Jems201206 dl

The
Conscience
of EMS
JOURNAL OF EMERGENCY MEDICAL SERVICES

56

I Stroke of the Clock I
‘Time is brain’ when treating stroke patients

By W. Ann Maggiore, JD, NREMT-P

June 2012 Vol. 37 No. 6

Contents
I 38

38 I Safety First I

Richmond Ambulance Authority creates comprehensive
culture of safety model
By Rob Lawrence, MCMI; Bryan S. McRay, BA; Dempsey Whitt,
NREMT-P/FP-C; Joseph P. Ornato MD, FACP, FACC, FACEP

Products 2012 I
I Hot
50 innovative new products

showcased at the 29th annual
JEMS EMS Today Conference Exposition

Departments columns
9 I Load go I Now on JEMS.com
14 I EMS in Action I Scene of the Month
16 I From the Editor I Is EMS a Game?
y A.J. Heightman, MPA, EMT-P
B

20 I Letters I In Your Words
22 I Priority Traffic I News You Can Use
26 I Train the Trainer I Sim for Students
y Al Kalbach, EMT-P
B

30 I Tricks OF the TRADE I Do No Harm
y Thom Dick
B

32 I case of the month I Difficult Airway

y Steven R. Allen, MD, Cayla G. Conover
B

36 I Research review I What Current Studies Mean to EMS
y David Page, MS, NREMT-P
B

66 I Hands On I Product Reviews from Street Crews
y Fran Hildwine
B

68 I employment Classified Ads
71 I Ad Index
72 I The Lighter Side I EPI Coasters

y Steve Berry
B
74 I LAST WORD I The Ups Downs of EMS

Aboutfrom Care Ambulance and an Orange County (Calif.) Fire Authority firefighter/paramedic
the Cover
EMS providers

assess a female patient in an ambulance in Santa Ana. Patients presenting with stroke can exhibit a variety
of signs and symptoms, including paralysis, sudden onset of confusion or loss of balance. Read “Stroke
of the Clock,” pp. 56–65, to learn more hallmarks of stroke, treatment options and a personal account of
how stroke can affect the lives of the victims and their families. Photo Vu Banh

Premier Media Partner of the IAFC, the IAFC EMS Section Fire-Rescue Med

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June 2012

JEMS

7

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Do you love your smartphone
or tablet? Device-lover and
EMS instructor Keith Widmeier,
NREMT-P, CCEMT-P, EMS-I,
does. So he rounded up some
of the latest EMS-related apps
available for Apple and Android
devices in four EMS-friendly categories. If you have an app-capable
device, “EMS Apps Assist Providers in the Field” might just help
you help your patients.

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But we’re much more
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s jems.com/article/technology/ems-apps-assist-providers-field

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54%

May
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Results

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celebrate EMS
Week?

17%

I recognize
it with
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I don’t even
know when
it is!

17%

My agency
hosts an
event.

polling our Fans

How long have you been in EMS?
p ess than one year.
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p years.
2–5
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JUNE 2012 JEMS

9

Conscience
of EMS

The
Conscience
of EMS

Editor-In-Chief I A.J. Heightman, MPA, EMT-P I a.j.heightman@elsevier.com
MANAGING Editor I Jennifer Berry I je.berry@elsevier.com
associate eDITOR I Lauren Hardcastle I l.hardcastle@elsevier.com
assistant eDITOR I Allison Moen I a.moen@elsevier.com
assistant eDITOR I Kindra Sclar I k.sclar@elsevier.com
online news/blog manager I Bill Carey I bill@goforwardmedia.com
Medical Editor I Edward T. Dickinson, MD, NREMT-P, FACEP
Technical Editors
Travis Kusman, MPH, NREMT-P; Fred W. Wurster III, NREMT-P, AAS
Contributing Editor I Bryan Bledsoe, DO, FACEP, FAAEM
Editorial Department I 800/266-5367 I editor.jems@elsevier.com
art director I Liliana Estep I alildesign@me.com
Contributing illustrators
Steve Berry, NREMT-P; Paul Combs, NREMT-B
Contributing Photographers
Vu Banh, Glen Ellman, Craig Jackson, Kevin Link, Courtney McCain, Tom Page, Rick Roach,
Steve Silverman, Michael Strauss, Chris Swabb
Director of eProducts/Production I Tim Francis I t.francis@elsevier.com
Production Coordinator I Matt Leatherman I m.leatherman@elsevier.com
advertising director I Judi Leidiger I 619/795-9040 I j.leidiger@jems.com
Western Account Representative I Cindi Richardson I 661-297-4027 I
c.richardson@jems.com
senior Sales coordinator I Elizabeth Zook I e.zook@elsevier.com
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SUBSCRIPTION DEPARTMENT I 888/456-5367
REprints, eprints Licensing I Wright’s Media I 877/652-5295 I reprints@jems.com
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Director of eMedia Sales I Paul Andrews I paul@goforwardmedia.com
Director of eMedia Content I Chris Hebert I chris@goforwardmedia.com
EMS Today Conference Exposition
reed exhibitions I Christine Ford I 203/840-5391 I cford@reedexpo.com
ems today exhibit sales I 203/840-5611
Jeff Stasko I jstasko@reedexpo.com
elsevier public safety
vice president/publisher I Jeff Berend I j.berend@elsevier.com
founding editor I Keith Griffiths
founding publisher
James O. Page
(1936–2004)

Choose 16 at www.jems.com/rs


The
Conscience
of EMS

EDITORIAL board
William K. Atkinson II, PHD, MPH, MPA, EMT-P
President Chief Executive Officer
WakeMed Health Hospitals
James J. Augustine, MD
Medical Advisor, Washington Township (OH) Fire Department
Director of Clinical Operations, EMP Management
Clinical Associate Professor, Department of
Emergency Medicine, Wright State University
steve berry, NRemt-p
Paramedic EMS Cartoonist, Woodland Park, Colo.
Bryan E. Bledsoe, DO, FACEP, FAAEM
Professor of Emergency Medicine, Director, EMS Fellowship
University of Nevada School of Medicine
Medical Director, MedicWest Ambulance
Criss Brainard, EMT-P
Deputy Chief of Operations, San Diego Fire-Rescue
Chad Brocato, DHS, REMT-P
Assistant Chief of Operations, Deerfield Beach Fire-Rescue
Adjunct Professor of Anatomy Physiology, Kaplan University
J. Robert (Rob) Brown Jr., EFO
Fire Chief, Stafford County, Va., Fire and Rescue Department
Executive Board, EMS Section,
International Association of Fire Chiefs
carol a. cunningham, md, FACEP, FAAEM
State Medical Director
Ohio Department of Public Safety, Division of EMS
Thom Dick, EMT-P
Quality Care Coordinator
Platte Valley Ambulance
Marc Eckstein, MD, MPH, FACEP
Director of Prehospital Care, Los Angeles County/
USC Medical Center
Medical Director, Los Angeles Fire Department
Professor, Emergency Medicine,
University of Southern California
Charlie Eisele, BS, NREMT-P
Flight Paramedic, State Trooper, EMS Instructor
Bruce Evans, MPA, EMT-P
Deputy Chief, Upper Pine River Bayfield Fire Protection,
Colorado District
Jay Fitch, PhD
President Founding Partner, Fitch Associates
Ray Fowler, MD, FACEP
Associate Professor, University of Texas Southwestern SOM
Chief of EMS, University of Texas Southwestern Medical Center
Chief of Medical Operations,
Dallas Metropolitan Area BioTel (EMS) System
Adam D. Fox, DPM, DO
Assistant Professor of Surgery,
Division of Trauma Surgery Critical Care,
University of Medicine Dentistry of New Jersey
Former Advanced EMT-3 (AEMT-3)
Gregory R. Frailey, DO, FACOEP, EMT-P
Medical Director, Prehospital Services, Susquehanna Health
Tactical Physician, Williamsport Bureau of
Police Special Response Team

12

JEMS

JUNE 2012

Jeffrey M. Goodloe, MD, FACEP, NREMT-P
Associate Professor EMS Division Director,
Emergency Medicine, University of Oklahoma School of
Community Medicine
Medical Director, EMS System for Metropolitan
Oklahoma City Tulsa

David E. Persse, MD, FACEP
Physician Director, City of Houston Emergency Medical Services
Public Health Authority, City of Houston Department. of Health
Human Services
Associate Professor, Emergency Medicine, University of Texas
Health Science Center—Houston

Keith Griffiths
President, RedFlash Group
Founding Editor, JEMS

John J. Peruggia Jr., BSHuS, EFO, EMT-P
Assistant Chief, Logistics, FDNY Operations

Dave Keseg, MD, FACEP
Medical Director, Columbus Fire Department
Clinical Instructor, Ohio State University
W. Ann Maggiore, JD, NREMT-P
Associate Attorney, Butt, Thornton Baehr PC
Clinical Instructor, University of New Mexico,
School of Medicine
Connie J. Mattera, MS, RN, EMT-P
EMS Administrative Director EMS System Coordinator,
Northwest (Illinois) Community Hospital
Robert J. McCaughan
Chief, City of Pittsburgh EMS
Chair, IAEMSC Metro Chief’s Section
Robin B. Mcfee, DO, MPH, FACPM, FAACT
Medical Director, Threat Science
Toxicologist Professional Education Coordinator,
Long Island Regional Poison Information Center
Mark Meredith, MD
Assistant Professor, Emergency Medicine and Pediatrics,
Vanderbilt Medical Center
Assistant EMS Medical Director for Pediatric Care,
Nashville Fire Department
Geoffrey T. Miller, EMT-P
Director of Simulation Eastern Virginia Medical School,
Office of Professional Development
Brent Myers, MD, MPH, FACEP
Medical Director, Wake County EMS System
Emergency Physician, Wake Emergency Physicians PA
Medical Director, WakeMed Health Hospitals Emergency
Services Institute
Mary M. Newman
President, Sudden Cardiac Arrest Foundation
Joseph P. Ornato, MD, FACP, FACC, FACEP
Professor Chairman, Department of Emergency Medicine,
Virginia Commonwealth University Medical Center
Operational Medical Director, Richmond Ambulance Authority
Jerry Overton, MPA
Chair, International Academies of Emergency Dispatch
David Page, MS, NREMT-P
Paramedic Instructor, Inver Hills (Minn.) Community College
Paramedic, Allina Medical Transportation
Member of the Board of Advisors,
Prehospital Care Research Forum
Paul E. Pepe, MD, MPH, MACP, FACEP, FCCM
Professor, Surgery, University of Texas
Southwestern Medical Center
Head, Emergency Services, Parkland Health Hospital System
Head, EMS Medical Direction Team,
Dallas Area Biotel (EMS) System

