Jan 2016

Visit us online at EMSWorld.
com
JANUARY 2016 | VOL. 45, NO. 1 $7.00
Offshore Helicopter
EMS Operations
CHI Aviations Sikorsky S-92 is a
combination rescue truck and
critical care transport ambulance
p. 60
EMS Compass
Update
p. 24
ACE InhibitorRelated
Angioedema
p. 41
Community
Paramedics and
the Drug-Seeker
p. 56
For More Information Circle 10 on Reader Service Card
EDITORIAL ADVISORY BOARD

Peter Antevy, MD
CEO & Founder, Pediatric Emergency
Standards
Tim Hillier, Advanced Care Paramedic

Director of Professional Development, M.D.
Ambulance, Saskatoon, SK Canada
Tim Perkins, BS, EMT-P

EMS Systems Planner, Virginia Office of
EMS, Virginia DOH, Glen Allen, VA
James J. Augustine, MD, FACEP

Medical Advisor, Washington Township Fire
Department, Dayton, OH; Clinical Associate
Professor, Department of Emergency
Medicine, Wright State University, Dayton,
OH; Director of Clinical Operations, US
Acute Care Solutions
Lou Jordan
PIO, Fire Police Officer, Union Bridge (MD)
Fire Department
Michael E. Poynter, EMT-P

Executive Director, Kentucky Board of
Emergency Medical Services
C.T. Chuck Kearns, MBA, EMT-P

EMS Consultant
Vincent D. Robbins
President & CEO, MONOC, MonmouthOcean Hospital Service Corporation,
Neptune, NJ
Raphael M. Barishansky, MPH, MS, CPM

Director, Office of Emergency Medical
Services, Conn. Dept. of Public Health
Eric Beck, DO, NREMT-P
Associate Chief Medical Officer, American
Medical Response
Bernard Beckerman, MD, FACEP
Associate Professor, School of Health and
Behavioral Sciences, York College (CUNY),
Jamaica, NY
Tom Bouthillet, NREMT-P
Captain, Town of Hilton Head Island (SC) Fire
& Rescue Division
Kenneth Bouvier, NREMT-P
Deputy Chief of Operations, New Orleans
EMS; NAEMT President 20042006
Elliot Carhart, EdD, RRT, NRP
Associate Professor, Emergency Services
Program, Jefferson College of Health
Sciences, Roanoke, VA
Chris Cebollero, NREMT-P
Senior Partner, Cebollero & Associates, St
Louis, MO
Will Chapleau, EMT-P, RN, TNS
Director of Performance Improvement,
American College of Surgeons
Kevin T. Collopy, BA, FP-C, CCEMT-P, NREMT-P,
WEMT
Clinical Education Coordinator, VitaLink/
AirLink, Wilmington, NC; Lead Instructor,
Wilderness Medical Associates
Michael W. Dailey, MD
Assistant Professor, Dept. of Emergency
Medicine, Albany Medical College, NY
Thom Dick
EMS Educator, Brighton, CO
William E. Gandy, JD, LP
EMS Educator and Consultant, Tucson, AZ
Erik S. Gaull, NREMT-P, CEM, CPP
Master Firefighter/Paramedic, Cabin John
Park (MD) Volunteer Fire Department
Troy M. Hagen, MBA, NREMT-P
CEO, Care Ambulance, Orange, CA;
President, National EMS Management
Association
Martin Hellman, MD, FAAP, FACEP
Attending Physician, Childrens Hospital of
Pittsburgh, Pittsburgh, PA
G. Christopher Kelly, JD
Attorney at Law, Atlanta, GA; Chief Legal
Officer, EMS Consultants, Ltd.
Skip Kirkwood, MS, JD, EMT-P, EFO, CMO
Director, Durham County (NC) EMS
Sean M. Kivlehan, MD, MPH, NREMT-P
International Emergency Medicine Fellow,
Brigham & Womens Hospital, Harvard
Medical School
William S. Krost, MBA, NREMT-P
Adjunct Assistant Professor of Emergency
Medicine, The George Washington
University
Ken Lavelle, MD, FACEP, NREMT-P
Clinical Instructor and Attending Physician,
Thomas Jefferson University Hospital,
Philadelphia, PA
Rob Lawrence, MCMI
Chief Operating Officer, Richmond (VA)
Ambulance Authority
Todd J. LeDuc, MS, CFO, CEM
Assistant Fire Chief, Broward Sheriff Fire
Rescue, Ft. Lauderdale, FL
Mark D. Levine, MD, FACEP
Assistant Professor, Dept. of Emergency
Medicine, Washington University School of
Medicine; Medical Director, St. Louis (MO)
Fire Dept.
Tracey Loscar, NRP, FP-C
Battalion Chief, Matanuska-Susitna (Mat-Su)
Borough EMS, Wasilla, AK
Craig Manifold, DO
EMS Medical Director, San Antonio Fire
Department and San Antonio AirLIFE;
Assistant Professor, University of Texas
Health Science Center at San Antonio
Paul M. Maniscalco, MPA, EMT-P
Senior Research Scientist & Principal
Investigator, The George Washington
University Office of Homeland Security
David Page, MS, NRP
Director, Prehospital Care Research Forum
at UCLA; Paramedic, Allina Health EMS;
Senior Lecturer, PhD candidate, Monash
University
Richard W. Patrick, MS, CFO, EMT-P, FF
Director, Medical First Responder
Coordination, Office of Health Affairs
Medical Readiness, U.S. DHS
PARTNERS
Mike Rubin
Paramedic, Nashville, TN
Angelo Salvucci Jr., MD, FACEP
Medical Director, Santa Barbara County &
Ventura County EMS, CA
Scott R. Snyder, BS, NREMT-P
Faculty, Public Safety Training Center,
Emergency Care Program, Santa Rosa Jr.
College, CA
Matthew R. Streger, Esq.
Executive Director, Mobile Health Services,
Robert Wood Johnson University Hospital;
Fitch and Associates, LLC, New Brunswick,
NJ
Dan Swayze, DrPH, MBA, MEMS
Vice President/COO, Center for Emergency
Medicine of Western Pennsylvania, Inc.
Cindy Tait, MICP, RN, PHN, MPH
President, Center for Healthcare Education,
Inc., Riverside, CA
John Todaro, BA, NRP, RN, TNS, NCEE
EMS/CME Academic Department
Coordinator, St. Petersburg College, St.
Petersburg, FL
William F. Toon, EdD, NREMT-P
EMS Training Manager, Loudoun County (VA)
Fire, Rescue and Emergency Management;
Battalion Chief - Training (ret.), Johnson
County (KS) EMS: MED-ACT
David Wampler, PhD, LP
Assistant Professor, Emergency Health
Sciences, University of Texas Health Science
Center, San Antonio, TX
Paul A. Werfel, MS, NREMT-P
Director, Paramedic Program, Clinical Asst.
Professor of Health Science, School of
Health Technology & Management, Asst.
Professor of Clinical Emergency Medicine,
Dept. of Emergency Medicine, Health
Science Center, Stony Brook University, NY
Katherine West, BSN, MSEd, CIC
Infection-Control Consultant, Infection
Control/Emerging Concepts, VA
Gerald C. Wydro, MD, FAAEM
Chief, Division of EMS, Temple University
School of Medicine, Philadelphia, PA
Matt Zavadsky, MS-HSA, EMT
Director of Public Affairs, MedStar Mobile
Healthcare, Ft. Worth, TX
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JANUARY 2016 | EMSWORLD.com
Convenience When it Matters Most
Together, the Pulmodyne O2-MAX with integrated nebulization and

Microstream sampling lines allow you to nebulize your patient while
delivering positive and consistent pressure as well as providing the
earliest indication for patients at risk of respiratory compromise.
New Disposable CPAP with Integrated Nebulization and

Microstream CO2 Sampling Lines
Both systems are completely disposable and help enable a seamless transfer of
care into the emergency department. They are packaged together for quick and
easy implementation of treatment.
800.533.0523
www.boundtree.com
For more information contact your dedicated Account Manager

or learn more at www.boundtree.com/o2maxneb.asp
JANUARY 2016
VOL. 45 | ISSUE 1
COVER REP OR T
60 When Size Matters: Ofshore

Helicopter EMS Operations
60
Providing medical and rescue services to the ofshore

oil industry is a massive mission
By Barry Smith
FE ATURE S
COLUMNS
24 How to Measure and Improve
14 GUEST EDITORIAL
The Next Great
Tradition
EMS Systems
EMS Compass is setting the profession on

a path toward performance measurement
and improvement
By Dan Swayze, DrPH, MBA,

MEMS
18 CASES WITH A
By Michael Gerber, MPH, NRP
TWIST
36 Evidence-Based EMS:
Repetitive Risks
By David Page, MS, NRP,
& Will Krost, MBA, NRP
Out-of-Hospital BiPAP vs. CPAP

Is one any better than the other?
36
22 LUDWIG ON
By Hawnwan Philip Moy, MD, & Blake Bruton, MD
LEADERSHIP
41 ACE Inhibitor-Related
How Will You Be

Remembered?
Angioedema
By Gary Ludwig
ACEI-RA is a diferent beast, less than

responsive to standard pharmacological
agents
66 THE MIDLIFE
MEDIC
Find Your Next
By Kristin Spencer, MS, NRP
By Tracey Loscar, NRP, FP-C
48 Oxygenate and Resuscitate
48
DEPARTMENTS
Before You Intubate
10 EMS World Online
Common pitfalls to avoid when managing

the crashing airway
16 News Network
51 Ad Index
By Russ Brown, NREMT-P
65 Classifed Ads
56 Community Paramedics and the

Drug-Seeker
Beyond pain, emotional and psychological

needs can help drive pseudoaddictive
behaviors
56
CONTAC T US
LETTERS TO THE EDITOR: Letters may be edited for

clarity or space. E-mail editor@EMSWorld.com.
SUBMISSIONS: E-mail queries, manuscripts, press
releases and news items to editor@EMSWorld.com.
PERMISSIONS: E-mail requests to editor@
EMSWorld.com.
By Jason R. Berman, EMT-P, & Dan Swayze, DrPH, MBA, MEMS
On the Cover
CHI SAR crews train an

average of 85 fight hours
per month. Photo by Barry
Smith.
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World content.
A major clinical study showed a
49
increase
in one - year survival from

cardiac arrest.1
Better Blood Flow.

Improved Survival.
The ResQCPR System is a CPR adjunct comprised of two synergistic devices the ResQPOD ITD 16
TM
and the ResQPUMP ACD-CPR Device. Used together, these devices increase blood fow to the brain
2
and vital organs, as well as increase the likelihood of survival.
For more information, please visit www.zoll.com or call 877-737-7763.

1 In adult patients with cardiac arrest from cardiac etiology. ResQCPR System Summary of Safety and Effectiveness Data submitted to FDA.
2 Lurie et al. J Med Soc Toho Univ 2012;59(6):305-315.
The ResQCPR System is intended for use as a CPR adjunct to improve the likelihood of survival in adult patients with non-traumatic cardiac arrest. Risk information: Improper use of the ResQCPR System could cause ineffective chest
compressions and decompressions, leading to suboptimal circulation during CPR and possible serious injury to the patient. The ResQCPR System should only be used by personnel who have been trained in its use. The ResQPUMP
should not be used in patients who have had a recent sternotomy as this may potentially cause serious injury. Improper positioning of the ResQPUMP suction cup may result in possible injury to the rib cage and/or internal organs,
and may also result in suboptimal circulation during ACD-CPR.
49-0879-000, 01
Illuminating the Path to Vein Access

Veinlite increases first-stick success, reduces waste and patient discomfort.
One of the most significant complaints among patients is

being stuck too many times when a medical professional is
trying to locate a vein to draw blood or start an IV. Thanks to
Veinlites innovative product line, it does not have to be such a
traumatic experience.
Venipuncture, or vein access, is one of the most routine
invasive procedures medical professionals conduct every day.
Sometimes, however, even the most experienced professionals
have difficulty locating a suitable veindue to age, especially
with elderly and pediatric patients; obesity; or even skin color.
This often results in sticking a patient several times, leading to
patient discomfort, dissatisfaction and delayed treatment.
Veinlite solves that problem by illuminating and isolating a
small portion of the vein for easy needle access. Veinlite delivers vein imaging in a unique and innovative way that increases
first-stick success while costing a fraction of other similar products.
I have been using the Veinlite in training nurses to start IVs,
primarily in the elderly, says Richard Johnston, of Lifeguard
Ambulance in Texas. Infants and the elderly typically are the
most difficult to gain IV access in. The Veinlite also gives care
providers who are not that experienced in starting IVs more
confidence to attempt an IV.
Johnston says there are several benefits to using the Veinlite.
In addition to reducing the number of attempts to gain IV
access on those with hard-to-access veins, it reduces pain and
stress to the patient, Johnston says. Using the Veinlite can also
reduce the amount of supplies used, thereby reducing costs.
Johnston says dehydration in particular among the elderly,
inhibits the ability to find veins.
With dehydration being a major problem, the ability to start
an IV is typically more difficult, Johnston says. The Veinlite can
help us locate the vein more easily. The Veinlite can also help
inexperienced nurses get needed fluids to patients faster and

reduce hospital admissions.
The Veinlite Vein Finder line of products is sold by TransLite
LLC, a small high-tech company that designs, manufactures
and sells medical devices to help reduce patient pain and
trauma.
Venipuncture is the most performed procedure in the
country, says TransLite President Nizar Mullani. Yet one in five
patients needs another nurse to come in and access the vein
after two attempts at sticking the patient. And theres just an
80% success rate after two sticks.
Clinical Trials Demonstrate Veinlites Value

Several clinical trials have been conducted to assess whether
vein finder devices help improve vein access. The results show
that Veinlite improves vein access, while near infrared light
(NIR) devices are no better than the normal standard of care. In
eight clinical trials of devices that use NIR, just oneon neonatesshowed improvement in accuracy for sticking veins.
TransLite LLC funded a study at Boston Childrens Hospital to
use Veinlite in a randomized clinical trial to access veins in the
hard-to-find vein patients in the emergency department. The
three-year trial showed that the use of the Veinlite improved
the success rate for vein access from 74% to 83% after two
attempts.
In hospital exit surveys, the biggest complaint among
patients is being stuck too many times for drawing blood or
inserting an IV, Mullani says. With Veinlite the medical professional can see the vein and put the needle right into it. If you
dont see the vein, you dont stick it. Were not a vein finder,
were a vein access device.
Mullani says Veinlite accesses veins without the need for a
tourniquet, which can unnecessarily cut off circulation.
The device accesses and helps hold the vein so it doesnt

roll, Mullani says. It anchors the vein. A whole bunch of devices use near-infrared light, which shines a light on the skin. Then
they use a camera to get the image, but it only shows the vein
Paramedics are out in the trucks by themselves.

