EMS News | Paramedicine 101

2010 AHA Updates

06/14/2010 by Adam Thompson, EMT-P 5 Comments

It’s that time again. As most of us Americans in the wide world of emergency medicine know, every five years the American Heart Association updates their recommendations. Those recommendations happen to be the standard for most prehospital agencies, and hospital systems. They say and we do. So what are we going to be doing now?

This year should not be bringing about any mega changes. The direction has stayed the same for the most part.

Where do the updates come from?

ILCOR – The International Liaison Committee on Resuscitation

Process for Evidence Evaluation

The publication of the 2010 International Consensus on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) Science with Treatment Recommendations (CoSTR) will represent the scientific consensus of experts from a variety of countries, cultures and disciplines. Internationally recognized experts were brought together by the International Liaison Committee on Resuscitation (ILCOR) to evaluate and form an expert consensus on all peer reviewed scientific studies related to CPR.

To achieve this goals, ILCOR is conducting systematic reviews and updates of scientific evidence supporting resuscitation treatment recommendations. More than 500 resuscitation scientific topics will undergo evidence-based review. This process represents the most comprehensive, systematic review of the resuscitation literature to date.

The worksheets posted at this site represent the first step of an international consensus evidence evaluation process that will culminate in the publication of the 2010 International Consensus on CPR and ECC Science with Treatment Recommendations. In addition, resuscitation council-specific guidelines will also be published based on this international science consensus. Worksheet authors and expert reviewers worked very hard to present the information objectively.

The information contained in these worksheets will be presented and discussed between now and early 2010. In early 2010, the International CPR Consensus Conference will convene to allow final presentation and discussion of these worksheets, leading to evaluation and consensus by respective ILCOR Task Forces.
Readers are cautioned that these worksheets are a preliminary review and do not represent any ILCOR Task Force or Resuscitation Council recommendations.

ILCOR recognizes that the integrity of the evidence evaluation process depends on successfully managing real and perceived conflict of interest. ILCOR has policies in place to manage conflict of interest.
The 2010 evidence evaluation and science review process will culminate with the International CoSTR Conference in early 2010, in Dallas, Texas.

A separate publication covering guideline recommendations will be published by each resuscitation council.

So what does this all mean?

The AHA is part of an international committee that uses a systematic review system to scan through all the most valuable research available. The research is graded by how useful an unbiased it is, and then recommendations are made based upon a compilation of the results. The package all of this up in a nice-looking book, packed with a bunch of fancy flow charts, tables, and algorithms, and we buy it.

Link to the questions asked for 2010

Time of old

Amiodarone – Back in 2000 Amiodarone was given a class IIb recommendation from AHA. This was a push from, who else, the manufacturers of Amio. This happened synchronously with the changing of Lidocaine from a class IIb to an indeterminate rating. This occurred after a study showed that Amiodarone improved the number of cardiac arrest that regained pulses. This was accepted by many, and all the better, Amio works in atrial and ventricular arrhythmias–yippee.

The facts:

Amiodarone improved the amount of people that regained pulses, but not the amount of cardiac arrests that survived to discharge. No more people are surviving on Amio compared to Lidocaine. AHA knows this now, and has known this for a while.

AHA says that an “indeterminate” rating is no different from class IIb. So why the change? Because class IIb sounds a whole lot better when your selling a new drug.

So does this mean we are going back to lidocaine? Not sure, because there isn’t any evidence that lidocaine is any better either–should we confuse everyone more? In fact, there is no evidence that any dysrhythmic does anything beneficial in cardiac arrest. That’s right, no quality evidence supporting beneficial effects of dysrhythmics. Want some more? NO DRUGS administered in cardiac arrest have any supporting evidence!

Olasveengen TM, Sunde K, Brunborg C, et al. Intravenous drug administration
during out-of-hospital cardiac arrest. JAMA 2009;302:2222-2229.

Despite the traditional use of intravenous medications such as vasopressors and antiarrhythmics for victims of cardiac arrest, there is actually very little evidence to support these therapies. On the contrary, a recent multicenter center study demonstrated that the use of intravenous medications that are advocated in standard advanced cardiac life support (ACLS) guidelines was ineffective at improving survival of patients with out- of-hospital cardiac arrest (1). Olasveengen and colleagues now add further support to the contention that the use of intravenous medications in victims of non-traumatic cardiac arrest is not associated with improvements in meaningful outcomes. The authors performed a prospective randomized trial of consecutive adults with non-traumatic cardiac arrest that were treated within their emergency medical services (EMS) system in Oslo between 2003 2008. Patients were randomized to either receive standard ACLS therapies with intravenous drug administration (IV group) or ACLS therapies without any intravenous drugs (no IV group). A total of 851 patients were included in the study, 418 patients in the IV group and 433 in the no IV group. The researchers found there was an increase in survival to hospital admission with return of spontaneous circulation in the IV group vs. the no IV group (32% vs. 21%, P < 0.001). However, there was no difference between the IV group vs. the no IV group in terms of survival to hospital discharge (10.5% vs. 9.2%, P = 0.61), survival with favorable neurological outcome (9.8% vs. 8.1%, P = 0.45), or survival at 1 year (10% vs. 8%, P = 0.53). The results demonstrate that with the use of IV ACLS medications, patients simply die in the hospital rather than in the ED. Practically speaking, this amounts to increased intensive care unit bed utilization, hospital resource utilization, and expenses; but without any increase in meaningful survival. In this era of ED and hospital overcrowding and the increasing demand for cost-effectiveness in medical therapies, Stiell’s and Olasveengen’s studies should force us to consider that the use of IV medications for patients in cardiac arrest should be the exception rather than the rule…or guideline.

1. Stiell IG, Wells GA, Field B, et al. Ontario Prehospital Advanced Life Support Study Group. Advanced cardiac life support in out-of-hospital cardiac arrest. N Engl J Med 2004;351:647-656.

Back to Amiodarone 2010:

CONSENSUS ON SCIENCE:
Evidence from 1 RCT demonstrates the benefit of amiodarone over placebo for shock refractory or recurrent VT/VF for the endpoint of survival to hospital admission, but not to survival to hospital discharge. Retrospective trials show that lidocaine may be more beneficial than placebo, but selection bias mars these trials. In trials that directly compare amiodarone to lidocaine, patients administered amiodarone generally do better in short term results (ie survival to hospital admission), but no trial has shown an improvement in overall survival (Dorian P 2002 p884, Somberg J 2002 p853).

These trials were performed before the benefits of hypothermia was known, thus they did not incorporate this now proven therapy which improves survival after ROSC. Whether survival to hospital discharge and neurologic survival could be improved with amiodarone and subsequent hypothermia is not known. If that is the case then a stronger argument for amiodarone could be made; if that is not the case then an argument could be made to not give an AAD at all.

CPR Before Defibrillation

It was taught, back in 2005 by AHA, that we need to prime the pump. It was theorized that performing early defibrillation has no benefit because the heart was not being adequately perfused. This lead to a 2 minutes of CPR prior to shocking in an unwitnessed arrest rule. This is what we, who are AHA compliant, are doing.

CONSENSUS ON SCIENCE:
Two randomized controlled trials (LOE I) (Baker 2008 p424; Jacobs 2005 p39) demonstrated no improvement in ROSC or survival to hospital discharge in patients suffering out-of-hospital VF or pulseless VT who received CPR by EMS personnel for a period of 1.5 to 3 minutes before defibrillation, regardless of EMS response interval being greater or less than 5 minutes. One case series study (LOE IV) (Campbell 2007 p229) also failed to demonstrate improvements in ROSC or survival to hospital discharge with bystander versus no bystander CPR before defibrillation.
One randomized controlled trial (LOE I) (Wik 2003 p1389) and clinical trial (LOE III) (Cobb 1999 p1182) identified overall similar findings however improvements in ROSC, survival to hospital discharge and neurological outcome were observed in patients where the EMS response interval was greater than 4 to 5 minutes.

Evidence from one LOE 1 study (Wik 2003, 1389), one LOE 3 study (Cobb 1999, 1182) and five LOE 5 studies (Berg 2004, 1352; Kolarova 2003, 2022; Menegazzi 1993, 235; Menegazzi 2004, 926; Niemann 1992, 281) support the strategy to delay defibrillation to give BLS first for 1,5 to 8 minutes, in particular when the delay to ambulance arrival exceeds 5 minutes and no BLS is given before ambulance arrival. Evidence from two LOE 1 studies (Baker 2008, 424; Jacobs 2005, 39), one LOE 3 study (Campbell 2007, 229) and nine LOE 5 studies (Berg 2004, 1352; Yakaitis 1980, 157; Menegazzi 2003, 261; Menegazzi 2000, 31; Seaberg 2001, 301; Kolarova 2003, 2022; Niemann 2000, 543; Menegazzi 1993, 235; Rittenberger 2008, 155) do not support this strategy and are neutral. One LOE 5 study (Indik 2009, 179) gave direct evidence for the opposite strategy

Level of evidence – all that LOE stuff you see above is a reference to the grade the mentioned study received by the reviewer.

LOE 1
Randomised Controlled Trials:
These studies prospectively collect data, and randomly allocate the patients to intervention or control groups.

LOE 2
Studies using concurrent controls without true randomisation:
These studies can be:
· experimental – having patients that are allocated to intervention or control groups concurrently, but in a non-random fashion (including pseudo-randomisation: eg. alternate days, day of week etc), or
· observational – including cohort and case control studies
A meta-analysis of these types of studies is also allocated a LOE = 2.

LOE 3
Studies using retrospective controls:
These studies use control patients that have been selected from a previous period in time to the intervention group.

LOE 4
Case series: A single group of people exposed to the intervention (factor under study), but without a control group.

LOE 5
As with other categories of Levels of Evidence, we have used LOE 5 to refer to studies that are not directly related to the specific patient/population. These could be different patients/population, or animal models, and could include high quality studies (including RCTs).

So according to the evidence, we may need more evidence. However, there isn’t much support to the current guidelines. Once again, do we change this back and confuse more people when we are uncertain if outcomes will improve?

Cardiocerberal Resuscitation or Cardiopulmonary Resuscitation?

Should EMS be doing chest compression only CPR? This is a good question when considering primary cardiac arrest. We know that primary respiratory arrest should involve aggressive airway management.

CONSENSUS ON SCIENCE
Six fair to good LOE 5 animal studies (Berg 1993, 1907; Berg 1997, 1635; Berg 2001, 2464; Ewy 2007, 2525; Kern 1998, 179; Kern 2002, 645) have shown comparable or better outcomes with continuous chest compression CPR as compared with interrupted compressions for ventilation in nonasphyxial cardiac arrest and in concept support such a change in resuscitation strategy. However animal models do not necessarily mimic the anatomical or arrest features of humans, and for these reasons arguably may be less applicable to human resuscitation. Clinical evidence from three retrospective cohort LOE 3 studies in adults suffering from cardiac arrest (Bobrow 2007, 1158; Kellum 2006, 335; Kellum 2008, 244) showed that provision of chest compressions in the absence of rescue breathing by trained professional (EMS) providers led to an improvement in survival to hospital discharge compared to provision of chest compressions with rescue breathing. However, these studies had methodological shortcomings that limit the ability to determine whether the improvements in survival were attributable to the provision of chest compression-only CPR in the absence of rescue breathing, including the lack of randomization, the implementation of other resuscitation protocol changes that may have affected outcomes, or simply a stronger clinical emphasis on the provision of good CPR. The remainder of clinical studies addressing this issue evaluated the outcome from continuous chest compression versus interposed ventilation CPR by untrained laypersons (bystander CPR),and did not directly address provision of care by trained professionals.

So there are studies out there, just maybe not enough–once again. There is also research on different compression:ventilation ratios showing promising data. Guess we will find out what really happens in October.

More of the same

There is a lot more evidence out there advocating chest compressions. No pulse checks, just compressions. More and more compressions. Push hard and push fast. Good chest compressions. Are you getting all of this?

Therapeutic hypothermia is gaining more popularity. The evidence is outstanding.

CONSENSUS ON SCIENCE:

Who to cool?
Evidence from one good randomized trial (LOE 1) (HACA, 2002, 549) and a pseudo-randomised trial (LOE 2) (Bernard, 2002,557) demonstrate improvement in neurological outcome after discharge from hospital in patients who had an out-of-hospital VF cardiac arrest, who were still comatose, and who were cooled within minutes to hours after return of spontaneous circulation to 32-34ºC for 12-24 hours. Two studies with historical control groups (LOE 3) showed improvement in neurological outcome after therapeutic hypothermia for comatose survivors of VF cardiac arrest (Belliard, 2007, 252; Castrejon, 2009, 733) One small (n = 30) randomized trial (LOE 1) showed reduced plasma lactate values and oxygen extraction ratios in a group (n =16) of comatose survivors after cardiac arrest with asystole or PEA who were cooled with a cooling cap (Hachimi-Idrissi, 2001, 275). Six studies with historical control groups (LOE 3) showed benefit after therapeutic hypothermia in comatose survivors of OHCA after all rhythm arrests (Bernard, 2007, 146; Oddo, 2006, 1865; Busch, 2006, 1277; Sunde, 2007, 29; Storm, 2008, R78; Don, 2009 3062). One studies with historical controls showed better neurological outcome after VF cardiac arrest but no difference after cardiac arrest from other rhythms (Bro-Jeppesen, 2009, 171). Two non-randomised studies with concurrent controls (Arrich, 2007, 1041; Holzer, 2006, 1792) indicate possible benefit of hypothermia following cardiac arrest from other initial rhythms in- and outof-hospital.

How to cool?
Nine case series (LOE 4) indicate that cooling can be initiated safely with intravenous ice-cold fluids (30 ml/kg of saline 0.9% or Ringer’s lactate) (Kliegel, 2005, 347; Kliegel 2007, 56; Bernard, 2003, 9; Virkkunen, 2004, 299; Kim, 2005, 715 ; Jacobshagen, 2009; Kilgannon, 2008; Spiel, 2009; Larsson, 2010;). Two randomised controlled trials (Kim, 2007, 3064; Kamarainen, 2009, 900), one study with concurrent controls (LOE 2: Hammer, 2009, 570) and three cases series (LOE 3) (Kamarainen,2008, 360;Kamarainen, 2008, 205) indicate that cooling with IV cold saline can be initiated in the pre-hospital phase.

More For Post-Arrest

There is evidence that patients who are resuscitated from primary cardiac arrest should be immediately cathed.

The significance of this new literature cannot be overstated. If further studies confirm these findings, it would strongly argue for enormous changes in prehospital systems of care to recommend that all survivors of primary cardiac arrest should be immediately transported to hospitals that have the capability of performing urgent PCI in conjunction with therapeutic hypothermia. Based on the current literature, it certainly seems advisable that emergency health care practitioners that care for resuscitated victims of primary cardiac arrest should engage in conversations with cardiology consultants and urge them to take an aggressive approach to PCI in these patients.

What does this mean for us? Post-arrest 12-lead ECGs for now. In the future, this may mean that we bypass non-PCI facilities with our post-arrest patients. If you think this will last long, you are wrong. Post-arrest patients are high dollar patients. Just think about all of the work-ups done on these patients. Don’t think that the non-PCI hospitals won’t be rushing to find a way around this. Will this mean more PCI centers? Probably not, because all of the other cardio-intervention seeking patients end up with big medical bills too–but who knows.

Shocking Stuff

So even though AHA came out and said that their initial recommendation for biphasic defibrillators is not backed by any evidence, there may be an actual benefit to having them. There is evidence supporting what I am about to tell you, but it may not make it into the 2010 update. I think it will though. It goes against what we have all learned. Remember “I’m clear, you’re clear, we’re all clear!”

There is no harm to a rescuer performing chest compressions, when defibrillation is performed using a biphasic monitor.

That’s right. It has been said that more electricity passes through your body on one of those scales that checks your BMI than touching a patient when they are getting shocked. It has to be a biphasic defibrillator though.

So that’s all so far. Go scan through the worksheets if you’d like. There is a ton of good research available. We can only assume, as of yet, what the final recommendations will be.

At the Florida Emergency Physicians‘ second annual symposium on critical care in the emergency department, Dr. Amal Mattu (yes, I am mentioning him once again) presented most of these updates. This motivated me to research and share them with you.

Filed Under: Cardiac Arrest, Cardiocerebral resuscitation, EMS News, Research

Advances in Resuscitation – CCR, if you’re not doing it now, you will be

11/11/2009 by Adam Thompson, EMT-P 4 Comments

Allow me to introduce myself. My name is Chris Kaiser, or Ckemtp, and I write the EMS blog http://www.lifeunderthelights.com/ – I am a Nationally Registered Paramedic holding licensure in Illinois, Iowa, and also in Wisconsin. A few months ago I was asked to become a contributor to write for this blog and I jumped at the chance to intermingle my stuff with the venerable names here. Unfortunately, it has taken me a while to get something up here with the work needed to move from my old site to the new site. Today I’m fixing that and I would like to repost this article here with a few updates. I hope you find it educational.

Visitors to my blog probably know that at my ambulance service we tend to bring back a lot of codes. I talk about it a lot. Back in 2004 our medical director, Dr. Michael Kellum, got us involved in a “Demonstration Project” to bring Continuous Compression CPR or Cardiocerebral resuscitation to a rural area. Since that time, the results have been more than dramatic. Depending on what statistics you look at, we may be “Saving” almost 50% of witnessed arrests found to be in ventricular fibrillation.

It’s all explained at http://www.callandpump.org/, but if you want to go right to the whitepaper that explains what we do, why we do it, and how it’s done then you want to go here: http://callandpump.org/assets/Proposal_Current.pdf – This link is explains the demonstration project initiated by Dr. Kellum et al. in the two county area that I work in. This paper was published in 2004 at the beginning of the project.

This is a link to the results published in the Annals of Emergenc Medicine in 2008 – http://www.ncbi.nlm.nih.gov/pubmed/18374452?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

Photographers On-Scene: Ready for Your Close-up?

10/10/2009 by Adam Thompson, EMT-P 3 Comments

Also posted at Star of Life Law.

Allegedly¹ a Firefighter/EMT with the Keene (N.H) Fire Department was being videotaped during a call. The resulting videotape has been published on YouTube and shows the Firefighter/EMT striking the video camera held by one photographer and confiscating a camera-equipped cell phone from another bystander.

Here is the video (H/T STATter911):

Here is an article describing the events surrounding the scene.² The notable portion of the article is this:

Aubern Goodwin was able to stay with Kurt for a short while when he was placed into a holding area. She reportedly witnessed Mr. Rivera violently attack the handcuffed Mr. Hoffman. A call was put out to the Keene Fire/EMS for an ambulance as the attack injured Kurt’s neck. The EMS and sheriffs arrived and started ordering cameras turned off and areas cleared of people, all while spouting irrelevant HIPAA regulations in a blatant attempt to assert authority. One of the EMS workers, Captain Ronald Leslie, even stole a camera, directly snatching it out of a videographer’s hand.

Here is a letter written by the person who had their cell phone confiscated directed toward the Firefighter/EMT.

In this day and age cameras are everywhere. If you haven’t yet been photographed or filmed, you will be.

Let’s discuss some important topics so that you won’t be immortalized on YouTube and have the Fire and EMS blogs replaying your 15-minutes of infamy.

1. Smile: A Picture is Worth a Thousand Words

People can photograph and film you performing your firefighting and/or EMS duties. The general rule is that anyone may take photographs of whatever they want when they are in a public place or places where they have permission to take photographs.³ Streets, sidewalks, and public parks are examples of places that are traditionally considered public.

Property owners may legally prohibit photography on their premises but have no right to prohibit others from photographing their property from other locations.⁴

There are some exceptions though. You can’t be photographed or filmed where it is specifically prohibited by law. By law, I mean there must be a specific local ordinance or state law that prohibits photography in that specific location. Private ‘No Photography’ signs not backed by a local ordinance or state law likely are worthless.

The take away: you can legally be photographed or filmed without your consent when you are in a public place where you have no reasonable expectation of privacy. ⁵

2. Film, Memory Cards, Video Tape: It’s Not Yours To Take

You cannot confiscate cameras, film, memory cards or video tape. That’s theft.

You cannot demand film, memory cards or video tape be erased. That’s theft, too.

You cannot physically threaten a photographer. That’s assault.

You cannot prevent a photographer from leaving the scene unless they comply with your unlawful confiscation or erasure demands. That’s false imprisonment or kidnapping.

Got it? Good.

3. Camera Grabbing: Relax, Don’t Do It

Battery is both a criminal act and a civil tort. At common law, simple battery is an unlawful application of force to the person of another resulting in either bodily injury or an offensive touching. The common-law elements serve as a basic template; but individual jurisdictions may alter them, and they may vary slightly from state to state.

Importantly here, battery need not require body-to-body contact. Touching an object “intimately connected” to a person (such as an object he or she is holding) can also be battery.⁶

Grabbing, striking or hitting a camera, camera-phone, or video camera held by a photographer is likely battery. The photographer can file criminal battery charges against you and the photographer can sue you civilly for battery.

It’s simple. Don’t touch the camera.

4. Three’s a Crowd: Properly Making a Safe Work Space

If you find yourself crowded by a gaggle of paparazzi or even an overzealous single photographer, they may be interfering with your ability to do your job. In this case there is a right way and a wrong way to create a proper and safe working environment. As we discussed above, grabbing cameras or physically pushing photographers is the wrong way.

Utilize the available law enforcement on scene or get them on scene to assist you. All jurisdictions have disorderly conduct laws that the LEO’s can enforce. Disorderly conduct laws prohibit people from engaging in behavior that causes inconvenience, annoyance or alarm through disruptive behavior. Interfering with a firefighter or paramedic in the performance of their duties is likely to constitute extreme behavior rising to disorderly conduct.

Additionally, most jurisdictions have specific laws against interfering with police, fire or EMS workers in the performance of their official duties.

However, as an EMT or Paramedic your job is patient care, not law enforcement. Let the experts handle it. Get law enforcement on scene to assist you and allow them to handle the situation while you focus on the patient.

5. Silence: It’s Not Just for Mimes

The initial mistake I see from the video above is that the FF/EMT acknowledged and responded to the verbal taunts from the photographer. The photographer appears to be purposefully taunting and berating in order to elicit a response to capture on film. In this case he succeeded.

There appears to be an increasing trend of citizen journalists and shock journalists that seek to provoke confrontation to record. By responding verbally to these photographers they are only encouraged and emboldened.

You do not have to talk to anyone but your patient or someone directly related to the patient so you can properly assess your patient.

Focus on the patient. Ignore the photographers.

Conclusion

With the increasing prevelance of cameras, camera phones, and small video cameras, it is only a matter of time before you encounter being photographed or filmed on scene. You need to understand the basics of photographer’s rights and more importantly you need to know what not to do.

By following the 5 simple tips outlined above you can avoid an embarrassment on YouTube, save yourself the trouble of a criminal or civil complaint, and serve your patient by focusing on them rather than the circus around you.

The word ‘allegedly’ is used here as a hedge, as I have not been able to locate a reliable source that details the actual sequence of events and actions. The posted video and statements from the links provided herein is all that I have presently located. [↩]
It is unclear from reading this if the author was shooting the video in the above clip, was the person who had his camera confiscated, or was an uninvolved witness. [↩]
The Photographer’s Right, Bert P. Krages, 2009. http://www.krages.com/ThePhotographersRight.pdf [↩]
Id. [↩]
You have a reasonable expectation of privacy only in places like dressing rooms, restrooms, inside your home, etc. In these instances, the photograph or film is not illegal, rather the invasion of privacy is illegal. In most jurisdictions invasion of privacy is a civil claim, not a criminal act. [↩]
See Fisher v Carrousel Motor Hotel, Inc., 424 S.W.2d 627 (1967 [↩]

Filed Under: EMS News, Legal

Less Is More

05/14/2009 by Adam Thompson, EMT-P 5 Comments

Kelly Grayson, who many of you probably know from his blog, A Day in The Life of an Ambulance Driver has a great column on ems1.com. His most recent article is titled “Too Much of a Good Thing”, and it is pretty damn good. He touches on the recent topics of CPR, CPAP, and intubation. He also mentions the ALS vs. BLS debate, and tiered responses.

I think this a very relevant article and just the kind of information I hope this blog will provide. He quickly talked about evidence-based medicine making its way into the prehospital setting. We have learned to question things more, and it will end up improving our practice. We need more people like this.

I just want to touch on the topic of ALS vs. BLS and tiered responses. Kelly stated that more paramedics isn’t necessarily a good thing. I whole-heartedly agree! Too many paramedics causes a few problems that extend way past the scene of a call.

