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JULY 2017
SERVICE
ANIMALS
The truth about EMS transport of service
dogs & other support animals, p. 32
32 CANINE CAREGIVERS
The truth about EMS transport of
service dogs & other support animals
By Criss Brainard, EMT-P
40 THE IT FACTOR
Leading with emotional intelligence
By Robert P. Girardeau, MSM-HCA, NRP, FP-C
Contents
48 CONNECTING THE DOTS
DEPARTMENTS & COLUMNS
James Dunford, MD, has dedicated his career to helping the vulnerable 6 FROM THE EDITOR Institutional Knowledge
By A.J. Heightman, MPA, EMT-P
By Lauren Crosby, NREMT
12 LETTERS IN Your Own Words
14 EMS INSIDER News and Winning Strategies for EMS Leaders
Chaotic Procedure
MOBILE INTEGRATED HEALTH EDITOR Matt Zavadsky, MS-HSA, EMT
CONTRIBUTING ILLUSTRATORS Steve Berry, NRP; Paul Combs, NREMT
CONTRIBUTING PHOTOGRAPHERS Vu Banh, Glen Ellman, Craig Jackson, Kevin Link, Courtney
McCain, Tom Page, Rick Roach, Scott Oglesbee, Steve Silverman, Matthew Strauss, Chris Swabb
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The Cric-Knife has a 10mm dual sided blade,
with a sliding tracheal hook to maintain FOUNDING PUBLISHER James O. Page (19362004)
of the tracheal rings. SENIOR VICE PRESIDENT, FINANCE AND CHIEF FINANCIAL OFFICER Brian Conway
SENIOR VICE PRESIDENT/GROUP PUBLISHER MaryBeth DeWitt marybethd@pennwell.com
EDITORIAL BOARD
UNITED STATES Andrew McCoy, MD, MS Jonathan D. Washko, FINLAND JAPAN William J. Leggio, EdD, NRP
Associate Medical Director, Seattle MBA, NREMT-P, AEMD Paramedic Program Coordinator, EMS
William K. Atkinson II, PHD, Pertti H. Kiira, RN Hiromichi Naito, MD, PhD
Fire Dept. Assistant Vice President, North Shore-LIJ Assistant Professor, Dept. of Emergency Education, Creighton Univ.
MPH, MPA, EMT-P Consultant of EMS
Health Care Advisor, Raleigh, N.C. Mike McEvoy, PHD, NRP, RN, CCRN Center for EMS Medicine, Okayama Univ. Hospital
James J. Augustine, MD, EMS Coordinator, Saratoga County, N.Y. Keith Wesley, MD, FACEP FRANCE Hideharu Tanaka, MD, PhD SCOTLAND
FACEP John McManus, Col. (Ret.), MD, Medical Director, HealthEast Medical Professor & Chairman, EMS System, Paul Gowens, FCPara, MSc, AASI,
Director of Clinical Operations, EMP MBA, MCR, FACEP, FAAEM Transportation Jean-Clause Deslandes, MD Graduate School & Research Insitute of
PGCert, DipIMC, RCSEd, MCMI
Management Professor of Emergency Medicine & Past Publisher, Urgence Practique Disaster & EMS, Kokushikan Univ.
Katherine H. West, BSN, Consultant Paramedic, Scottish
Paul Banerjee, DO EMS Fellowship Director, Georgia MSEd, CIC Marilyn Franchin, MD Ambulance Service
Medical Director, Polk County (Fla.) Regents Univ. Infection Control Consultant, Infection Prehospital Emergency Physician, Fire LUXEMBURG
Fire Rescue Jason McMullan, MD Control/Emerging Concepts Inc. Brigade of Paris Steve Greisch, RNA SINGAPORE
Bryan E. Bledsoe, DO, FACEP, Associate Director, Division of EMS, Registered Nurse Anesthetist & Continuing
Keith Widmeier, BA, NRP, FP-C Medical Education Instructor, Centre Marcus Ong Eng Hock
FAAEM Dept. of Emergency Medicine, Univ. GERMANY
Adjunct Faculty, Emergency Services
Professor of Emergency Medicine, Director, of Cincinnati Hospitalier Emile Mayrisch Senior Consultant, Clinician Scientist
Program, Jefferson College of Health Jan-Thorsten Grsner,
EMS Fellowship, Univ. of Nevada Mark Meredith, MD & Director of Research, Dept. of
Sciences
Scotty Bolleter, BS, EMT-P Associate Professor of Pediatrics, Le MD, FERC MEXICO Emergency Medicine, Singapore
Chief, Clinical Direction, Bulverde Spring Bonheur Childrens Hospital (Memphis,
Stephen R. Wirth, Esq. Director, Institute for Emergency General Hospital
Attorney, Page, Wolfberg & Wirth LLC. Armando Alvarez, BSBME,
Branch (Texas) Fire and EMS Tenn.) Medicine, Univ.Medical Center
MBA, EMT-P, PA
Douglas M. Wolfberg, Esq. Schleswig-Holstein CEO, Sistemedic SLOVAKIA
Criss Brainard, EMT-P David A. Miramontes, MD,
Fire Chief, San Miguel Fire & Rescue Attorney, Page, Wolfberg & Wirth LLC Klaus Runggaldier, PhD, EMT-P
FACEP, NREMT Viliam Dobias, MD, PhD
(Spring Valley, Calif.) Medical Director, San Antonio Fire Dept. Wayne M. Zygowicz, MS, Dean and Professor, Medical School THE NETHERLANDS Chair of Emergency Medicine, Medical
Chad Brocato, JD, DHSc, CFO EFO, EMT-P Hamburg, Univ. of Applied Sciences Ingrid Hoekstra, MSc School of Slovak Medical Univ.
Brent Myers, MD, MPH, FACEP
Assistant Chief, Pompano Beach (Fla.) Chief Medical Officer & Excutive Vice EMS Division Chief, Littleton (Colo.) and Medical Univ. Ambulance Nurse, RAVU Utrecht Bratislava
Fire Rescue President, Evolution Health Fire Rescue Ambulance Service, Dept. of Research
Thomas Semmel, EMT-P
Carol A. Cunningham, MD, Joseph P. Ornato, MD, FACP, Educator, European Resuscitation Council SLOVENIA
FAAEM, FAEMS
FACC, FACEP
MULTI-NATIONAL NEW ZEALAND
State Medical Director, Ohio Dept. of Andrej Fink, MSHS , RN, EMT-P
Public Safety, Division of EMS
Operational Medical Director, Richmond Jerry Overton, MPA HUNGARY Craig Ellis, MD Head of Ambulance Service, Univ. Medical
Ambulance Authority Chair, International Academies of National Medical Advisor, St. Johns
Mark E.A. Escott, MD, MPH, Laszlo Gorove, MD Centre Ljubljana
Paul E. Pepe, MD, MPH, MACP, Emergency Dispatch Ambulance Service
FACEP Managing Director, Hungarian Air
Medical Director, Austin-Travis County EMS FACEP, FCCM Corina Bilger, NREMT-Ret Ambulance Nonprofit Ltd. Hugo Goodson, MBA, PgCertEd, SOUTH AFRICA
Professor of Emergency Medicine, Director of International Sales, H&H BHSc
Jay Fitch, PhD Internal Medicine, Pediatrics, Public Medical Corp. Lecturer, Paramedicine, Auckland Univ. Neil Noble, CCP
President & Founding Partner, Fitch & Health, Univ. of Texas Southwestern ICELAND of Technology Director, Paramedics Australasia
Associates Medical Center
AUSTRALIA Njall Palsson, EMT-P
Ray Fowler, MD, FACEP, FAEMS David E. Persse, MD, FACEP President, Professional Division for EMT- NIGERIA SOUTH KOREA
Professor and Chief, Division of EMS, Colin Allen, EMT-P
Physician Director, City of Houston EMS Paramedics Nnamdi Nwauwa, EMT,
Univ. of Texas Southwestern School Director, Brisbane Operations Center, Sang Do Shin
of Medicine P. Daniel Patterson, PhD, Queensland Ambulance Service CCEMTP, MBBS, MPH, MMSCEM Professor, Dept. of Emergency Medicine,
MPH, EMT-B INDIA Founder, Emergency Response Services
Adam D. Fox, DPM, DO, FACS Paul Middleton Seoul National University College of
Research Associate, Cecil G. Sheps Center; Group
Section Chief, Division of Trauma, Rutgers Chair/Principal Investigator, DREAM George P. Abraham, MD, FRCS, Medicine and Seoul National University
N.J. Medical School N.C. Rural Health Research and Policy
(Distributed Research in Emergency
Ola Orekunrin, MD Hospital
FACS, FWACS, MHA
Mark Piehl, MD Director, Flying Doctors Service
John M. Gallagher, MD and Acute Medicine) Collaboration Medical Director, Western Alliance
Medical Director, Wichita/Sedgwick Pediatric Intensivist & Pediatric Critical EMS System SWEDEN
Care Transport Advisor, WakeMed Peter OMeara NORWAY
County (Ks.) EMS System Professor, Rural & Regional Paramedicine, G.V. Ramana Rao, MD, DPH, Kenneth Kronohage, MSc,
Ryan Gerecht, MD, CMTE Edward M. Racht, MD La Trobe Univ. (Victoria) Carl R. Christiansen, EMT-P,
PGDGM CRNA, BSc, RN
EMS and Emergency Medicine Physician, Chief Medical Officer, American Medical MPhilEd
Robyn Smith Director of Emergency Medicine Learning Hospital Lecturer, Oslo & Akershus Univ. President, Swedish Ambulance Forum
Tacoma, Wash. Response
Editorial Staff Member, Response Center & Research, GVK Emergency College of Applied Sciences
Jeffrey M. Goodloe, MD, NRP, Jeffrey P. Salomone, MD, FACS Management Research Institute UNITED ARAB EMIRATES
FACEP, FAEMS Trauma Medical Director, Banner Desert Live Oftedahl, Cand.Philol.
