CONSORTIUM of Care p. 54 HIGH-RELIABILITY Organizations p. 60 AMBULANCE Showcase p. 42 Always En Route At ® JUNE 2013
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CONSORTIUM of Care p. 54 HIGH-RELIABILITY Organizations p. 60AMBULANCE Showcase p. 42
Always En Route At
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JUNE 2013
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Contents
PREMIER MEDIA PARTNER OF THE IAFC, THE IAFC EMS SECTION & FIRE-RESCUE MED www.jems.com JUNE 2013 JEMS 3
42
54 64
DEPARTMENTS & COLUMNS
5 LOAD & GO Now on JEMS.com
10 EMS IN ACTION Scene of the Month
12 FROM THE EDITOR A Win for HROs By A.J. Heightman, MPA, EMT-P
14 LETTERS In Your Words
16 PRIORITY TRAFFIC News You Can Use
22 LEADERSHIP SECTOR What’s the Buzz? By Gary Ludwig, MS, EMT-P
23 VOLUNTEER VOICE Rural Colorado Care By Dennis Edgerly, EMT-P
24 TRICKS OF THE TRADE Dumbness By Thom Dick
25 CASE OF THE MONTH One-pill Killers By Dennis Edgerly, EMT-P
26 RESEARCH REVIEW What Current Studies Mean to EMS By David Page, MS, NREMT-P & Alex Trembley, NREMT-P
28 2020 VISION International EMS Sponsored by Ferno 2020 Vision Series
66 HANDS ON Product Reviews from Street Crews By Dominic Silvestro, EMT-P, EMS-I
68 LIGHTER SIDE Whu’sat You Say? By Steve Berry
69 EMPLOYMENT & CLASSIFIED ADS
71 AD INDEX
72 LAST WORD The Ups & Downs of EMS
About the CoverThis year at the EMS Today Conference & Exhibition, a team of judges reviewed and evaluated doz-ens of new products and innovations in EMS to determine the “25 Hot Products from EMS Today 2013.” Read more, pp. 30-41. photos glen ellman; illustration kermit mulkins
HOT PRODUCTS FROM EMS TODAY 201325 innovative new products showcased at the 30th
annual JEMS EMS Today Conference & Exposition
By Dominic Silvestro, EMT-P, EMS-I
30
42 AMBULANCE SHOWCASE Innovations offered in ambulance design, safety & efficiency
at the 2013 EMS Today Conference & Exposition
Compiled by A.J. Heightman, MPA, EMT-P
54 CONSORTIUM OF CARE University of New Mexico’s EMS Medical Direction Consortium
encourages collaboration & shared responsibility
By Scott Oglesbee, BA, CCEMT-P
58 SCENE-SAFE MANTRA Why this common & popular safety assesment should
be replaced
By Skip Kirkwood, MS, JD, NREMT-P, EFO, CEMSO
60 EMS & HIGH RELIABILITY ORGANIZING Achieving safety & reliability in the dynamic, high-risk environment
By Daved Van Stralen, MD, FAAP & Thomas A. Mercer, RAdm, USN
64 EATING HEALTHY Shopping tips to help busy EMS personnel By Elizabeth Smith, EMT-B
JUNE 2013 VOL. 38 NO. 6
1306JEMS_3 3 5/28/13 1:40 PM
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1306JEMS_4 4 5/28/13 1:41 PM
FOLLOW US ON
LOAD & GO LOG IN FOR EXCLUSIVE CONTENT
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JEMSCE.COM ONLINE CONTINUING
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JEMS.com offers you
original content, jobs,
products and resources.
But we’re much more
than that; we keep
you in touch with
your colleagues
through our:
> Facebook fan page;
> JEMS Connect site;
> Twitter account;
> LinkedIn profile;
> Product Connect site; and
> Fire EMS Blogs site.
EMS NEWS
ALERTS
jems.com/enews
www.jems.com jUNe 2013 JEMS 5
FEATURED BLOG: Rescuing Providence
PH
OT
O C
OU
RT
ES
Y J
ON
PO
LIT
IS
Visit www.ems2020
vision.com to watch
the latest 2020 Vision
Leadership Series
video interviews.
JEMS.com
Setting our sights on the future of EMS
www.FernoEMS.com
http://linkedin.ems2020vision.com
Choose 5 at www.jems.com/rs
THE NEW GUY“Why are they sending an
Engine company?” asked
my partner, a new guy who
knew everything. “It’s just
another drunk.”
“You'll figure it out.”
I heard the slight urgency in the dispatcher’s tone
and knew that she sensed something in the caller’s
voice other than the usual intoxicated person call.
I scanned the horizon, looking for the patient.
The scene through my windshield resembled a set
from “The Walking Dead”; semi and fully intoxi-
cated persons wandered about aimlessly, homeless
for the most part, restless, hungry and unsteady.
One of the regulars, “Junior,” waved us over.
“He's over here,” he said, unsteadily leading us
around the corner where a man in his 40s sat on
a curb, leaning on a building, clutching his chest.▲ jems.com/rp-new-guy
INTERNATIONAL EMSThe participants in the 2020 Vision Series’ Inter-
national EMS video recording session touched on
several concerns for prehospital providers around
the world. They included:
> ‘Free at the point of delivery:’ Is it easier to
efect change in a government-run EMS system,
such as the socialized system in the U.K.—where
the national motto is that healthcare is ‘free at the
point of delivery?’ Feelings were mixed. How do
you feel?
> Telephone triage: EMS agencies around
the world use telephone triage to assign prior-
ity to calls and, in some cases, tell patients a trip
to the hospital is not needed. Challenges to that
approach in the U.S. often focus on liability and
localization. Would a similar approach, such as
telephone triage by a nurse, work in your area?
> Safety: The U.S. accepts the fact that EMS
providers die on the job, while a similar outcome
in the U.K., for example, would be a criminal of-
fense. How can the U.S. improve safety standards
and instil a culture of safety in EMS?
Read more in “International EMS: How demand
is shifting around the world,” p. 28, and join the
discussion by posting in the EMS 2020 Vision
LinkedIn group.
▲ jems.com/2020-vision
1306JEMS_5 5 5/28/13 1:41 PM
EDITOR-IN-CHIEF – A.J. Heightman, MPA, EMT-P – [email protected]
MANAGING EDITOR – Jennifer Berry – [email protected]
ASSOCIATE EDITOR – Ryan Kelley – [email protected]
ASSOCIATE EDITOR – Kindra Sclar – [email protected]
ASSISTANT EDITOR – Allie Daugherty – [email protected]
ONLINE NEWS/BLOG MANAGER – Bill Carey – [email protected]
ONLINE NEWS EDITOR – Brian Hutchins – [email protected]
EDITORIAL DIRECTOR – Shannon Pieper – [email protected]
MEDICAL EDITOR – Edward T. Dickinson, MD, NREMT-P, FACEP
CONTRIBUTING EDITOR – Bryan Bledsoe, DO, FACEP, FAAEM
ART DIRECTOR – Kermit Mulkins – [email protected]
CONTRIBUTING ILLUSTRATORS –Steve Berry, NREMT-P; Paul Combs, NREMT-B
CONTRIBUTING PHOTOGRAPHERS – Vu Banh, Glen Ellman, Craig Jackson, Kevin Link, Courtney McCain, Tom Page, Rick Roach, Steve Silverman, Michael Strauss, Chris Swabb
DIRECTOR OF ePRODUCTS – Tim Francis – [email protected]
PRODUCTION COORDINATOR – Katie Noftsger – [email protected]
PUBLICATION OFFICE 800-266-5367 — Fax 858-638-2601
ADVERTISING DEPARTMENT 800-266-5367 — Fax 858-638-2601
WESTERN ACCOUNT REPRESENTATIVE – Cindi Richardson – 661-297-4027 – [email protected]
EASTERN ACCOUNT REPRESENTATIVE – Paige Rogers Berra – 918-831-9441 – [email protected]
REPRINTS, ePRINTS & LICENSING – Rae Lynn Cooper – 918-831-9143 – [email protected]
VICE PRESIDENT, MARKETING SERVICES – Paul Andrews 240-595-2352 – [email protected]
SUBSCRIPTION DEPARTMENT 888-456-5367
DIRECTOR, AUDIENCE DEVELOPMENT – Mike Shear – [email protected]
CONFERENCE DIRECTOR – Debbie Murray – [email protected]
CONFERENCE & OUTREACH COORDINATOR – Vanessa Horne – [email protected]
CHAIRMAN – Frank T. Lauinger
PRESIDENT & CHIEF EXECUTIVE OFFICER – Robert F. Biolchini
CHIEF FINANCIAL OFFICER – Mark C. Wilmoth
SENIOR VICE PRESIDENT & GROUP PUBLISHER – Lyle Hoyt – [email protected]
VICE PRESIDENT/PUBLISHER – Jeff Berend – [email protected]
www.EMSToday.com
EXECUTIVE DIRECTOR – Jeff Berend
CONFERENCE DIRECTOR – Debbie Murray
EDUCATION DIRECTOR – A.J. Heightman
EVENT OPERATIONS MANAGER – Amanda Wilson
EXHIBIT SERVICES MANAGER – Raymond Ackermann
EXHIBIT SALES REPRESENTATIVE – Sue Ellen Rhine – 918-831-9786 – [email protected]
EXHIBIT SALES REPRESENTATIVE – Tracy Thompson – 918-832-9390 – [email protected]
FOUNDING EDITOR – Keith Griffiths
FOUNDING PUBLISHER – James O. Page (1936–2004)
®
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•
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1306JEMS_7 7 5/28/13 1:41 PM
8 JEMS JUNE 2013 www.JEms.com
EDITORIAL BOARD
WILLIAM K. ATKINSON II,
PHD, MPH, MPA, EMT-P
President & Chief Executive Officer, WakeMed Health & Hospitals
JAMES J. AUGUSTINE, MD, FACEP
Medical Director, Washington Township (Ohio) Fire Department
Associate Medical Director, North Naples (Fla.) Fire Department
Director of Clinical Operations, EMP Management
Clinical Associate Professor, Department of
Emergency Medicine, Wright State University
STEVE BERRY, NREMT-P
Paramedic & EMS Cartoonist, Woodland Park, Colo.
BRYAN E. BLEDSOE, DO, FACEP, FAAEM
Professor of Emergency Medicine, Director, EMS Fellowship
University of Nevada School of Medicine
Medical Director, MedicWest Ambulance
CRISS BRAINARD, EMT-P
Deputy Chief of Operations, San Diego Fire-Rescue
CHAD BROCATO, DHS, REMT-P
Assistant Chief of Operations, Deerfield Beach (Fla.) Fire-Rescue
Adjunct Professor of Anatomy & Physiology, Kaplan University
J. ROBERT (ROB) BROWN JR., EFO
Fire Chief, Stafford County, Va., Fire and Rescue Department
Executive Board, EMS Section,
International Association of Fire Chiefs
CAROL A. CUNNINGHAM, MD, FACEP,
FAAEM
State Medical Director, Ohio Department of Public Safety, Division
of EMS
THOM DICK, EMT-P
Quality Care Coordinator, Platte Valley (Colo.) Ambulance
BRUCE EVANS, MPA, EMT-P
Deputy Chief, Upper Pine River Bayfield Fire Protection,
Colorado District
JAY FITCH, PHD
President & Founding Partner, Fitch & Associates
RAY FOWLER, MD, FACEP
Associate Professor, University of Texas Southwestern School of
Medicine
Chief of EMS, University of Texas Southwestern Medical Center
Chief of Medical Operations,
Dallas Metropolitan Area BioTel (EMS) System
ADAM D. FOX, DPM, DO
Assistant Professor of Surgery,
Division of Trauma Surgery & Critical Care,
University of Medicine & Dentistry of New Jersey
Former Advanced EMT-3 (AEMT-3)
GREGORY R. FRAILEY, DO, FACOEP, EMT-P
Medical Director, Prehospital Services, Susquehanna Health
Tactical Physician, Williamsport (Pa.) Bureau of
Police Special Response Team
JEFFREY M. GOODLOE, MD, FACEP, NREMT-P
Professor & EMS Section Chief, Emergency Medicine,
University of Oklahoma School of Community Medicine
Medical Director, EMS System for Metropolitan
Oklahoma City & Tulsa
KEITH GRIFFITHS
President, RedFlash Group
Founding Editor, JEMS
DAVE KESEG, MD, FACEP
Medical Director, Columbus Fire Department
Clinical Instructor, Ohio State University
W. ANN MAGGIORE, JD, NREMT-P
Associate Attorney, Butt, Thornton & Baehr PC
Clinical Instructor, University of New Mexico,
School of Medicine
CONNIE J. MATTERA, MS, RN, EMT-P
EMS Administrative Director & EMS System Coordinator, Northwest
(Ill.) Community Hospital
MIKE MCEVOY, PHD, REMT-P, RN, CCRN
EMS Coordinator, Saratoga County, N.Y.
EMS Editor, Fire Engineering Magazine
Resuscitation Committee Chair, Albany (N.Y.) Medical College
MARK MEREDITH, MD
Assistant Professor, Emergency Medicine and Pediatrics,
Vanderbilt Medical Center
Assistant EMS Medical Director for Pediatric Care,
Nashville Fire Department
GEOFFREY T. MILLER, EMT-P
Director of Simulation Eastern Virginia Medical School,
Office of Professional Development
BRENT MYERS, MD, MPH, FACEP
Medical Director, Wake County EMS System
Emergency Physician, Wake Emergency Physicians PA
Medical Director, WakeMed Health & Hospitals
Emergency Services Institute
MARY M. NEWMAN
President, Sudden Cardiac Arrest Foundation
JOSEPH P. ORNATO, MD, FACP, FACC, FACEP
Professor & Chairman, Department of Emergency Medicine, Virginia
Commonwealth University Medical Center
Operational Medical Director,
Richmond Ambulance Authority
JERRY OVERTON, MPA
Chair, International Academies of Emergency Dispatch
DAVID PAGE, MS, NREMT-P
Paramedic Instructor, Inver Hills (Minn.) Community College
Paramedic, Allina Medical Transportation
Member of the Board of Advisors,
Prehospital Care Research Forum
PAUL E. PEPE, MD, MPH, MACP, FACEP,
FCCM
Professor, Surgery, University of Texas
Southwestern Medical Center
Head, Emergency Services, Parkland Health &
Hospital System
Head, EMS Medical Direction Team,
Dallas Area Biotel (EMS) System
DAVID E. PERSSE, MD, FACEP
Physician Director, City of Houston Emergency Medical Services
Public Health Authority, City of Houston Department
of Health & Human Services
Associate Professor, Emergency Medicine,
University of Texas Health Science Center—Houston
EDWARD M. RACHT, MD
Chief Medical Officer, American Medical Response
JEFFREY P. SALOMONE, MD, FACS, NREMT-P
Trauma Medical Director, Maricopa Medical Center
Professor of Surgery,
University of Arizona College of Medicine—Phoenix
KATHLEEN S. SCHRANK, MD
Professor of Medicine and Chief,
Division of Emergency Medicine,
University of Miami School of Medicine
Medical Director, City of Miami Fire Rescue
Medical Director, Village of Key Biscayne Fire Rescue
JOHN SINCLAIR, EMT-P
International Director, IAFC EMS Section
Fire Chief & Emergency Manager,
Kittitas Valley (Wash.) Fire & Rescue
COREY M. SLOVIS, MD, FACP, FACEP,
FAAEM
Professor & Chair, Emergency Medicine,
Vanderbilt University Medical Center
Professor, Medicine, Vanderbilt University Medical Center
Medical Director, Metro Nashville Fire Department
Medical Director, Nashville International Airport
WALT A. STOY, PHD, EMT-P, CCEMTP
Professor & Director, Emergency Medicine,
University of Pittsburgh
Director, Office of Education,
Center for Emergency Medicine
RICHARD VANCE, EMT-P
Captain, Carlsbad (Calif.) Fire Department
JONATHAN D. WASHKO,
BS-EMSA, NREMT-P, AEMD
Assistant Vice President, North Shore-LIJ Center for EMS
Co-Chairman, Professional Standards Committee,
American Ambulance Association
Ad-Hoc Finance Committee Member, NEMSAC
KEITH WESLEY, MD, FACEP
Medical Director, HealthEast Medical Transportation
KATHERINE H. WEST, BSN, MED, CIC
Infection Control Consultant,
Infection Control/Emerging Concepts Inc.
STEPHEN R. WIRTH, ESQ.
Attorney, Page, Wolfberg & Wirth LLC.
Legal Commissioner & Chair, Panel of Commissioners,
Commission on Accreditation of Ambulance Services (CAAS)
DOUGLAS M. WOLFBERG, ESQ.
Attorney, Page, Wolfberg & Wirth LLC
WAYNE M. ZYGOWICZ, BA, EFO, EMT-P
EMS Division Chief, Littleton (Colo.) Fire Rescue
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1306JEMS_8 8 5/28/13 1:41 PM
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help providers guide ventilation rates and assess the
effectiveness of CPR allowing them to make adjustments
in the course of treatment, breath by breath.
Immediate Capnometry at
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Choose 8 at www.jems.com/rs
1306JEMS_9 9 5/28/13 1:41 PM
EMS IN ACTIONSCENE OF THE MONTH
10 JEMS JUNE 2013 www.JEms.com
ROPE RESCUE
San Diego Fire-Rescue paramedic/firefighters use a Stokes basket to carry a 46-year-old
male patient up a steep embankment after being called to a single-vehicle crash. The
call came in after a man drove off the road, remained airborne and traveled about 140 feet
forward while dropping about 25 feet. The driver and vehicle landed in ice plant and bounced
once, which moved the car about 15 feet from the initial impact point to the base of a steep
canyon bank. Less than six minutes after a truck company arrived, the crew was able to
quickly assess and perform a rapid extrication to remove the driver from the car while taking
C-spine precautions. The patient was then immobilized to a backboard, placed in a Stokes
basket and transferred up the slope by ropes and pulleys attached to an engine and ladder
truck. The rescue took 24 minutes to get the patient from his car back to road level, and para-
medics spent six minutes assessing and loading the patient for transport. Despite the serious-
ness of the event, the transport to Sharp Memorial Hospital was made without lights and
siren because the patient sustained only minor lacerations and no life-threatening injuries.
>> PHOTOS BOB GRAHAM
1306JEMS_10 10 5/28/13 1:41 PM
12 JEMS JUNE 2013 www.JEms.com
A WIN FOR HROSEmploying high-reliability organization characteristics in EMS
FROM THE EDITORPUTTING ISSUES INTO PERSPECTIVE
>> BY A.J. HEIGHTMAN, MPA, EMT-P
JEMS founding publisher Jim Page, often
called the father of modern EMS, came
in my office one day and told me about
a sharp physician, Daved Van Stralen, MD,
a former Los Angeles City Fire Depart-
ment paramedic who was working in the
Loma Linda University School of Medicine
Department of Pediatrics. Page said Van
Stralen was “onto something big,” called
high-reliability organization (HRO) pro-
cesses, that I “needed to pay attention to.”
So I contacted Dr. Van Stralen, discussed
the concept with him and attended an HRO
conference where I was blown away by the
content presented. I heard representatives
from the U.S. Navy, NASA, offshore gas
industry and major airlines vividly explain
how the following can stop an unsafe pro-
cess before it gets out of control: A careful
consideration of predictable risks, a system of
defined corrective actions and the empower-
ment of any employee or responder in a high-
hazard environment to take action.
Dr. Van Stralen and retired U.S. Navy
Rear Admiral Thomas Mercer honor us
this month with the first of two articles
they agreed to author for JEMS on the
principles of HRO, so I won’t go into great
detail here. But I did want to give you an
example of how HRO principles can affect
your decision-making processes and actions
at a high hazard scene, because I experi-
enced it personally.
As an EMS operations director for a
large, progressive, high-performance EMS
service in Pennsylvania, I was alerted one
day to a highway incident where three of my
crews were. It involved an overturned tanker
truck that was leaking Freon.
The hair on my neck stood up when I
heard the word Freon because, early in my
EMS career, I treated a young boy who
had huffed Freon from PAM cooking spray
through a toilet paper tube packed with
toilet tissue. He did it to get a “buzz.” He
inhaled an excessive amount and excited his
heart so much that he lapsed into v fib that
couldn’t be reversed. He died two days later.
FREON TOXICITY
Freon is the trade name for a group of man-
made chemicals called chlorofluorocarbons
(CFCs). CFCs contain chlorine, fluorine
and carbon and are often found in air con-
ditioners and refrigerators. The manufac-
turing and use of Freons is restricted and
is gradually being phased out. People are
usually exposed to Freon by accidentally or
deliberately breathing it in.
High concentrations can reduce the activ-
ity of the central nervous system, cause
weakness, an irregular heartbeat, convul-
sions and death. In addition, high concen-
trations can cause severe abdominal pain,
vomiting (including vomiting of blood) and
loss of vision. People who take medications
used by asthmatics may face a greater risk
and should avoid too much exposure.