Edward M. Racht, MD
Chief Medical Officer, American Medical Response
Jeffrey P. Salomone, MD, FACS, NREMT-P
Associate Professor of Surgery,
Emory University School of Medicine
Deputy Chief of Surgery, Grady Memorial Hospital
Assistant Medical Director, Grady EMS
Kathleen S. Schrank, MD
Professor of Medicine and Chief,
Division of Emergency Medicine,
University of Miami School of Medicine
Medical Director, City of Miami Fire Rescue
Medical Director, Village of Key Biscayne Fire Rescue
John Sinclair, EMT-P
International Director, IAFC EMS Section
Fire Chief Emergency Manager, Kittitas Valley Fire Rescue
Corey M. Slovis, MD, FACP, FACEP, FAAEM
Professor Chair, Emergency Medicine,
Vanderbilt University Medical Center
Professor, Medicine, Vanderbilt University Medical Center
Medical Director, Metro Nashville Fire Department
Medical Director, Nashville International Airport
Barry Smith, EMT-P
CQI Coordinator, Regional EMS Authority (REMSA), Reno, Nev.
Walt A. Stoy, PhD, EMT-P, CCEMTP
Professor Director, Emergency Medicine,
University of Pittsburgh
Director, Office of Education,
Center for Emergency Medicine
Richard Vance, EMT-P
Captain, Carlsbad Fire Department
Jonathan D. Washko, BS-EMSA, NREMT-P, AEMD
Assistant Vice President, North Shore-LIJ Center for EMS
Co-Chairman, Professional Standards Committee,
American Ambulance Association
Ad-Hoc Finance Committee Member, NEMSAC
keith wesley, MD, facep
Medical Director, HealthEast Medical Transportation
Katherine H. West, BSN, MED, CIC
Infection Control Consultant,
Infection Control/Emerging Concepts Inc.
Stephen R. Wirth, Esq.
Attorney, Page, Wolfberg Wirth LLC.
Legal Commissioner Chair, Panel of Commissioners,
Commission on Accreditation of Ambulance Services (CAAS)
Douglas M. Wolfberg, Esq.
Attorney, Page, Wolfberg Wirth LLC
Wayne M. Zygowicz, BA, EFO, EMT-P
EMS Division Chief, Littleton Fire Rescue

EMS IN ACTION
Scene of the month

14

JEMS

JUNE 2012

Photo kevin Link

catching a fall

P

aramedics from Lethbridge Fire EMS in Lethbridge, Alberta,
Canada, begin their assessment of a pedestrian who fell from
a curb and became injured. The crew was confronted with a patient
who appeared to be under the influence of alcohol and who was not
able to adequately communicate with them. The crew performed a
complete primary and secondary assessment. Because the patient was
unable to communicate with them, they were unable to safely rule out
a spinal injury. They carefully immobilized and packaged the patient.
He was transported to a local hospital in stable condition.

www.jems.com

JUNE 2012

JEMS

15

from the editor
putting issUes into perspective

by A.J. HEIGHTMAN, MPA, EMT-P

Is EMS A Game?
Inefficiency can cost patient lives

16

JEMS

JUNE 2012

Photo istockphoto.com

Y

ou get called to a wedding rehearsal
dinner packed with excited family
members and friends of the brideand groom-to-be. The people are there to
celebrate the wedding of two of their favorite
people when, suddenly and without warning, the bride’s grandmother collapses with
nausea, weakness and respiratory distress.
You were right around the corner from
the restaurant when the call came in, so you
arrived in less than a minute. The crowd’s
emotions were already charged up before
this medical emergency occurred. Now, you
arrive and find the beautiful bride-to-be
screaming over “Nanna,” who’s lying on
her side, nauseous, vomiting and gasping
for air.
The bride-to-be’s grandfather and her
“daddy” (Nanna’s son), are all standing in a
circle around the woman when you reach
her and set down your oxygen bag, airway
case and medical kit.
In the game of life, the cards are already
stacked against you.
You, in your role as the lead paramedic,
kneel down to establish communications
with the 85-year-old patient and start an
assessment. She’s drooling and mumbling
incoherently, and she has a confused look
in her eyes as she tries to listen to you.
She exhibits right-sided facial droop and is
unable to follow your request to hold her
arms out straight and level. One side of her
body is clearly weaker than the other.
Your partner readies the cardiac monitor
and tries to politely place leads on her, but
he can’t get them all in place because her
dress, slip, girdle and bra are in his way. He’s
hesitant to cut them open and expose her in
front of her family. So he says, “I think I’ll
wait to hook her up and run a 12-lead when
we get her out to the rig.”
He turns his attention to spiking an IV
bag and readying it to administer to the
patient. He begins to slap her hand to find
a good vein to cannulate. He then says, “I
can’t find any good veins and can’t get to

Running a cardiac EMS call is similar to running a football play. EMS providers should be a well-oiled team.
her antecubital without cutting open the
tight sleeve of her dress.”
You say, “OK, give me a minute, and I’ll
take a look to see if I can find one.” Your
partner then kneels next to her with the
IV tubing dangling from his one hand and
an alcohol prep, IV catheter and tape in his
other hand, waiting for you to take a look.
Engine 52 arrives, and the crew walks
in without any extra equipment or the
ambulance stretcher. One of the firefighters cracks open the valve on your oxygen
(O2) tank, sets the regulator to 10 LPM, tears
open the plastic bag of a high-concentration
non-rebreather oxygen mask and fills it
with oxygen so it’s ready to deliver 80–90%
oxygen to the woman.
A police officer arrives with his own
O2 bag but places it down because he sees
that yours is already on the floor near the
patient. He then stands nearby with his
small notebook open, waiting to hear her
name and age for his police report. The
engine’s company officer stands next to

him with his computer open, waiting to
chart the care being given—as it’s being
given. Another firefighter stands near the
“O2 firefighter” and awaits orders from you.
The “O2 firefighter” dutifully stands by
and awaits the OK from you to place the
oxygen mask on the elderly patient who’s
now very weak, pale and diaphoretic. Early
signs of cyanosis are showing around her
vomit-laced lips. He seems to be waiting
for you to stop attempting communication with her before he places the mask on
her face.
The family and other nearby guests can
clearly see she’s in trouble. Then they hear
the lead paramedic say, “Where the hell is
the suction unit?”
The unassigned firefighter responds,
“Out at the rig. Do you want it?”
Suddenly, you hear the patient’s son
shout, “Of course he wants it! She’s got a
ton of vomit in her mouth.”
You pull the radio off your hip and radio
out to Engine 52’s driver/engineer, “Medic

FROM THE EDITOR
continued from page 16

21 to Engine 52 engineer, bring in the suction unit.”
Then you hear comments yelled from
the crowd:
Don’t just stand around. Do some“
thing for her.”
You brought all that crap in here, and
“
you don’t even have anything to clear
her airway out?”
Give her some oxygen. Why is that
“
fireman just holding that mask in his
hand? Put it on her face. She’s turning blue.”
Where’s the stretcher? They brought
“
in a computer and left the stretcher
outside.”
Quit playing doctor, she’s having a
“
‘stroke!’ Get her out of here!”
You’ve heard that last statement before,
and it makes your blood boil. You look at
the guy saying it and tell him, “Sir, I am not
playing doctor. I’m a paramedic trying to
take care of this woman. Please let me do
my job.”
His reply is, “I see what you and your
partner are trying to do, but everybody else
is standing around with their hands in their
pockets. Why are you two the only ones
working on her?”
It’s a rude awakening. His comments hit
you like a wet wash cloth.
You suddenly realize you’re in the middle
of a large crowd of people with a very sick
patient who’s clearly having a cardiovascular accident complicated by an unstable
airway, and only two of the seven responders on scene (28.5%) are actively involved in
patient care.
You begin to bark out orders.
To the O2 firefighter: “Suction her airway,

put that O2 mask on her and get an 8
endotracheal tube and large straight
blade ready for me.”
To the engineer: “Please get a few peo
ple to go out with you and get our
stretcher in here ASAP. And, while
you’re out there, tell dispatch to call
the stroke center and advise them we
are declaring a stroke alert and will be
there in 20 minutes.”
To the police officer: “Officer, please get a

tablecloth and use a few people to create a curtain to give our patient some
privacy while we cut her clothes open
to put electrodes on her and start a
humeral IO.”

18

JEMS

JUNE 2012

To the fire captain: “Captain, could you
hold off on charting, get the EZ-IO
drill out of our kit and ready it for my
partner please?”
To your partner: “Mike, cut her clothes,
get that 12-lead running, establish an
IO and draw some blood to check her
glucose level.”
Things begin to happen rapidly now. The
patient is cared for. Her frail body is covered
by a sheet and blanket, and you exit the restaurant with your precious cargo.
The woman’s husband is escorted to the
ambulance by the fire captain and told that
his wife is being taken to a specialty center.
He’s then buckled into the front passenger
seat of the ambulance to accompany her to
the hospital.
The police officer sees a large crowd of
“out-of-town” relatives piling into their cars
to attempt to follow the ambulance to the
hospital. He politely orders them not to do
so because it would be unsafe and tells them

weren’t happening quick enough.”

Lessons Learned
You walk away realizing there was a lot to
be learned from this call. You were operating
at only 28.5% efficiency and in an uncoordinated manner. You also realize that if it was
your grandmother lying on the floor and the
same approach was taken to her care, you’d
be upset like the patient’s son was.
At the station, the captain calls you all
together for a quick post-incident discussion
of the call and says that it wasn’t managed as
well as it could have been. He tells the crews
that this was an example of how they need to
function as more of a team on medical calls,
much like they do at a structure fire.
He compares it to a football team that has
to go out on the field and march down the
field in the last two minutes to score a winning touchdown.
He points out that, in football, each play is
planned and called in advance—like an ALS

You suddenly realize that you’re in the middle
of a large crowd of people with a very sick
patient who’s clearly having a cardiovascular
accident, complicated by an unstable airway,
only two of the seven responders on scene
(28.5%) are actively involved in patient care.
to follow his cruiser to the hospital.
After turning over your patient to the
hospital emergency department (ED) staff,
you come out to clean and restock your
ambulance and find a few of the crew standing around the back of the ambulance. One
pulls out a cigarette to have a smoke. Two
others are laughing about a skit they saw
the night before on Saturday Night Live.
As this is occurring, you see the family arriving and heading toward the ED
entrance. You tell the crews, “Folks, the
call’s not over until we’re out of sight of the
family. Let’s clean up and save all the nonwork related stuff for back at the station.”
The patient’s son then walks over and
thanks you and the rest of the personnel involved for taking such good care of
his mother. He apologizes for getting too
“wound up” at the scene but says he just
got upset because he felt like things “just

protocol—and everybody is expected to execute their assignment without the quarterback having to tell each team member who
they need to block, where to run or how to
hold the football.
The crew gets the analogy, understands
their inefficiencies and realizes that their
inactions, or delayed actions, could cost a
patient their life. They then agree to follow
the “pit crew” approach that the department’s EMS training coordinator has been
preaching for months.
In an odd, but practical, way, EMS is, in
fact, very much like a game. There’s always
an objective to each patient situation and a
prescribed action plan (and tasks) that are
developed in advance of “playing the game”
to enable the best, most organized and
methodical players to win.
The winner of the game of EMS is your
patient. JEMS

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FREE WEBCASTS
did you Miss a live webcast? Check out the archives at www.JEMS.com/webcasts.
• May the G-Force Be With You
• CPAP in EMS: The Standard of Care Argument
• Top 5 Ways an In-Vehicle Router Improves EMS Operations
Patient Care
• CPR Quality Improves Survival
• Breathe Deeply: How CPAP and Ventilation Can Help Your Patients
• Simulating Work: How to Effectively Incorporate Simulation
into Prehospital Care

• Connecting Care Teams and Collecting Data:
How it helps both you and your patient—The Houston
Experience
• Blast Injuries: What You Need to Know
• CPAP for Everyone!
• Effective Documentation in a Digital World
• How Mechanical CPR Devices Are Changing EMS Protocols
• Decide to Save Lives

• CPAP: Filling The Sails to Respiratory Relief

• Influenza: Is This an Emergency?

• Technologies Practices: Is EMS Driving Hospital Care?

• Top 5 Ways an In-Vehicle Router Improves EMS Operations
Patient Care

• Universal Capnography: What, When, How and Why!

Go to www.JEMS.com

LETTERS
in your words
This month, readers chimed in on
two feature articles: one from May
JEMS that discussed the prevalence
of bedbugs (“What’s Buggin’ EMS:
How to rid your rigs of a bedbug
infestation,” by Wayne Zygowicz,
BA, EFO, EMT-P) and one April
clinical education article on treating penetrating trauma wounds
(“Breaking the Surface: Arm yourself with knowledge about penetrating trauma,” by Bryan E. Bledsoe, DO, FACEP, FAAEM, EMT-P; Michael Casey,
MD, Ryan Hodnick, DO).
In addition to the interest these two articles garnered, a Street Science review on
JEMS.com by Keith Wesley, MD, FACEP Marshall Washick, NREMT-P, added to
the long-standing debate over the effectiveness of endotracheal intubation (“Study
Analyzes Use of ETI vs. King LT-D for Cardiac Arrest Patients).
Finally, we asked our Facebook fans to fill in the blank: “You know you’re a
medic when ______.” Read what they said.
Bedbugs Bugging You?
We have ambulances getting patients with bedbugs on a weekly basis. It’s become a huge epidemic among our “hometels” in San Diego. We
subcontracted with a company that comes out
and completely disinfects the entire ambulance
from top to bottom. This involves taking every
single piece of equipment out of the ambulance
that isn’t bolted to the ground.
They take you out of service immediately
after you notify a supervisor that you had a contamination. Four hours later, they put you back in
service. I suppose they’re using such an aggressive approach because a few of our fire stations
got infested with bedbugs after contact with a
patient. Gross.

ETI Debate
This study’s researchers have reanalyzed that first
attempt “placement” is more successful for King
LT-Ds over endotracheal intubation (ETI). There is
no data included in this study to support patient
outcomes with regards to cardiac arrest outcome
data. It’s certainly possible that a bag-valve mask
(BVM) plus an orophayrangeal airway (OPA) until
intubation is indicated in the patient would provide better end-result outcomes than either of
these options. Just because something is more
successfully inserted doesn’t mean it’s a better
option for use.

Lauren Dengate
Via Facebook

A pediatric study comparing ETI and King Airway
LT-Ds is about to be published in Prehospital
Emergency Care. It was a small study in simulated
patients, but it’s the first pediatric study looking
at the King Airway that I’m aware of. Examining

Tom Steiner
Via Facebook

illustration steve berry

Our department uses Tyvek suits for everyone,
including the patient. We carry a can of pyrethrum that we can spray down
the crew, inside a bus. Then,
we call an exterminator who
comes out who treats the
entire truck. Next, we strip
down and place our clothing
into a dryer on high for 30
minutes. We are placed out of
service for the duration. This is
a daily occurrence.

Jeffrey Mancini
Via Facebook


20

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JUNE 2012

020_021LETTERS.indd 20

6/15/2012 3:20:47 PM

There are simply too many providers with not
enough [endotracheal intubation] skills. It’s easy
to say ‘train more,’ but large departments are hard
pressed to have the time, money tracking ability to
keep medics properly trained.
alternative airways for pediatrics in the prehospital
setting is a perfect area for further research.
Alabama EMSC

be and leave the subtle politics out of it.
Andrew Friedman, NREMT-P
Leesburg, Virginia

Via Facebook

I would say ETI no doubt. It’s a tube that goes into
the trachea; King tubes rarely do. It’s a blind airway
device that’s fine for a rapid need to provide ventilation, but why not just use an OPA and a BVM?
We got rid of practicing rapid sequence intubation
because many couldn’t properly intubate, wouldn’t
cooperate with capnography or couldn’t figure out
that they tubed the stomach. I personally think
there needs to be a rigorous airway course in all
schools, and I also think all ALS agencies need to
drill on the importance of ETI, the proper techniques and the appropriate use.
Manda Lin

Author Bryan E. Bledsoe, DO, FACEP, FAAEM
responds: First, I am a hunter and a gun owner.
There was a great deal of discrepancy in these
numbers, and multiple sources were reviewed.
We had two weapons experts, one military and
the other civilian, review the document and they
made no comments. There appears to be a great
deal of irritability regarding this, and the purpose
was primarily to give relative examples—not be
totally precise in terms of ballistics.
The purpose of the article is more related
to penetrating trauma than ballistics, and in the
future it might be prudent to leave the ballistics
out. There was no hidden agenda.

Via Facebook

A King is obviously easier and causes minimal disruption of the most important part, which is CPR.
Endotracheal tubes are important when they’re
needed, but it depends on which medics are doing
the tubing. There are simply too many providers
with not enough skills. It’s easy to say “train more,”
but large departments are hard pressed to have the
time, money and tracking ability to keep medics
properly trained.
Stuart Rhinehart
Via Facebook

Surface Issue?
Let’s just stick to the science please. In the article,
it mentions “assault rifles.” Epic fail gang. Most
“assault” rifles are of smaller caliber than hunting
rifles. They’re nothing more than military-style
rifles, and the term “assault rifles” is a political term
that isn’t needed in a magazine like JEMS.
To nitpick some more, the ballistic charts are far
from accurate, nor do they list a source.
The AK 7.62 X 39 doesn’t come in 168 grain and
doesn’t achieve the optimistic figures you give it,
just as the 30-06 is bit more potent than you state,
and it’s a more common hunting round. This begins
to make me wonder if there is an agenda behind
this article because the numbers aren’t exact. So
let’s be accurate as a science-based article should

What MAkes a MEdic?
Eric Henry: You find yourself staring at everyone’s
veins, from family friends to total strangers.
Crystal Haynes: The term “frequent flyer” has
nothing to do with getting on a plane.
Tiffany Johnson Groves: You sit down with
your family at dinner, and your food is gone in 90
seconds flat.
Dylan Beickman: You run on a regular patient,
and play the game “how much of the patient
healthcare record can I complete before I
get there?”
Michael White: When you were an EMT, friends
always introduced you as a paramedic, and now
that you’re actually a paramedic, friends introduce
you as an EMT. Also, you know every homeless
person in town on a first-name basis and have no
problem having a casual conversation with them
even while you’re off duty, even while all your
friends are trying as fast as they can to get away.
Cheryl Menkhorst: You’ve stopped at a red light,
made sure it was clear and went through ... in your
personal car, followed by “oh crap, I am not in an
ambulance.” JEMS
www.jems.com

JUNE 2012

JEMS

21

PRIORITYUSE
TRAFFIC
NEWS YOU CAN

Breaking the RULES
Is it always a bad thing?

Types of Errors
LeSage stressed learning to identify and distinguish the three types of errors: human
error (HE), ARB and reckless behavior (RB).
LeSage is a proponent of not punishing individuals for HE or ARB. Instead, these are
coaching opportunities for management.
For example, LeSage introduced the severity outcome bias. He believes the natural
tendency is to punish employees for ARBs or
HE based on severe outcomes. More simply
stated, an entire agency might be pencilwhipping their checklists before the start

Photo istockphoto.com

P

aul LeSage, assistant chief (ret.) for
Tualatin Valley (Ore.) Fire and Rescue,
talked at the Fire-Rescue Med conference about high-reliability organizations
(HROs). He told a story about a law enforcement officer who accidentally shot a naked
man out of a tree.
The story goes that two law enforcement
officers were called to a large urban mall
where a naked man in a tree had drawn
quite the crowd. Fire and EMS was called to
standby. Law enforcement officers decided
they’d have to use a Taser to get the man out
of the tree.
They asked EMS what they thought about
that plan. “Awesome,” was their unified
response. The first officer aimed and missed.
He instructed his partner to shoot. She did,
and she hit the man. As he fell to the ground,
they realized she had mistakenly grabbed her
gun and not the Taser weapon.
LeSage explained that 74% of errors are
caused by a failure to intervene. EMS could
have realized this was a poor plan, but they
let law enforcement continue. More to the
point, the law enforcement personnel were
demonstrating at-risk behavior (ARB). One
of the factors in this situation was that the
law enforcement policy was to carry both
their weapons on the same side of their
body. Had the policy dictated wearing the
weapons on opposite sides, this story might
have had a different outcome.

best kind, according to LeSage, is
peer-to-peer coaching. If you can
get the entire system involved, it
may deter that behavior. Finally,
reckless behavior warrants punishment. Reckless behavior is a conscious disregard for a substantial
and unjustifiable risk. Although
LeSage believes these types of
errors are rare, they are the type
The idea of HROs originated in the Navy, to enable anyone to
that deserve punishment.
stop dangerous actions from occurring.
Again, the key is educating yourof their shift, but no one is punished until self, your staff and your external imposers
something goes wrong. LeSage says this how to differentiate between these errors.
just encourages an environment in which
employees hide their mistakes, leaving man- Event Investigation
agement with little understanding about the So your agency has an error. Now what?
problems in their agency.
Now comes the event investigation. LeSage
It’s a difficult balance of accountability says one of the biggest mistakes you can
vs. punishment. Not punishing employees make during the investigation is to first ask
sounds great in theory, but how do you the employee what the procedure requires.
satisfy an angry board of directors or city He suggested that the only people who
councilmen who want to see someone fall know the procedure manual back to front
on the sword?
are your new recruits. And what happens
when a new EMS provider says after a call,
“That’s not how we’re supposed to do it?”
Internal External Imposers
Instead of hammering out the policy
Internal and external imposers are those
who keep the rules. Externally, a lawyer that no one follows, the better approach is
may find the ARB or HE negligent, but the to identify what the normal procedure is.
internal imposer (e.g., chief) coaches the There’s likely an ARB occurring throughout
employee not to make the mistake again and the agency. LeSage introduces five quesensures proper training for the entire agency tions, numbered in both chronological
order and order of importance:
to reduce the ARB.
1. What happened?
The key to keeping those external impos2. What normally happens?
ers satisfied—which admittedly may be no
3. What does procedure require?
small feat—is to get their buy-in up front.
4. Why did it happen?
Involve these decision makers in your event
5. How were we managing it?
investigation. LeSage provided algorithms to
Following that line of questioning will
help determine the difference between HE,
allow internal imposers to identify the probARB and RB.
His system means HE results in counsel- lem, tie it to a current practice (likely an
ing. Explain to the employee that you’re ARB), reflect on the actual policy and prosorry the mistake happened but also tell pose a new solution. Numerous agencies
them they have an obligation to tell you across the U.S. are using this practice to minhow to avoid it from happening again and imize errors and learn from their mistakes.
identify the problem within the organiza- Keep an eye out for more about HROs from
tion’s training. ARBs require coaching. The LeSage on JEMS.com. —Lauren Hardcastle

For more of the latest EMS news, visit JEMS.com/news

22

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I

f you haven’t been affected yet, it’s probably just a
matter of time until you are. The national drug shortage is really starting to hit home for EMS agencies, and
there’s no relief in sight for the foreseeable future.
Nearly half of the drugs on a shortage list recently
released by the Federal Drug Adminstration (FDA) are
administered by EMS providers, and many of those
medications are used to treat seizures, cardiac arrests
and other life-threatening conditions that occur in the
prehospital setting.
As a result, many EMS agencies have been forced
to make hard choices among alternatives that range
from bad to worse. Some use alternative medications,
or even expired medications, in the face of this crisis.
Other agencies are simply waiting for direction from
their state or regional EMS agencies and hoping for
the best. But this raises an important question: Could
an EMS agency incur liability for taking these kinds of
actions or for failing to take any action at all?

General Rules
The more prepared you are to weather a drug shortage, the less likely you are to incur liability. Of course,
EMS agencies can never completely inoculate themselves from lawsuits. But devising clinical strategies
that best promote patient care in the event that critical prehospital drugs become completely unavailable
can decrease the likelihood of being sued successfully.
Fortunately, prehospital professionals are protected from liability if they act in good faith and
without gross negligence in most states. Some states
specifically provide immunity for EMS personnel if they
follow applicable protocols or medical direction from
an authorized physician, again presuming the EMS provider acts in good faith and without gross negligence.
Many states also provide similar liability protection for
the EMS agency itself, and for physicians who develop
protocols or provide medical direction, if such activities
are done in good faith and without gross negligence.
That means that in most states, a plaintiff will likely
have to prove that an EMS agency went far beyond
“ordinary negligence” if they want to successfully sue
the agency. But that may not be the standard in every
state, and the immunity statutes and gross negligence
standards may not apply to decisions regarding which
medications to carry.
Regardless of whether a simple negligence standard
or gross negligence standard applies, most courts will
ultimately look at things like whether EMS agencies
acted in the best interests of their patients, followed
applicable rules and protocols, and actually took reasonable and timely action when faced with a potential

drug shortage. Generally, courts understand we’re
often faced with circumstances beyond our control.
There may be circumstances for which there’s simply
no viable alternative to a medication that’s unavailable. In such cases, courts are often reluctant to
impose liability. But EMS agencies still need to prepare
for contingencies so that it’s clear what happens in the
event that there are no alternatives.

Protocols

Photo A.J. Heightman

Could EMS Drug ShortageS Present Liability Risks for the Industry?

State laws and local protocols may dictate how your
agency can address drug shortage concerns. For examIs your EMS agency at risk with how you manage
ple, in some states, medical directors are given wide the drug shortage crisis?
latitude in determining which drugs will be carried on
the ambulance and in developing local clinical proto- agencies and facilities. State ambulance or EMS assocols. In these states, alternative therapies that involve ciations may be able to help organize group purchasmore widely available medications can be more eas- ing options to increase EMS buying power. There are
ily implemented. In other states, changing a drug may also established purchasing cooperatives that may be
require going through a bureaucratic process that could able to help. Hospitals may have much better buying
power with drug manufacturers and can obtain prefertake several months.
States that rigidly regulate EMS drug lists, or have ence in purchasing drugs that are in short supply. Just
statewide protocols that include specific medica- make sure these agreements dictate that you’ll pay fair
tions, may need to invoke an emergency rule-making market value for the medications and have the agreeprocesses to respond to these challenges and allow ment reviewed by your legal counsel for potential Antitheir EMS agencies to continue to provide high-quality Kickback Law concerns.
Always follow laws and protocols: When considpatient care. Nevertheless, certain strategies can be
applied universally, and applying these strategies can ering and/or using alternative treatments and medications, or when using drugs with lapsed expiration
help reduce the risk of liability for EMS agencies.
Inventory frequently: EMS agencies should inven- dates, always adhere to applicable laws, protocols
tory all their drugs and check their expiration dates and medical direction. If there’s a way to relax those
on a frequent basis. Agencies should assign drugs with laws and protocols, pursue those avenues. Consider
more recent expiration dates to be used before those obtaining an emergency exception from the state if
with later expiration dates. It’s a good practice to look one is available.
Consider viable alternatives: EMS agencies, in
at historical usage rates for your organization so the
organization knows when it has fallen below a critical conjunction with their medical directors, need to be
level. Also, ensure medications are properly distrib- proactive in making protocol recommendations when
uted among vehicles and establish benchmark levels a drug is in short supply or when a drug will likely be in
for medications on each ambulance in adherence with short supply. Is there an equivalent medication that’s
safe? If so, consider any side effects and other contraapplicable laws and protocols.
Track shortages: EMS agencies should also assign indications of its use. If there’s a way to have medicaan individual or committee to track drug shortage tions approved beyond their expiration date, consider
information and trends on a local, regional and national this option. Or the agency may wish to consider using
level. The American Society of Health-System Pharma- compound medications.
Have a contingency plan: The
cists (ASHP) maintains the most current
Pro Bono is written by
agency should have a contingency
list of drugs in short supply and anticiattorneys Ryan Stark,
plan in place in the event there’s no
pated dates of resolution. You may also
Doug Wolfberg and Steve
drug, or viable alternative, available.
wish to work with state and regional
Wirth of Page, Wolfberg
Consider other treatments, besides
EMS agencies.
Wirth LLC, a national
medication, that might assist the
Work cooperatively: Other providEMS-industry law firm. Visit
patient. Work with medical direcers may have what you need. If state
the firm’s website at www.
tors to develop protocols that deal
law permits, consider implementing
pwwemslaw.com for more
EMS law information.
with worst-case scenarios. JEMS
purchase agreements with other EMS

Conduct a keyword search for “drug shortage” at JEMS.com for more information.

24

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JUNE 2012

Higher Learning Practice
Educational Theories Put into

by Al Kalbach, EMT-P

Sim for Students
Master the use of simulation in your classroom

E

MS has used simulation for decades in the form of CPR manikins, task trainers and standardized patients (i.e., real “victims”
moulaged and simulating illnesses and injuries).
However, with the advancement of high-fidelity (HF) manikins
and the use of standardized patients in critical-thinking exercises,
we’re now capable of offering scenarios that immerse students
and providers in real-world exercises. And it’s had great results in
improving the educational process and changing a lot of the traditional behaviors.
Case in point: the 2012 JEMS Games. The use of HF manikins
proved essential in providing a scenario that simulated a deterio-

rating patient and provided the participating teams a platform to
perform all necessary treatments in a realistic environment. The
Laerdal/JEMS folks strategically designed and implemented an integrated educational approach by creating an article about asthma
and announcing that asthma would be seen in the competition.
In conjunction with this new educational approach, Laerdal
provided its comprehensive Discover Simulation Toolkit to each
JEMS Games attendee. The teams obviously paid attention, which
emphasizes a key point of simulation: It’s designed to be constructive, not critical. Simulation is a safe place to learn, make mistakes
and take away positive reinforcement.

The Theory

S

imulation in healthcare is used for education, evaluation, research
and system integration.
The goal of this article is
to assist the instructor in building a relevant
scenario and providing a positive learning
experience for the student. We can divide the
simulation experience into the four “Ps:”
Prepare;
Practice;
Present; and
Post-review.