Medical Center/Cardon Childrens AUSTRIA Editor-in-Chief, Ambulanseforum Ahmed Alhajeri
Medical Director, EMS System for
Metropolitan Oklahoma City & Tulsa Medical Center Christoph Redelsteiner, IRELAND Ronald Rolfsen Deputy CEO, National Ambulance
Jullette M. Saussy, MD, FACEP DrPhDr, MSW, MS, EMT-P Darren Figgis Special Adviser, Division for Prehospital
Keith Griffiths Medicine, Ambulance Dept., Oslo
President, RedFlash Group Emergency Medical Physician Professor, Dept. Social Work & Health, Advanced Paramedic, Health Service UNITED KINGDOM
Univ. of Applied Sciences St. Plten Executive National Ambulance Service Univ. Hospital
Andrew J. Harrell, MD Geoffrey L. Shapiro Steinar Olsen, RN, NREMT-P Jon Ellis, MBA
Assistant Professor, Dept. of Emergency Director, EMS & Operational Medicine Technical Expert, BSI & CEN Committees
CANADA ISRAEL Director, Dept. of EMS, Norwegian
Medicine, Univ. of New Mexico Training, School of Medicine and Ambulance Systems & Patient
Directorate for Health
Joe Holley, MD Health Sciences EHS Program, George Randy Mellow Dov Maisel, EMT-P Handling Equipment
Medical Director, Memphis Fire Dept. Washington Univ. President, Paramedic Chiefs of Canada Senior Vice President of International POLAND Mike Jackson, MSc (Dist), DipIMC,
Chris Kaiser, NREMT-P Corey M. Slovis, MD, FACP, Ronald D. Stewart, MD, FACEP Operations, United Hatzalah United MBA, FCPara
Paramedic, Central Wisconsin FACEP, FAAEM Professor, Emergency Medicine, Rescue
Jamie Chebra, EMT-P, CEM,
MS, DHAc Chief Consultant Paramedic & Assistant
Medical Director, Metro Nashville Dalhousie Univ.
Dave Keseg, MD, FACEP Fire Dept. Sody Naimer EMS Educator & Advisor, Poland EMS Clinical Director, North West
Medical Director, Columbus Fire Dept. Senior Lecturer, Division of Community Systems Ambulance Service NHS Trust
Chetan U. Kharod, MD, MPH, E. Reed Smith, MD, FACEP CZECH REPUBLIC Health, Ben-Gurion Univ. of the Negev
Co-Chairman, Committee for Tactical
Marek Dabrowski Ian Maconochie, FRCPCH, FECM,
Colonel, USAF, MC, SFS
Emergency Casualty Care
Jana eblov, MD, PhD Oren Wacht, EMT-P, MHA, PhD Lecturer, Poznan Univ. Medical Sciences, FRCPI, FERC, PhD
Program Director, Dept. of Defense EMS & Head Physician, EMS Education, Central Rescue & Disaster Medicine Dept. and Consultant, Paediatric Emergency
Professor, Ben Gurion University, Dept. of
Disaster Medicine Fellowship Walt A. Stoy, PhD, EMT-P, CCEMTP Bohemian Region Sim Center
Medicine, St. Marys Hospital, Imperial
Professor & Director, Emergency Emergency Medicine & Health Systems
Keith Lurie, MD Management Mateusz Zgoda, MPH, EMT-P Academic Health Sciences Centre
Medicine, Univ. of Pittsburgh
Codirector, Central Minnesota Heart DENMARK Paramedic, Krakow Rescue Public
Center Resuscitation Center Peter P. Taillac, MD Ambulance Service Fionna Moore, MBE, FRCS, FRCSEd,
Medical Director, Bureau of EMS and
Kjeld Brogaard, EMT-P INDONESIA FRCEM, FIMC RCSEd
W. Ann Maggiore, JD, NREMT-P EMS Senior Manager, Falck Denmark
Clinical Instructor, Univ. of New Mexico, Preparedness, Utah Dept. of Health Ahed Al Najjar, BSc, AREMTP, SAUDI ARABIA Chief Executive, Consultant in Prehospital,
School of Medicine Freddy Lippert, MD London Ambulance Service NHS Trust
Michael Touchstone, MPH, FAHA Kenneth J. DAlessandro,
CEO, EMS Copenhagen Director of Life Support, EMS Faculty & Andy Newton, PhD
Shaughn Maxwell, EMT-P BS, EMT-P BS, MS EMS, EMT-P
Captain & Medical Services Officer, Regional Director, Philadelphia Regional Heidi Vikke, MSc Researcher, Prince Sultan Bin Abdulaziz EMS Program Advi er, Saudi Red Crescent Chief Clinical Officer, South East Coast
Snohomish County Fire District 1 (Wash.) Office of EMS Head of Research, Falck Denmark College for EMS King Saud Univ. Authority Ambulance Service NHS Trust
THE F-650/F-750
Vehicle shown with optional features and aftermarket equipment. *Based on IHS Markit TIP Registrations /// FORD.COM
for GVW 4-7 vehicles with sales over 1,000 units for CYTD Dec. 2016 vs. CYTD Dec. 2015.
INSTITUTIONAL
KNOWLEDGE
The often-unrecognized value of seasoned personnel
By A.J. Heightman, MPA, EMT-P
H
uman resource experts have shown In one case, a new fire chief moved an inex- out to reporterswho he kept well informed
that employees who leave an organi- perienced fire officer into the position of EMS on a daily basisand give them accurate facts
zation take a substantial amount of battalion chief position and transferred the and reasons why eliminating the ambulance
invaluable business and operational knowledge, seasoned 25-year EMS veteran to head up service would be detrimental to city residents.
as well as organizational and political contacts another division. The new EMS chief knew His well-established media sources would
and connections, with them. This large bun- nothing about this experienced employees then editorialize why the city should main-
dle of knowledge that a person acquires over EMS history, advances or projects underway. tain its valuable and highly respected ambu-
time is known as institutional knowledge. Their program has since spiraled backward; lance service.
Its difficult to replace or duplicate by orga- it will take years to recover from this loss of He also wisely mirrored the professional
nizations, especially when internal systems to institutional knowledge in that position. appearance of the respected medical commu-
retain, replace or document it are nonexistent. In another instance, an industry colleague nity, requiring his personnel to wear a uniform
Very few metrics or measures exist to quan- who did the work of four people stated her hat and white, starched coveralls or a starched
tify the lossor valueof institutional knowl- case to a new owner and requested more assis- white shirt and navy blue pants. In addition to
edge, continuity and history. The loss typically tance. It fell on deaf ears and resulted in her looking professional, he made sure his crews
is manifested as turnover, recruitment, replace- resignation. They lost more than 20 years of understood that bright white ensured they
ment and training costs that many organiza- solid institutional knowledge which may take could be easily seen in traffic and large crowds.
tions face.1 them years to recover. When I was 18 years old and heading out
Ive recently witnessed several people in I dont have firm solutions to stop inept, the front door to return to college, a man
our industry either pushed out of key posi- political or budget-blind managers from approached and asked me to get my father. I
tons or who quit after their experience and making stupid moves that cost them to lose did and he made my father sign for a certified
value to their organization was overlooked employees with extensive institutional knowl- letter from the city of Scranton informing him
or dismissed. edge, but I want to present a few points to that, because of severe budget problems, a deci-
make you more aware of the problem and help sion had been made to terminate the employ-
you avoid creating a black hole that will dam- ment of six firefighters. The city made the
age or slow the progress of your organization. crazy decision to eliminate the top three high-
est in seniority and three newest firefighters.
A PERSONAL EXAMPLE My dad was then number two in depart-
My fathers knowledge, ability and drive for ment seniority. I was crushed, but the cruel
serving the citizens of Scranton, Pa., as the action offered valuable imprint to my young
captain-in-charge of the fire departments mind, and because of what I saw occur after
ambulance division was legendary. I was in my father was summarily terminated after his
awe of how much he knew and, more impor- 30 years of experience, I became committed to
tantly, the people and connections he had made never ignore a persons institutional knowledge.
throughout his long career. My father attempted to move on, but, even
I was also amazed at how many times he though hed mentored each of his lieutenants,
saved the fire department ambulance divi- his staff hadnt been able to absorb the depth
Theres significant nutritional value in a fruit or veg- sion because of his institutional knowledge, of his institutional knowledge.
etable thats ripened just as theres also significant respect and political aptitude. Torn between the emotional pain and anger
value in the individual who has been cultivated, Every time the city council or mayor threat- of his abrupt dismissal and his dedication to
trained, nurtured, mentored and blossomed in your ened to eliminate the ambulance service to the city ambulance service, my father contin-
organization. Photo A.J. Heightman reduce the city budget, my dad would reach ued to counsel his beloved crews behind the
S C At www.foxfury.com/ems
760-945-4231 WWWFOXFURYCOM
For more information, visit JEMS.com/rs and enter 5.
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QUESTIONING COMPRESSIONS interfere with procedural interventions that not include data of total trauma arrests, only
External compressions add little to no value are likely to be more beneficial to patient out- those transported. It could represent only a
in hemorrhagic shock. You arent really going comes. Treating reversible causes of death from small fraction of traumatic arrests and looking
to increase perfusion and just make the hem- trauma, as you suggest, should be part of initial at the total numbers I suspect thats the case.
orrhage worse. If the patient codes just before management of traumatic arrest. We did elect to Lee H.
arrival, decompress both sides of the chest and include external compressions in the algorithm Via Facebook
pericardiocentesis. Call it if return of sponta- as theyre included in the NAEMSP/ASCOT
neous circulation isnt achived. If cardiac arrest Position Statement. We hope this article pro- AUTHORS MATTHEW CHINN,
is witnessed and < 10 min from trauma center motes discussion of the use of more advanced MD, & M. RICCARDO COLELLA,
(because after loading and into the bay you are resuscitation procedures, field thoracotomy and DO, MPH, RESPOND:
really looking at 15 minutes), go fast and needle REBOA as you mention, among others in the We agree that traumatic arrest survival numbers
both sides of the chest on the way in and get US. Additionally, we feel it highlights the poten- from systems that utilize physicians on scene
some access! The reason Europe does a good tial increased physician role here in the U.S. in are likely not directly applicable to the current
job is that they have low transport times and prehospital medical care from medical direc- system of EMS in the U.S. However, they do
judicious use of field thoracotomy and resus- tion to direct patient care. highlight the potential for medically salvageable
citative endovascular balloon occlusion of the With the formalization of EMS as a sub- patients and should maybe spark discussion on
aorta (REBOA). These arent commonly done specialty by the American Board of Medical how we can push to improve our current sys-
in the United States. Specialties (ABMS) in 2010 and the first EMS tem. We did try to ensure that this limitation
Josh G. physician certification exam in 2013, theres was addressed in the article as a possible con-
Via Facebook been a push toward recognizing the increas- founding factor.
ing physician expertise needed and the value You do bring up an excellent point regard-
AUTHORS MATTHEW CHINN, they provide to lead EMS here into the future. ing the inclusion criteria of the studies. The
MD, & M. RICCARDO COLELLA, Huber-Wagner et al. study only included those
DO, MPH, RESPOND: ON-SCENE PHYSICIANS? patients who received external compression and
The role of external compression is certainly The numbers used in this article reflect studies were transported to a trauma center. Similarly,
debatable and we feel that they shouldnt where they use physicians on scene and does Pickens et al. had limited field termination
P
lanning for response to an active setting didnt yet exist. Run, hide, fight was
shooter event, from both a victim and thought to be too harsh, especially with a vul- To design an active shooter response plan, you
public safety perspective, began in ear- nerable patient population, and worries of first need to define what an active shooter is.
nest after the tragedy of the Columbine High abandonment, ethics and possible criminal An active shooter event, as defined by the FBI,
School shooting in 1999. In 2008, the Depart- charges confused the matter. Some healthcare is one or more individuals engaged in killing
ment of Homeland Security issued the guid- facilities ignored it; others made policy requir- or attempting to kill people in a populated
ance of evacuate, hide out and take action, ing staff to stay with patients, while others area. Between 2000 and 2013, there were four
which eventually became run, hide, fight. allowed staff to decide if they wanted to stay or active shooter incidents in healthcare facili-
However, guidelines for an active shooter in leave. None of it, however, was evidencebased, ties, resulting in 10 killed and 10 wounded.1
a hospital, nursing home or other healthcare or included experts to help design a solution. Active shooter is a unique event, and isnt a
Our field sales team is available to meet with you in person to help customize the best buying solutions for your
agency/organization and demonstrate products and technologies before you purchase them.
We offer a variety of effective EMS Inventory Management solutions to help you better manage your inventories,
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Always Forward
ColumbiaSouthern.edu/JEMS | 800.349.4202
SERVICE ANIMALS
Draft a policy to avoid unlawful discrimination claims
By Christie Mellot, Esq., EMT-B
I
n nearly 18 years of practice representing should be even rarer for an EMS agency to been certified, trained or licensed as a service
EMS agencies nationwide, weve dealt not allow a patients service animal to accom- animal.4 Second, its not necessary that the
with a number of cases involving alleged pany him or her in the back of the ambulance. dog wear a vest, ID tag, or anything else that
discrimination against patients based on race, The ADA specifies, a person with a dis- would identify it as a service animal.1 Third,
color, national origin, religion, sex, age, disabil- ability cannot be asked to remove his service allergies and fear of dogs are not valid reasons
ity and other protected categories. animal from the premises unless: 1) the animal for denying access or refusing service to people
Many EMS agencies dont realize that fed- is out of control and the handler does not take using service animals.5 EMS agencies should
eral and state laws protect the right of the effective action to control it, or 2) the animal also check their state laws related to service
patient with a disability to rely on a service is not housebroken.2 animals to ensure complete legal compliance.
animal to assist them with the activities of daily All EMS agencies should adopt a policy on
livingincluding accompanying them while the transport of service animals that complies CONCLUSION
in a motor vehicle, such as on a public con- with federal, state and local laws. This way, an Having a service animal policy can help ensure
veyance like a city bus and even an ambulance. EMS agency can ensure its staff knows how to that your EMS agency and its staff know
If your EMS agency outright refuses to properly handle a situation in which a patient whats required to comply with the ADA.
permit service animals to accompany patients presents with a service animal. A well-crafted policy can also help ensure
in ambulances, odds are your agency may be that patients with service animals will only
subject to a claim for unlawful discrimina- DRAFTING A POLICY be separated from their service animals on the
tion. With some exceptions related to safety, In drafting a service animal policy, the first rare occasion that the animal interferes with
these legal protections for individuals with a helpful thing to keep in mind is the federal patient care or starts exhibiting aggressive or
disability extend to allowing a service animal definition of service animal. protective behaviors that the patient is unable
to accompany the patient on an ambulance. The ADA defines a service animal as: to control. JEMS
The Disability Rights Section of the United [A]ny dog that is individually trained to do
States Department of Justice (DOJ) Civil work or perform tasks for the benefit of an REFERENCES
Rights Division is in charge of enforcing the individual with a disability, including physi- 1. Frequently asked questions about service animals and the ADA.