They have to have the IV access in the field and dont
have backup of another nurse to access a vein. The
paramedics love it because it makes their jobs easier.
Nizar Mullani
on the surface of the skin. The medical professional cant get to
the actual vein. Those devices are vein finders, but they dont
help access or sequester the vein.
The Veinlite ring helps close off the vein, and traction can be
applied to the skin by pushing the ring back from the opening.
This secures the vein and makes it easier to access.
Veinlite creates a local tourniquet that pops the vein up but
doesnt block the entire area of circulation, Mullani says.
Mullani also sought to create a hand-held device that could
operate on a battery. Research showed that orange/amber
light provided the highest contrast for imaging superficial

blood vessels, while red light penetrated deepest for imaging
deeper veins. The two colors of LEDs could produce reasonable images of veins using only two watts or less of power, and
the portable Veinlite LED was created in 2004.
Three variations of the portable devices are available:
Veinlite EMS is a simpler, lower-cost device for use by
prehospital emergency medical services.
Veinlite LEDX is a larger, more powerful version of the
Veinlite LED and effective for use on overweight patients
and for sclerotherapy.
Veinlite PEDI is a tiny device, streamlined for use on
neonates and infants.
And in 2015 the Veinlite EMS PRO was introduced. The
Veinlite EMS PROs new, integrated exam light provides quick,
one-button access to a built-in flashlight mode. Day or night,
this aids in initial patient assessment and reduces the amount
of gear required to deliver quality care. The device is suitable
for use on adults and children, and for both light and dark
skin tones.
For more information on TransLite LLC visit www.veinlite.com,
e-mail info@veinlite.com or call 281/240-3111.
Veinlite EMS PRO
The Ultimate Vein Access Device

for Emergency
SAVE $50
ON ALL MODELS
PLUS FREE
CARRYING CASE
ENTER CODE
EMSWO116
at Veinlite.com
Integrated white exam light

for low-light situations
www.veinlite.com
Patent Number US 7,874,698 B2
Registered Trademark of TransLite, LLC Designed and manufactured in the USA.
Free leather
carrying case
included

EMSWORLD.com | JANUARY 2016
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FEATURES
BUILDING BIG DATA
With the acquisition of Rural/Metro Corp.,
AMRand the larger world of EMSis
poised to learn a lot more about the
efectiveness of a lot of the things we all
do. The companys already-substantial
focus on data will encompass millions
of additional points with the subsuming
of Rural/Metros various operations and
patient loads. That will tell all of us even
more even faster about the impacts of interventions across the spectrum
from 9-1-1 responses to transfers to community paramedicine and
mobile integrated healthcare.
Read more at EMSWorld.com/12146730.
QUICK TIME
Whats next for you in EMS? Catching up on your PCRs is certainly in the
mix, but what about a year from now or 10 years from now? Maybe youll
want to try something diferent. In this months Life Support column, Mike
Rubin discusses career options.
PODCASTS
WORD ON THE STREET:

REPORT FROM ECCU
Host Rob Lawrence
reports from this years
ECCU conference
held in San Diego,
December 8-11, 2015,
just weeks after the release of
the new Resuscitation Guidelines.
What will the science tell us about

ways to improve survival? How
will the new guidelines impact
instruction and practice? What are
the best practices in training and
community programs? Listen to
the resuscitation professionals
instructors, practitioners, survivors
and researchersdiscuss the
latest in cardiac care.
See EMSWorld.com/podcast.
10
THE MEDBOT EDUCATOR

How many of you know what a mobile virtual
presence device is? Of those who said yes, you
probably frst heard of them from an episode
of the TV show The Big Bang Theory. Well, get
ready to put your geek on, because we are
about to look at how these devices might be
used for prehospital education and even more.
WEBCASTS
Visit EMSWorld.com/webcasts to
register for upcoming presentations:
FEB 10, 2 PM ET:
RECOGNIZING AND
REACTING TO THE LOST
ADVANCED AIRWAY
All advanced airways are at
risk of dislodgement and failing
to recognize a dislodgement
can lead to serious morbidity
ranging from anoxic brain injury
to death. This webinar ofers
best practices to prevent airway
dislodgement and immediately
recognize the lost airway,
and ofers fve strategies for
rapid and efective emergency
airway intervention. Presented
by Kevin Collopy, BA, FP-C,
CCEMT-P, NREMT-P, WEMT, and
sponsored by Physio-Control.
NEW
MOULAGE
OF THE MONTH
Bobbie Merica continues her guide to
simulating injuries and illnesses
through efective use of moulage.
This month: Industrial response, steam
burn, second degree.
See EMSWorld.com/12146211.
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Paramedic certifcation.
Hybrid Paramedic program
offered through LCC Continuing
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four on-site visits required for
skills training and evaluations. All
coursework is done online. Tuition
is $360.
Clinicals can be completed in your area.
Contact LCC regarding available areas.
Graduates are eligible for the NCOEMS
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Associate Degree in
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Complete the degree at your own pace!
231 Hwy. 58 South Kinston, NC
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55,300 new medics by 2022

The Emergency Medical Services feld is expected to grow
more than 23% over the next decade, adding over 55,000
paramedic and EMT jobs. Are you ready?
Hire the right people based on science:
Increase
retention
Enhance
performance
Talent Science
Improve
succession
planning
Support
diversity
Infor Talent Science measures 39 key behavioral

attributes of your best employees and creates a profle
for screening applicants. Profles can be incorporated
into your existing civil service processes to help
select, develop, and retain your medics and EMTs.
infor.com/publicsector
Infor Public Sector delivers a comprehensive suite of integrated, specifc solutions that drive fnancial management, human
capital management, asset and work management, regulatory compliance, and healthcare information exchange. Infor
solutions increase operational efciency, citizen satisfaction, government accountability, and process transparency and are
transforming how governments provide services to citizens.
Addressing the EMS workforce

crisis with science
Kurt A. Steward, Ph.D., Vice President, Infor Public Sector
The US Bureau of Labor Statistics expects the
emergency medical services (EMS) feld to grow by
more than 23% over the next 10 years, adding over
55,000 paramedic and EMT jobs to the 235,000
skilled paramedics and EMTs already faithfully serving
across the United States. The additional workforce
needs are to due to increasing call volumes, aging
populations, and a generally heavier reliance on
governmental services. This presents additional
challenges to an EMS community already grappling
with the impact of the Afordable Care Act, shifts
towards community-based care, value-based
payments, and an aging workforce, especially in
fre-based EMS organizations.
Consider the fndings of the most recent report

from the National Highway Transportation Safety
Administration Ofce of Emergency Medical Services:
Retaining workers is a challenge, with poor
management practices, low wages and benefts, lack
of career ladders, and disability contributing
to turnover.
Retention of older or more experienced workers
[conserves] talent and experience within the EMS
workforce and increases workforce supply.
Developing strategies to accommodate older or
more experienced workers and increasing successful
recruitment and retention of older individuals would
prove helpful for addressing the [workforce] issue.
Its a complex proposition to hire the right candidates
for roles that require highly technical medical skills
and a willingness to put oneself in harms way for the
beneft of a stranger. To help meet this challenge, the
EMS community could beneft from science-based
hiring practices.
Copyright 2015 Infor. www.infor.com. All rights reserved.
Talent science, or science-based hiring practices, is

a predictive and analytics-based approach to
managing human resource processes, like candidate
selection, medics development, and succession
planning. This approach both objectively and
statistically links specifed performance metrics to
behavioral characteristics of medics within an agency
to help establish a model of best ft that is unique to
each agency.
Heres how talent science works. Custom profles are
built using large samples of incumbent medics and
EMTs that refect the behavioral makeup of the bestsuited candidate for a specifc organization. This is
important because while nearly all medics and EMTs
share a common sense of civic duty to help those in
need, the behavioral characteristics of a successful
medic in a large fre-based organization may be
diferent from the behavioral characteristics of a medic
or EMT in private agency or a quasi-governmental
organization.
Next, job candidates are evaluated and ranked
based on their responses to a comprehensive
online assessment that is designed to measure 39
behavioral characteristics. The assessment compares
each candidates behaviors to the custom profle
corresponding to the position of medic or EMT within
a specifc organization. A report is then generated,
visually describing how and where the candidate aligns
and difers from the unique requirements of the profle
and the defned needs of the organization.
This approach has proven to signifcantly reduce
turnover and improve organizational performance
in an industry with similar challenges to the EMS
communitythe nursing profession. A recent
controlled study of over 1,000 newly hired nurses
comparing the use of science-based hiring practices
to traditional hiring practices demonstrated a turnover
reduction of 47% and produced an annual savings of
over $2.4 million. By employing a similar approach
within EMS, agencies can become more efective
at identifying the most qualifed candidates from a
skills perspective and can isolate those individuals
whose characteristics make them the best ft for the
organization at large.
The workforce crisis facing the EMS profession will
not solve itself through procrastination and inaction.
When medics leave, the loss in knowledge capital is
substantial and the ability to serve the community is
diminished. The community deserves the best from
our agencies, and using science can help the EMS
community deliver on those expectations.
GUEST EDITORIAL
By Dan Swayze, DrPH, MBA, MEMS
The Next Great Tradition
Its time to support the more than 1,000 EMS providers

working as community paramedics and MIH practitioners
Today more
than 1,000 EMS
providers have
been trained to
help save lives
differently than
in the past.
More than 200 years of tradition, uninterrupted by
him in his cause. Larreys followers undoubtedly
progress. Ive heard that phrase often to describe
faced opposition but were courageous enough to
how some firefighters hold strong to their rituals
embrace the new role despite the personal risk they
and practices. But truth be told, the same could be
encountered. As brilliant as Larrey was, he could not
said of EMS.
have put his idea into motion without the help of oth-
Since the days of Napoleon, ambulance services

have existed primarily to transport the ill and injured
from where they fell to a hospital where they could
be treated.
ers willing to gamble on a new model to help save
more lives.
Today more than 1,000 EMS providers have been

trained to help save lives differently than in the
More than 200 years ago, tradition dictated that
past: in new roles as community paramedics and
local townsfolk would transport injured soldiers to
mobile integrated healthcare practitioners. Thats
the closest hospital in their hay wagons, but only
a small portion of all EMS personnel, but enough to
once the battle moved away. At the hospital, sur-
convince the editors of EMS World that it is time to
geons would begin their lifesaving interventions on
support these brave new providers by dedicating a
those who survived that long. But one surgeon, Dr.
series of articles over the coming year to this new
Dominique Jean Larrey, was different. He believed the
type of patient care. While articles on the finance
surgeons should be deployed into combat to retrieve
and administration of these programs remain criti-
the injured even while war raged around them. He
cally important discussions, EMS World recognizes

that those serving in this new role also need articles
focused on the aspects of patient care they will

encounter that are different than those faced in their
traditional roles.
We start the new series this month on page 56
discussing substance abuse. Instead of describing
the traditional approach to treating an overdose, the

article focuses on the terminology and treatment
paths available to those who suffer from either
addiction or pseudoaddiction caused by their chronic

pain. While the topic may not be popular among
those holding strong to our EMS traditions, those
practicing in this new role will encounter patients
needing these treatments regularly.
I applaud EMS World Editorial Director Nancy Perry

and Senior Editor John Erich for dedicating time and
space to help these new providers. Thanks to their
Heather Bogdon and

David Dupra from the
CONNECT Community
Paramedic Program in
Pittsburgh, PA, are part
of the rapidly growing
number of community
paramedics in the
United States.
efforts and the bravery of the 1,000-plus providargued that by beginning care sooner, he could save
ers willing to break from their traditional roles, we
many more lives. Despite a belief that was undoubt-
are looking at the start of the next great tradition
edly unpopular with his peers, Larrey persevered and
of EMS.
invented the ambulance, the modern system of triage and many other surgical innovations.
While you may have heard of Larreys contribution to our beginnings, think about this: He could
not have done it alone. He had to find colleagues
brave enough to risk breaking with tradition to join
14
A B O U T T H E AU T H O R
Dan Swayze, DrPH, MBA, MEMS, is the vice president and
COO of the Center for Emergency Medicine of Western
Pennsylvania and is widely considered one of the pioneers
of the emerging field of community paramedicine. Dan has
been involved in EMS for more than 30 years.
NEWS NETWORK
Virginia Office of EMS Awards Agency of Excellence Designation
At a recent event, the City of

Manassas Fire and Rescue System
was among the first agencies to be
awarded with the Agency of Excellence designation from the Virginia
Office of EMS.
This was the first year of a pilot
program that seeks to recognize
agencies that strive to operate
above the standards and requirements of Virginia EMS regulations.
Agencies were evaluated in
eight program areas: leadership/
EMS Supervisor Lt. Matt Fox (pictured), along
management; emergency medical
with Battalion Chief Todd Lupton, helped
dispatch; clinical care measures;
steer the City of Manassas Fire and Rescue
operational medical direction; life
System through the pilot program.
safety; community support and
involvement; recruitment and retention; and performance and risk.
Im glad we could be part of this pilot program, said Manassas Fire and Rescue
Chief Brett Bowman. The men and women of the City of Manassas Fire and
Rescue team are exceptional, and I am proud that they have been recognized for
their service to the community.
The designation as an Agency of Excellence lasts for three years, at which time
an agency must reapply for the certification. For more information, visit www.
vdh.state.va.us/OEMS.
Fla. Paramedic Elected to National Board Position
Sunstar Paramedics Community Outreach Coordinator, Charlene

Cobb, has been elected to the Board of Directors for the National
Association of Emergency Medical Technicians (NAEMT). She
will serve as an at-large director.
During her two-year term, Cobb plans to work on creating
industry solutions for an easier transition for military medic veterans who want to move into an EMS career. She also plans to develop strategies
to improve workplace safety and working with government representatives and
industry officials to pass the Field EMS Modernization and Innovation Act.
Cobb has been an active member of NAEMT since 2005. I am extremely honored to have been elected by my fellow NAEMT members, said Cobb. Over the
last 30 years, I have watched this field evolve and am excited to take a larger role
in making a difference for EMTs around the country.
For more on NAEMT, visit naemt.org.
Cool /Not Cool
Happy Breathe-day!
Jane Powers sure knows how to throw a party!

Three years after surviving a cardiac arrest, Powers has turned her own birthday celebrations into
annual CPR training events complete with EMS
instructors.
Powers, a longtime employee of the Arizona Diamondbacks baseball team, collapsed in a tunnel
under the Diamondbacks stadium after a 2012
game, and was pulseless when found by umpire
Jim Joyce. Joyce used the CPR hed learned as a
young man to help resuscitate Powers, who now
offers hands-only CPR familiarization to dozens
of volunteers each year. You never know when
you could be in that situation (to use CPR), says
Powers. You want to be as prepared as Jim Joyce
was for me. Cool!
A Barbaric Ritual
Jason Waldeck, a former volunteer firefighter

in Ellis County, TX, says he put up with months
of hazing after joining the Waxahachie station.
According to Waldeck, though, none of that comes
close to the sadistic treatment he endured last
January at the hands of fellow firefighters.
Waldeck says he was pinned down and sexually
assaulted by five colleagues while the girlfriend of
one videotaped the incident.
Eight people, including the departments chief
and assistant chief, have been indicted on charges
associated with the assault.
I cant get it out of my mind, says Waldeck. Ive
had thoughts of suicide.
It would be deplorable to classify the alleged
incident merely as hazing gone awry, or to link the
accused to a work-hard-play-hard characterization
of emergency services. This isnt about firefighting or volunteering; its about savage, sociopathic
behavior perpetrated by the strong against the
weak. Uncool!
JANUARY IS NATIONAL BLOOD DONOR MONTH
Every two seconds

someone in the
U.S. needs blood.
16
More than 41,000

blood donations
are needed
every day.
The average
red blood cell
transfusion is
approximately
3 pints.
The blood type

most often
requested by
hospitals is Type O.
The number of
blood donations
collected in the
U.S. in a year is
15.7 million.
There are 9.2

million blood
donors in the U.S.
each year.
MY DEGREE IS A
STEPPING STONE
E
TO EXPANDING
G
MY CAREER
R
Vera Morrison
2015 Graduate
DeKalb (Ga.) Fire Rescue
Battalion chief
TEXTBOOKS
INCLUDED
Learn more about our online degrees, workshops, and CEUs.
FLEXIBLE.
AFFORDABLE.
ONLINE.
ColumbiaSouthern.edu/EMSworld | 877.258.7153
Gainful employment information available at ColumbiaSouthern.edu/Disclosure.
CASES WITH A TWIST
By David Page, MS, NRP, & Will Krost, MBA, NRP
Repetitive Risks
For this EMS crew, unloading the stretcher proved

dangerous to both patient and provider
T
Remember,
slow is smooth
and smooth is fast.
his inaugural column is dedicated to our peers
was on the patients right side, watching and ready
who risk their lives to serve others daily. In this
to catch the wheels.
column we will explore cases in which things
As expected, with ER staff watching as they met
didnt quite go as planned. Sometimes this
the ambulance in the garage, the crew was moving
means we were surprised by a clinical presentation,
quickly to get the critical patient inside. Crew mem-
while others involve near-misses or adverse events.
ber #1 began to give a quick report while starting to
While we love EMS, the work we perform is often
pull back on the stretcher. The hospital has a slightly
conducted in unpredictable and harsh environments
uneven garage floor (to allow for drainage in the
with limited information and resources and high
center), and the vehicle and stretcher were slightly
stress. EMS personnel are 2 times more likely to
tipped to the patients left side.
be killed on duty, and five times more likely to suf-
As the crew pulled the stretcher out, the safety
fer a transportation-related injury, than the average
bar missed the safety hook. The stretcher came
worker.1 We hope this column will help promote an
out of the back of the ambulance rapidly, with its
open, honest and timely process to communicate
wheels still retracted. Crew member #1 at the foot
potential mishaps and promote a culture of safety
of the stretcher tried to hold the weight. Unfortu-
in EMS operations.
nately the stretcher tipped toward the left, and the
This Months Case
#2 (on the patients right side) pulled up, trying to
After an emergent transport to the hospital, the crew
help prevent the stretcher from hitting the ground.
was unloading the stretcher loaded with a roughly
Momentum shifted to the left side.
200-pound critical patient in congestive heart fail-
To complicate matters, this stretcher was
ure. Crew member #1 was at the foot of the stretcher,
equipped with a canvas basket behind the head.
operating the manual control, while crew member #2
When the stretcher began tipping out of balance, a
Straps, oxygen bottles

