1. Feb.25-27,
2016
Always En Route At
United Rescue sends
trained laypersons to
emergencies in N.J., p. 30
CITIZEN
RESPONDERS
REBUILDING Detroit EMS p. 42 ILLINOIS Patient Navigators p. 54GETTING EMS Fit p. 48 BACTERIAL Meningitis p. 58
JANUARY 2016
ANNUAL JEMS SALARY SURVEY — SEE INSIDE, p. 34
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34 2015 SALARY SURVEY
A new approach to JEMS’ annual benchmarking
By Jonathan D. Washko, MBA, NREMT-P, AEMD & Michael Ragone
42 REBUILDING EMS IN THE MOTOR CITY
Subhead: Detroit strives to strengthen & integrate its response system
By Teresa McCallion, EMT
48 GETTING ‘EMS FIT’
Tips & exercises to strengthen your body for job-specific challenges
By Bryan Fass, ATC, LAT, CSCS, EMT-P (ret.)
52 BOARD-APPROVED RESEARCH
Institutional Review Boards ensure EMS-based studies have appropriate
ethical oversight
By Brittany W. Mayfield, MD & Corey M. Slovis, MD, FACP, FACEP, FAAEM
54 UNNECESSARY CALLS
Illinois patient navigator pilot program successfully redirects
non-emergent patients
By Tom Bik, PhD; Dennis Presley, MPA & Dottie Miles, EMT-P
58 PEELING BACK THE LAYERS
An overview of bacterial meningitis
By Robert P. Girardeau, BS, NRP, FP-C
About the CoverCommunity-based emergency caregivers in Jersey City, N.J., are available 24 hours a day, seven days a
week to respond and provide lifesaving care before the arrival of an ambulance. Read more about how
city leaders implemented this program, pp. 30–33. photo david lacombe
DEPARTMENTS & COLUMNS
8 EMS IN ACTION Scene of the Month
10 FROM THE EDITOR Battling Demons
By A.J. Heightman, MPA, EMT-P
13 LETTERS In Your Own Words
14 PRIORITY TRAFFIC News You Can Use
17 MANAGEMENT FOCUS Self Attributes
By Michael Touchstone, BS, EMT-P
18 BACK TO BASICS A Holiday Heart
By Dennis Edgerly, BS, EMT-P
25 CASE OF THE MONTH Delayed Death
By Abigail T. Harning, EMT-P, MEd
27 RESEARCH REVIEW Nasty Noses
By Alexander L. Trembley, NREMT-P & David Page, MS, NRP
28 STREET SCIENCE ALS vs. BLS
By Keith Wesley, MD, FACEP & Karen Wesley, NREMT-P
33 VEHICLE SHOWCASE Special Advertising Section
62 FOCUS ON PRODUCTS & TECHNOLOGY Special
Advertising Section
65 FIELD PHYSICIANS Carrying the Weight
By Mark E.A. Escott, MD, MPH, FACEP
66 AD INDEX & CLASSIFIEDS
68 LAST WORD The Ups & Downs of EMS
JANUARY 2016 VOL. 41 NO. 1
Contents
30 CITIZEN RESCUERS
Trained & equipped volunteers alerted by smartphone to quickly respond
to emergencies in Jersey City, N.J.
By Robert Luckritz, JD, NREMT-P
34
48
58
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McCain,TomPage,RickRoach,ScottOglesbee,SteveSilverman,MatthewStrauss,ChrisSwabb
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MARKETINGSOLUTIONS–PaulAndrews–240-595-2352–pandrews@pennwell.com
SUBSCRIPTION DEPARTMENT
847-763-9540
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CHAIRMAN–RobertF.Biolchini
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EXECUTIVEVICEPRESIDENT,CORPORATEDEVELOPMENTANDSTRATEGY–JayneA.Gilsinger
SENIORVICEPRESIDENT,FINANCEANDCHIEFFINANCIALOFFICER–BrianConway
SENIORVICEPRESIDENT/GROUPPUBLISHER–MaryBethDeWitt–marybethd@pennwell.com
TM
www.EMSToday.com
SENIORVICEPRESIDENT/GROUPPUBLISHER–MaryBethDeWitt
EDUCATIONDIRECTOR–A.J.Heightman,MPA,EMT-P
MARKETINGMANAGER–AmandaBrumby–amandab@pennwell.com
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FOUNDINGEDITOR–KeithGriffiths
FOUNDINGPUBLISHER–JamesO.Page(1936–2004)
10. EMS IN ACTIONSCENE OF THE MONTH
8 JEMS | JANUARY 2016 www.Jems.com
OVERTURNED BUS
Emergency personnel work at the scene of an accident
involving a Lehigh University bus and a car in Bethlehem,
Pa. Paramedics placed an elderly patient in full C-spine pre-
cautions, including a C-collar and backboard. The bus, carry-
ing 20 members of the university’s men’s and women’s row-
ing teams, flipped onto its roof but no students had major
injuries. A passenger in the car, however, didn’t survive.
12. 10 JEMS | JANUARY 2016 www.Jems.com
FROM THE EDITORPUTTING ISSUES INTO PERSPECTIVE
BATTLING DEMONSAll agencies need to have EAP resources to address
stress & reduce suicides
By A.J. Heightman, MPA, EMT-P
W
e battle a lot of demons in EMS.
We battle cardiac arrhythmias in
an attempt to reverse their nega-
tive effects on the heart. We battle infections
by taking preventive actions to ensure we,and
our patients, don’t succumb to its predict-
able damage.And we battle time with trauma
patients, taking rapid action to prevent irre-
versible shock.But yet,we’re a stubborn,proud
breed that does very little to help ourselves
battle one of our worst demons: stress.
EMS, fire, rescue and law enforcement
attracts compassionate and physically strong
people. But some responders feel that admit-
ting to suffering stress because of what they’ve
seen or experienced in the field is somehow a
show of weakness. It’s not.
By the nature of what we do, we’re often
labeled as “adrenaline junkies.”That’s not a bad
thing because adrenaline,a natural hormone in
our body,increases our rates of blood circula-
tion,breathing and carbohydrate metabolism,
and prepares our muscles for exertion.These
are all very important in stressful and demand-
ing situations and help us get through them.
But adrenaline,like all hormones or chem-
icals,has a limited strength and effective time
period.Therefore, soon after a stressful event
occurs, so too does our adrenaline level and
its compensatory mechanism.
That’s when we begin to feel the physical and
emotional aftermath of an incident and stress
builds.It becomes greatly accelerated if we have
a second or third stressful call on the same shift,
often referred to as “cumulative stress.”
When this occurs and we lack proper coping
mechanisms or time to defuse or dissipate our
emotions, we can become an emotional time
bomb and victims of depression. Depression,
defined as feelings of severe despondency,can
get worse if not addressed.1
I got a phone call recently informing me
that one of my star students at a two-day mass
casualty incident (MCI) workshop—21-year-
old Katie Broeker, a paramedic student in
Gloucester County, N.J.—took her own life.
She was a wonderful, vivacious EMT who
stepped forward to lead a complex MCI drill.
She did a great job and I left New Jersey happy
to see such a young EMT do so well.
But she had several stressors in her life
including paramedic class, which took their
cumulative toll.Her mom and dad are allow-
ing me to tell her story so others realize that
cumulative stress, depression and suicide are
not age-dependent, can creep up on you or
your co-workers and must be recognized and
addressed.
RESIDUAL STRESS
The word “residual” means “something that
remains after the greater part or quantity has
gone.” Synonyms of residual include: endur-
ing,remaining,leftover,lingering,unused and
unconsumed.Residual stress can hit you at any
time after a major incident.
I suffered an attack of residual stress years
after I helped locate,sort and place the ampu-
tated legs, arms and torsos of small children
in the appropriate body bags after a mid-air
collision of two airplanes in Allentown, Pa.