Americans with Disabilities Act (ADA). On cal, sensory, psychiatric, intellectual, or other (July 20, 2015.) U.S. Department of Justice Civil Rights Division:
its website, the DOJ has posted frequently mental disability.3 Information and Technical Assistance on the Americans with
asked questions about service animals and In drafting a service animal policy, its also Disabilities Act. Retrieved May 19, 2017, from www.ada.gov/
the ADA on its website. Question 16 asks, important to understand what EMS crews are regs2010/service_animal_qa.html.
Must a service animal be allowed to ride in permitted to ask patients concerning possible 2. 28 CFR 36.302(c)(2)(i) and (ii).
an ambulance with its handler?1 service animals. 3. 28 CFR 35.104, 36.104.
The answer is, Generally, yes. However, The ADA significantly limits the questions 4. 28 CFR 36.302(c)(6).
if the space in the ambulance is crowded and that a covered entitys employees, including 5. ADA requirements: Service animals. (July 12, 2011.) U.S. Depart-
the dogs presence would interfere with the EMS crews, can ask to determine if a dog is ment of Justice Civil Rights Division: Information and Technical
emergency medical staff s ability to treat the a service animal. In situations where its not Assistance on the Americans with Disabilities Act. Retrieved May
patient, staff should make other arrangements obvious that the dog is a service animal, EMS 19, 2017, from www.ada.gov/service_animals_2010.htm.
to have the do transported to the hospital.1 crews may only ask: 1) Is the dog a service
animal required because of a disability? and Christie Mellott, Esq., EMT-B, is an EMS
TRANSPORTING ANIMALS 2) What work or task has the dog been trained attorney with Page, Wolfberg & Wirth,
Most of us would agree that the space in the to perform?1 which represents EMS agencies throughout
back of an ambulance is always crowded. How- The DOJs interpretation of certain issues the United States.
ever, except in very rare circumstances, a ser- that EMS agencies may run across with respect Pro Bono is written by the attorneys at Page, Wolfberg &
vice animal thats well-trained wont interfere to service animals is also helpful to know when Wirth, The National EMS Industry Law Firm. Visit the firms
with a crews ability to treat the patient. This drafting a policy. First, its not permissible for website at www.pwwemslaw.com
means that, although it may be rare for crews an EMS crew to ask for or require documen- or find them on Facebook, Twitter
to encounter patients with service animals, it tation, such as proof that a service animal has or LinkedIn.
3,500lbs
Using the back as a lever
exponetially increases the
amount of pressure on the
lower back.
350
lbs
FACT
1 in 2 Fire/EMS
providers will sustain an
on the job back injury
from lifting. 1
1. National Association of Emergency Medical Technicians. Four in Five EMS Workers Injured on the Job. 2006
USE A TOOL
BINDER LIFT TM
TM
When lifting like this providers are able to team lift while using proper ergonomics.
Made In USA
SIREN SCIENCE
No more emergency warning devices?
By Vincent D. Robbins, FACHE, FACPE
W
hen an ambulance or medic unit is significant savings in response time with 2014, underscore the perception by many that
dispatched, we routinely turn on the use of EWD, however it did not assess an ambulance should respond fast.
our lights and siren to warn the patient outcomes.3 Still today, many contracts for EMS
public on the roadways of our approach, to take According to the National Highway Traf- require specified fractile response times,
priority in traffic and to reduce our response fic Safety Administration (NHTSA), between which require that a certain high percent-
time in getting to the patient. Most systems 1992 and 2011, there were an estimated mean age of responses must be in less than eight
continue to use lights and siren when mov- of 4,500 motor vehicle crashes involving an or nine minutes.
ing the patient to the hospital, at least when ambulance every year. Of these crashes, 65% Even more progressive EMS systems still
our practitioners believe the patient respond with EWD on most of their
is seriously ill or injured. dispatches. First responders, such
For years now, a growing num- as fire and police departments also
ber of our colleagues have begun to At what point do we engage emergency lights and siren
doubt the efficacy of using emer- when answering EMS calls.
gency warning devices (EWD). decide to follow the
Some believe they should only be FINAL THOUGHTS
used to respond to the scene, and logic of the science At what point do we decide to fol-
turned off when transporting the low the logic of the science and the
patient to the hospital. Others think & the evidence being evidence being collected on this
using them during transport to the issue? When do we decide to alter
hospital is still warranted in certain collected on this issue? our response to almost all EMS dis-
time-sensitive cases. Still others feel patches and transports to medical
we should abandon them altogether. facilities to a no lights and siren
resulted solely in property damage, 34% protocol nationwide? Is there a role for NHT-
MOUNTING EVIDENCE resulted in an injury and less than 1% ended SAs Office of EMS on this issue beyond the
Theres increasing evidence suggesting that with a fatality. Still, that less than 1% repre- release of information to the paramedicine
using EWDs contributes to traffic conges- sented an annual mean of 33 people. community? JEMS
tion, slowing provider response, causing more Theres an aspect of public expectation that
motor vehicle crashes and playing no appre- overlays this issue, which must be considered. REFERENCES
ciable part in helping the outcome of patients. Most in the field would agree that theres a 1. Kupas D, Dula D, Pino B. Patient outcome using medical proto-
There have been several studies looking at belief held by the public that the use of EWDs col to limit lights and siren transport. Prehosp Disaster Med.
the consequences and effectiveness of using saves time and saves lives. Failing to respond 1994;9(4):226229.
lights and siren specific to risk of injury (to to a persons emergency, whatever they per- 2. Brown L, Whitney C, Hunt R et al. Do warning lights and
the provider, patient and the public) as well ceive that to be, could be perceived as a cava- sirens reduce ambulance response times? Prehosp Emerg Care.
as patient outcomes. lier, uncaring attitude by the EMS providers. 2000;4(1):7074.
In 1994, a study regarding the use of a med- This could result in poor public opinion of the 3. Ho J, Lindquist M. Time saved with the use of emergency warn-
ically based protocol to limit the use of lights EMS agency and the quality of its services ing lights and siren while responding to requests for emer-
and siren resulted in 92% of patients being not exactly the kind of relationship we want gency medical aid in a rural environment. Prehosp Emerg Care.
safely triaged to non-EWD transport with- to build with the public. 2001;5(2):159162.
out adverse effect on their medical conditions In fact, some civil lawsuits against EMS
or outcomes.1 agencies filed over the years include allega- Vincent D. Robbins, FACHE, FACPE, is the
At least one study revealed that using tions that slow response times by ambulances president and CEO of MONOC, New Jerseys
EWD did reduce response times by a statisti- caused or contributed to the death of patients. single largest ALS and mobile integrated
cally significant amount, but failed to improve Headlines like NY city settles wrongful healthcare service. Hes In partnership with
patient outcomes.2 death suit over late ambulance arrival from also president of the
Another study also found a statistically the Lockport Union-Sun & Journal in May National EMS Management Association.
SODIUM BICARBONATE
A tool for management of traumatic head injury?
By Jazmine Valencia, NNP-BC, RN, CCRN; Thomas Carrion, RN, CCRN;Mike Mendez, NRP;
Kori Martinez, RN, CCRN, CFRN; Greg Johnson, EMT-P; Aaron T. Britnell, EMT-P, CCEMT-P;
Larry D. Levy, MD, FAAEP, EMTP, ATP; Ken Davis, BA, EMT-P, FP-C & Ryan Hodnick, DO, NRP, FAWM
Y
our aeromedical EMS crew is dis- much fluid could be detrimental. (decerebrate or decorticate) with increasingly
patched to Mexico for a head injury The decision is made to reduce ICP using nonreactive pupils and changes in vital signs
patient whos an American citizen a medication approach. Both hypertonic saline such as bradycardia, hypertension and irreg-
being repatriated back home. and mannitol are used clinically to reduce ICP; ular respirations.