and special baskets can
catch on the safety latch,
creating further danger.
18
patient reached out to the left side as crew member
worn and loose strap caught the safety hook, mak-
ing it harder for both crew members to maintain the

stretcher upright.
At this point the stretcher twisted and inverted,
almost completely falling to the ground. The patient

struck their head, face and upper left shoulder on
the jagged ambulance bumper first, then the floor.
Assisted by the ER staff, the patient was rolled and

placed on a long spine board with cervical precautions and then quickly moved into the critical care
room.
Crew member #2, leaning while trying to lift,

immediately felt severe back pain and fell forward,
striking their head on the overturned stretcher and
sustaining an inch-long laceration to the forehead.
The patient died of heart failure shortly after

admission. On review the traumatic injuries, while
serious and possibly having delayed care, were not
found to be directly responsible for the patients
death. Crew member #2 sustained a herniated L5-S1

low-back injury that required a laminectomy and
extensive rehab, and continues on light duty with
CRM Tips
THIS COLUMN WILL FEATURE A MONTHLY TIP ON CREW RESOURCE
Management (CRM) principles and techniques that apply to the cases we
present.
CRM techniques have led to improved communication, teamwork and
safety in the military, commercial aviation and now EMS/fire agencies.
In this inaugural column, patients and providers were injured in a stretcher mishap. In aviation most crashes occur on take-off and landing. If we
apply this principle to EMS, lets imagine a systematic process to improve
stretcher loading (take-off) and unloading (landing):
Sterile cockpitDuring take-offs and landings, crews are silent unless
there is a concern for safety. In our EMS case, we do not want to create
distractions until critical stretcher procedures are completed. These might
include wheels being up and the stretcher being latched.
Key wordsThe critical step in stretcher unloading is to ensure the
wheels are down and locked.
ChecklistsFor procedures we know might injure a patient or ourselves,
we have to take additional steps to reduce risks. One of these is to pause,
review key steps in a checklist, and read back these steps for a second
person to confirm we have not missed anything. For procedures that carry
excess risk like aviations red rulechecklists force crews to stop, read
back and ensure we have critical elements covered.
the goal of returning to work in the field.
Root Cause Analysis
Nonpreventable Factors
When analyzing adverse events, safety experts
The single hook, combined with a stretcher safety
talk about gaps or holes in safety practices lin-
bar that is curved, combined with a garage that
ing up to cause a perfect storm that results in
is tilted, combined with straps from equipment
injury. (See the Swiss cheese model explained
baskets, combined with an unload procedure that
here: https://psnet.ahrq.gov/primers/primer/21/
requires holding weight until wheels descend and
systems-approach.)
lock, is a system design disaster waiting to happen.
In this case the crew, with a combined 14 years of
experience, acted like so many other crews would.
Preventable Factors
With a critical patients best interest in mind, they
Crew distraction, lack of communication during a
moved quickly performing a routine taskunload-
critical task, moving too quickly and disregarding
ing the stretcher, a procedure they have completed
risks are all elements that could have been mitigated
thousands of times without mishap. They were nei-
in this case.
ther disregarding safety nor acting recklessly. In the

blink of an eye, they became distracted with reports
Lessons
to the ER staff and relied on a safety hook that had
This event is as tragic as it is common. Clearly we
never failed them.
need systems that have improved safety design.
It is common for us to be complacent and disre-
Help may be on the way from stretcher manufac-
gard risks during repetitive tasks that have never
turers offering no-lift systems. In the meantime,
caused us harm. Like our use of stretchers on every
what can you do to prevent this from happening on
call, pilots will take off and land an airplane on every
your next call?
flight. And like aviation, where most crashes occur
We are big fans of crew resource management
on take-off and landing, we also know most injuries
(see sidebar). In keeping with aviations red rule
to providers and patients will occur during stretcher
when potential risks exist, it is essential that we stop
loads and unloads. Have you ever thought, I dont
(or at least slow down enough to think about the
need to wear my seat belt, Im just driving down the
procedure), perform a cross-check with a partner,
block to the store? When it hasnt happened to us,
follow a clear checklist, use clear verbalization of
we can think It doesnt happen to me. Our compla-
keywords, and repeat back confirmation (closed
cency leads us to slip, then trip.
loop communication). Maintaining a sterile cockpit
19
CASES WITH A TWIST

could also prevent unnecessary distraction. In this
medic Gary Wingrove, this tool allows EMS providers
case identifying an environmental hazard (tilted
to anonymously report near-miss or actual adverse
garage floor) and waiting for a third person to help
events without fear of punishment.
is also possible.
REP OR T
E VENTS
Please help us identify
errors and near-miss
events that affect the
safety of EMS providers
and patients. Report
events anonymously at
www.emseventreport.
com.
E.V.E.N.T. is an anonymous tool designed
to improve the safety,
quality and consistent
delivery of EMS. The
data collected will
be used to develop
policies, procedures
and training programs.
A similar system used
by airline pilots has led
to important system
improvements based
upon pilot-reported
near-miss situations
and errors.
things simply didnt go as planned. We will hide
loose straps, placing two safety hooks and ensur-
details to protect the privacy of those who share
ing the stretcher bar is updated to be flat, will help
these events, but we want to help create a national
mitigate some risks.
culture of safety that is not afraid to shed light on
Standardizing the process of loading and unload-
near-miss or adverse events. We are committed to
ing would be the single greatest mitigator of risk in
facilitating honest and prompt reporting so that oth-
this case. Streamlined and vetted processes have
ers will learn from them and avoid them. Send com-
been proven to mitigate almost all errors.
ments and feedback to editor@emsworld.com.
From simple procedures such as ensuring a door is
locked before an airplane takes off to complex crash
landings into a river, cross-checks with a standardized checklist have saved many lives. Remember,
slow is smooth, and smooth is fast.
Why Do We Need This Column?

Recent studies report between 98,000 and 210,000
deaths each year are due to preventable medical

errors.24 We know that errors in areas like medication administration, airway management, assess-
Video Challenge
CAN YOU COME UP WITH A VIDEO THAT
demonstrates sterile cockpit, key words and
use of a checklist for safe loading and unloading of the stretcher? If you do, please send the
link to editor@emsworld.com. Our partners
at North Ambulance and Jones and Bartlett
Learning filmed this stretcher cross-check
seen here: EMSReference.com/checklists.
ment errors and patient falls are not just happening
in hospitals. These same errors occur in ambulances,
R E FE R E N CE S
but providers are afraid to report them for fear of
1. Braithwaite S, et al. Strategy for a National EMS Culture of Safety; p 6,

www.emscultureofsafety.org.
2. James JT. A new, evidence-based estimate of patient harms associated
with hospital care. J Patient Safety, 2013 Sep; 9(3): 1228.
3. Institute of Medicine. To Err is Human, https://iom.nationalacademies.
org.
4. Department of Health and Human Services Offce of Inspector
General. Adverse Events in Hospitals: National Incidence Among Medical
Benefciaries, http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf.
being dismissed, and agencies are afraid to report
them from fear of being sued. Unfortunately, without
reporting or tracking these errors, we cannot understand the depth of the problem or create systems
to improve our safety.
In 2013, responding to a request from the Nation-
al EMS Advisory Council (NEMSAC), the National

Highway Traffic Safety Administration (NHTSA)
collaborated with the American College of Emergency Physicians (ACEP) to publish the Strategy for
a National EMS Culture of Safety (www.emscultureofsafety.org). This landmark document outlines the
need, framework and steps for EMS to implement

major operational changes that will lead to improved
safety.
To become more reliable we must implement just
Editors note: Cases
culture. Learning from our mistakes so we do not
are obfuscated and
repeat them is a key component of this process. We
amalgamated to
must make it safe to report errors without fear of
protect patient privacy
reprisals and analyze the root cause of the adverse
and provider anonymity.
event. Like aviation, we need to focus on systems of
While staying as true as
safety, not blaming individuals.
possible to the actual
The Center for Leadership and Research (CLIR),
event, creative license
in collaboration with the National Association of
is used to better explain
EMTs (NAEMT), has set up an international report-
the lesson(s) in the
ing website and database to track these errors at
case.
www.emseventreport.com. The brainchild of para-
20
In this column we intend to report on cases where
Improving safety parameters, such as removing
B IB L I O G R A PH Y
Hobgood C, XIe J, Winder B, Hooker J. Error Identifcation, Disclosure, and
Reporting: Practice Patterns of Three Emergency Medicine Provider Types.
Acad Emerg Med, 2004; 11: 1969.
Hubble MW, Paschal KR, Sanders TA. Medication calculation skills of
practicing paramedics. Prehosp Emerg Care, 2000; 4: 25360.
Kothari R, Barsan W, Brott T, Broderick J, Ashbrock S. Frequency and
accuracy of prehospital diagnosis of acute stroke. Stroke, 1995; 26: 93741.
Rittenberger JC, Beck PW, Paris PM. Errors of omission in the treatment of
prehospital chest pain patients. Prehosp Emerg Care, 2005; 9: 27.
Vilke GM, Tornabene SV, Stepanski B, et al. Paramedic self-reported
medication errors. Prehosp Emerg Care, 2006; 10: 45762.
A B O U T T H E AU T H O RS
David Page, MS, NRP, is director of the Prehospital Care
Research Forum at UCLA. He is a senior lecturer and PhD
candidate at Monash University. He has over 30 years of
experience in EMS and continues to be active as a field
paramedic for Allina Health EMS in the Minneapolis/St. Paul
area.
Will Krost, MBA, NRP, is a fourth-year medical student and a
faculty member at the George Washington University School
of Medicine and Health Sciences in the Departments of Clinical
Research and Leadership and Health Sciences. He has over 23
years of experience in EMS operations, critical care transport
and hospital administration.
LUDWIG ON LEADERSHIP
By Gary Ludwig, MS, EMT-P
How Will You Be Remembered?

It is your responsibility to leave your EMS
organization better than you found it
Management is doing things right, leadership is doing
payroll, inventories and computer systems, but we
the right things. Peter Drucker
lead people.
Leaders who fail and whose staff cannot wait

hen you come to the end of your career in
until they retire lack vision of where the organization
whatever leadership role you retire from,
should be and, since they have no vision, they cannot
how will you be remembered? Will the
share that vision with their subordinates.
number of people who show up at your
Leaders who leave an organization better than
retirement party not even fill a telephone booth,
they found it learn to create a vision of where the
or will it be a large hall overflowing with those who
organization should be and then find that one ingre-
want to wish you well and thank you for everything
dient that motivates people to share in that vision.
you did to contribute to the organization?
When you
accept a
leadership
position,
it is not
just a title.
Just because you create a vision of where the
I have worked with some chief fire officers in my
organization should be does not mean your employ-
career for whom the only people who showed up at
ees will rubberstamp your vision. You have to be
the retirement party were the retirees family and
able to share your vision and find a way of getting
those working in the building so they could get the
employees to buy into your vision.
free food. It is very sad that your subordinates could
Most leaders find a way to get employees to share
think so little of you and that you made no contri-
their vision by empowering them in the process. As
butions to better the organization; in fact, you may
President Dwight Eisenhower said, Leadership is the
have made it worse. For these individuals, that will
art of getting someone else to do something you
be their legacy and how they will be remembered
want done because he wants to do it. Eisenhower
for years to come.
certainly understood this concept. Who else could
Clean the Campsite
command millions of troops in battle to conquer

Europe while he had never been in battle himself?
The Boy Scouts have a saying: Leave the campsite
You may not care what your employees think
better than you found it. This means making sure
about you when you retire. You may just wish to walk
you clean up any mess you created. All your trash
out the door on your last day, never to be seen again.
should be picked up and all camp fires put out,
If that is the case, then you were not a leader and you
restoring the campsite to its natural state. Even if
were probably not even a manager.
you arrived and found cans and wrappers left by
In a leadership position you have a responsibility
someone else, it is your responsibility to clean it up.
to lead your organization and your employees and
This saying can also apply to leaders of EMS orga-
make your EMS organization successful. If you do not
nizations. Whatever leadership role you find yourself
accept this responsibility, you should have stepped
in, whether it is a supervisor, a middle-level man-
down from your position way before your retirement.
agement position or the head of the EMS organiza-
When you accept a leadership position, it is not just
tion, one of your responsibilities is to move the EMS
a title. It is a responsibility that you should fully accept
organization forward and leave it better than you
and strive for the success of your EMS organization.
found it. How do you do this? You become a leader

instead of a manager.
Leadership vs. Management

What is the difference between leadership and
management? It is very simple: You lead employees and manage things. We manage budgets, fleets,
22
Gary Ludwig, MS, EMT-P, is chief of the Champaign (IL)
Fire Department. He is a well-known author and lecturer
who has successfully managed large, award-winning
metropolitan fire-based EMS systems in St. Louis and
Memphis. He has a total of 37 years of fire, rescue and EMS
experience and has been a paramedic for over 35 years.
By Michael Gerber, MPH, NRP
How to Measure and

Improve EMS Systems
EMS Compass is setting the profession on
a path toward performance measurement
and improvement
hen staff in the National Highway Traffic Safety Administration (NHTSA)

Office of EMS decided to support EMS
Compass, it made perfect sense. For
decades, NHTSA has funded projects
that have helped make the nations EMS systems what
they are today. Twenty years ago, the Agenda for the
Future presented a vision of a data-driven EMS system; more recently, the National EMS Information
System (NEMSIS) established data standards and the
24
Prehospital Evidence-Based Guidelines (EBG) project

established treatment guidelines based on research
findings. Each has built on those that came before
it, and EMS Compass is no different.
Its the logical next stepapplying those standard data elements and medical research to create
performance measures that will help EMS agencies
meaningfully use their data to improve patient care.
In December 2014 the National Association of
State EMS Officials (NASEMSO), through a coop-
How EMS Leaders Use Data to Improve EMS Systems
The use of analytics and data to save lives is at the

heart of operations at The Richmond Ambulance
Authority in Richmond, VA. Two of RAAs leaders were
featured in the EMS Compass webinar series, COO Rob
Lawrence on the use of performance management in
EMS and Fleet Manager Dan Fellows who discussed
metric-led fleet management.
erative agreement with NHTSA, publicly launched

EMS Compass. Since then, the initiative has tackled
difficult issues, from how to decide which measures
to use to how to be inclusive of the entire EMS community. But the focus of EMS Compass has been creating a replicable process for identifying, designing
and testing performance measuresa process that
can be used well into the future by organizations
hoping to develop measures that support improving
prehospital medical care.
In order to take the next step as a profession, EMS
must embrace a culture of improvementone where
we measure the things that truly matter to patients
and we work to improve the processes that result in
the best possible patient care, says Bob Bass, MD,
If we have measures that are truly patient-centeredI believe

well make much better decisions and make much more significant
improvement, said Mike Taigman, General Manager of AMR in Ventura
County, CA, during one of a series of 10 webinars held in June 2015 by EMS
Compass as part of the initiatives effort to engage and receive input
from the EMS community. Each webinar tackled one of the 9 domains of
measures EMS Compass is addressing.
Taigman admitted that measuring patient outcomes is a struggle in
EMS and medicine generally. But that doesnt mean EMS shouldnt strive
to have performance measures that are as patient-centered as possible.
During the session on population and public health, Taigman described
the process measures that he believes EMS can use when true patient
outcome measures are difficult to assess. A process measure, EMS
Compass Project Manager Nick Nudell explained, is one that evaluates
a step in the process that is linked to outcomes but is not the outcome
itself.
Taigmans examples included measuring the time from the first 9-1-1
call to certain evidence-based procedures for time-sensitive conditions,
such as:
First chest compression for cardiac arrest;
Restoration of blood flow for STEMI;
First CT scan interpretation for stroke;
Infusion of two liters of fluid for sepsis.
There are six domains of measures that correlate to the priorities in
the U.S. Department of Health and Human Services National Quality
Strategy. Population and public health is one; the other five are patient
and family engagement, patient safety, care coordination, efficient use of
healthcare resources, and clinical process and effectiveness. In keeping
with the project charter to address all aspects of an EMS system, the
initiative added three other domains: workforce, fleet and data.
In the EMS workforce webinar, Daniel Patterson, PhD, a senior scientist
with the Carolinas Healthcare System in Charlotte, NC, discussed ways
to measure fatigue and the safety culture within an organizationall of
which have been linked to safety outcomes by research, he said.
While in the past some of these measures have used questionnaires
that can be time-consuming to administer to staff, Patterson and other
researchers have been working to refine those surveys to make them
shorter but still valid. Other ways of measuring these factors, such as
using text messaging to assess fatigue, are currently being investigated.
Mike Ragone, director of system design for AMR, spoke about the
difference between measuring on scene times and at patient times
during the session on efficient use of healthcare resources. On scene
time versus at patient side, as we all know, can be a huge difference,
Ragone said, citing the example of responding to a casino where it may
take 15 minutes to reach the patient after arriving. If we do not separate
them, we wont be able to draw conclusions about the clinical relevance
of response times, he added.
Ragone discussed some of the different ways systems are trying to
measure accurate at-patient times, from communicating via the radio in
order to let dispatchers mark the time to using handheld devices, such
as smart phones, that allow the practitioners in the field to accurately
record the time.
Although EMS Compass aims to create performance measures around
the data standards established by NEMSIS, it was clear that this effort to
use data to assess system performance may also drive changes to how
data is collected, as EMS systems determine which elements are most
critical to analyze.
25
former director of the Maryland Institute

for EMS Systems, who is serving as the EMS
Compass steering committee chair.
On January 13 the EMS Compass steering
committee meets in person for the third
time to discuss the progress of the measure development process. The committee,
composed of several experts in performance
measurement and improvement from both
inside and outside the EMS community, is
also expected to be reviewing and prioritizing the first sets of performance measures.
Building Measures
But the bulk of the work for EMS Compass
has occurred between those meetings, when
dozens of volunteer members of the initiatives working groups have spent countless
hours designing, refining and testing the
measures.
When the EMS Compass Measurement
Design Group first gathered in Washington nearly a year ago, its members knew
they had a challenge before them. Since
then, they have helped create a measure-
ment design process that is transparent

and evidence-based, with opportunities
for members of the public to participate.
In addition, they have sifted through
hundreds of potential measures submitted
by the EMS community and present in the
literature, choosing the ones that EMS agencies can use to help them in their pursuit of
providing high-quality care to patients and
making a difference in their communities.
Choosing the vital few measures and
making sure we specify clear operational
definitions to know the data to include,
what to exclude and how to calculate the
measures are essential to ensuring EMS
agencies can use the measures to support improvement, says David Williams,
PhD, executive director at the Institute
for Healthcare Improvement and chair of
the EMS Compass Measurement Design
Group. Measurement is vital to knowing
how an agency is reliably delivering results
and whether efforts to improve processes
are moving their dots on their charts, and
EMS Compass will help provide a good place
for agencies to start to look at meaningful

process and outcome measures that can
enable them to focus on improvement and
reliability.
From the start, EMS Compass has
focused on using NEMSIS data points in
its measures when possible. Because NEMSIS creates a standard for collecting EMS
patient data, the vast majority of U.S. EMS
agencies are gathering the same information on each patient. NEMSIS-compliant
electronic patient care reports (ePCRs)
also ensure that the data are stored in the
same way, so they can be sent to state and
national databases and used for research
and analysis.
But for EMS Compass, the NEMSIS standard also means that clinical performance
measures can be designed so that any agency
using NEMSIS-compliant PCRs can use the
measures in the same way. They can even be
built into software that automatically pulls
the information from individual ePCRs and
calculates how an agency is performing on
a specific measure.
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To support EMS Compasss efforts to

design measures that can be automated
when using NEMSIS data, the project has
enlisted a group of volunteers from several leading EMS technology and software
companies. Chaired by FirstWatch Product
Strategist Debbie Gilligan, the EMS Compass Technology Developers Group has
focused on matching the proposed performance measures to NEMSIS data points,
and testing them to make sure EMS agencies could implement the measures with the
EMS clinical data they already have.
The possibilities created by having electronic records, a uniform data standard, and
performance measures using that data are
pretty exciting, Gilligan says. Its been fun
to get in a room with people from all these
innovative companies who are in many ways
competitors, but who all have one goal in
mindfinding ways to make it easier for
people to get more out of their data.
Building consensus around performance
measures is not easy, as many other areas
of healthcare have discovered. During the
EMS Compass process, the committee

members and project leaders have navigated some complicated questions, from
what level of evidence review was needed
to which sources of data could be considered. Early on, it became clear that many
members of the initiative recognized some
Building consensus around

performance measures is not
easy, as many other areas of
healthcare have discovered.
key measuresclinical outcomeswould
rely on EMS agencies being able to access
data from outside sources, such as hospitals.
Information should flow seamlessly
from prehospital care to hospital care and
back, Bass says. To me I see that as a really
important part of what were doingto say
heres the science, here are the measures,
heres the way it needs to be done.
28
At the same time, he acknowledged, most

EMS agencies continue to struggle to get
access to outcome information from hospitals. Recognizing that, many of the measures were designed to serve as surrogate
measures that use data currently collected
by providers when they complete patient
care reports only until they are able to link
with hospital data to collect the complete
measures.
Maybe you have to do that initially just
so you get some baseline on the EMS processes and start measuring, Bass says. But
we have to be willing to say that the right
way to measure performance often includes
patient outcomes, such as survival to discharge for cardiac arrest. And maybe having
a measure that says that will help improve
the state of data-sharing between hospitals
and EMS systems.
Establishing a Foundation
Based on Evidence
Equally important to using available data
is creating measures that are based on the
EMS1507S
they are expected to perform, EMS Compass leaders chose to focus on measures
linked to patient outcomes, such as the ability to accurately identify stroke patients, or
administration of aspirin for heart attack
victims. Members of the initiative looked
to sources such as American Heart Association guidelines and articles published
in the peer-reviewed medical literature to
ensure the EMS Compass measures would
be assessing evidence-based practices.
A key opportunity in improvement is
to use measurement to support EMS systems to reliably deliver evidence-based
care, Williams says. Not measuring the
care processes that matter will not improve
outcomes.
latest evidence and best practices in prehospital care. The ultimate purpose of performance measures is to improve patient
care and EMS practiceand therefore the
patient experience and outcomes. Performance measures often drive programmatic
Involving the entire EMS

community and building
consensus around measures was a
priority for the initiative.
changes, so it was essential to the EMS
Compass leaders to only measure processes
that have a demonstrated positive impact.
For example, while measuring IV success
rates has long been a standard for many
EMS performance management programs,
there has never been a proven association
between IV success rates and patient outcomes. While it is clearly important that
paramedics can competently perform skills
Focus on Local Improvement

EMS Compass leaders say the initiative is
focused solely on creating measures that
support systems to improve care, and the
project has no ability or authority to require
agencies to use or report the measures. But
with changes to healthcare funding occur-
ring across the industry, many members of

the EMS community and EMS Compass
team have acknowledged that in the future,
healthcare payers, local governments and
other entities may look for additional measures to use to assess EMS payments or hold
systems accountablein a sense, this is
already happening in cities across the country that have response time requirements
tied to contract payments for EMS services.
If insurance companies and the U.S. Centers
for Medicare and Medicaid Services (CMS)
later link payments to performance, some
EMS leaders argue, itd be better for them to
use measures developed by the EMS community and based on solid medical research.
Our goal is to create evidence-based
measures that support the improvement of
the quality of care at the local level, period,
says Dia Gainor, executive director of NASEMSO. If agencies, regulators or communities choose to use the EMS Compass measures, then they will be using measures that
are good for patients and good for EMS.
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and building consensus around measures

was a priority for the initiative, regardless of
potential other uses of the measures. From
the start, EMS Compass has involved dozens
of EMTs, paramedics, educators, administrators, medical directors and other experts
on its various committees. The steering
committee also included several experts
from outside EMS, including Kedar Mate,
MD, a physician and improvement expert
with the Institute for Healthcare Improvement (IHI); Patria de Lancer Julnes, PhD,
a performance measurement expert and
researcher at Penn State Harrisburg; Todd
Olmsted, PhD, a health economist at the
University of Texas; and Martha Hayward,
a patient advocate with IHI.
A Community Efort
Beyond the impressive roster directly associated with the project are the dozens of
individuals and agencies who submitted
measures during the public call for measures. In order to be as open and inclusive
as possible, EMS Compass began its mea-
surement design process by asking members

of the public to submit ideas for measures.
The response exceeded even the expectations of the initiatives leaders when they
received more than 400 submissions.
From the beginning, Ive been receiving
so many e-mails, seeing great turnout at
meetings, hearing from so many different
members of the EMS community, says Nick
It is clear that EMS performance

measures created today cannot be
thought of as permanent.
Nudell, the EMS Compass project manager.
Its exciting to see so many people engaged
and interested in contributing.
Since then, EMS Compass has hosted
several webinars and conference sessions
to share information and receive feedback,
and the proposed measures are all available for public comment on the initiatives
website, emscompass.org, prior to review by
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also encouraged agencies to test the specific
measures to ensure that agencies are able to
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as intended.
Even with a process that is so focused on
inclusiveness and evidence and testing, it is
clear that EMS performance measures created today cannot be thought of as permanent. As research reveals new findings and
different data becomes available, the EMS
community must be willing to adapt and
re-evaluate performance measures. What
EMS Compass has focused on, rather than
specific measures, is a process for developing and revisiting measures. The members of the EMS Compass team hope that
the process theyve createdbased largely
on the model used by the National Quality Forum and the larger healthcare communitywill be used in the future by the
EMS profession to develop new measures,
to reassess old measures and ensure that
EMS agencies continue to have the tools
they need to support improvement.
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The real legacy of EMS Compass, and

our main measure for knowing it is a success, will be a culture of performance
improvement across EMS, from volunteers
in the smallest rural agencies to chiefs in the
busiest urban departments, Gainor says.
Everyone in EMS shares the same goal
providing the best care to our patientsand
EMS Compass will help us do just that.
In fact, creating a sustainable process for
designing measures is only part of the EMS
Compass initiativea result of the project
will be a guide to using performance measures for improvement. Frequently in the
past, efforts have focused solely on the measures. While agencies have started collecting the data and even calculating measures,
many struggle with implementing change
based on what they learn.
A critically important part of that process
will be a shift away from thinking of measurement for compliance, accountability or
judgment. Measurement for improvement
focuses less on people and errors and more
on understanding process reliability that
enables outcomes. This is a major cultural

shift for EMS, which has not had widespread experience of using measurement
for improvement.
Figuring out how to calculate the measures might seem like the difficult part, but
its just the first step, Bass says. Whats
usually the real challenge is knowing what
those numbers mean and recognizing when
improvements can be made and figuring out
the best way to drive that change.
The EMS Compass Legacy

Over the next several months, the EMS
Compass team will also lead discussions
about how to ensure the increased focus on
measurement for improvement doesnt end
when the funding for the current initiative
runs out. Some leaders in the EMS community hope that federal funding will be used
to extend the EMS Compass process. Others have suggested that EMS stakeholder
associations could work together to keep
EMS Compass alive. Another possibility is
that the EMS Compass process of designing
performance measures is used by different

organizations looking to create measures.
While the exact future of EMS Compass
beyond its initial funding is not decided, it
is clear that the EMS profession is ready to
move beyond simply measuring IV rates and
response times. By using evidence-based
and thoughtfully designed performance
measures, EMS agencies have the opportunity to improve the quality of patient care
and enhance their service to their communities. And thats a goal every EMS provider
can agree on.
Editors note: The EMS Compass steering committee is scheduled to meet on Jan.
13 to review and prioritize several performance measures. For the latest update, visit
emscompass.org.
Michael Gerber, MPH, NRP, is an instructor,
author and consultant in Washington, DC.
E-mail him at mgerber@redflashgroup.com.
EMS1601
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By Hawnwan Philip Moy, MD, & Blake Bruton, MD
VitaLink Transport teams of all

levels apply CPAP early during
the care of patients experiencing
respiratory emergencies. Only
critical care teams utilize BiPAP.
Evidence-Based EMS:
Out-of-Hospital I
BiPAP vs. CPAP
Is one any better than the other?
36
ts that crazy weather again. One minute its a

beautiful sunny day, and the next its freezing rain.
As you bundle up for the cold weather, you get
dispatched to a 75-year-old male with difficulty
breathing. You arrive on scene to find a thin, frail
elderly man sitting in the kitchen, leaning forward
with elbows propped on the table. He struggles to
say, I cant breathe.
On exam you note pursed-lip breathing with a prolonged expiratory phase. He has intercostal retractions, diffuse wheezing with rales bilaterally, with
pitting edema in his lower extremities. Initial vital
signs are a pulse of 130, blood pressure of 165/60,
respiratory rate of 25, and a pulse oximetry reading
of 85% on room air. His medical history is significant
for severe COPD and congestive heart failure.
While you debate whether this is a COPD or
CHF exacerbation, you decide to put the patient on
continuous positive airway pressure (CPAP) while
administering nebulized albuterol. The patient is
still anxious with labored breathing, but his pulse
ox improves to 90%. On arrival at the hospital, the

emergency department physician immediately orders
the respiratory therapist to switch from your CPAP
to biphasic positive airway pressure (BiPAP).
Youve seen this switch occur on multiple occasions
when youve brought in a patient on CPAP and wonder why the ED always switches to BiPAP. Is BiPAP
really that much better than CPAP? If so, should we
be using BiPAP in the EMS world?
Background
As a quick review, patients in acute respiratory distress have a problem with oxygenation, ventilation or
both. Oxygenation is the process of providing oxygen to the patient. However, pathologies like COPD
and CHF may require more than just oxygenation
as a result of alveolar disease preventing appropriate
diffusion of oxygen and carbon dioxide across the
alveolar membranes (i.e., pulmonary edema and bronchoconstriction). This is when ventilation becomes
important. Ventilation can be thought of as the actual
physiologic process of breathing, which is inhalation,
diffusion of gases and exhalation.
Ventilation and oxygenation are important for
understanding the utility of noninvasive positive
pressure ventiliaton (NIPPV). NIPPV is a form of
mechanical ventilation delivered through the use
of tight-fitting nasal or facial masks that does not
require endotracheal intubation. It can be delivered
in two forms: CPAP or BiPAP.7 CPAP provides a
continuous pressure of oxygen to the alveoli. This
constant pressure provides oxygen directly to the
lungs, prevents alveolar collapse, and may even open
up previously closed alveoli (alveolar recruitment).
In essence, CPAP primarily provides oxygenation
and may indirectly influence ventilation by allowing alveoli to remain or become available.7 As a result
of this constant pressure throughout the respiratory
cycle, the patient has to overcome this pressure during exhalation. Thus, CPAP is limited by the patients
ability to overcome the very pressure CPAP provides.
Here is where BiPAP can help. BiPAP provides
CPAP, but senses and adjusts the oxygen pressure
to the patients breathing cycle. The oxygen pressure increases during inhalation to provide maximal
alveolar recruitment but decreases during exhalation
to ease breathing while keeping alveoli open with its
adjustable CPAP function. In essence, BiPAP provides greater control for acute respiratory distress
and may provide better gas exchange to optimize
cardiopulmonary performance. Thus, many hospitals
use BiPAP for this very reason: better control.
The use of BiPAP is further supported by a 2004
Cochrane review in which the authors examined 14
randomized controlled trials in which standard medi-
cal therapy (SMT)defined as supplemental oxygen,

bronchodilators, steroids and antibioticswas compared to BiPAP in patients with COPD. With a total
of 758 patients analyzed, the authors found a 48%
reduction in the risk of mortality for patients treated
with BiPAP. This demonstrated a number needed to
treat (NNT) of 10, meaning that for every 10 patients
treated with BiPAP, one life was saved compared to
SMT alone. This review also demonstrated a 60%
decrease in the risk of intubation with a NNT of 4.8
Clearly this review supports the use of BiPAP as a
first-line NIPPV therapy in treating COPD. Before we
claim that BiPAP is superior, though, lets remember
that this review did not specifically compare the use
of CPAP against the use of BiPAP. So lets look at the
evidence comparing the two before we throw our
CPAP machines out the window.
In-Hospital Evidence
To begin, there are studies that showed worse outcomes with BiPAP compared to CPAP. In 2012, Brazilian researcher Juliana Nalin de Souza Passarini
demonstrated an increased need for endotracheal
intubation in patients who received BiPAP compared
to those who received CPAP in treatment of acute
cardiogenic pulmonary edema (ACPE) and COPD
exacerbation.10 However, this study was limited by
a nonrandomization of subjects, leading to bias in
Some rural EMS systems may take the long-term effects of

