circadians
work in the transportation industries.
ties like seminars, online training programs,
books, expert interviews and preparing
training programs.
This approach would promote critical
thinking and better prepare medics to move
into the kinds of expanded roles anticipated
in the future of EMS.
We also know there is a need for
paramedics to develop nonclinical skills and
competencies to prepare them to advance
into EMS leadership positions. Training
directors could serve the succession needs
of their organizations as well as the profes-
sion by supporting employee plans to grow in
areas like leadership, nance, risk manage-
ment and marketing.
Pillar 3: Assigned Education
There will always be a need for educa-
tion assigned by a training ofcer to all
paramedics across an organization or groups
of paramedics within an organization.
Courses in this pillar would include compli-
ance topics to meet regulatory requirements
and service-specic training on topics like
documentation and vehicle operations. It
is essential these courses be relevant and
specic to the EMS workplace to be valued
by the workforce and actually applied.
I imagine that initially this pillar will
make up a majority of paramedics educa-
tion and could be potentially crowded with
the tiresome refresher courses that already
reteach initial education. As paramedics
transition to self-directed learning and data-
driven course assignments, the amount of
time in this pillar should decrease signicantly.
Another option to reduce time spent on
training director-assigned education is to
use competency-based education. Assess
competency with written, oral and skill exam
stations. Paramedics who pass the test dont
need instruction on the learning objectives
tested and can complete additional pillar #1
and #2 training. Paramedics who fail need
time for competency practice and instruction.
We know we need something better. We
will only nd it if we start trying something
different.
Greg Friese, MS, NREMT-P, is director of education for CentreLearn
Solutions, LLC. Connect with him at greg@centrelearn.com.
Scan QR code
to nd bonus
content online at
www.EMSWorld.
com/2020.
EMS 2020 Online
For More Information Circle 49 on Reader Service Card
EMSWORLD.com | FEBRUARY 2013 25
BEYOND THE BOOKS | By Mike Smith, BS, MICP
IVE HAD AN ongoing fascination with
the patient assessment process for most
of my career. Every provider with whom
Ive worked had certain subtleties and
nuances to the way they obtained infor-
mation from their patients, just as I did.
Once you meet and greet your patient
and start the assessment process, the
actual questions that get asked, how
they get asked and the sequence in
which they get asked can each alter
both the volume and quality of infor-
mation you obtain. Over the years I
have found there are three questions in
particular that I refer to as big-money
questionsi.e., the time you invest in
asking them will yield big returns in
what is gleaned from the answers.
1. How does the patient present?
Primary benefts: safety assessment,
qualify whether patient is sick/not sick.
The moment you walk into any
emergency scene, you get a brief
opportunity to snapshot the initial
presentation of the scene and your
patient. Finding your patient half-
slumped over an easy chair, beer in
hand and smile on face, saying, Hey,
what are you guys doing here? is far
different than meeting the same guy
standing in the doorway, legs spread
wide with arms crossed over his chest,
a scowl on his face, asking you the
same question. Hostile or aggressive
postures, loud responses and overly
animated movements can all point
to a patient who is, for some reason,
spun up. My experience has been that
spun-up patients are much more likely
to result in safety issues than overly
subdued or obtunded patients.
Skin color can provide quick and
helpful information about perfusion,
with overly pale skin and the dusky
blue tint of cyanosis both being big red
fags. When you touch your patient as
you greet them, that cool, slimy sweat
tied to sympathetic discharge is another
indicator you are dealing with a really
sick human being. A quick pulse check
can also yield big dividends as you note
whether it is particularly slow, fast or
non-regular.
Noting an excessive effort to breathe
should also move the sick/not sick
meter toward sick.
2. What is the patients level of
consciousness?
Primary benefts: Evaluation of
reliable historian status; further refne
sick/not sick status.
There are multiple methodologies for
assessing a patients LOC. While clearly
being the simplest, the AVPU query
doesnt yield much other that what your
patient is responsive to. A&O x 3 or 4
(person, place, time, plus knowledge
of events) provides insights on long-
and short-term memory. The GCS is
most helpful and replicable, as it yields
insights on overall brain function as you
assess eye opening, along with verbal
and physical responses.
At some point, whatever method-
ology you employ, you have to decide
if your patient is a reliable historian.
Clearly, the more reliable your patient,
the more you can use the information
you extract during your assessment with
confdence. By comparison, informa-
tion squeezed from a hypoxic, markedly
confused patient is much less valuable,
forcing you to rely more heavily on your
diagnostics.
One comment on assessing the
patient with alcohol on board: This
common situation alters your ability
to assess pain because of the CNS-
depressive qualities of alcohol, but
you can still extract valuable informa-
tion (sometimes much more than you
would like). But in the end, you are
better off having more information to
sift through than less.
3. What is the chief complaint?
Primary benefts: helps focus your
assessment and care plan; comforts
your patient; further feshes out the
sick/not sick status.
Whether its Why did you call
9-1-1? or What brings us to your
home tonight? this big-money question
provides you with the patients take on
just whats going on.
Once you have cleaned up the
primary survey and identifed and,
if need be, corrected any immediate
life threats to the patients airway,
breathing, circulatory or neurological
status, focusing your energy in response
to the chief complaint will usually get
your patient to calm downa clear
beneft regarding patient stability. When
a patient tells you what they believe is
wrong and you immediately begin to
evaluate their complaint, at least for
the time being, you have validated their
concerns. Clearly your assessment may
take you down other pathways, but as a
general rule, following up on what the
patient perceives as being wrong today
will generally get you more buy-in as
you start to work your treatment plan.
Ultimately, matching the patients
chief complaint with what the signs,
symptoms and diagnostics tell you
about their condition should frm up
your quantifcation of how sick your
patient truly is.
When its all said and done, getting
these three questions asked and
answered should set you up to do better
diagnostic work and ultimately lead you
down the path of quality patient care.
Until next month
Mike Smith, BS, MICP, is director of
clinical education and lead instruc-
tor for the EMS program at Tacoma
Community College in Tacoma, WA,
and a member of the EMS World
editorial advisory board.
Three Big-Money Questions
The answers will improve your medicine
26 FEBRUARY 2013 | EMSWORLD.com
By Steven Kelly Grayson, NREMT-P, CCEMT-P, & William E. Gene Gandy, JD, NREMT-P
|
FROM CLASSROOM TO STREET
IT STARTED AS a simple lift assist,
helping another crew get an obese CHF
patient out of his house and into the
rig. Soon, however, it became apparent
that the responding crew would need
more than just extra muscle to manage
the patient.
His level of consciousness was deteri-
orating, and his oxygen saturation and
capnography readings were worsening
despite the CPAP the responding crew
applied. Before we could muscle him
out of his cramped, dark bedroom, he
stopped breathing altogether, and the
frst-in medic looked at me hopefully
and asked, Get the airway for me?
This is the way most EMS war
stories start: So there we were, with
a 460-pound snowman CHFer who
needed a tube, with only me and my
trusty laryngoscope standing between
him and certain death. And thats when
it happened: A deep voice boomed from
above, Need any help, son? and shaft of
white light bathed the patients face
No, really, thats the way it happened.
I dont know where the cop came from,
but at the moment I was immensely
happy to see him and his xenon fash-
light. After I handed him a pair of gloves
from my thigh pocket, he probably
regretted the offer, but together we
managed to get the airway secured.
Paramedics have long prided
themselves for intubating under condi-
tions that would daunt the most skilled
anesthesiologist, but challenging condi-
tions are not an acceptable excuse for
failure. What matters are results. This
article explores strategies for managing
diffcult airways in the prehospital
environment, focusing on the tools and
techniques available to EMS providers.
Skills Development
Airway management is not merely a
psychomotor skill to be utilized when
the patient can no longer manage
their own. Rather, it is a mindset and
a constellation of skills, tools and
techniques that we employ not only to
manage non-patent airways with various
adjuncts, but also to preserve patients
ability to manage their own airways.
The following are strategies we can
use to manage diffcult airways.
1. ITS NOT ABOUT THE TUBE
There is a reason we call it airway
management. The goal is not to employ
a specifc device, but to ensure adequate
oxygenation and ventilation. As long
as that goal is achieved, it should not
matter whether we use an oropharyn-
geal airway, a King LTS-D, an endotra-
cheal tube or simply lean over and tap
our narcotic overdose patient on the
shoulder and remind him, Hey, buddy,
take a breath, whenever we see the
capnograph waveform pause for longer
than we deem comfortable.
Airway management is not just one
thing; it is a continuum of interven-
tions ranging from simple positioning
to surgical cricothyrotomy. Generally
we need only progress as far along the
continuum as is necessary to achieve
adequate oxygenation and ventilation.
In the aforementioned narcotic
overdose patient, if we can keep our
lethargic, somnolent patient breathing
adequately during transport by the
simple act of engaging him in conver-
sation, shouldnt we do that, rather than
resort to an invasive airway procedure or
risk the effects of narcotic withdrawal
by using naloxone?
2. POSITIONING MAKES A DIFFERENCE
Supine positioning can result in a
marked reduction in functional residual
capacity and some decrease in total lung
capacity, particularly among the obese,
1

and a 25-degree head-up position has
been demonstrated to be superior to
supine positioning in preoxygenation
of obese patients.
2
We should weigh
the benefts of supine positioning
versus the risk of respiratory decom-
pensation and transport our patients
in semi-Fowlers position whenever
possible. Positioning is equally impor-
tant when preparing the patient for
insertion of an airway adjunct. While
the sniffng position is generally consid-
ered optimum for aligning the axes of
the airway in direct laryngsocopy, there
has been little consensus on what the
sniffng position actually is. Many
providers simply hyperextend the neck
in an attempt to better visualize airway
structures; in reality this practice may
misalign airway structures and make
visualization more diffcult. Achieving
the sniffng position requires not hyper-
extension, but flexion of the neck
roughly 35 degrees, with 15 degrees of
head extension.
3
Doing this while keeping the axes
of the airway properly aligned for
direct visualization requires elevation
of the head in all but the smallest of
children. Older children and adults will
require several layers of padding under
the head, and the morbidly obese will
require the addition of signifcantly
more padding under the shoulders, a
technique known as ramping.
Ideally, the patients face should
remain parallel with the ceiling, and
the external auditory meatus should be
horizontally aligned with the sternum.
Add padding wherever needed to approx-
Airway Management Strategies
Add these six tips to your airway tool bag
Forget about the 30-second rule for an
intubation attempt.
EMSWORLD.com | FEBRUARY 2013 27
FROM CLASSROOM TO STREET
imate this position. Even when
not performing direct laryngos-
copy, this position allows for
better airfow and oxygenation
than supine positioning.
3. USE THE RIGHT TOOL FOR
THE JOB
There is a reason why
laryngeal mask airways
are supplanting endotra-
cheal intubation in hospital
operating suites: Supra-
glottic airways work. If the
ED is scant minutes away
and your patients airway can
be effectively secured using
a blindly inserted, minimally
invasive supraglottic airway,
why intubate? For resuscita-
tion purposes and relatively
short transport times, supra-
glottic airways have been
demonstrated to be as effec-
tive as ETIs, and theyre easier
to place. Keep in mind that
for certain patients, particu-
larly those with anatomical
impediments to direct laryn-
goscopy, a supraglottic airway
adjunct may not simply be
your rescue airway; it may be
your preferred airway.
For patients with anterior
glottis (thyromental distance
less than 3 fnger widths), the
use of a gum elastic bougie
may facilitate passage of the
endotracheal tube. Bougies are
helpful in many cases and can
make the difference between
missed airways and successful
ones. Some EMS medical
directors may even require their
routine use.
4. ASSESS YOUR PATIENTS
For any patient with signif-
icant respiratory distress or
neurological compromise,
assess with the potential need
for airway management in mind.
While scoring systems like
Mallampati and the LEMON
(look externally, evaluate the
3-3-2 rule, Mallampati scoring,
obstruction, neck mobility)
mnemonic may represent the
ideal pre-intubation assess-
ment, their use requires a calm,
cooperative patient.
EMS patients, particularly
those in need of advanced
airway management, are
rarely calm and cooperative,
and the LEMON mnemonic
has signifcant limitations
in prehospital application.
4

In one study, a ratio of neck
circumference to thyromental
distance of greater than
5.0 was found to be a more
accurate predictor of diffcult
intubation in the obese,
5
and
may be more readily adaptable
to prehospital use than other
currently used indices.
A more helpful assessment
tool may be Cormack-Lehane
grading of laryngoscopic views.
If the initial laryngoscopic view
does not show the vocal cords,
a diffcult airway is identifed.
Using the BURP technique
(backward, upward, rightward
pressure on the thyroid carti-
lage with the operators right
hand while looking with the
laryngoscope in the left hand),
many diffcult airways can be
managed with a bougie. The
BURP technique can improve
a view one degree in most
cases, sometimes allowing
the bougie to be used effec-
tively. The BURP technique
works best when the operator
who is intubating uses it to
help bring the glottic opening
into view. This is sometimes
called bimanual tracheal
For More Information Circle 28 on Reader Service Card
EMS patients
are rarely
calm and
cooperative.
28 FEBRUARY 2013 | EMSWORLD.com
FROM CLASSROOM TO STREET
manipulation in the literature. After
fnding the right place, the operator
can ask an assistant to replace his
thumb and frst fnger with theirs and
maintain the view he has found.
5. BE A TEAM PLAYER
Success at securing a diffcult airway
does not lie solely with the person
holding the laryngoscope. Preplan-
ning, even during a crash intubation,
is vital. Making proper use of
your partner and additional
personnel may mean the differ-
ence between success and
failure. After the operator has
achieved a view of the cords
using the BURP technique, an
assistant can help the operator
by placing their hands in the
same position and maintaining
the view. This technique, plus
lip retraction at the right
corner of the mouth, can
greatly improve a direct laryn-
goscopic view, usually by at
least one Cormack and Lehane
grade.
6,7
You only have to see
this work once to become a
believer. BURP plus bougie
can work wonders with a diff-
cult airway.
6. TAKE YOUR TIME
Forget about the 30-second
rule for an intubation attempt.
This is a fallacy without any
scientifc basis. It has been
repeated ad infnitum in EMS
texts. An otherwise healthy
adult patient preoxygen-
ated to 98% saturation takes
68 minutes to desaturate
after the onset of apnea. For
children, the obese or those
with signifcant chronic respi-
ratory pathology, you can cut
that window in half. Still, you
have a window measured in
minutes, not seconds.
8
The only time limitation you
realistically need to consider
is the brief window during a
compressor switch in cardio-
pulmonary resuscitation. If
you cant pass a tube without inter-
rupting chest compressions, perhaps
the wiser course of action would be
to insert a supraglottic airway or defer
intubation as a post-ROSC stabilization
maneuver, if needed.
There is a saying that applies here:
Slow is smooth, and smooth is fast. By
slowing down and taking a methodical
approach to preparation of equipment
and communicating with your team
members, not only do you reduce the
likelihood of mistakes, but you give
yourself and your team the opportunity
to calm and center yourselves for what
can be a stressful, lifesaving procedure.
One technique also has the poten-
tial to greatly broaden that window for
successful intubation: Adding a nasal
cannula at 15 LPM to your other preox-
ygenation techniques has been shown
to maintain an oxygen saturation of 98%
For More Information Circle 29 on Reader Service Card
EMSWORLD.com | FEBRUARY 2013 29
FROM CLASSROOM TO STREET
or better in apneic patients for as long
as an hour.
8,9
Yes, you read that correctly: a nasal
cannula at 15 LPM. The principle
here is one of simple physics: By flling
the nasopharynx and oropharynx with
oxygen, you create an oxygen reser-
voir, and oxygen will migrate down its
concentration gradient into the lungs
and into the blood, thus improving
the saturation level.
Conclusion
While the advent of supraglottic
airways and CPAP and the de-emphasis
of endotracheal intubation in ACLS
guidelines have resulted in ever-
dwindling opportunities to practice
endotracheal intubation, profciency
at airway management remains a vital
element in the prehospital provider
skill set. While new airway adjuncts
and tools like video laryngoscopy offer
intriguing possibilities, they are still no
substitute for thorough assessment,
preplanning and communication with
team members.
Do those things well, and they may
make an impossible intubation merely
diffcult, and a diffcult intubation
relatively easy. Mental preparation and
rehearsal are the keys. Think about your
plans for managing diffcult airways,
practice scenarios with your team
members, and when the time comes
to perform, you will be ready.
REFERENCES
1. Salome CM, King GG, Berend N. Physiology of obesity
and effects on lung function. J Appl Physiol, 2010 Jan;
108(1): 20611.
2. Dixon BJ, Dixon JB, Carden JR, et al. Preoxygenation
is more effective in the 25 degrees head-up position
than in the supine position in severely obese patients: a
randomized controlled study. Anesthesiology, 2005 Jun;
102(6): 1,11015, discussion 5A.
3. El-Orbany M, Woehlk H, Salem MR. Head and neck
position for direct laryngoscopy. Anesth Analg, 2011 Jul;
113(1): 1039.
4. Dowdy B. When Life Gives You Lemons. EMS World,
2011; 40(1):3539.
5. Kim WH, Ahn HJ, Lee CJ, et al. Neck circumference to
thyromental distance ratio: a new predictor of difcult
intubation in obese patients. Br J Anaesth, 2011 May;
106(5): 7438.
6.Takahata O, Kubota M, Mamiya K, et al.The efcacy
of the BURP maneuver during a difcult laryngoscopy.
Anesth Analg, 1997 Feb; 84(2): 41921.
7. Benumof JL, Cooper SD. Quantitative improvement
in laryngoscopic view by optimal external laryngeal
manipulation. J Clin Anesth, 1996 Mar; 8(2): 13640.
8. Weingart SD, Levitan RM. Preoxygenation and prevention
of desaturation during emergency airway management.
Ann Emerg Med, 2012 Mar; 59(3): 16575.
9. Levitan R. NO DESAT! (Nasal Oxygen During Efforts
Securing a Tube). Emergency Physicians Monthly, www.
epmonthly.com/archives/features/no-desat-/.
Steven Kelly Grayson, NREMT-P,
CCEMT-P, is a critical care paramedic
for Acadian Ambulance in Louisiana.
He is a the author of the book En
Route: A Paramedics Stories of Life,
Death, and Everything In Between, and the popular
blog A Day in the Life of An Ambulance Driver.
William E. Gene Gandy, JD, LP, has
been a paramedic and EMS educa-
tor for over 30 years. He has testied
in court as an expert witness in a
number of cases involving EMS pro-
viders. He lives in Tucson, AZ.
For More Information Circle 30 on Reader Service Card
30 FEBRUARY 2013 | EMSWORLD.com
elirium is a serious symptom and is commonly seen in
emergency departments.1 One of the most challenging
problems with altered mental status can be determining
its etiology. Unfortunately acute altered mental status often
goes unrecognized.2 While it is easy to recognize a
patient who is unresponsive or responds only to painful
stimuli, it can be extremely difcult to distinguish subtle mental
status changes in patients a provider hasnt met before.
Delirium is one cause of acute altered mental status that is particu-
larly difcult to identify. Even emergency department physicians struggle to
recognize delirium, and only identify it in 35% of patients with acute changes.
2

While diagnostic checklists for identifying delirium are being developed,
they are far from perfect. One study just demonstrated that a prehospital
delirium checklist may identify 63% of patients with delirium, but is really
no more accurate than recognition of a GCS less than 15.
3
This months
CE article discusses causes of delirium and acute altered mental status
in geriatric patients.
| By Kevin T. Collopy, BA,
FP-C, CCEMT-P, NREMT-P,
WEMT, Sean Kivlehan, MD,
MPH, NREMT-P, and Scott R.
Snyder, BS, NREMT-P
This CE activity is approved by EMS World, an organization accredited
by the Continuing Education Coordinating Board for Emergency Medical
Services (CECBEMS), for 1.5 CEUs.
OBJECTIVES
Discuss epidemiology of elderly patient
population
Review sepsis as cause of altered
mental status
Review subacute subdural hematoma
as cause of altered mental status
Discuss prehospital assessment and
management of these patient groups
CONTINUING EDUCATION
There are two ways to take the CE test that accompanies this article and receive 1.5 hours of CE credit accredited by CECBEMS: 1. Go online to EMSWorld.com/cetest to download a PDF of
the test.The PDF has instructions for completing the test. 2. Or go online to www.rapidce.com to take the test and immediately receive your CE credit. Questions? E-mail editor@EMSWorld.com.
What can cause geriatric AMS and delirium?
EMSWORLD.com | FEBRUARY 2013 31
CE ARTICLE
Epidemiology
The elderly population is defined
as those 65 and older.
2
In the 2000
U.S. Census, the elderly made up 10%
of the population, with 34.6 million
individuals; this is expected to rise to
82 million (20% of the population) by
2050. Altered mental status is present in
10% of all elderly patients who present
to emergency departments, yet it is only
recognized 20% of the time.
4
Many of
these patients will present via EMS.
In one study, the average age of
patients with AMS presenting to the
ED was 66.5 years. One in nine (11%)
of these ultimately died during their
hospital stay, signifying the serious
morbidity associated with AMS.
1
Among
these patients the most common etiolo-
gies of AMS were neurologic (34.4%),
infectious (18.3%) and metabolic (12%).
There are many causes of mental
status changes. AMS caused by delirium
is particularly important to recognize
because it represents a serious under-
lying condition and is marked by an
acute change in the patients cognition.
Delirium is defined by the American
Psychiatric Association as a disturbance
of consciousness and change in cogni-
tion that develops over a short period of
time.
2
It is not natural and not associ-
ated with diseases such as dementia and
Alzheimers. Rather, delirium is a hyper-
or hypoactive alteration in brain func-
tion, and thus affects behavior, memory,
actions and attitude. While patients with
delirium are often described, based on
the words Latin root, as going crazy
or deranged, this description only
addresses the hyperactive form of
delirium. A patient with delirium can
also have a hypoactive brain and present
with lethargy and decreased motor func-
tion. Table 1 identifies several causes of
delirium, which can be remembered
using the mnemonic I watch death.
5
In
many cases delirium may be the only
symptom of a serious underlying medical
condition.
2
Delirium and dementia are not the
same. Delirium is also not the same as
a gradual mental status change. The
prehospital screening assessment for
dementia mentioned in the introduction
asks paramedics to look for:
1) An acute onset of the condition;
2) Patient inattention;
3) Disoriented thinking; and
4) Altered level of consciousness.
3

These items focus on sudden changes.
It is important to try to distinguish
sudden changes in mental status, as
they represent underlying conditions
that are serious but also likely revers-
ible. Gradual mental status changes are
not associated with delirium and suggest
different pathologies.
Dementia is a completely different
condition and for the most part beyond
the scope of this article. While dementia
OptimizerouteswithGPStracking.
Ensureon-timevisitswithmobiletimeclock.
SubmitpaperworkinstantlywithAWFapp.
Assignvisitswithdraganddropdispatch.
For Healthier Fleet Operations Contact:
www.actsoft.com/eptt/healthcare
888.732.6638
sales@actsoft.com
Actsoft

