Six months ago, on January 1st, many of us pledged to lose weight, exercise more, eat better, floss daily, write a daily blog post, read an EMS research article each week or attain some other goal. Converting that resolution into a habit is a significant challenge.

One method that has helped me is tracking my accomplishments toward turning the goal into a habit. Not long ago, I set a goal to lose about fifteen pounds. My first step was a daily food journal. Using the MyFitness Pal app, I recorded every calorie I ate or drank, along with my weight every day.

At first, this was an arduous additional task that I struggled to remember to do. But as the days went by, the calorie tracking became part of my meal routine - prepare, eat and track. My increasing caloric awareness led to a gradual weight loss which helped reinforce the calorie tracking. My calorie tracking streak lasted for 30 days, but the subsequent diet change and weight loss has lasted 18 months and counting.

I recently used the Habit Streak app to track my success at doing a "plank," a type of core exercise every day. Once the "habit" was created, the app asked me every morning if I had done a "plank" the day before. The app gamified my exercise routine with useful stats, such as "days in a row completed" and "days completed out of total days."

Tracking a habit or skill might be useful to you as an EMS student or professional. "Days in a row" are just one way to score success toward a lifestyle change or developing a skill. Use an app or simply make tick marks in a pocket notebook to track success on:

• Successful IV starts
• 30 minutes of daily cardiovascular exercise
• Days without a soda
• Chapters read in a textbook
• Patients assessed
• Miles walked or run
• Total amount of weight lifted during a workout

What habit are you trying to form or break" Have you successfully used a goal setting app" Share your experience in the comments.

When I first started in EMS, pacemakers were quite common but ICDs were quite rare. I would see them inside the hospital but almost never out in the field. In fact, once upon a time you had to survive not one, but two sudden cardiac deaths to qualify for an ICD.

Following a series of clinical trials including MADIT I (pronounced "made it"), MADIT II, DEFINITE, SCD-HeFT (pronounced "scud heft"), and COMPANION, the indications for the device have grown exponentially. Now patients with Class II and Class III heart failure (and poor ejection fractions) qualify for an ICD.

The bottom line is that EMS is now far more likely to be called to patients who have suffered an ICD shock. In my system we see several a year. On one occasion the patient received 14 shocks prior to EMS arrival (apparently he was counting). Anecdotally speaking, about half the time the shocks are appropriate, and half the time the shocks are inappropriate. The most common cause of inappropriate ICD shocks is atrial fibrillation with rapid ventricular response.

Let's get back to the case study and take another look at the 12-lead ECG. If you're an ECG nerd like me, you probably noticed the concordant ST-depression in the precordial leads. You might even have squinted at the inferior leads to see if excessive discordant was present (more on that in a future article).

What do I mean by concordant ST-depression"

That means that the ST-depression is in the same direction as the majority of the QRS complex. This satisfies one of Sgarbossa's criteria for identifying acute MI in the presence of left bundle branch block (which many experts agree also applies to paced rhythm).

Could this patient's primary problem be acute STEMI"

Possibly, but before we call a Code STEMI based on this 12-lead ECG, it's important to remember one very important piece of information: this patient just received an ICD shock! It is not uncommon for ICD shocks to cause a transient current of injury that resolves within a few minutes.

Our protocols preclude us from calling a Code STEMI in the presence of left bundle branch block or paced rhythm. What we do is transmit the ECG to the hospital and discuss the situation with online medical control. On this particular occasion, an astute paramedic noticed the suspicious changes and called for immediate transport.

The patient was placed in the back of the ambulance and another 12-lead ECG was recorded.

Only 3 minutes have passed since the first 12-lead ECG and the concordant ST-depression in the right precordial leads is almost entirely resolved.

In addition, there appears to be slightly less ST-elevation in the inferior leads.

There's no one correct answer for how this patient should be treated, although I would not recommend disabling tachydysrhythmmia therapy with a ring magnet at this point. We must assume that the ICD shocks were appropriate until proven otherwise.

Some might argue that EMS should give the patient an antiarrhythmic or be prepared to administer sedation. However, at this point the treating paramedics had not seen any life-threatening arrhythmias on the monitor.

They did not have to wait long. This patient went into a very ugly-looking ventricular tachycardia as the ambulance arrived at the hospital. The patient's ICD shocked him unsuccessfully. The treating paramedics provided chest compressions as they rolled him into the resuscitation bay where the ED physician used a defibrillator to shock the patient back into a paced rhythm.

The patient was placed on an amiodarone drip, cardiology was consulted, and a device rep was called to interrogate the device. No further outcome information is available.

Do you think it would be a good idea for your EMS system to have a game plan for patients who have received an ICD shock" Leave your answers in the comments below.

When it comes to chest compressions, two philosophies emerge: improve human powered techniques, or use a machine. Physio-Control's TrueCPR technology works to optimize manual compressions that are crucial in the first moments of a cardiac arrest.

During the past decade, much of the medical scientific community's focus on successful resuscitation techniques from cardiac arrest have been on optimizing chest compressions during a "working code."

In 2005 and more strongly in 2010, the American Heart Association Emergency Cardiac Care Guidelines has emphasized that all elements of a resuscitation must revolve around high quality chest compressions.

Current guidelines call for compressions to be at least 2 inches in depth, and provided at a rate of at least 100 beats per minute. There must be full recoil of the chest wall during the return stroke, to permit adequate filling of the cardiac chambers.