Problem#1, the more certified paramedics out there, the cheaper it is for an organization to just hire the new guy and mold them into what they want as opposed to hiring a seasoned veteran, or keeping one for that matter. I am all for fresh blood, but we need a mix of experience, in my opinion, and I am seeing with my own agency how this can become a problem. If you can hire a fresh out-of-school medic for $45,000 as opposed to a 10-year medic for $55,000, why hire the experienced guy? I predict this to become more of a problem with this economy.
Problem#2, more medics = more egos. For some reason, we aren’t very good at learning from our peers. We are quicker to point fingers sometimes, than we are to lend a helping hand. You also might hear “I want the tube”. This is the problem with too many medics on a scene. We are leaders by nature, and taking direction may be difficult for some of us. I find it a great idea to bounce ideas around on scene, this may help diffuse that problem(even if you’re only with EMTs, this may be something worth doing).
Problem#3, The more medics the less accountability. Another problem I see right here in my system. Just imagine having ten kids, would you really be able to spend the amount of time going over all of their report cards?

Of coarse, I am not advocating a BLS only system. The next time you have a CHF or STEMI patient, think about how an EMT only truck would handle that patient. Our ALS modalities are very helpful given the right patient and used appropriately. ECG interpretation lowers door-to-balloon times. CPAP and nitro improve the outcome of a CHF exacerbated patient. Antiarrhythmics acutely improve patient conditions. I believe a tiered response is the way to go. This would decrease the demand of paramedics and there would leave some room for the fixes I think are necessary.

Fix#1, Improve the curriculum for paramedics, and make an associate degree a requirement. Six months to a year isn’t enough education to do the stuff we do. We should emphasize more ride-alongs, and OR time.
Fix#2, We should and could QI/QA every ALS call. At least every priority one call could be reviewed. This would improve overall education, and professionalism. Incidents would be reduced, and a sense of responsibility would spread.
Fix#3, The medical director could spend more time with paramedics. This would improve the working relationship, and probably provide some great education. This may also open up some medical directors to more progressive protocols. Smaller systems may be familiar with this idea, because their medical director might know everyone by name and has probably run a few calls with them.

I know it may sound like I am saying that we should get rid of medics, I’m not. I am saying that we should make it harder to become a paramedic, academically. We should, of coarse, keep the positions that are filled right now, but only fill when necessary. We have to show our worth in this economy, and sometimes the most expensive answer isn’t the best one. Just look up the OPALS study if you question this. Of coarse the problems and fixes are my own opinions based on what I have read. This topic is open for much discussion, as always.

Are we getting too big for our britches? What do you think?

Filed Under: EMS News, General Discussion

Updates: Swine Flu

05/01/2009 by Adam Thompson, EMT-P 1 Comment

UPDATES ON SWINE FLU FROM MULTIPLE RESOURCES:

Podcasts:
May 1st Swine Flue update from EMRAP

April 26th update from EMRAP

University of New Mexico

Links to more podcasts:

News Columns:

‘Walking Well’ Flood EDs with Flu Fears By Madison Park (CNN)
CNN.com

A runny nose. A cough. A sore throat. And even pork eaten a week ago.

After a week of headlines about the H1N1 virus, or swine flu, many emergency rooms and hospitals are crammed with people, many of whom don’t need to be there.

The visits by the “worried well” have triggered concerns of overburdening the nation’s hospitals and emergency departments, several health care professionals told CNN.

This week, some hospitals saw record numbers of patients. A few emergency departments shut down to paramedics because of overcrowding.

“We have had a lot of nervous patients with minimal respiratory tract symptoms,” said Dr. Mark Bell, principal of Emergent Medical Associates, which operates 18 emergency departments in Southern California. “It has caused signficiant amount of delays in emergency care. They’re all walking well.”

“I haven’t seen such a panic among communities perhaps ever,” Bell said. “We are spending significant time in the emergency department, calming people down. Right now, people think if they have a cough or a cold, they’re going to die. That’s a scary, frightening place to be in. I wish that this hysteria had not occurred and that we had tempered a little bit of our opinions and thoughts and fears in the media. It just went haywire.”

In California, triage tents were set outside. Clinics doubled their traffic in major cities like Dallas, Texas, and Chicago, Illinois. In the Los Angeles area, some Emergent Medical Associates locations shut down their paramedic traffic.

“We’re closing to the real emergencies that may be befalling our community,” said Bell. “There is a little sense of hysteria among the community about the H1N1 virus.”

Emergency rooms are usually crowded and “if you increase that volume, you’re throwing them right over the edge,” said Bill Briggs, president of the Emergency Nurses’ Association.

“This has the potential to clog the system and emergency departments already facing serious crowding issues throughout the U.S.,” said Briggs, a registered nurse at Tufts Medical Center, in Boston, Massachusetts.

Some came to the hospital because they reported eating pork and having a cough, and thought this meant they had H1N1 virus. Though commonly known as swine flu, this virus is not contracted through eating pork products.

Even in cities that have yet to have a confirmed case of H1N1, health care workers have noticed an uptick in the number of patients. The Minute Clinic, a walk-in health care chain that has 500 offices around the country, saw a 50 percent increase in flu-related visits Thursday.

Chicago Children’s Memorial Hospital’s emergency department had more than double their average number of patients this week.

“It was a lot of ‘worried well’ people,” said Cathleen Shanahan, the nursing director for the emergency department at the hospital. “A lot of parents who were worried they about the flu.”