fromAT&T

&
EnhancedPush-to-Talk
Your Lifesaving Mobile
Management Solution
For More Information Circle 35 on Reader Service Card
32 FEBRUARY 2013 | EMSWORLD.com
CE ARTICLE
is generally thought of as a single
disease, it is really a constella-
tion of syndromes caused by
decreased brain size and func-
tion that manifest in permanent
cognitive impairment worse than
would be expected for a specic
age. Dementia is not reversible
and represents a progressive
decline in an individuals ability
to function on a daily basis.
Case 1
72-year-old female cancer
patient.
Medic 12 responds to a
suburban home for a 72-year-
old female hallucinating. When
the crew arrives at the well-kept
house, the patients concerned
daughter leads them to a first-floor
bedroom and says her mother
was brought home following
an extended hospital stay for
leukemia, during which she
received chemotherapy. She
has been recovering well for the
past week but woke today with
fast breathing and has been
talking to her husband, who has
been deceased for 15 years.
The crew finds the patient
talking toward the wall. When
they try to talk with her, she
keeps talking past them,
addressing her dead husband.
She is warm to the touch, with
pale and clammy skin. On exam
her eyes are PERRL, no JVD is
present and her lungs are clear;
however, she is tachypneic at
a rate of 32/min, with normal
heart tones. The EKG shows
sinus tachycardia at a rate of
112/min. Her abdomen is flat
and soft, and palpation elicits
Lifesaving info at
your ngertips.
Download the AHAs new
CPR event tracking tool,
designed to help you
improve documentation
of a resuscitation event.
Available for your
iPhone and iPad.
FREE
on the App store
For More Information Circle 36 on Reader Service Card
Cause Form
Infectious abscess .......................... Sepsis, encephalitis, meningitis,
syphilis, central nervous system
(CNS)
Withdrawal ...................................... Alcohol, barbiturates, sedative-
hypnotics
Acute metabolic disturbances ........ Acidosis, electrolyte
disturbance, hepatic or renal
failure, other metabolic
(increase/decrease in glucose,
magnesium, calcium)
Trauma ............................................ Head trauma, burns
CNS disease ..................................... Hemorrhage, stroke, vasculitis,
seizures, tumor
Hypoxia............................................ Acute hypoxia, chronic lung
disease, hypotension
Deciencies ..................................... Vitamin B12, hypovitaminosis,
niacin, thiamine
Environmental ................................. Hypothermia, hyperthermia,
endocrinopathies: diabetes,
adrenal, thyroid
Acute vascular ................................ Hypertensive emergency,
subarachnoid hemorrhage,
sagittal vein thrombosis
Toxins, drugs ................................... Medications, street drugs,
alcohol, pesticides, industrial
poisons (e.g., carbon monoxide,
cyanide, solvents)
Heavy metals ..................................Lead, mercury
Table 1: Causes of Delirium: The I Watch
Death Mnemonic
5
EMSWORLD.com | FEBRUARY 2013 33
CE ARTICLE
no tenderness. She has a Foley catheter
in place with dark urine in the bag and a
foul smell, with particulate matter visible
as well. She has 2-plus edema in the legs
but moves all of her extremities well. The
crew obtains a blood pressure of 86/56
mmHg and tympanic temperature of
101.4F.
Differential diagnoses to consider:
advancement of cancer, stroke, hypo-
glycemia, infection, sepsis, medica-
tion/drug dosing error.
While lifting their patient onto the
cot, the crew discusses their list of
possible problems. To help complete their
assessment, they ask about the patients
history and medicines. The daughter says
her mother has no allergies, and provides
a list of more than 20 medicines she
takes. The daughter says the medicines
are tracked with the assistance of a
home health nurse who places them in
a daily dispenser for the daughter to give
morning and night. Shes diligent about
giving the medicines on time, which
places an overdose lower on the list of
likely diagnoses.
Besides cancer, the patients history
includes hypertension, coronary stent
placement, a hysterectomy 24 years
ago and hypothyroidism. A blood sugar
check returns a result of 424 mg/dL. After
reconfirming it, they ask about diabetes,
which the daughter confirms the patient
does not have.
Working through the differential diag-
noses, hypoglycemia has been ruled out,
but this patient is hyperglycemic, and
her blood sugar could be high enough
to be the primary cause of her AMS.
Before settling on hyperglycemia as the
primary problem here, though, consider
it a symptom of a problem. Well come
back to this in a bit.
Cancer can spread to the brain,
causing hallucinations. However, the
spread of cancer is slow and unlikely
to cause an acute change within 24
hours. Metastasis to the liver could cause
hepatic derange-
ment and also cause
delirium, but without
jaundice and ascites,
this is unlikely as well.
It is possible this
patient has had a
stroke. Hemorrhagic strokes can occur
when a patient is receiving chemo-
therapy; however, the blood pressure is
not consistent with intracranial bleeding.
As intracranial pressure rises, as it would
in a head bleed, it is common to see
EMS1302
For More Information Circle 37 on Reader Service Card
Sepsis causes mental status
changes for several reasons.
34 FEBRUARY 2013 | EMSWORLD.com
CE ARTICLE
blood pressure rise. This patients blood
pressure is low. Also, the patient moves
all of her extremities well. So while
her mental status makes performing a
stroke exam nearly impossible, stroke
would remain low on the list of poten-
tial causes. This patient, then, likely has
altered mental status from sepsis.
Altered mental status is present in
23% of patients with sepsis,
6
and this
patient has several symptoms of sepsis.
Sepsis is present whenever a local
infection develops and causes systemic
inflammatory response syndrome (SIRS).
This patients risk factors for infection
include receiving chemotherapy (which
causes immunosuppression), being
bedridden and having a Foley catheter.
Taking a temperature can confirm an
infection, and this patients temperature
is 101.4F. A SIRS response is present
whenever a patient has at least two of the
following: tachycardia, tachypnea, fever,
elevated white blood cells or hypergly-
cemia (see Table 2). This patient has four
signs of a SIRS response. Hyperglycemia
occurs during a SIRS response because
the bodys insulin shifts from its balance
with other regulatory hormones. As a
result insulin releases at higher level
than the patients baseline, and their
body decreases its use of glucose. The
presence of hyperglycemia with no
history of diabetes suggests the potential
for serious illness.
Sepsis causes mental status changes
for several reasons. During a sepsis infec-
tion the entire body has an increased
oxygen demand (thus tachypnea). If the
patients respiratory system cannot keep
up, hypoxia develops, and the brain is one
of the first organs affected. Additionally,
toxins released by the bacteria causing
the infection, particularly gram-negative
bacteria, can impair normal brain func-
tion. Finally, when patients are in septic
shock (diagnosed by a blood pressure
less than 100 systolic after 2 liters of
normal saline or by an elevated lactic
acid level greater than 4.0 mmol/L),
acids building up within the body can
lead to metabolic acidosis, which also
interrupts normal brain function.
Where is this patients infection?
Sometimes infection sources are not
obvious. However, this patient likely has
developed sepsis from what was origi-
Take the best in EMS continuing education
NAEMT courses provide high quality, evidence-based, cost-effective education that helps
you strengthen your skills and knowledge to improve patient care. Choose from PHTLS,
AMLS, EPC, TCCC and EMS Safety courses.
All courses are CECBEMS accredited and meet NREMT recertication requirements.
Serving our nations EMS practitioners
Learn more at www.naemt.org.
For More Information Circle 38 on Reader Service Card
Temperature >100.4F (38C)
or <96.8F (36C)
Heart rate >90 bpm
Respiratory rate >20/min
Arterial CO
2
(PaCO
2
) <32 mmHg
White blood cell count <4
cells/mm
3
or >12 cells/mm
3
Hyperglycemia with BGL >400
mg/dL
Table 2: Symptoms
of a SIRS Response
EMSWORLD.com | FEBRUARY 2013 35
CE ARTICLE
nally a urinary tract infection (UTI). She
has a Foley catheter in place, and more
than 90% of patients with long-term
Foley catheter placement eventually
experience bacteriuria, or bacteria in the
urine.
7
Once in the urine, the bacteria can
easily move up the bladder and cause
infection. The supporting evidence for a
UTI includes the foul odor and particulate
matter in the bag.
An individual need not have a Foley
catheter to develop a UTI. UTIs are one of
the most common causes of delirium in
patients over 50, with 10% of men and
20% of women having bacteriuria.
8
Any
time an elderly patient appears toxic and
has a history of diabetes or is immuno-
compromised, consider a urinary tract
infection. Without a Foley catheter in
place, this patient may have complained
of difficult or painful urination, blood in
her urine or fatigue. Keep in mind that
patients who are incontinent or have
dementia may not complain directly
about their symptoms.
Prehospital care of altered mental
status from sepsis focuses on comfort
care and identifying the cause. Crews
suspecting sepsis need to look for an
infection source, such as evidence of
pneumonia, a urinary tract infection or
an infected wound. After establishing
baseline vital signs and pulse oximetry,
supplemental oxygen via nasal cannula
may be indicated to maintain a normal
SpO
2
. The 2010 AHA guidelines recom-
mend it for patients with SpO
2
readings of
less than 94%.
9
While this guideline was
developed with cardiac emergencies in
mind, the same principle can reasonably
apply to other medical emergencies. IV
access and normal saline are indicated,
as aggressive fluid therapy is needed
in sepsis. Avoid Ringers lactateit
contains lactate, which may exacerbate
the patients condition if they are expe-
riencing lactic acidosis.
When a patients blood pressure
is less than 100 mmHg, consider early
administration of vasopressors. While
dopamine is the most common prehos-
pital vasopressor, it is likely to exacerbate
any tachycardias. Levophed is generally
the vasopressor of choice in sepsis, as
it has limited effects on heart rate and
For More Information Circle 39 on Reader Service Card
Hospital strive to intervene with sepsis
within 60 minutes of patient arrival.
36 FEBRUARY 2013 | EMSWORLD.com
CE ARTICLE
is titrated to effect from 220 mcg/min.
Hospitals strive to intervene with sepsis
within 60 minutes of patient arrival; for
each hour that passes prior to antibi-
otic administration, patients mortality
increases by 7.6%.
10
It is essential that
prehospital providers communicate the
suspicion of sepsis whenever its in the
working diagnosis.
Case 2
Confused 75-year-old female at
skilled nursing facility.
EMS 22 is dispatched to Livewell
Skilled Nursing Facility for a 75-year-
old female patient with confusion and
difficulty walking. The arriving crew is
directed to the common room, where
they find their patient lying on the couch
and holding her head. She is irritable and
argues with anyone who speaks to her,
and will not answer questions appropri-
ately. The staff report the patient is here
for rehab following a right
hip replacement, and has
been doing well besides a
fall 10 days ago. She went to
the hospital for the fall, but
the new hip was fine. Shes
been ambulatory since then
on a daily basis.
Over the past 24 hours, though, the
patient has developed difficulty walking,
begun complaining of a worsening
headache, and this morning was found
disoriented and arguing. She is normally
very sweet, according to her nurse. The
staff assisted her to the couch and called
9-1-1. Other than her hip replacement,
the patient has been healthy, although
she does have a history of hyperten-
sion. She is currently taking lisinopril,
Coumadin for a month following the hip
replacement, and ibuprofen as needed
for her pain.
Differential diagnoses to consider:
stroke, embolism, subdural hematoma,
tumor, meningitis.
As the crew start to evaluate their
patient, she yells at them and largely
ignores their questions. To hell with
you all, she shouts repeatedly, then rolls
over and holds her head. Nonetheless
crew members are able to determine her
vitals: pulse 82/min, respirations 16/min,
blood pressure 172/94/min, SpO
2
96%,
tympanic temperature 97.8F. The woman
will not follow commands to perform
any stroke assessment but appears to
move all of her extremities freely without
noticeable motor deficit, and she has no
facial droop or slurred speech. The crew
800-434-7989 | www.prestanproducts.com
Take your training to the next level!
Proudly Made in the U.S.A
Prestan Professional AED Trainer
Setting the Standard
Prestan Professional Manikins
For More Information Circle 40 on Reader Service Card
Type Symptoms develop
Acute Within 24 hours of injury
Subacute After 24 hours, within 14 days
Chronic At least 14 days following injury
Table 3: Types of Subdural Hematomas
EMSWORLD.com | FEBRUARY 2013 37
CE ARTICLE
does notice that her right pupil appears
quite dilated compared to the left, and
there is bruising between the right eye
and ear that extends superiorly into the
hair. It appears several days old, and a
staff member says the bruising has been
present since two days after her fall.
This patient is experiencing a
subacute subdural hematoma (SDH).
Subacute SDHs begin showing symp-
toms between 24 hours and 14 days
following the original injury and are
particularly common in elderly patients.
There is an increased frequency for intra-
cranial hemorrhage of 12% for patients
taking Plavix and 5% for those taking
Coumadin.
11
A subdural hematoma is a slow
venous bleed between the dura and
arachnoid layers of the brains meninges.
The hemorrhage is not actually within the
brain itself. Table 3 identifies the three
classifications for subdural hematomas.
Subacute SDHs often bleed and develop
in elderly patients because the brains
of older patients experience atrophy
and shrink in size, allowing more space
for blood to collect. With this additional
space the SDH can grow in size before
symptoms begin to develop. Symptoms
from an SDH appear when the hematoma
begins to press against the brain and
inhibits normal brain function.
Subacute and acute SDHs have the
same symptoms; the difference is when
the symptoms first appear. Symptoms
include headache, nausea, irritability
and confusion, level of consciousness
changes, personality changes, weak-
ness, pupil changes, blurred or double
vision, raccoon eyes, Battles sign and
hemiparesis. In this case patient history
and presentation strongly support SDH
as a differential diagnosis, but crew
suspicions cannot be confirmed until a
CT scan is performed at the emergency
department.
Prehospital management of a
subacute subdural hematoma is
supportive in nature and focuses on
protecting the critical systems. Be a good
investigator and obtain a thorough history.
It may be necessary to dig several weeks
into the patients activities to identify a
traumatic event that could have triggered
a SDH. Immobilizing these patients is
debatable. If the spine was never cleared
EMS1302S
For More Information Circle 41 on Reader Service Card
Complete immobilization on a longboard
is unlikely to be beneficial.
38 FEBRUARY 2013 | EMSWORLD.com
and the brain is bleeding, there is
certainly a mechanism for spine
injury. Further, the absence of
current decits and a patients
being able to ambulate do not
rule out fracture. If allowed, it may
be prudent to perform a spine
assessment on these patients.
Always follow local medical direc-
tion; however, it is our opinion
that complete immobilization
on a longboard is unlikely to be
benecial in the subacute setting
and is more likely to cause the
patient pain or discomfort and put
them at risk for vomiting.
Applying supplemental oxygen
may improve patient comfort.
Advanced providers should
establish IV access and mainte-
nance uids of normal saline or
Ringers lactate. EKG monitoring
is not necessary for an SDH but is
prudent whenever treating a patient
with an altered mental status. Keep
in mind, its not possible to deni-
tively diagnose an SDH until a CT
scan is performed. If the patient
has a headache or other pain,
consider use of an analgesic such
as fentanyl.
Conclusion
Delirium, or an acute change
in a patients consciousness,
cognition or personality, is a
serious symptom that may
signal a life-threatening under-
lying medical condition. When
presented with a patient with
acute memory or personality
changes or who suddenly
develops hallucinations, seek
out potential underlying causes.
Remember that delirium is not
associated with dementia and is
not a normal part of the aging
process. Provide these patients
a thorough assessment and
careful transport. Delirium is
often subtle and easy to miss, so
use family members and close
friends for help in understanding
patient behavior. Identifying
subtle changes from baseline
can help early recognition of
the underlying cause and as a
result reduce the patients risk
for serious morbidity.
REFERENCES
1. Leong LB, Jian KH, Vasu A, Seow E.
Prospective study of patients with altered
mental status: clinical features and outcome.
Int J Emerg Med, 2008 Sep; 1(3): 17982.
2. Gower LE, Gatewood MO, Kang CS.
Emergency department management of
delirium in the elderly. West J Emerg Med,
2012 May; 13(2): 194201.
3. Frisch A, Miller T, Haag A, Martin-Gill C,
Guyette FX, Suffoletto BP. Diagnostic accuracy
of a rapid checklist to identify delirium in older
patients transported by EMS. Prehosp Emerg
Care, 2013 Jan 2 [e-pub ahead of print].
4. Fitch MT. Altered Mental Status in the
Elderly: Neurologic Nightmares. Presentation
at Boston Scientic Assembly, October 2009,
www.acep.org/workarea/downloadasset.
aspx?id=46370.
5. Smith J, Seiram J. Chapter 102: Delirium and
Dementia. In: Marx J, Hockberger R, Walls R,
Rosens Emergency Medicine. Mosby, 2009.
6. Zampieri FG, Park M, Machado FS, Azevedo
LC. Sepsis-associated encephalopathy: not
just delirium. Clinics (Sao Paulo), 2011;
66(10): 1,82531.
7. Brusch JL. Catheter-Related Urinary Tract
Infection. Medscape, http://emedicine.
medscape.com/article/2040035-overview.
8. Brusch JL. Urinary Tract Infection in Males.
Medscape, http://emedicine.medscape.com/
article/231574-overview#a0156.
9. OConnor RE, et al. Part 10: Acute Coronary
Syndromes: 2010 American Heart Association
Guidelines for Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care.
Circulation, 2010; 122: S787817.
10. Kumar A, Roberts D, et al. Duration of
hypotension before initiation of effective
antimicrobial therapy is the critical
determinant of survival in human septic
shock. Crit Care Med, 2006 Jun; 34(6):
1,58996.
11. Nishijima DK, Offerman SR, Ballard DW,
Vinson DR, Chettipally UK, Rauchwerger AS,
Reed ME, Holmes JF; Clinical Research in
Emergency Services and Treatment (CREST)
Network. Immediate and delayed traumatic
intracranial hemorrhage in patients with head
trauma and preinjury warfarin or clopidogrel
use. Ann Emerg Med, 2012 Jun; 59(6):
4608.
Kevin T. Collopy, BA, FP-C, CCEMT-P,
NREMT-P, WEMT, is performance im-
provement coordinator for Vitalink/Airlink
in Wilmington, NC, and a lead instructor
for Wilderness Medical Associates.
E-mail kcollopy@colgatealumni.org.
Sean M. Kivlehan, MD, MPH, NREMT-P, is
an emergency medicine resident at the
University of California, San Francisco.
E-mail sean.kivlehan@gmail.com.
Scott R. Snyder, BS, NREMT-P, is a faculty
member at the Public Safety Training
Center in the Emergency Care Program
at Santa Rosa Junior College, CA.
E-mail scottrsnyder@me.com.
CE ARTICLE
EMP is proud to announce the
release of the 2013 EMP Medical
Equipment & Supply catalog!
Featuring over 100 new products including
LMA Supreme, Curaplex