Learn your simulator’s capabilities: Many institutes and departments have purchased HF
manikins to augment their training program. Their use ranges from critical-thinking exercises to using the simulator as an
advanced “task trainer.”
Although all positively enforced training
is good, it’s recommended that the instructor
participate in training sessions offered by the
manufacturer, and simulation-based training
offered by such recognized organizations
as the Society for Simulation in Healthcare
(www.ssih.org), to understand the components of a successful simulation program.
Skilled educators and technical consultants are also available to assist with planning and developing simulation learning.
EMS conferences now regularly have simulation as a topic, so this can help the opera-

26

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JUNE 2012

photo glen ellman

Prepare

This year’s JEMS Games competitors demonstrated ALS skills on Laerdal’s HF manikins.
tor keep current on trends.
High-stakes risk assessment: Every training institute and department has its own
unique risks and encounters. A primary
goal of your simulations should be how
to address the high-stakes situations that
your students/EMS providers encounter. Is
there a trend your students are struggling
to grasp? Is there a new method or protocol you want them to learn? Has a prob-

lem been encountered that affects crew or
patient safety?
You can gather the information from
classroom and exercise performance,
patient charting/documentation, crew
reports, hospital/command feedback and
any stakeholder resource. Once the risk is
identified, you can begin to plan your strategy for a simulation exercise.
Critical-thinking points: No matter the exer-

Higher Learning

cise, critical-thinking points should be limited
to the main point of the exercise.
Let’s take the subject of identifying an
ST-elevation myocardial infarction (STEMI)
patient and transporting the patient to an
appropriate facility. The provider should be

able to do the following:
1. Identify STEMI;
2. now of and be capable of directing
K
appropriate care;
3. ommunicate with command physiC
cian and recommend STEMI alert; and

4. ommunicate well with receiving facilC
ity staff.
This example stays within the parameters
of care, treatment and transport of a STEMI
patient. It doesn’t add complications or “gotcha” points.

advanced cardiac life support and pediatric
ALS and standards.
This saves you from having to build these
programs from scratch. However, you should
ask yourself whether the program meets the
needs of your simulation education because if
it doesn’t, you’ll have to build or modify your
program to suit your specific needs.
Scenario building/environment: We emphasize that instructors need to be able to
program and operate their simulator efficiently. Sketch out your scenario into a
logical flow. Using a template or flow chart
is an ideal way to lay out the scenario on
paper. Check all sections for accuracy and
have your key instructors check and agree
that all points are included in the template.
Building scenarios in your simulator’s program: This will vary by each manufacturer
and even between models from any manufacturer. Consider your critical-thinking
points as key trigger points in your simulation. Other triggers can be skills and procedures that normally would be encountered
in the given scenario. Simulator manufac-

turers provide a good number of skills and
procedures, but you may want to add more
to meet your specific needs.
Running a program “on the fly:” This type of
program is completely manual. It depends
on the simulation operator to make all
necessary parameter changes and record
all critical-thinking and skills assessments.
Obviously, the operator needs to be familiar
with the simulator and its systems to be able
to run an “on the fly” program successfully.
This type of program can also be used for
situations in which a preprogrammed or
built scenario fails to advance and critical
parameters need to be changed.

The practice

S

kills: Simulators are
also valuable because
they can be used effectively to develop, maintain or augment various
lifesaving skills. This
can include the administration of drugs,
advanced airway care, medication and
most BLS and ALS skills.
Simulators have the ability for instructors to log skills in real time as they occur,
and some skills are automatically logged
by the program. The instructor can also
log in during the scenario run and make
comments that may aid in instruction after
the scenario is complete.
Pre-programmed scenarios: Many simulator
manufacturers have common, frequently
seen (and seldom seen) simulations for
clinical (medical and traumatic) cases, to
get you started.
They also offer programs you can purchase that are designed to meet the needs
of specific healthcare practices. For example, you can purchase programs that meet

Practice
Now that your simulation is operational and
loaded with key simulation scenarios, you
should do run-throughs with key instructors
and personnel to be sure that all key criticalthinking points have been met, correct procedures are implemented and all teaching
points are included. Running the program
will alert the instructor to possible conflicts
or errors in the program as well.
A checklist of critical-thinking points and
skills should be provided to each instructor
to ensure all training criteria have been met.
Use this “shake-down run” to ensure you
work out any bugs and eliminate surprises.

photo glen ellman

Presenting to the Masses

After starting the simulation, allow students to immerse themselves into the care of the patient.

28

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JUNE 2012

You’re now prepared to present your simulation to the learners. Make sure that everything they need to learn is presented in
advance and that all required equipment is in
place before you start.
The learner should be made aware of the
type of simulation they’ll be participating in
and given an outline of what’s expected of
them before they start.
Allow sufficient time for learners to check
equipment and environment for their comfort. It’s recommended to advise the students
to check their environment and ask any
questions they may have before starting.

Start the simulation and allow the students to immerse themselves
into the care of the patient. You should only interrupt if there’s a safety
concern or if the student(s) prompt you. If possible, it’s best for the
instructor to be in a separate room or other remote location where
you can view the entire process.
Let the scenario flow. You should have an on-screen checklist
of the points and skills you want covered. This will help you in the
debriefing process. The instructor running the simulation usually
acts as the voice of the patient via microphone and headset.
Video recording is another tool commonly used in the simulation
process. Students should be made aware they’re being recorded for
educational purposes only and that the video won’t be stored or used
to embarrass or show negative outcomes.

Post-Simulation Review
Student debriefing (review) should be accomplished immediately
after the scenario is concluded or as soon as feasible. Debriefing is
the process by which students interactively review their performance
after completing a simulation exercise. The procedure should be
guided by session objectives, course material and student comments
and questions. Instructors should serve as a resource and interject
goals and outcomes of the scenario in a positive manner, not act as a
lead voice in the debriefing process.
Instructors should debrief and review participants to reflect on
the presentation and its benefits in the learning process as soon as
possible after the simulation presentation. The instructor can have
debriefing files generated during the simulation. Some simulators
have the capability of recording video that synchronizes with the
debriefing file. Key points that occur can be marked in the file for
fast retrieval and playback during the debriefing.
In your review, consider the following:
ere the main critical thinking points covered in the simulaW
tion?
ere all skills addressed and completed?
W
id the participants respond appropriately to the presented
D
scenario?
ere crew and patient safety appropriate?
W
as there anything else that should have been covered to meet
W
the goals of the scenario?
hat’s the feedback from the participants?
W

Conclusion
Healthcare HF simulation is advancing and has joined the ranks of
aviation, space flight, military and other high-stakes roles. With the
continual advancement of computer science and simulation design,
we can provide a safe learning environment for EMS providers and
produce a more effective and efficient EMS system. JEMS
Al Kalbach, EMT-P, is a simulation specialist for Good Fellowship Training Institute in
West Chester, Pa. He’s also the owner of Safety Watch LLC. Contact via e-mail him at
al@safetywatchtraining.com.

Resources
https://ssih.org/about-simulation

www.jems.com/article/training/simulation-play-key-role-2012-jemsgames
www.jems.com

JUNE 2012

JEMS

29

TRICKSour patients ourselves
OF THE TRADE
caring for

by Thom Dick, EMT-P

Do No Harm

It’s important to not inflict unnecessary pain

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JUNE 2012

Photo Thom Dick

J

ust when you think you’re never going
to be surprised again in your life, you
get the surprise of your life.
I recently spent a week in a hospital
because I had to have an ankle removed.
I learned a ton, Life-saver. Then, I spent a
week in a skilled nursing facility (SNF) and
learned another ton. Gotta say, I received
some great care (and a renewed sense of
humility) in that SNF. You’ll probably be
reading about my stay there, someday. But
that’s another story. This one’s about something that happened in the hospital.
I’ve often marveled that the word “hospitality” is mostly made out of “hospital,”
and yet the staff in so many hospitals seem
to understand so little about hospitality.
(Small wonder there’s a joint commission.)
As evidence, I’d like to tell you about my IV.
That’s it, just the IV. I won’t bore you with
the rest of a very long list of observations
I made before and after the Versed part,
which came right after the IV. (I think.)
My wife and I reported to a surgery center, where a nurse named Karen gathered
my clothes and a whole lot of information
about me. Now, I have great veins. I know
that because they’ve all been found by student EMTs and medics. In particular, I have
great “intern’s” veins. (You know the ones.
They’re the veins formed by that big branch
of the cephalic vein that intersects with the
crease of the lateral wrist.)
Well, Karen started exploring the veins
on the backs of my hands before she settled on my left intern’s vein, which was so
prominent I could see its shadow. I don’t
know how she could have missed it with
that big 20, but she managed. Finally, after
poking, digging and stabbing, she nailed it.
I have hairy arms. I noticed Karen was
going for the IV without shaving the hair
on my wrist and thought maybe I should
say something. But I was too slow, so she
poked me and slapped an OpSite on top of
all that hair, then plenty of tape on top of
that. Writing this, I would like to tell you

Taking the time to shave a patient’s arm before starting an IV may seem simple, but they’ll appreciate it.
(and her what happened in the course of the
next five days.
On the day after surgery, the site had to
be re-taped because the IV became unstable.
To secure it, another nurse simply added
more tape (circumferentially, I might add).
The day after that, another nurse ripped
all the tape off (but left the original OpSite,
clinging only to my hair) and just replaced
the tape. When I asked her to moisten
the tape with alcohol before ripping it off,
she said she was too busy to do that. Two
days later, I mentioned to a fourth nurse
that the IV was falling out (again). By that
time, a lot of congealed blood was visible in
the tubing.
The nurse cleared the line by flushing it
and shoving the congealed blood into my
vein. I’m sure it’s now a space-occupying
lesion in one of my lungs. Then he asked if
I minded having a newly graduated nurse
start a replacement IV. I agreed, and within
five minutes, a pair of really young nurses
entered the room with an IV tray.
When they started ripping the
tape off, I asked them if they would
please moisten the tape with an alcohol prep. One of them kept on ripping, saying he didn’t have time for
that, so this time I insisted. Sure enough, the
alcohol soaked through the backing on the

tape, and within seconds it had softened the
adhesive. The tape came right off. But then
they treated me like a smart ass for making
the suggestion.
“Sorry,” I said. “I’ve started a lot of IVs in
my life, and I just know it works.”
That didn’t impress them, especially after
I asked them to shave the site this time. In
fact, one of them looked at me as though I
was being a jerk.
“You know,” he said. “We’re not students.
We’re nurses.”
“I’m just telling you,” I said. “It really hurts
when people rip that tape off of somebody’s
hairy skin. Not to mention the added risk
of infection.”
I know you start lots of IVs on hairy people. And sometimes when you do, you’re in
a real hurry. But do them a favor. Hell, do
me a favor. Give ’em the benefit of a onesecond shave.
They may never know the difference. In
that case, let me say this in advance. Thank
you! JEMS
Thom Dick has been involved in EMS for
42 years, 23 of them as a full-time EMT and
paramedic in San Diego County. He’s currently
the quality care coordinator for Platte Valley
Ambulance, a hospital-based 9-1-1 system in Brighton,
Colo. Contact him at boxcar414@yahoo.com.

CASE OF THE MONTH
DILEMMAS IN DAY-TO-DAY CARE

BY Steven R. Allen, MD Cayla G. Conover

Difficult Airway

Providers treat patient with multiple gunshot wounds

Assessment Treatment
Providers learned that the patient was allegedly in an altercation with another man outside a bar. The conflict became violent, and

the patient sustained multiple gunshots to his
chest and right thigh. The patient was unresponsive with labored breathing and unstable
vital signs. He did not present with signs
of external exsanguinations. In addition to
his hemodynamic instability, the patient was
noted to have crepitus over his left chest.
The patient was unresponsive and had a
Glasgow Coma Scale (GCS) score of 3. He
was unable to protect his airway, so providers
attempted an endotracheal intubation (ETI)
with a 7-0 endotracheal tube (ETT) by the firstarriving EMS crew. However, this was aborted
because of the patient’s strong gag reflex. The
patient was transported
to the landing zone,
where a PennStar flight
crew performed rapid
sequence intubation.
On the first attempt,
the patient was noted to
have a very swollen airway with poor visualization of airway landmarks.

The plain radiograph of the head and neck shows the bullet hole, which
is marked by the paperclip. The patient was transported emergently to
undergo a computed tomography (CT) scan with an angiogram of the
neck and left lower extremity to assess for vascular injuries of the neck
and injured leg, respectively.

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After two failed attempts with standard
laryngoscopy, the providers successfully
placed the ETT using the King Vision video
laryngoscope blade.
Successful ETI was confirmed with endtidal carbon dioxide (EtCO2), and breath
sounds were confirmed bilaterally. Providers
noted subcutaneous emphysema, which was
demonstrated with palpable crepitus over the
patient’s left chest and hemodynamic instability, which prompted needle decompression
of the left chest.
The patient’s vital signs improved with
these interventions. A rapid evaluation of his
wounds at the scene identified a single wound
just inferior to his left clavicle and multiple
wounds to his left thigh, all of which weren’t
actively bleeding. A C-collar was placed on
the patient, and he was transferred to the
flight stretcher and transported to the trauma
center by an air medical crew.

Trauma Center Care
On arrival at the trauma center, the trauma

Images Courtesy Steve Allen

A

fire rescue crew responded to a call
that described someone who was
reportedly “shot in the chest.” The
scene was secured by law enforcement before
EMS arrival. On arrival at the scene, EMS
providers discovered a patient reportedly in
his 30s who was unresponsive in the supine
position with multiple gunshot wounds to his
chest and extremities.

This CT scan shows the angiography of the neck. Note the degree of tracheal deviation due to hematoma and swelling.

team performed the primary survey and
placed the patient on the monitor to measure
vital signs. They recorded a heart rate of 106
beats per minute; blood pressure of 79/48
mmHg and EtCO2 of 31 mmHg.
During the primary survey, the trauma
team used direct laryngoscopy and color
change capnography during their primary
assessment to confirm the patient’s airway
was in the correct position.
Because the patient underwent needle
decompression of his left chest, a left tube
thoracostomy was immediately placed in the
standard fashion without a return of air or
blood. The patient was sedated after intubation and remained with a GCS of 3. Although
movement of extremities couldn’t be assessed
on this evaluation due to sedation, the patient
presented with priapism, which is concerning
for a spinal cord injury.
The wounds were again identified and
marked, and plain radiographs were obtained
to assess the trajectory. A single wound was
identified over the left chest just inferior to the
clavicle with a primary bullet fragment in the

This intra-operative photograph demonstrates the near-complete transection of the left common carotid
artery near the level of the clavicle.
midline of the neck. Two wounds were identified on the left thigh. There was no active
bleeding from the wounds.
The patient was transported emergently to
undergo a computed tomography (CT) scan
with an angiogram of the neck and left lower
extremity to assess for vascular injuries of the

neck and injured leg, respectively.
Cessation of blood flow was recorded in
the left common carotid artery with reconstitution above the bifurcation. The CT angiogram of his left leg was normal. The patient
was moved emergently to the operating room
for exploration of his neck to identify and

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Case of the month

repair the injury to the carotid artery and
assess for injuries to the trachea, esophagus
and surrounding structures.
The patient underwent a median sternotomy that was extended up onto the neck to
better expose the carotid artery. A destructive
injury of the common carotid artery at the
level of the clavicle was identified.
The carotid artery was controlled in the
chest and repaired with a saphenous vein
interposition graft. The trachea was assessed
and found to be uninjured. An endoscope
identified a small area of ecchymosis on the
esophageal wall. However, because of the
presumed injury and the patient’s inability to
eat for a prolonged period of time, a percutaneous feeding tube was placed in his stomach.
The patient was found to have a complete
spinal cord transection at C-6 with associated
quadriplegia. He suffered ventilator-dependent respiratory failure and required a tracheostomy for prolonged ventilator support.
He was weaned from the ventilator and discharged to an inpatient rehabilitation center,
where he continues to improve.

Discussion
ETI is the standard of care for definitive airway
management. Success rates of ETI in the prehospital setting vary significantly in the literature. The presence of a difficult airway in any
setting is a life-threatening scenario, which
requires significant skill and forethought with
other alternatives in the event that standard
strategies fail. Multiple reports have demonstrated higher incidence of unanticipated difficult intubations in the prehospital setting
compared to those in the operating room.
Although the incidence of difficult intubation is only 2% in elective anesthesia care,
the incidence in the prehospital environment
approaches 10%.1 Management of an airway
in the prehospital setting may be difficult for
many reasons:
The patient is in extremis, hemodynamically unstable or uncooperative;
The patient has particular injury patterns, such as fractures and trauma to the face
and neck with associated bleeding and swelling in and around the neck and orpharynx; or
The patient has emesis and aspiration.


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Although controversy surrounds the use
of ETI in the prehospital setting, there’s also
a body of evidence that demonstrates the
benefits in patient outcomes with prehospital intubation in patients with traumatic
brain injury, cardiac arrest and risk for loss
of airway patency or aspiration.2 Prehospital
providers must weigh the risks and benefits
to the establishment of an artificial airway.
Complications related to ETI include
unrecognized esophageal intubation with
associated hypoxia and hypoventilation,
oropharyngeal or tracheal injury or even
hyperventilation, which may lead to cerebral
ischemia.1 With these risks in mind, providers need to consider the risks of not establishing a definitive airway prior to transport
of the patient. In the case presented here, in
which the patient had labored breathing and
increased swelling of the patient’s neck, a
delay in airway control could’ve been a mortal decision because loss of airway patency
was imminent.
Multiple airway management algorithms
have been established. One study defines a

difficult airway as a failure of tracheal intubation after a single attempt in a patient with
a Cormack-Lehane class IV airway or two
failed attempts in a patient with a CormackLehane class of III or less.2
Most recently, a variety of video laryngoscopes (VLs) have been advocated to facilitate successful ETI in the case of a difficult
airway. The proposed benefit of using a
VL is improved visualization of anatomy
with improved graphics on the monitor in
contrast to the minimal view one may see
on a traditional laryngoscope—especially in
dark, austere environments.
Early studies have demonstrated quicker
intubation and improved success rates in ETI
with a VLs when used by medical students,
nurses and paramedics.1,3
However, these data are preliminary
and haven’t been reproduced. Other
studies have demonstrated the advantages of VLs in patients with difficult
anatomy compared with a Macintosh
laryngoscope. Although video-assisted
intubation may have its advantages, it’s not

recommended as a first-line technique in standard intubations.3

Conclusion
Penetrating wounds to the chest and neck
may present EMS providers with significant
challenges related to airway management.
It’s important to use sound judgment whenever a case requires definitive airway management because it’s key to act quickly to
secure the airway in cases involving traumatic brain injury or impending airway loss.
A difficult airway may be encountered in
those patients with penetrating injuries to
the head, neck or chest.
The provider must be skilled at ETI. In the
case that standard intubation is unsuccessful,
the provider must be able to use other means
to establish the airway, which may include a
bougie, laryngeal mask airway, video laryngoscopy or even a surgical airway. JEMS
Steven R. Allen, MD, is an assistant professor of surgery
at the University of Pennsylvania in Philadelphia. He’s board
certified in surgery and surgical critical care and practices

as a trauma surgeon and surgical intensivist. He can be
contacted via e-mail at Steve.Allen@uphs.upenn.edu.
Cayla G. Conover is an undergraduate student at
Temple University in Philadelphia. She’s a biology major
with plans to attend medical school.

References
1. Butchart AG, Tjen C, Garg A, et al. Paramedic
laryngoscopy in the simulated difficult airway:
Comparison of the Venner A.P. Advance and
GlideScope Ranger video laryngoscopes. Acad Emerg
Med. 2011;18(7):692–698.
2. Warner KJ, Sharar SR, Copass MK, et al. Prehospital
management of the difficult airway: A prospective
cohort study. J Emerg Med. 2009;36(3):257–265.
3. Dupanovic M, Fox H, Kovac A. Management of
the airway in multitrauma. Curr Opin Anaesthesiol.
2010;32(2):276–282.

Resources
Combes X, Jabre P, Margenet A, et al. Unanticipated
difficult airway management in the prehospital
emergency setting: Prospective validation of an
algorithm. Anesthesiology. 2011;114(1):105–110.

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RESEARCH REVIEW ems
What current studies mean to

by David Page, MS, NREMT-P

Epinephrine’s Effects

Study examines drug’s influence on cardiac arrest survival
Hagihara A, Hasegawa M, Abe T, et al. Prehospital
epinephrine use survival among patients with outof-hospital cardiac arrest. JAMA. 2012;307(11):1161–1168.
pinephrine has been the mainstay of
cardiac arrest management for decades,
but is it effective? These authors used a
Japanese national database of prospectively
collected cardiac arrest data to see whether
epinephrine was associated with positive
outcomes. This analysis included 417,188
arrests between 2005–2008.
Return of spontaneous circulation was
observed in 18.5% of patients who received
epinephrine (2,786 of 15,030), and 5.7%
(23,042 of 402,158) of patients who didn’t
receive epinephrine.
The overall survival rate for the epinephrine group was 5.4%, but only 1.4% had good
neurological outcomes. The non-epinephrine
group had a 4.7% survival rate, and 2.2% had
good neurological outcomes.
Although this study sampled a large
number of patients and was published in
a prestigious medical journal, we need to
be careful about the conclusions we draw
from it.
The authors discuss some major limitations: Japanese EMS personnel started
giving epinephrine in 2006, but the data
doesn’t include the amount that was given.
Hospital care was variable. The authors
don’t know whether in-hospital epinephrine was given or whether therapeutic
hypothermia was used.
I also think the study needs information
on immediate conversion of v fib and v
tach without prolonged resuscitation, rate
of compressions, mechanical compression/
decompression, ventilation rates, oxygen
administration, excessive pauses and use of
an impedance threshold device.
Effective, outcome-driven cardiac arrest
management is multi-factorial. The authors
addressed the need for a randomized
placebo controlled trial, and I completely
agree. Obtaining ethics board approval for

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Photo david page

E

Researchers examined whether epinephrine was associated with positive cardiac arrest outcomes.
a trial of such a standard medication as
epinephrine will be challenging. We should
applaud these authors for taking another
step to lay the groundwork for more intentional studies in the future.
The bottom line is we should remind
ourselves that all interventions come with
unintended consequences. We need to continue with practicing the status quo, but we
also need to be careful with epinephrine
and get more involved in research.

Bottom Line
What we know: Epinephrine is used widely.
Studies in 2007 and 2009 showed increases in
ROSC but not in survival to hospital discharge.
What this study adds: This study provides
evidence that epinephrine is associated with
ROSC but not with survival to discharge.

I IV Analysis I
Selker HP, Beshansky JR, Sheehan PR, et al. Outof-hospital administration of intravenous glucoseinsulin-potassium in patients with suspected acute
coronary syndromes: The IMMEDIATE randomized
controlled trial. JAMA. 2012;3;307(18):1925–1933.

B

y way of disclosure, I want to state that
one of my medical directors is involved
in this study. So I claim immediate bias
and conflict of interest, but I still think it’s
a good idea to report on this study and
its results, especially because this column

previously reported the initial use of the
“ACI-TIPI” predictive ischemia scale used
in this trial. (Search JEMS.com for “research
review.”)
The group of researchers studied the
use of glucose insulin and potassium (GIK)
to protect from myocardial injury during
acute coronary syndromes. The idea was
to give agents that might protect the cells
from metabolic derangements (promoted
by elevated free fatty acids, or FFAs) and
reperfusion injury. Cellular FFAs and their
derivatives are believed to accumulate during ischemia, disrupt the mitochondria,
increase intracellular calcium and promote
arrhythmias. GIK might be a relatively safe,
cost effective and plausible way to begin
prehospital treatment.
The original goal of this study was to
enroll more than 15,000 prehospital
patients because the benefits were thought
to be dependent on early administration.
Unfortunately, the National Institutes of
Health changed the study due to the lack
of resources and funding to include in-hospital administration, and enrollment was
curtailed at 880 patients. One-year outcome
data is still being collected. So the final data
isn’t yet available.
For now, this paper reports that GIK
didn’t seem to stop further myocardial
damage (i.e., no statistical difference was
found in the patients who progressed).
The authors suggest this may be because

the medication wasn’t administered
early enough because the damage had
already started.
Interestingly, although not statistically
significant, the mortality rate at 30 days
was 4.4% with GIK and 6.1% without GIK.
If we add a composite end point of cardiac arrest in combination with mortality
(e.g., patients who arrest, as well as those
who died), then the difference would be
statistically significant (6.1% with GIK and
14.4% without GIK; P=0.01). GIK needs to
be tested more, but it appears that it may be
a safe and effective therapy to decrease cardiac arrest and death in patients with acute
myocardial infarctions.
I Emotion Work I
Williams A. A study of emotion work in student
paramedic practice. Nurse Educ Today. 2012;Apr 2
[Epub ahead of print].

T

oo often we focus on research that’s
quantitative (research that attempts
to measure something numerically).
Qualitative research is focused on descriptive and human factors. In this project,
Williams interviewed eight paramedic
interns in England. The objective was to
describe the emotions and coping mechanisms that a new paramedic student has
when they’re faced with cardiac arrests and
other critical cases.
This study is a great reminder that our
new clinicians need support as they’re
involved in new critical events. They
observe these through the lens of a novice,
like a magnifying glass that accentuates
their emotions and reactions. Williams discusses two main themes: “getting on with
the job” and “struggling with emotion,” the
latter of which relates to students struggling
to control and suppress their emotions.
Educators beware: It’s essential for you
to prepare for and support your students
through these emotions. JEMS


Visit www.pcrfpodcast.org for
audio commentary.
David Page, MS, NREMT-P, is an educator
at Inver Hills Community College and a
paramedic at Allina EMS in Minneapolis/
St. Paul. He’s a member of the Board of
Advisors of the Prehospital Care Research
Forum. Send him feedback at dpage@ehs.net.

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Richmond Ambulance
Authority creates
comprehensive culture
of safety model

The Richmond Ambulance Authority has
worked hard to create and foster a culture
centered on safety in all areas.

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By Rob Lawrence, MCMI; Bryan S. McRay, BA;
Dempsey Whitt, NREMT-P/FP-C; Joseph P. Ornato,
MD, FACP, FACC, FACEP

T

he Institutes of Medicine’s landmark publication
To Err is Human estimates that at least 44,000 and
perhaps as many as 98,000 Americans die in
hospitals each year as a result of medical errors.1
And hospital patient safety incidents account for $6 billion
in extra costs annually in the U.S.2 Is EMS any different?
In a 2002 Prehospital Emergency Care study, the authors
wrote a consensus statement that represented the views
of several respected operational medical directors regarding the national state of EMS safety.3 The group identified
common EMS errors and concluded, “Standard operating
procedures to prevent and recover from such errors in
the field are in their infancy.” Shortly thereafter, several
researchers conducted a survey of 283 EMS providers
attending a North Carolina EMS conference and found that
one or more errors had occurred during the previous year
in 44% of those surveyed.4 However, only half of the errors
were reported to their supervisor or medical director.
In 2008, two authors wrote an editorial calling for the
establishment of a national center for EMS provider and
patient safety.5 A national center doesn’t exist yet. However,
a number of local and state initiatives, such as the Missouri
Center for Patient Safety, are beginning to focus on at least
some aspects of safety in EMS.
This article describes the comprehensive, multidimensional safety program developed and implemented
at the Richmond Ambulance Authority (RAA), a highperformance EMS system serving Richmond, Va.

RAA is a self-operated public utility model EMS system
employing a system status management approach to its
deployment, command, control and communications. It’s
a member of the Coalition of Advanced EMS Systems and
is accredited by both the Commission on the Accreditation
of Ambulance Services and the National Academy of
Emergency Medical Dispatch as an Accredited Center
of Excellence.
RAA employs unit hour utilization (UHU) as its
currency to ensure that all available income is transformed into helping deliver world-class EMS. A
unit hour is equal to one hour of service by a
fully equipped and staffed ambulance available
for dispatch or assigned to a call. UHU is a
measure of productivity, which compares the
available resources (i.e., unit hours) with the
actual amount of time those units being
used for patient treatment and transport or

Photos Richmond Ambulance Authority

Transformation to AN EMS Culture
of Safety

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Safety First

productive activity. UHU is the
measurement of unit hours “conTaking Safety to the
sumed” in productivity compared
Streets 2011 Data
with the total staffed unit hours. In
Fatality rate for EMS providers
simple terms, UHU monitors the
is 2.5 times higher than the
provision of resources available in
national average.
the right quantity, at the right time
Non-fatal injury rate for EMS
practitioners is five times
and in the right place to perform,
higher than the rate for other
treat and transport efficiently.
healthcare providers.
Conceptually, RAA operates
EMS providers are seven times
within a total quality and safety
more likely than the average
bubble, employing lessons learned
worker to miss work as result of
an injury.
from other high-quality, safety-oriented industries, such as nuclear
• Transportation-related Fatalities
and aviation.
(per 100,000)
In 2008, RAA’s operational
National average: 2.0
medical director, a pilot with first Firefighters: 5.7
Studies comparing and contrasting EMS with both national and public
Police officers: 6.1
hand experience in how aviation
safety incident data reveals a telling story and provides focus in the immehas achieved a high level of safety, insti- EMS practitioners: 9.6
diate need to develop and embrace a safety culture across EMS.
gated a successful error self-reporting
• Fatal Occupational Injuries
program patterned after the Aviation
non-work related governing emergency driving and RAA’s 12
(per 100,000)
Safety Reporting System (ASRS) devel- National average: 5.0
injuries
and standards of driving adopted from the Allsafe
oped by the National Aeronautics Firefighters: 16.5
miss 10 shifts or Driving System.
and Space Administration (NASA). Police officers: 14.2
more must pass
Focus on safe vehicle operation is main EMS providers: 12.7
The NASA system was designed to
the PAT before tained through consistent reiteration of the
detect all near misses and to translate
they’re cleared to 12 standards of driving via periodic safety
lessons learned into operational process permanently return to work.
campaigns as well as safety talking points
changes rather than blaming individuals for
highlighted by field providers and safety and
human errors.
risk staff during everyday operations. Checks
Induction to the Organization
RAA’s approach to safety pervades all lev- Introducing, developing and embedding a and balances are kept on drivers via an onels and departments, from the frontline to the culture of safety are core functions of the board road safety system. The “black box
back office. This starts in the pre-hire phase. new employee orientation program. The ini- technology” interactively monitors preset
Conceptually, RAA also looks ahead to plan tial classroom-based induction covers scene driving parameters, giving the vehicle operaand anticipate the next set of safety issues that safety, the operating principles of all of RAA’s tor immediate feedback through the use of
may arise.
key pieces of equipment, safe and skilled audible tones. Monitored parameters include
operation of vehicles, and correct appropriate
patient transfer techniques.
Pre-Hire Process
All new employees are immersed in safety
RAA’s approach to safety begins even before
the employees receive an offer letter. RAA from orientation through field preception.
contracts with an occupational health ser- For 26 shifts, RAA’s field training officers
vice that conducts a pre-hire physical agility carry on where the classroom left off, providtest (PAT) on all field operations candidates ing practical instruction and leadership by
to determine their existing muscular skeletal example in a controlled environment, ensurstrength, which is often predictive of future ing that providers are prepared to operate
physical problems, such as a back injury. The safely as RAA crew members. RAA instruccomputer-based system RAA has used for the tors also teach the National Association of
past two years has proven to be an effective EMTs’ safety course to its employees.
predictive tool.
For example, RAA now factors the PAT Safe Driving
results into its decision whether to offer New hires are required to be emergency vehiemployment to an applicant. Some highly cle operator course (EVOC) qualified prior
qualified candidates have failed to make it to employment at RAA. From this baseline,
to the initial New Entry Orientation because safe and skilled vehicle handling is built on
they haven’t met the PAT requirements. with the successful completion of the inAs a prudent risk-reduction measure, staff house driver training program. This program RAA uses data and reports to identify and correct
members who have suffered either work or includes a review of EVOC material, state laws potential safety issues before they occur.