The patient is a 47-year-old male who was however, the clinic and the flight crew dont have The Monro-Kellie doctrine states that the
found unresponsive on the side of the road in access to either of the medications. After con- volume of contents within the skull: Brain,
Mexico the previous day and was diagnosed sultation with medical direction, the decision blood and CSF are constant. To maintain
with a subarachnoid hemorrhage. Its unclear is made to use sodium bicarbonate mixed with balance, an increase in one should cause a
what happened, but the patient may have fallen normal saline to obtain 3% hypertonic saline decrease in the other.1 After a traumatic insult
or been hit by a car. There are no signs of exter- solution. The patient is given the hypertonic to the brain, swelling of brain tissues ensues.
nal trauma noted. He was brought to the local saline solution with no increase of ICP and is If the pressure is allowed to increase with-
clinic where surgery was performed for a sub- able to complete the flight. out change, the brain can herniate through
arachnoid hemorrhage. one of the dural folds or, even worse, through
On arrival, the crew finds an intubated male DISCUSSION the foramen magnum at the base of the skull.
with a Glasgow coma scale (GCS) of 3 with Increased ICP is a common problem faced by At the same time, its important to optimize
pupils of 4 mm and nonreactive bilaterally. On EMS providers when working with trauma the patients intravascular volume as well as
physical exam, the crew notes a Foley catheter patients with head injuries. An increase in mean arterial pressure to maintain adequate
coming from his skull with a glove containing ICP compresses the brain within the rigid cerebral blood flow.
serosanguinous fluid tied to the other end. The skull, thereby reducing blood flow and wors- Its also important to prevent hypoxia,
Foley catheter was placed within the patients ening damage. maintain eucapnia, and decompress the stom-
ventricle in an attempt to drain cerebral spinal As the pressure in the head increases, the ach as increases in intra-abdominal pressure
fluid (CSF) and decrease intracranial pressure. brain can no longer stay within the rigid skull can translate to other compartments.1 In the
The patient has no intracranial pressure and begins to herniate. On physical examina- prehospital setting, its difficult to optimize
monitoring (ICP) in place. His vital signs are tion, this most often presents as posturing cerebral perfusion without intracranial pres-
as follows: Heart rate of 58, blood sure monitoring or medication to
pressure of 135/67, respiratory rate reduce cerebral swelling.
of 16 on a ventilator, blood oxygen If the ICP remains high, cere-
saturation (SpO2) of 100% with a bral injuries can worsen leading
fraction of inspired oxygen (FiO2) to poor neurological outcomes.
of 90%. A midazolam infusion is Medications such as mannitol and
running for sedation. hypertonic saline may be useful in
Transportation from the clinic reducing ICP. These medications
to the airport was initially arranged work by increasing the osmolal-
by means of a flatbed pick-up truck ity of the blood thus pulling fluid
followed by a three-hour jet flight from within the brain tissue to the
back to the United States. intravascular space.
The crew has concerns about The theory is that the fluid
cerebral herniation and doesnt want involved in the brain swelling is
to drain more fluid off via the Foley exchanged for perfusion of oxy-
catheter without knowing the ICP, Patients with traumatic head injuries are associated with high morbidity and gen-carrying blood to the dam-
understanding that draining too mortality. Photo courtesy Ryan Hodnick aged parts of the brain.
Stretchers
Evacuation Chairs
Backboards
First Aid
Fire Blankets
S TA B I L I Z E I N P L A C E
APPROPRIATE REFERRALS
Transport & referral strategies of international EMS systems
By Christoph Redelsteiner, Dr.PhDr, MSW, MS, EMT-P
MEETING NEEDS age of the regions inhabitants is 45 vs. the aver- Conclusion: Overall, in the observed services,
Redelsteiner C: Current and future requirements age age of EMS patients at 72 years. Calls for theres a tendency to treat and release patients
for gatekeeping in the prehospital setting with spe- patients older than 60, representing 27% of the if ambulance providers also have a nursing or
cial consideration of sociodemographic require- general population, make up for 79% of all calls. community/advanced paramedic background,
ments; with a special focus on two rural border Nearly three-quarters (75%) of the rural fam- combined with standardized assessment pro-
regions in the Austrian province of Burgenland. ily doctors in the region will retire by 2025. This tocols or if there are general practitioners sys-
Stumpf + Kossendey: Edewecht, Germany, 2016. requires steering patients, either by phone or tematically involved in out-of-hospital care.
[Book in German.] on-scene assessment, to resources that arent On-scene patient assessment requires a sys-
hospital-based and guiding patients to appro- tematic, reliable and specific low-threshold
Many European countries face a reduction of priate community resources. To control this mobile resource. General practitioners, nurses,
active physicians and health professionals on process, a tight logistical connection between social workers and paramedics could be utilized
one side and an increase of older people on the general practitioners, home nursing, EMS and for this task, following specific interprofessional
other. Although the ratio of emergency calls to hospitals is needed. training and education. A concept for a new
population remains stable, the overall number The seven hypothetical patient scenarios interdisciplinary degree program, the commu-
of calls is rising. (simple wound; adult asthma attack, known nity care specialist, could be usedand may be
Background: Current data show that in asthmatic; lumbago; cough and chest pain; fall especially helpful in rural regionsthat would
urban areas, 75% of calls to patients under age in nursing home; patient with fever; 75-year-old bridge social and health professions. Training and
20 are minor disturbances that could be taken male urinary catheter change) were compared in education for this role would include assessing,
care of by self-help, general practitioners or out- the context of provider type and system design clearing and treating non-emergent conditions
patient care clinics. Furthermore, 94% of these for services from 17 European nations and one (e.g., psychosocial and simple medical patients).
patients are transported to hospitals for evalu- in the United States. The organizational con- The overall goal is to adapt strategies of
ation. In rural settings, 72% of calls for an ALS text of these services is quite different, as are caller handling in dispatch centers and while
doctor unit are also non-emergent or could be the responding professions, which include basic on scene and facilitate collaboration and net-
covered by alternative resources. Prehospital ambulance attendants, nurses, paramedics, gen- working between the main primary care medical
EMS agencies are hence faced with a high vol- eral practitioners and emergency physicians or institutions and related social work, psychosocial
ume of requests for simple social, nursing and a combination of multiple tiers. and nursing resources to ensure fair, ethical and
medical interventions that could be served bet- Three major strategies have been detected: non-discriminatory distribution of care regard-
ter by other health and social care providers. 1) systems that use transport to hospital as a less of age, social level and urban/suburban/rural
Methods: This was a mixed method research prime strategy, are financed by a fee for trans- settings. JEMS
study. Quantitative data was researched by ret- port reimbursement, and where a large edu-
rospective assessment of calls, demand patterns cation gap exists between basic-trained EMS Christoph Redelsteiner, Dr.PhDr, MSW,
and call severity. Three different statistical prog- providers and ALS response by physicians; MS, EMT-P, is a professor at St. Pltens Uni-
nostic techniques were used to calculate future 2) systems that refer patients to alternative versity of Applied Sciences and scientific
call demand, combining historic data and demo- resources early on, such as during the 9-1-1 director of the Master in Emergency Health
graphic scenarios. Qualitative data was collected call; and 3) systems that refer systematically Services Management Program at Danube
by field research, responding to calls with differ- to alternative resources or dispatch non-ALS University in Austria. He was the first recipient of the James
ent services and creation of case reports. Field response for evaluation and on-scene treatment O. Page/JEMS Leadership Award and is a member of the JEMS
providers and managers of different services (e.g., via community paramedics). International Editorial Board.
were given seven hypothetical patient scenar-
ios and outlined their local strategy options to
triage and steer patients to different resources.
Asian
Results: Depending on the patient scenario, Association
the two rural regions studied will have to handle for EMS
teleflex.com/ems
Rx only.