The Material Safety Data Sheet (MSDS)
on Freon notes that inhalation of high con-
centrations of its vapor is harmful and may
cause heart irregularities, unconsciousness or
death. Reference material notes that inten-
tional misuse or deliberate inhalation can
be fatal.1
Immediate effects of overexposure by
inhalation may include central nervous sys-
tem depression with dizziness, confusion,
incoordination, drowsiness or unconscious-
ness. Gross overexposure can cause death
from v fib that often starts as an irregular
heartbeat during the early stages of exposure.
PH
OT
OS
A.J
. H
EIG
HT
MA
N
A high-reliability organization must not rely on only one source of data during an emergency decision-making
process when detailed information on a hazard isn't immediately available or isn't informative.
1306JEMS_12 12 5/28/13 1:41 PM
www.jems.com jUNe 2013 JEMS 13
It often presents with a strange sensation in
the chest, “heart thumping,” apprehension,
light-headedness, feeling of fainting, dizzi-
ness and weakness, and it sometimes pro-
gresses into loss of consciousness and death.
According to the National Institutes of
Health, most symptoms are a consequence
of inhaling Freon. It also notes that Freon
vapors are heavier than air and pose a threat
of suffocation if you're trapped in enclosed
or low places and that inhalation may cause
dizziness, headache, confusion, incoordina-
tion and loss of consciousness.2 A leaking
tanker truck carrying CFCs can also present
a significant hazard to emergency respond-
ers who won't find Freon or CFCs in their
standard Emergency Response Guidebooks.
ENACTING HRO PRINCIPLES
So I called my crews on an operational chan-
nel and asked how far they were from the
leaking product. They said they were told
by incident command (IC) to stay 1,000 feet
away from the tanker and that it was spew-
ing a “rather harmless” gas/refrigerant.
The Department of Transportation
Emergency Response Guidebook, which we’re
all are supposed to know and use, doesn’t
specifically list Freon or CFCs. However,
it does list in Guide 115 that: “Gases:
Flammable (including
refrigerated liquids)
as extremely flamma-
ble, lighter than air”
and that “some may be
irritating if inhaled at
high concentrations.”3
The Guidebook also
doesn’t truly describe
the effects of Freon
or CFCs. However,
under “Evacuation,” it
does state that “during
a large spill,” incident commanders should
consider “initial downwind evacuation for at
least 800 meters (1/2 mile).” That is 2,640
feet—1,640 feet further than where my
crews were positioned.
I opened the massive Railroad Hazard-
ous Material binder that I carried with me at
all times and confirmed that excessive inha-
lation of Freon could result in irreversible v
fib. I then called my crews and asked them
to alert the IC that Freon was involved and
that “6202” (my county ID number, which
indicated that it was their ops director on
the line) recommended that the evacuation/
positioning zone be extended to 1/2 mile.
They reported back that the IC “felt they
were not in danger and felt no need to move
their vehicle position.” I responded that I
would be en route to their location.
With the Railroad Hazardous Material
binder under my arm, I responded to the
scene, presented the specific sections rela-
tive to the true haz-
ards of Freon to the
IC. He was still reluc-
tant to move my crew
back, so I politely told
him that, regardless
of his decision, I was
going to reposition
my paramedics out-
side the stated hazard
zone. I told him they
would be available to
“attempt to resusci-
tate” his personnel if they were exposed to
the high Freon concentration and “needed to
be resuscitated.” He finally agreed to move
my crews to the 1/2-mile perimeter.
SUMMARY
Was I insubordinate, arrogant or disrespect-
ful? You may feel that I was. But in reality, I
was educated to a level that could have been
validated and should have been respected by
command. I was, in fact, practicing a key
aspect of HRO. I was stopping an obvious
dangerous condition before it could harm
or kill emergency responders. My IC col-
league knew it from the facts presented and,
in fact, joked with me about my “subtle sar-
casm” and moved the perimeter to the rec-
ommended half-mile distance.
Did I win, or did a proactive HRO win?
Actually, HRO won and potentially saved
30 lives. I simply presented the hazards of
CFC inhalation. A high-reliability organi-
zation must not rely on only one source of
data when detailed information on a hazard
isn’t immediately available, or if it isn’t very
informative during an emergency decision-
making process.
Read “EMS & High Reliability Orga-
nizing: Achieving safety & reliability in the
dynamic, high-risk environment and prac-
tice its important principles,” pp. 60–63. It’s
really common sense, not rocket science, and
may save you, your crews or others in your
community. JEMS
REFERENCES
1. Thompson L. (1999–2013). What are the dangers of inhal-
ing Freon. In EHow. Retrieved May 1, 2013, from www.
ehow.com/lis t _7598789_dangers-inhaling-f reon.
html#ixzz2S5zGzvXr.
2. DuPont. (Nov. 4, 2002). Material Safety Data Sheet: Freon.
In DuPont. Retrieved May 1, 2013, from http://msds.dupont.
com/msds/pdfs/EN/PEN_09004a2f8000630b.pdf.
3. U.S. Department of Transportation: Emergency Response
Guidebook: A guidebook for first responders during the initial
phase of a dangerous goods hazardous materials transpor-
tation incident. Claitor’s Law Books and Publishing; Baton
Rouge, La., 2008, p. 176–177.
High-reliability organizations carefully consider predictable risks, institute a system of defined corrective actions & empower any employee in a high-hazard environment to stop an unsafe process before it gets out of control.
EMS can learn from organizations that have developed high-reliability programs, including the U.S. Navy,
where there are high risks that must be controlled.
1306JEMS_13 13 5/28/13 1:41 PM
14 JEMS JUNE 2013 www.JEms.com
LETTERSIN YOUR WORDS
Author Kristen Spencer, MS, NREMT-P,
writes: Just a few days after publication of the
”Provider to Patient” article in the April issue of
JEMS, I received a heartwarming story from Bruce
Kilburn, AEMT-CC, a resident of Lake George, N.Y.
Mr. Kilburn expressed how he, too, experienced a
“widow-maker” acute myocardial infarction while
on duty—but with a far different outcome than
that of John Davis, the subject of the April article.
Unfortunately for Mr. Kilburn, he now requires an
implantable cardioverter defibrillator (ICD) and
multiple medications to maintain adequate car-
diovascular function because he elected to ignore
his symptoms.
It is for this precise reason that John Davis’ story
needed to be shared with your readers. EMS provid-
ers are subjected to stressful events, work long hours
and often fail to adopt healthy dietary habits. The
article was intended to remind EMS providers that
they are not invincible and can succumb to cata-
strophic cardiovascular events—just like the same
patients they are called to treat.
'KICKED IN THE CHEST'
I’m an AEMT-CC in upstate New York and have
been involved in EMS for 20 years. I was on call
on July 22 when my partner and I got a serious
personal injury call for a motorcycle accident.
Upon arrival we found a young man lodged under
a car. Needless to say he was in rough shape. So I
did my job and took care of him and got him to
the hospital.
While I was writing up my PCR in the EMS
room at 10:15 p.m., I suddenly felt like someone
had kicked me in the chest. The pain increased
quickly, like my chest was in a vice and someone
was turning the crank. But I thought it was just my
dinner coming back.
You know that little voice in the back of your
head? Well, it told me three times not to leave the
emergency department and to tell a doctor what
was going on; but I chose not to do that. I thought,
“I treat people for this, I don’t get this.” But I was
wrong—almost dead wrong.
I got back in the ambulance and returned to
work. Fifteen minutes later the pain had become
unbearable. My left arm was numb and I knew
something bad was happening. I got out of the
ambulance and back in the patient compartment
and told my partner that I needed a monitor
placed on me to see what was going on.
He did a 12-lead ECG and I could tell by his
voice when he called the doctor that he didn’t like
what he was seeing. I knew it wasn't good when
I heard him relay my ST elevations to the doctor.
They were the same as in your article. I was having
the big one: the “widow-maker.”
It took 11 minutes to get me back to the ED and
I was in the cath lab within 10 minutes of arrival. I
had two stents placed, one was 100% blocked and
the other was 80% blocked left anterior descend-
ing. I was in the cath lab about an hour.
I was lucky to be alive. It has been a long road to
recovery and I know I will never be 100% again. My
ejection fraction was running between 35% and
40% and was holding until April of this year when it
took a nose dive to 25%. Needless to say I now have
an ICD in place to bring me back if I go into v fib or
v tach. This was not something I had planned on.
I guess the take-home message here is: take
care of yourself early in life and don’t think it
won’t happen to you. We are not bulletproof like
so many of us in this profession think we are.
Also, listen to your inner voice. Had I simply said
something instead of falling into denial, I probably
would not have done so much damage.
Bruce Kilburn, AEMT-CC
Via email
ROLE REVERSAL
The job of an EMT or paramedic
is by nature high-stress and both
physically and mentally demanding.
But when taking care of others, we
have to also remember to take care
of ourselves. In April, we published
the compelling story of John Davis,
an EMT who found himself on the
other end of a cardiac monitor after
years of putting aside his own health.
Kristen Spencer, MS, NREMPT-P,
co-author of the article “Provider to
Patient: One EMT’s close call offers
lessons for all providers,” received a
letter from a reader whose own story
further underscores the importance of
being aware of your own health, not
just your patient’s.PH
OT
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ES
Y K
RIS
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N S
PE
NC
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Facebook Poll
Adam G.: If you don’t, you should. If you
don’t know, you should find out.
Michael T.: My partner used the red button
a few months ago when his truck flipped. He
had a brain bleed and no recollection of the
event but he managed to press the red button.
Kendra M.: I used it once when a family
wanted to kick our butts because the patient
was dead. We were stuck doing meaningless
CPR while waiting for deputies to come save us.
I was terrified and grateful for that red button!
73%
YES
18%
NO9%
don’tknow
My radio has a code system or emergency
identifier that I can use when facing an
immediately violent situation.
1306JEMS_14 14 5/28/13 1:41 PM
ì When youíre hiring a consultant, you want
knowledge, integrity and responsiveness.
Fitch & Associates tops the list.î
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TOM JUDGE, EXECUTIVE DIRECTOR, LIFEFLIGHT OF MAINE
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1306JEMS_15 15 5/28/13 1:41 PM
PRIORITY TRAFFICNEWS YOU CAN USE
16 JEMS JUNE 2013 www.JEms.com
In a profession where
staffers are known to
pack extra equipment
into their belt loops, a few
EMS and fire providers in
Bethel Township, Ohio,
are adding just a little more
kick—firearms.
For about a year, the
Bethel Township Fire and
EMS Department has
allowed first responders to
carry concealed weapons on
emergency calls as a way to
protect themselves in an area
where having law enforce-
ment respond to calls in a
timely manner when needed
can be a challenge due to
reduced staffing.
The idea to let first responders carry
weapons was hatched after budget cuts
reduced the number of available officers
in the response area served by the depart-
ment, says Bethel Township Fire and EMS
Department Chief Jacob King.
“Law enforcement is a huge piece of
this,” King says. “When you’re lacking a lot
of assistance, you have to change the way
you do business.”
King’s department handles 2,100
calls a year, some 1,600 of them for
medical emergencies. King says there
have been times when his staff hasn’t
felt a scene was safe and the delay in
getting law enforcement support has
made the wait to render aid too long.
“The ones that do carry [guns] feel
safer,” King says, adding that just a few
members participate in the program.
Under the Bethel Township program,
staff members who hold concealed carry
gun permits through the state of Ohio may
carry them while on duty. Before doing
so, King says, they’re provided significant
training on when and how to use them. So
far, he says, not one provider has used their
weapon in the line of duty.
VIOLENT INCIDENTS
Word of the Bethel Township Fire Depart-
ment gun program has surfaced at a time
when there have been intense conversa-
tions within the field on EMS staff safety
and what may be done about it. Although
first responder safety is always an issue,
concerns escalated to a heightened level
of awareness in December when a man
in Webster, N.Y., set fire to his home and
then shot at firefighters responding to the
blaze. Four were shot and two were killed
in the ambush.
Then in April 2013, a man in Gwin-
nett County, Ga., called in a medical
emergency. When firefighters responded
to the house, he took them hostage. Police
SWAT team members eventually gained
access to the home and killed the man. The
firefighters later said the man admitted to
them he called for medical help because he
didn’t think they would be armed.
Even before those inci-
dents, there had been
an increased focus on
responder safety. Indeed,
street safety classes teach
EMS responders how to
react in unsafe conditions.
And more agencies are get-
ting bulletproof vests for
their employees.
For instance, in March,
Dorchester County, Md.,
officials voted to allow the
county’s emergency ser-
vices department to shop
for bulletproof vests after
a crew showed up for a
seizure call only to find out
the seizure was secondary
to a gunshot wound and
the scene was unsecured when the team
got there.
The decision to carry guns is a personal
one for every department, says King, and
it may not be right for every situation. In
the case of Bethel Township, they’re simply
providing the same rights that every other
Ohio resident has to carry a concealed gun.
“And in no way, shape or form do we ever
want to inf lict harm against any of our citi-
zens,” adds King.
Likewise, King says, the decision
to let staff carry their own weapons
isn’t an effort for them to replace law
enforcement. Instead, it’s a way for
his staff to feel comfortable helping
people where they might not otherwise
feel safe.
“We saw several calls that would require
immediate [medical] intervention to help
save a person’s life and we would just sit
and wait,” King says.
“They didn’t have the opportunity to
even do something,” he adds. “When I
don’t have the opportunity to even try to
save someone’s life—that gets to me more
than when I make a mistake.”
— Richard Huff, NREMT-B
Paramedics PACKING HEAT
Ohio EMS department allows first responders to carry guns for protection
“The ones that do carry [guns] feel safer.” —Bethel Township (Ohio) Fire Department Chief Jacob King
PH
OT
O A
.J. H
EIG
HT
MA
N
Staff members who hold concealed carry gun permits in Bethel Township (Ohio) may
carry guns while on duty.
1306JEMS_16 16 5/28/13 1:42 PM
TM
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WHERE PEOPLE, PRODUCTS AND IDEAS
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where camaraderie, pride of service and dedication to saving lives is celebrated.
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1306JEMS_17 17 5/28/13 1:42 PM
18 JEMS JUNE 2013 www.JEms.com
PRIORITY TRAFFIC>> CONTINUED FROM PAGE 16
CARRYING CONCEALED WEAPONS By Doug Wolfberg & Steve Wirth
800.558.6270
Responding
to EMS
Have you seen us lately? We’re proud to have
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we continuously strive to make ordering supplies
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Recently, a fire/EMS agency in Ohio (see “Paramedics Packing
Heat,” p. 16) began allowing its personnel to carry concealed
weapons while on duty. Media reports indicate that this policy was
adopted in response to the deadly ambush of firefighters in Webster,
N.Y., on Christmas Eve and an April incident that occurred in Geor-
gia in which a man held responding personnel hostage before he was
shot and killed by the police. This month, we examine the legal rami-
fications of carrying concealed weapons on the job in EMS.
First and foremost, before implementing
any policy, your agency must look at your
state’s concealed weapons laws. Some laws
specify whether employers can prohibit or
must allow employees to carry permitted
concealed weapons while on duty. In gen-
eral, most state laws permit the employer to
restrict or prohibit the carrying of concealed weapons on duty. Some
state laws, however, provide that the employee must be allowed to keep
their concealed weapons in their cars, even if parked on the employer’s
property, and even if they use their personal vehicles for work. In any
event, it is important that any policy regarding concealed weapons in
the workplace be consistent with the conceal/carry laws in effect in
your state, county and/or city.
Second, check your state’s EMS laws, regulations and policies to
see if they address the carrying of weapons by EMS personnel or
on board an ambulance. For instance, in Pennsylvania, state EMS
regulations prohibit the carrying of weapons on board an ambu-
lance and prohibit EMS personnel from carrying them. These spe-
cific laws regulating ambulance services and EMS agencies would
likely trump any general conceal/carry laws.
After considering your state’s laws on the subject, your agency
then has to evaluate the merits of permit-
ting personnel to carry concealed weapons
on duty. Although reports of assaults on
EMS personnel are certainly not rare, the
use or threat of deadly force against EMS
providers is, thankfully, rare. Examples like
the hostage situation in Georgia are also
uncommon. EMS personnel are trained how to respond to threats
and other response techniques, including physical and chemical
restraint. Generally, EMS training and applicable standards of care
for managing difficult or violent patients doesn’t include the use of
firearms to threaten or subdue a patient, or the use of deadly force
by EMS providers. In other words, unless state law provides specific
legal protections or immunity in this situation (which most do not),
an EMS agency could well be opening itself up to tort liability for
any harm or injuries—to a patient, a bystander or anyone else—
caused by weapons carried by EMS personnel on duty.
And, of course, there’s always a threat that a weapon will end
up being used against the EMS providers themselves, particularly
since EMS providers may not be able to guard or secure their
weapons at all times due to the normal distractions that come with
providing patient care. It isn’t difficult to perceive a situation in
which a violent patient could take a weapon from an EMS provider,
which could have very unfortunate consequences.
Allowing personnel to carry weapons on duty would also open
up a host of other questions, such as:
>> What type of weapons may be carried?
>> How does the EMS agency ensure that the personnel have
appropriate permits and verify that they are kept current?
>> How does the agency verify the training that the personnel
have received on the use of firearms?
>> How does the agency verify that the weapons are in proper
working order?
>> How and where are the weapons secured when personnel
must remove them for operational or patient care purposes?
Adopting a policy to permit carrying weapons is one thing; deal-
ing with all of the unforeseen ramifications is another.
The carrying of concealed weapons by on-duty EMS personnel—if it
is allowed at all—must be done only after careful consideration of your
state firearms laws, EMS regulations, immunity statutes, and training
and safety concerns. EMS standards of care don’t include the use of
firearms when providing patient care, so unless state law grants specific
immunity for their use, bear in mind that your agency may be opening
itself up for more liability than it bargained for in the event that injuries
or deaths are caused by a weapon carried on duty by EMS personnel.
Pro Bono is written by attorneys Doug Wolfberg
and Steve Wirth of Page, Wolfberg & Wirth
LLC, a national EMS-industry law firm. Visit the
firm's website at www.pwwemslaw.com for more
EMS law information.
1306JEMS_18 18 5/28/13 1:42 PM
www.jems.com jUNe 2013 JEMS 19
PH
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OR
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Choose 12 at www.jems.com/rs
Each year, hundreds of family mem-
bers, friends, EMS, political leaders
and colleagues from EMS agencies
from around the nation gather together to
remember EMS personnel who have died
in the line of duty and recognize the ulti-
mate sacrifice they made for their fellow
man. This year, there are 19 honorees.
The National EMS Memorial is not a
single event but rather a weekend of events
centered on the ceremony known as the
National EMS Memorial Service. This
year the National EMS Memorial Service
will be held on Saturday, June 22, at 6
p.m. MDT at the Pikes Peak Center in
Colorado Springs. It’s open to anyone who
wishes to attend. The Service is a non-
denominational ceremony that includes
honor guard presentations, bagpipes, a
helicopter f lyover and distinct presenta-
tions to each family. Honorees’ families
are presented with three items:
TOGETHER, WE REMEMBER …Annual National EMS Memorial Service & Air Medical Memorial ceremony to be held this month
Honorees’ families are presented with a U.S. flag, a white rose and a medallion signifying their eternal memory.
1306JEMS_19 19 5/28/13 1:42 PM
20 JEMS JUNE 2013 www.JEms.com
PRIORITY TRAFFIC
>> CONTINUED FROM PAGE 19
QUICK›TAKE
1. A U.S. f lag that has f lown over the U.S. Capitol, denoting the
honoree’s service to their country;
2. A white rose representing their undying love; and
3. A medallion signifying their eternal memory.
The National EMS Memorial is on display for the service, and
it’s composed of the Tree of Life and the Memorial Book. The Tree
of Life is a representation of an oak tree, which symbolizes strength.
The name, agency and date of loss of each National EMS Memorial
Service honoree are engraved on a bronze oak leaf, which is then
added to the Tree of Life. The Memorial Book contains a page for
each honoree. These pages contain photos, biographies and agency
patches for each individual honored. The Memorial Book is kept on
display near the Tree of Life. The display includes all EMS line of
duty death honorees for all years since its inception in 1991.
The Air Medical Memorial ceremony will take place this year
on Friday, June 21—one day prior to the National EMS Memorial
Service—at sunrise. The ceremony will begin at 7 a.m. at the
future site of the Air Medical Memorial at 10901 West Toller
Drive in Littleton, Colo (see “Permanent EMS & Air Medical
Memorials,” below). This year it honors six crew members lost in
air medical related crashes.
— Jana Williams, RN, BSN, CMTE & Krista Haugen, RN, MN, CEN
NATIONAL EMS MEMORIAL SERVICE 2013 HONOREES
> Ethan Lynn Amsbaugh, of Priority Response Ambulance, Mount Union, Pa., died in the
line duty on June 2, 2012, of injuries sustained in an ambulance-involved motor vehicle collision.
> Ruben Berrios, of FDNY EMS, Brooklyn, N.Y., died in the line duty on Dec. 10, 2012, of
complications from working 9/11 World Trade Center site.