Extrication Collars,
Laerdal Compact Suction Unit 4, Philips FR3 AED
and Phasin EMMA Capnometer
Includes an expanded selection of 5.11
Tactical Products
The exclusive home of L.A. Rescue Bags
FREE UPS ground shipping on most orders
www.buyemp.com
Check out the interactive online version of the catalog
or request a free printed copy at www.buyemp.com.
For More Information Circle 42 on Reader Service Card
EMSWORLD.com | FEBRUARY 2013 39
MS appssmall, EMS-
specic applications that
run on smartphonesare
proving to be extremely
valuable tools for EMTs.
Collectively they bring sophisticated
lifesaving technologies and knowledge
bases to wherever an EMT is working,
even in the remotest of areas.
There are several apps out there
now useful to EMS, says Josh Mularella,
DO, owner of Denali Apps and an emer-
gency medicine resident at Einstein
Medical Center in Philadelphia. These
range from protocol apps to drug refer-
ences and hazmat guides. Some are
even designed for prehospital documen-
tation of patient encounters.
Worth noting: Most developers of
EMS apps realize these will be used out
in the field and that sometimes a wireless
signal will not be available, Mularella
adds. Because of that, most of these
apps (including all of mine) are designed
to have all the content within the app
itself. Therefore, they will run with or
without cell coverage or Internet access.
Whats Available
All kinds of EMS apps are avail-
able through specific makers websites
or third-party retailers like iTunes.com.
Additionally, a simple Google search
using the words EMS apps reveals a
stunning range of apps for this medical
sector.
Example #1: The popular and free
Epocrates Rx app (available at www.
epocrates.com) provides EMTs with a
comprehensive drug reference guide
right on their iPhones and Android
handsets. Epocrates Rx lets users search
specific drugs and their effects using
brand names, generic alternatives and
over-the-counter (OTC) versions.
Epocrates Rx includes thousands
of brand, generic and OTC medicines,
dosing information, adverse reactions,
black box warnings and a pill ID tool,
says Marianne Braunstein, Epocrates
VP of product management. It also
features MultiCheck, our comprehensive
drug interaction checker, which allows
users to enter up to 30 prescription and
OTC medications at a time and instantly
review potential interactions.
EMTs need a way to stay updated on
| By James Careless
How to put your smartphone to better use
40 FEBRUARY 2013 | EMSWORLD.com
TECHNOLOGY RESOURCE GUIDE
the most important drug and diagnostic infor-
mation, which keeps changing as new prod-
ucts are introduced. This is where an EMS app
like Epocrates Rx can help: There are millions
of drug-drug interactions, even with OTC or
alternative medicines, that no one person can
memorize, and our MultiCheck product allows
users to type in the medications and view
potential contraindications or adverse effects
on the spot, says Braunstein. For emergency
responders, Epocrates can also be helpful in
identifying mystery pills through shape and
color characteristics.
One last perk: The Epocrates app lets its
usersnot just EMTs, but physicians and
nursesconnect directly to drug manufac-
turers to ask clinical questions.
All of this capability is free. Meanwhile,
for an annual $159 subscription fee, clini-
cians can upgrade to Epocrates Essentials, a
clinical suite with additional disease content
and diagnostic tools, Braunstein notes. This
version also provides access to treatment
guidelines, lab tests and panels with refer-
ence ranges.
Example #2: Time is precious at an acci-
dent scene, especially if an air ambulance has
to be called. To reduce waiting times Northwest
MedStar, a nonprofit air ambulance service
based in Washington, has created the MedStar
Alert app.
This free EMS app (available at www.
nwmedstar.org/Sub.aspx?id=1561) lets an
EMT send GPS coordinates from their smart-
phone to Northwest MedStars Communication
Center. The data puts MedStar on alert,
allowing them to determine which helicopter
is nearest the scene and how long it would
take to fly there if needed. A crew is put on
standby at the same time. If the responding
EMT subsequently decides helicopter transport
is required, this app ensures it is ready to go
as soon as possible.
This is an innovative way to let that
mobile device aid in the care of our customers
by helping reduce our on-scene times within
the golden hour, notes Howard Johnson III, a
division chief with Spokane County Fire District
#4 in Chattaroy, WA.
Denali Apps also focuses on the emer-
gency medicine market. We have one app,
called ERres, which is more suitable for doctors,
nurses, techs and other hospital-based staff
but has a lot of great info for prehospital
workers too, Mularella says. Additionally we
have developed EMS statewide protocol apps
for several states that let providers look up
protocols in an easy-to-navigate mobile app.
To date Denali has such apps for
the states of Maine, Massachusetts and
Pennsylvania under the respective names
of MEems, MAems and PAems. Available
for $1.99 at itunes.apple.com, each app
contains the official statewide protocols
broken down into individual sections for
quicker access, says the iTunes Web page.
No one can remember hundreds of pages
of protocols, especially in an emergency
situation...thats what smartphones are for!
EMS apps also exist to log critical events,
manage triage at mass-casualty incidents
and take detailed field notes on patient
conditions, among others.
Some take photos of an ECG or acci-
dent scene that can be sent to a receiving
hospital, says Eveline Bisson. She is vice
chair of the Association of Air Medical
Services (AAMS) board of directors, as well
as Northwest MedStars program director
in Spokane Valley, WA. Some ePCRs are
starting to integrate with apps to provide
a mobile method of entering some of the
patient care information through a smart-
phone, Bisson adds. There are so many
more ways people are starting to think of
apps as support tools for the fieldthese
are just a few.
Limitations
For EMTs who embrace apps, however,
there are some limitations to take into
account when selecting and deploying them.
The first is that all apps are not created
equal. Given that EMS is literally a business
of life or death, it is critically important for
EMTs and their agencies to choose EMS apps
that are the best of their breed.
How do you know? As a rule, the app
should be easy to use and provide some
useful function, Bisson says. It also must
fulfill the intended function, so in regard to
EMS apps, if you promote an app for some
useful purpose, the app better fulfill that
purpose, or it will fail.
Apps should also reduce an EMTs work-
load, rather than increase it by demanding
time and attention to be mastered. If the
app creates more complication than doing
that same task without the app, it will fail,
says Bisson. The app is supposed to make
877-217-3707
emsworld@operativeiq.com
www.operativeiq.com
2013 EMS Technology Solutions
Dedicated to
improving your
Inventory,
Asset,
Purchasing
and Fleet
Management.
For More Information Circle 54 on
Reader Service Card
EMSWORLD.com | FEBRUARY 2013 41
TECHNOLOGY RESOURCE GUIDE
life easier, not harder.
The second limitation is finding the
right apps. Given that theyre generally
found on the Webnot always the most
reputable source for productsbuyers
have to be extra careful in assessing app
quality and suitability.
Fortunately, there are ways to
steer yourself right, says Mularella. For
instance, If youre looking to get apps
for your mobile device, the best places
to look are probably the various app
stores (iTunes and Google Play) and the
various EMS-related blogs and Facebook
pages out there, he explains. On the
other hand, if youre looking to get into
the app development game yourself, I
highly recommend checking out buzz
touch.com. They help anyone, regardless
of prior coding experience, develop apps
you can sell on your own.
Thats right: It is possible for an EMT
to develop an app that meets the needs
of themselves or their agency and, if its a
good app, be able to sell it online, making
money for themselves, their employer or
both.
Smartphones
Users of smartphones know these
devices can be very brittle in the wrong
circumstances. This is why it makes
sense to fit them into hardened cases
with screen protection wherever possible.
This said, EMTs should do their home-
work when selecting the right case for
their iPhone or Android. There have
been instances where case manufac-
turers promise to protect phones from
water damage, only to declare that their
warranty only covers leaks, not a phone
being soaked and destroyed.
In the same vein, carry an extra
battery for your smartphone or an external
power supply (such as a rechargeable
battery) in your pocket. Car chargers are
also a smart idea, but remember not to
recharge your phone every second of
the day. This could cause its battery to
develop battery memory, a condition
where the battery quickly loses power
after minimal usage. Generally, batteries
last longest when they are fully drained
of power before being recharged.
Conclusion
EMS apps can be a valuable addi-
tion to any EMTs toolkit. They can bring
medical knowledge to scenes where its
needed, improve the accuracy of diag-
noses and summon air support as quickly
as possible.
Finally, many EMS apps are free and
just waiting to be downloaded from the
Web and put to work. When money is
tight, this kind of free capability is too
good to be ignored.
James Careless is a freelance writer with extensive
experience covering computer technologies.
The rst iPhone was released on June 29, 2007. By June 2012,
400 million had been sold worldwide, according to Apple. The
rst Android phone came out in October 2008. According to
Google, 333.6 million Android handsets have been shipped
since.
Clearly, smartphones have become mass-market for
personal use, and EMTs are among their most avid users.
Yet the EMS industry as a whole is still grappling with
smartphones possibilities.
Why the hesitation? I think the
EMS community is in the early stages
of understanding the value apps can
add, says Eveline Bisson, vice chair
of the Association of Air Medical
Services (AAMS) board of
directors. It is still an
emerging technology for
EMS, and it will be very
interesting to watch
how it is used by
agencies in diferent
parts of the country
for varied purposes.
There are a number
of other reasons EMS
agencies are going slow
on apps.
First, smartphones
are a consumer
technology. First
responders have
historically shied away
from consumer tech,
preferring to use more
robust professional-grade radios and computers. This is why
makers of rugged radio equipment such as Motorola and Harris
have become key players in rst responder communications,
and why comparatively fragile smartphones are may still be
viewed with suspicion by senior public safety commanders.
The second sticking point is security. Compared
to professional-grade comms equipment, consumer
smartphones are vulnerable to hacking and hijacking.
Proprietary professional-grade equipment is much harder to
hack, both because its systems are designed to be secure and
simply because its small-base, specialized platforms arent
popular with hackers.
Then theres the issue of reliability: Consumer wireless
networks are among the rst to fail during natural disasters
or to be overloaded with calls if they do remain in service. First
responders cannot aford to lose service, whatever the reason.
(This is why smartphones should be used as supplements
to dedicated rst responder radio networks, rather than as
replacements.)
Another reason smart phones encounter resistance is
that they are, well, so new. This resistance is simply due to
demographics: The senior ofcials currently in command
didnt grow up with smartphones, the Web and social media,
and so they can be uncomfortable bringing this technology
into the public safety space.
This resistance will decline over time, as todays tech-
comfortable users move into command positions. But for now,
theyre not in charge.
It will only grow as more people and agencies begin to use
smartphones and as the cellular network grows, decreasing
the gaps in coverage, Bisson says. Its a foregone conclusion,
in my mind, that apps for EMS will only increase over time.
Why Has EMS Been Slow to Embrace Apps?
42 FEBRUARY 2013 | EMSWORLD.com
TECHNOLOGY RESOURCE GUIDE
NISC Brings Together Thought
Leaders
Group seeks to drive dialogue on technology best practices
Frequently in EMS, as in just about any
industry, leaders realize theyre not the
only ones implementing protocols or
doing business in a certain way.
But, as is often the case, everyone
reinvents the wheel and duplicates
efforts without ever trying to define one
best practice that fits everyone. Just take
a look at the number of governmental
agencies that all do the same thing but
never get together with each other to
talk about it.
The National Information Sharing
Consortium (NISC) seeks to put an end
to that practice, at least for emergency
providers.
The NISC brings together data
owners, custodians and users involved
in the fields of emergency prepared-
ness, management and response to
drive an ongoing dialogue on how
to best leverage efforts related to the
governance, development and sharing
of technology, data and best practices.
By bringing together practitioners
on local, state and federal levels, NISC
strives to:
Inuence national policy around
public safety and emergency management.
Standardize information sharing
efforts on a global scale.
Improve community resilience.
In partnership with the U.S.
Department of Homeland Security
Science and Technology Directorates
First Responders Group, NISC presents
an opportunity for information sharing
on a whole of government scale.
Over the years, many technolo-
gies have been developed, and critical
data that render such technologies
operational exists in various formats,
is housed by various owners, and is
governed by various methods and
approaches for ensuring information
is trustworthy and timely.
While rapid advancement is prom-
ising, progress has inherent challenges
much has been spent on building non-
interoperable systems, and it is increas-
ingly difficult to locate and access crucial
information and data, and/or to establish
needed information sharing standards. In
todays environment of leaner budgets,
it is important for public servants in all
areas of government to work together to
meet these challenges.
Through the sharing of technologies,
data and best practices, a cultural shift
can occur, bringing about savings in cost
and time, and ultimately resulting in a
safer, more secure nation.
For years, state and local jurisdic-
tions have been sharing code, data
and other tools on an ad hoc basis
and, most recently, through the Virtual
USA pilot projects sponsored by the U.S.
Department of Homeland Security (DHS)
First Responders Group (FRG).
In reflecting on the value of these
experiences, the State of Oregon and the
Commonwealth of Virginia recognized
the many opportunities to leverage one
anothers efforts toward operational-
izing each of their situational aware-
ness and information sharing capa-
bilities. The State of California; the City
of Charlottesville, VA; and the City of
Charlotte, NC, joined the conversation,
and the group agreed that a formalized
approach to accessing and sharing
information was needed. And thus, the
non-profit NISC was formed.
Oregon set NISC activities in motion
by sharing a micro-programthe
MyOregon widgetwith the cities
of Charlotte, NC and Charlottesville,
VA, exemplifying the NISCs mission to
build capacity through collaboration and
information sharing. The cities quickly
connected the widget and rebranded it
MyVirginia and MyUASI, respectively,
enabling connection to open and secure
Web map services from any source (inter-
national, federal, tribal, regional, state or
local government and the private sector).
The result, outside of enhanced situ-
ational awareness, was savings of time
and moneytwo resources currently
in short supply on both state and local
levels.
Additionally, underutilized data that
was already paid for was put to use. The
three jurisdictions immediately recog-
nized the value of the NISC, and the NISC
members intend to replicate this kind of
sharing across the country.
For more information or membership
inquires, e-mail info@nisconsortium.org.
Oregon set
NISC activities
in motion by
sharing a micro-
programthe
MyOregon
widgetwith
the cities of
Charlotte,
NC and
Charlottesville,
VA
| By Jason Busch, Associate Editor