It hit me hard and without warning one
evening as I watched the 1992 made-for-TV
movie Crash Landing:The Rescue of Flight 232,
a realistic depiction of the crash of United
Airlines flight 232 during an emergency land-
ing at Iowa’s Sioux City Gateway Airport on
July 19, 1989.
Although 185 of the 296 people on board
survived that horrible crash, 111 didn’t.2
And
even though dead bodies weren’t shown during
the movie,there was a very short but impact-
ful scene that hit me like a ton of bricks and
triggered a deep emotional release.
The scene showed a group of responders
and investigators matching the little limbs and
sneakers of children in the body bags.
Even though it was a movie and not real
footage, it took me right back to my stressful
experience and opened an emotional log jam
that never left the deep recesses of my mind.
You see,the brain is the most advanced and
complex image retention mechanism ever cre-
ated.It’s like a camera that doesn’t lose images
due to battery failure and doesn’t have an SD
or sim card that you can remove or easily alter.
Chemical imbalances and physical trauma
Katie Broeker was a bright, young paramedic stu-
dent who left us all too soon. Photo A.J. Heightman
13. www.jems.com jANUARY 2016 | JEMS 11
such as concussions and traumatic brain inju-
ries have almost the same effect as a damaged
computer hard drive or faltering central pro-
cessing unit (CPU).
And,like your computer CPU or hard drive,
your ability to forget or delete traumatic or
stressful experiences from your memory is
seriously impacted and it takes an educated
“technician”or psychologist to find and fix bad
“data sectors,” or redirect or recover lost (or
repressed) images and memories.
HELP IS AVAILABLE
Stress is recognized and unavoidable as part of
the job in public safety and military roles.But
it’s also one of the least-discussed problems
addressed by individuals and their agencies.
Length of service, ego, fear and shame are
common reasons personnel avoid discussing
the crippling stress,nightmares or depression
they’re experiencing.
However, with the increasing number of
reported suicides in public safety agencies,we
have to pay closer attention to the debilitating
effects of stress, particularly in the aftermath
of a critical incident.
And it’s not just the stress of EMS that’s
causing problems for emergency responders.
Failed relationships, alcohol abuse, financial
problems,work harassment,obesity and a loss
of self-esteem can compound stress and cause
people to spiral out of emotional control.
Jeff Mitchell,PhD,noted psychologist and
founder of the International Critical Inci-
dent Stress Foundation (ICISF) program,
reminded me recently that when people are
overly stressed and lose their self-esteem, it
often transfers to self-loathing,which can put
them in a dangerous and fragile state of mind.
If they begin to think the pain of dying is less
than the pain of continuing to live, they may
contemplate taking their own lives.If they feel
there’s no hope for the future, their situation
becomes even more personally threatening.
In the October 2015 issue of JEMS,an epic
study by Reviving Responders,a group of EMS
personnel born out of a research assignment
at Fitch & Associates’ Ambulance Service
Manager Program, pointed out the preva-
lence and severity of EMS provider stress in
the workplace.
In the study,critical stress (CS) was defined
as: “The stress we undergo either as a result
of a single critical incident that had a signif-
icant impact upon you, or the accumulation
of stress over a period of time.”3
This study included responses from 4,022
emergency responders,showed that stress has a
strong emotional impact on providers,regard-
less of their years of service. It also showed
that 86% of the respondents experienced CS.
More shocking, 37% reported they had con-
templated suicide, and 6.6% said they had
actually attempted to take their own life—an
act that probably went unnoticed.3
Most distressing to the researchers and oth-
ers was the fact that,while 40% of the respon-
dents reported they had either contemplated or
attempted suicide and had access to support,
they didn’t seek help because they were con-
cerned about how they’d be viewed or treated
at work if they had.
However, for those who had the support
of their service managers and peers,and were
encouraged to utilize the formal support insti-
tutions in place,the suicide contemplation rate
dropped by 66%!3
There’s a critical message in this study:
Every agency needs to ensure their staff
(paid or volunteer) has access to group criti-
cal incident stress management (CISM) ses-
sions and an effective employee assistance
program (EAP) so they can obtain counseling
in a rapid and confidential manner.And they
should be encouraged to participate in them.
The fact is, however, that many agencies,
particularly volunteer agencies, either don’t
have an EAP or the one they have isn’t effective
because the affiliated counselors don’t under-
stand the complexities and stressors involved in
EMS. But there are solutions for that.Mitch-
ell notes that services seeking a therapist who
truly understands the demands and stressors in
public safety can usually find one who is closely
involved with their CISM program—therapists
and psychologists who have learned over time
and through extensive training and experience
to understand and appreciate our problems.
Many agencies now have stress recogni-
tion and management as a high priority. The
National Association of EMTs (NAEMT),the
American Ambulance Association (AAA) and
the International Association of Fire Fighters
(IAFF) all have programs designed or under
development to address this silent, apolitical
epidemic.
The IAFF has pilot programs underway
offering advice to emergency responders on
how to react to stress,such as an online,interac-
tive behavioral health awareness course to help
address the stigma surrounding these issues in
the fire service.4,5
The course provides a basic
overview of common behavioral health prob-
lems and available treatment options,informa-
tion on balancing work and life stressors, and
information on how to improve the behavioral
health services offered in local departments.
In addition, the IAFF will soon launch a
new peer support training program that gives
members the knowledge and skills they need
to implement and sustain an effective peer
support team in their department.
In addition to excellence in advocacy,AAA
membership now offers benefits never before
available to many volunteer and moderate
call volume EMS agencies. The AAA has
expanded its membership categories (and
rates), to enable volunteer agencies, munici-
pal agencies,manufacturers,state associations
and international services to join and receive
important benefits such as CISM and an EAP.
These benefits include:
>> Free access to a Ceridian LifeWorks
EAP for EMS staff, including up to
three free in-person counseling sessions
per employee/volunteer member;
>> Free CISD counseling should a traumatic
event, active shooter, or staff death occur
and a member service needs a team(s) from
outside their region;
>> Human Resources and operations tool-
kits covering workplace violence, suicide
prevention, intercultural communication,
and more;6
For information on AAA membership cat-
egories and rates, visit www.AAA.com.
NAEMT is also taking an active role in
this area, bringing mental health resources to
members to help them or their coworkers get
the assistance they need, and supporting the
Code Green Campaign.
Two weeks after the March 2014 suicide of
a 25-year-old co-worker’s death, Ann Marie
Farina, EMT-P, and a group of concerned
EMS practitioners from Spokane,Wash.,and
around the country launched the Code Green
Campaign to raise awareness and let those
struggling with mental health issues know they
aren’t alone.Code Green allows EMS practi-
tioners to anonymously share their struggles
with depression,substance abuse and anxiety.
NAEMT reports in their fall 2015 news-
letter that their efforts and the nonjudgmen-
tal, supportive environment offered by Code
Green are already having a positive impact.
Last fall, a 20-year-old EMT wrote to Code
Green about the horror of doing CPR on a
1-month-old baby who didn’t survive.
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FROM THE EDITOR
“I was struck with an indescribable emo-
tional cocktail of helplessness,anger,and sad-
ness …It took everything out of me,”he wrote.
“I feel as though I’m at the breaking point.”
Six months later, he shared an update. His
new posting talked about him seeking help,
being diagnosed with PTSD, depression and
anxiety, and the changes it meant for his life.
“Today I look back,in awe that I could ever
get to such a low point … This website, my
therapist, my doctor, and my support system
saved my life …If you are struggling,you can’t
do it alone. Be vocal, lose your pride and get
some help.”
NAEMT is calling on EMS agencies to
ensure they establish an environment that
supports their EMS practitioners in reporting
problems,seeking help and providing training
to help them cope and build resiliency.