The anxiety is understandable, but Shanahan cautioned, “At some point, they need to realize it’s still flu season and it could be a normal flu season, and have nothing to do with [H1N1] flu.” CNN.com: Regular flu has killed thousands since January

“The situation is that people get the flu all the time,” said Dr. Nick Jouriles, president of the American College of Emergency Physicians. “H1N1 flu is just a bad strain of that. If you have flu symptoms and you ordinarily see the doctor for that, go ahead. If you would not ordinarily go to the doctor, don’t.”

If a person has no symptoms, then he does not need to seek emergency care, said Jouriles, an emergency room doctor at Akron General Medical Center in Akron, Ohio. And if the person does not have a fever or cough, it is extremely unlikely it’s the H1N1 virus.

“Very often when this happens, people naturally become afraid and overinterpret every symptom as a harbinger of the flu or what the epidemic is,” said Dr. Jeffrey Steinbauer, professor of family medicine and the medical director of the Baylor Clinic in Houston, Texas. “That’s part of providing care to patients and it’s kind of expected.”

Rather than panicking when you have a cough or runny nose, Steinbauer advised finding more objective measures.

“A temperature is very objective,” Steinbauer said. “If the temperature is normal, the allergens in the world and other viruses in the world can give you cough and runny nose. But if you don’t have a fever, chances of it being a flu is very low.”

While, the symptoms of the current swine flu and seasonal flu are very similar, reports suggest that this flu virus may result in nausea, vomiting and diarrhea more often than the typical flu. Symptoms include excrutiating body pains, difficulty breathing, significant nasal congestion and high fever. Doctors in Mexico have reported seeing sudden dizziness as well.

Health care workers find themselves trying to balance caution while allaying fears and panic about the virus.

“We recognize this as an infectious disease, this is moving,” Dr. Robert Salata, the chief of Infectious Diseases at the University Hospitals Case Medical Center in Cleveland, Ohio. “For the general population, we’re trying to calm the fears of people and the worried well, by stressing other elements like cough and sneezing etiquettes, and that you shouldn’t go to work if you’re feeling sick. If there is a concern, working through this with your physicians would be very important.”

But dashing into the emergency department because of a runny nose is not helpful.

“We have a tendency in the U.S. to abuse our emergency departments,” Salata said. “If this escalates, you want to use them for people that are not having mild or moderate symptoms.”

Swine Flu Cases Pass 100 in US, Vaccine Pursued
Lauran Neergaard
Associated Press
2009 May 1

WASHINGTON — U.S. authorities are pledging to eventually produce enough swine flu vaccine for everyone but the shots couldn’t begin until fall at the earliest.
Worries about the spread of the virus mounted Thursday as the nation’s swine flu caseload passed 100, and nearly 300 schools closed in communities across the country. Federal officials had to spend much of the day reassuring the public it’s still safe to fly and ride public transportation after Vice President Joe Biden said he wouldn’t recommend it to his family.
“There’s not an increased risk there,” Dr. Richard Besser, acting director of the Centers for Disease Control and Prevention, said Friday. “If you have the flu or flu-like symptoms, you shouldn’t be getting on an airplane or you shouldn’t be getting in the subway, but for the general population that’s quite fine to do,” he said.
Clinics and hospital emergency rooms in New York, California and some other states are seeing a surge in patients with coughs and sneezes that might have been ignored before the outbreak.
Scientists were racing to prepare the key ingredient to make a vaccine against the never-before-seen flu strain – if it’s ultimately needed. But it will take several months before the first pilot lots begin required human testing to ensure the vaccine is safe and effective. If all goes well, broader production could start in the fall.
“We think 600 million doses is achievable in a six-month time frame” from that fall start, Health and Human Services Assistant Secretary Craig Vanderwagen told lawmakers.
“I don’t want anybody to have false expectations. The science is challenging here,” Vanderwagen told reporters. “Production can be done, robust production capacity is there. It’s a question of can we get the science worked on the specifics of this vaccine.”
Until a vaccine is ready, the government has stockpiled anti-viral medications that can ease flu symptoms or help prevent infection. The medicines are proving effective.
Reassurances from top health officials didn’t stop the questions from coming.
An estimated 12,000 people logged onto a Webcast where the government’s top emergency officials sought to cut confusion by answering questions straight from the public: Can a factory worker handling parts from Mexico catch the virus? No. Can pets get it? No.
And is washing hands or using those alcohol-based hand gels best? Washing well enough is the real issue, Besser said. He keeps hand gel in his pocket for between-washings but also suggested that people sing “Happy Birthday” as they wash their hands to make sure they’ve washed long enough to get rid of germs.
Although it is safe to fly, anyone with flu-like symptoms shouldn’t be traveling anywhere, unless they need to seek medical care.
The swine flu outbreak penetrated over a dozen states and even touched the White House, which disclosed that an aide to Energy Secretary Steven Chu apparently got sick helping arrange President Barack Obama’s recent trip to Mexico but that the aide did not fly on Air Force One and never posed a risk to the president.
The Washington Post identified the aide as Marc Griswold, a former Secret Service agent who was doing advance work for Chu. It said that Griswold has complained about the infection placing his family in an awkward position with family and neighbors.
“We’re not the Typhoid Mary family, for goodness sake,” he said. “We’ve been told that we’re not contagious. We’re already past the seven-day mark for that.”
So far U.S. cases are mostly fairly mild with one death, a Mexican toddler who visited Texas with his family – unlike in Mexico where more than 160 suspected deaths have been reported. Most of the U.S. cases so far haven’t needed a doctor’s care, officials said.
Still, the U.S. is taking extraordinary precautions – including shipping millions of doses of anti-flu drugs to states in case they’re needed. The World Health Organization is warning of an imminent pandemic because scientists cannot predict what a brand-new virus might do. A key concern is whether this spring outbreak will surge again in the fall.
The CDC confirmed 109 cases Thursday, and state officials confirm 22 more. Cases now are confirmed in New York, Texas, California, South Carolina, Kansas, Massachusetts, Indiana, Ohio, Arizona, Michigan, Nevada, New Jersey, Delaware, Maine, Colorado, Georgia and Minnesota.
Besser appeared Friday morning on ABC’s “Good Morning America” and NBC’s “Today” show.