BiPAP into consideration given their longer transport times.
the patients who received BiPAP and CPAP. This
was demonstrated when the authors concluded that
the increased need for intubation was likely due to
greater disease severity in those patients who received
BiPAP. Despite these limitations, this study still demonstrated that a majority of patients managed with
NIPPV avoided the need for endotracheal intubation.
In contrast, an older, more methodologically sound
study stated that BiPAP may provide slightly better
results than CPAP. These authors attempted to evaluate whether BiPAP improved ventilation, acidemia
and dyspnea more rapidly than CPAP in patients with
ACPE by measuring vital signs and specific blood
lab values. What makes this manuscript methodologically superior to the former study is that it was
a randomized, controlled, double-blinded study, so
bias was kept to a minimum. The authors concluded that BiPAP improves ventilation and vital signs
quicker than CPAP. However, they added a word of
caution after discovering a relationship with having
a myocardial infarction (MI) and the use of BiPAP.6
37
Fortunately, a meta-analysis nine years later

demonstrated this relationship of new-onset
MI and BiPAP utilization did not reach statistical significance.5
However, many who support CPAP state
that both interventions lack a difference
in meaningful outcomes (i.e., the need for
intubation and/or effect on mortality). One
such study compared BiPAP to CPAP in
200 patients with ACPE. The authors discovered that BiPAP was associated with
faster resolution of respiratory failure (159
vs. 210 mins.). However, there was no difference in mortality or rate of intubation
in BiPAP and CPAP patients. In essence,
CPAP may be just as good as BiPAP in the
long run. 8
Furthermore, a recent article in the New
England Journal of Medicine further supported that CPAP is just as beneficial as
BiPAP in terms of meaningful outcomes.
The objective was to determine whether
noninvasive ventilation reduced mortality and whether there were important differences in outcomes associated with the
method of treatment (CPAP or BiPAP). The

authors discovered that 11.7% of patients
on CPAP and 11.1% of patients on BiPAP
either died or were intubated. This small
difference was not statistically significant,
and the authors concluded CPAP can be just
as effective as BiPAP in short-term (sevenday) mortality.4
Before we say that CPAP can be just as
good as BiPAP, though, lets look at the prehospital evidence.
Prehospital Evidence
Although limited in number of studies,
the prehospital evidence for the utility of
BiPAP and CPAP shows comparable results
to the in-hospital research. The University of Sheffields Steve Goodacre, et al.,
published a systematic review comparing
OOH CPAP and BiPAP to SMT. There was
an overall reduction in mortality and intubation rate when compared to SMT, but
they found no statistical difference with
the use of BiPAP and CPAP. While this
review seems to be the most complete to
date, the authors noted, The analysis of

BiPAP in particular involved fewer studies
and fewer patients (190 receiving BiPAP
vs. 610 receiving CPAP). 3 Additionally,
Sheffields Abdullah Pandor and colleagues
provided a similar systematic review that
showed a decrease in mortality and need
for intubation in the CPAP group that was
similar to the BiPAP group.9
Bottom Line
After looking at the evidence of BiPAP
against CPAP, the only advantage BiPAP
appears to provide is a decreased time to
resolution of respiratory symptoms, vital
signs and improvement of laboratory values.
However, keep in mind that this difference
doesnt occur until late in the treatment
course. While this shouldnt affect most
EMS systems with short transport times,
some rural EMS systems may take the longterm effects of BiPAP into consideration
given their longer transport times. Otherwise, current evidence demonstrates minimal benefit to BiPAP over CPAP.
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What we do know is that BiPAP provides

better outcomes in patients with COPD
when compared to SMT, and CPAP may
be better for ACPE. However, the studies
reviewed in this article have not shown
a clear or consistent advantage to BiPAP
over CPAP in clinically significant outcomes such as decreased mortality, need
for intubation, ICU admission and length
of hospital stay.
As a prehospital provider, it is always a
good to question yourself, broaden your
differential impression for acute respiratory failure and maintain that inquisitive
mind. With the evidence reviewed here, the
hospital changing your prehospital CPAP to
BiPAP every time should not distress you.
In the short run, CPAP is just as good as
BiPAP. The next time you are faced with a
patient with acute respiratory distress, the
best thing you can do is relax, remember
your training and think about what you can
do to best help your patient. If you decide
CPAP is the way to go, you now have the
evidence to support your decision.
R E FE R E N CE S
1. Baird JS, Ravindranath TM. Out-of-hospital noninvasive
ventilation: epidemiology, technology and equipment. Pediatr
Rep, 2012 Apr 2; 4(2): e17.
2. Cross AM, Cameron P, Kierce M, Ragg M, Kelly AM. Noninvasive ventilation in acute respiratory failure: a randomised
comparison of continuous positive airway pressure and
bi-level positive airway pressure. Emerg Med J, 2003 Nov;
20(6): 5314.
3. Goodacre S, Stevens JW, Pandor A, et al. Prehospital
noninvasive ventilation for acute respiratory failure:
systematic review, network meta-analysis, and individual
patient data meta-analysis. Acad Emerg Med, 2014 Sep; 21(9):
96070.
4. Gray A, Goodacre S, Newby D, et al. Noninvasive Ventilation
in Acute Cardiogenic Pulmonary Edema. N Engl J Med, 2008;
359: 14251.
5. Ho KM, Wong K. A comparison of continuous and bi-level
positive airway pressure non-invasive ventilation in patients
with acute cardiogenic pulmonary oedema: a meta-analysis.
Crit Care, 2006; 10(2): R49.
6. Kollef M, Isakow W. The Washington Manual of Critical Care,
2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2012.
7. Mehta S, Jay GD, Woolard RH, et al. Randomized,
prospective trial of bilevel versus continuous positive airway
pressure in acute pulmonary edema. Crit Care Med, 1997 Apr;
25(4): 6208.
8. Nouira S, Boukef R, Bouida W, et al. Non-invasive pressure
support ventilation and CPAP in cardiogenic pulmonary
edema: a multicenter randomized study in the emergency
department. Intensive Care Med, 2011; 37(2): 24956.
9. Pandor A, Thokala P, Goodacre S, et al. Pre-hospital noninvasive ventilation for acute respiratory failure: a systematic
review and cost-effectiveness evaluation. Health Technol
Assess, 2015 Jun; 19(42): 1102.
10. Passarini JN, Zambon L, Morcillo AM, et al. Use of noninvasive ventilation in acute pulmonary edema and chronic
obstructive pulmonary disease exacerbation in emergency
medicine: predictors of failure. Rev Bras Ter Intensiva, 2012
Sep; 24(3): 27883.
11. Ram FS, Picot J, Lightowler J, Wedzicha JA. Non-invasive
positive pressure ventilation for treatment of respiratory
failure due to exacerbations of chronic obstructive pulmonary
disease. Cochrane Database Syst Rev, 2004; (1):CD004104
Hawnwan Philip Moy, MD, is an assistant
medical director of the Saint Louis City Fire
Department and emergency medicine
clinical instructor and core faculty of the EMS
Section of the Division of Emergency
Medicine at Washington University in St.
Louis, MO. He completed his emergency
medicine residency at Barnes Jewish
Hospital/Washington University in St. Louis and his EMS
fellowship at the University of North Carolina in Chapel Hill.
Blake Bruton, MD, earned his Doctor of
Medicine degree from the University of
Arkansas for Medical Sciences. He is
currently in his second year of emergency
medicine residency at Washington University
in St. Louis. He is a certified Advanced
Trauma Life Support instructor for the
American College of Surgeons. His current
interests include prehospital care, trauma resuscitation,
bedside ultrasound and pediatric emergency medicine.
EMS1601S
40
ACEI-RA is a diferent beast, less than responsive

to standard pharmacological agents
By Kristin Spencer,
MS, NRP
f I were to ask you to list the treatment modality for angioedema, your list would probably
include oxygen therapy, IV, cardiac monitoring,
pulse oximetry, capnography, IM epinephrine,
corticosteroids, diphenhydramine and, in some
cases, rapid sequence intubation. In most cases of an
allergy-induced angioedema, your answer would be
spot on. Angiotensin-converting enzyme inhibitorrelated angioedema (ACEI-RA) is a different beast,
however. Before we discuss why ACEI-RA is less than
responsive to the standard pharmacological agents
Angioedema of
the lips and face
Photos courtesy of Bechera Y. Ghorayeb, MD, www.ghorayeb.com.
listed above, we should cover its epidemiology and

pathophysiology.
More than 40 million people worldwide are prescribed ACE inhibitors,1,2 and chances are several
of your previous patients have been taking them
for heart failure or hypertension. ACE inhibitors
are the drugs that end in the familiar -pril: lisinopril, captopril and enalapril, for example. Like any
prescription medications, there are potential side
effects from ACE inhibitors, angioedema being one
of the most serious.
Angioedema is estimated to occur in 0.1%0.7%
of patients on ACE inhibitor therapy. 3,4 Of those who
present to an emergency department with angioedema, 35% of cases are attributed to ACEI.1 Additionally, one study concluded that African-Americans are
three times more likely to develop ACEI-RA within
six months of starting ACE inhibitor therapy.1,5
The most common signs and symptoms of ACEIRA are mild and may not even be reported by the
patient; in other cases the situation can be life-threatening. According to the Journal of Emergency Medicine
(2011), the most common sign of ACEI-RA is asymmetric (and isolated) swelling of the lips and face,
although cases of isolated swelling have been documented in the small bowel, genitals, uvula, tongue
and floor of the mouth.6 Urticaria is usually absent.
Unlike other types of allergic reactions that can occur
rapidly and aggressively, several studies have shown
ACEI-RA can occur with those who have been taking ACE inhibitors for weeks, months, even years.1,2,4
41
Angioedema
of the tongue
Most cases of angioedema are mediated by IgE

antibodiesthe endogenous antibodies that
attack seemingly innocuous allergens (antigens)
in those with type I sensitivity reactions. Insect
stings, seafood, pollen
and some medications
are frequently associated
with IgE-mediated allergic reactions. IgE antibodies have a high affinity for
mast cells and basophils,
and when bonded together result in the formation and
subsequent release of chemical mediators. Of course,
the chemical mediator closely examined in the paramedic curriculum is histamine. Histamine causes its
effects by binding to H1 and H2 receptors that cause
contraction of smooth muscles of the airway and GI
tract, increased vascular permeability, vasodilation,
enhanced mucus production, pruritus and gastric
acid secretion. Translated, a histaminergic-mediated
angioedema means your patient with allergy sensitivities could present with a runny nose, conjunctivitis,
nausea and vomiting, diarrhea, bronchoconstriction,
increased bronchial mucus secretions, generalized
swelling, urticaria/wheals and hypotensiona multisystemic reaction. Again, angioedema induced by
histamine will respond to conventional therapies like
antihistamines and corticosteroids, pharmacological agents commonly emphasized in most paramedic
curricula.
Interestingly, ACEI-RA is not IgE mediated; the
physiology of the condition is caused by the levels of
the blood vessel-dilating peptide bradykinin in the
body.2,4 Bradykinin counterbalances the vasoconstrictive workings of the renin-angiotensin-aldosterone
system and is thought to be a primary mediator in
nonallergic angioedemas. There are two kinds of bradykinin receptors: B1 and B2. When bradykinin binds
with these receptors, increased vascular permeability
and isolated, nonpitting edema occurs. Glossitis is
frequently seen. Given the pathophysiology behind
ACEI-RA, you can now understand why conventional
interventions for angioedema probably will not work
with these specific cases. 3,4
Safer for Patient, Provider

Safety is one of the biggest concerns in EMS when
handling a patient.
Making sure the patient is comfortable is
another focal point.
Mangar Internationals Elk Lifting Cushion helps
providers cover both of those areas.
The compact, battery powered cushion inflates
with the push of a button to help patients reach a
seated position, making it easier for them to stand.
Chris Mulberry, assistant chief paramedic of
Platte Valley Ambulance Service, says his agency has been using the lifting cushion and is very
satisfied with the results.
The nice part is that its not big and its not
heavy, Mulberry says.
The cushion applicable for use on patients of
any age.
Chris Lokits of Louisville Metro EMS says the
lifting cushion is a blessing.
Being by myself doing lift assist, I was confident that I could successfully get the patient
up without hurting them or myself, Lokits says.
Mulberry says the cushion is especially useful
when handling older patients.
With elderly people, some have more fragile
skin because theyre on certain medications,
Mulberry says. The cushion makes it more safe
and more comfortable, and makes it so youre not
just grabbing or yanking.
Lokits says some elderly patients had concerns

at first that the cushion was not stable, but after
some explanation and doing his best to keep the
patient stable, those concerns subsided.
The lifting cushion also allows the provider
to come in less contact with any bodily fluids or
waster from a patient because it requires less
contact, Lokits says.
Prior to using the Elk Lifting Cushion, Mulberry
says his agency just lifted patients manually.
The cushion, designed for either indoor or
outdoor use, makes it so providers can shimmy
42
or roll a patient onto the cushion.

Lokits says that although some pushing, pulling or lifting is still required to get the patient
positioned correctly on the cushion, it prevents
providers from having to deadlift patients, reducing the risk for personal injury. Lokits says this is
invaluable.
Even though some contact with the patient is
still required, Lokits says the product increases
safety for both the patient and the
provider.
I believe this device will pay
for itself in the long run with a
decrease in IODs and
workmans compensation claims, Lokits says.
The device provides
additional safety for the
crews, not to mention the safety provided for the
patient we are lifting.
Mulberry also says the device is durable.
When you see the pictures, it doesnt look
too rugged, Mulberry says. EMS people are
hard on equipment, but this product stands up
to any EMS use.
Lokits says the majority of the device is easy to
clean when using the appropriate cleaner.
To learn more about the Mangar Elk Lifting
Cushion or other products, visitmangarusa.com.
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How to Proceed
So what do you do? Do you not treat the
angioedema? Of course you do. Most cases
of angioedema are not caused by ACE inhibitors, and it may be difficult to make a precise correlation between the two. If youre
a person who would prefer a specific treatment algorithm for ACEI-RA or a definitive
diagnostic test, you will be disappointed.
When assessing a patient with upper airway obstruction/edema, conduct a fastidious yet rapid exam. Identification regarding its etiology is extremely time-sensitive,
especially when dealing with ACEI-RA. For
purposes of this discussion, the upper airway is defined as the conduit from the nose
and mouth to the larynx.
Youve probably heard it, but it bears
repeating: Avoid approaching your patient
with tunnel vision. Not all cases of angioedema are secondary to shellfish, hymenoptera
stings or penicillin, so keeping a broad list of
differentials is important. You must weigh
the likely causes of upper airway obstructions considering age, medical history,
recent events and physical examination. For

example, you would not diagnose a young
patient with a history of fever, dysphagia,
sore throat and drooling as ACEI-RA.
There are multiple causes for upper
airway swellingsome are progressive
and potentially lethal, some more benign.
Through your physical examination and
history-taking, you can rule out some of
the more common differentials. See box.
Understanding the underlying causes of
common upper airway obstructions and
identifying life threats is paramount, as
treatment modalities differ. You would not
treat a patient with massive maxillofacial
injuries as you would a patient presenting with anaphylaxis, epiglottitis or croup.
Although the endpoint may be the same in
most airway management challenges (i.e.,
oral intubation), patients with ACEI-RA may
be nonintubatable through the oral cavity;
glossitis may be severe enough to make the
mouth impenetrable with an OPA, endotracheal tube, LMA, Combitube or King. (As a
side note, although glossitis may look out-
Causes of Upper Airway