EMSWORLD.com | FEBRUARY 2013 43
TECHNOLOGY RESOURCE GUIDE
12-Lead ECG Challenge by
Limmer Creative
Device: iPhone & Android
12-Lead ECG Challenge sharpens your
12-Lead ECG interpretation skills, presenting
a variety of cardiac pathologies, including
an emphasis on acute STEMI and the STEMI
mimics, electrolyte imbalances and others.
Price: $4.99
AFib Educator by sano-
aventis U.S., LLC
iPhone & Android
An interactive resource to help illustrate how
AFib can affect the heart and visually demon-
strate the symptoms, risks and management
strategies of atrial brillation (AFib).
FREE
Ambu Airway Management
eLearning by Vertic Portals
iPhone & Android
View demonstrations of airway manage-
ment and intubation procedures, and keep
updated on best practices, new clinical data
and products.
FREE
ASHI Passport by Health &
Safety Institute
iPhone & Android
ASHI students can unleash the power of
their certication card by registering their
card in Passport, providing immediate access
to step-by-step instructions to more than 25
emergency care topics.
FREE
Critical Care ACLS Guide by
Informed Publishing
iPhone & Android
The Critical Care ACLS Guide gives immediate
access to critical information in an easy-to-use
app with rich content, detailed illustrations and
pioneering features.
$5.99 iPhone; $7.99 Android
ECG in Motion HD by cipm
GmbH
iPhone
Shows 30 detailed heart animations parallel
to the respective ECGs. At the same time as an
ECG curve is displayed, the stimulus produc-
tion and stimulus conduction, the contraction
and valve function are shown in open-heart
presentation. The speed of the animations is
controlled manually, enabling the direct corre-
lation between the ECG pattern and the excita-
tion situation in the heart.
$18.99
ECGsource by ECGsource,
LLC
iPhone
ECGsource has been developed for medical
education and board review, and assists institu-
tions in documenting trainee competency in
electrocardiogram (ECG) interpretation.
$1.99
EMS ACLS Guide by
Informed Publishing
iPhone & Android
The original EMS Field Guide from Informed
Publishingthe trusted leader in emergency
reference information since 1986now puts
critical information at the ngertips of an EMT.
$5.99 iPhone; $7.99 Android
EMS BLS Guide by
Informed Publishing
iPhone & Android
The guide in every EMTs pocket is now
available as an app, providing EMS Basic Life
Support with AHA updates for ACLS algorithms,
stroke and CPR.
$5.99 iPhone; $7.99 Android
EMS Logger Plus by Gary
Huntress
iPhone
This application builds on the success of the
free EMS Logger application and has been
improved based on user feedback. The original
version was requested by a paramedic in order
to quickly and easily log critical events without
the need of pencil and paper.
$2.99
EMS Notes by EMS
Operations
Android
EMS Notes is a eld data collector for EMTs
and paramedics. Log your call information,
vitals, treatments, call times and pretty much
everything else.
$6.99
EMS Pocket Drug Guide by
McGraw-Hill
iPhone & Android
EMS Pocket Drug Guide contains detailed
information on 1,000 of the most commonly
prescribed medications, typically found only in
much larger reference books.
$14.99 on iPhone and Android
EMS Supply Usage by EMS
Operations
Android
Keep track and report the supplies used
during an EMS run. The app even imports call
data from EMS Notes and lls itself out.
$3.99
EMT Academy by Peakview
Software, LLC
iPhone
EMT Academy is a complete training guide
for EMT-Basic level EMS personnel. This is an
excellent tool to help you pass your initial
certication exam, or to refresh and keep your
skills sharp.
$4.99
Heres a small selection of some of the EMS and medicine-related apps available for
both iPhone and Android devices. E-mail your favorites to editor@emsworld.com and
we will feature in an expanded online roundup at EMSWorld.com/10851549.
44 FEBRUARY 2013 | EMSWORLD.com
TECHNOLOGY RESOURCE GUIDE
For More Information Circle 55 on
Reader Service Card
EMT Tutor NREMT-B Study
Guide by Code3Apps
iPhone & Android
The EMT Tutor is a comprehensive training
tool for the EMT-Basic and features over 900
quiz questions and ashcards. The material
has been prepared and veried with 2011
textbooks and includes additional information
now presented in most classes.
$3.99
Mobile EMT by USBMIS,
Inc.
iPhone & Android
This interactive tool allows EMS providers to
quickly access detailed information on patient
assessment, common medical emergencies,
pharmacology, MCI situations, documentation
and medications.
$9.99
palmEM by palmER
Worldwide, LLC
iPhone & Android
palmEM is an all-in-one evidence based
emergency medicine quick reference. Internal
medicine, critical care, family medicine and
urgent care clinicians will also nd palmEM
useful.
$9.99
palmPEDi by palmER
Worldwide, LLC
iPhone & Android
palmPEDi is designed for physicians, nurses,
EMS providers, PAs and others caring for chil-
dren in an emergency or intensive care setting.
$1.99
Paramedic Meds by Jonsap
Android
This medical app contains nearly 100 of the
most commonly used drugs and drips for quick
reference at your nger tips. It also includes
calculators to give you either mL/hr or gtt/min.
$2.99
Pediatric EMS by Informed
Publishing
Android
Critical pediatric information for the para-
medic or EMT-P, based on content from
Informeds EMS Field Guide.
$4.99
Pill Identier by Drugs.com
iPhone
Pill Identier is a searchable database which
includes more than 10,000 Rx/OTC medica-
tions found in the U.S.
$0.99 for Lite or $39.99 for
Premium on iPhone; Lite version
coming soon to Android
Porters Pediatric ALS by
Informed Publishing
iPhone
Based on William Porters popular Porters
Pocket Guide to Pediatrics, this app provides
everything you need to respond quickly and
efciently to pediatric cases in the eld and
in the ER.
$3.99
The Difcult Airway App
by Airway Management
Education Center
iPhone
The Difcult Airway App is an essential tool
for clinicians who manage emergency airways
in any setting: the ED, ICU, in-patient unit or
the many EMS practice environments. This app
rapidly and easily selects the right drugs for
RSI, automatically adjusting for obesity and
various complicating conditions. Pediatric
dosing and equipment selection is a snap
using the Broselow-Luten color system or the
childs estimated weight.
$2.99
The Merck Manual
Professional Edition by
Agile Partners
iPhone
The Professional Edition app puts the widely
used medical textbook at the professionals
ngertips, addressing thousands of diseases
and treatments, featuring clinical approaches
to each category of disorder, and providing
specic guidance on patient evaluation.
$34.99
WISER by National Library
of Medicine
iPhone & Android
WISER (Wireless Information System for
Emergency Responders) is a mobile appli-
cation designed to assist rst responders in
hazardous-material incidents.
FREE
EMSWORLD.com | FEBRUARY 2013 45
TECHNOLOGY RESOURCE GUIDE
With RFID, Asset Management
Has Never Been Easier
Tiny technology saves time and money
| By Jason Busch, Associate Editor
RFID, or radio-frequency identification,
sounds and even looks like something
out of science fiction, but its very real
and hardly new.
It is, however, becoming more
advanced, and that creates an opportu-
nity for EMS agencies to better manage
assets and reduce costs.
Were probably most familiar with
RFID through electronic toll collection
systems found in a number of U.S.
states, or the tiny tags implanted subcu-
taneously in many pets to aid in iden-
tification if theyre lost or abandoned.
RFID is a wireless, non-contact system
that employs radio-frequency electro-
magnetic fields to transfer data from a
tag attached to an object. Its used for
tracking and identification and can be
particularly useful for inventory control.
There are two types of RFID
systemspassive and active. Passive
systems are the least complicated and
offer a quick, easy way to take inventory
of your assets. Unlike a barcode system,
where each barcode needs to be indi-
vidually scanned, passive RFID allows
users to scan an entire area quickly
and all the assets within itwith the pull
of a trigger. What once took hours now
takes only minutes, as the information is
relayed to a database through the wire-
less PDA scanner. Paramedics and EMTs
in the field can just walk through the
ambulance and scan, and the system
will tell them which, if any, assets arent
onboard so they can retrieve them from
the scene before leaving.
The upside is obvious, says Max
Petersen, business development director
for EMSAR, which began selling its RFID
asset management system, VuePoints, to
EMS clients on January 1: The system can
be used to take inventory of assets in the
ofce or on vehicles, and all items scanned
are ported to the same software database
for easy reconcilliation. Rather than using a
pad of paper or spreadsheets, you can go
into a room, scan it in about 30 seconds
and easily identify which assets are present
and which are missing.
The active RFID system provides real-
time visibility to assets and has custom-
ized alert capabilities. An RFID reader
can be placed into a building or vehicle
and provide real-time visibility within
that portal. It essentially becomes an RID
hotspot, even if the truck is out on the
road. At any given time the asset manager
or administrator can go online, pull up a
website specic to them and nd the loca-
tion of an assetnot only which truck that
asset is on, but whether its in the correct
truck or out of the truck altogether.
And the active RFID system allows
alerts to be set up for specific assets.
For example, if a stretcher needs to be
preventatively maintained, an alert can
be pre-set to go out to the system admin-
istrator via text message on a certain day
to remind them of scheduled mainte-
nance. Also included in EMSARs active
RFID system is a temperature and tamper
sensor for drug boxes. So, if somebody
For More Information Circle 56 on Reader Service Card
CFP-15M
MOGS-100
MObile OxyGen trailer
Generate your own
OxyGen On-site 24/7.
Are you PREPARED
for the next Hurricane?
BEnEfits of An oxygEn systEm:
Become Completely Self-Sufcient
Transportable to Disaster Site
Transll Directly to an Ambulance
Fill High Pressure Oxygen Cylinders
Generate Oxygen During Power Outages
(gen-sets and solar power available)
Contact OGSI today to
enroll in their FREE grant
assistance program.
tel: (716) 564-5165 or (800) 414-6474 | fax: (716) 564-5173
oxygen generating systems intl. | www.ogsi.com | Email: ems@ogsi.com
See us at
EMS Today
BOOth
#1428
46 FEBRUARY 2013 | EMSWORLD.com
TECHNOLOGY RESOURCE GUIDE
For More Information Circle 58 on Reader Service Card
888-458-6546
3121 Millers Lane
Louisville, KY 40216
Tel: 502-775-8303
Fax: 502-772-0548
S A F E T Y A P P L I A N C E C O M P A N Y
www.junkinsafety.com
PROUDLY MANUFACTURED IN THE USA
JSA-400
Aluminum Break-Apart Stretcher
Specifcations
Dimensions: 66 " L x 17 " W x 2 58" H
Folded Length: 49 "
Folded Depth: 3 "
Adjustable to: 80"
Load Capacity: 400 lbs.
Shipping Weight: 21 lbs.
Designed to gently maneuver stretcher under
patient without rolling or lifting.
The center of the Junkin Aluminum Break-Apart
Stretcher can be opened to allow the patient to
be X-rayed while secured on the stretcher.
Features sturdy, lightweight aluminum
construction with an adjustable length and
three patient restraint straps. Folds for easy
storing and separates in half during
application and removal.
JSA-400
For More Information Circle 57 on Reader Service Card
breaks into a drug box it will send an alert. If the temperature gets
too high or low and those drugs are going to expire based on
temperature, it will send an alert. The active RFID system provides
more real-time solutions to managing the expensive assets that
exist on that truck, says Petersen. And it provides a degree of
accountability on the medics, to accept or reject that they have all
their equipment that they took to the scene.
The capital system itself is not cost prohibitive, and its rela-
tively easy to implement, too. Petersen says EMSAR works directly
with customers to customize the system to exactly what they want
to see. Depending on the size of the system, installation takes
approximately three to four hours per portal. That includes tagging
items, uploading those items into the database and putting in the
hardware, whether in the truck or the building. And the system is
completely scalable; it can be implemented a piece at a time or
all at once, and implemented both passively and actively, so the
systems can interface with one another.
One agency currently using a similar system, says Petersen,
even made its system scalable across the entire county. What it
did was significantly reduce their time to take inventory, reducing
those manpower costs associated with the inventorying process
and it also allowed them to keep better records, Petersen says.
Petersen can be reached at mpeteresen@emsar.com for ques-
tions regarding the RFID system.
EMSWORLD.com | FEBRUARY 2013 47
48 FEBRUARY 2013 | EMSWORLD.com
Info.zolldata.com/easypcr
ADVERTISER INDEX
EMSWORLD.com | FEBRUARY 2013 49
COMPANY PAGE INQ #
Actsoft, Inc. .............................. 32 ......... 35
Airspace Monitoring Systems .... 57 ......... 47
American Heart Association...... 33 ......... 36
ArchieMD, Inc. .......................... 48
B. Braun Medical Inc. ................ 11 ......... 51
Bound Tree Medical, LLC ............ 7 .......... 33
Cindy Elbert Insurance
Services .................................. 57 ......... 48
CompX Security Products ......... 12 ......... 52
Digitech Computer, Inc. ............ 30 ......... 30
Emergency Medical Products ... 39 ......... 42
EMS Manager ........................... 48
EMSA ........................................ 56 ......... 45
EMT Review .............................. 49
Ferno ........................................ 25 ......... 49
First Airway LLC ......................... 48
Ford .........................................4-5 ........ 32
Gerber Outerwear ..................... 29 ......... 29
Healthmark Industries ............... 57 ......... 46
Intermedix ................................. 3 .......... 11
IPMBA ....................................... 56 ......... 44
Junkin Safety Appliance Co. ..... 47 ......... 58
LMA North America .................... 8 .......... 50
COMPANY PAGE INQ #
Masimo Corporation ................. 60 ......... 60
Microtek Medical, Inc. ............... 36 ......... 39
Minto Research and
Development .......................... 15 ......... 34
Minto Research and
Development .......................... 45 ......... 55
NAEMT ...................................... 35 ......... 38
Nasco ....................................... 34 ......... 37
National Education &
Training Center/NMETC ........... 56 ......... 43
OnSpot Automatic Tire Chains .. 47 ......... 57
Operative IQ ............................. 41 ......... 54
Oxygen Generating
Systems, Inc. ........................... 46 ......... 56
Physio-Control div Medtronic .... 13 ......... 53
Prestan Products ...................... 37 ......... 40
Sansio ...................................... 49
Simulaids Inc ............................ 38 ......... 41
Stryker EMS .............................. 59 ......... 59
VidaCare Corporation ............... 48
Ziamatic Corporation ................ 28 ......... 28
ZOLL .......................................... 2 .......... 10
Zoll Data Systems ..................... 48
FREE PRODUCT
INFORMATION
Use your product information card
to receive FREE information on
products and services advertised
in this issue. Simply circle the
numbers on the product informa-
tion card that correspond to the
enquiry numbers on this months
ads. If you want information from
several advertisers in a category,
circle the category number on
the product information card. For
online reader service, go to
EMSWorld.com.
501 Ambulance/Vehicle
Manufacturers
502Equipment/Supplies
503 ProtectiveClothing,Shoes,
Uniforms
504CommunicationEquipment/
Products
505Full-LineDistributors
506 ComputerHardware/Mounts
507 Debrillator/Cardiac/Monitor
Devices
508Education/Training
510 Hazmat/WMD/Disaster
Response
511 InfectionControl/Gloves
512 Immobilization/PatientHandling
515 Pharmaceuticals
516RescueEquipment
517Airway/RespiratoryProducts
518VehicleEquipment
520 ThirdPartyServices
(Billing,Admin,etc.)
522ComputerSoftware
523 Batteries/Chargers/Lights/
Generators
RequestFreeInformationatwww.emsworld.com/e-inquiry
s the number of critical-care transport
(CCT) programs has grown, theyve
begun to specialize into pedi-
atric, neonatal and even high-risk
obstetric/gynecological teams.
1,2