NAEMT’S EMS Workforce Committee
has compiled a valuable collection of mental
health resources that practitioners and agen-
cies can turn to for information about suicide
prevention, depression, anxiety and how to
prevent mental health issues from developing
by improving their resiliency.
The NAEMT listing of helpful articles,
treatment and prevention programs, hotlines
and websites is available at www.naemt.org
and via links attached to the Web version of
this article.
CONCLUSION
Don’t let the demons of stress defeat you or
your co-workers.Recognize that we all experi-
ence stress and that some of us receive higher
doses than other.
Talk about your stress with trusted con-
fidants and take the steps necessary to get
professional counseling when you feel stress
is winning.
With emergency service suicides 10 times
that of the general populace,6
it’s critical we
all address this area so we don’t lose our most
valuable resource: our personnel.Please make
this one of your top priorities in 2016; JEMS
and PennWell Corp.are,by offering multiple
expert sessions at our 2016 EMS Today Con-
ference and Exposition and follow-up articles
in JEMS. JEMS
REFERENCES
1. Clinical depression. (2015.) Treatment4Addiction.com.
RetrievedNov.17,2015,fromwww.treatment4addiction.com/
conditions-disorders/mood/clinical-depression/.
2. Thompson P. How the crash of United Flight 232 changed the
waywefly.(July19,2014.)FlightClub.RetrievedNov.17,2015,
fromhttp://flightclub.jalopnik.com/how-the-crash-of-united-
flight-232-changed-the-way-we-f-1606999239
3. NewlandC,BarberE,RoseM,etal.Criticalstress:Surveyreveals
alarming rates of EMS provider stress & thoughts of suicide.
JEMS. 2015;40(10):30–35.
4. Reactions to traumatic stress. (n.d.) IAFF. Retrieved
Nov.17,2015,fromwww.iaff.org/et/jobaid/eap/reactions_to_
traumatic_stress.htm.
5. Morrison P, Leto F. Behavioral health and suicide awareness.
(n.d.) IAFC. Retrieved Nov. 17, 2015, from www.iafc.org/files/
3LMIconf2013/lmi13_FireFighterHealth.pdf.
6. EMS mental health. (n.d.) NAEMT. Retrieved Nov. 17, 2015,
from www.naemt.org/emshealthsafety/ems-mental-health.
Hear more from A.J. Heightman and about
important stress and suicide prevention topics at
the EMS Today Conference & Expo in Baltimore,
Md., February 25–27, 2016. EMSToday.com
TM
15. www.jems.com jANUARY 2016 | JEMS 13
LETTERSIN YOUR OWN WORDS
LEFT WANTING MORE
I picked up the July issue of JEMS last night
at my volunteer fire department meeting and
thoroughly enjoyed reading the “Impaled &
Obese” article. As an ED RN, who’s taken a
Mobile Intensive Care Nurse (MICN) course
for responding to incoming calls from vari-
ous ambulances,I’m left with some questions
about the case.
I’m asking myself, what would I have
thought about the request for sodium bicar-
bonate? First, did the Level 2 trauma facility
utilize an MICN to answer their radio? If
not,who answers,and do they
follow a written protocol or
is a physician at the radio to
answer specific requests? Also,
when the second request was
made for sodium bicarbon-
ate,was it to the same medical
command or a different one
(the Level 1 trauma center)?
How did the paramedic
feel when the first request
was denied? Was there a post-
call review? Is there a review
protocol? I’m not even sure
sodium bicarbonate would
have been the best call—the
Emergency Nurses Association’s Trauma Nurs-
ing Core Course book says that evidence of the
benefits hasn’t been clearly established. But,
I think it was an extremely heads-up good
call regardless.
I also read that calcium gluconate could be
used to treat hyperkalemia to protect against
cardiotoxic effects and even possibly insulin
since the patient was a diabetic with an ele-
vated blood glucose level. I’m wondering so
that if I’m ever faced with a similar request, I
know more about making the best response.
I do wish we were all on the same page
working together for the best outcomes for
our patients. The local hospital I work at as
an EMT-B isn’t the same hospital I work at
as an RN and I think the communication and
respect of the hospital staff toward EMS pro-
viders could be hugely improved with some
case reviews and open discussion of what each
other’s expectations are.
Thank you for a great article,but I’m wait-
ing for “the rest of the story.”
Diana Braun, RN, EMT-B
Via email
AUTHOR MATTHEW KUNKLE,
EMT-PM, CCP, RESPONDS:
There are several issues with crush injuries.In
our case, the patient’s leg had been without
perfusion for 12–24 hours, meaning anaero-
bic metabolism had taken place creating lactic
acid, myoglobin from muscle tissue necro-
sis and other toxic byproducts. When cells
are damaged they release potassium, caus-
ing hyperkalemia. There are several treat-
ments that cause the potassium to re-enter
the cells—albuterol, D50 with insulin, and
calcium chloride—but the ECG performed
didn’t show peaked T waves usually found
in hyperkalemia.
On scene, I was very concerned with the
patient’s pH.Studies show that the amount of
myoglobin precipitated in the urine is directly
proportionate to the patient’s pH: the more
acidic,the more severe the rhabdomyolysis (on
arrival at the ED the patient’s pH was 7.1). I
wasn’t happy when the local Level 2 hospital
denied my request for sodium bicarbonate,and
I was speaking with an ED physician.
We have two local Level 2 EDs, both of
which have physicians to
answer the radio as medical
control. However, we were
diverted from the scene to a
Level 1 ED 25 minutes away.
As soon as we were loaded,
I contacted the Level 1 ED
for medical control,requested
and received an order for 2
ampules of sodium bicar-
bonate.There was a post-call
review and from that we now
have a protocol in place that
allows for the administration
of sodium bicarbonate with-
out calling medical control.
There are crush injury protocols online from
several services that I’ve looked over, and all
included bicarbonate to combat the lactic acid.
From my studies, D50 has to be given with
insulin for the effect on potassium to occur;
we don’t carry insulin in part because it needs
to be refrigerated.
Crush injuries are very interesting calls and
I’m hoping in the near future our protocols
will be able to be more up-to-date and allow
more aggressive treatment on scene.
QUESTIONS & ANSWERS
This month, Matthew Kunkle, EMT-PM,
CCP, answers questions about his Case of
the Month, “Impaled & Obese: Trauma
isn’t always the most important aspect at
the scene,” from the July issue. In the arti-
cle, Kunkle’s 400-pound patient has fallen
and impaled himself on two wooden dow-
els of a magazine rack. His right leg, which
he’s been sitting on for 12–24 hours, pres-
ents with cyanosis.
There was a post-call review
& from that we now have a
protocol in place that allows
for the administration of
sodium bicarbonate without
calling medical control.
16. 14 JEMS | JANUARY 2016 www.Jems.com
PRIORITY TRAFFICNEWS YOU CAN USE
Legislative SUPPORT
A review of state laws supporting mobile integrated healthcare
I
nnovation often happens at a faster pace than rules governing
the delivery model are established,and mobile integrated health-
care (MIH) has been no exception. During a presentation at the
November 2015 American Ambulance Association conference,noted
EMS legal expert and JEMS editorial board member Doug Wolf-
berg, JD, EMT, stated that many states don’t have specific legislation
supporting or prohibiting the delivery of MIH and community para-
medicine (MIH-CP).
Further,because the published reports about MIH programs across the
country demonstrate the inherent benefit to the patients in the programs,
he commented that some providers are using the tried and true philoso-
phy,“sometimes it’s easier to seek forgiveness than to gain permission.”
Some states—usually at the behest of tenacious EMS providers—
have passed legislation specifically supporting MIH-CP program
development. Following is a summary of legislation enacted in the
past three years that specifically relates to MIH-CP.