Cardiac arrest specialists such as EMS providers have been following one of two pathways to achieve optimal compressions. The development of mechanical CPR devices has allowed rescuers to not have to provide manual compressions 100 percent of the time.

However, today's devices can be expensive to acquire and maintain, prohibiting many services from purchasing one for each unit. It requires practice and significant team coordination to place the devices on the patient while minimizing compression down time.

The second pathway is to improve human-powered compressions. Training and continuous practice is certainly one way to accomplish this. However, because of the infinite combination of patient size, shape, environment and rescuer ability, it is very difficult to know when optimal compressions are achieved.

Manufacturers have used a variety of techniques to provide "real time" feedback to the compressor during a working code. Voice, sounds and lights have been used to effectively improve the rate of compressions.

Accelerometers measure changes in the speed of the chest wall as it is being compressed. This can be translated into distance, providing feedback to the rescuer about how deep the compressions are.

However, the technology is limiting; it only measures the rate of acceleration, not direction. It doesn't directly measure depth. And it only takes measurement relative to the space it is measuring.

An exciting advancement in chest compression technology is now on the horizon. Physio-Control, a leading maker of portable EMS monitor/defibrillators, has released a device that addresses the limitations of accelerometer technology and provides precise feedback during CPR.

Called the TrueCPR coaching device, two paddle-shaped devices are easily placed above and below the patient's chest. The devices generate a low energy magnetic field that measures changes in distance in three separate directions – up/down, side to side, and roll.

Known as triaxial field induction, this field provides significantly more precision on the depth and rate of compressions. It is not affected by the surface underneath the patient. Visual and audio prompts provide positive feedback to the rescuer.

Given the known fact that we humans get tired while performing high quality CPR, it becomes clear that the rate of feedback is directly related to the moment when rescuers must change positions so excellent compressions are maintained.

It may mean that, rather than waiting a full two minutes to swap personnel, it may happen sooner – or later.

Not only does TrueCPR provide assistance during the working code, but it also helps for future performance. Data is collected by the device and viewable by providers on the device , and is downloadable for performance review and improvement.

For the data-driven clinician this is a treasure trove of information that can help overall system performance by improving training and practice cycles.

The cost of the device retails for less than $2000. That's inexpensive enough to have one on each ambulance in a service fleet. That means it's immediately available for use during the first moments of the resuscitation, which is crucial to successful outcomes.

We have learned more about the importance and specifics of optimal CPR performance in the past 10 years compared to the previous 40. TrueCPR provides EMS personnel the ability to truly refine their techniques and provide the patient the best opportunity for survival.

Take a look at our favorite responses to the post, and add more in the comments section below!

"Wireless electrodes would be a billion dollar idea!" — Chip Duboise

"An espresso machine." — Thomas Burke

" Wireless everything. Monitors, 12 leads done with one electrode, wireless BP cuffs. Maybe a spray that makes blood or had to find germs light up. How about a gurney pad that can warm up or cool down for environmental emergencies. And of course…self-applying instant restraints!" — Brian Villanueva

"Add a BP machine, thermometer, pulse Ox and add an IV pump as well…1 machine for all." — Greg Gilbert

"How about being able to guide you with PALS, ACLS on the screen while you’re working a code…voice command operations." — Benjamin Martinez

"GPS that will actually get you there!" — Eleanor Alexander

"Star Trek scanner style." — James VB

"Go back to manual defibrillators. Miss the feel of paddles in my hand." — Matt Yarbrough

"One’s that say “stand back” when it is activating." — Johanna Wise

"Wireless or Bluetooth technology straight to the receiving physician for the EKG." — John Wothers

If enough cells are affected, tissues, organs and eventually entire systems succumb to shock's devastating effects. This is the reason EMS providers have to recognize the early signs and not depend upon a falling or low blood pressure to set off the alarm bells.

Let's talk about how the body tries to manage shock on its own. It is an interesting series of interactions that it uses to preserve life. Check out the video below.

We have a time bandit in our midst, and we have to him from stealing our time. Going through the steps of problem solving allowed me to come up with some common pitfalls to my time management breakdown.

Multitasking
You hear it all the time: people professing their ability to multi-task. To be as productive as we can, we often use our "multitasking abilities" to get as much done as possible. So, we talk on the phone while responding to emails, or we talk to employees and work at our computer.

One of the things that surprised me in my research of multitasking was we can actually kill 20-40% of our productive time when we do more than one task at a time. It is in reality best to work on one task at a time, and focus all your attention on completing the task before moving on to the next.

Below are a few suggestions to help maximize your productivity:

• Plan your day in blocks of time. Set specific times for things like returning calls and answering emails.
• Develop ways to improve your concentration. Focus on one thing at a time.
• Turn off alerts when emails, texts and calls come in.

Filling the Plate
We have all had too much on our plates from time to time. As leaders, not saying no to others can actually hurt us more in the long run. In the rush to complete all our projects, tasks and commitments, something has to give — and it’s usually productivity. We lose time, we cut corners, and our projects are not completed to the best of our ability.

As we try to take on as much as we can, we now develop a reputation of someone who takes on too much and does not produce great outcomes.

What’s the best way to deal with not developing a full plate"

• Learn your capabilities of handling multiple projects.
• Understand the difference in saying yes to the person and saying no to the task.
• Offer assistance once your plate is more manageable. