Professional Documents
Culture Documents
com
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
Lou Jordan
PIO, Fire Police Officer, Union Bridge (MD)
Fire Department
Vincent D. Robbins
President & CEO, MONOC, MonmouthOcean Hospital Service Corporation,
Neptune, NJ
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
800.533.0523
www.boundtree.com
JANUARY 2016
VOL. 45 | ISSUE 1
COVER REP OR T
FE ATURE S
COLUMNS
14 GUEST EDITORIAL
The Next Great
Tradition
EMS Systems
18 CASES WITH A
TWIST
36 Evidence-Based EMS:
Repetitive Risks
By David Page, MS, NRP,
& Will Krost, MBA, NRP
36
22 LUDWIG ON
LEADERSHIP
41 ACE Inhibitor-Related
Angioedema
By Gary Ludwig
66 THE MIDLIFE
MEDIC
48
DEPARTMENTS
16 News Network
51 Ad Index
65 Classifed Ads
56
CONTAC T US
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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.
Read more at EMSWorld.com/12146735.
PODCASTS
10
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
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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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GUEST EDITORIAL
Today more
than 1,000 EMS
providers have
been trained to
help save lives
differently than
in the past.
said of EMS.
have put his idea into motion without the help of oth-
be treated.
more lives.
efforts and the bravery of the 1,000-plus providargued that by beginning care sooner, he could save
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
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
Happy Breathe-day!
A Barbaric Ritual
16
The average
red blood cell
transfusion is
approximately
3 pints.
The number of
blood donations
collected in the
U.S. in a year is
15.7 million.
MY DEGREE IS A
STEPPING STONE
E
TO EXPANDING
G
MY CAREER
R
Vera Morrison
2015 Graduate
DeKalb (Ga.) Fire Rescue
Battalion chief
TEXTBOOKS
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Repetitive Risks
T
Remember,
slow is smooth
and smooth is fast.
in EMS operations.
18
room.
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.
Nonpreventable Factors
here: https://psnet.ahrq.gov/primers/primer/21/
systems-approach.)
Preventable Factors
in this case.
Lessons
19
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.
ers will learn from them and avoid them. Send com-
landings into a river, cross-checks with a standardized checklist have saved many lives. Remember,
slow is smooth, and smooth is fast.
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.
R E FE R E N CE S
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-
a National EMS Culture of Safety (www.emscultureofsafety.org). This landmark document outlines the
safety.
To become more reliable we must implement just
amalgamated to
case.
20
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
lead people.
When you
accept a
leadership
position,
it is not
just a title.
about you when you retire. You may just wish to walk
If that is the case, then you were not a leader and you
22
A B O U T T H E AU T H O R
Gary Ludwig, MS, EMT-P, is chief of the Champaign (IL)
Fire Department. He is a well-known author and lecturer
who has successfully managed large, award-winning
metropolitan fire-based EMS systems in St. Louis and
Memphis. He has a total of 37 years of fire, rescue and EMS
experience and has been a paramedic for over 35 years.
24
25
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-
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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
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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-
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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.
A B O U T T H E AU T H O R
Michael Gerber, MPH, NRP, is an instructor,
author and consultant in Washington, DC.
E-mail him at mgerber@redflashgroup.com.
EMS1601
34
ADVERTISERS INDEX
COMPANY
PAGE INQ #
COMPANY
PAGE INQ #
Ambu, Inc.
15
17
Mangar International
26
21
Ambu, Inc.
43
43
Mangar International
42
32
12
Mercury Medical
39
30
27
22
Mercury Medical
53
38
Columbia Southern
University
17
18
23
20
Columbia Southern
University
38
29
30
25
EMP, Inc.
32
27
Nasco
34
28
EMP, Inc.
44
34
Nasco
67
42
EMS Store
46
55
40
33
45
Simulaids Inc
29
24
Simulaids Inc
40
31
Gathering of Eagles
51
21
19
GKR Industries
55
41
Taylor Healthcare
Products
12-13
16
28
23
Instrumentation
Industries Inc
47
36
Taylor Healthcare
Products
Teleflex, Inc.