Specialized pediatric education programs
now exist for critical-care paramedics
(CCPs), who require unique advanced skills.
One of those is umbilical vein catheteriza-
tion line placement, which involves place-
ment of an intravenous line into the vein of
the umbilical cord of a newborn following
delivery. Its not a difcult procedure, but
it requires a review of the anatomy of the
umbilical cord and the technique itself.
| By Scott Tomek, MA, EMT-P,
& Susan Asch, PhD, MD
Umbilical Vein
Catheterization
in the Critical Newborn
A review of anatomy and technique
50 FEBRUARY 2013 | EMSWORLD.com
CRITICAL CARE
Umbilical Vein
Catheterization
The umbilical cord is a babys life-
line in utero. It serves as a conduit for
nutrients between the fetus and moth-
ers placenta. It consists of two (paired)
thicker-walled arteries and one thinner-
walled vein located at 12 oclock
(Figure 1) covered by a proteoglycan-
rich matrix of connective tissue referred
to as Whartons jelly. This covering not
only protects the vessels but keeps the
umbilical cord from twisting and cutting
off fetal circulation.
3
Once the baby is
born, the umbilical arteries typically
spasm shut, whereas the umbilical
vein does not. (What we often refer to
as a baby is more accurately described
as a newborn for the rst few hours
following birth and then a neonate for
the next 28 days.)
Umbilical vein catheterization
(UVC) has been used by neonatal
specialists for many years for central
pressure monitoring, infusion of uids,
and administration of medications
during and following neonatal resus-
citation.
4
Since the umbilical vein
remains patent for up to one week
after birth,
4,5
it offers an effective route
for vascular access in the neonate, and
even more so in the premature neonate.
The procedure does require specialized
equipment, training and conrmation
of correct placement by x-ray.
3
Many
organizations have begun looking at
this option for vascular access in the
depressed newborn.
Fast-Cath
One option for placing a UVC line
is the Fast-Cath system developed by
the OB department and pediatricians
at Minnesotas Lakeview Hospital. The
Fast-Cath was designed for use by
physicians, nurses and paramedics
during the initial resuscitation of a
depressed newborn. It places a tradi-
tional UVC line under sterile conditions
for use in central venous pressure
monitoring and infusion of uids and
medications.
The Fast-Cath technique utilizes
equipment most physicians, nurses
and paramedics use regularly and
are familiar with. This provides an
advantage over specialized kits in
time-stressed environments
6
and
leads to higher success rates.
79
The
Fast-Cath utilizes a standard 14-gauge
protective IV catheter inserted until it
ushes easily. Other UVC line kits utilize
a specialized umbilical vein catheter
and require formulas for correct place-
ment and radiographic conrmation.
3