References:
1. Rhodes A, Phillips G, Beale R, et al. The Surviving Sepsis Campagin bundles and outcome: results from the international Multicentre Prevalence Study on Sepsis
(the IMPreSS study). Intensive Care Med 2015;41:1620-1628 DOI 10.1007/s00134-015-3906-y
2. Stimac J, Paxton J. The Golden Hour of Volume Resuscitation: Pilot Data From the Shock Access For Emergent Resuscitation (SAFER) Study.
Annals of Emergency Medicine 2015;66(4S): S110
E
ngine 30 and Medic 6 respond to their local shopping mall and find, Nancy,
a 38-year old female complaining of tightness in her chest. Nancy is sitting
on a sidewalk bus bench with her dog.
Bystanders tell you she seemed to get upset when she missed her bus and within
minutes began complaining she wasnt feeling well.
Nancy is visibly upset, but able to answer your questions appropriately. Her heart
rate is 96, strong, regular and corresponds to sinus rhythm on your monitor, with a
blood pressure of 156/88 and a respiratory rate of 28, non-labored.
The rest of her vital signs and physical assessment are within normal limits. She
denies any medical problems except occasional panic attacks. Nancy requests and
agrees to be transported to the hospital, which is 20 minutes away, but insists her
canine companion join her.
She tells you hes a service dog who provides her with emotional support and
produces official-looking papers indicating her dog has been certified by Service
Dogs of America.
EMS providers are only required to accommodate service dogs as defined by the Americans with
Disabilities Act, and crews can legally deny transporting all other types of animals.
Photos Matthew Strauss
We are all familiar with a guide dog with a in our own country, with varying degrees of legitimate disability the ability to stay with
leather-handled harness leading a blind person post-traumatic stress disorder (PTSD).2 Many his or her service dog, if possible.
down our streets and safely navigating them have received effective support and treatment Unfortunately, many people (and some-
through traffic and many other everyday obsta- by the loving support of a service dog. times our patients) are abusing this valuable
cles. This human and canine partnership is no These service dogs have been trained to human-animal partnership, in order to take
longer limited to just a blind person, nor those perform specific tasks. For example, the ser- their pet with them to the store or hotel.
confined to a wheelchair. Today, specialized vice dog places a paw on the lap of a veteran There are dozens of online options to pay a
assistance is now available for patients with suffering from PTSD after sensing a trigger fee and with no credible justification; you can
dozens of other conditions. is occurring. This type of canine-specific task receive an officiallooking certificate, identifi-
Several types of animals, but primarily dogs, training is recognized by ADA requirements cation card and tag for the animals collar. The
are being trained in many new protection and that apply to paramedics and EMTs in the ADA doesnt recognize any of these types of
detection arenas. For example, since canines prehospital setting. programs and makes it clear these certifica-
have incredible senses, they can be trained to Federal and state service animal regula- tions dont provide any meaningful service
alert their human partner of an impending sei- tions are often broadly worded, which opens animal documentation.4
zure.1 This partnership is extremely valuable the door for people to label their pet as a ser- The slippery slope is knowing the ADA
and to be effective, its necessary for the dog vice animal and pass themselves off as a per- requirements and tactfully assessing each
to be with their human partner at all times. son with a disability. This is unfortunate but situation to determine a legitimate partner-
Service animals not only provide assistance a reality we must deal with in a professional, ship and to identify when someone is gaming
for physical conditions, but they often also non-threatening manner. the system.
provide emotional support. Our service men The Americans with Disabilities Act
and women, and even police officers, firefight- (ADA) lays out a set of guidelines that clar- REGULATIONS & RESPONSIBILITIES
ers and paramedics far too often are returning ify what is and what isnt a service animal.3 The U.S. Department of Justice published revi-
home from war or the violent streets right here No one would want to deny a person with a sions to ADA regulations on Sept. 15, 2010,
Whats keeping
you safe?
Braun SolidBody Construction ambulances
are built as one integrated module from .125
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roof, sides and doors are all constructed from
brake formed parts with fully welded seams.
Since there is no separate extruded frame,
SolidBody Construction reduces the weight Our arched roof design allows for more
and adds strength, providing many internal headroom, gives more strength to
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In the event of impact, SolidBody design length side rails to create exceptional
incorporates all body components into one strength and safety.
integrated module, absorbing impact,
minimizing the transferred damage, and Braun SolidBody ambulances offer a
providing added safety. smooth, quiet, and comfortable ride. The
module design provides a very low center of
Precision engineering and quality begin with gravity and exceptional balance across the
3D modeling software and computer axles, allowing the vehicle to hug the road
controlled routers, punch machines and and stop smoothly and evenly. During the
brake presses ensuring all components are construction process, sprayed-on foam
manufactured to close tolerances for insulation in the ceiling, walls, doors, and the
exceptional stability and durability in our entire underside of the body provides
ambulance bodies. superior acoustical and thermal insulation to
eliminate road and environment noises.
In our design, special attention is given to the
floor design and construction to increase SolidBody Construction also drives down
safety and strength of the module. Floor both operational and maintenance costs
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Reinforcement plates for chassis mount, cot Construction is lighter and stronger so you
hardware and attendant seat installation are can carry more personnel, more patients and
added for increased safety. more gear!
By Robert P. Girardeau, MSM-HCA, NRP, FP-C occurring. Just look at the emergence of the
buzzword EMS 3.0, which dominates the
O
rganized prehospital emergency with all things, unchecked growth is unsus- leadership tracks at all the major conferences.
medicine is but a teenager in terms tainable and doomed to collapse.1 Just think of EMS 3.0 is all about the development of pre-
of its lifespan. The profession mean- the most recent recessions: the dot com bomb hospital emergency medicine into a healthcare
dered for many decades as communities around and housing market bubble burst. These were delivery model that brings greater value to its
the world realized that the novel services pro- both due to growth that was unchecked and stakeholders. Simply responding to calls is no
vided by the industry were necessary and valu- unfounded on sustainability. longer good enough.
able. Now as the necessity is well-understood, Our industry is no different. Now that the
EMS has experienced an explosive growth. growth of our industry has dominated the THE CASE FOR EMOTIONAL
However, the focus of our industrys future marketplace for most of its history, a para- INTELLIGENCE
cant and must not be reliant on growth. As digm shift from growth to development is Theres little doubt the development of our
of EI : 1) Self-awareness; 2) Self-management;
3) Empathy; and 4) Relationship management.
(See Figure 1.)
Self-awareness Self-management Self-awareness is the component of EI that
focuses on the appreciation and understanding
that a person has for his or her own self. Persons
who possess self-awareness operate from a sense
of pragmatic confidence and keen emotional
Emotional discernment. Self-awareness enables a person
intelligence to know what their own strengths and weak-
nesses are, act in a way that makes the greatest
Social management
AMERICA
AM
AMERICA STR
MERICA S
STRONG
RON
RO
RONG
ONG
tion not only serves the goals of the leader, it
also empowers others to take ownership of the
Call Toll Free: tasks at hand. EI allows leaders to manage an
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organization in a way that the staff feels like
theyre part of the team. This is most often evi-
denced by a staff that can laugh togetherand
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For more information, visit JEMS.com/rs and enter 25.
In terms of leadership potential, I tend to live
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REFERENCES
1. DesJardins J: Business, ethics, and the environment: Imagining a sustainable future. Pearson Prentice
Hall: Upper Saddle River, N.J., 2007.
2. Porter-OGrady T, Malloch K: Quantum leadership (Fourth ed.). Jones & Bartlett Learning: Burling-
ton, Mass., 2015.
3. Salovey P, Mayer J. Emotional intelligence. Imagination, cognition, and personality. 1990;9(3):185211.
4. Mauboussin M: The success equation: Untangling skill and luck in business, sports, and investing.
Harvard Business Review Press: Boston, 2012.
5. Vandewaa E, Turnipseed D, Cain G. Panacea or placebo? An evaluation of the value of emotional
intelligence in healthcare workers. J Health Hum Serv Adm. 2016;38(4):438477.
6. Jones D. (October 25, 2015.) Proof success has nothing to do with a high IQ. Fortune Magazine.
Retrieved May 24, 2017, from www.fortune.com/2015/10/25/halogen-success-tips-high-iq/.