Arkansas: House Bill 1133 Act 685 was enacted this year.The law
creates a program for licensure of community paramedics and allows
community paramedics to provide services as directed by a patient
care plan after the plan has been developed, approved, or both by the
patient’s physician in conjunction with the community paramedic’s
agency’s medical director.
Idaho: House Bill 153 was enacted in 2015.It defines “community
health EMS”as the evaluation,advice or treatment of an eligible recip-
ient outside of a hospital setting,which is specifically requested for the
purpose of preventing or improving a particular medical condition,and
which is provided by a licensed EMS agency.It also defines a “commu-
nity emergency medical technician” and an EMT or advanced EMT
with additional standardized training who works within a designated
community health EMS program under local medical control as part
of a community-based team of health and social services providers.
Maine: Public Law Chapter 562 was enacted in 2012.It allows the
Maine EMS Board to authorize up to 12 pilot projects throughout
the state. Working under the supervision of a primary care provider,
community paramedics can work with chronically ill patients who are
at risk for hospital readmission. Community paramedics can also do
follow-up care for patients referred by healthcare providers including
vital sign checks, clinical evaluations, assure medication compliance
and conduct treatments.The law also requires the EMS Board to sub-
mit a written report to the legislature that summarizes the work and
progress for each authorized pilot.
Massachusetts:House Bill 3650 was enacted in 2015 and becomes
effective Dec. 31, 2015. It requires the Massachusetts Department of
Public Health to evaluate and approve “community EMS programs”
and other MIH programs developed and operated by the primary
ambulance service with the approval of the local jurisdiction and the
affiliate hospital medical director. These programs can provide com-
munity outreach and assistance to residents of the local jurisdiction in
order to advance injury and illness prevention within the community.
The law also establishes a statewide MIH advisory council.
Minnesota:Senate File 0119 Session Law Chapter 12 was enacted
in 2011. It defines EMT-community paramedics (EMT-CP) and
establishes a process for certification. It also establishes training and
clinical requirements for certification,including completion of a com-
munity paramedic training program from an approved college or uni-
versity, and authorizes community paramedics to provide services as
directed by the patient’s primary care physician. It also enables com-
munity paramedics to provide specific health services, as well as pre-
vention,emergency care,evaluation,disease management and referrals.
A subsequent Bill, Senate 1543, enacted in 2012, authorizes medi-
cal assistance (Medicaid) reimbursement rates as determined by the
Human Services Commission to cover community paramedic services
to certain high-risk individuals,including frequent ED users or other
patients who have been identified as at-risk for hospital readmission.
Missouri: House Bill 653 was enacted in 2013. It authorizes para-
medics who receive additional education and certification to serve
as community paramedics—working under a medical director—to
provide healthcare services to populations with limited access to pri-
mary care services.It specifies that a community paramedic shall prac-
tice in accordance with protocols and supervisory standards established
by the medical director and shall provide services of a healthcare plan
if the plan has been developed by the patient’s primary physician or
by an advanced practice registered nurse or a physician assistant and
there’s no duplication of services to the patient from another provider.
Nevada: Assembly Bill 305 was enacted in 2015. It creates a defi-
nition of community paramedicine services that are provided by an
EMT, advanced EMT or paramedic to patients who don’t require
transportation to or services at a hospital and provided using mobile
equipment in a manner that’s integrated with the healthcare and
social services resources available in the community.It goes on to state
that such services may include, without limitation, transportation to
a facility other than a hospital, which may include a mental health
facility, and the provision of healthcare services provided to patients
on a scheduled basis.
Ohio: House Bill 64 was enacted in 2015. Section 4765.361 allows
EMTs and paramedics employed by public agencies to work on patients
in nonemergency situations.The law also states that in nonemergency
situations,no medical director or cooperating physician advisory board
shall delegate,instruct or otherwise authorize a technician to perform
any medical service that the technician isn’t authorized by law to per-
form. Due to a unique governance board arrangement, this law only
applies to publicly employed EMTs and paramedics.Private providers
are governed by a different set of rules and laws.
Tennessee:Senate Bill 2029 was enacted in 2014.It did two things for
EMS personnel:1) It allows them to provide non-emergent patient care;
and 2) Prohibits them from functioning as home care organizations.
17. www.jems.com jANUARY 2016 | JEMS 15
As enacted,it revises duties and the authority
of EMS personnel in regard to the provision
of certain care and treatment, including in
nonemergency settings.The previous law only
allowed personnel to function in an “emer-
gency”setting while still specifying that pro-
viders aren’t authorized to function as a home
care organization.
Washington: Senate Bill 5591 Chapter 93
was enacted in 2015.It authorizes EMS pro-
viders that levy an EMS tax and federally rec-
ognized Indian tribes to establish community
assistance referral and education services pro-
grams. It also allows EMTs, advanced EMTs
and paramedics to provide care in nonemer-
gency and non-life-threatening situations if
they’re participating in a program and the care
provided doesn’t exceed their training and cer-
tification standards. JEMS
— Matt Zavadsky, MS-HSA, EMT
PATIENT
ABANDONMENT ISSUES
Arecent incident in New York—where a pri-
vate ambulance transporting a patient from
a hospital to an assisted living center stopped to
assist a 7-year-old choking victim—generated
significant discussion after the EMT who stopped
the ambulance to assist the young girl was sus-
pended from his job.
According to news reports, the first patient was
in the back of the ambulance with an EMT while
the EMT driver got out to assist the choking child.
There’s no indication the first patient suffered any
compromise or harm as a result of this delay in
transport. The big question was: Did he abandon
the first patient by assisting the second patient?
Thissituationraisesbothlegalandethicalissues.
Whether the first patient was “abandoned” is a
question of both law and fact. Medical dictionar-
ies generally define abandonment as the unilateral
termination of the provider/patient relationship at
a time when continuing care is still needed.
Abandonment is really a form of negligence
under common law principles. It’s hard to prove,
as a plaintiff must show there was a duty to the
patient,andthatthisdutywasbreachedbyceasing
to provide care when it was still needed.
Typically, if an EMS provider is already engaged
in the care of one patient, there would generally
not be a duty to initiate care for the second patient
whom the EMS provider comes upon. But negli-
gence is all about reasonableness. Juries could find
you negligent if you didn’t act as a reasonable and
prudent EMS provider would, given the same or
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PRIORITY TRAFFIC
similar circumstances. If you did absolutely noth-
ing to assist a critical patient you came upon while
transporting a stable patient in no distress, a jury
could potentially find that you had a duty to assist
that second patient. What may be “reasonable” to
one juror may not be reasonable to another.
So whether there was legal abandonment
really depends on the situation. If the
first patient was in dire need of medical
assistance and suffered harm as a result
of the ambulance stopping for a second
patient, then the EMS provider’s actions
would be more likely negligent than if
the first patient suffered no harm. But if
the first patient was simply being trans-
portedunderroutineconditionswithno
need for medical interventions and the
delay didn’t harm that patient while assisting the
second patient, a successful claim of negligence
would be unlikely.
Anytimeanambulanceistransportingapatient
and a second patient who needs help suddenly
appears or the ambulance literally has to drive by
thatpatientontherouteoftravel,ethicaldilemmas
emerge. Should the ambulance stop? Should the
ambulance contact dispatch for a second unit to
be sent? Should the ambulance keep going with-
out interrupting the first transport? There’s simply
no easy answer as it all depends on the situation
and using common sense and good judgment to
help those who need care the most.
The key to avoiding potential legal and ethi-
cal issues in these situations is to preplan accord-
ingly. This means developing a policy that defines
what should be done when encountering this
situation and educating everyone on that policy.
Under what circumstances would it be permissi-
ble for the ambulance to stop and assist a second
patient? The typical scenarios can be defined. But
not everything can be defined, and sometimes we
havetorelyoncommonsenseandgoodjudgment
in the hopes of making the best decision possible
for the patients involved when confronted with
conflicting interests.