The Fast-Cath kit can be made by
purchasing the various components
and packaging them into a medium-
size sealable plastic bag (Figure 2).
For hospital-based services, the central
supply department can sterilize and
package all the components.
Insertion of the Fast-Cath is best
accomplished by two clinicians: The
primary clinician (PC) inserts the
catheter, and the secondary clinician
(SC) assists by stabilizing the umbilical
cord. The PC opens the kit and lays out
the components, verifying that all are
present. The SC takes the Betadine
swabs and paints the umbilical cord
base and the cord itself. The SC then
takes the umbilical tape and ties it at
the base of the cord. It should be tied
tightly enough to stop blood ow, but
not so tight that you cant pass the
catheter through the vein. While the SC
does this, the PC puts on sterile gloves,
takes the 14-gauge angiocatheter
and removes the needle. Next the PC
connects the preloaded 10-ml syringe
to the extension tubing and ushes it.
Once the SC has an IV solution bag and
administration set ushed and ready
to go, placement of the UVC line can
begin.
Wearing sterile gloves, the SC
grasps the umbilical cord with a sterile
2x2 and cuts horizontally across it. The
cord should be left long in case it is
cut at an angle and needs to be recut
later by neonatal specialists. Typically,
the minimum an umbilical cord can be
cut down to is around 12 cm from the
abdominal wall.
10
The SC continues to
stabilize the umbilical cord while the
PC inserts the angiocatheter into the
umbilical vein to the hub of the cath-
eter and then aspirates for blood return
into the extension tubing. If blood is not
Figure 1: You can see the larger umbilical vein and the secondary
clinician painting the umbilical cord and base of the cord with
Betadine.
Figure 2: The Fast-Cath kit.
The second clinician ties the umbilical tape at the base of the cord.
The primary clinician connects the preloaded 10-ml saline syringe
to the extension tubing and flushes it.
EMSWORLD.com | FEBRUARY 2013 51
CRITICAL CARE
aspirated, attempt to ush the IV line
with saline. If it ushes easily, the line
is patent.
Due to the short length of the
angiocatheter, this is essentially a
peripheral IV lineunlike a tradi-
tional UVC, which is placed near the
right atrium. Ideally this procedure is
done by two clinicians, though it can be
accomplished by one by setting up the
equipment and placing it on a sterile
eld. In that case the PC takes a sterile
2x2, grasps the umbilical cord and
inserts the Fast-Cath, then stabilizes
the cord and catheter, and attempts
to aspirate and/or ush the line.
Once its established that the UVC
is patent, clamp the extension tubing
(with clamp-on tubing) to prevent
possible air embolisms. Since this
is a venous line, not arterial, the risk
of air embolism is greatly reduced.
Next disconnect the syringe and
attach a three-way stopcock to the
extension tubing and IV administra-
tion set. Unclamp the extension tubing
and adjust the IV ow rate accord-
ingly. Secure the catheter in place by
making a small tape bridge so the
weight and movement of the stopcock
and IV line do not dislodge it.
The Fast-Cath system also allows
receiving neonatal specialists to place
their UVC by using a modied Seldinger
technique.
11,12
A 3.5 French UVC can
be inserted through the angiocatheter,
then the angiocatheter is removed and
slid up the UVC. This allows the UVC line
to be used as a central line.
Summary
Why attempt a UVC line when
intraosseous access is often available
and the literature has demonstrated its
ease of placement and effectiveness
even in neonates?
13,14
This article is
not intended to suggest giving up IO
vascular access if you currently have
it in your toolbox. The intent was to
discuss an alternative to IO vascular
access when it failsfor example,
when a tibia is fractured during an IO
attempt
15
or is not an option for other
reasons. The Fast-Cath UVC is another
tool in the advanced EMS clinicians
arsenal that can be easily learned
and utilized. It is an effective option
for vascular access in the distressed
newborn when other options have
failed or are not available.
REFERENCES
1. Air Evac 22. Sierra Vista Area Chamber Business
Nomination 2012, http://sierravistachamber.org/
wp-content/uploads/2012/03/Air-Evac-Nomination.
pdf.
2. AirLife Denver. High Risk OB, http://airlifedenver.
com/specialty-teams/high-risk-ob.dot.
3. Butler-OHara M, Buzzard CJ, et al. A randomized
trial comparing long-term and short-term use of
umbilical venous catheters in premature infants
with birth weights of less than 1251 grams.
Pediatrics, 2006 Jul; 118(1): e2535.
4. British Columbia Ambulance Service. Critical
Care Transport Program, www.bcas.ca/EN/main/
services/critical-transport-program.html.
5. Stathers CL, et al. Chapter 1: Introduction to
Critical Care Transport. In: Murphy M, Stathers CL,
et al, eds, Critical Care Transport. Burlington, MA:
Jones and Bartlett, 2011.
6. Amedi A, Malach R, Hendler T, Peled S, Zohary
E. Visuo-haptic object-related activation in the
ventral visual pathway. Nat Neurosco, 2001 Mar;
4(3): 32430.
7. Lederman SJ, Klatzky RL. Hand movements:
a window into haptic object recognition. Cogn
Psychol, 1987 Jul; 19(3): 34268.
8. Lawson R. An investigation into the cause of
orientation-sensitivity in haptic object recognition.
Seeing Perceiving, 2011; 24(3): 293314.
9. Cannon-Bowers J, Salas E. Making Decisions
Under Stress: Implications for Individual and Team
Training. Washington, DC: American Psychological
Association, 1998.
10. Procedures. University of Iowa Childrens
Hospital, http://www.uichildrens.org/childrens-
content.aspx?id=233973.
11. www.cvc-partner.com/index.cfm?7F880D3CB2
4B4A6586A771F17149822C.
12. Schwartz AJ, Jobes DR, et al. Carotid artery
puncture with internal jugular cannulation using
the Seldinger technique: incidence, recognition,
treatment, and prevention. Anesth, 1979; 51(3):
161.
13. Kliman HJ.The Umbilical Cord, http://info.med.
yale.edu/obgyn/kliman/placenta/articles/EOR_UC/
Umbilical_Cord.html.
14. Ellemunter H, Simma B,Trawoger R, Maurer
H. Intraosseous lines in preterm and full term
neonates. Arch Dis Child Fetal Neonatal Ed, 1999
Jan; 80(1): F7475.
15. Fisher R, Prosser D. Intraosseous access in
infant resuscitation. Arch Dis Child, 2000 Jul;
83(1): 87.
Scott Tomek, MA, Paramedic, has been in EMS
for the past 30 years. He oversees quality
improvement, patient safety and risk man-
agement at Minnesotas Allina Health EMS,
and serves as a faculty member with the
Century College paramedic program and is
a subject-matter expert on prehospital airway
management.
Susan Asch, PhD, MD, is a pediatrician with
Lakeview Hospital, part of Lakeview Health in
Stillwater, MN. She has been involved in pe-
diatric and neonatal resuscitation education
for over 30 years.
The primary and secondary clinicians work as a team to cut the
cord to the appropriate length.
The primary clinician inserts a 14-gauge angiocatheter with the
needle removed into the umbilical vein. Curved umbilical vein
tweezers may be used to open the vein and facilitate placement.
Once the umbilical vein is aspirated with blood return and/or
easily flushes, a 3-way stop cock is attached to the end of the
extension tubing and then a standard IV line may be connected
to that.
Shows the umbilical
catheter now secured in
place with a tape bridge
and the newborn ready
for transport or other
procedures as needed.
52 FEBRUARY 2013 | EMSWORLD.com
PRODUCT SHOWCASE
1
Strapless Cylinder
Brackets
Zico Strapless Cylinder Brackets are fast
becoming THE bracket of choice for
quick and simple D and E cylinder
storage. Theyre safer, easier to use,
and hassle-free. Interested to see what
everyone is raving about? You can!
Call 800/711-FIRE today and request
to try one out for 30 days of test and
evaluation. Youll be glad you did.
Visit www.ziamatic.com.
Circle 61 on Reader Service Card
2
eLock Narcotic Access
Control Device
The CompX eLock secures narcotics
for EMS vehicles. The eLock provides
an audit trail of access attempts and
allows controlled access through PIN, or
with access cards. Using existing facility
proximity or magnetic stripe cards
eliminates the need to buy additional
cards. The eLock easily installs on
existing or new cabinets and the motor-
driven latch provides the convenience of
automatic relocking. Network and non-
network versions available.
Visit compx.com/csp.html.
Circle 12 on Reader Service Card
3
ZOLL X Series
Monitor/Defibrillator
The new ZOLL X Series Monitor/
Defibrillator is about half the size
and weight of competitive full-feature
monitor/defibrillators, yet much more
powerful. Weighing less than 12
pounds, the X Series is compact without
compromise in capability, performance
or display size. This monitor/defibrillator
combines the clinically superior
therapeutic capabilities of ZOLL
defibrillation, pacing and CPR assistance
with advanced monitoring parameters.
The X Series has every advanced
monitoring and communication
capability required by EMS providers.
Visit www.zoll.com/emsfire.
Circle 13 on Reader Service Card
4
Introcan Safety 3
Closed IV Catheter
B. Braun Medical introduces the new
Introcan Safety 3 Closed IV Catheter.
Its passive safety needle shield deploys
automatically and cannot be bypassed,
preventing needle stick injuries. The
multiple access blood control septum
helps prevent blood exposure each
time the catheter hub is accessed.
The integrated stabilization platform
improves catheter stability and
minimizes movement within the vessel,
reducing the number of catheter-related
complications.
Visit www.bbraunusa.com.
Circle 14 on Reader Service Card
5
911 Tech Parka
The 911 Tech Parka is a NFPA
1999-certified bloodborne pathogen-
impervious jacket paired with either a
fleece or soft shell liner. The shell and
liners can be trimmed with a variety
of Scotchlite reflective packages, plus
customized graphics, embroidery and a
variety of other features. The shell jacket
has a concealable three-panel hood, four
generous pockets, a double storm flap
and mic tabs standard.
Visit www.gerberouterwear.com.
Circle 15 on Reader Service Card
6
S.A.L.T. Offers
Effective Airway
Management
The disposable S.A.L.T. (Supraglottic
Airway Laryngopharyngeal Tube)
enables prompt, safe endotracheal
intubation, particularly for difficult,
special and blind airway management.
Simply lubricate S.A.L.T., insert like an
oropharyngeal airway and introduce an
endotracheal tube through the center of
the device in seconds. Then secure the
patented clamp to the ET tube, verify
tube placement and secure the strap to
the ET tube.
Visit www.microtekmed.com.
Circle 16 on Reader Service Card
7
Disposable CO
2