Officials provide outlook on swine flu for EMS providers
By Maveric Vu
EMS1 News Editor

It has been more than seven days since reports began of the first major outbreak in swine flu. Since then, more than 360 cases have been confirmed in 13 countries, with thousands of suspected cases.

As reports of possible infections and school closures continue to surface, many EMS officials are relaying one message.

“Now is not the time for anyone to panic,” said Gary Wingrove, president of the National EMS Management Association.

The Centers for Disease Control and Prevention released interim guidelines for EMS providers Thursday that assist in the treating and transport of potentially infected patients.

“The problem is you just never know who’s going to be impacted,” Wingrove said. “Having plans ready on the shelf, and having reviewed them and knowing they’re current…those are all critical for everyone to do right now.”

For American Medical Response employees, pieces of information started circulating from managers last Friday evening, the first day swine flu reports became public.

Since then, safety and assessment guidelines have been disseminated to regional chief operating officers and on the AMR employee portal, said Scott Bourn, director of clinical programs for AMR.

“Our greatest risk in the patient arena is probably in the period before the patient has influenza,” Bourn said. “There are things we can do to protect our crews.”

The first step in protecting EMS providers — identified by the CDC — is for 911 dispatchers to get as much information as possible when dealing with a potential influenza call and to inform the first responder.

The CDC guidelines offer the following precautions for EMS providers entering a call with a suspected swine flu patient:

EMS personnel should stay more than six feet away from patients and bystanders with symptoms and exercise appropriate routine respiratory droplet precautions.
Wear fit-tested disposable N95 respirator and eye protection, disposable non-sterile gloves, and gown, when coming into close contact with the patient.
Some providers were concerned that the recommended distance away from patients would hinder proper assessment.

“If this is out of your realm of comfort, put a N95 mask on before you even approach the patient,” Bourn said. “You need to have a conversation at a distance or a conversation behind the relative safety of a N95 mask.”

CDC guidelines also say to assess all patients for symptoms of acute febrile respiratory illness, which is fever with nasal congestion/ rhinorrhea, sore throat, or cough.

Considered a “hallmark” indicator of influenza, Bourn said providers should ask if the patient has a fever as part of the initial assessment if there is no thermometer available.

Since swine flu, or Influenza A (H1N1) can be spread through the air, the CDC recommends infection control precautions in any areas that the suspected patient inhabited.

This includes proper ventilation and decontamination of the ambulance, as well as informing the receiving facility, which may have a designated area established for influenza cases.

“There is a fairly decent likelihood that some other people (in the household or school) have the flu as well,” Bourn said. “In addition to putting a mask on the patient, put a mask on anyone riding in the ambulance.”

Bourn said that an extra level of consideration is necessary for paramedics and EMTs to protect themselves against swine flu, especially since health officials are still unsure of the severity of the situation.

“You don’t know what the disease will be exactly or how it will progress,” Bourn said. “You can’t really know what you need, or what it really is, until you get in the middle of it.”

According to Wingrove, he has encouraged EMS managers from around the globe to share best practices on the NEMSMA Web site in hopes of approaching a solution “globally.”

“Talking to people this past week, I was amazed at the number of services that haven’t done any planning so far,” he said.

Wingrove said it is the responsibility of impacted EMS departments to seek out resources in these initial stages, until the federal government decides how it will act.

“I know people are frustrated with not getting things faster from their state EMS office,” Wingrove said, “[But] what I see going on is a real attempt on the part of the federal government to be comprehensive and to be accurate.”

As cases continue to sprout up in countries around the world, EMS providers should continue to rely on information from the CDC and the World Health Organization.

“The hard thing is that [swine flu] looks so pedestrian. People may look at the symptoms and ask, ‘what’s the big deal?’” Bourn said. “The blessing is that it’s not hard to protect against.”

For more information on Influenza A (H1N1), including tips for EMS providers, visit the Centers for Disease Control and Prevention at http://www.cdc.gov/h1n1flu/.

Filed Under: EMS News

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