As Jim Page said in his classic book The Magic of
3A.M., “In the process of trying to keep everybody’s
rearcovered,wetendtoforgetthattheexceptional
performersinEMSoccasionallyneedthe
liberty to do what they do best—make
quick decisions and stick their neck out
to save a patient. There will always be a
need for people who are brave enough
tothinkforthemselvesandtakeachance
when a human life is at stake.”
There’s no protocol for every difficult
situation we’ll encounter, and at times
we need to see the bigger picture and
do what we think is right, or in the best interest of
all concerned when the situation doesn’t fit the
policy or procedure. JEMS
Pro Bono was written by the attorneys at Page, Wolfberg
& Wirth, The National EMS Industry Law Firm. Visit the
firm’s website at www.pwwemslaw.com or find them
on Facebook, Twitter or LinkedIn.
Abandonment is really a
form of negligence under
common law principles.
19. www.jems.com jANUARY 2016 | JEMS 17
TM
Inpartnershipwith
MANAGEMENT FOCUSSTAY ON TOP OF YOUR GAME
SELF ATTRIBUTESCompetencies for current & aspiring leaders
By Michael Touchstone, BS, EMT-P
H
appy 2016! Over the course of this
new year, I’ll be using the National
EMS Management Association’s
Seven Pillars of EMS Officer Competencies as
a framework for this column.This document,
which can be downloaded at www.nemsma.
org, outlines a competency model breaking
down best practices to describe the seven key
components of a successful EMS leader.
I’m skipping the first pillar, which is made
of general job performance prerequisites,and
jumping right into dissecting the second pil-
lar: self attributes. This pillar includes com-
petencies in the following categories: work
habits, work attitudes, stress management,
self-insight and learning.
WORK HABITS
A competent supervisor demonstrates time
management skills and will be able to effi-
ciently and effectively plan and structure the
workday, prioritizing effort to ensure time is
concentrated on the most important items and
tasks.Multitasking is important in that activ-
ities are regularly interrupted by emergency
responses, unplanned events and a constant
stream of emails and telephone calls. There
are many tools and methods to help manage
your time and control your days.
Goal orientation is related to time manage-
ment, and both require the supervisor to plan
and prioritize.Setting attainable yet challenging
goals is important to professional development,
personal growth and achieving job success.
Organizational skills include the ability to
organize work flow to ensure assignments are
completed in a timely manner and roles and
responsibilities are met efficiently and effectively.
A successful supervising officer demon-
strates a work ethic through action by accom-
plishing tasks while treating people with
respect, fairness and honesty.The work ethic
includes a professional and caring attitude
when working to meet the needs of both inter-
nal and external customers.
WORK ATTITUDES
The work attitudes of a competent supervis-
ing officer include initiative,effort,persistence,
energy and optimism. Initiative is beginning
and completing a task without prompts.Effort
is demonstrated by exertion and serving as
a role model for staff. Continuing to work
through problems, overcoming obstacles,
defeating challenges, breaking down barriers
and achieving goals demonstrates persistence
and energy. Maintaining a positive attitude,
even in the face of difficulties,shows optimism.
STRESS MANAGEMENT
The work we do is demanding and there are
many stressors. Add non-work stressors such
as home life,school,kids,finances,health and
family,and we have a high level of stress in our
lives.We must learn to better control ourselves
and how we respond to stress.
For example, after a long week I was
stopped in major traffic while headed home
when a woman in a car wanting to make a left
turn chose that moment to yell at me,“You’re
blocking my turn! You should know better!”
You can imagine what I really wanted to say.
However, I maintained control and took sev-
eral deep breaths.Needless to say,I was stressed
and aggravated the rest of the drive home.
This sort of treatment is hard to tolerate, but
we’re faced with stress constantly and we must
have a level of stress tolerance and resiliency
to survive and thrive.
Maintaining a balance between work and
home life is also critical to keeping stress under
control.And finally,keeping up with changes
in healthcare science and practice and adapt-
ing our lifestyle accordingly is critical to being
healthy and stress free.
SELF-INSIGHT
The competencies included in the self-insight
domain are: self-confidence, self-awareness,
self-reliance, humility and suspended judg-
ment.To achieve these, spend time reflecting
on behavior and actions to perform an honest
assessment. You can gain valuable insights by
using a 360-degree assessment—asking your
subordinates,your peers and superiors to eval-
uate your behaviors,actions and performance.
Balancing each of the five competencies that
make up self-insight requires work,concentra-
tion,honesty and ongoing situational awareness
on several levels:the personal and interpersonal
level,the incident or event level,the organiza-
tional level and multiple “community”levels.
LEARNING
The competencies in the learning category
relate to scholarship and both formal and
informal education.They’re not only import-
ant for the supervising officer, but also to the
staff they supervise and the individuals the
supervisor works for.People who demonstrate
these competencies will strengthen and accel-
erate personal and professional development,
will facilitate the growth and development
of subordinates, and contribute to the overall
improvement of the organization.
CONCLUSION
A successful supervising EMS officer should
strive to demonstrate the self attributes com-
petencies through their actions and behaviors.
These competencies provide a guide for anyone
who is, or aspires to be, a supervisor people
respect and want to emulate. JEMS
Michael Touchstone, BS, EMT-P, is the
regional director for the Philadelphia
Regional Office of EMS and president of the
National EMS Management Association. He
holds a BS in health sciences from George
Washington University and has completed the coursework
for an MA in security studies from the
Naval Postgraduate School (thesis
in progress).
Learn more from Michael Touchstone at the
EMS Today Conference & Expo, Feb. 25–27, in
Baltimore, Md. EMSToday.com
20. 18 JEMS | JANUARY 2016 www.Jems.com
BACK TO BASICSCASES IN BLS CARE
A HOLIDAY HEARTHow celebratory excess drinking can affect your patient
By Dennis Edgerly, BS, EMT-P
I
t’s New Year’s Eve and the ball is about to
drop. You and your partner respond to a
party that’s been going for several hours
to care for a person who’s dizzy.Making your
way through the streamers and horns, you’re
ushered to a back bedroom where you’re intro-
duced to Uncle Bill.
Uncle Bill is 52 years old and lying on the
bed.He looks up at you and says,“Something’s
not right,boys.”You reach to feel his pulse and
ask what he means by his statement.
You note the smell of alcohol on his
breath as he tells you the evening
was going great until he suddenly
felt faint and his heart began to race.
He sat down and had a glass of water
but the symptoms remained.His sis-
ter helped him to the bedroom and
called 9-1-1.
He tells you he never actually
passed out nor did he fall or injure himself,
and,when asked,he tells you nothing like this
has ever happened before. His pulse is about
130 and irregular.His skin is cool and clammy
and he’s “a little short of breath.” Uncle Bill
reports a past medical history of hypertension
controlled with Prinivil (lisinopril) and high
cholesterol treated with Zocor (simvastatin).
He also says he’s a borderline diabetic but isn’t
medicated for that condition.
When asked about alcohol consumption,he
says, “Hey, it’s New Year’s Eve, of course I’ve
been drinking!” but then says he rarely ever
drinks alcohol in excess. Uncle Bill’s blood
pressure is 100/68 and a dextrose stick reveals a
blood glucose level of 200 mg/dL.The remain-
der of the history and physical are unremark-
able, including no chest pain and clear lung
sounds,but he remains tachycardic and dizzy.
Your partner applies oxygen via nasal can-
nula as you load Uncle Bill into the ambulance,
where you establish IV access.Transport to the
hospital is uneventful. Uncle Bill’s symptoms
don’t change as you give your hand-off report
to the ED staff.
HOSPITAL COURSE
The ED staff acquires a 12-lead ECG that
reveals rapid atrial fibrillation.Labs reveal no
indication of cardiac ischemia and a cardiac
echo revealed what appears to be normal ven-
tricular wall function.Uncle Bill’s blood alco-
hol content (BAC) was 0.198 (0.08 is legally
intoxicated), so he received a liter of IV fluid,
which increased his blood pressure to 124/80.