> Luis Bonilla, of Mayo Organ Transplant Team, Rochester, Minn., died in the line of duty on
Dec. 26, 2011, of injuries sustained in a medical aviation accident.
> Peter P. Carbonneau, of Van Buren Ambulance Service, Van Buren, Maine, died in the
line of duty on April 8, 2012, of an on-duty cardiac event.
> James M. “Jim” Dillow*, of REACT, Rockford, Ill., died in the line duty on Dec. 10, 2012,
of injuries sustained in a medical aviation accident.
> Gene Grell*, of Mercy Air Med/Med-Trans, Mason City, Iowa, died in the line duty on Jan.
2, 2013, of injuries sustained in a medical aviation accident.
> Billie J. Grills, of Carter County EMS, Grayson, Ky., died in the line duty on Nov. 11, 1986, of
an intercerebral hemorrhage while on-duty.
> David Hines, of Mayo Organ Transplant Team, Rochester, Minn., died in the line duty on
Dec. 26, 2011, of injuries sustained in a medical aviation accident.
> Karen Marie Hollis*, of REACT, Rockford, Ill., died in the line duty on Dec. 10, 2012, of
injuries sustained in a medical aviation accident.
> Justin Michael Hueston, of Vernon County Ambulance District, Nevada, Mo., died in
the line duty on Sep. 25, 2012, of injuries sustained in a motor vehicle collision.
> Shelly Lair-Langenbau*, of Mercy Air Med, Mason City, Iowa, died in the line duty on
Jan. 2, 2013, of injuries sustained in a medical aviation accident.
> Andrew H. “Andy” Olesen*, of REACT, Rockford, Ill., died in the line duty on Dec. 10,
2012, of injuries sustained in a medical aviation accident.
> Russell Piehl*, of Mercy Air Med, Mason City, Iowa, died in the line duty on Jan. 2, 2013,
of injuries sustained in a medical aviation accident.
> David Restuccio, of LIJ/Staten Island University Hospital EMS, Staten Island, N.Y., died in the
line duty on Aug. 27, 2012, of injuries sustained in an ambulance involved motor vehicle collision.
> Joseph V. Schiumo, of FDNY EMS, Brooklyn, N.Y., died in the line duty on Dec. 9, 2013,
of complications from working on the 9-11 World Trade Center site.
> Ray Shriver*, of Teton County Sheriff's Search & Rescue, Jackson, Wyo., died in the line duty
on Feb. 15, 2011, of on injuries sustained in a search and rescue aviation accident.
> E. Hoke Smith, of Mayo Organ Transplant Team, Rochester, Minn., died in the line duty on
Dec. 26, 2011, of injuries sustained in a medical aviation accident.
> Timothy Kyle Southern, of Priority Patient Transport, Harrisonburg, Va., died in the line
duty on Jan. 6, 2012, of injuries sustained in an ambulance involved motor vehicle collision.
> Joshua A. Weissman, of Alexandria Fire Department, Alexandria, Va., died in the line
duty on Feb. 9, 2012, of injuries sustained in a fall from a bridge while operating at the scene of
an motor vehicle crash.
*Also being honored at the Air Service Memorial ceremony.
PERMANENT EMS & AIR MEDICAL MEMORIALS
Each year, many in EMS and the air medical communities
make the ultimate sacrifice, losing their lives in the service of
others. Currently, there’s no permanent national memorial for
either group.
Land has been donated for both the National EMS Memo-
rial, in Colorado Springs Memorial Park, and the Air Medi-
cal Memorial, in Littleton, Colo. Both groups are organized,
poised and ready to build not only physical memorials, but also
networks to support families and survivors, as well as programs
to promote safety, health and resilience for our EMS profes-
sionals from the ground to the air.
Together, the groups are teaming together to issue “The
Ultimate Challenge.” That is, each EMS agency in the
country is challenged to raise $1,000 and each air medical
program is challenged to raise $3,000. Both organizations
encourage agencies to reach out to the community they serve
to raise funds: hold a bake sale, do a car wash, pass the hat,
sell donuts or be creative and come up with a unique idea to
get the job done!
Take the challenge and commit your agency to support one
or both memorials at www.ultimate-challenge.org.
For more information,
visit the National EMS Memorial Service
website at www.NEMSMS.org
and the Air Medical Memorial website at
www.airmedicalmemorial.org
1306JEMS_20 20 5/28/13 1:42 PM
www.jems.com jUNe 2013 JEMS 21
Visit our website at www.ColumbiaSouthern.edu/Disclosure for information about gainful employment
including cost of attendance, on-time graduation rates, occupational opportunities, median student
debt and other important information about CSU programs.
www.ColumbiaSouthern.edu/JEMS | 800.349.4202
Online Degrees. Affordable Tuition. Superior Service.
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Choose 13 at www.jems.com/rs Choose 14 at www.jems.com/rs
WEST, TEXAS: IN MEMORIAM
On April 17, an explosion at the West Fertilizer Co. dev-
astated the small town of West, Texas. The explosion
occurred as volunteer firefighters were battling flames
and beginning evacuation from the plant, and EMS pro-
viders were staged to provide emergency medical care.
The 35-year volunteer ambulance service, West EMS,
is currently out of service after losing its building, sup-
plies and two ambulances in the explosion. In addition
to those material losses, the following 10 EMS and fire
service members were killed in the blast that registered
2.1 on the Richter scale:
> Morris Bridges of West Volunteer Fire Department;
> Perry Calvin of West EMS and Mertens and Navarro Hills Vol-
unteer fire departments;
> Jerry Chapman of West EMS and Abbot Volunteer
fire departments;
> Cody Dragoo of West Volunteer Fire Department;
> Kenny Harris of Dallas Fire-Rescue;
> Joseph Pustejousky of West Volunteer Fire Department;
> Cyrus Reed of West EMS and Abbot Volunteer Fire Department;
> Kevin Sanders Bruceville-Eddy Volunteer Fire Department
and West EMS;
> Douglas Snokhous of West Volunteer Fire Department; and
> Robert Snokhous of West Volunteer Fire Department.
West EMT Terase Alexander leans on the
casket of West firefighter Cyrus Reed fol-
lowing a memorial service for victims of the
fertilizer plant explosion in West, Texas.
AP
PH
OT
O/E
RIC
GA
Y
In light of the tragic event in West, Texas,
the National Fallen Firefighters Foundation
has established a national fund to accept
monetary donations to assist the survivors
and coworkers of the
fire and EMS person-
nel who died in the line
of duty. Donate at
www.regonline.com/
westtx.
1306JEMS_21 21 5/28/13 1:42 PM
22 JEMS JUNE 2013 www.JEms.com
PH
OT
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KP
HO
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.CO
M/R
AP
IDE
YE
In today’s EMS culture, it’s hard to escape the con-
stant use of buzzwords and other business jargon.
As I sat in a meeting the other day, I
noticed the speaker kept using buzz-
words—words that sound authorita-
tive or technical and have worked their way
into management culture. I couldn’t help but
think how these words and phrases have also
crept into the EMS profession and how, from
time to time, I catch myself using buzzwords
when I make a comment to someone.
Why do I feel the need to use these buzz-
words? Am I trying to sound authoritative or
well educated? Am I trying to impress some-
one? Or am I just caught up in the whirlwind
of using words that I have heard others use?
To understand the use of buzzwords, I
guess I could “reach out to someone” to get
a better understanding. But before I could do
that I would have to devise a “reverse retro-
grade action” to get out of the meeting I was
currently sitting in.
SPEAKING THE JARGON
The use of buzzwords is commonplace
among EMS managers these days. Many
of us have experienced less revenue coming
into our agencies throughout the last several
years, mostly due to the economic downturn
and insurance providers seemingly becoming
less willing to pay for things.
As a result, many of us have had to “down-
size” our operations and “rebrand” some of
the things we do. We have also had to become
more “patient centric” in the process. By
becoming more “patient centric” we have had
to look at “reinventing” how we run our EMS
organizations. We find ourselves trying to
hit “benchmarks” and “core competencies” in
“quality care” while still trying to “herd cats.”
ADAPTING
It’s not easy being an EMS manager. We've
had to resort to “knowledge process outsourc-
ing” and, on some occasions, we find our-
selves doing “conflict resolution.”
In order to adapt to the “changing work-
force,” EMS managers have had to learn new
management practices by “thinking outside
the box.” This includes “empowering” our
employees and doing more “face time” so that
we can create “win-win” situations for us, our
employees and patients. EMTs and para-
medics who still “miss the mark” have usually
found themselves in “coachable moments”
with their EMS manager or supervisor.
EMS managers who do not perform well
have found themselves developing “survival
strategies” and “leveraging” themselves in the
event they are “separated from the service.”
Buzzwords have even worked their way
into our operational vernacular. What major
city hasn't had to deal with a “surge”—when
more people call 9-1-1 than we have ambu-
lances? And during civil disturbances, when
we align the police with ambulances, we call
it “force protection.” During major events
such as Hurricane Sandy, we saw the new
buzzword “crowdsourcing” emerge, where the
collection of individuals, communities and
interests can be either a very powerful enemy
or asset, depending on the situation. During
powerful and “high-intensity” events, EMS
managers should also use “accountability” to
ensure their personnel are safe.
THEY’RE EVERYWHERE
EMS training hasn’t escaped the buzz-
word explosion either. We now develop
students with “critical thinking” skills
through “outcome-based education.”
The goal is to provide “mastery learn-
ing” through “world class standards”
with the “end goal” of producing
“higher-order thinking skills.” I walked into
the training academy at the Memphis Fire
Department one day and found my instruc-
tors doing “gamification” with the students by
playing Jeopardy! with questions about module
three of their textbook.
I predict with the implementation of the
Affordable Care Act, EMS systems will
have to shift to another “paradigm” and
“think outside the box” on how we deliver
care. We’re already seeing the emergence of
change through “outcome-based medicine”
and the “interoperability” of systems merg-
ing and working together to share health-
care data. Hospitals and Accountable Care
Organizations in the future will be pressured
to decrease cost for patient care and should
expect to see the acronym ALARP—“as low
as reasonably possible.”
CONCLUSION
With the way healthcare will be chang-
ing throughout the next several years, EMS
managers will need to look at the way they
do business from the “30,000-foot level.”
Don’t forget to do a “360-degree evaluation”
of your EMS organization because of the
“megadigm” that will result with healthcare
changes. “Best practices” will certainly be the
order of the day with the changes that we will
see. But before you start making the major
changes, you’ll probably need to go after the
“low hanging fruit” first.
As I go about my daily job of running
an EMS system, I know “at the end of the
day” I need to keep my organization “cutting
edge” so that we can remain “proactive” to
the changes occurring within the EMS pro-
fession. If I fail, I know I will probably need
to devise an “exit strategy” and “move for-
ward” to another “opportunity.” Thankfully,
I’ll always have my JEMS column.
Therefore, I “thank you in advance”
for reading this. JEMS
Gary Ludwig, MS, EMT-P, is a deputy fire chief with
the Memphis (TN) Fire Department. He has over 35
years of fire, EMS and rescue experience. He is also
the immediate past Chair of the EMS Section for the IAFC. He
can be reached at www.garyludwig.com.
WHAT’S THE BUZZ?Industry buzzwords have crept their way into the EMS world
>> BY GARY LUDWIG, MS, EMT-PLEADERSHIP SECTORPRESENTED BY THE IAFC EMS SECTION
1306JEMS_22 22 5/28/13 1:43 PM
www.jems.com jUNe 2013 JEMS 23
RURAL COLORADO CAREWest Routt Fire Protection District provides BLS & ALS
>> BY DENNIS EDGERLY, EMT-P VOLUNTEER VOICEYOUR CHALLENGES, YOUR SOLUTIONS
About 181 miles outside of Den-
ver is the town of Hayden, Colo.
Although Hayden's population is
just over 1,700, its volunteer fire and EMS
agency serves the entire county of West
Routte. Appropriately called West Routt
Fire Protection District (WRFPD), the
volunteer providers oversee a population of
about 2,200 spread across 600 square miles.
A BRIEF HISTORY
The WRFPD was formed in 1963. In 1981,
the department became responsible for pro-
viding basic EMS in addition to fire suppres-
sion. Prehospital care was initially provided
by seven volunteer EMTs, and in 1993 three
of these EMTs attended an EMT Inter-
mediate (EMT-I) class in a neighboring
town. At that time in Colorado, EMT-Is
could provide advanced airway management
with endotracheal intubation, obtain vas-
cular access, interpret ECG tracings and
administer many first-line medications. In
1999, Colorado adopted the new national
EMT Intermediate level (EMT-I/99), and
West Routt continued providing advanced-
level care. Since the original EMT-Is were
certified, there have been several EMT-I/99
courses taught at WRFPD allowing several
more providers to increase their knowledge
and scope of practice.
One of the most cherished department-
traditions includes the famous gun-slinging
Looney Toon. Early in the department’s
history, a picture of Yosemite Sam was
drawn depicting him with bunker gear.
Members liked the picture so much that to
this day Yosemite Sam, holding a fire hose
in one hand and the American flag in the
other, rides along to all calls.
THE STAFF
Chief Bryan Rickman is an EMT-I/99 and
has been with the department for 38 years.
Rickman is well known and respected in
Colorado and frequently participates in
many state EMS task forces. Dale Leck, an
EMT-I/99 with 21 years of service in the
department, is the assistant chief. Together
they oversee 22 volunteer members includ-
ing five EMT-I/99s and five EMTs. In
recent years, the chief and assistant chief
have become paid positions.
The medical director, Laila Powers, MD,
is board certified in emergency medicine
and works as an emergency physician at
the closest hospital, Yampa Valley Medical
Center (YVMC). She works closely with
Rickman to assure the agency is able to
provide the most current level of care and
to ensure everyone involved in patient care
is up-to-date with current standards of care
and proficient in their practice. Volunteers
attend monthly clinical education sessions,
conferences and classes.
SERVICES
Total call volume for the district is about
400 per year with about 75% needing EMS
response. The remaining calls include fires,
smoke investigations and Hazmat events.
The District also provides standby services
for fairgrounds events.
The region is well known as an excel-
lent location for deer and elk hunting.
During designated hunting seasons the
region’s population increases substantially
with hunters ranging in experience. These
visitors offer the district the opportunity to
conduct rescue operations for hunters with
fractures, cold emergencies and exacerbated
underlying medical conditions.
The majority of patients take the 30-mile
transport to YVMC. On the east side of
Hayden is Yampa Valley Regional Airport,
which is the landing point for medical air-
craft transporting patients who need higher
levels of care from YVMC to specialty cen-
ters in Denver and Salt Lake City. WRFPD
provides transportation for these patients.
CONCLUSION
These providers give their time uncondi-
tionally, often leaving their own families
to care for others. The WRFPD members
demonstrate this every day, be it respond-
ing to a call or doing a medical standby at a
high school football game. They take their
roles as prehospital providers seriously and
are always an asset to their community. JEMS
Dennis Edgerly, EMT-P, began his EMS career in 1987 and is
currently the paramedic education coordinator for the para-
medic education program at HealthONE EMS. Reach him at
PH
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KM
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The West Routt Fire Protection Service has 22 volunteers to serve a population of 2,200.
FAST Facts>> Population served: About 2,200
>> Service area: 600 square miles
>> Area type: Rural
>> Annual call volume: 400
>> Number of volunteers: 22
>> Service level: ALS
>> Website: www.co.routt.co.us
1306JEMS_23 23 5/28/13 1:43 PM
24 JEMS JUNE 2013 www.JEms.com
>> BY THOM DICK, EMT-PTRICKS OF THE TRADECARING FOR OUR PATIENTS & OURSELVES
There’s a principle we both
may have forgotten after
our first EMS shift, Life-
Saver, and it goes like this: Heavy
is dumb.
I admit there’s nothing fancy
about that rule. Nor is it as self-
explanatory as “Never Do Anything
You Know Is Stupid” or “Come to a
Complete Stop at Every Opposing
Signal.” But you can bet on it, just
the same. In the field, heavy really
is dumb. So you choose lightweight
equipment. You use your wheels to bear
weight, instead of your body. (You get the
big wheels as close as you can, then you get
the little wheels as close as you can, then you
consider helping sick people to walk if they
can. Then you carry what you must, when
you must, with help.)
So why do our monitors need to be boat
anchors?
They don’t. They’re big and heavy
because we let the manufacturers think
we need stuff we don’t need. And we don’t
imagine stuff. For instance, the screen
resolution of our most popular monitor
is 640 x 480. That’s Flint-
stone technology—about a
tenth the resolution of an
iPad 3, which weighs a few
ounces and has a much larger
screen. An iPad also has a
much smaller battery, which
lasts for hours instead of minutes on a sin-
gle charge—and can be charged during
use. Not to mention, the iPad can be used
simultaneously to write a chart, access any
number of medical references, check the
status of your area’s EDs, map your rout-
ing, monitor the weather and play music.
(We really should be playing more music
for sick people. We’ve known for years, it’s
good for them.)
What if you had a quick-release clamp
on the head end of your cot that could hold
an iPad, perhaps mounted on a ball joint,
so you could see it every time you look at
a patient’s face? A pair of inexpensive, sin-
gle-use ear buds would enable them to lis-
ten to their choice of music while you keep
an eye on their cardiac rhythm, vitals, sats
and capnometry. A cable (or even a Blue-
tooth interface) could connect them to a
10-ounce module that’s only a few inches
square that might integrate with their sen-
sors and electrodes.
In fact, if you were to attach the patient’s
end of the electrodes to a piece of mesh,
or stretchable, removable plastic film (like
Saran Wrap), you could apply them all
in seconds without tangling. If you had
the right app and, say, 24
electrodes instead of 12,
you could simultaneously
gather enough data to see a
three-dimensional image of
an organ instead of making
inferences about its size, ori-
entation and functions based on what you
see on a primitive oscilloscope.
You could use the same tool to photo-
graph trauma mechanisms or document
video of patient behaviors. This includes
documenting refusals.
The reason a conventional mon-
itor-defibrillator is so bulky, weighs
so much and does so little is that it’s
a conventional monitor-defibrillator
(with a strip-chart recorder built in).
Why? We probably use a monitor
100 times as often as a defibrillator. If the
resolution of the monitor were high enough
(especially with zooming capabili-
ties), it would be better for diagnosis
than anything we’ve ever seen.
Manufacturers also think a defi-
brillator has to be capable of welding
people 30 or more times, rather than
five. And it has to generate a therapeu-
tic charge in five seconds. So it needs
big, honkin’, heavy batteries. Why?
In fact, a defibrillator could deliver
a few shocks on a set of penlight bat-
teries. Those could be supplemented
by the vehicle’s electrical system. The
defibrillator could be linked to an iPad
for (rare) synchronized cardioversion. If it
weren’t built around a video display, it could
weigh a pound or two and look like an AED.
You could easily connect an iPad’s video
output to a big, 24-bit color flat-panel dis-
play, mounted on the wall of your ambulance
and visible from any angle. The iPad’s audio
system could alert you with spoken alarms
when you’re busy and something bad hap-
pens. And you wouldn’t have to learn which
buttons increase amplitude or select leads,
because you wouldn’t need any buttons.
Chances are, you’re already comfortable with
an Apple-style interface, and you could con-
trol that using your smart phone as a remote.
What if you didn’t need a $1,200 clamp
to prevent a $25,000 monitor you can’t
even reach from becoming a lethal projec-
tile in the event of a collision? If that were
the case, you might actually be able to wear
your ambulance’s safety restraints!
C’mon, you can make this happen. Next
time you’re at a conference, talk to the
product reps and tell them what you need.
Or better yet, email the manufacturers
directly. Do that now.
You can use your iPad.
Thom Dick has been involved in EMS for 41 years,
23 of them as a full-time EMT and paramedic
in San Diego County. He’s currently the quality
care coordinator for Platte Valley Ambulance, a
hospital-based 9-1-1 system in Brighton, Colo. Contact him
DUMBNESSAre we stuck in Heavy-land?
Next time you’re at a conference, talk to the product reps & tell them what you need.
What if you could read ECG strips on a screen as small as an iPad?
PH
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1306JEMS_24 24 5/28/13 1:43 PM
CASE OF THE MONTHDILEMMAS IN DAY-TO-DAY CARE
www.jems.com jUNe 2013 JEMS 25
The mother of the 3-year-old is frantic
when she meets you at the door. She
leads you to the family room where
her child, Braden, is lying on the floor with
his grandmother next to him. His mother is
concerned because she can’t get him to wake
up. When questioned, she says Braden has
no previous medical history and denies recent
trauma; Braden is a healthy, active little boy.
PATIENT ASSESSMENT
Your physical exam reveals a healthy-
appearing 3-year-old who is pale and only
responds—by pulling away and uttering a
soft cry—to a finger pinch. His respiratory
rate is 30 and uncompromised with good
tidal volume. Breath sounds are clear in all
fields. His skin is cool with slow capillary
refill in the hands and feet and his pulse rate
is 68 and weak. A heal stick reveals a blood
glucose of 70 mg/dL.