Swelling
Burns;
Epiglottitis
Laryngotracheobronchitis
(croup);
Massive maxillofacial trauma;
Acute laryngeal injury;
Ludwigs angina;
Laryngeal stenosis;
Laryngeal tumors.
landish, the larynx may not be affected, and

the patient can still move air.) If the patient
needs ventilatory assistance, perform BVM
ventilations while simultaneously watching the rise and fall of your patients chest
to ensure adequate tidal volume. Observe
SpO2, the patients color, mental status, heart
rate and EtCO2your patient may respond
surprisingly well. It would be difficult to
justify performing, say, a surgical airway
when assisted ventilations prove beneficial.
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Sometimes the least invasive practices are

preferred over invasive procedures that may
have catastrophic consequences.
If you determine BVM ventilations are
ineffectual, intubate through the orotracheal route. If you cannot insert an ETT
through the orotracheal route, consider the
nasotracheal route. Although its becoming
a lost art and at times forgotten as a viable
option, a scenario may arise where using the
nasotracheal route may be your only option
in securing a definitive airway.4
Arguably controversial and not instituted
in some places, rapid sequence induction
(RSI) is an option and should be included in
every paramedics treatment toolbox. If necessary and viable, RSI can be very beneficial
in cases of ACEI-RA when you have a conscious patient showing signs of imminent
airway closure (e.g., stridor, hoarse voice,
reports of dysphagia) or respiratory failure. If you anticipate a difficult intubation
due to anatomic changes, prepare two or
three different sizes of ETTs. If the larynx is
edematous, you may not successfully pass a
tube normally appropriate for the stature of

your patient. If you can visualize the glottic
opening but are unsuccessful with direct
laryngoscopy, consider using fiber-optic
intubation if available.
In extreme cases, a cricothyroidotomy
may be required when all other attempts
have failed. According to physicians Jose
Yataco and Atul Mehta (2008), orotracheal
intubation is successful in 97% of airway
management cases, leaving only 3% of
patients requiring immediate cricothyroidotomy.7 But dont let these numbers lure you
into thinking I will never get that patient.
You may get that patient and should
always be prepared to perform this procedure if the worst-case scenario falls in your
lap. Practice surgical airways frequently.
Once you have determined, through ruling out various differentials, that ACEI-RA
is the probable etiology for your patients
angioedema, examine the airway and act
accordingly based on the patients presentation. Your ultimate treatment goal is more
than managing the airway through basic or
advanced devices; attempts to abate airway

swelling through pharmacological agents
are also vital.
Case studies show great promise in treating ACEI patients with fresh frozen plasma
(Class II) or bradykinin blockers (e.g., icatibant, Class II). However, neither is carried in
ambulances. Nor is there a precise antidote
to treat ACEI-RA.6 Based on that harsh reality, paramedics are forced to rely on conventional therapies including epinephrine, corticosteroids and antihistamines. According
to some clinicians, evidence-based treatment
recommendations for ACEI-RA are:
Supplemental oxygen;
Securing the airway and assisting ventilations if needed;
Pharmacologically assisted intubation
(RSI);
Nasotracheal intubation if orotracheal
intubation impossible;
Capnography, pulse oximetry;
IV and fluids, if necessary;
Although controversial, treatment
still involves consideration of H1 and H2
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blockers (e.g., ranitidine, cimetidine; class

indeterminate);
Corticosteroids (e.g., prednisone,
methylprednisolone; class indeterminate);
Cardiac monitoring;
Racemic epinephrine;
Epinephrine 1:1,000, 0.30.5 IM,
repeat if needed.
Examining the list above, you may question why histaminic antagonists and epinephrine are included as part of the suggested treatment plan for ACEI-RA, given
histamine release is not the triggering agent.
Epinephrine is administered primarily for
its alpha-1 properties; the vasoconstrictive
actions may reduce swelling in the affected
areas, although several case studies have
shown less than impressive results when
using epinephrine for bradykinin-mediated
angioedema.1 Histamine blockers are generally used if the source of the angioedema is
either histaminic-induced or unknown. It is
reasonable to administer H1 and H2 blockers for angioedemas of unknown etiology
because the side effects are relatively few and
benign.1 It is important to note that in a small

study published in the New England Journal
of Medicine, patients with ACE inhibitorinduced angioedema recovered nearly three
times faster with the administration of a bradykinin blocker than those given a standard
glucocorticoid/antihistamine treatment.3
Conclusion
Although ACEI-RA is rarely examined in
either initial or ongoing paramedic training,
airway management is. If your patient shows
signs of airway closure or indicators that
airway compromise is imminent, be aggressive in securing the airway before it becomes
impossible. Although basic maneuvers such
as the insertion of an NPA and BVM ventilations may prove successful, watch your
patient closely to determine how he/she
is trending. Complete airway obstruction
secondary to laryngeal edema may occur
rapidly and unexpectedly. Immediate intubation, by either the oral or nasal route, RSI
or, in extreme cases, cricothyrotomy, may
be required. With those suspected of ACEI-
RA, this fundamental training may very well

be the most important intervention we can
makeafter all, it always comes down to
your ABCs.
R E FE R E N CE S
1. Flattery MP. When ACE inhibitors cause angioedema.
American Nurse Today, http://www.americannursetoday.com/
when-ace-inhibitors-cause-angioedema/.
2. Winters M. Clinical Practice Guideline: Initial Evaluation
and Management of Patients Presenting with Acute
Urticaria or Angioedema. American Academy of Emergency
Medicine, http://www.aaem.org/em-resources/positionstatements/2006/clinical-practice-guidelines.
3. Bas M, Greve J, Stelter K, et al. A randomized trial of
icatibant in ACE-inhibitor-induced angioedema. N Engl J Med,
2015; 372: 41825.
4. Wilkerson RG. Angioedema in the Emergency Department:
An Evidence-Based Review. Emerg Med Practice, https://
umem.org/fles/intl/Angioedema%20-%20Final%20copy.pdf.
5. Busse PJ, Buckland MS. Non-histaminergic angioedema:
focus on bradykinin-mediated angioedema. Clin Exp Allergy,
2013 Apr; 43(4): 38594.
6. Winters ME, et al. Emergency department management of
patients with ACE-inhibitor angioedema. J Emerg Med, 2013
Nov; 45(5): 77580.
7. Yataco J, Mehta A. Upper Airway Obstruction, https://store.
acponline.org/ebizatpro/images/ProductImages/books/
sample%20chapters/CCM37.pdf.
Kristin Spencer, MS, NRP, is program director for
EMS education at Crowder College in Neosho, MO.
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47
Oxygenate and Resuscitate

Before You Intubate
Common pitfalls to avoid when managing the crashing airway

By Russ Brown,
NREMT-P
Case #1
You are dispatched to a call for a 16-year-old female
patient with a chief complaint of possible anaphylaxis.
Upon arrival you find the patient lying supine in
the front yard with a crowd of bystanders huddled
around. The patient is not alert to even painful
stimulus, and her breathing is shallow and labored
at a rate of 34 a minute. Her skin is pale, and her
lips appear cyanotic. Her initial oxygen saturation
reads 75%.
You instruct your partner to bag-mask ventilate
the patient as you quickly move her to the ambulance. As the engine crew obtains IV access and
places the ECG electrodes, you attempt to obtain a

history from bystanders, but it is sketchy at best. All
they can tell you is they think the patient is allergic
to pistachios and they were in her meal at dinner.
Her initial oxygen saturation only increases to
80%, and administration of IM epinephrine does
little to improve things. The patients respirations
are now becoming shallow and agonal, and her oxygen saturation continues to decrease. Your partner
increases ventilations in an attempt to improve the
oxygen saturation. You attempt to intubate, but just
as you are about to place the endotracheal tube, the
patient vomits and aspirates. What now?
Ensure adequate oxygenation

and ventilation before any
intubation by maximizing oxygen
delivery with the use of a BVM
with attached PEEP valve and
2-provider mask-ventilations.
Courtesy of NHRMC AirLink/VitaLink
Critical Care Transport
48
Case #2
You are dispatched to a call to your local nursing home
for a 64-year-old patient with altered mental status.
Upon arrival you find the patient lying supine in bed
with a nasal cannula placed in her nares, set at a flow
rate of 2 lpm. The patient is responsive to painful stimulus, and her skin is pale and hot to the touch.
The staff informs you she has had a recent diagnosis
of pneumonia and has become increasingly altered since
this morning. They report her temperature is 102.3F
and that she is normally alert and oriented to person,
place and time. You quickly obtain a set of vital signs,
which reveals the patient is tachycardic at a rate of 108
and tachypneic at a rate of 30. Her oxygen saturation is
82% on 2 lpm of oxygen, and her blood pressure reads
82/56. You place a nonrebreather on the patient at 15
lpm and obtain IV access as well as a 12-lead ECG.
The 12-lead shows a sinus tachycardia, and the oxygen
saturation does not improve at all. You remember reading somewhere about using a high-flow nasal cannula
to improve oxygenation, so you turn up the patients
cannula to 15 lpm, along with the nonrebreather. This
only improves the saturation to 84%, so along with the
patients mental status, you decide to intubate.
Your equipment is prepped and ready, and IV access
has been obtained. You instruct your partner to bagmask ventilate the patient to improve the saturation as
you administer your induction agent followed quickly by
your paralytic. The patients oxygen saturation begins to
fall rapidly as you attempt intubation, but you secure the
airway with the help of a gum elastic bougie. Intubation
is confirmed via waveform capnography and bilateral
breath sounds. Soon after intubation the patient goes
into a bradyasystolic arrest and cannot be revived. What
happened? How could this have been prevented?
Oxygenation and Ventilation

Proper airway management is a fundamental skill
in which every emergency care practitioner must be
proficient.
The two cases illustrated above, while different,
occur in both hospital and prehospital arenas every day.
Whether you are a paramedic, EMT, nurse or physician,
it is imperative to have a firm understanding of both
basic and advanced airway management.
Concepts such as delayed sequence intubation
(DSI), apneic oxygenation and the use of supraglottic
airways have broadened our medical armamentarium
and helped improve patient outcomes. It is important
to understand that not every airway case is the same,
and there is no one treatment modality that works for
every clinical situation.
If we are to truly do no harm for our patients, we
have to understand the pathophysiology of those treatments as well as the end goal of oxygenation and ventila-
tion. Before exploring these common pitfalls sometimes

associated with our interventions, we must first discuss
the principles behind oxygenation and ventilation.
Oxygen is transported in the body in two ways.
Approximately 97% of it is bound to hemoglobin, while
the remaining 3% is dissolved in the blood plasma.
Ventilation is the process by which we move oxygen
from the environment into the body and the process of
exhaling the byproducts of cellular respiration, mainly
carbon dioxide.
In the prehospital environment we can measure oxygenation status via pulse oximetry. An acceptable range
on the patient breathing room air is 95% or greater.
Keep in mind that pulse oximetry only measures the
amount of oxygen bound to the hemoglobin molecule
and not the actual percentage of hemoglobin in the
body. Anemic patients can show an oxygen saturation
well above 95% and yet still be clinically hypoxemic
due to the lack of hemoglobin that can carry oxygen
molecules.
Increasing our FiO2 (fraction of inspired oxygen)
typically is the fastest way to correct hypoxia. During
procedures such as RSI, we preoxygenate our patient
with 100% oxygen, ideally for three minutes, to increase
the amount of oxygen in the lungs, thus building a
reservoir. By filling every available functional alveoli
in the lung with oxygen, we extend the time it takes
before our patient becomes hypoxic.
As oxygen diffuses across the alveolar capillary membrane, it is bound to deoxygenated blood returning from
the right side of the heart. This oxygen-rich blood can
now be pumped out by the left side of the heart into
the systemic circulation to diffuse into tissue cells and
complete the process of cellular respiration.
One of the byproducts of cellular respiration is
the production of carbon dioxide. Once again, blood
returning to the right side of the heart is rich in carbon dioxide. This CO2 now diffuses across the alveolar
capillary membrane into the lungs, where it is exhaled
to the external environment. Many factors, such as
cardiac output, percentage of hemoglobin, and certain
disease processes such as pneumonia and acute respiratory distress syndrome (ARDS), can influence this
process of oxygenation and ventilation. It is beyond
the scope of this article to discuss every possible factor
that influences cellular respiration, but this simplified
explanation given above lays a foundation as we further
explore three pitfalls that providers sometimes make
in regard to positive-pressure ventilation and how to
correct them.
Three Pitfalls
Overzealous bag-mask ventilation
Bag-mask ventilation is a cornerstone of basic life support. It is often one of the first airway skills we learn as
49
Alveolar PAo2
FIGURE 1
50
new EMTs. Proper mastery of this skill, as well as a

thorough understanding of possible adverse events,
can greatly influence the care we provide. Conversely,
a lack of fundamentals in the skills proper use and lack
of respect for the dangers imposed by it can have disastrous consequences, as evidenced in the cases above.
Often we lose sight of how fast we are ventilating
our patients due to the high-stress environment of
a resuscitation. As a result, the patient can inadvertently become hyperventilated.1
One study published in the Journal of Critical
Care Medicine showed that with increased ventilations, survival rates decreased.2 The study design
was a prospective clinical trial in adults intubated
for out-of-hospital cardiac arrest, as well as a study
using three groups of seven pigs with induced cardiac
arrest. In the group of cardiac arrest patients being
ventilated, the average ventilation rate was around
30 breaths a minute, with a range of 15 to 49! For the
pig study group, ventilation rates were set at 12, 20
and 30 breaths/minute, and physiological parameters
were then assessed.
40%
30%
In the group of pigs
ventilated with the
12 bpm, 6 of 7 survived. In the group
25%
of pigs that received
30 bpm, none sur21%
vived. 3
Another study,
although small,
demonstrated that
even in emergency
department environments, nurses
and doctors were
ventilating at rates
of up to 41 times per
2
4
6
8
10
minute!4
Alveolar ventilation (liters/min)
Hy p er vent i l ation is known to
increase intrathoracic pressures, thus decreasing
venous return and left ventricular filling pressures.
This drop in preload and coronary filling pressures
will also cause a resultant drop in cerebral perfusion
pressures. 5 This is exactly the opposite of what we
want to do in a resuscitation!
As illustrated in Case #2 above, the patient was
hypotensive to begin with. Any further drop in preload can cause a precipitous drop in blood pressure,
resulting in an undesirable outcome.
Studies show that elderly patients are at an
increased risk for adverse hypotensive events and
cardiac arrest shortly after intubation and positivepressure ventilation.6 The elderly are also on medica-
tions that can change their physiology and decrease

preload. It is important to take this into consideration
when attempting to intubate the hypotensive patient
or the geriatric patient in general.
Another complication of overzealous bag-mask
ventilation and positive-pressure ventilation is vomiting and aspiration.
When a patient is hyperventilated prior to intubation, much of this ventilation is put into the stomach.7
This rapid insufflation of air distends the abdomen
and pushes against the esophageal sphincter until
the contents of the stomach are expelled upward.
This is the exact place you did not want them to be!
One reason we perform rapid sequence intubation
in the field is to decrease the risk of vomiting in the
patient who is not NPO. Paralytics will paralyze all
the muscles of the body, including the lower esophageal sphincter, thus mitigating this risk.
Prior to administration of our paralytic, though, we
must be cognizant of our ventilation rate and tidal volume. Pulmonary physiology studies have shown that
on room air, it takes very few breaths to adequately
ventilate our lungs.8 Adequate ventilation is defined
as a PaO2 (partial pressure of oxygen in the alveoli)
around 100, taking into account any dead space. This
is the amount of oxygen that is in the alveoli of the
lungs and can be used to diffuse across the capillary
membrane and dissolved into deoxygenated blood
coming in from the right side of the heart.
At room air, which is 21% oxygen, it only takes
around 3 lpm to reach a PaO2 of 100. Assuming you
are ventilating with a tidal volume of 500 ml, that
would be around six breaths. If you were ventilating
at a tidal volume of 700 ml, this would be around
45 breaths. At increased FiO2 (fraction of inspired
oxygen), the number of breaths needed to maintain
an acceptable PaO2 is decreased further (see Figure 1).
While many other factors can influence oxygenation
and cellular respiration, such as acid-base balance,
physiological and anatomical shunts, and cardiac output, the take-home point is that faster ventilations are
not necessarily better. In the next few paragraphs, we
will explore simple maneuvers, such as proper mask
seal in conjunction with an adequate rate and tidal
volume, that can improve the oxygenation status of
our patients before intubation and help to prevent
adverse events.
Improper mask seal

The inability to obtain a proper mask seal can be the
difference between oxygenating your patient or not.
Prehospital and emergency care providers are
typically taught a variety of methods for obtaining
a mask seal, including the E-C technique. Much of
what we learn in terms of airway management comes
February 19 & 20, 2016

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Preparation for disaster situations

through sharing frsthand
experience in actual disaster
challenges;
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discussions affecting the cost and
operations of EMS systems.
There will be forty 10-minute plenary

sessions given over the two-day period,
plus several lightning-round sessions
involving more than 30 medical
directors.
This event is especially relevant for
medical directors, chiefs, offcers,
system directors, managers, educators,
paramedics and EMTs, as well as
emergency nurses, researchers,
physicians and policy makers interested
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For more information and to register, visit GatheringOfEagles.us

Sponsored by UT Southwestern Offce of Health Systems Affairs
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The University of Texas Southwestern Medical Center is accredited
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This live activity is approved for AMA PRA Category 1 Credits.