3000 Marcus Avenue, Suite 3E6,
7. Cherniss C. (1999.) The business case for emotional intelligence. Consortium for Research on Emo- Lake Success, NY 11042-1012
tional Intelligence in Organizations. Retrieved May 24, 2017, from www.eiconsortium.org/reports/ W: www.quantum-ems.com
business_case_for_ei.html. E: sales@quantum-ems.com
8. Goleman D. (April 7, 2015) How to be emotionally intelligent. The New York Times. Retrieved T: 516.321.9494
I
t would be easy to trip over the seemingly Its from this belief that hes been instru- family, he actually credits a friend for pushing
endless supply of plaques and awards pos- mental in implementing several key projects him toward medicine. At the time, Dunford
sessed by James Dunford, MD, if they for his city, including San Diego Project Heart imagined applying his altruistic nature and aca-
werent so meticulously tucked away out of Beat, the Resource Access Program (RAP), demic curiosity to helping the planet through
sight. The fact that the awards are hidden Project 25, and countless medical trials in coor- science. His friend challenged him to use his
behind his well-organized desk isnt because dination with such impressive medical institu- talents to save people and to leave the algae to
their owner trivializes them. Its merely a tes- tions as National Institutes of Health (NIH), others, and after receiving his first acceptance
tament to the disarming humility of this emer- Resuscitation Outcomes Consortium (ROC), letter to medical school, Dunford began to rec-
gency physician. and the American Heart Association (AHA). ognize his ability to build a career in medicine.
Dunford isnt in it for the praise. Hes on a When asked why he chose medicine as a He enrolled in Columbia Universitys
tireless quest to fix a broken system. But tal- profession, Dunford responds like so many medical school and distinctly remembers the
ent like his cant hide behind a desk, which is other gifted yet unassuming innovators who moment in anatomy lab, when, after working
why its no surprise that hes the 2017 James seem to stumble into their brilliance: He deliv- on a cadaver for six weeks, its face was finally
O. Page/JEMS Leadership Award recipient. ers a casual shrug and smile, saying it never revealeda sweet old woman with a pink
Dunford passionately believes in helping really crossed his mind. bow in her hair. This planted the seed for his
some of societys most vulnerable patients who strong connection with his patients.
often pose the biggest financial burden on the EARLY LIFE But it was one of the first weekends he put
healthcare system and subsequently drain tax- Having lived in six different cities by the age his white coat on that resonated most. He was
payer dollars. of 15, Dunford developed resilience early on observing in the ED when an elderly male
Succinctly put, Dunford observed that and quickly realized he wanted to surround trauma patient from a motor vehicle crash was
100% of what comes into the hospital is bro- himself with intelligent, like-minded individ- rolled in. Asked to hold a catheter, he watched
ken, and 90% of it didnt have to be. uals in his education. in horror as blood gushed from the patients
Always Forward
ColumbiaSouthern.edu/JEMS | 800.349.4202
VS
T
he future of EMS hangs in the balance the importance of conformity while penalizing completion in a rigid administrative framework.
and few seem to appreciate that the cri- those who think independently. We work hard to EMTs are focused on maintenance and man-
sis is no longer loomingits arrived. quash those who buck the system and stray from agement of the physical plant (i.e., ambulances
Over the past several years, weve witnessed the the prescribed path. This stepwise approach of and stations) while the paramedic is focused on
convergence of workforce shortages, decreas- EMT to advanced EMT to paramedic has been maintenance and management of the patient
ing reimbursement, increasing bills associated the primary path of advancement so far, but its and the clinical practice. When at the station,
with EMS transportation and worsening bud- no longer effective at providing the workforce the EMT is focused on resupply, equipment
get constraints which threaten the longevity of that our industry currently needs. maintenance and clinical skills training while
this third emergency service. Without question, we need technicians within the paramedic is focused on chart review, patient
Weve seen ad after ad for top-tier EMS sys- the EMS system and many of our personnel are follow-up, review of medical literature and prac-
tems in a perpetual hiring phase. Increased pay, well-suited for this essential role. Stations have tice improvement.
sign-on bonuses and relocation support often to be managed, vehicles have to be stocked and This model is by no means exclusionary
help entice prospective paramedics to come to cleaned, ambulances have to be driven by skilled toward the advancement of technicians but like
a new home. professionals and clinical procedures have to be the military, perhaps we should consider that the
Why do we continue to struggle to recruit performed. We also have many medical emer- technicians we enlist enter through a vocational
and retain our workforce in this exciting field? gencies that are suited to a highly protocolized, route and clinician/paramedics enter through a
Some will say that pay appropriate to the technician-based approach where procedural collegiate route. Then, you have an alternate path
demands of the job remains lacking. Though aptitude is critically important for success. that allows equipping technicians with the skills
many advocate for advancement of formal edu- Technicians are critical to the operation of to become clinicians.
cation requirements in order to justify signifi- EMS agencies; however, we do expect them to The future of the industry will be bleak if we
cant salary increases for clinician paramedics, transition to the role of a free-thinking clini- continue to embrace only the technician model,
theres also pressure to maintain the technician cian capable of managing complex situations which focuses on protocols directing our work-
model of care. and teams. Although a v fib cardiac arrest has force to transport patients to the hospital while
a relatively straightforward algorithm, pulseless doing what you can along the way.
THE CHALLENGE electrical activity and asystole arrests require We need to embrace recruiting and educat-
Some arguments focus on ease of recruitment significantly more evaluation, investigation and ing clinicians who can be decision-makers with a
and affordability of a less skilled workforce. The medical decision-making. medical education that goes beyond the current
workforce itself is divided on the issue, with In that circumstance, we need clinical masters pattern recognition-based approach and diverges
some EMTs and paramedics focused on hold- who can paint on a canvas that has no lines. The from the assumption that most patients will be
ing onto the public safety identity rather than challenge is that the personality needed to be a transported. This realignment will allow us to
accepting that the role of EMS is transitioning master clinician is often not someone whos toler- recruit college-educated paramedics who can
to one of healthcare delivery. The public safety ant of arbitrary rules. They often dont respond safely disposition patients, while we increase
model entices the workforce through the hope well to task assignments that arent consistent pay, increase autonomy and hopefully increase
of advancements in administrative hierarchy, with their level of aptitude. job satisfaction so that we can stem the hemor-
while the healthcare delivery model focuses on The conflict between education, mindset and rhage of the EMS workforce. JEMS
advancement of the clinical practice leading to task assignment may be part of the stress that
increased responsibility and autonomy. leads folks out of the industry and into other Mark E.A. Escott, MD, MPH, FACEP, is the
One of the key elements that we may be miss- healthcare areas where independent thinking medical director for Austin-Travis County
ing is that weve created one system and one is welcome. EMS System, a medical director and founder
path for entry into and advancement: Every- of Rice University EMS in Houston, and an
one enters the paramilitary-like EMS system A NEW APPROACH assistant professor of emergency medicine
as an EMT. During the indoctrination process, Perhaps the answer is to approach staffing with at Baylor College of Medicine. Hes the chair-elect of the
we stress the importance of the uniform, good an aim to align roles and responsibilities with the American College of Emergency Physicians Section of EMS
driving, radio operations, stocking, cleaning and personalities and skill sets of the individuals we and Prehospital Medicine and is board certified in emer-
following the rules of the organization. We stress recruit. We need folks who are focused on task gency medicine and subspecialty board certified in EMS.
VITALS
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Fran Hildwine, BS, NRP, is a simulation learning technician at the Pennsylvania College of Health Sciences in Lancaster, Pa., and is also an EMS instructor
at Good Fellowship Ambulance Club in West Chester, Pa. Contact him at fran100b@zoominternet.net.