The most alarming finding is the abnor-
mally slow heart rate and signs of hypoperfu-
sion. Knowing that bradycardia in children
is most commonly caused by hypoxia, you
administer oxygen via mask even though
there are no signs of respiratory compromise.
When asked about medications in the
home, Braden’s mother says neither she
nor her husband take any, but she knows
Braden’s grandmother has several bottles.
The grandmother shows you her three bot-
tles on the bathroom counter. Medications
include amlodipine for her blood pressure,
OxyContin for her arthritis and Elavil for
her migraines. She keeps the caps off because
they're difficult to open with her arthritis.
No bottles appear to be disturbed and she
says it doesn’t appear any pills are missing.
Recognizing Braden as being in critical con-
dition, you document the names and doses of
the medications and begin transport to the
emergency department (ED).
During transport you continue to monitor
Braden’s airway and respiratory drive. You
administer 1.5 mg of Narcan intranasal using
a mucosal atomization device and obtain
vascular access, but both cause no change.
The emergency physician later determined
Braden took his grandmother’s amlodipine.
DISCUSSION
This case is a good reminder of the toxic
effects many medications have when taken
by children. The initial assessment of Braden
revealed hypoperfusion without a compen-
sating increase in heart rate, but the heart
rate was actually slowed. Hypoxia com-
monly causes a slow heart rate or bradycar-
dia in children, but Braden showed no sign
of respiratory compromise and his presen-
tation did not change with the administra-
tion of oxygen. His blood glucose level was
OK and there was no history of trauma. The
only other likely cause in this scenario was a
toxic ingestion.
The grandmother’s medications include
pills that can be labeled as “one-pill killers”
for children. OxyContin, a brand name for
oxycodone, is an opiate-based pain reliever.
Toxic effects of oxycodone include respi-
ratory depression, hypotension and altered
mental status. A typical adult dose of Oxy-
Contin ranges from 5–30 mg, but toxic
effects have been seen in adults with amounts
as low as 40 mg. In children, toxic levels will
be seen at much lower amounts.
Elavil is a tricyclic antidepressant (TCA).
It's used to treat depression and sometimes to
treat migraines and other neurologic condi-
tions. At toxic levels, TCAs can have nega-
tive effects on cardiac function and blood
pressure. A typical adult dose ranges from
10–150 mg1. Toxic effects of Elavil and
other tricyclics can be as low as 5 mg/kg. In
a 3-year-old that equates to less than 70 mg.
Braden took amlodipine, a calcium chan-
nel blocker that helps control blood pressure
by decreasing heart rate and the force of car-
diac contraction, both of which were seen in
Braden. A typical adult dose of amlodipine is
2.5 mg. Toxic effects can be seen in children
with doses as low as 2.5 mg (0.15 mg/kg)2.
TREATMENT
All of these medications have treatments to
reverse or temper their effects if the ingestion
is discovered fast enough. OxyContin can
be treated with Narcan, Elavil with sodium
bicarbonate and amlodipine with calcium.
Other medications of concern in children
include alpha-2 agonists such as Catapres,
beta blockers such as metroprolol, and oral
hypoglycemic medications such as glyburide.
All of these can cause lethal effects in chil-
dren after the ingestion of just one pill.
The role of EMS providers is to manage
life threats including problems with airway,
breathing and circulation. Ventilate patients
with slow or shallow respirations and con-
sider CPR in children with heart rates less
than 60 that do not increase with ventila-
tions. Recognize the potential overdose, pro-
vide appropriate therapies to reverse or limit
toxic effects as allowed by protocol and trans-
port rapidly to the closest most appropri-
ate hospital. Remember, it may not require
large quantities of a medication to have lethal
effects in a child. One pill can kill. JEMS
Author's Note: Special thanks to the American Association
of Poison Control Centers, 800-222-1222.
REFERENCES
1. Mosby’s Drug Consult. Mosby. 2006.
2. Benson B, Spyker D, Troutman W, et al. Amlodipine toxicity
in children less than 6 years of age: a dose-response analy-
sis using national poison data system data. J Emerg Med.
2009;39(2):186-193.
Dennis Edgerly, EMT-P, began his EMS career in 1987 and
is currently the paramedic education coordinator for the
paramedic education program at HealthONE EMS.
PH
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Seemingly harmless pills can be deadly for children.
ONE-PILL KILLERSOne dose of adult medication can be deadly to children
>> BY DENNIS EDGERLY, EMT-P
1306JEMS_25 25 5/28/13 1:43 PM
RESEARCH REVIEWWHAT CURRENT STUDIES MEAN TO EMS
26 JEMS JUNE 2013 www.JEms.com
>> BY DAVID PAGE, MS, NREMT-P & ALEX TREMBLEY, NREMT-P
STAYING OFF THE LEDGEEffectiveness of follow-up postcards to suicidal patients
POWERFUL POSTCARDS
Carter GL, Clover K, Whyte IM, et al. Post-
cards from the EDge: 5-year outcomes from
a randomised controlled trial for hospi-
tal-treated self-poisoning. Br J Psychiatry.
2013;202(5):372–380.
We give kudos to these researchers for this
longitudinal five-year study. In an original
project, this Australian emergency depart-
ment group showed that suicidal patients
who received a personal follow-up postcard
from the staff in the emergency department
(ED) were half as likely to re-attempt suicide
or return to the ED. In this follow-up study,
the authors report on the same population
five years later.
From April 1998 to December 2001, 378
patients (roughly 50% of total) receiving ser-
vices from a regional toxicology service in
New South Wales, Australia, were randomly
selected to receive follow-up postcards. In
addition to standard treatment, postcards were
sent every two months for one year. Their
rates of hospital readmission for self-poison-
ing, psychiatric hospital admission and death
were compared with patients who received
only standard treatment (control group).
Interestingly, a small group of seven
patients (out of 76 who refused the interven-
tion) accounted for 33 total repeat hospital-
izations for self-poisoning. Over a five-year
period, 484 individual events in the control
group required re-admission for self-poison-
ing vs. 252 in the postcard group. Of patients
readmitted, 61% overall required treatment
for a pharmaceutical-only overdose.
The authors report that psychiatric hos-
pital admissions were significantly less in
the postcard group (447 vs. 710 per patient),
resulting in 2,525 fewer hospital-bed days
for patients who simply received a postcard.
This is an interesting, novel and inex-
pensive treatment that requires almost no
face time and minimal follow up. Imagine
what EMS might accomplish if we were to
send follow-up postcards to our patients.
We hope someone reading this column is
inspired to try it, measure it and report it.
STRESS IN EMS
Bentley MA, Crawford JM, Wilkins JR, et
al. An assessment of depression, anxiety,
and stress among nationally certified
EMS professionals. Prehosp Emerg Care.
2013 Feb 15. Epub ahead of print.
It’s no secret that EMS takes a toll on pro-
viders. Previous research has shown the long
hours and repeated exposure to high-stress
situations that have led to an increase in sub-
stance abuse and missed work due to psychi-
atric health issues. In this study, the National
Registry of EMTs (NREMT) set out to
determine the prevalence of depression, anxi-
ety and stress among EMS providers.
EMS professionals who applied for
recertification through the NREMT
in 2009 were given a self-administered
questionnaire along with their recertifi-
cation. The questionnaire asked demo-
graphic and work-related questions, along
with a Depression Anxiety Stress Scale-
21 (DASS-21). This was a cross-sectional
study covering multiple variables.
A total of 23,451 study participants
were included for review. Respondents were
divided into nine groups based on certi-
fication level, the size of community the
respondent works in, service type (fire-
based, municipal, private, hospital-based or
other), years of service, race, gender, edu-
cation level, marital status, general health,
exercise in the past month and whether the
respondent is a smoker.
Of note is that just less than 64% of
respondents are current smokers. In addi-
tion, 6.8% of respondents tested positive
for some form of depression, with para-
medics being more likely to have some
form of depression, at 9.3%, than EMTs, at
4.4%. Anxiety and stress levels were simi-
lar, with 6% of respondents testing posi-
tive for anxiety and 5.9% testing positive
for stress. Respondents indicating that they
were of fair to poor health were most likely
to test positive for some form of depres-
sion or anxiety. The respondents who indi-
cated that they hadn’t exercised in the past
month had the highest percentage for some
sort of stress at 12.10%. Individuals who
had never been married or were separated
from their spouse were more likely to be
depressed (9.42%) than those who were
married (6.03%).
It should come as no surprise that peo-
ple who care for themselves report much
lower levels of depression, stress and anxi-
ety. As the authors state, the design of this
study leaves room for some self-reporting
bias—which is why the statistics seem low.
EMS is a family, from first responders to
f light crews, medics to medical directors.
We all need to keep in mind that there’s
help available.
REDUCED ADMISSIONS FOR ALCOHOL
Hughes NR, Houghton N, Nadeem H,
et al. Salford alcohol assertive outreach
team: A new model for reducing alco-
hol-related admissions. Frontline Gastro-
enter. 2013;4(2):130–134.
Last month, we praised American Medi-
cal Response Colorado Springs for its alter-
nate transport disposition for intoxicated
patients. This month, we praise the National
Hospital Service trust, the national pub-
licly funded healthcare system in the United
PH
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EMS providers deal with a great amount of emo-
tional stress from the traumatic events they’re
exposed to while on the job.
1306JEMS_26 26 5/28/13 1:44 PM
www.jems.com jUNe 2013 JEMS 27
2014 Call for Abstracts
Now Accepting Research Abstracts for Presentation. Submit your abstract or learn more via online at:
www.pcrf.mednet.ucla.edu Category: Clinical, system, management, or personnel
Deadline: October 31st
, 2013 Presented at: EMS Today Conference 2014
Category: Educational
Deadline: March 31st
, 2014
Presented at: NAEMSE Conference 2014
For additional questions contact the Prehospital Care Research Forum at:
Telephone: (310) 312-9315
Email: [email protected]
Choose 15 at www.jems.com/rs
Visit www.pcrfpodcast.org
for audio commentary.
Kingdom. This Salford, Greater Manches-
ter group is taking an active approach in
reducing the number of hospital admissions
due to alcohol-related illness.
The group created an alcohol assertive
outreach team (AAOT) composed of ED
physicians and nurses, as well as psycholo-
gists, alcohol workers and social workers.
The team set out to determine if aggressive
intervention can effectively reduce hospital
admissions by patients frequently admitted
for alcohol related problems. They compared
hospital admission three months prior to and
after interaction with the AAOT.
There were 54 total patients who were
case managed for a total of six months.
There were no exclusion criteria. Although
each patient received highly personalized
care, the most commonly identified cares
included psychological and alcohol sup-
port and access to detoxification and out-
patient facilities, including rides to and
from appointments. Hospital admissions in
the three-month period following interven-
tion by the AAOT were 50 in comparison
to 151 in the three-month period prior to
intervention. ED visits decreased to 146
from 360.
This is exciting news, because two-
thirds of alcohol-related hospital admis-
sions and more than half of ED visits
disappeared with appropriate access to pri-
mary care resources. Like the first study
mentioned earlier, this seems like a great
opportunity for the growing field of com-
munity paramedicine in the U.S.
David Page, MS, NREMT-P, is an educator at Inver Hills Com-
munity College and a paramedic at Allina EMS
in Minneapolis/St. Paul. He’s a member of
the Board of Advisors of the Prehospital Care
Research Forum and the JEMS Editorial Board.
Send him feedback at [email protected].
Alexander L. Trembley, NREMT-P, is
a paramedic for North Memorial Ambu-
lance in Brooklyn Center, Minn., and at
Lakeview Hospital in Stillwater, Minn. Con-
tact him at [email protected].
BOTTOM LINE
What we know: Emergency department
overcrowding is a frequent problem due to
intoxicated patients.
What this study adds: With appropriate
resources, such as community-based para-
medics, emergency department admissions
due to intoxication can drop dramatically.
GLOSSARY
Exclusion criteria: Predetermined vari-
ables set by the study authors that would
preclude a particular piece of data from
being added to the study. For example: an
incomplete survey.
Cross-section: A large group of people
from one particular population, regardless
of multiple variables. A snapshot of that
group which is then divided into groups
based on research criteria.
1306JEMS_27 27 5/28/13 1:44 PM
2020 VISIONLEADERSHIP SERIES
28 JEMS JUNE 2013 www.JEms.com
There’s an old adage that if you’ve seen
one EMS system, you’ve seen one
EMS system. With all the compo-
nents that make up a working EMS system,
from funding and legislation to transport
vehicles and receiving hospitals, it’s no sur-
prise that what works in the U.S. doesn't
necessarily work in other parts of the world.
The similarities (and differences) between
EMS systems across the world is what four
panelists from the U.S. and U.K. discussed in
the latest video installment of the Ferno 2020
Vision program. The International EMS
event brought together London Ambulance
Service (LAS) Director of Service Delivery
Jason Killens, Richmond (Va.) Ambulance
Authority Chief Operating Officer Rob
Lawrence, International Academies of
Emergency Dispatch Chair Jerry Overton
and moderator Chris Montera.
HIGHER DEMAND, LOWER ACUITY
The discussions, which are available on
jems.com/2020 vision, focused on how care
is being paid for around the world and the
different models countries use to deliver
appropriate and affordable care. Overton said
overall EMS demand is changing, with an
increase in calls for non-acute care being seen
from Killens’ system in London to Malaysia
and China: “We’re seeing a definite shift.
Not only are we seeing a growing demand
all over the world, but that demand is not in
acute care cases.”
Customer needs might be similar in rela-
tion to acuity, but specific healthcare needs,
and how systems are responding to meet
those needs, are different. When Montera
asked if growing demand requires EMS to
better manage its customers’ expectations,
Killens suggested that it can be done by
measuring success of outcomes, not response
times, and shifting funding mechanisms into
bundles to incentivize better behavior.
He said that in the U.K., much like the
U.S., EMS is moving toward measuring
the success of how patients are dealt with
instead of how rapidly they’re treated. This is
allowing LAS to move toward becoming the
hub, the initial access point, for healthcare in
London. He sees LAS providing traditional
EMS, but also possibly providing district
nursing facilities, telephone triage and access
to general practitioners. This model includes
having paramedics with additional skills.
The other participants drew parallels to
U.S. programs. These included renaming
the MedStar system in Ft. Worth, Texas,
to MedStar Mobile Healthcare, the abil-
ity of Salt Lake City Fire Department to
get 100 healthcare community leaders to
agree to a new delivery model that would
save downstream healthcare costs and the
public health aspects of the community para-
medicine program in Montera’s Eagle Creek
(Colo.) EMS.
Lawrence, who moved from a rural British
community to run the large Richmond
Ambulance Authority System, added that
this shift has been organic, stemming from
the needs of the rural communities in the
U.K.—much like in the U.S. “From the
need, we created the guy for the role [general
practitioners] and the role evolved, and it
was very successful,” he said. “And it’s kind
of pleasing to see that we’re thinking of that
over here. Because that is the solution.”
SUMMARY
The panelists agreed that prehospital systems
around the world might very well begin
seeing higher demand and lower acuity.
However, the unique aspects of each culture
that create different prehospital concerns also
create different solutions to these needs. U.S.
providers must consider for-profit organiza-
tions when attempting to reduce fragmenta-
tion to gain one lobbying voice, while EMS
providers in some nations, such as in Latin
America and India, must consider integrat-
ing their treatments with local shamens to
gain patient acceptance.
In Franco-German systems, efficient
doctor training has allowed placement of
anesthesiologists on ambulances, while pre-
hospital providers in Vietnam have basic
concerns, such as whether prehospital care
can be sustained in the hospital environment.
The shift in EMS around the world will
depend more on the expectations and demands
of the customers in each nation. It will also
depend on the ability of its EMS leaders and
administrators to come up with solutions that
get customers the most appropriate care in the
most affordable manner. To learn more, go to
www.jems.com/2020vision. JEMS
INTERNATIONAL EMSHow demand is shifting around the world
Pictured is London Ambulance Service Director of
Service Delivery Jason Killens, far left; International
Academies of Emergency Dispatch Chair Jerry
Overton, left of center; Richmond (Va.) Ambulance
Authority Chief Operating Officer Rob Lawrence,
right of center; and moderator Chris Montera.
Time vs. quality: Is it possible for your
system to change customer expectations
from speedy response to slower but more
appropriate care? Share your thoughts with
the EMS 2020 Vision group on LinkedIn:
http://linkedin.EMS2020vision.com.
What’s in a name: If paramedics do differ-
ent things in different countries and their
roles are shifting, should they all still be
called paramedics? Tell us what you think in
the EMS 2020 Vision group on LinkedIn:
http://linkedin.EMS2020vision.com.
2020 Vision Leadership Series sponsored by
www.FernoEMS.comw
This article is sponsored by Ferno’s 2020 Vision series.
1306JEMS_28 28 5/28/13 1:44 PM
ADVANTAGE # 1:
OVER 50%
LESS OXYGEN
CONSUMPTION
Uses less oxygen while delivering
high FiO2.
ADVANTAGE # 2:
BUILT-IN
MANOMETER
& PRESSURE RELIEF VALVE
Verifies delivered CPAP pressure.
ADVANTAGE # 3:
NEBULIZER (IN-LINE CAPABILITY)
Clinicians can administer meds without the need
for mask removal.
ADVANTAGE # 4:
ADVANCED MASK DESIGN
Lightweight contoured mask and nylon headpiece provide a better seal and comfort.
SAFE. SURE.
SUPERIOR CPAP.
www.mercurymed.com
Visit the Mercury Medical Booth #502
at the National Association of EMS Educators,
Omni Shoreham Hotel, Washington, D.C.
August 8 - August 10, 2013
A major leap in product innovation, it takes Emergency Care to a whole new level ... Over 50% less oxygen consumption with high FiO2 delivery and uses standard flowmeters.
With so many advantages, it clearly puts you at an advantage.
®
A REVOLUTION IN EMERGENCY CARE
NEW DESIGN
Choose 16 at www.jems.com/rs
1306JEMS_29 29 5/28/13 1:44 PM
30 JEMS JUNE 2013 www.JEms.com
This year at the EMS Today Conference
and Exhibition, a team of judges
reviewed and evaluated numerous new
products and innovations in EMS
equipment, vehicles and programs on
display by the nearly 300 exhibitors and
released to the EMS market within the
previous eight-month period.
They reviewed products designed to
not only improve your ability to deliver
optimal emergency medical care to sick
and injured patients, but also allow you
to do it safely, more efficiently and with
enhanced comfort for the patient.
The review team rated each of the
new and innovative products on their
originality, functionality, ease of use
and need in the EMS setting.
Their selection of the 25 Hottest
Products at EMS Today 2013 are
presented here in random order for
you to check out. Look for additional
coverage of other products reviewed in
upcoming JEMS Hands On columns.
25 INNOVATIVE NEW PRODUCTS SHOWCASED AT THE 30TH ANNUAL JEMS EMS TODAY CONFERENCE & EXPOSITION
HOT PRODUCTS FROM EMS TODAY 2013
MASIMO
[email protected] an industry leader in pulse oximetry, the iSpO2 allows
you to noninvasively track and trend blood oxygenation
(SpO2), pulse rate, and perfusion index—even during move-
ment and low blood flow to the finger. The iSpO2 device fea-
tures Measure-Through Motion and Low Perfusion Masimo
SET technology for use
with iPhone, iPad or
iPod touch with 30-pin
connector. Note: Not
intended for medi-
cal use. For sports and
aviation use only. The
professional version for
medical use is pending
CE Mark and U.S. FDA
510(k) clearance.
VIVID MEDICAL INC.
VividTrac is a USB-based, single-use
video intubation device with an inte-
grated endotracheal tube (ETT) channel
that requires no stylet, battery, clean-
ing or maintenance. VividTrac uses an
open system, meaning it’s compatible
with Windows, Android, iPad and iPhone displays, and its design is sturdy (stain-
less steel blade), lightweight and low profile (only slightly larger than an airway
device), which allows for simultaneous suction with the free hand. No head tilt is
necessary, making the ETT easy to guide into the airway.
1306JEMS_30 30 5/28/13 1:56 PM
www.jems.com jUNe 2013 JEMS 31
WELDON, A DIVISION OF AKRON [email protected] 8051 Low Profile LED Recessed Dome
Lamp is the newest addition to Weldon’s line of quality
interior dome lights. This ultra-slim LED light features a
low profile design with integrated cooling fins. Protruding
less than 3/16" (4.8 mm) below the headliner, it frees
up valuable headroom space. The cast housing design
improves cooling performance and provides additional
light, excellent lumen stability and longer operational life.
With an incredible 1,600 lumens, it distributes light evenly
and consistently throughout the entire working space.
[email protected] XPS Expandable Patient Stretcher helps to address
growing obesity trends by providing an expanded patient sur-
face area, allowing it to be the all-in-one solution for a variety of
patients and environments. The XPS, designed with patient com-
fort in mind, is adjustable with seven locking positions and includes
a wider mattress than most stretchers, which reduces transfer gap.