About an hour after arrival his cardiac
rhythm converted to a normal sinus rhythm.
He was kept for an observation period,during
which time his BAC decreased,and his blood
pressure and cardiac rhythm remained in nor-
mal ranges without change. Uncle Bill was
released with a referral to a cardiologist and
a diagnosis of cardiac induced arrhythmia and
holiday heart syndrome (HHS).
DISCUSSION
Consumption of small amounts of alcohol
may be beneficial, but the cardiac effects of
excessive alcohol consumption are well known
and include cardiomyopathy,which causes the
heart to work inefficiently.Long-term effects
of alcoholic cardiomyopathy include heart fail-
ure and arrhythmias.Typically, this is seen in
those persons who chronically consume large
amounts of alcohol. In 1978, Philip Ettinger,
MD, identified a relationship between binge
drinking and the development of cardiac
arrhythmias in normally healthy persons.1
This
condition was coined HHS because binge
drinking commonly occurs around holidays
such as New Year’s. Most of the arrhythmias
identified with HHS were atrial in nature.
Atrial fibrillation was the most common, but
atrial flutter,atrial tachycardia and ventricular
ectopy were also noted.
When the heart develops a rhythm like atrial
fibrillation,the atria stop contracting in unison,
which decreases the amount of blood moving
through the heart.This causes a drop in blood
pressure that can result in syncope or dizziness
and, in response, the body increases the heart
rate.2
The mechanism of HHS isn’t
fully understood, but alcohol affects
the conduction paths of the heart
and there’s commonly a sympathetic
response that,in combination,may be
the trigger for the atrial arrhythmias.
Treatment for HHS is mostly
supportive while monitoring for
lethal arrhythmias,dangerous drops
in blood pressure and signs of acute
heart failure. Treat decompensating patients
per normal cardiac guidelines as indicated.
The patient described here had several risk
factors and his signs and symptoms could have
been caused by several things. Just as pro-
viders shouldn’t assume all intoxicated dizzy
patients are “just drunk,”they shouldn’t assume
all arrhythmias found in intoxicated patients
are alcohol induced. Other causes such as
myocardial infarction must be considered.Be
complete and thorough with your assessment
including history and the physical exam. JEMS
REFERENCES
1. Ettinger PO,Wu CF, De La Cruz C Jr, et al. Arrhythmias and the
“Holiday Heart”: Alcohol-associated cardiac rhythm disorders.
AmHeartJ. 1978;95(5):555–562.
2. Tonelo D, Providência R, Gonçalves L. Holiday heart syndrome
revisitedafter34years.ArqBrasCardiol.2013;101(2):183–189.
Dennis Edgerly, BS, EMT-P, began his EMS
careerin1987andiscurrentlytheparamedic
education coordinator for the paramedic
educationprogramatHealthONEEMS.Reach
himatdennis.edgerly@healthONEcares.com.
‘Hey, it’s New Year’s Eve,
of course I’ve been
drinking!’
21. 2016 EVENT PREVIEW
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24. TOP 10REASONS YOU SHOULD ATTEND
EMS TODAY 2016
DON’T FORGET TO TAKE PICTURES
WITH “A.J” AND POST TO SOCIAL
MEDIA #EMSTODAY2016
By A.J. Heightman, Editor in Chief, JEMS
10. Attend innovative preconference workshops, including cadaver
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8. Hear cutting-edge lectures on today’s most important clinical issues.
7. Earn NEMSMA EMS Supervising Officer credential credits from
more than 50 sessions.
6. Listen to keynote speaker Brian O’Malley, a world-famous
expedition traveler, paramedic/firefighter, police officer and
SWAT team member.
5. Saturate yourself with information on active shooter response,
preparedness and protection.
4. Learn, have fun, earn CEH and root for the teams engaged in the
JEMS Games “Excellence in EMS” Clinical Competition.
3. Learn about dozens of new products on our exhibit floor.
2. At least twelve conference sessions focused on how to understand and fight
EMS stress and depression.
1. Network through fun events such as ride-alongs, tours of world-
renowned specialty centers and the popular ZOLL SHOCKFEST party!
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27. www.jems.com jANUARY 2016 | JEMS 25
CASE OF THE MONTHDILEMMAS IN DAY-TO-DAY CARE
DELAYED DEATHInitial findings in strangulation injury aren’t indicative of outcome
By Abigail T. Harning, EMT-P, MEd
P
olice and EMS are dispatched for a
domestic dispute as reported by a
neighbor who states he heard a distur-
bance.The crew responds for a female patient
with a head injury.She’s seated in a chair speak-
ing to a police officer as the crew enters the
front of the home.Her husband is being inter-
viewed by other police officers outside.
As she sees the EMS crew enter, she tells
the police officers, “I told you I don’t want to
go to the hospital.I’m fine.Why are you mak-
ing such a big deal out of this? Married people
are still allowed to argue, aren’t they?”
The patient has a small, red, swollen area
about 1" in diameter over the left brow. She
says their toddler accidentally kicked her in the
head while she was putting his shoes on. She
has no other visible injuries, but appears to be
about 7 months pregnant.
The crew calmly reassures her their concern
is for her and her baby’s welfare.She reluctantly
agrees to have her vitals taken and cooperates
with a focused physical exam. Her respiratory
rate is 22, heart rate is 128, blood pressure is
148/80 and SpO2 is 99%. She’s agitated and
her hands are trembling.
Five minutes later,when she appears visibly
calmer, her respiratory rate is 18, heart rate is
104,blood pressure is 126/74 and SpO2 is 98%.
The patient and her husband both insist
there was no physical altercation—they simply
had a disagreement. The furniture is in place
and the police find no property damage. A
detailed patient refusal is completed, signed
by the patient and witnessed by a police officer.
The next day,9-1-1 is called back to the res-
idence by the patient’s sister, who requested a
welfare check when her sister failed to show
up at work. The EMS crew finds last night’s
patient dead, lying supine in bed with rigor
mortis and lividity.There’s no sign of a strug-
gle and no obvious signs of external injuries.
The EMS providers are left wondering what
went wrong.Did they miss any signs the patient
was gravely injured? Could something have
been done to convince the patient to cooperate?
POSTMORTEM FINDINGS
Media outlets soon report the patient died
unexpectedly from strangulation injuries.The
crew is called to meet with investigators and
the patient care report (PCR) is subpoenaed.
Questioning of the crew throughout the inves-
tigation and court hearing is consistent:Did the
patient have any red discoloration or spots on
her face? Did they notice any subconjunctival
hemorrhage? Was her voice muffled,harsh or
raspy? Had they inspected her neck and shoul-
ders for signs of soft tissue injury?
The PCR describes the patient as having
no apparent injuries in addition to the small
hematoma over her left brow.The crew learns
it would’ve been more accurate to document
that the patient denied additional injuries,and
that a visual inspection of the patient revealed
no obvious injuries, but that she was wearing
jeans and a long sleeve shirt with a scarf around
her neck. During the autopsy, injuries were
documented that wouldn’t have been plainly
visible to the crew.
Both crew members recall red spots on her
face they assumed were due to a skin con-
dition. Those marks were petechial hemor-
rhages due to strangulation injury. They did
document subconjunctival hemorrhage in the
right eye,which they were aware is often due to
sneezing or coughing,and are minor and self-
limiting.They were unaware these can also be
an indication of strangulation injury.
DISCUSSION
It’s important to distinguish between stran-
gulation, suffocation, choking and smother-
ing.Strangulation is a form of asphyxia caused
by mechanical obstruction of blood vessels or
the airway.1
Suffocation occurs when a person
has been inhibited from breathing.2
“Choking”
means to mechanically obstruct the upper air-
way,and smothering is mechanical obstruction
of airflow through the mouth and nose.1
Strangulation accounts for 10% of violent
deaths in the United States,with most victims
being female.3,4
It’s an extremely common and
serious consequence of domestic violence:Up to
68% of domestic violence victims suffer stran-
gulation by their male partner in their lifetime.1
The initial patient presentation isn’t reliably
predictive of outcome,and is often subtle and
underappreciated by everyone involved.Histor-
ically,limited detection,medical evaluation and
treatment have led to subsequent deteriorationIn ligature strangulations, a rope, chain or other object is used. Photo Edward T. Dickinson
28. 26 JEMS | JANUARY 2016 www.Jems.com
CASE OF THE MONTH
and bad outcomes, and left persecutors with-
out adequate proof to intervene.1
Strangulation can be a means of suicide and
can also occur accidentally, despite the vio-
lent nature often associated with these inju-
ries.“Choking games”and autoerotic behavior
can lead to accidental strangulation, and are
most common in teenagers and young adults.3
In children, strangulation sometimes occurs
when a child’s body fits through a railing, but
the head is too large to pass through the same
opening. Children may also suffer accidental
strangulation due to curtain cords or ties on
hats and hoods.
PATHOPHYSIOLOGY
The structures of the neck are poorly pro-
tected and extremely vulnerable to severe
injury. Vascular injuries due to strangulation
aren’t uncommon. Venous obstruction leads
to cerebral stagnation and petechial hemor-
rhages develop due to lack of drainage of the
deoxygenated blood.Continued obstruction of
venous blood flow may cause ruptured blood
vessels and hemorrhagic stroke.Carotid pres-
sure causes low cerebral blood flow and cerebral
hypoxia. A single blocked carotid artery can
cause neurologic findings on the opposite side
of the body due to cerebral hypoxia.Thrombo-
sis can form in blocked vessels. Embolization
of the clot to the brain can result in an isch-
emic cerebral vascular accident. Bradycardia
and cardiovascular collapse occur from pres-
sure on the carotid sinuses,overstimulating the
vagal nerve and increasing parasympathetic
tone.1
(See Table 1.)
Mechanical airway compromise plays a
minimal role in the immediate death of vic-
tims of strangulation.2
Several reports exist of
suicidal post-tracheostomy patients who suc-
cessfully hung themselves with ligatures well
above the tracheostomy, where death wasn’t
related to spinal cord injury.3
In cases where
death isn’t immediate,the risk of delayed airway
obstruction is significant due to swelling.Stran-
gulation injuries can also result in delayed death
due to vascular injuries, stroke, dysrhythmias
and hypoxic brain damage.
Victims of strangulation often trivialize their
injuries and fail to report strangulation due to
a misconception that if you survived the event,
you’ll be OK.Victims will often try to protect
their attacker,who’s often closely related to the
victim.Sometimes the perpetrator prohibits the
victim from seeking aid.In many states,stran-
gulation is being given felony-level prosecution
due to the lethality of strangulation injuries.4
CONCLUSION
An awareness of the signs and symptoms of
strangulation injuries can help EMS responders
to identify potential victims, provide needed
treatment and make appropriate transport deci-
sions,and properly document physical findings.
Knowledge of the many potential complica-
tions of strangulation,including delayed death,
will allow EMS providers to better educate
their patients and possibly convince victims
to seek care and crisis intervention before the
situation become fatal.When an index of sus-
picion is raised due to historical information
or physical exam findings, it’s appropriate to
ask directly if the patient was grabbed,choked
or strangled during an assault.2
If an unreported strangulation injury is sus-
pected, every attempt to convince the patient
to be evaluated and monitored at the hospital
is essential for the patient’s physical and men-
tal recovery. JEMS
REFERENCES
1. GreenW:Strangulation.InAmericanCollegeofEmergencyPhysi-
cians(Eds.),Evaluationandmanagementofsexuallyassaultedor
sexuallyabusedpatient,2ndedition.ACEP:Dallas,pp.83–90,2013.
2. Faungo D,Waszak D, Strack G, et al. Strangulation forensic
examination:Bestpracticeforhealthcareproviders.AdvEmerg
Nurs J. 2013;35(4):314–327.
3. ErnoehazyW.(June14,2013.)Hanginginjuriesandstrangula-
tion.Medscape.RetrievedAug.24,2015,fromhttp://emedicine.
medscape.com/article/826704-overview.
4. Schwartz A. (Nov. 19, 2010.) Strangulation and domestic vio-
lence: Important changes in NewYork criminal and domes-
tic violence law. Empire Justice. Retrieved Aug. 24, 2015, from
www.empirejustice.org/issue-areas/domestic-violence/case-
laws-statues/criminal/strangulation-and-domestic.html.
Abigail T. Harning, EMT-P, MEd, is a professor for the EMS
department at Erie Community College in Buffalo, N.Y., and
has taught in EMS for over 25 years.
Mental status
Light-headed or dizzy
Loss of memory
Disorientation
Loss of consciousness
Behavioral
Anxiety, fear, agitation,
restlessness, combativeness
Head and face
Subconjunctival hemorrhages
Skin petechiae cephalad to the site of
strangulation, also called Tardieu spots
Vision or hearing changes
Swollen tongue or lips
Neck
Musculoskeletal neck pain
Scratches and fingernail marks, scrapes
and abrasions
Redness and bruising
Pain on gentle palpation of the larynx
Sore throat
Swelling
Ligature marks
Throat
Cough
Stridor
Drooling
Voice changes (muffled, hoarse,
or absent)
Difficult or painful swallowing
Shoulders
Redness, scratches, bruises, abrasions
Chest
Respiratory distress
Pulmonary edema or pneumonia may
develop, but is often delayed as much as
two weeks
Worsening of conditions such as asthma
Abdominopelvic/renal
Nausea and vomiting
Involuntary incontinence
Miscarriage due to fetal hypoxia
Table 1: Signs and symptoms of strangulation
29. www.jems.com jANUARY 2016 | JEMS 27
TM
RESEARCH REVIEWWHAT CURRENT STUDIES MEAN TO EMS
NASTY NOSESStudy examines the risk of MRSA infection in EMS
By Alexander L. Trembley, NREMT-P & David Page, MS, NRP
WASH UP
Orellana RC, Hoet AE, Bell C, et al. Methicillin-
resistant Staphylococcus aureus in Ohio EMS
providers: A statewide cross-sectional study.
Prehosp Emerg Care. Oct. 30, 2015. [Epub
ahead of print.]
We in EMS are involved in a risky business.
The hazards involved in emergency driving,
physical violence and lifting people are risks
we take every day in the service of others. But
what about the risks we can’t see?
Exposure to microscopic superbugs like
methicillin-resistant Staphylococcus aureus
(MRSA) go undetected in our daily work and
can be responsible for prolonged hospitaliza-
tion, amputations and severe organ damage.
A new study from the department of epi-
demiology at the Ohio State University may
offer some insight as to the prevalence of
this bad bug.
Methods:Orellana and his team performed
a first-of-its-kind study on 280 randomly cho-
sen EMS personnel from 84 EMS agencies
in the state of Ohio. Participants were asked
about handwashing frequency,glove usage and
the presence of open wounds. Confounding
factors such as the use of antibiotics or a his-
tory of staph infections were also documented.
Results: Study participants had samples
from their anterior nares gathered with a ster-
ile swab.The samples were then transported
to a lab for further testing.Of the 280 EMTs
and paramedics, 13 (4.6%) tested positive
for MRSA colonies. Further, providers who
didn’t practice regular hand washing after
removing their gloves saw a 10-fold increase
in the risk of MRSA infection (odds ratio:
10.51). EMS workers with an open wound
were nearly seven times more likely to carry
MRSA colonies in their nasal passages.