Sampling Lines
Capnography is the earliest indicator
of adverse airway and respiratory
issues. With Oridion Disposable CO
2

Sampling Lines, EMS providers can
immediately detect airway obstruction
and other ventilation problems. The
lines provide continuous feedback on
the breathing and ventilatory status of
patients in emergency care. Visit www.
boundtreeuniversity.com.
Circle 17 on Reader Service Card
5
1
4
6
7
2
3
EMSWORLD.com | FEBRUARY 2013 53
8
Life/form Airway
Management Trainers
The Life/form Airway Management
Trainers simulate non-anesthetized
patients for practicing intubation,
ventilation, suction and CPR techniques.
Realistic anatomy and landmarks
including teeth, tongue, oral and nasal
pharynx, larynx, epiglottis, arytenoids,
false cords, true vocal cords, trachea,
lungs, esophagus, and stomach. The
trainers allow you to practice oral, digital
and nasal intubation, as well as ET, EOA,
PTL, LMA, EGTA, Combitube and King
System insertion. Suction techniques
and proper cuff inflation may also be
practiced and evaluated.
Visit eNasco.com/healthcare.
Circle 18 on Reader Service Card
9
LUCAS Chest
Compression System
The LUCAS Chest Compression System
is designed to help improve outcomes for
sudden cardiac arrest victims and improve
operations for medical responders.
Designed to provide effective, consistent
and uninterrupted compressions
according to AHA Guidelines, LUCAS
can be used on adult patients in out-
of-hospital and hospital settings. This
device can be deployed quickly (less than
20 seconds) with minimal interruption
to patient care. Maintaining high-
quality, hands-free compressions allows
responders to focus on other lifesaving
therapies and enables them to wear seat
belts during transport.
Visit www.physio-control.com.
Circle 19 on Reader Service Card
10
Professional AED
Trainer
Prestan once again is setting the
standard: Introducing the the new
Prestan Professional AED Trainer. The
unique Pads Sensing System allows the
unit to sense when pads are placed on
the manikin, eliminating any need for
a remote. This gives a more realistic
training experience because the Prestan
AED Trainer operates more like a live
AED. This product carries the same
quality and durability you expect with
Prestan products. Proudly made in the
USA. Visit www.prestanproducts.com.
Circle 20 on Reader Service Card
11
Education Materials
Simulaids offers two scenario
groups to assist you in fulfilling your
curriculum. The Loose-Leaf Binder
Presentation includes 10 EMS or 10
nursing scenarios that offer objectives,
patient history, patient presentation
and vital signs. Single Page Categories
includes 105 EMS scenarios that offer
objectives, patient history, patient
presentation, vital signs, medical I and
II, cardiac I and II, trauma, OB/GYN,
pediatric and/or 30 essential pages.
Visit simulaids.com.
Circle 21 on Reader Service Card
12
Prehospital Trauma
Life Support Course
The National Association of Emergency
Medical Technicians Prehospital Trauma
Life Support (PHTLS) course is the worlds
premier prehospital trauma education,
developed in cooperation with the
American College of Surgeons to promote
critical thinking in addressing multi-system
trauma and provide the latest evidence-
based treatment practices. It is now
available in more than 55 countries.
Visit www.naemt.org.
Circle 22 on Reader Service Card
13
Mobile Data Tablet
Intermedix Mobile Data Tablet for
Android allows crews to communicate
their status directly to your agencys CAD
system. We use Google Maps navigation
for turn-by-turn directions to reduce
response times. The interface is specially
designed for in-vehicle use, offering you
intuitive call progression, finger-friendly
buttons and high-contrast colors. Ask for
a demo to experience this next generation
of mobile data tablets.
Visit www.intermedix.com.
Circle 23 on Reader Service Card
14
Emergency Fracture
Response System
The Sager Emergency Fracture Response
System (SEFRS) is your complete
fracture response system! It combines
a compact bilateral traction splint
(for treatment of proximal third and
midshaft fractures) with an adaptorfor
treatment of all other extremity fractures,
dislocations and joint injuries without
traction. SEFRS customizes the splint to
the patient. Fractures can be splinted in
position found. Features rapid assembly
and rapid application.
Visit www.sagersplints.com.
Circle 24 on Reader Service Card
11
12
13
14
10
8
9
PRODUCT SHOWCASE
54 FEBRUARY 2013 | EMSWORLD.com
PRODUCT SHOWCASE
15
Ambulance
Commander
Ambulance Commander is Digitechs
suite of products, providing robust and
comprehensive support for EMS billing
and all data management associated
with billing ambulance transport claims.
Featuring Portal secure patient access;
Sentinel metrics monitor; Appeal-IT
automated appeals system; Dashboard
real-time metrics; SecureDocs
document imaging system; and Sleuth
demographic search tool.
Visit www.digitechcomputer.com.
Circle 25 on Reader Service Card
16
AHA Full Code
Pro App
The AHAs Full Code Pro App is a
easy-to-use, mobile application that
allows you to quickly document critical
interventions during cardiac arrest
resuscitation events. Download the
free app from the App Store today.
Visit www.heart.org.
Circle 27 on Reader Service Card
17
Power-LOAD Cot
Fastener System
Power-LOAD helps reduce injuries
when loading and unloading. The
Power-LOAD cot fastener system from
Stryker EMS improves operator and
patient safety by supporting the cot
and patient throughout the loading and
unloading process. By reducing spinal
loads on operators, cumulative trauma
injuries can be reduced. Power-LOAD
wirelessly communicates with Power-
PRO cots for maximum convenience
and efficiency. Visit ems.stryker.com.
Circle 26 on Reader Service Card
15
16
Grab it
Get in-depth, behind-the-scenes
coverage and experience EMS
World in an entirely new way.
The all-new EMS World iPad
Edition. Brings print to life with
sight, sound and motion.
grabs you.
and it
360
17
EMSWORLD.com | FEBRUARY 2013 55
EMERGENCY MARKETPLACE
Circle 45 on Reader Service Card
Circle 44 on Reader Service Card Circle 43 on Reader Service Card
I P M BA 23rd Annual
Conference & Expo
Ap ril 27- M ay4 , 2013
B at o n R o u ge, L o u i s i a n a
PUT ON
YO U R
TRAI NING
WHEELS
IPMBA
The standard in public safety
bicycle training since 1991.
w w w.ipmba.org ~ info@ipmba.org
1- 410-744-2400
APPLY NOW
www.emsaonline.com
$10,000 Sign-On/Relocation Bonus
ExceIIent HeaIth Benets Package
Matching 401K
Salary Commensurate with Experience
Paid CEUs and Refresher Classes
PARAMEDIC?
Looking for a rewarding
company to join?
EMSA is seeking Nationally Registered
Paramedics to join our team.
OkIahoma City TuIsa
Online Paramedic
and Online Advanced
EMT Programs
The National Medical Education &
Training Center sponsored by The
University of Texas Health Science
Center announces an innovative
state-of-the-art Online Paramedic
Program
Its time to break down the brick-
and-mortar barriers of the traditional
classroom and build the foundation for
your future. Enroll in an unparalleled
paramedic program using the best of
todays technology
NMETCs Live Interactive Online Program is a web-
based virtual classroom that couples the convenience
of web-based training with the value of the face-to-
face classroom. Experience total-application-sharing
at its nest. Instructors show and narrate PowerPoint
slides, enhance your learning with audio and video
clips as examples, provide handouts to guide self-study
any traditional classroom convenience is available to
maximize the learners experience. Interact with expert
instructors and students at various levels in the learn-
ing process. Ask questions, make comments, and be a
part of a community with a common goal.
www.nmetc.com
56 FEBRUARY 2013 | EMSWORLD.com
CLASSIFIEDS
Circle 46 on Reader Service Card Circle 48 on Reader Service Card Circle 47 on Reader Service Card
Find out more 1

888

654

5126
www.airspaceinc.com
Five year guarantee,
including the sensor.
No calibration.
Automated
performance.
No monthly
bump testing.
Never misdiagnose
CO poisoning.
Protect yourselves as well.
So affordable the argument becomes;
Can you afford not to equip?
CPR Instructors
For information, please call
Chad Breedlove at toll-free:
(866) 932-2331
LI FEGUARD
MEDICAL SOLUTIONS
www.lifeguardmed.com
As a training provider for the
American Heart Association,
we are looking for people to
join our national network of
AHA-Certifed Instructors. We
offer great pay with fexible
schedules. Please note that
all applicants must have their
current & valid AHA Instructor
Certifcation Card.
Contact: Chuck Barnett
800-280-9743 (913) 489-5118
charlesb@olatheford.com
Mention This Ad and Receive $100 Off Per Contract!
EXTENDED
SERVICE PLAN
for Ambulances and Buses
ExtraCARE from Ford up to 5
years or 200,000 miles (113
covered items)
ESP oered exclusively through
Olathe Ford
$100.00 or $200.00 deductible
Work can be done at any Ford
or Lincoln dealership
Gas or diesel engines
Coverage available for new, used
or demonstrators still under
base 36/36 OEM warranty
www.AEDSupplyStore.com
The Most Complete
Source for Quality
and Affordable
AEDs & Accessories
Toll-Free
(866) 932-2331
EMSWORLD.com | FEBRUARY 2013 57
LIFE SUPPORT | By Mike Rubin, BS, NREMT-P
AS I WRITE this, Im six weeks into my
annual holiday bout with sciatica. Im
not sure why my Christmases have
become so emphatically un-jolly. All
I know is my new favorite stocking
stuffer is Vicodin.
I mention my less-than-robust state
because I know many of you suffer from
similar or worse work-related maladies.
Im trying to fnd the humor in mine.
Heres what Ive learned about having
a bad back:
The Borg scale goes to 11.
Dogs understand the noises you
make.
Children lift things you cant.
Easy chairs are anything but.
You bend over to pick something
up and wonder what else you should
do while youre down there (thanks to
country legend Little Jimmy Dickens for
that one).
I have an L5/S1 herniation that
irritates my left sciatic nerve.
Usually theres just mild, intermit-
tent discomfort, but when it fares
up I seriously consider felonious
acts against the partners who taught
me to use stair chairs instead of
stretchers to load patients onto
ambulances. Then I embark on a
routine of pills in the morning, pills
at night and a cane by my side, all of
which can become crutches.
Being away from EMS is almost
as frustrating as not being able to do
chores around the house. The last
time I was recovering from sciatica,
The Lovely Helen asked me to drag
an old gas grill to the curb. I said that
sounded like a good way to pay down
the years health insurance deductible.
She thought that was pretty funny.
Then she got a neighbor to move ita
middle-aged, petite female neighbor.
My ego took a direct hit; I told Helen
Id probably need little blue pills for life.
She offered to buy them.
(Memo to signifcant others: Its risky
to make fun of gimpy paramedics. Were
sensitive, and we carry needles.)
This year was different because I
ended up horizontal in an ambulance
just before Thanksgiving. It was an act
of desperation; my usual right-lateral-
recumbent contortions to curb pain
had no effect, and I couldnt sit or
stand long enough for Helen to drive
me to my doctor.
I was extremely reluctant to call
9-1-1. I suppose that had something
to do with all the abuses we see. Also,
the thought of entering the system
the same system Id been a part of for
so longmade me feel self-conscious
and vulnerable. I didnt want to be
someone elses patient.
After promising Helen not to
micromanage my own care, I asked
her to use the nonemergency number
of the dispatch offce where shed
worked. Then I considered slipping
into something less comfortable but
more fashionable for transport before
yielding to the notion of underwear
as outerwear.
Heres how Id grade the performance
of my communitys medical services:
EMS: A-. Courteous, gentle, no
mindless backboarding, and they took
me to the hospital of my choice. The
only problem was they didnt have any
good drugs. Or maybe they did, but
I didnt qualify. I knew I shouldnt
have offered to slide from my bed to
the stretcher.
Admission: B. No waiting for a
bay, triaged on the way, and my nurse
agreed a rectal exam wouldnt be
good for either of us. I was starting
to hate hospitals less when someone
from billing badgered me about a
down payment (my wife had already
presented our insurance).
Treatment: A. The attending ordered
morphine and steroids right away
even before the x-rayand two nurses
made sure I got my meds promptly. The
shots didnt help much, but I appreci-
ated the sense of urgency.
Discharge: Something at the end of
the alphabet. While Helen went to fetch
clothing more substantial than under-
wear for my trip home, I was banished
to the waiting room touhwait.
If youd been there, you would have
seen this scary-looking barefoot guy
in a t-shirt and paper pantsthe best
the hospital could offer to preserve my
modesty. I looked like an extra from One
Flew Over the Cuckoos Nest.
Today is special: Its my frst day
back at work in more than a month.
I was supposed to wait another week,
but some of our people are in worse
shape than I am. No problem, Im
ready. Im eager to engage. I want to
show everyone I can do all the things
I did before.
Or maybe Ill just try standing up
straight.
Mike Rubin, BS, NREMT-P, is a
paramedic in Nashville, TN, and a
member of EMS World Magazines
editorial advisory board. Contact him
at mgr22@prodigy.net.
Talking Back
An on-the-job injury keeps giving forever
The thought of entering the systemthe
same system Id been a part of for so long
made me feel self-conscious and vulnerable.
58 FEBRUARY 2013 | EMSWORLD.com
Power-LOAD

For more information

800 784 4336 or
www.ems.stryker.com
PowerLOAD is available for shipment,
specications subject to change without notice.
Copyright 2012 Stryker
47 percent of medics have
sustained a back injury while
performing EMS duties.
Reduce the risk of injuries when loading and unloading
N
o
w

S
h
i
p
p
i
n
g
!

O
r
d
e
r

T
o
d
a
y
!
For More Information Circle 59 on Reader Service Card
800-257-3810 | www.masimo.com
2013 Masimo Corporation. All rights reserved.
1
EMMA Users Manual.
Worlds smallest portable
self-contained capnometer
EMMA (Emergency Mainstream Analyzer) is a fully self-
contained mainstream capnometer that requires no
routine calibration and virtually no warm up time.
1
With
rapid measurement of end-tidal CO2 and respiration
rate, EMMA can help providers guide ventilation rates and
assess the eectiveness of CPR allowing them to make
adjustments in the course of treatment, breath by breath.
Accurate from the First Breath
For More Information Circle 60 on Reader Service Card