INTUBRITE760-727-1900
The VLS 6600 Video Laryngoscope System offers
flexibility, durability and portability at an affordable price.
Developed for use in the field through real-world experiences,
the VLS 6600 video laryngoscope is designed to be familiar,
easy-to-use, reliable and economical while also featuring
state-of-the-art technology.
1306JEMS_31 31 5/28/13 1:56 PM
32 JEMS JUNE 2013 www.JEms.com
HOT PRODUCTS FROM EMS TODAY 2013 MASIMO
[email protected] Mainstream Capnometer is a fully self-contained main-
stream capnometer that requires no routine calibration and virtually no
warm-up time. With rapid measurement of end-tidal CO2 and respiration
rate, EMMA can help providers guide ventilation rates and assess the effec-
tiveness of CPR, allowing them to make adjustments in the course of treat-
ment breath by breath.
MEDLOGIC LLC
[email protected] Infrascanner Model 2000 is a lightweight handheld screening device that uses
near-infrared technology to identify patients with
intracranial bleeding and is able to identify those
who would most benefit from immediate referral
to a CT scan and neurosurgical intervention. It pro-
vides an easy-to-read positive or negative graphic
report and can be used as an extension of routine
neurological examinations.
RTT MOBILE INTERPRETATION
www.rttmobile.comELSA (Enabling Lanugage Services Anywhere) is the first mobile language
interpretation device connecting users to live interpreters in more than 180 languages.
ELSA is a hands-free device measuring 3" x 5". It easily clips to a shirt/jacket, and has the
ability to record calls for future access. ELSA is priced at $395.00 per unit with a $20.00 per month
and $1.50 per minute live interpreter access fee.
1306JEMS_32 32 5/28/13 1:56 PM
Better outcomes
demand exceptional CPR
©2013 Physio-Control, Inc. Redmond, WA
Today’s responsive emergency team is always looking to elevate the
level of care they deliver, and they rely on evidence and data to get there.
TrueCPRTM Coaching Device delivers accurate CPR depth measurement
through proprietary Triaxial Field Induction (TFI) technology.
TrueCPR helps your team optimize their manual CPR performance with the
real-time feedback they need on the most critical resuscitation parameters.
TrueCPR measures actual chest compression depth on hard or soft
surfaces, and in moving vehicles. The result is a clearer picture of
resuscitation performance during compressions, after CPR and during
post-event review to help you improve performance for the future.
Get ready for a more responsive
approach to CPR.
Respond with TrueCPR from Physio-Control
www.physio-control.com
Contact a Physio-Control representative
at 800.442.1142
Choose 17 at www.jems.com/rs
1306JEMS_33 33 5/28/13 1:56 PM
34 JEMS JUNE 2013 www.JEms.com
HOT PRODUCTS FROM EMS TODAY 2013
EVS LTD
www.evsltd.comDesigned by an EMS safety seating product indus-
try leader, the EVS 1769 Seat with Mobil-
ity 1 Tracking System features a seamless
seat with three-point belting system and a track-
ing system (available in a 36" or 48" long track)
that allows access to both equipment and the
patient while belted in the seat. When not in use,
the seat can be detatched from the base to gain
additional space inside the ambulance.
ACTION TRAINING SYSTEMS
800-755-1440info@action-training.comwww.action-training.comInfection control and prevention training is vital to any organization providing EMS.
The three-title Infection Control & Prevention Series provides a system-
atic understanding of bloodborne, airborne and other diseases of concern to emergency
responders. These programs demonstrate how to minimize or prevent the spread of
diseases through proper precautions and infection control practices, and how to mitigate an exposure to communicable
diseases. As a series, it provides a comprehensive framework to help instructors fulfill initial and annual infectious dis-
eases training requirements.
ZOLL MEDICAL CORPORATION
The X Series Monitor/Defibrillator is about half the
size and half the weight of competitor full-featured monitor/
defibrillators. Weighing less than 12 lbs. (6 kg), the X Series is
compact without compromising capability, performance and
display size. This monitor/defibrillator combines the clinically
proven therapeutic capabilities of ZOLL defibrillation, pacing
and CPR assistance with advanced monitoring parameters.
The X Series boasts advanced monitoring and communica-
tion capability required by EMS providers.
1306JEMS_34 34 5/28/13 1:56 PM
www.jems.com jUNe 2013 JEMS 35
Vision to Help Save Lives
VividTrac®Single Use
Video Intubation Device
www.VividMed.com
www.MyViv idMed .com
USB Device
Play Video on Toughbooks and Tablet PCs
Superior Imaging
ET Tube Channel Guided
Use Other Hand to Perform Concurrent Suction
Intubate Patient in Any Position
Record Video of Entire Procedure
Integrates to most ePCR applications
No Stylet Required
No Batteries
No Cleaning
Anti-Fog Camera
Vivid Medical, Inc.
Only $ 68.50(in a box of five)
Place orders at:
oocecedudurere
ppplplicicatatioionsns
Choose 18 at www.jems.com/rs
MERET [email protected] all new M.U.L.E. Pro proves to be the very popular big brother of the world-renowned MERET Omni Pro Series of
response bags. The M.U.L.E. (also known as “the bag on wheels”) has been widely received by EMS providers for mass causalty
incident preparation, medical helicopter/flight crews and other intensive care unit transport teams, and those who respond
to high-rise emergencies. The pull-up handle looks like
a piece of carryon luggage you might take on a plane.
Like other bags from this brand, it can also be worn as
a backpack and continues to be trauma system-ready by
attaching ALS/BLS modules (four standard modules or
two of the new X2 Pro modules).
1306JEMS_35 35 5/28/13 1:56 PM
36 JEMS JUNE 2013 www.JEms.com
HOT PRODUCTS FROM EMS TODAY 2013
PANASONIC CORPORATION OF NORTH AMERICA
[email protected] new Toughpad FZ-G1 Windows 8 Pro Tablet offers a fluid user experi-
ence while providing crucial port connectivity and feature-rich options in a compact size.
Designed for highly mobile field workers, including EMS providers, it's a thin, light and
rugged 10.1" tablet running genuine Windows 8 Pro 64-bit (with an available Windows 7
downgrade option). Powered by a third-generation Intel Core i5vPro processor with a MIL-
STD-810G and all-weather IP65 design, this tablet is a powerful entry from a leader in rug-
ged mobile computing.
M2 INC.
The Pediatric Ratcheting Medical Tourniquet RMT is
a compact, lightwieght and rugged tourniquet designed for pediatric
applications that allows providers to apply precise mechanical pressure
through intuitive "gross motor" operation. The self-locking device makes
a ratcheting sound when activated and application instructions are clearly
printed on the tourniquet, making this device simple and easy to use.
SIERRA NEVADA CORPORATION
In many communities, EMS providers function independently from hos-
pitals to provide care during transit, meaning receiving hospitals can
be unaware of patient status on arrival. Transport Telemedi-
cine is an open architecture system that intends to improve care by
capturing and communicating patient care and condition in real time.
It integrates customer-defined and configurable tablets with inter-
faces to existing communications and medical devices. The patient
care record is customizable and the system supports voice data entry,
intelligent access point and a portal that offers secure global access to
patient status.
1306JEMS_36 36 5/28/13 1:56 PM
www.jems.com jUNe 2013 JEMS 37
Reward your personnel with a subscription to JEMS.
JEMS magazine makes a great appreciation
gift, retention tool or incentive.
Take advantage of
discounts on multiple
subscriptions.
A one-year subscription
to JEMS consists of
twelve issues including
the Buyer’s Guide and
Hot Products issues.
(888) 456-5367 or www. JEMS.com
Choose 19 at www.jems.com/rs
IMPACT INSTRUMENTATION [email protected] Specialty Mounts for either Ferno or Stryker stretchers
hold a 731 Series ventilator as well as two IV solution bags. The mounts conve-
niently fold and lock in place when not in use. Each mount is approximately 20" in
length, weighs less than 2 lbs. and is priced at less than $250.00.
1306JEMS_37 37 5/28/13 1:57 PM
38 JEMS JUNE 2013 www.JEms.com
HOT PRODUCTS FROM EMS TODAY 2013
INOVATIVE PRODUCT SOLUTIONS
The primary aims of the Smart Lift System vest are to reduce back
injuries and provide an efficent patient lifting tool for EMS providers.
Whether you need to safely transfer a patient to a stretcher or pick them
up from the floor, this vest helps to make the task safe for both provider
and patient. The Smart Lift System stores easily for quick access and is
priced at $299.00.
IMPACT INSTRUMENTATION INC.
[email protected] Eagle II MR and EMV+ conditional ventilators are
pressure- and volume-targeted ventilators featuring AC, SIMV
and CPAP NPPV-PPV modes with pressure support and auto-
matic apnea backup. They also feature auto-leak compensa-
tion up to 15 L/min of suplemental flow for the patient when
leaks are present, improving patient comfort. The Eagle II MR
can be used in MRI suites and can be placed as close as 6.6'
(2 m) to the magnet bore. Both ventilators weigh approxi-
mately 9.5 lbs.
1306JEMS_38 38 5/28/13 1:57 PM
www.jems.com jUNe 2013 JEMS 39
BINDER E-Z LIFT
[email protected] you ever arrived on scene and wondered, “How can we pick
this person up off the floor?” Patients don't come with their own
handles. The Binder E-Z LIFT MX/XLT weighs less than 3
lbs. but allows EMS providers a safe way to lift patients who weigh
600+ lbs. Once it is wrapped around the patient, you have 14–18
handles that allow you to lift even the heaviest patient without
compromising lifting posture. It is available in two adjustable sizes
ranging from 34–84".
DIGITAL ALLY INC
The FirstVu HD allows you to record HD video and optional
audio from your own point of view whenever you need it—day
or night—to protect both your job and agency. The system
offers covert mode, can imprint a time stamp on the video and
boasts 32GB of internal memory.
MOBILITYWORKS COMMERCIAL
www.mobilityworkscommercial.comSmartFloor is a patented and modular floor system that
allows easy and quick moving of seats and wheelchair positions
nearly anywhere within a van. The system offers more than
1,000 different seating configurations—from 12 ambulatory to
four wheelchair passengers and nearly anything in between—
creating opportunities for additional income streams in wheel-
chair and traditional transportation. Wheeled seat bases mean
you don’t have to lift and move seats in, out or around the van.
1306JEMS_39 39 5/28/13 1:57 PM
40 JEMS JUNE 2013 www.JEms.com
HOT PRODUCTS FROM EMS TODAY 2013
MERCURY [email protected] Flow-Safe II EZ is a major leap in innovative disposable CPAP systems. It is a combina-
tion CPAP system with an integrated nebulizer that uses only one oxygen source to drive both
the CPAP and nebulizer devices simultaneously. Use it as a CPAP delivery device or turn on the
nebulizer switch to run both devices. It also includes a built-in manometer to verify delivered
CPAP pressure and a deluxe mask designed for easy placement and patient comfort.
WELDON, A DIVISION OF AKRON BRASS800-989-2718
The Seat Belt Warning System is designed to alert the driver when
restraints of occupied seats are properly fastened, keeping personnel safe. It
is designed to meet your safety needs by meeting NFPA 1917 requirements
for your ambulance. Simple and reliable, the Seat Belt Warning System is
based on the patented and proven V-MUX multiplexing technology.
PERSYS MEDICAL888-737-7978
EMS providers now have a comprehensive alternative to static kitting.
CustomMedKits.com is a unique service allowing medics to com-
pletely build customized medical kits online. With the benefits of the Web
site, you canindependently purchase items that that are normally pur-
chased in bulk, receive advice on building kits and watch product reviews.
The control to customize a medical kit is now at your fingertips.
1306JEMS_40 40 5/28/13 1:57 PM
www.jems.com jUNe 2013 JEMS 41
Choose 20 at www.jems.com/rs
RESCUE ESSENTIALS866-711-4843
Based on a rugged assault pack platform,
the RE Aid Bag is a major medical kit
that includes two “throw & go” bags,
enabling two other providers to work on
multiple patients. Throw & go bags are
secured with Velcro, keeping them stable
in the pack while in motion but also allowing for quick removal. The bag contains a
complete TCCC-compliant list of medical supplies designed to allow multiple respond-
ers to render aid to several patients. There are a total of four compartments in this
18" x 10" x 10" rescue bag that weighs 10.5 lbs.
HOT PRODUCT IN THE WORKS?
To have your product considered in next
year’s Hot Products section, you need to
first sign up to be an exhibitor at EMS
Today. All conference exhibitors with prod-
ucts launched between March 10, 2013,
and Feb. 5, 2014, will be invited by email
later this year to submit their product(s)
for consideration. To learn more about
exhibiting at EMS Today, please go to
www.emstoday.com/exhibit.html or contact
an exhibit sales representative:
>> Tracy Thompson (A-L)
Phone: 918-832-9390
Email: [email protected]
>> Sue Ellen Rhine (M-Z)
Phone: 918-831-9786
Email: [email protected]
1306JEMS_41 41 5/28/13 1:57 PM
www.jems.com jUNe 2013 JEMS 43
Innovations offered in ambulance design, safety & efficiency at the 2013 EMS Today Conference & Exposition
The gleaming ambulances that grace the EMS
Today Conference & Exposition show f loor are
always a hit. The ones showcased during this
year’s show in Washington, D.C., were no exception. They
introduced many cool new interior and exterior features
and clever, practical innovations, including increased safety
measures, improved aerodynamics and fuel systems and
better lighting.
We all know that safety inside a moving ambulance
is paramount to EMS providers and their patients. This
includes driving and handling of the vehicle itself, as well
as the construction of the interior of the patient compart-
ment and the position of the patient care seats. It also means
making it easier to load and unload patients from the raised
patient compartment, making cabinets easier to disinfect and
adding lighting to chevrons for better visibility—all innova-
tions you’ll find by flipping through the next pages.
We invite you to study the new innovations offered
by these ambulance manufacturers and see how they can
assist you during your next ambulance purchase in making
your vehicle safer, more efficient and comfortable for your
patients. JEMS
Compiled by
A.J. Heightman,
MPA, EMT-P
1306JEMS_43 43 5/28/13 1:57 PM
44 JEMS JUNE 2013 www.JEms.com
AMERICAN EMERGENCY VEHICLES165 American Way
Jefferson, N.C. 28640
www.aev.com
Phone: 800-374-9749
Email: [email protected]
Randy Barr
Sales Manager
336-982-9824 Ext. 402
Vicki Sansbury
Sales Representative
336-982-9824 Ext. 401
The Demers Diffusion Airflow System is a unique, inte-
grated heating system that projects heat from a specially
designed channel below the medical cabinet that sends the
airflow across the floor and deflects it on the walls in a dif-
fuse fashion for gentle heating; there is no direct air stream
on the occupants.
This AEV configuration offers a special, eas-
ily accessible portable 02 compartment that
features an auto-lock holder.
The head-turning aerodynamic roof design and cab roof
lines of a Demers ambulance aren’t just cool to look at—
they can save up to a cool 14% in fuel costs.
This signature aerodynamic roof design is available on
all Demers ambulances and incorporates LED warning lights
in multiple configurations for enhanced safety, intersection
clearance and housing durability.
Sliding and rotating curbside attendant
seating allows the crew to access and treat
patients while properly restrained.
The ergonomically designed switch panel is custom built and positioned within easy reach
of the driver and passenger-seat crew member in an AEV cab.
Unique and new in the ambulance industry, automotive-style
windows have been engineered by Demers for ambulances.
Located on the side and rear doors of the patient compart-
ment, they are more durable and lighter than other windows.
They also provide increased natural light and visibility. Rear
window de-icing and defroster capability is also offered.
AEV vehicles are not just built to be highly functional; they are designed to be safe for all
occupants. AEV does not believe that crash simulation is enough to effectively prove the
crashworthiness and safety of a vehicle, so the company actually crash tests their vehicles
to validate the structural integrity and occupant protection level of their ambulances in case
of a real-life collision. The crash test was designed to reflect a common, and often deadly,
risk faced by emergency vehicles: the threat of being hit broadside while driving through
an intersection. They were conducted by SAE International engineers at a leading indepen-
dent test facility used by the National Highway Transportation Safety Administration and
automakers for their crash evaluation programs.
1306JEMS_44 44 5/28/13 1:57 PM
www.jems.com jUNe 2013 JEMS 45
DEMERS AMBULANCE28 Richelieu
Beloeil, QC J3G 4N5
Canada
www.demers-ambulances.com
Phone: 800-363-7591
Email: [email protected]
Guillaume Brisson
Demers Marketing Coordinator
450-467-4683 Ext. 222
EXCELLANCE INC.453 Lanier Road
Madison, Ala. 35758
www.excellance.com
Phone: 800-882-9799
Email: [email protected]
Angie Walker
Sales Representative
256-772-9321
This Type IIIL ambulance was built to meet the specific high-performance requirements of the Richmond (Va.) Ambulance
Authority. Built on a Ford E-450 chassis with 14,050 lbs. gross vehicle weight rating and a 158" wheelbase, the ambulance is
equipped with front and rear anti-sway bars, all-wheel disc brakes and a 55-gallon fuel capacity.
An Excellance Golden Eagle Type I Extra Heavy Duty (EHD)
ambulance built for Phoebe Putney Memorial Hospital in
Albany, Ga. It features an extremely durable, all-welded alu-
minum body and interior cabinetry which increases opera-
tional efficiency. It sits on an agile Ford F-650 heavy duty
chassis that uses proven long-life engine/transmission com-
binations along with an oversized brake system that will
withstand the everyday stresses of emergency response. It
also features a turning radius that is less than a Type III unit.
The interior of the Richmond Ambulance Authority ambu-
lance features multiple crew safety innovations such as pad-
ded cabinets, corners and bulkhead areas.
A Type I EHD Excellance built for Columbus Regional Medical
Center in Columbus, Ga., on a 2013 International 4300 chas-
sis. The EHD is available with a “pass-through” window or
full “walk-through“ option. Module lengths can vary from
162-175" with 69-75" of headroom and endless choices of
interior and exterior storage compartments.
A special hydraulic ramp was built into the rear step area of
the Columbus Regional Medical Center unit by Excellance to
facilitate lifting of patients and equipment.
All Demers ambulances have cabinetry constructed of light-
weight materials combining Demers-exclusive “Interlock”
rounded aluminum extrusion with modular fiberglass cabi-
net inserts, shatterproof Lexan doors and aluminum panels.
The result: a safer work environment, a long-lasting interior,
better fuel economy and optimal resale value.
Powered by the Demers Electrical Management System, the
Demers ECOSMART System creates an intelligent, super-
efficient anti-idling engine—an innovation that delivers
automatic fuel savings of $1,500–$2,000 a year, or a reduction
in fuel consumption of up to 40% while idling. That’s almost
4.5 tons fewer CO2 emissions per vehicle/year.
1306JEMS_45 45 5/28/13 1:57 PM
46 JEMS JUNE 2013 www.JEms.com
FRAZER LTD.PO Box 5000
Bellaire, Texas 77402
www.frazerbilt.com
Phone: 888-372-9371
Email: [email protected]
Cathy Perez
Sales Representative
713-772-5511
This Grand Prairie (Texas) Fire Department’s Type I ambulance built by Frazer is equipped with an inside/outside (I/O) radio
compartment that enables easy access to radio equipment and battery chargers from any location. The custom I/O compart-
ments also offer easy access to important gear.
Horton builds ambulances on the chassis of choice for its customers and builds in features
emphasizing safety and patient comfort throughout the manufacturing process.
Austin-Travis County's (Texas) Urban Command Vehicle (UCV) is a custom-built squad unit used to transport medical equipment. The UCV has a
slide-out tray specifically designed to house a large Coleman brand cooler and has a 300-lb. weight capacity.
The custom cabinet configurations and interior storage
areas were designed from the ground up, providing crews
with quick access to all of their tools.
This Northport (Ala.) Fire Rescue vehicle allows crews to get
the right gear to their patients quickly via external storage
compartments with roll-top doors and pull-out trays.
Mounted on a new M2 Freightliner chassis, this Tuscaloosa
(Ala.) Fire Rescue unit features multiple custom features,
from roll-top doors to multiple scene light, and an extra-
large ALS compartment complete with slide-out trays.
The Horton crash barrier system offers a safe
seating position with a forward cabinet while
still allowing space for the second patient
that needs to be placed on a long board or
other stretcher.
The new chevron lighting from Horton
improves visibility while maintaining the
chevron look for safety.
1306JEMS_46 46 5/28/13 1:57 PM
www.jems.com jUNe 2013 JEMS 47
MARQUE AMBULANCE INC.2737 N. Forsyth Road
Winter Park, Fla. 32792
www.marqueambulance.com
Phone: 888-999-2175
Email: [email protected]
Michelle Yoder
Sales Representative
574-970-6799
HORTON EMERGENCY VEHICLES3800 McDowell Road
Grove City, Ohio 43123
www.hortonambulance.com
Phone: 800-282-5113
Email: [email protected]
Dave Cole
Sales Representative
856-768-2162
A forward-facing independent work station positioned where the traditional squad bench
used to be is safer for the attendant and more efficient for the delivery of patient care.