Suction a SALAD
Whenever you arrive as the second unit on a critical call and hear the hum of the suction unit, you
know the call isnt going well. Clearing the airway of vomitus, blood and other nastiness takes time,
and it may significantly delay intubation. Jim DuCanto, MD, an anesthesiologist from Milwaukee
has collaborated with SSCOR in developing the DuCanto Catheter, which features a larger bore to
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When you need to move a patient any distance more than a few hundred feet on
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type you may need up to six or eight people, and using less than four to carry a patient
over rocks, sand or hills is unsafe. So how do you safely move a patient from point A
to point B? Simpleyou roll them. The new REX One rapid extrication stretcher from
REX EMS enables a single rescuer to safely move a patient weighing up to 400 lbs. over
100 yards. The REX One can be deployed from its backpack in about a minute by simply
unfolding the sections, attaching the wheels and extending the handle. An optional
braking system gives you a margin of safety when moving downhill. There are three
tire options including 18" tubeless, 20" all-terrain and wide-track sand tires. Bicycle
////////////
EMS teams can also add a transport capability with the bike attachment hitch.
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MOVING EDUCATION
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! >> Have staff learn the base knowledge that a ued employees, synthesize and capture their from www.hbr.org/2013/03/how-to-preserve-institutional.
AD INDEX
FREE
STROKE CERTIFICATION
Bon Secours DePaul Medical Cen-
ter in Norfolk, Va., recently earned a
Comprehensive Stroke Center Certification
from DNV GL Healthcare, becoming one of
just 43 hospitals and medical centers in the
country to hold the prestigious title. In addi-
tion, Bon Secours Virginia is the only health
system on the east coast with two compre-
hensive stroke centers. After rigorous reviews
and examinations, this certification is given
to medical centers that are committed to top-
of-the-line diagnosis, treatment and rehabil-
itation of strokes.
In addition to offering comprehensive
stroke care, the Bon Secours DePaul Med-
ical Center provides stroke education pro-
grams to local fire and EMS professionals. Richard Young (left), a firefighter advanced EMT, and Heather Joyner, a firefighter paramedic with Norfolk
Not only does this training help hone the Fire-Rescue, deliver a patient to Bon Secours DePaul Medical Center in Norfolk, Va.
skills of EMS workers, it also helps strengthen Photo courtesy Richard Muldez/Bon Secours Hampton Roads Health System
collaboration between prehospital providers
and the hospital. Center knowing the patient will receive the the education and treatment of strokes. Rais-
Depending on the severity of a patients best treatment in the region. ing awareness as well as the hospitals ability
stroke symptoms, EMS can confidently take We give a thumbs up to the Bon Secours to provide exceptional and rapid interventions
the patient to Bon Secours DePaul Medical DePaul Medical Center for their dedication to for strokes will surely save lives.
LEGISLATIVE PROGRESS In 2015, a law was passed that allowed med- This legislation comes after a recent increase
In a victory for mobile integrated ics to help treat patients, even when its not in crimes against first responders. In 2016, 21
healthcare (MIH), Washington state an emergency police officers were killed ambush style, which
legislators recently passed a law that provides We give a thumbs up to the Washington was the highest amount in more than 20 years.
sustainable funding for community paramed- state government for realizing the importance A total of 135 officers were killed while on the
icine programs. Governor Jay Inslee signed of supporting community paramedicine pro- job in 2016the most since 2011.
House Bill 1358 into law in May, which prom- grams and mobile integrated healthcare. This Senator and former EMT Phil Boyle said in
ises to reimburse fire departments and EMS shift puts patient health and comfort first, a press release, With the staggering increase
for treating Medicaid patients who dont need streamlines the states emergency healthcare of targeted attacks on our law enforcement
ambulance transport to an ED. system and further strengthens the bond EMS and emergency personnel, this crucial piece
Local first responders are celebrating the has in caring for their community. of legislation shows our steadfast support for
law as a win for patient-centered care. This our first responders and that well do every-
law allows EMS to be recognized and used PROTECTING RESPONDERS thing we can to protect them.
less as a transportation service and more as a The New York state senate has passed We give a thumbs up to New York state
healthcare partner that serves it community a bill that would designate crimes legislators for committing to defend the states
throughout the continuum of patient care. It committed against fire, police and EMS pro- first responders and for taking a stand against
will also help prevent costly and unnecessary fessionals as hate crimes, therefore carrying senseless attacks. Although one law may not
transportations if the patient is first treated heftier fines and sentences. The Community completely prevent people from harming
in their home. Heroes Protection Act would bump up the invaluable medics, firefighters and law offi-
This is just the latest development in Wash- level of such crimes, turning a class C felony cers, it does send a message that such crimes
ingtons support of community paramedicine. into a class B felony, etc. will not be tolerated in any capacity. JEMS
JEMS (Journal of Emergency Medical Services) (ISSN 0197-2510) USPS 530-710, JEMS is published 12 times a year, monthly by PennWell Corporation, 1421 S. Sheridan, Tulsa, OK 74112. Periodicals postage
paid at Tulsa, OK 74112, and at additional mailing offices. SUBSCRIPTION PRICES: Send $19.99 for one year (12 issues) or $29.99 for two years (24 issues) to JEMS, P.O. Box 3425, Northbrook, IL 60065-9912,
or call 847-559-7330. Canada: Send $49 for one year (12 issues) or $94 for two years (24 issues). All other foreign subscriptions: Send $59 for one year (12 issues) or $114 for two years (24 issues). Single copy:
$10.00. POSTMASTER: Send address corrections to JEMS (Journal of Emergency Medical Services) , P.O. Box 3425, Northbrook, IL 60065-9912. Claims of non-receipt or damaged issues must be filed within
three months of cover date. JEMS is a registered trademark. PennWell Corporation 2017. All rights reserved. Reproduction in whole or in part without permission is prohibited. Permission, however, is
granted for employees of corporations licensed under the Annual Authorization Service offered by the Copyright Clearance Center Inc. (CCC), 222 Rosewood Drive, Danvers, Mass. 01923, or by calling CCCs
Customer Relations Department at 847-559-7330 prior to copying. We make portions of our subscriber list available to carefully screened companies that offer products and services that may be important
for your work. If you do not want to receive those offers and/or information via direct mail, please let us know by contacting us at List Services JEMS (Journal of Emergency Medical Services), 1421 South
Sheridan Road, Tulsa, OK 74112. Printed in the USA. GST No. 126813153. Publications Mail Agreement no. 40612608.
Introducing
Rugged-X
TM
restraints
Safe.
Dynamically crash tested to meet the SAE J3027 crash safety standard1.
Light color helps caregivers identify soils on the restraint webbing.
Durable.
Polyurethane coating protects underlying webbing from
damage due to abrasion.
Resistant.
Soil resistant coated webbing makes Rugged-X easy to clean.
More power
to you
1. Meets SAE J3027 dynamic crash standard with Power-LOAD cot fastener system used with Power-PRO XT ambulance cot, Performance-LOAD cot
fastener system used with Power-PRO XT ambulance cot, or Performance-LOAD cot fastener system used with Performance-PRO XT ambulance cot.
Stryker Corporation or its divisions or other corporate affiliated entities own, use or have applied for the following trademarks or service marks: Power-
PRO XT, Power-LOAD, Rugged. All other trademarks are trademarks of their respective owners or holder.
teleflex.com/ems
Rx only
References:
1 Teleflex Internal Data on File 2014.
2 Davidoff J, Fowler R, Gordon D, Klein G, Kovar J, Lozano M, Potkya J, Racht E, Saussy J, Swanson E, Yamada R, Miller L. Clinical evaluation of a novel intraosseous device
for adults: prospective, 250-patient, multi-center trial. JEMS 2005;30(10):s20-3. Research sponsored by Teleflex Incorporated.
3 Cooper BR, Mahoney PF, Hodgetts TJ, Mellor A. Intraosseous access (EZ-IO) for resuscitation: UK military combat experience. JR Army Med Corps. 2008;153:314-6.
4 Philbeck TE, Miller L J, Montez D, Puga T. Hurts so good; easing IO pain and pressure. JEMS 2010;35(9):58-69. Research sponsored by Teleflex Incorporated or its affiliates
*Based on adult proximal humerus data For more information, visit JEMS.com/rs and enter 40.
Apple and the Apple logo are trademarks of Apple Inc., registered in the U.S. and other countries.
Google Play is a trademark of Google Inc.
Teleflex, the Teleflex logo, Arrow and EZ-IO are trademarks or registered trademarks
of Teleflex Incorporated or its affiliates, in the U.S. and/or other countries.
2016 Teleflex Incorporated. All rights reserved. MC-002927
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