This continuing education activity is approved by the
Continuing Education Coordinating Board for Emergency
Medical Services (CECBEMS).
from techniques used in

the operating room. The
difference between us
and providers in the OR
is that they perform this
procedure many times
daily over many years
and develop mastery of
it. We may go many shifts
before we are called upon
to mask-ventilate someone, causing skill retention to erode.
For the typical street
paramedic or nurse in the
ED, any break in the mask
seal will negate any benefits to oxygenation due
to entrainment of room
air and a loss of high-flow
FIGURE 2
oxygen. The addition of a
An alternative way for obtaining a proper mask seal is
high-flow nasal cannula
called the thenar eminence technique.
under the mask can provide a continuous source
of oxygen, even when the bag is not being squeezed.9
While there are many factors that can influence the
oxygenation of your patient, collapsed and inefficient
alveoli are one culprit when the administration of
high-flow oxygen does not work. Positive-pressure
ventilation can help achieve this, but only with a good
mask seal.
An alternative way for obtaining a proper mask
seal is called the thenar eminence technique or, more
simply, the two thumbs down technique.10 This is
done by placing your two thumbs down against the
edge of the mask and performing a jaw thrust to lift
the face into the mask (see Figure 2). A first provider
FIGURE 3
Expel 1ml of saline and then draw up 1ml of EPI 1:10000
52
is designated to squeeze the mask, while the second

holds the seal. This works well because it incorporates the strongest parts of your hands to hold the
seal while allowing you to detect the slightest mask
leak and adjust accordingly.
Focus on intubation before resuscitation

Another possible pitfall that emergency providers
can make is becoming fixated on securing an airway
as fast as possible, while ignoring the physiological
derangements the patient is showing.11
We should always take a step back and view the
patients entire clinical picture before rushing in to
place an endotracheal tube. The acutely decompensating patient with shock, whether from a hemorrhagic or cardiac etiology, may need to be stabilized
first. Hypotension due to volume depletion or a failing pump only increases our possible adverse events
from intubation.
As discussed before, intubation and positivepressure ventilation increase intrathoracic pressures
and will decrease preload. With decreased preload
comes decreased left ventricular filling pressures.
All of this sets the patient up for hypotension and
possible cardiac arrest.
Many medications used in the practice of RSI can
also decrease preload and cause respiratory depression, further increasing our risk of an untoward event.
BLS maneuvers such as the administration of highflow oxygen and proper bag-mask ventilation should
always be performed prior to intubation. Use slow,
easy breaths, as discussed above, and administer a
fluid bolus to increase volume status and stave off
intubation-related hypotension. The administration
of fluids will increase intravascular volume, thus
increasing right ventricular preload to the heart. If
the patient is in cardiogenic shock, vasopressors such
Courtesy of NHRMC AirLink/VitaLink Critical Care Transport
use consists of drawing up a small dose of a vasopressor such as

epinephrine and administering small aliquots to increase blood
pressure. One advantage of push-dose pressors is that they can
be faster to administer then a drip, especially in time-sensitive
settings such as with a hypotensive patient who is about to arrest.
For example, one popular option is to take a 10-ml saline syringe
and expel 1 ml out. Then draw up 1 ml of cardiac-dose epi and mix
by shaking (see Figure 3). This will give you a concentration of 100
mcg of epi in 10 ml of saline. You can now administer 510 mcg
every 25 minutes as needed to increase blood pressure before or
after intubation. Always make sure to follow your local protocols
and discuss these treatment options with your medical director.
Conclusion
Before stopping ventilations to intubate, ensure apneic oxygenation
via high flow nasal cannula is applied.
as norepinephrine or dobutamine can be started and the patient
further stabilized before proceeding with your RSI.
If it is imperative to intubate immediately and if your medical
direction allows it, push-dose pressors may be an option.12 Push-dose
pressors are a relatively new treatment modality in the prehospital
realm but have been used in the operating room for years. Their
Now we can apply what weve learned to the cases above. In Case #1
you recognize that your partner is ventilating too fast. You instruct
him to slow down and squeeze the bag with slow, easy breaths. You
also have an engine crew member assist your partner using a twoperson BVM technique. The addition of a high-flow nasal cannula
under the mask helps to improve oxygenation as well.
With the patients oxygenation status corrected, you can now
proceed safely with intubation. As you intubate, you notice substantial swelling of the oropharynx, but intubation is successful
with the aid of a bougie. En route, you continue to monitor the
airway and start the patient on an epinephrine drip. Upon arrival
Become a member
The International Public Safety

Association welcomes everyone
to join.
www.joinipsa.org
54
at the hospital, it is determined the patient had a life-threatening

anaphylactic reaction, and she is further stabilized.
In Case #2 you realize the patient may be septic and her hypotension needs to be further stabilized before proceeding with
intubation. You administer a 500-ml fluid bolus as you maximally oxygenate the patient with high-flow nasal cannula and a
nonrebreather. As a precaution you draw up a push-dose pressor
of epi in cause the patients blood pressure does not respond to
the saline bolus.
Her saturation does not respond to high-flow oxygen, so you
decide to quickly move to assisted ventilations with a BVM and a
two-person mask seal. A nasopharyngeal airway and jaw thrust is
also added to maintain airway patency. The patients blood pressure improves after administration of the fluid bolus and with the
oxygen saturation. With the patients hypotension and oxygenation status corrected, you can now safely intubate. Intubation
is successful, and the patient is transported to the emergency
department, where a diagnosis of bilateral pneumonia and sepsis
is confirmed. The patient spends several days in the ICU and is
eventually extubated and discharged.
In conclusion, it is important to understand our patients physiological state and how it relates to the procedures we perform. We
must first realize that oxygenation and ventilation are our main goals,
not necessarily placing an endotracheal tube. We should understand that basic airway maneuvers such as bag-mask ventilation
can sometimes be just as dangerous as advanced airway maneuvers
and have a methodical plan in place to deal with these situations.
So remember, the next time you are faced with an airway emergency, think resuscitate and oxygenate before you intubate!
R E FE R E N CE S
1. Aufderheide TP, Lurie KG. Death by hyperventilation: a common and life-threatening
problem during cardiopulmonary resuscitation. Crit Care Med, 2004 Sep; 32(9 Suppl):
S34551.
2. Ibid.
3. Ibid.
4. ONeill JF, Deakin CD. Do we hyperventilate cardiac arrest patients? Resuscitation, 2007 Apr;
73(1): 825.
5. Manthous CA. Avoiding circulatory complications during endotracheal intubation and
initiation of positive pressure ventilation. J Emerg Med, 2010 Jun; 38(5): 62231.
6. Hasegawa K, Hagiwara Y, Imamura T, et al. Increased incidence of hypotension in elderly
patients who underwent emergency airway management: an analysis of a multi-centre
prospective observational study. Int J Emerg Med, 2013 Apr 24; 6: 12.
7. Weiler N, Heinrichs W, Dick W. Assessment of pulmonary mechanics and gastric infation
pressure during mask ventilation. Prehosp Disaster Med, 1995 AprJun; 10(2): 1015.
8. Calder I, Pearce A, eds. Core Topics in Airway Management. Cambridge University Press,
2005.
9. Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency
airway management. Ann Emerg Med, 2012 Mar; 59(3): 16575.
10. Jin Y, Lee BN, Park JR, Kim YM. Comparison of two mask holding techniques for two person
bag-valve-mask ventilation: A cross-over simulation study. Resuscitation, 2010 Dec; 81(2).
11. Dunford JV, Davis DP, Ochs M, Doney M, Hoyt DB. Incidence of transient hypoxia and pulse
rate reactivity during paramedic rapid sequence intubation. Ann Emerg Med, 2003 Dec; 42(6):
7218.
12. Weingart S. Push-dose pressors for immediate blood pressure control. Clin Exp Emerg Med,
2015; 2(2): 1312.
Russ Brown, NREMT-P, is a firefighter/paramedic and EMS field training
officer for Southlake Fire Department in Southlake, TX. He has worked for a
variety of services including fire, private and hospital-based EMS systems.
He has a particular interest in airway management and cardiac resuscitation
science. Contact him at Rbrown@ci.southlake.tx.us.

55
Beyond pain, emotional and psychological needs

can help drive pseudoaddictive behaviors
By Jason R.
Berman, EMT-P,
& Dan Swayze,
DrPH, MBA,
MEMS
Editors note: In 2015 EMS World published a series

looking at key aspects of establishing mobile integrated
healthcare and community paramedic programs in
EMS. This series continues in 2016 with coverage of
clinical issues and profiles of systems that have moved
beyond the early stages and contended successfully
with more advanced issues. Magazine articles will be
supplemented by additional content on EMSWorld.
com. If your system has an MIH-CP program, let us
know your experiences at jerich@southcomm.com.
argaret was a 74-year-old woman who lived

alone in an apartment in a low-income
senior high-rise. What little help she
received was from a daughter who lived
nearby but whom Margaret suspected of
stealing her medications and money. As with many of
our patients, Margaret had been dealing with a history of serious medical issueshigh blood pressure,
a dysfunctional thyroid and a heart bypass. She was
simultaneously battling anxiety and depression that
had been untreated for years. But it was the relentless
56
and excruciating back pain that began after a back

surgery 10 years ago that kept bringing her back to
the emergency department.
The only thing that killed the pain was opioids.
Most days Margaret would lie in bed all day, only
getting up to take another pain pill. When the pain
wasnt being anaesthetized by the pills (or if she ran
out), she would head back into the emergency department to find comfort. At first we assumed she used
the medications to control her back pain. However,
the longer we worked with her, the more evident it
became that the pain pills were also her only way of
coping with her emotional pain.
Margaret told the community paramedics that
she may have gone to the hospital two, maybe three
times a month to seek relief for her pain. Different
sources confirmed she was actually going to various
local hospitals 23 times a week. Some days Margaret
would be discharged home from one hospital in the
morning, only to end up at a different hospital later
in the day. Many of those same sources told us she
had been labeled as a classic drug-seeker.
Opioid Dependency
The Substance Abuse and Mental Health Services
Administration estimates that approximately 6.9 million people in the U.S. are dependent on or abusing
prescription drugs.1 Community paramedics (CPs)
working in programs designed to reduce 9-1-1 utilization or 30-day readmissions are likely to encounter
this population of patients regularly, yet very little formal education is available to help CPs understand the
nature of prescription drug dependency. This article
will introduce the types of drug dependencies and
the resources most likely to help patients suffering
with addiction.
Common prescription opioids include hydrocodone (Vicodin), oxycodone (OxyContin, Percocet), morphine (Kadian, Avinza), codeine and similar drugs.
These drugs work in part by blocking certain pain
receptors, activating the mesolimbic (reward) system
of the brain and creating a sense of euphoria. Opioids
not only control the physical pain associated with an
injury, but also alleviate the mental stress that both
acute and chronic pain can produce. Unfortunately
the body soon develops a tolerance to opioids that
requires the patient to take higher doses of the drug
to achieve the same effect.2
Compounding the issue is the paradoxical effect
opioids have on the perception of pain. Patients
undergoing opioid therapy often suffer from opioidinduced hyperalgesia, which actually increases their
sensitivity to pain. 3 There are several theories about
the molecular mechanisms involved, but the result
is that the patient may require higher and more frequent doses of the opioid to achieve a pain-free state.
Escalating the dose of opioids to counter the
patients increased tolerance or hyperalgesic state
increases the risk the patient becomes physically
dependent on the drugs to function. Opioid dependency occurs when the patient experiences symptoms
of withdrawal when the opioid levels are reduced.4
However, having a high tolerance to the medication
or being dependent on opioids does not necessarily mean a person is addicted to their prescriptions.
According to a joint policy statement issued by the
American Academy of Pain Medicine, American Pain
Society and American Society of Addiction Medicine:
Addiction is a primary, chronic, neurobiological
disease, with genetic, psychosocial and environmental
factors influencing its development and manifestations. It is characterized by behaviors that include one
or more of the following: impaired control over drug
use, compulsive use, continued use despite harm,
and craving.4
The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) characterizes
a diagnosis of substance use disorder as a patient
who experiences two or more of the criteria listed

in Table 1 within a 12-month period. The manual
defines a continuum of substance use disorders as
ranging from mild (patient demonstrates 23 criteria)
to severe (6 or more).5
Compounding Margarets case was the potential
that her chronic pain was being undertreated due
to her recurrent use of the ED and lack of a primary
CPs who work in programs to reduce 9-1-1 use or hospital

readmissions may encounter patients who are dependent on,
or even abuse, prescription drugs.
care physician. Physicians David Weissman and
David Haddox coined the term pseudoaddiction to
describe cases where the patients chronic pain is not
adequately managed, the patients demand for opioids
increases and there is growing mistrust between the
patient and her healthcare providers.6 In those cases
the patient may display signs of addiction, but their
primary objective is pain relief, not the high of using
the opioids. Once the pain is adequately controlled,
the maladaptive behaviors disappear.
Plan of Care
Margaret did not have a doctor whom she saw on a
regular basis because the one whod cared for her
had died and she could not find another she liked.
Furthermore, she hadnt seen anybody for her depression or anxiety for many years and lacked any type of
TABLE 1:
DSM-5 CRITERIA FOR SUBSTANCE USE
DISORDER AND SEVERITY SCALE
1. Hazardous use;
2. Social/interpersonal problems related to use;
3. Neglected major roles to use;
4. Withdrawal;
5. Tolerance;
6. Used larger amounts/longer;
7. Repeated attempts to quit/control use;
8. Much time spent using;
9. Physical/psychological problems related
to use;
10. Activities given up to use;
11. Craving.
With a substance use

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

Mild: 23 criteria
Moderate: 45 criteria
Severe: 6 or more criteria
Center for Emergency Medicine of Western Pennsylvania
57
Patients with chronic

pain are vulnerable
to undertreatment,
as providers fear
promoting an
addiction.
Center for Emergency
Medicine of Western
Pennsylvania
mental health support. The patients ultimate goal was

to be completely pain free. Our objective was to have
her utilize the healthcare system more effectively to
achieve her goal. To develop our plan of care, we needed
to build the medical and psychosocial support system
she lacked. After conducting our
initial assessment of Margarets
situation, we developed a plan
of care with input from other
community paramedic team
members, our medical command
physician and, most important,
Margaret.
The first priority was making sure she was being seen by
a primary care physician and
a therapist for her anxiety and
depression. We began by searching for local doctors using criteria Margaret provided, then
ultimately helped her choose
one she was comfortable seeing.
Next we worked together to find
a therapist to help her manage
her anxiety and depression. Ultimately she reconnected with a
psychiatrist whod treated her in
the past. Fortunately the psychiatrist also specialized
in geriatric mental health.
Rather than asking her therapist to address her potential substance use disorder, we worked with Margaret
to enroll her in a pain clinic to better manage her pain.
As is often the case, pain management at the local pain
clinic was directed by a physician, but included both
traditional and alternative medicine options to create an
individualized treatment plan uniquely tailored for each
patient. To increase the chances of success with this
approach, we explained how pain clinics work, helped
her enroll in a nearby clinic and provided encouragement to help Margaret adhere to the program while
her therapy began.
To provide a more sustainable solution for her social
support needs, we evaluated Margarets existing social
network, which consisted of a small circle of friends who
were neighbors in her apartment building. While they
fulfilled some of her social needs, Margaret complained
she still experienced times of loneliness. She reported
that she would often sit alone in the lobby of her complex. We offered to connect her with local resources
such as a nearby senior center, but she ultimately refused
help accessing those programs.
Results
Lacking an alternative social support system, Margaret
relied heavily on the community paramedic program
58
for her emotional support. Telephonic and in-person