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seatbelt compliance, lights and sirens usage,
acceleration and deceleration forces, turn signals and safe vehicle reversing.
The latter feature also requires the use of a
spotter who activates a reverse button located
in the rear of the vehicle to alert the driver of
any hazards. A weekly league table of emergency and non-emergency driving that scores
vehicle operators is produced. In the rare
event of a vehicle collision, road safety data
is downloaded to analyze the activity of the
vehicle at the time of the incident. This ability
to instantly review the incident helps create a
clear picture of what occurred, which allows
RAA to fully understand the root cause of the
incident so the operational changes can be
made to prevent a recurrence.

just regarding patient care but also regarding
vehicular safety.
The driver and the paramedic crew member are both responsible for the vehicle’s
safety. They must work as a team to coordinate navigating to calls, obtain additional
information from the mobile data terminals, work the siren and communicate on
the radio. The single most important thing
employees can do for their patients and for
themselves is to have both sets of eyes looking
outside the unit as much as possible.
Crews are discouraged from performing

any tasks during the response phase that
aren’t absolutely critical to the current call.
This is similar to the “sterile cockpit” rule used
in aviation, which dictates that a crew isn’t
allowed to have non-task critical conversation or distracting activity during the takeoff,
approach and landing phases of flight.

Safety All Day Every Day
RAA’s operations are designed with efficiency and effective response in mind. The
by-product of this planning is safety. We’re
convinced that lights and sirens responses

Self-Reporting Program
The RAA self-reporting program provides an
employee who makes a mistake the opportunity to report that incident without fear of
punitive action, as long as it’s not a criminal
act. Once reported, an investigation and root
cause analysis are conducted by the clinical
safety review committee, which is chaired
by the operational medical director and
attended by the chief operating officer, chief
clinical officer and director of safety and risk.
The goal is to identify whether a systemic
issue needs to be addressed. As in the ASRS,
an individual who self-reports is deemed to
have an appropriate, positive attitude regarding safety and won’t have punitive action
(including termination) taken against them
provided the action:
Was reported promptly;
Was inadvertent and not deliberate;
Wasn’t a criminal offense;
Wasn’t due to a substantial lack of qualification or competency; and
Wasn’t repetitive.
Training, remediation and changes in
protocols, processes and procedures typically result from self-reports to minimize the
likelihood that a similar incident will occur
involving any provider in the future.

Reducing Risks
The greatest risk and exposure to fatal
vehicular accidents occurs during the
response phase of any call. The team effort
to deliver each vehicle and its crew to a call
safely is of paramount importance. RAA
emphasizes crew resource management
(CRM) in its training and operations, not

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Safety First

Table 1: Standard Driving Report for July 25–31, 2011
Total Driving: 17,138 miles
Emergency Driving: 2,217 miles
Non-Emergency Driving: 14,921 miles
Average Daily Fleet Speeds (mph)
Date
Total
Emergency Non-Emergency
7/25
28
28
28
7/26
27
26
27
7/27
31
26
32
7/28
28
27
28
7/29
25
25
25
7/30
26
29
26
7/31
29
29
29

reduce musculoskeletal injuries. An outward
success in the past year has been the purchase
of pneumatic lifting cushions. Patients are
placed and then elevated by compressed air
to a sitting position, from which they can be
assisted to their feet. RAA is currently equipping its entire fleet with powered stretchers to
reduce the amount of lifting required. Better
back care is an issue RAA takes seriously in
its effort to reduce staff injuries and attrition.
One role of RAA’s operational team is to keep
the workforce rested and prepared for the
rigors of busy shifts, so RAA’s scheduling and
shift-building rules prevent a member of staff
from returning to work within eight hours of
their last shift.

should be used sparingly—and only when
medically justified—to reduce the risk of
vehicular accidents. Instead of basing units
at fixed locations and requiring fast driving, Communication
RAA uses system status management to RAA’s philosophy is that communication
place units to post locations throughout the isn’t a skill reserved for the radio. Root cause
city dynamically based on computer predic- analysis in aviation as well as EMS frequently
tions of where the next most
likely life-or-death calls will
occur. This has proven to
be highly accurate using historical data factoring in the
time of day, day of the week,
and month.
The result is that RAA’s
ALS units arrive on scene in
less than or equal to eight
minutes from the time of
A team effort is essential for implementing a safety culture.
the call receipt 93–96% of
the time in all sectors of its service area on identifies a lack of communication between
life-threatening calls, despite the fact that crew members on a day-to-day basis as a
our average fleet speeds aren’t much differ- significant contributory factor to safety incient between emergency and non-emergency dents. RAA’s supervisors and managers train
responses (see Table 1 ).
crews to have open, frank and honest diaA response to calls in which dangerous logue with each other any time any issues—
activity is suspected enacts the call staging even seemingly minor ones—occur.
safety procedure. Crews are required to wait
We also stress the importance of CRM,
off scene until the area is cleared and deemed making it clear that each crew member has
safe by police. Similarly, a crew on scene the responsibility to speak up promptly
potentially compromising their safety has the within the chain of command whenever
discretion to evacuate and await further back they have a concern that something isn’t
up. All crew members have personal radios quite right. This is especially true if it might
equipped with mayday buttons that issue a constitute a safety risk to the patient or
silent alarm to dispatch and place the radio responding personnel.
into continuous transmit mode. A mayday
triggers an immediate top priority police Measuring Safety Success
response to the ambulance location, which RAA’s transformation to a culture of safety
is constantly monitored in dispatch using culture is an ongoing journey. Its mission is to
RAA’s automatic vehicle locator system.
provide world-class EMS, and we recognize
Regarding the more common situations of we can’t do that without striving to be among
lifting and moving a patient, RAA is always the safest EMS agencies in the world. Success
looking for better devices and techniques to must be measured on multiple dimensions,

42

JEMS

JUNE 2012

both for employees and patients.
RAA has reduced worker’s compensation injury claims since it began a “culture
change,” which reduced our NCCI experience
modification factor (an insurance premium
adjustment that recognized the merits or
demerits of individual risks) from 1.04 to
0.83. This translates into a 20% premium
reduction. RAA’s insurance carriers use RAA
as a model of a best practice, and they refer
clients with similar operations to RAA for
information.
Finally, for RAA, overall success is defined
by keeping the promises we make to employees during orientation: “Our primary goal is
to get you home in the same way you came to
work. No injuries and no illnesses. You may
be sore and tired, but you aren’t hurt or sick.”
We work hard each day to meet or exceed
this challenge. JEMS
Rob Lawrence, MCMI, is chief operating officer at
Richmond Ambulance Authority and was named a JEMS
EMS 10: Innovator of EMS for his work on the Rider Alert
program in 2011.
Bryan S. McRay, BA, is the safety and risk director for Richmond Ambulance Authority. He has been
involved in EMS for 22 years both in volunteer and
career agencies. He’s currently pursuing his master’s in
Public Administration.
Dempsey Whitt, NREMT-P/FP-C, is the director of
operations for the Richmond Ambulance Authority and
serves in the Virginia Army National Guard’s 29th Infantry
Division as the chief medical non-commissioned officer.
Joseph P. Ornato, MD, FACP, FACC, FACEP, is professor
and chairman of the Department of Emergency Medicine
at Virginia Commonwealth University and Operational
Medical Director for the Richmond Ambulance Authority.
He’s also a member of the JEMS Editorial Board.

References
1. Institute of Medicine. To Err is Human: Building a
safer health system. Washington, D.C.: The National
Academies Press, 2000.
2. Levenson D. Hospital patient safety incidents account
for $6 billion in extra costs annually. Rep Med Guidel
Outcomes Res. 2004;15(16):1–2,6–7.
3. O’Connor RE, Slovis CM, Hunt RC, et al. Eliminating
errors in emergency medical services: Realities and recommendations. Prehosp Emerg Care. 2002;6(1):107–113.
4. Hobgood C, Bowen JB, Brice JH, et al. Do EMS personnel identify, report and disclose medical errors?
Prehosp Emerg Care. 2006;10(1):21–27.
5. Paris PM, O’Connor RE. A National Center for EMS
provider and patient safety: Helping EMS providers
help us. Prehosp Emerg Care. 2008;12(1):92–94.

50 Innovative
new products
showcased
at the 29th
annual JEMS
EMS Today
Conference
Exposition
This year at the EMS Today Conference and Exhibition, a team of judges
reviewed and evaluated numerous
new products and innovations in EMS
equipment, vehicles and programs on
display by the nearly 300 exhibitors.
These products were released to the
EMS market within the previous eightmonth period.
They reviewed products designed
to not only improve your ability to
deliver optimal emergency medical care
to sick and injured patients, but products that also allow you to do it safely,
more efficiently and with enhanced
comfort for the patient.
The review team rated each of
the new and innovative products on
their originality, functionality, ease of
use and need in the EMS setting. Their
selection of the 50 hottest products
at EMS Today 2012 are presented here
in random order for you to check out.
Look for additional coverage of many
other products reviewed in upcoming
JEMS Hands On columns.

44

JEMS

Hot Products

JUNE 2012

Rip Shears
info@ripshears.com
www.ripshears.com
RIP SHEARS is an innovative, compact, removable dual-blade cutter that attaches to almost
any size and style trauma shears. It enables
you to more rapidly remove the toughest and
thickest clothing and turnout gear in seconds.
Once you insert it in an opening, or start a cut
with the shears, all you have to do is pull it
through the material and it zips through it like
a hot knife through butter. The replaceable
blades used in the RIP SHEARS are made of
440 surgical-grade stainless steel that improve
your cutting ability and sharp-edge retention
and will last five times longer than standard
carbon blades.

LOLA Advanced
Assessment
818/530-7900
www.lolaadvanced.com/about-us/

The LOLA Advanced Assessment stethoscope is an innovative tool that combines multiple patient assessment tools into one package:
the stethoscope, penlight, pupil gauge and ruler.
Each stethoscope comes with a clear set of comfortable earbuds, three extra pairs of earbuds and
an extra battery for the light. The stethoscope
head is stainless steel, and the tympanum is a
clear plastic. A push button located conveniently
on the top of the head activates the LED light. A
pupil gauge with examples of pupil sizes from 1–8
mm is located right on the LOLA stethoscopes
non-latex tubing, making it easy to see and use.
There’s also a 40 cm ruler printed on the tube,
complete with millimeter markings.

Karl Storz Endoscopy
America Inc.
424/218-8712
Bernd.bay@karlstorz.com
www.karlstorz.com
Karl Storz offers the portable C-MAC Video Laryngoscope, which has virtually no learning curve
owing to its use of standard Macintosh and Miller blades for adults through neonates. The new
C-MAC Pocket Monitor now offers even more portability as it sits right on the laryngoscope
handle and can be used with all existing durable stainless steel C-MAC blades. The screen is movable and can be folded to the side of the laryngoscope for transportation and storage.

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