Lexington (Va.) Fire Department’s 148 Commando Type I ambulance is built on a 2012 Ford F-450 SD XLT 4x4 chassis.
The Horton Occupant Protection System offers air bag pro-
tection for the EMS provider.
This custom work station offered by Marque Ambulance allows the person in the primary
attendant seat to also swivel forward to access key equipment and connections without hav-
ing to leave the safety of their seat.
CoolTech II is the latest in cooling innovation. This new
ambulance roof-top system will provide 100,000 btu of
cooling capacity using a four fan smart condenser. This is
cool and smart. It also includes a solar charging panel to help
keep your batteries fully charged.
1306JEMS_47 47 5/28/13 1:58 PM
48 JEMS JUNE 2013 www.JEms.com
MEDIX SPECIALTY VEHICLES3008 Mobile Drive
Elkhart, Ind. 46514
www.medixambulance.com
Phone: 574-266-0911
Email: [email protected]
David Wood
Richard Hamilton
MCCOY MILLER2737 N. Forsyth Road
Winter Park, Fla. 32792
800-326-2062
www.mccoymiller.com
Phone: 800-326-2062
Email: [email protected]
A pedastal-mounted, chrome Eagle Sirens “Screaming Eagle” motor siren mounted on a custom-made McCoy Miller extended bumper is an ideal siren for helping clear traffic in addition to
an electronic siren.
McCoy Miller offers multiple interior configurations and custom exterior options.
The patient compartments in Medix Specialty Vehicles are
custom crafted to the customer’s needs, with cabinets and
equipment positioned within safe and easy reach of the per-
sonnel secured in their attendant seat locations.
Medix’s well-lit interior includes 11 standard dome lights.
Each row's brightness setting (HI/LO) is independently con-
trolled to provide optimum patient compartment lighting.
1306JEMS_48 48 5/28/13 1:58 PM
www.jems.com jUNe 2013 JEMS 49
MILLER COACH COMPANY1744 West College Street
Springfield, Mo. 65806
www.millercoach.com
Phone: 800-824-9643
Email: [email protected]
David A. Duncan
General Manager
The patient access side of the custom, space-efficient “Medic Workstation” was built by
Miller Coach in a Sprinter patient compartment.
This special graphic wrap was custom made for a custom Sprinter chassis and interior built
by Miller Coach for Choice Care Ambulance in Dublin, Ga.
The interior patient compartment cabinets feature a spe-
cial location for a crash stable defibrillator mount that is
installed for safe and easy access and viewing.
Standard Medix curbside wall configuration with optional
EVS-V4 seating on the squad bench.
The Medix standard street side wall includes angled cabinets
on each side of the attendant seat to eliminate overhead
obstructions for a safer working environment. A tilt-out
sharps and waste cabinet below the rear monitor shelf, suc-
tion and O2 outlets are positioned for easy access.
Exterior compartments
include a rubberized
polyurethane finish
over smooth aluminum,
one piece CNC cut and
formed exterior doors
with full perimeter
seal, full stainless seal
plates. The O2 cylinder
rack is fully adjustable
for H/M cylinder mount-
ing. The compartment is
also designed to facili-
tate installation of a Zico
hydraulic lift.
The curbside view of the “Medic Workstation” built inside
the Sprinter by Miller Coach.
1306JEMS_49 49 5/28/13 1:58 PM
50 JEMS JUNE 2013 www.JEms.com
PL CUSTOM2201 Atlantic Ave.
Manasquan, N.J. 08736
www.plcustom.com
Phone: 732-223-1411
Email: [email protected]
Chad Newsome
Sales Representative
732-223-1411
PL Custom offers a wide range of custom paint and graphic designs, like this wavy American
flag, and can match any existing paint color and lettering design.
Engineered with innovation and advanced technology, this
Type III E450 158" unit—as well as each Road Rescue
ambulance vehicle—is designed for outstanding perfor-
mance and reliability.
PL Custom offers an optional sliding side-entry door for situations when you need to work in confined spaces with limited
clearance. Lowered side skirts allow for easier access into the side entrance with an intermediate step. Single-handed opera-
tion for both interior and exterior handles makes opening and closing this door a breeze.
PL Custom’s proactive ambulance interiors are designed for “full time” safety for the patient
and the attendants. The special “Medic in Mind” layout features easy access to key equip-
ment and function switches from a seated position on either side of the vehicle, allowing the
attendant to remain seated. The interior of PL Custom ambulances can be custom designed
to incorporate your department’s special layout needs.
Road Rescue’s all-aluminum interior protects against blood-
borne pathogens while providing a whisper-quiet envi-
ronment that virtually eliminates outside noises, allowing
personnel to assess their patients’ vital signs without distrac-
tions. Cabinet restocking is also made easy in the Road Rescue
interior because the entire face frame is hinged to open and
stay in the up position via gas shocks on each side.
The upper-band area of the Road Rescue patient compart-
ment is covered in commercial-grade, heavy-duty vinyl for
safety. The mid-area is covered in an antimicrobial ther-
moplastic material that meets disinfection requirements.
In addition, all grab bars are made from antimicrobial 1 ¼"
stainless steel.
1306JEMS_50 50 5/28/13 1:58 PM
www.jems.com jUNe 2013 JEMS 51
WHEELED COACH INDUSTRIES2737 North Forsyth Road
Winter Park, Fla. 32792
www.wheeledcoach.com
Phone: 800-422-8206
Email: [email protected]
Paul Holzapfel
Sales Representative
ROAD RESCUE2737 North Forsyth Road
Winter Park, Fla. 32792
www.roadrescue.com
Phone: 877-813-9226
Email: [email protected]
Greg Gleason
Sales Representative
The Wheeled Coach SafePASS system features emergency “direct release” door tabs that enable all patient compartment
doors to be opened in the event an accident has bent the door lock control rod. Other locking mechanisms can jam, making
patient unloading and crew exit difficult and possibly dangerous.
This Type I F-350 4x4 ambulance is an example of Wheeled Coach’s commitment to safety
and innovation, which has made them one of only two U.S. ambulance manufacturers with
ISO 9001:2008 certification.
“Be Seen, Be Cool” is the way Wheeled Coach introduces its latest innovation, the multi-
purpose Cool-Bar: an external air condenser mounted on the front of the ambulance box
that doubles as a multi-angle warning light platform that can be spec’d and configured
in multiple ways by the purchasing agency. The Wheeled Coach Cool-Bar increases the
air conditioning capacity of the ambulance by 30% (30% greater BTU capacity and 30%
greater condensing capacity) and increases the overall airflow by 50%.
Check out Road Rescue’s innovative Class1 Multiplex Touch Screen Display.
1306JEMS_51 51 5/28/13 1:58 PM
JOIN TODAY
TRAINING & LEADERSHIP
FOR TODAY’S CHIEFS AND
TOMORROW’S CHIEF OFFICERS
www.iafc.org/join
Dues start at just $95 for Company Of cers and $189 for Chiefs.
Deputy Chief Laura Baker,
Tucson, AZ
– MEMBER SINCE 2010
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Milpitas, CA
– MEMBER SINCE 2005
Division Chief Alan Rufer,
Monroe, WI
– MEMBER SINCE 2001
Lieutenant Randy Hanifen,
West Chester, OH
– MEMBER SINCE 2010
Choose 21 at www.jems.com/rs
1306JEMS_52 52 5/28/13 1:58 PM
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JEMS.com WebsiteYour online connection to the EMS world, JEMS.com gives you information on:• Products• Jobs• Patient Care• Training• Technology
For more information on the JEMS Family of EMS Products: www.JEMS.com
• PEARS: Helping You Help Kids• Lessons From Our Battlef elds: New Approaches to Shock Management• Securing the Airway: The Expanding Role of Extraglottic Devices• Maximizing Your Revenue• Advances in Assisted Ventilation: Where have we come from
& where are we going?• Update on 360-Degree Data: How to collect better
data in the f eld • Slaying the Immobilization Dragon
The JEMS Family of Products:
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Archived Webcasts
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1306JEMS_53 53 5/28/13 1:58 PM
54 JEMS JUNE 2013 www.JEms.com
Albuquerque Fire Department Medical Director
Andrew Harrell, MD, helps a patient out of her home
during a 9-1-1 call.
BY SCOTT OGLESBEE, BA, CCEMT-P
University of New Mexico’s EMS Medical
Direction Consortium encourages
collaboration & shared responsibility
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Having a physician on scene not only provides a second set of eyes, but also helps reassure prehospital provid-
ers they’re doing what’s right for the patient.
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associate medical directors for all of the
agencies within the Consortium.
“The Consortium is much like a group
of obstetricians,” says Consortium Director
Darren Braude, MD, EMT-P. “Each woman
has her own obstetrician for routine appoint-
ments, but it is understood that any member
of the group may deliver the baby if they are
on call. None of us would be able to pro-
vide 24-7 availability to our agencies, but as
a group we can. So now we can be a real part
of the system, not just someone who attends
meetings, writes protocols and signs forms.”
Medical direction in New Mexico
requires an atypical approach to wisely man-
age scarce resources. Consortium doctors
wear a number of hats, providing tactical
physician support for SWAT field medi-
cine, remote wilderness (or austere) medi-
cal response and medical direction for fire/
rescue and EMS services around the state.
Braude believes the major benefit of oper-
ating in the field is the systems-level obser-
vations physicians make while listening to
the radio, responding to calls and talking
with providers. “We have amazing EMTs
and medics in our system. If they need us for
patient care on more than 1% of calls, then
we have done something horribly wrong as
educators and medical directors,” he explains.
“But if you are trying to run an EMS system
from an office, you never really appreciate the
problems that are ripe for fixing.”
Some advanced procedures provided
New Mexico, also called the Land of
Enchantment, is known for its hot
chilies, adobe buildings and pink
sunsets. It has a long and fascinating mul-
ticultural history. It is the fifth-largest state
by land area and consists of a small popula-
tion of only about 2 million people. Out-
door activities stretch throughout its rugged
country from the Rocky Mountains to the
Chihuahua Desert.
Unfortunately, residents of this frontier
paradise have a plethora of health-related
problems. Statistically, its children and most
adults have the highest rates of uninten-
tional injury deaths in the country, due to
causes such as drunken driving, accidental
firearm discharge, fire and drowning.1
According to the Centers for Disease
Control, the homicide rate in New Mexico
has been the third highest in the U.S. for
more than 10 years.1 For the past 20 years,
the overdose rate has been among the high-
est in the nation.2 Compounding the prob-
lem, New Mexico is also considered to be
one of the three most medically underserved
states for adult men and women.3
Because of these factors, a group of
emergency physicians at the University of
New Mexico (UNM) Hospital in Albu-
querque—the state’s only Level 1 Trauma
Center—has developed a new collaborative
approach to EMS medical direction. Keep-
ing New Mexico’s epidemiology in mind,
the approach is applicable to both rural and
urban areas, and it may be a more effective
service model than was used in the past. The
EMS physicians involved in this new EMS
Consortium are both medical directors and
field responders—a model that is consistent
with the new medical subspecialty of EMS
approved by the American Council of Grad-
uate Medical Education in 2011.
SHARING RESOURCES
The UNM EMS Consortium brings EMS
fellows and EMS medical directors, who
had previously worked independently at
multiple agencies, together into one col-
lective group. Fellows are physicians who
choose to spend an extra year in specialty
training after completing a three- to four-
year residency in emergency medicine.
Each agency keeps one physician assigned
as a primary medical director, but the other
physicians are contractually considered
by the physicians include field ultrasound,
rapid sequence intubation for advanced air-
way placement and whole blood adminis-
tration. A cooperative agreement between
the Consortium and the blood bank at
UNM Hospital resulted in the Field Blood
Extraordinary Use Protocol. A total of eight
units of blood, two units of type O positive
and six units of type O negative are available
for a Consortium physician to pick up on a
moment’s notice. The protocol is used sev-
eral times a year, mostly for tactical call-outs
in remote areas or mountain rescue cases.
REMOTE RESCUE
The Shield is a prominent rock formation
in the Sandia Mountains overlooking Albu-
querque. The Sandia Mountains are known
internationally for challenging mountain-
eering. An extremely difficult route up the
Shield is called Rainbow Dancer, named
after the arches along the face of the rock
climb. However, it’s a rescuer’s nightmare
because technical rescues are logistically dif-
ficult to coordinate.
On Sept. 23, 2011, a climber fell more
than 60 feet during a technical rock climb.
The 26-year-old female suffered a bilateral
pneumothorax, open elbow fracture, and
more than three hours of exposure before
extrication was possible. Several agencies
participated in her rescue, including Berna-
lillo County Fire Department, Albuquer-
que Medical Rescue Council, New Mexico
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56 JEMS JUNE 2013 www.JEms.com
State Police and the New Mexico National
Guard, whose members used a Black Hawk
helicopter for the actual extrication.
The second leg of the National Guard
helicopter rescue consisted of picking up
Consortium physician Andrew Harrell,
MD, and an Albuquerque Mountain Res-
cue Council physician’s assistant for an
advanced-care intercept. During flight, the
patient’s pulse oxymetry had dropped to
70%, heart rate increased to 160 beats per
minute and her shortness of breath was
worsening. The providers initiated a blood
transfusion for hypovolemic shock, started
antibiotics due to soft tissue injuries and
performed bilateral pleural decompression
because of a worsening tension pneumotho-
rax. On arrival at University of New Mexico
Hospital Emergency Department (ED), her
pulse oximetry was greater than 90% and
heart rate had decreased to 110 beats per
minute. The patient is reported to have made
a full recovery.
Justin Spain, EMT-P, an Albuquerque Fire
Department paramedic/firefighter and an avid
mountaineer, was one of the providers who
responded to the Rainbow Dancer Rescue. He
is also a member of Albuquerque Mountain
Rescue Council, the volunteer search and res-
cue organization that participated in the actual
rescue. Spain helped stabilize, initiate IV flu-
ids, package and perform a technical lower-
ing to the helicopter hoist spot. He thinks the
Consortium in New Mexico has improved the
overall capability of first responders, and says
he’s “glad to see the Consortium is growing
and going in the direction it is.”
VALUABLE EXPERIENCE
Physicians who complete their residency in
emergency medicine are eligible to apply for
a one-year fellowship in EMS at UNM. The
fellows, numbering one to two yearly, are fun-
damental to the program. Responsibilities
include over-the-phone or radio consultations,
field response, on-site continuing education,
paramedic and EMT training, quality assur-
ance and engaging in prehospital research.
Harrell completed the EMS fellowship at
UNM and is currently medical director for
the Albuquerque Fire Department (AFD).
Harrell believes EMS fellows are the back-
bone of the Consortium and gain invaluable
hands-on experience during the one-year
program. “We are closing the loop. Instead
of a medic calling and asking me, ‘Can I do
this?’ I can be operational and on scene with
them,” Harrell says. “Then I offer feedback,
gather and disseminate patient follow-up
and take my observations back to the office
to make the system better.”
Some of the difficult situations Con-
sortium doctors have encountered are ter-
mination of a traumatic arrest of a law
enforcement officer in the field, reduction
of a shoulder dislocation at 10,000 feet in
the Sandia Mountains and coordination of
a complicated refusal of care. Ultimately, the
end-of-life wishes of a hospice patient were
respected after 9-1-1 was activated. One of
the most stressful cases involved a toddler.
PEDIATRIC AIRWAY OBSTRUCTION
A two-tiered response is standard in Albu-
querque, a city with a population of 552,804.4
AFD delivers first response and Albuquer-
que Ambulance Service (AAS) provides a
transporting paramedic unit to more than
100,000 EMS calls per year.5
On July 14, 2012, Braude was just clear-
ing from a rollover when the public-safety
answering point (PSAP) dispatched units to
a 14-month-old who was choking and not
breathing. The PSAP coded the call 9E1,
cardiac or respiratory arrest, with life status
questionable. A rescue, engine and ambulance
EMS Fellows Jenna White, MD, and Chelsea White, MD, NREMT-P, help the crews gather patient information
from a family member.
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EMS physician response is a chance to debrief with providers, share education in the context of the call and
occasionally intervene with physician-level procedures.
PH
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CONSORTIUM OF CARE
>> CONTINUED FROM PAGE 55
1306JEMS_56 56 5/28/13 1:59 PM
www.jems.com jUNe 2013 JEMS 57
Choose 23 at www.jems.com/rs
arrived to the home in Northwest Albuquer-
que within a matter of minutes.
AFD paramedics Reed Page, EMT-P,
and Melvin Martinez, NREMT-P, removed
a foreign object with direct laryngoscopy and
Magill forceps. When Braude arrived, the
boy was sitting up in a paramedic’s arms, alert
and grabbing at the non-rebreather mask on
his face. The providers all thought the prob-
lem was solved, but Braude still accompanied
AAS and AFD crews to the closest com-
munity ED. While in the ED, the patient
deteriorated two or three more times again
(it turned out there was a secondary obstruc-
tion), but the providers were able to establish
a marginal airway with basic maneuvers.
Braude and the attending physician, Cathy
Drake, MD, agreed that sedating or para-
lyzing the child might be disastrous and the
patient needed to be in the operating room
(OR) with a pediatric ear, nose and throat
(ENT) doctor, but no such resources were at
this facility. Braude was able to rapidly arrange
for a direct admission to the OR at UNM
Hospital with no further questions asked. The
patient was transported by the AAS critical
care transport (CCT) team, with critical care
paramedics Mike Nuanez, CCEMT-P, and
David Chapek, CCEMT-P, as well as Braude,
attending to the patient after spending less
than 15 minutes in the ED.
The team remained calm as the patient
obstructed several more times during the CCT
transfer. At one point he became apneic and
bradycardic so they attempted direct laryngos-
copy again, but the patient vomited, obstructing
the view. The patient relaxed and oxygen satu-
ration quickly improved with optimal bag-
valve mask ventilation. They bagged the patient
all the way into the OR and handed the patient
off to the awaiting pediatric ENT surgeon and
anesthesiologist with an oxygen saturation of
100%. A foreign object was removed from his
vocal cords and the patient was discharged,
neurologically intact, several days later.
CONTINUING EVOLUTION
Medical director of AAS, Philip Froman,
MD, has firsthand knowledge of the improve-
ment the Consortium has brought to EMS
medical direction. In addition to AAS, Fro-
man directs several other EMS and fire/rescue
services around New Mexico including San-
doval County Fire Department. “Our EMS
system has evolved dramatically over the last
20 years that I have been providing medi-
cal direction,” says Froman. “The advent and
expansion of the EMS Consortium was the
appropriate next step in providing excellent
and advanced care to the population of Ber-
nalillo County.”
Consortium physicians plan on tak-
ing 12-hour shifts on a rotational basis to
improve coverage beginning in July. This
schedule change will allow the group of
doctors to be consistently available on the
radio, rather than being on-call or monitor-
ing intermittent radio traffic. JEMS
Scott Oglesbee, BA, CCEMT-P, is an author, researcher
and critical care paramedic at Albuquerque Ambu-
lance in Albuquerque, N.M. His areas of interest include
antiemetics, ambulance response times and occupational
medicine, and he is currently pursuing a Master’s degree
in public health.
REFERENCES
1. Web-based injury statistics query and reporting system
(WISQARS). (2013). In Centers for Disease Control and Pre-
vention. Retrieved March 17, 2013, from www.cdc.gov/
ncipc/wisqars.
2. Whorton, B. Sales of prescription opioids and drug over-
dose deaths in New Mexico. New Mexico Epidemiology.
2012;2012(7):1–4.
3. Making the grade on women’s health: A national and state-
by-state report card. (2010). In National Women’s Law
Center. Retrieved Jan. 28, 2013, from http://hrc.nwlc.org/
status-indicators/people-medically-underserved-areas.
4. Table 3. Annual estimates of the resident population for incor-
porated places in New Mexico: April 1, 2010 to July 1, 2011.
(2011). In U.S. Census Bureau. Retrieved March 18, 2013,
from www.census.gov/popest/data/cities/totals/2011/
SUB-EST2011-3.html.
5. Albuquerque ambulance service: About us. (2013). In
Presbyterian Healthcare Services. Retrieved March 18, 2013,
from www.phs.org/PHS/programs/Ambulance/AboutUs/
index.htm.
On board a Black Hawk helicopter en route to UNM Hospital, Dr. Harrell prepares to transfuse blood during
extrication of a patient who fell while rock climbing.
Video from
the ‘Rainbow
Dancer Rescue’
taken on board
the helicopter.
SC
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EN
SH
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TE
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58 JEMS JUNE 2013 www.JEms.com
It’s become a mantra: “Is the scene safe?
BSI in place?” Once the answer is deter-
mined, a course of action follows. Either
we go about our business with an assumption
that we can't be hurt, or we vacate the scene.
This is easy to test and has become embedded
in the culture of EMS. It’s also dead wrong
and presents the possibility of providers (of
any level) getting hurt because they aren't suf-
ficiently aware, or sufficiently trained, to deal
with the hazards they may encounter.