follow-up conversations included conducting medication reconciliation and education, helping her complete
various paperwork and applications for her care teams,
and providing positive encouragement and social support.
As the patient began utilizing her new medical and
mental health providers, her dependence on the ED for
pain control decreased dramatically. Her utilization
of the ED dropped from 15-25 times a month in the
months before she was enrolled in our program to 23
visits in the 45 months after our intervention. She
instead relied on the healthcare system we helped her
build to continuously evaluate and manage her chronic
back pain as well as her depression and anxiety.
Conclusion
This case illustrates a patient who was likely displaying
pseudoaddictive behaviors rather than having a more
severe substance abuse disorder. Had the patient refused
care from the pain clinic, displayed more symptoms
of substance abuse disorder or been fired from the
pain clinic for a breach of contract, substance abuse
counseling would have been a more appropriate recommendation. Chronic pain patients are particularly
vulnerable to undertreatment for their pain, as caregivers fear making the patient addicted to pain control
medication. Lacking relief from other venues, those
patients frequently turn to the ED for pain control.
Rather than just dismissing them as drug-seekers,
community paramedics can play a vital role in helping
these patients find more appropriate sources of care for
their physical and psychological needs.
R E FE R E N CE S
1. Substance Abuse and Mental Health Services Administration. Results
from the 2012 National Survey on Drug Use and Health: Summary of National
Findings, www.samhsa.gov/data/sites/default/fles/NSDUHresults2012/
NSDUHresults2012.pdf.
2. Dumas EO, Pollack GM. Opioid Tolerance Development: A Pharmacokinetic/
Pharmacodynamic Perspective. AAPS J, 2008 Dec; 10(4): 53751.
3. Lee M, et al. A comprehensive review of opioid-induced hyperalgesia. Pain
Physician, 2011; 14(2): 14561.
4. American Academy of Pain Medicine, the American Pain Society and the
American Society of Addiction Medicine. Defnitions related to the use of
opioids for the treatment of pain. WMJ, 2001; 100(5): 289.
5. Hasin DS, et al. DSM-5 Criteria for Substance Use Disorders:
Recommendations and Rationale. Am J Psychiatry, 2013; 170(8): 83451.
6. Weissman DE, Haddox JD. Opioid pseudoaddictionan iatrogenic syndrome.
Pain, 1989; 36(3): 3636.
Jason R. Berman, EMT-P, is a community paramedic
with the CONNECT Community Paramedic Program
at the Center for Emergency Medicine of Western
Pennsylvania.
Dan Swayze, DrPH, MBA, MEMS, is the vice president
and COO of the Center for Emergency Medicine of
Western Pennsylvania and is widely considered one of
the pioneers of the field of community paramedicine.
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CHI SAR crews train to

hoist from land, open
water and ships.
60
Cover Report by Barry D. Smith
Providing medical and

rescue services to the
ofshore oil industry is a
massive mission
Photos by Barry Smith
t is licensed in the state of Louisiana as an air

ambulance, but this is not your typical air ambulancenot in its size or the scope of its mission.
Its fuselage is 56 feet long with a rotor diameter
of 56 feet. Its maximum weight is 26,000 lbs. The
cabin is 20 feet long, six feet wide and six feet high. It
has a maximum speed of 190 mph. Its mission is to
provide medical and rescue services to the offshore
oil industry in the Gulf of Mexico.
Vital Statistics
The helicopter is a Sikorsky S-92, and its crewed
by five people: a pilot, copilot, flight medic and two
rescue specialists. It is based in Galliano, LA, and

operated by CHI Aviation. The operation is run on a
subscription basis for oil companies with platforms in
the Gulf of Mexico. CHI also has an AgustaWestland
AW139 helicopter it uses for the same mission on
an ad hoc basis for customers without subscription
contracts for the S-92. They also get rescue assignments from the U.S. Coast Guard. Both ships are
crewed 24/7.
61
The contract covers personnel on oil platforms, the

ships that supply the platforms and the helicopters
that transport the workers to and from the platforms.
Containing one of the worlds largest oil fields, the
Gulf of Mexico has about 5,000 oil-related structures,
supported by dozens of supply ships and a fleet of
over 400 helicopters. In 2014 these helicopters made
740,000 flights over the gulf and transported two
million passengers.
We use the S-92 because of its range, speed and
payload capabilities, explains David Jacob, CHIs
director of offshore operations and a longtime paramedic. Some of the platforms are 200 miles or more
offshore. We can carry a huge amount of rescue gear.
Our rescue specialists are certified in vertical rope,
confined-space and hazardous-atmosphere rescue.
We can also rescue all of the passengers of the largest
helicopters used for offshore transport if one ditches
in the gulf.
The S-92 is one of the newest helicopter designs. It
has an all-glass electronic display instrument panel
that incorporates the latest flight control, navigation,
communication and engine systems. The helicopter
can perform rescue missions day or night and in bad
weather. It has a color weather radar that can also
detect the oil platforms. It has dual GPS systems for
navigation.
It also has forward-looking infrared (FLIR) and
low-light television cameras in a gyrostabilized turret under the nose. The helicopter can be used as
an airborne command post for an incident on an oil
platform. Its crew can record and transmit imagery,
and an oil company representative can be on board
and talk with his personnel via the satellite phone in
the cabin. They can also use it to see hot spots on an
oil platform in case of a fire.
Another feature is a sophisticated autopilot system
customized for search and rescue missions. It can
automatically come to a 50-foot hover at any location specified by the pilot. Search patterns can be
programmed and flown by the autopilot coupled to
the GPS system to maximize search coverage. It is
also equipped with dual rescue hoists in case one fails.
The facilities at Galliano are high-tech. The hangar
is climate-controlled, which is especially important in
the summer, with its high temperatures and humidity.
The base has its own power supply, and the hangar
is rated for a Category 3 hurricane.
Stafng and Training

Acadian Ambulance provides the paramedics for
our operation, Jacob says. They also provide all
the medical equipment, protocols, 24-hour online
medical control, and dispatching and flight-following services. We can use Acadians aircraft to back
62
us up, and we may handle a local call

for them with our AW139. Acadian
ground operations span from Mississippi to Texas, so if we need additional
equipment or personnel for an MCI,
we can get them from Acadian ground
ambulances.
The flight medics do not go through
the rope and confined-space rescue training, says flight paramedic
Anthony Cramer, Jr., who is also an
RN. We do go through hoist training.
In water rescues, the rescue swimmer
would deploy and bring the patient
into the helicopter, where the flight
medic would then begin treatment. If
the patient is on land, a vessel or an
oil platform, the flight medic would be
hoisted down to the victim, as well as
a rescue specialist. There are always
two people going down to the patient.
The flight medics have a good
working relationship with the rescue specialists. We pretty much live
together when were on duty. The rescue specialists have a varied amount
of medical training. The minimum is
EMR, but many are EMTs and paramedics. They can work on the patient
under the direction of the flight medic.
Since we work so much together, they
can anticipate the flight medics needs.
It is just like a crew in the back of an
ambulance.
The flight medics work under the
same protocols as the Acadian Air Med
flight crews, which are pretty extensive. We can do RSI, CPAP and 12-lead
ECG, and we carry a ventilator. We can
initiate a lot of treatment before arrival at the hospital because of our long
transport times. They have a protocol
for what they call chemical extrication.
They use it in case they have a patient
who is trapped by machinery or has a
difficult extrication from where they
fell. They use etomidate as a hypnotic
sedative. The patient isnt aware and
has no memory of the event afterward.
Our calls run the gamut from
trauma to medical, explains Cramer.
There is a lot of heavy machinery and
moving heavy equipment on oil platforms. We have all the medical-type
calls found in any community. One of
our biggest complaints is chest pain.

We do 12-leads and can send them to
the hospital while were en route. We
also carry beta blockers and IV nitrates
for STEMI patients. Once the hospital has the 12-lead, the ED doctor and
cardiologist decide whether to bypass
the ER and send the patient directly
to the cath lab when we land. We have
done that several times with very good
results. If we need to talk with medical control for orders or to contact the
receiving facility, we have a satellite
phone as part of the communications
suite on the helicopter.
Acadian Air Med has a QA/QI process, and we are part of that as well.
Our charts get reviewed like any other
Air Med chart. We can also use the Air
Med quality improvement coordinator for advice and opinions on patient
care issues that occur. Our flight medics are all very experienced, and most
have come from the Air Med side of
Acadian. We work seven-on, seven-off,
and many work shifts for Air Med to
keep their skills fresh.
An MCI is a real possibility on oil
platforms. Do people just need to be
moved off a platform because it is on
fire or in danger of sinking? Or was
there an event that created a large number of casualties? If there is a medic
stationed on the platform, he or she will
have done the initial triage by the time
the helicopter arrives. If not, we can
begin to do the triage and packaging
for transport. We might move victims
to another close platform with medics
A. The hoist operator at the FLIR station

on the S-92.
B. Hoisting from vessels underway
and adrift must be accomplished on a
regular basis to maintain proficiency.
C. The S-92 uses an electronic LCD
instrument panel system to integrate
sensors, communications and
navigation.
D. CHI employs former U.S. Navy and
U.S. Coast Guard rescue swimmers and
U.S. Air Force pararescuemen as rescue
specialists.
E. Overland SAR is practiced in case a
transport helicopter crashes in a bayou.
63
A Hazardous Environment
OIL PLATFORMS ARE BUILT LIKE
ships, with compartments, vertical ladders and complex machinery.
Dangerous chemicals and gases like
methane and hydrogen sulfide are
common, so the rescue specialists
can extricate people from hazardous
atmospheres with low oxygen using
air tanks. They can also do vertical
rope rescue for victims of falls or others who cannot use the ladders inside
the platforms.
Hoist missions in the water and
bayous have their own set of unique
hazards. In addition to looking for
the normal hazards for a helicopter
hoist operation, we are also looking
for natural hazards such as sharks and alligators, says
Mike Fout, a rescue specialist instructor and former U.S.
Navy rescue swimmer. We also look for debris or contaminants in the water. In addition, we have to think about
the sea state and water temperature. For contaminants,
we will minimize our time in the water and use a directdeployment rescue method where were never unhooked
from the hoist cable. We also have dry suits we put on to
minimize skin exposure.
Many of the rescue specialists had this training in the
military, but all of them are current with the necessary
civilian certifications for these skills. They have to recertify every two years on all of them. They also adhere to
international standardized training and hold internationally recognized certifications for their rescue skills. All the
paramedics are nationally registered and certified by the
states of Louisiana and Texas.
When were first hired, we get qualified in one position
on the team, and then we get dual-qualified with time as
both hoist operators and rescue swimmers, Fout says.
The goal is to have all rescue specialists dual-qualified.
on it and transport the more serious patients

to shore. We can also use our AW139, and
Air Med might be able to send some of their
helicopters offshore to platforms. We can
also pick up some Acadian Air Med crews
and their gear on the way out to a known
MCI.
Due to the size and weight of the S-92,
the crew may have to land at an airport near
the hospital and have a ground ambulance
transport the patient and flight medic from
there. Theyll go to the most appropriate
facility for the patients conditionSTEMI
center, stroke center, trauma center, burn
center, etc. The dispatch center, which is
Acadians, finds the closest, most appropri-
64
In addition to maintaining currency with

the different helicopter
deployment methods, day
and night, we also have
confined-space and vertical rope rescue training to
The CHI SAR S-92 is
stay current with. We do a
equipped with an autohover
lot of training. We try not
feature that can bring the
to be idle. We will pull out
helicopter to a 50-foot hover.
our confined-space and
rope rescue gear a couple
times a week and train.
Our hangar is about three
stories high inside, and we
can practice vertical rope
rescue techniques in there.
A new person gets qualified on the aircraft first and
then is sent to different rescue schools. We work with
Roco Rescue, which specializes in industrial rescue training, for high-angle rope and confined-space rescue training. Medical training is done by Acadian Ambulance.
There is an instructor cadre that includes hoist operators and rescue swimmers who meet regularly to discuss
new gear and new procedures they might want to adopt. If
a new piece of equipment looks promising, they will get it
and test it both in a static environment in the hangar and
then with the aircraft.
The instructor cadre also meets to decide on future
training needs, updates that might be needed in the process, and any improvements to the operation they might
be able to make. They also look at how other civilian and
military rescue units do things to see if they might want to
add to or adjust their program.
We are fortunate enough to have a large cross-section
of military rescue experience, says Fout. Each brings
their own experiences we can look at to see if something
would be a good fit here.
ate destination so the crew doesnt have to

shop for a receiving facility.
Almost 100% of our pilots and rescue
specialists have military search and rescue
experience, says Jacob. We have U.S. Air
Force pararescuemen and rescue pilots, U.S.
Coast Guard rescue swimmers and pilots,
and U.S. Navy pilots and rescue swimmers.
There is a large amount of trust among
the crews because of that. We know we
will revert to our military training when
things get challenging. The crews rely on
their crew resource management training,
which they all had in the military. We all
know how to communicate effectively in
stressful situations.
Conclusion
CHIs S-92 helicopter is a combination
rescue truck and critical care transport
ambulance. It can handle rescue and medical incidents on ships, oil platforms and
in the bayous and open water of the Gulf
of Mexico. All of the people interviewed
by EMS World said there is no better air
ambulance and rescue helicopter anywhere
in the world.
Barry D. Smith is an instructor in the
Education Department at the Regional
Emergency Medical Services Authority
(REMSA) in Reno, NV. E-mail bsmith@
remsa-cf.com.
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65
THE MIDLIFE MEDIC
By Tracey Loscar, NRP, FP-C
Find Your Next
What would you do if you could no longer work in the feld?
I
Today the
world of EMS
is more than
taking the
patient to
the hospital.
f you woke up tomorrow and found your job was no
certifications to college degrees are available in each of
longer there, or that you could not do the work, what
these arenas. A few hours out of your week might pique
would you do?
your interest and help you find an inroad into another
I cannot remember the last time I considered a
component of the work you already love. Do not assume
role outside of EMS, or even different from what I have
that because you are a good provider you are good at
been doing. All my marketable skills tie back to EMS and
anything else, it takes work.
the work Ive done there. My options are limited. I have
Communication is both an art and a science. Just
no next. The reality is that my strongest days may be
because you cant lift a stretcher does not mean you
behind me and one can only climb in and out of ambu-
can lift a mic. Dispatching requires training, patience and
lances for so long.
the ability to multitask on a different level.
As young providers we are resilient, enthusiastic and,
Those who cant do, teach. There is some nonsense
with that patch on, we come dangerously close to believ-
right there, because the reality is that, Most that can
ing ourselves invincible. Time and circumstance teach us
do cant teach very well. Learning how to educate is as
otherwise on all counts. If you are careful and fortunate
important as the material youre providing.
enough to escape injury, age remains the great equal-
Emergency management in todays world leads peo-
izer. At some point double shifts are no longer a minor
ple to experience disaster planning, grant writing and
thing and a night of posting in an ambulance has you
public health. These are not small skills and can carry
reaching for the Advil.
you effectively through to a lifelong career in this field
Adventures for the midlife medic come with recovery
that you love. Look at the clock, look in the mirror and
time and the realization that this is not a job that you
ask yourself what you have done to prepare for the next
can do forever.
phase of your life or career.
Today the world of EMS is more than taking the patient
Me? I talked to my husband, reworked my budget,
to the hospital. Taking care of the sick and injured
quit my part-time job and enrolled in school to finish
remains at its core, but as this still-young career field
my bachelors. I looked ahead, beyond the next class
evolves there are new paths and opportunities that play
or next shift, and realized that the only thing that could
an integral role in the effective delivery of care on a much
change was me.
broader scope.
elors degree. I spent time on myself and looked outside
stretcher anymore? Are you prepared to work outside of
of my box and confronted unique midlife fears about
an operational role? Do you have a secondary skill set or
becoming obsolete and feeling past my value. Now I
an interest in areas outside of patient care?
am about to embark on the biggest adventure of my
Many of us began and remain in the field because we
life and career as I take my family and my experience
love the work. We should think ahead and understand
across the continent to try my hand at EMS in Americas
our importance to the new providers that will come after.
last great frontier, Alaska, working as a battalion chief for
There is an absolute need for mentorship in this field
Matanuska-Susitna (Mat-Su) Borough EMS in Wasilla.
that revolves around the human experience, things
I am far from where I started when I was 18 years old
that have nothing to do with algorithms or dosages.
and as invincible as my patch. However, Ive also learned
Yet we lose priceless providers every year to injury or
that I am far from being donethere is an entire field out
age, because there was either no mechanism in place
there with room for growth and maturity.
for them to change their role or they were unwilling to
consider it because they felt it was boring or beneath

themthat it made them less than what they were.
Todays EMS has avenues in leadership, emergency

management, education and communication. If you
have ever had an interest in any of those areas, did you
pursue it? Everything from awareness level classes to
66
It is one year later, and I am four terms shy of my bach-
What are you going to do when you cannot lift that
Whats your next?
Tracey Loscar, NRP, FP-C, is a battalion chief for MatanuskaSusitna (Mat-Su) Borough EMS in Wasilla, Alaska, and a member
of the EMS World editorial advisory board. Contact her at
taloscar@gmail.com or www.taloscar.com.
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EDITORIAL ADVISORY BOARD

Tim Hillier, Advanced Care Paramedic

Tim Perkins, BS, EMT-P

James J. Augustine, MD, FACEP

Michael E. Poynter, EMT-P

C.T. Chuck Kearns, MBA, EMT-P

Raphael M. Barishansky, MPH, MS, CPM

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24 How to Measure and Improve

EMS Compass is setting the profession on

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By Michael Gerber, MPH, NRP

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How Will You Be

ACEI-RA is a diferent beast, less than

Find Your Next

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48 Oxygenate and Resuscitate

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56 Community Paramedics and the

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