31
26
International Public
Safety Association
54
39
Teleflex, Inc.
68
43
TransLite, LLC
8-9
14
10
Wisconsin EMS
Association
59
47
35
ZOLL
KARL STORZ
Endoscopy-America, Inc
11
Lenoir Community
College
11
15
13
ion: Integ
rated
de
lIvery
networ
ks to wa
tch 17
Septem
ber/Octo
ber 2015
Evolutiona
Leader ry
X erI
c h.
Evolution Beck, do, MPh
Health's
Harnesses
CEO
the Pow
Interpro
er of
fessional
Teamwork
14
10 car
olin
ry
Delive
grated
10 Inte rks to Watch
Ne t wo
rship
e leade
s whos e U.S.
ation
th
organiz nsform
profles lping tra
he
utive
ec
are
Ex
IH
ovation
and inn are system
healthc
as
Big data healthcare's
warehous
e
12 he
althca
consum re
Providerserism: what
need to
know
25 Imp
roving the
way IhI
Improv
es healt
hcare
35
Evidence-Based EMS:
Out-of-Hospital I
BiPAP vs. CPAP
Is one any better than the other?
36
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-
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
37
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
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.
MY UNPREDICTABLE
E
SCHEDULE
E
William DeCastro
2015 Graduate
TEXTBOOKS
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AFFORDABLE.
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38
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
A B O U T T H E AU T H O RS
Hawnwan Philip Moy, MD, is an assistant
medical director of the Saint Louis City Fire
Department and emergency medicine
clinical instructor and core faculty of the EMS
Section of the Division of Emergency
Medicine at Washington University in St.
Louis, MO. He completed his emergency
medicine residency at Barnes Jewish
Hospital/Washington University in St. Louis and his EMS
fellowship at the University of North Carolina in Chapel Hill.
Blake Bruton, MD, earned his Doctor of
Medicine degree from the University of
Arkansas for Medical Sciences. He is
currently in his second year of emergency
medicine residency at Washington University
in St. Louis. He is a certified Advanced
Trauma Life Support instructor for the
American College of Surgeons. His current
interests include prehospital care, trauma resuscitation,
bedside ultrasound and pediatric emergency medicine.
EMS1601S
40
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
41
Angioedema
of the tongue
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
42
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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,
Burns;
Epiglottitis
Laryngotracheobronchitis
(croup);
Massive maxillofacial trauma;
Acute laryngeal injury;
Ludwigs angina;
Laryngeal stenosis;
Laryngeal tumors.
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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-
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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
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?
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
FIGURE 3
52
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
54
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.
A B O U T T H E AU T H O R
Russ Brown, NREMT-P, is a firefighter/paramedic and EMS field training
officer for Southlake Fire Department in Southlake, TX. He has worked for a
variety of services including fire, private and hospital-based EMS systems.
He has a particular interest in airway management and cardiac resuscitation
science. Contact him at Rbrown@ci.southlake.tx.us.
55
56
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
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.
57
Results
Lacking an alternative social support system, Margaret
relied heavily on the community paramedic program
58
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.
A B O U T T H E AU T H O RS
Jason R. Berman, EMT-P, is a community paramedic
with the CONNECT Community Paramedic Program
at the Center for Emergency Medicine of Western
Pennsylvania.
Dan Swayze, DrPH, MBA, MEMS, is the vice president
and COO of the Center for Emergency Medicine of
Western Pennsylvania and is widely considered one of
the pioneers of the field of community paramedicine.
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60
Vital Statistics
The helicopter is a Sikorsky S-92, and its crewed
by five people: a pilot, copilot, flight medic and two
61
62
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.
64
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.
A B O U T T H E AU T H O R
Barry D. Smith is an instructor in the
Education Department at the Regional
Emergency Medical Services Authority
(REMSA) in Reno, NV. E-mail bsmith@
remsa-cf.com.
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65
I
Today the
world of EMS
is more than
taking the
patient to
the hospital.
public health. These are not small skills and can carry
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.
or next shift, and realized that the only thing that could
broader scope.
66
A B O U T T H E AU T H O R
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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