The truth is that safety isn't a binary con-
cept. It's neither present nor absent. It's rela-
tive, and continually evolves throughout the
course of a patient encounter. EMS providers
need to be re-trained and re-oriented to stop
thinking that a safety evaluation occurs only
once at the beginning of the call, and to start
seeing safety as something that needs to be
continually re-evaluated and addressed. They
also need to be trained to evaluate and address
evolving threats, and to implement processes
and techniques to mitigate those threats at
each level of escalation.
Consider the following scenario: EMS-32
is dispatched to a call for respiratory distress
in a private residence. The unit arrives with no
indication of difficulty at the scene (“the scene
is safe”). The paramedics begin their routine
of the 68-year-old woman—assessment, treat-
ment and decisions about transportation. The
patient gets some relief from her albuterol
treatment, and a discussion ensues between
the patient and the paramedic about whether
the patient wants to go to the hospital. As
often occurs, the conversation becomes ani-
mated. Nothing unusual so far, right?
Suddenly, the patient’s son, who was sleep-
ing in a bedroom by the front door, awakens,
appears in the doorway with a handgun hol-
stered on his hip, and tells the medics, “You
stop disrespecting my mother.” What now?
In a heartbeat, the scene has turned from
benign to... what? Is it now dangerous?
Maybe. It’s surely more dangerous than it was
an instant before. Is it life-threatening? The
actions of the paramedics in the next few sec-
onds may make that determination. A proper
application of verbal de-escalation techniques
may cause the son to close the bedroom door
and mind his own business while the medics
wrap up their activities. An improper response
may cause the handgun to move from the
holster to the hand—worsening the situation.
Change the scenario a bit. The son is loud
and threatening but has no weapon. Or per-
haps the weapon is a knife. In either case, he’s
standing between us and the door, and the
patient still needs care. What do we do? In any
of these situations, our training teaches little
or nothing. Even much of what is “discussed”
is anecdotal or even just plain dangerous.
Our focus needs to change. Safety should
be an ongoing concept for providers, which is
addressed realistically in any scenario. Every
EMT and paramedic needs to understand
that the relative safety of a scene is something
that is always changing, that just like the con-
dition of the patient, it must be continually re-
assessed and dealt with appropriately.
To accomplish this, some fundamental
changes need to occur, both in pre-service
education and in daily practice.
First, the concept of “safe” vs. “unsafe”
scenes has to be eliminated. All scenes are rel-
atively safe along a continuum ranging from
“not very safe” to “quite safe right now.”
Second, providers need to develop a new
set of competencies involving awareness of
scene safety and ability to respond to con-
dition changes at all types of scenes. These
should include, as a minimum, the following
competencies:
>> Understanding the difference between
patient and attacker;
>> Understanding the limits of the concept
of abandonment when applied to a situ-
ation where a provider is in danger;
>> Understanding that violence is not
just “part of the job” and knowing the
cultural implications of violence (zero
tolerance of violence against paramed-
ics, and zero tolerance of other para-
medics teasing or harassing colleagues
who have been victims of violence);
>> Understanding the mental and
BY SKIP KIRKWOOD, MS, JD, NREMT-P, EFO, CEMSO
1306JEMS_58 58 5/28/13 1:59 PM
www.jems.com jUNe 2013 JEMS 59
psychological issues involved in seeing
and dealing with violence.
>> Customer service skills so patients, fam-
ilies and bystanders perceive paramedics
as helpful, non-threatening responders;
>> Verbal conflict management and de-
escalation skills;
>> Escaping physical encounters (e.g.,
blocking, parrying, releasing choke holds
and establishing distance);
>> Self-defense skills, in case you can’t
escape from an aggressor, and
>> Documentation of encounters involving
violence, and preparing for the legal process
that will follow an assault on a paramedic.
Along with competencies, we need to have a
realistic discussion about the need for personal
protective equipment. Some agencies are com-
pelled to issue soft body armor to their person-
nel. Some allow but do not require the wearing
of PPE, and some feel this is unnecessary. Pro-
viders are concerned about the violence they
face on a regular basis, and part of that solution
is appropriate protective equipment.
So where do we begin? I think the first
starting point is easy; We do away with the
“Is the scene safe?” mantra at the beginning
of each patient encounter and recognize that
scene safety is a relative and fluid concept. Per-
haps we should initially decide, “Should we
go in?” This would provide for an assessment
of the scene based on what we know at the
time we approach or arrive on the scene, and
it acknowledges that no scene is completely
and forever safe.
Once that decision is made, we need to
teach providers to keep their "head on a
swivel.” This means they should maintain
situational awareness, continually re-assess
the safety of their environment and maintain
situational awareness throughout any patient
encounter. A scene that might have seemed
safe, or might once have been safe, is likely to
change. Our safety depends on our awareness
and responses to those changes.
Unfortunately, violence against EMS pro-
viders appears to be on the rise. (Either that, or
it has been an ongoing issue but we are hear-
ing more about it because of improved com-
munication capabilities). In either case, our
community isn't well-prepared to avoid, pre-
vent, respond to or survive hostile encounters.
Some paramedics, through lucky experience,
may have learned these skills in the school of
hard knocks (not the best place for develop-
ment of personal survival skills). We need, as
a community, to start taking this issue seri-
ously, We should demand coverage of these
important topics in pre-service education,
continuing education and operational support.
Let’s get “scene safe? BSI?” out of our vocabu-
lary and start learning how to keep ourselves
safe. Let’s make going home at the end of our
shifts uninjured a real priority.
Be safe. Train. Keep your head on a swivel,
and stay alive! JEMS
Skip Kirkwood, MS, JD, NREMT-P, EFO,
CEMSO, is the Chief of the Wake County (N.C.)
EMS Division and the immediate past presi-
dent of the National EMS Management Asso-
ciation (NEMSMA). He can be reached at skip.
What you had to say about the “scene safe” mantra on the JEMS Facebook page
First we need to change everybody’s thoughts about
a scene. It has to start at the top. Management needs
to write SOP/SOGs about us using self-defense tactics
to defend ourselves, instead of firing us [for defending
ourselves against attackers]. Then the people working
the street have to change how we think while respond-
ing on scene and en route to the hospital. We have to
know when to go, think tactically and have the mindset
that everyone on that scene can kill you. Know how to
talk to people, know your body language, know others.
Maybe we need to form an association to have
these things added to the EMT/EMT-P curriculum and
also to be mandated in CEU training. – Tom S.
Having your partner's back means eyes everywhere.
Even granma gets freaky with a weapon. – Laura H.
Yes, it is time to do away with the scene safety mantra,
and teach street survival. We need guns, while we're at
it. These situations are no time to repeat some bogus
philosophical nonsense about doing no harm and the
like. Your life is in danger. Act, or be acted upon. It's not
ideal, but it's real. – B. Dean B.
Dispatcher errors happen all the time. We were sent to
a male with a cut leg, but they didn't bother to tell us
his passenger beat the cops up and they had him at
gun point under arrest. –Brett C.
“Unresponsive in the snow” became a female with a
shotgun holding us hostage for a while. – Steve H.
Almost 20 years ago, fresh out of school and roll-
ing in south L.A, I was called to a "patient down,
UNK cause" in front of a liquor store. Upon arrival
the victim was supine, motionless and surrounded
by several people. PD was enroute and it seemed
like a medical call upon first glance. What could go
wrong? When we started the work up and tried to
get a response to verbal commands, the victim rolled
over and we saw he was covered in blood. Turns out
he's a stabbing victim and the suspect was standing
in the crowd. When the victim started to moan the
suspect jumped forward and began attempting to
knife him further. Thankfully PD was on scene just
as that occurred. Learned a HUGE lesson that night.
– Helen G.
1306JEMS_59 59 5/28/13 1:59 PM
60 JEMS JUNE 2013 www.JEms.com
The concepts behind high-reliability organizations
(HROs) were first identified when researchers studied
the crew of the USS Carl Vinson. The ship’s operators iden-
tified and solved problems before they became significant.
EMS & HIGH-
RELIABILITY ORGANIZINGAchieving safety & reliability in the dynamic, high-risk environment
PH
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BY DAVED VAN STRALEN, MD, FAAP & THOMAS A. MERCER, RADM, USN, RET.
1306JEMS_60 60 5/28/13 1:59 PM
www.jems.com jUNe 2013 JEMS 61
Systems today, particularly those like
EMS that are tightly linked between
human actions and technology, have
become complex to the level that “acci-
dents” are not only predictable, but they can
be expected. Charles Perrow described this
as Normal Accident Theory after he stud-
ied the Three Mile Island nuclear power
plant incident.1
A few years later, academics from the
University of California, Berkeley were
studying the notion that “accidents” in high-
risk environments can be considered “nor-
mal.” They came across the aircraft carrier
USS Carl Vinson. Thomas A. Mercer, who
was the carrier’s captain, invited the Berke-
ley researchers to study his crew for methods
to improve their performance.
According to a personal communication
by Karlene Roberts, PhD, the Berkeley
team found an efficient team of operators
who solved problems before they became
significant; the team was unable to identify
areas requiring significant improvement.
Therefore, they codified the methods as
indicative of a high-reliability organization
(HRO) and found an exception to the idea
that it was normal for consequential errors
to occur in high-risk environ-
ments.2 From their studies, they
codified the ship as an HRO
due to its organization.
HROs are defined as orga-
nizations in which significant
failure or catastrophic events are
rare despite operating in hazard-
ous environments. This defini-
tion is useful for research and
the identification of principles
and concepts.
The operators of the USS Carl Vinson
used these principles for the purpose of
improving the crew’s performance in uncer-
tainty and threat, while at the same time
strengthening their organization. To do this,
they instituted and used specific attitudes,
behaviors and beliefs. They also evaluated
themselves using well-defined reportable
incidents or problems.
HROs can be found not only in U.S.
Navy aircraft carriers, but in EMS as far
back as the 1970s. In 1980, author Daved
van Stralen enrolled in medical school
after experience as an “ambulance man,”
including paramedic training, for a private
ambulance service and the Los Angeles City
Fire Department. He used his knowledge
of working under uncertainty and threat
throughout his career and as he assisted in
development of a pediatric intensive care
unit. Karlene Roberts, one of the UC Berke-
ley academics, heard about van Stralen’s use
of 1970s EMS in healthcare and described
his work in several articles. Later, organi-
zational theorist Karl Weick included his
experience in his writings.
TRANSIENT RELIABILITY
Reliability is transient. It’s like a moving tar-
get because it is a localized accomplishment
and specific to situations. One study on
transient reliability described reliability as
a dynamic non-event, one that is constantly
moving and changing though nothing seems
to happen.3 For example, think of how riding
a bicycle requires constant balance. Events,
like bumps in the road, constantly interrupt
balances in the system. These interruptions
require continuous management to restore
balance. This means reliability is a process
and is constantly being reestablished.
Because EMS is partly a public safety
service, it responds to dynamic events in
hazardous conditions. EMS also operates
in an austere environment that is often
without the staffing and resources thought
necessary to properly stabilize and treat criti-
cally ill or injured patients. In structure and
dynamics, EMS differs little from a space
shuttle, nuclear power plant, commercial
jet or operating room. Catastrophic failure
in these similar environments includes the
Challenger and Columbia shuttle tragedies,
the Three Mile Island incident, the Tenerife
and Potomac River jet crashes, and wrong-
site surgeries.
The concept of HRO has helped aca-
demicians, government regulators, system
managers and operators better understand
catastrophic failure and improve each of these
systems. Failures in each system have signifi-
cantly decreased through application of HRO
principles. The experience of U.S. commer-
cial aviation further shows this reduction in
failures also reduces daily financial costs, not
from fewer air crashes but from more efficient
and productive daily actions.
Just as the concepts of HRO can be
attributed to better efficiency and produc-
tion in the aviation industry, they can also
describe our failures in EMS. A catastrophic
event in EMS is a potentially prevent-
able death or disability. Significant failures
include increased injury, longer hospital
admissions and patient injuries resulting
from our treatments.
It’s critical to remember that the concepts
of high-reliability organizations came origi-
nally not from academic research but from
codification of a command philosophy and
modern leadership methods.
THE FIVE HRO PRINCIPLES
EMS can move toward high-performing,
stronger systems within its current con-
straints through the use of HRO concepts
and principles. Better sensemaking, prob-
lem solving and collaboration
methods based on HRO are
instrumental for the time-com-
pression and uncertainty of the
EMS scene.
Social psychologist Karl
Weick, PhD, and Kathleen
Sutcliffe, PhD, codified five
principles of HROs in the book
Managing the Unexpected.4 They
include 1) preoccupation with
failure; 2) reluctance to simplify; 3) sen-
sitivity to operations; 4) commitment to
resilience, and 5) deference to expertise.
We’ll discuss each here.
HRO Principle 1: Preoccupation with failure.
Ignoring small failures leads to cascading
failure and larger, catastrophic events. HROs
are organized to respond to early heralds
of failure, and individuals in the HRO are
vigilant to failures in the covert, physiologi-
cally compensated state. For example, before
a patient enters obviously identifiable hypo-
volemic shock, there’s a period, no matter
how short, of asymptomatic hypovolemia.
Respiratory failure is also a process with
In structure & dynamics, EMS differs little from a space shuttle, nuclear power plant, commer-cial jet or operating room.
1306JEMS_61 61 5/28/13 1:59 PM
62 JEMS JUNE 2013 www.JEms.com
mild findings of nasal flaring and tachypnea
preceding hypoventilation and apnea.
HRO Principle 2: Reluctance to simplify.
When we accept simple diagnoses, we stop
looking deeper or further. HROs are reluc-
tant to accept these simplifications. EMS is
an environment of ambiguity, complexity and
imperfect information. To perform in this
environment, it becomes necessary to sim-
plify. But HROs recognize the risk of sim-
plification, hence the term “reluctant.” You
simplify because you choose to, not because
it’s easier or your only method of analysis.
HRO Principle 3: Sensitivity to operations.
Taking frontline operations for granted, not
supporting them and not accept-
ing the complex interactions
necessary to work in dynamic,
hazardous environments contrib-
utes to avoidable failures. The
frontline performs the real work
in an HRO. It’s where the “big
picture” is less strategic and more
focused on the changing situa-
tion. This requires the free flow
of information, something most
easily lost when crews have a fear
of speaking up or giving discon-
firming evidence when it’s present.
HRO Principle 4: Commitment to resil-
ience. Resilience is the ability to maintain or
regain a dynamically stable event. Neglect-
ing the capabilities your EMS system or per-
sonnel have for resilience contributes to an
inability to work problems to completion. As
a situation unfolds, the demands may exceed
the performance of individuals or the sys-
tem. To continue operations, the organiza-
tion must identify errors early for correction
while also improvising workarounds within
constraints of the environment.
HRO Principle 5: Deference to expertise.
An HRO reduces the authority gradient that
interferes with communication and facilitates
migration of authority to those with the
knowledge to make the best decisions. Defer-
ring to authorities, especially because of higher
status or rank and rigid hierarchy, disrupts use
of local or situational knowledge and subject
matter experts for anticipation and contain-
ment of a situation. In dynamic, high-risk
situations, circumstances will change—and
may change significantly—while informa-
tion is reaching a distant, higher authority.
There are those with intimate knowledge
of the circumstances, those with expertise
in the necessary subject matter and those
with command experience who must make
rapid decisions with short feedback loops to
modulate actions.
MINDFULNESS
There are other characteristics of HROs
that we believe are necessary for an HRO
to be operational. They include collective
mindfulness, sensemaking and enactment.
Karl Weick developed the idea of collec-
tive mindfulness from the description of
mindfulness by Ellen Langer, PhD.5 Langer
distinguishes mindfulness from mindless-
ness by the following five features:
1. Create new categories on the spot.
People in HROs aren’t trapped by precon-
ceived categories. Mindfulness creates new
categories with new information and there-
fore avoids the trap of placing information
into rigid categories. In EMS, fire and res-
cue operations, normal evacuation distances
may not fit under all circumstances. If you
have an oil tanker leaking fuel, an evacuation
distance of several feet may be appropriate.
However, if you have a tanker leaking Freon,
that distance will change.
2. Welcome and use new information.
Don’t fall back on automatic behavior. After
reaching a conclusion, it becomes easy to
search for information supporting the con-
clusion, called confirmation bias, and dis-
regard or discount conflicting information.
Authority gradients, when a person with
authority suppresses disconfirming infor-
mation, can be deadly and often occurs in
low-reliability organizations.
3. Use more than one point of view. Don’t
act from a single perspective, such as think-
ing everything is a rule or category. In the
dynamic environments of EMS, with limited
ability for any one person to see the big pic-
ture, multiple points of view are crucial to
understanding the scene and patient’s illness
or injury.
4. Evaluate information in relation to
context. Do this instead of maintaining the
belief that information is context-free. In the
ambiguity of an EMS scene, it’s the context
that gives information its value and mean-
ing. Context-free evaluations, the belief that
the information is true regardless of circum-
stances, leads people to rigidly following
rules despite evidence that those rules aren’t
working. This has been described as “the
strong but wrong rule.”6
5. Be process oriented. Getting it right
is a process. Don’t be preoccupied with out-
come. HROs focus on getting it
right rather than doing it right.
Realizing that a process pre-
cedes every outcome and every
situation improves our judgment
about the circumstances we
encounter on scene.
Weick expanded Langer’s
concept of mindfulness from
mindfulness in the individual
to collective mindfulness. Col-
lective mindfulness is shared
across the team through interac-
tive behaviors and awareness.7 This requires
open and aggressive communication, includ-
ing both verbal and nonverbal cues, between
all members involved—whether on scene or
at a distance from the scene.
SENSEMAKING
Sensemaking is how we give meaning to the
ambiguous stimuli we encounter on scene.
Collective sensemaking refers to the com-
mon meaning obtained through shared ref-
erences and framing of events. As anyone
who trains novices can attest, sensemaking
requires a common vocabulary and grammar
beyond the technical terms we use.
This is a selective vocabulary, and a rookie
can become perplexed when describing a
dynamic scene that’s full of ambiguity and
nuance. Sensemaking in emergencies in par-
ticular must be made without reference to
past events or future trajectories, because we
often don’t have sufficient information to
know where the events originated from or
where they are going.
Sensemaking goes beyond alertness,
which is an effort to notice things that are
out of place. Instead, we refer to awareness,
which is an effort to generate conjectures
Just as the concepts of HRO can be attributed to better effi-ciency & production in the avi-ation industry, they can also describe our failures in EMS.
HIGH-RELIABILITY ORGANIZATIONS
>> CONTINUED FROM PAGE 61
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www.jems.com jUNe 2013 JEMS 63
about the meaning of events. In emergen-
cies, we tend to search for meaning, settle
on something plausible, and then move on.
During a transition from a public safety
approach of decision making to a medical
approach, you must accept the fact that, in
the rapid moving environment of prehos-
pital EMS, paramedics decide and phy-
sicians evaluate. This means paramedics
would make a decision and move on with
other tasks, which include reassessment,
while doctors would evaluate and re-evaluate
searching before they decide the correct
diagnosis and treatment.
We tend to simplify sensemaking for
easier analysis and decision making. Adrian
Wolfberg, PhD, describes two analytic pro-
cesses: puzzle-solving and mystery-solving.9
With puzzle-solving, the analyst has faith
that collecting sufficient data will fill the
puzzle blanks and produce the answer. In a
mindless state, as opposed to one of mind-
fulness, this produces the drive to fill in all
the boxes on a form despite irrelevance or
if it interferes with treatment. The goal is
to collect as much information as possible
with blind faith that an answer will emerge.
It’s consistent with deductive reasoning pro-
cesses where facts guarantee the hypothesis.
This can become a drive to collect more facts
simply for security.
MYSTERY-SOLVING
Mystery-solving emphasizes the uncertainty
of a situation, which comes more naturally to
those working in the field environment. The
uncertainty is from the complexity of human
interactions on today’s battlefield.9
For EMS, we add together the interac-
tions between the patient and disease or
injury along with human interactions on
scene between bystanders and other public
safety officers. Wolfberg describes this as
full-spectrum analysis; that is, we analyze
the full spectrum of events and the environ-
ment rather than discrete segments that fit
our models.
The discrete concepts we use for sense-
making in dynamic situations simplify and
lag behind the full-spectrum, continuous
perceptions of our experience. Our grasp of
events, then, becomes subject to misidentifi-
cation and misunderstanding.3
EMS is a dynamic mystery, not a static
puzzle. Decisions, once made, become pos-
sessions. Compared to decision-making,
sensemaking is more adaptive to the ambi-
guity and dynamics of EMS. For example,
“If I make a decision, it is a possession; I
take pride in it. I tend to defend it and not
to listen to those who question it. If I make
sense, then this is more dynamic and I listen
and I can change it. A decision is something
you polish. Sensemaking is a direction for the
next period.”3
One of the first things rookies in EMS,
fire and law enforcement or the military learn
is to engage the situation, not to withdraw.