Discussion: MRSA prevention is a major
focus of healthcare organizations, but it
appears we fall short in EMS. So-called
superbugs like MRSA aren’t going away any-
time soon. This study sampled providers in
every EMS region of Ohio,which means this
isn’t a problem that can be isolated to a sin-
gle service.The presence of MRSA colonies
provides a risk to the patients we treat, not
to mention ourselves and our fellow EMTs
and paramedics.
It’s time to go back to basics.Simple hand
washing is a critical process before and after
taking care of patients, and wearing gloves
makes all the difference. JEMS
AlexanderL.Trembley,NREMT-P,isthequal-
ityresourcespecialistforNorthMemorialAmbu-
lanceinBrooklynCenter,Minn.,andaparamedic
at Lakeview Hospital EMS in Stillwater, Minn.
Reachhimatalex.trembley@gmail.com.
DavidPage,MS,NRP,isthedirectorofthePre-
hospitalCareResearchForumattheUniversity
ofCalifornia,LosAngeles,andafieldparamedic
withAllinaHealthEMSinMinneapolis/St.Paul,
Minn.Sendhimfeedbackatdpage@emsed.net.BOTTOM LINE
What we already know: The rate of MRSA
infection is a growing concern in healthcare.
Whatthisstudyadds: EMS providers have
10 times the risk of carrying MRSA if they
don’twashtheirhandsafterremovinggloves.
FLASHBACK: DIRTY HANDS
Ho JD, Ansari RK, Page D. Hand sani-
tization rates in an urban emergency
medical services system. J Emerg Med.
2014;47(2):163–168.
Do you remember this study performed in
2005?Inthisblindedsix-monthobservational
study, paramedics washed their hands 62%
of the time after patient care activities—but
only 1% before and 3% during care of the
patient. Gloves weren’t worn 12% of the time
andhandsanitationonlyoccurred19%ofthe
time before the crew had a meal.
Learn more from David Page at the EMS Today
Conference & Expo, Feb. 25–27, in Baltimore, Md.
EMSToday.com
CANSTOCKPHOTO/IOFOTO
Visit www.pcrfpodcast.org
for audio commentary.
30. 28 JEMS | JANUARY 2016 www.Jems.com
TM
STREET SCIENCECONVERSATIONS ABOUT EMS RESEARCH
ALS VS. BLSAssumptions should be kept out of research studies
By Keith Wesley, MD, FACEP & Karen Wesley, NREMT-P
THE RESEARCH
Sanghavi P, Jena AB, Newhouse JP, et al. Out-
comes after out-of-hospital cardiac arrest
treated by basic vs advanced life support.
JAMA Intern Med. 2015;175(2):196–204.
THE SCIENCE
The authors undertook a comparison of BLS
vs.ALS care on the outcome of cardiac arrest
by examining a representative sample of Medi-
care beneficiaries from non-rural counties in
the United States who had “cardiac arrest”as
their hospital admission diagnosis between
2009 and 2011.
They made the assumption an EMS
agency that billed Medicare at the BLS rate
delivered BLS care and billed ALS rates for
ALS care.They linked the EMS cases to their
respective hospital admission and examined
their outcomes.
Cardiac arrest victims cared for with BLS
had a greater likelihood of surviving to hospital
discharge as compared to ALS (13.1% vs 9.2%,
respectively).Survival to 90 days post-discharge
was also higher than ALS (8.0% vs 5.4%).And
not surprising,BLS patients had better neuro-
logical function than ALS (79.2% vs 55.7%).
Authors also examined the medical expen-
ditures on the Medicare patients throughout
the year following their cardiac arrest.
They concluded, “Patients with out-of-
hospital cardiac arrest who received BLS had
higher survival at hospital discharge and at 90
days compared with those who received ALS
and were less likely to experience poor neuro-
logical functioning.”
In their discussion portion of the paper
the authors further state:“Our estimates sug-
gest that each year,1,479 additional Medicare
beneficiaries who experience out-of-hospi-
tal cardiac arrest would survive to 90 days if
provided BLS instead of ALS. Furthermore,
incremental medical spending per additional
survivor to one year for BLS relative to ALS
was $154 333,substantially less than the mean
medical spending per survivor to 1 year for
ALS ($206 775).”
DOC WESLEY COMMENTS
ALS or BLS? That question is the Holy Grail
of EMS. From the Ontario Prehospital ALS
(OPALS) study in Canada to today,countless
numbers of system directors,governing bodies
and medical directors have sought to deter-
mine if the level of care correlates to outcomes.
Unfortunately,this study fails to answer the
question they pose.I congratulate the authors
on their ingenious attempt to link level of
care by examining Medicare billing.However,
there’s no data to substantiate the linkage.The
authors could have addressed the landslide
of criticism that followed the publication by
simply examining in detail a subset of cases
to determine the following:
First, did the patients transported by BLS
really suffer cardiac arrest and achieve return
of spontaneous circulation (ROSC),and were
being transported by BLS? Were these trans-
ports in communities without ALS intercept?
What communities are included in “non-
rural”? Why were nursing home patients with
cardiac arrest more likely to be transported
by BLS?
The authors present many analyses of their
data to address these criticisms,but the bottom
line comes down to the fallacy of their basic
assumption that BLS cardiac arrest transports
were the same as ALS transports.
Final thought? The search for the Holy
Grail continues.
MEDIC WESLEY COMMENTS
Lost in translation? I dream of the day a sci-
entific study is completed by someone who
has an understanding of our capabilities.This
study is based on Medicare and hospital cod-
ing. The authors even admit that coding is
often inaccurate.
Somewhere along the line,a huge compo-
nent of patient survival and outcome was left
out of the study.That being said, where’s the
information on the ED resuscitation attempts,
or lack thereof? What about inpatient care?
Doesn’t that play a huge part in outcomes?
Although I have to agree that intubation in
the prehospital setting still needs some answers
to resolve which ACLS medications make a
difference,my experience tells me there must
be distinct differences in BLS- and ALS-re-
suscitated patients. Yet, the authors provided
no data on those differences other than more
BLS patients came from nursing homes and
were older. There was no description of the
difference in treatment the patient received.
Instead,they rest all their assumptions on BLS
vs. ALS billing.
Although the study attempts to prove that
BLS alone has better outcomes than ALS, It
falls short in not having the understanding of
the prehospital environment and considering
that in their data analysis.
As with all street science, I have to ask if
anything will be changed or re-examined based
on the nature and outcome of this study.In this
case,I would hope not.But knowing the ALS
vs. BLS argument is a political one, I’m sure
someone is going to use this study to change
their EMS system all in the name of saving
patient lives. JEMS
Keith Wesley, MD, FACEP, is the medical
directorforHealthEastMedicalTransportation
inSt.Paul,Minn.,andUnitedEMSinWiscon-
sinRapids,Wis.He’sservedasthestatemed-
icaldirectorforbothMinnesotaandWisconsin
andisafrequentspeakeratbothstateandnationalconferences.
He can be reached at drwesley@charter.net.
KarenWesley,NREMT-P,isaparamedicand
educator for Mayo Clinic Medical Transport
andisthemedicteamleaderfortheEauClaire
County (Wis.) Regional SWAT team. She can
be reached at admkaren22@hotmail.com.
Learn more from Keith Wesley at the EMS Today
Conference & Expo, Feb. 25–27, in Baltimore, Md.
EMSToday.com
31. WHERE WORLD CLASS LEADERS COME TO TRAIN
HANDS-ON TRAINING
WORKSHOPS
CLASSROOM SESSIONS
EXHIBITS
APRIL 18-23, 2016
INDIANA CONVENTION CENTER | LUCAS OIL STADIUM
INDIANAPOLIS, IN | WWW.FDIC.COM
www.fdic.comPRESENTED BY OWNED & PRODUCED BY
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