For safety purposes one may, of course, with-
draw to a safe location, but observation is a
form of engagement; inaction is an active
decision. This is described as enactment as a
much deeper level than engagement, but this
is necessary to understand how HROs work.10
SUMMARY
Enactment describes how we engage the
situation to make sense of it. But by our
engagement, we also change the situation.
Our presence, alone, will change the situa-
tion. At times, we may fail to act. Here, we
are at risk of interpreting this as a sense of
personal “limitation” in what we can do. This
will inhibit us in engaging in other incidents.
Rather, we should understand that while we
may often fail after engaging, acting is part of
performing in uncertainty.
In EMS, the system, as it’s set up, can
lead people to fail to act. For reasons specific
to a system, the EMT or paramedic may
not act for fear of doing something wrong.
This failure to act reinforces the limitations
one feels. When you avoid acting, you don’t
learn. By avoiding testing ourselves, we con-
clude that constraints exist. This is contrary
to the historical approach public safety and
EMS personnel use to learn. In the past,
it was accepted that we learn what works
through action.
We also perceive, or sensemake, through
interaction with the environment. We watch
for responsiveness to our actions, such as
cooperation from bystanders vs. defiance.
However, this is influenced by how we
approach the scene. One EMS provider may
obtain cooperation while another experi-
ences defiance. We bracket this information
by placing it in context. This interaction is
difficult to communicate to those not pres-
ent at the incident, because they don’t know
when one “story” begins and when another
leaves off.
HROs have developed in organizations
that adapted to time constraints in uncer-
tain and hazardous environments. There,
lessons were actually learned through the
blood of live-or-die situations. Academics
have codified these principles and concepts
that are accessible to EMS caregivers. EMS
can benefit from the principles and concepts
of HRO through improved performance by
individuals and stronger organizations. JEMS
Daved van Stralen, MD, FAAP, is a consultant with Strategic
Reliability LLC; medical director for American Medical Response
in San Bernardino County (Calif.); and a physician with the
Loma Linda University School of Medicine Department of Pedi-
atrics. He can be reached at [email protected].
Thomas A. Mercer, RAdm, USN (retired), is a consultant with
Strategic Reliability LLC. He flew 255 Vietnam combat missions;
his awards include the Defense Distinguished Service Medal, the
Distinguished Service Medal (two awards), Legion of Merit (two
awards) and Distinguished Flying Cross (three awards).
Acknowlegements: The authors would like to acknowl-
edge the work of Ron Stewart, MD, who, in the 1970s, combined
the principles of ambulance work and firefighting with medical
care; James O. Page, JD, who encouraged the application of
HRO principles as developed from 1970s EMS into today's EMS;
and Karl Weick, PhD, who brought science to applied HRO and
reviewed this manuscript.
REFERENCES
1. Perrow C: Normal accidents: Living with high risk technologies.
Basic Books: New York, 1984.
2. Rochlin GI, La Porte TR, Roberts KH. The self-designing high-
reliability organization: Aircraft carrier flight operations at
sea. Naval War College Review. 1987;76–90.
3. Weick K. Organizing for transient reliability: The production of
dynamic non-events. Journal of Contingencies and Crisis Man-
agement. 2011;19(1):21–27.
4. Weick K, Sutcliffe K. Managing the Unexpected: Resilient Per-
formance in an Age of Uncertainty, 2nd ed. Jossey-Bass: San
Francisco, 2007.
5. Langer E. Mindfulness. Da Capo Press: Cambridge, Mass., 1989.
6. Reason J. Human Error. Cambridge University Press: Cam-
bridge, U.K., 75–76, 1990.
7. Weick K, Roberts K. Collective mind in organizations: Heedful
interrelating on flight decks. Administrative Science Quarterly.
1993;38(3):357–381.
8. Weick K. Reflections on enacted sensemaking in the Bhopal
disaster. Journal of Management Studies. 2010;47(3):537–550.
9. Wolfberg A. (July–August, 2006). Full-spectrum analysis:
A new way of thinking for a new world.” In Military Review.
Retrieved from http://usacac.army.mil/CAC2/MilitaryReview/
Archives/English/MilitaryReview_20060831_art008.pdf.
10. Weick K. “Enactment and organizing.” In The Social Psychol-
ogy of Organizing, 2nd Ed. McGraw Hill, Inc.: New York:147–
169, 1979.
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PH
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Good nutrition starts in the grocery store, because having
healthy ingredients on hand is the first step for preparing
healthy meals. For a lot of people, the amount of food on
grocery store shelves can be overwhelming. The average supermar-
ket stocks thousands of items, and there are more new items avail-
able each day. Products are strategically advertised and placed to
catch our eyes and convince us that we need them. Grocery stores
intend to sell food, after all. Information on labels can be confus-
ing and misleading, causing us to buy “healthy” products that we
think are good for us but aren’t healthy at all. All of this, combined
with personal habits, lack of knowledge and lack of time, can mean
walking out of the store $50 lighter with nothing to show for it but
a box of soy cookies and 15 packs of microwavable noodles.
PRODUCT PLACEMENT
One of the best tactics for being an informed consumer is to under-
stand the anatomy of the grocery store. It’s most important to know
that the healthiest foods are on the perimeter. In the vast majority
of markets, the produce section, dairy refrigerator, meat and fish
counters, and bakery with fresh-baked breads all lie on the outer
edges of the store. The middle of the store contains mainly pro-
cessed, pre-packaged convenience foods. These foods are high in
sodium and often low in nutritional value, so you should eat them
sparingly. This layout is intentional. We have to walk past all these
money-making processed foods to get to the back of the store for
the staples we actually need.
Another strategy for being a healthier consumer is to be aware
of the way items are placed on the shelf. The area right at the cus-
tomer’s eye level is considered prime space. Stores actually charge
more to place products there, so those shelves tend to carry national
brands and bestselling products. The lower shelves, set in the line
of sight of a child, usually carry products with bright colors and lots
of sugar, meant to appeal to children who are at the right height to
reach out and grab them. The very bottom shelf tends to have larger
BY ELIZABETH SMITH, MS, RD, LDN, EMT-B
Plan your week’s worth of meals before
going to the grocery store to avoid buying
sugary and overly processed foods.
PH
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www.jems.com jUNe 2013 JEMS 65
items, often bulk, that can be comparable to
and more affordable than items placed more
visibly. So if we head in without a plan,
we’re more likely to buy the items that are
most easily seen and most brightly colored
(especially if there’s a child helping with the
shopping), rather than those that are the
best price or most healthful.
SHOP WITH A STRATEGY
The soundest strategy for avoiding these
marketing tactics is to start your shopping
adventure armed with a plan. Before head-
ing to the store, make a list of the meals
you want to prepare for the week. For each
day, plan out breakfast, lunch and dinner.
This doesn’t need to be fancy. You may eat
cereal for breakfast every day, so that’s all
you need to write in your menu.
From your menu, make a shopping list.
Include each item you will need for your
planned meals and its quantity. For exam-
ple, if you’re making grilled chicken breast
for two meals, you would write: “Boneless,
skinless chicken breast (2).” This tells you
exactly what you need to pick up off the
shelf (see examples above). As you become
more familiar with your grocery store, you
can arrange your list in order of the store
layout, making it easier to avoid retracing
your steps and reducing the amount of time
you spend shopping.
When you’re ready to go shopping, make
sure to eat a small snack or meal before
you leave. Going to the store hungry dras-
tically increases the chances you will buy
junk food.
Once you arrive, stick to your list.
Remember the tactics vendors use to con-
vince you to spend more, and don’t buy into
them. Buy only what you need, and you will
save money while avoiding the temptation
brought by having a cabinet full of sand-
wich cookies and potato chips. JEMS
Elizabeth Smith, MS, RD, LDN, EMT-B, is a registered dieti-
tian and clinical nutritionist based out of Pittsburgh. She
works part time as an EMT-B. She's interested in providing
practical nutrition information and healthy eating strategies
to her fellow emergency responders. Contact her at eliza-
Sample One Week Menu
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Bre
ak
fast
Frosted Mini Wheats with
skim milk
Whole wheat toast, scrambled eggs
toppped with salsa
Frosted Mini Wheats
with skim milk
Frosted Mini Wheats with skim milk
Eggs over easy with whole wheat
toast
French toast made with whole wheat
bread, eggs and skim milk, topped with fresh strawberries
Omelet stuffed with green peppers, onions and shred-
ded low-fat cheddar cheese
Lu
nch
Turkey sandwich on whole wheat bread with side
salad and Italian dressing
Healthy restaurant
dinner
Leftover spaghetti with microwaved frozen vegetables
Chicken sandwich made with leftover
chicken tenders, apple and peanut butter
Healthy restaurant
dinner
Black bean burger (from frozen), micro-waved and served on whole wheat bread
with whole wheat tor-tilla chips and salsa
Leftover tacos and brown rice
Din
ne
r
Whole wheat spaghetti sauce, baked aspara-
gus topped with olive oil and black pepper
Vegetable pizza (crust, marinara
sauce, 2% fat moz-zarella cheese, green peppers, onions and
mushrooms)
Baked chicken ten-ders (chicken breast,
sliced, dipped in skim milk and bread crumbs with steamed
green beans
Tacos (lean ground beef, taco seasoning, fat-free sour cream,
salsa, low-fat shredded cheddar cheese, shred-ded lettuce), brown rice
spiced with cumin
Pork chops, baked; mashed potatoes (Idaho potatoes, skim milk, salt, and
pepper)
Healthy restaurant
dinner
Grilled chicken salad (one chicken breast, grilled, over romaine lettuce) with whole
wheat bread and spray butter
1306JEMS_65 65 5/28/13 1:59 PM
66 JEMS JUNE 2013 www.JEms.com
HANDS ONPRODUCT REVIEWS FROM STREET CREWS
Dominic Silvestro, EMT-P, EMS-I,
is a firefighter/paramedic for the
Richmond Heights (Ohio) Fire
Department. He is also an EMS coor-
dinator and EMS educator for the University Hospitals
EMS Training and Disaster Preparedness Institute and
an adjunct faculty member at Cuyahoga Community
College. He can be reached at [email protected].
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Protection from Blunt Force & StabsFront-line EMS providers are subject to situations that can turn violent in
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68 JEMS JUNE 2013 www.JEms.com
ILL
US
TR
AT
ION
ST
EV
E B
ER
RY
My nervous partner Eric loudly and
with exaggeration asked the patient,
“CAN. YOU. READ. MY. LIPS?”
The Deaf patient replied, “No. I. CAN'T.
READ. YOUR. LIPS.” The humor was lost on
Eric as he relayed the patient’s limitations to me.
“Really?" I melodramatically replied. “I
thought all Deaf inhabitants could visually con-
vert external orifice configurations into mean-
ingful linguistic interpretation.” The patient
and I exchanged a brief grin.
“Now what are we going to do?” Eric was
too nervous to notice my admiration for the
patient’s cunning intellect. “I don’t know sign
language,” he whined.
“Sure you do,” I deadpanned. “Show him
your middle finger and see what happens.”
“Hey, I’m serious!” Eric blurted.
“How do you even know he uses sign lan-
guage to communicate?” I questioned.
“Well, duh,” he asserted while confidently
turning toward the patient with an affirming
thumbs-up gesture. The patient returned the
signal, mimicking my partner’s excessive body
language and facial expressions.
Giving a satirical wink to the patient, I told
Eric, “With pen and paper, ask the patient what
method he would prefer to use when commu-
nicating with him.” With a deadpan expression
the patient quickly jotted down one word and
handed it back to Eric. “Brail.”
Poor Eric. He was a part-time newly
licensed EMT who was not privy to the fact
that I had once been a teacher for the Deaf
and hard of hearing (D&HH) before I was
naively drawn to EMS. Not that I volunteered
that information to Eric, mind you, The patient
was quite stable, and I wanted to see how Eric
would handle this situation.
As it turns out, the Deaf patient’s primary
means of communication was indeed sign lan-
guage. Fortunately for Eric, the patient was
trying to integrate humor to put Eric at ease.
Unfortunately, Eric proceeded to tell me, not
the patient, that he could not treat the patient
until an interpreter arrived. It was at that
moment our patient afforded Eric an unso-
licited lesson in sign language, involving ana-
tomical parts being placed in other anatomical
locations usually not reserved for cohabitation.
And believe me, knowledge of sign language
was not required to get the gist.
Stretching my fingers, I then took on the
role of interpreter for both Eric and the patient.
“Telling you that I am Deaf does not mean
‘Don’t communicate with me,’” signed the
patient. This was punctuated with another sign
for incorporating unsolicited body segments.
Continuing, our patient stopped signing and
reverted to using his intelligible speech. “It’s not
how you exchange ideas, but that you do.”
Our patient apologized to Eric for the choice
of signs he used to accentuate his passion for
treating the D&HH with the same dignity and
equality afforded everyone else. My partner in
turn apologized and requested some helpful
communication tips. Here’s what he learned:
1. Don’t yell. You just look silly, and it draws
unnecessary attention.
2. If the individual who is D&HH prefers
to lip-read, speak clearly and don’t over
enunciate. More unnecessary silliness.
3. If the patient requests an interpreter,
request through dispatch that the hospi-
tal contact one before you leave the scene.
4. Speak directly to the individual and not
the interpreter.
5. Protect the individual’s rights by only
using bystander interpreters whom the
patient agrees to have present.
6. Make sure you have the attention of the
person, but don’t wildly wave your hands
or stomp your feet to draw their atten-
tion. Now you really look silly.
7. Use direct and to-the-point short sen-
tences when using writing as a means of
communication. This saves time.
8. Don’t be afraid to be animated. Any sign-
ing is better than no signing. Gestures
work well.
9. English is typically the Deaf person’s
second language with different rules for
grammar and syntax.
10. Hearing aids don’t work well in loud
environments.
11. Never use the term “Deaf and dumb”
unless you want to see more signs related
to incompatible organs.
From an EMS perspective, I offer the fol-
lowing suggestions:
1. Spinal immobilization and C-collars by
themselves significantly reduce the visual
periphery of the D&HH.
2. Take out the individual’s hearing aids if
you spinal immobilize them. Don’t lose
them, either. They’re veeeery expensive.
3. Don’t wear gloves when you sign. Oth-
erwise you’re mumbling. Just kidding.
4. Don’t expect a patient who is D&HH to
lip-read when light is poor or the sun is
in their eyes. Oh, and don’t wear a mask.
That is silliness at an awesome level.
5. Wash your hands before you sign so you
don’t talk dirty. Just kidding again.
6. Yelling “clear” with multiple hearing-
impaired persons on scene could have
negative consequences. I crack myself up.
7. Be aware a professional interpreter will
sign everything in the presence of the
D&HH. That includes auditory flatu-
lence (Not really necessary in my opinion
as their olfactory system is still intact).
Until next time, remember that kindness is
the language the Deaf can hear and the blind
can see. JEMS
Steve Berry is an active paramedic with Southwest Teller
County EMS in Colorado. He’s the author of the cartoon
book series I’m Not An Ambulance Driver. Visit his website at
www.iamnotanambulancedriver.com to purchase his books
or CDs.
WHU’SAT YOU SAY?A lesson in treating Deaf & hard of hearing patients
>> BY STEVE BERRYTHE LIGHTER SIDEWHAT THEY DIDN'T TELL YOU IN MEDIC SCHOOL
1306JEMS_68 68 5/28/13 2:01 PM
www.jems.com jUNe 2013 JEMS 69
Employment
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It’s easy to f ll out the online form and submit your
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where it will be posted at the top of the EMS Jobs page as
well as highlighted in rotation throughout JEMS.com.
In addition, your listing will be featured in the JEMS.com
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For more information, please go to www.jems.com/ems-jobs/post-job
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70 JEMS JUNE 2013 www.JEms.com
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LAST WORDTHE UPS & DOWNS OF EMS
72 JEMS JUNE 2013 www.JEms.com
JEMS (Journal of Emergency Medical Services), ISSN 0197-2510, USPS 530-710, is published 12 times a year (monthly) by PennWell Corporation, 1421 S. Sheridan Road, Tulsa, OK 74112; phone 918-835-3161. Copyright © 2013 PennWell Corporation. SUBSCRIPTIONS: Send $44 for one year (12 issues) or $74 for two years (24 issues) to JEMS, P.O. Box 3425, Northbrook, IL 60065-9912, or call 888-456-5367. Canada: Please add $25 per year for postage. All other foreign subscriptions: Please add $35 per year for surface and $75 per year for airmail postage. Send $20 for one year (12 issues) or $35 for two years (24 issues) of digital edition. Single copy: $10.00. POSTMASTER: Send address changes 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. Periodicals postage paid at Tulsa, Oklahoma and at additional mailing offices. Advertising information: Rates are available at www.jems.com/about/advertise or by request from JEMS Advertising Department at 4180 La Jolla Village Drive, Ste. 260, La Jolla, CA 92037-9142; 800-266-5367. Editorial Information: Direct manuscripts and queries to JEMS Editor, 4180 La Jolla Village Drive, Ste. 260, La Jolla, CA 92037-9142. No material may be reproduced or uploaded on computer network services without the expressed permission of the publisher. JEMS is printed in the United States. GST No. 1268113153.
SAFETY IN THE RIG
Concerned by the amount of EMS
line-of-duty deaths where the provider had
been an “unrestrained operator/passenger”
of the emergency vehicle, EMS Chiefs in
Pennsylvania have developed a new way to
promote seatbelt use.
The group, in partnership with the
Emergency Medical Services Institute
(EMSI), developed and distributed bright
orange seatbelt covers to more than 139
ambulance services in the region. The high
visibility of these covers is to remind and
motivate providers to stay buckled; passing
vehicles and pedestrians are able to see the
neon strip and know whether or not safety
providers are practicing what they preach.
“We value the safety of our EMS provid-
ers, and these seatbelt covers are a highly
visible reminder of the importance of seat-
belt use every time a person gets into a
vehicle,” says Thomas J. McElree, EMSI
executive director. “Through this program,
our EMS providers are role models for the
entire community.”
The goal of the “Safety Shows to Pro-
vider, Patients, Public” program is to have
100% compliance by all front-seat occu-
pants of EMS vehicles. The program
started with the seatbelt initiative but is
intended to carry over to other ways safety
can be promoted. Members of different
EMSI committees and the Pennsylvania
Department of Health will also be work-
ing to gather seatbelt usage data for fur-
ther analysis.
Meanwhile, in Alabama, Lauderdale
County’s newest ambulance provider is
requiring all employees to wear helmets
while inside the ambulance.
“The back of an ambulance is an unsafe
place. We’re driving at high rates of speed
through red lights and stop signs,” said
Shoals Ambulance Service CEO Bryan
Gibson in an interview with local news sta-
tion WAFF. “Hopefully they stop, and they
should, but things happen and sometimes
people don’t see us and we get hit.”
The service is one of the first in the
nation to require protective headgear, and
the employees are excited for the extra pro-
tection. Some even said the helmets make
them look more professional.
The noggin defenders also have adjust-
able face shields to guard against any
splashes of blood or other bodily f luids that
may occur while when tending to a patient.
We give a big thumbs up to all these
organizations for taking steps toward
increasing responder safety. It’s proactive
measures like these that can make a differ-
ence in decreasing the amount of on-the-
job deaths and injuries. JEMS
FIGHTING DRUG ABUSE
A Las Vegas paramedic partnered
with a group of Brigham Young University
engineering students to invent a new pill
bottle in hopes of combatting drug abuse.
The paramedic was inspired after witnessing
too many deaths caused by drug abuse—in
America, 100 overdose deaths occur every day.
The new bottle, which is currently
unnamed, regulates and dispenses painkill-
ers based only on a doctor’s prescription. It
is tamper- and hack-proof, which the team
hopes will stop users from purposefully or
accidentally taking too many pills.
According to a press release, “The device
must be plugged into a computer by USB
cable for the pharmacist to access it and to
load the pills. The pharmacist then uses soft-
ware created by the students to specify how
often the pills can be retrieved each day. Once
the device is unplugged from the computer, it
locks and dispenses only according to those
instructions. As an added safety measure,
patients must key in an access code on the
bottle each time a pill is ready to dispense.”
The bottle was designed to be reusable and
affordable (reports suggest a $20 retail price).
“The fact that there isn’t a solution to the
drug-overdose epidemic really drove us,”
says Dallin Swiss, one of the students work-
ing on the project.
We applaud this group of innovators for
taking a serious problem and actively finding
a solution that can easily be accessible to most
Americans. This device could not only save
lives, but also has the potential to decrease
the number of drug overdose calls an EMT or
paramedic encounters in the line of duty.
PH
OT
O C
OU
RT
ES
Y J
AR
EN
WIL
KE
Y/B
YU
EMT Kimberly Torbert of Elizabeth Township Area
(Pa.) EMS uses her Safety Shows orange seatbelt
cover to stay safe and demonstrate proper safety
measures to her community.
PH
OT
O C
OU
RT
ES
Y D
AV
ID G
. H
OF
FM
AN
1306JEMS_72 72 5/28/13 2:02 PM
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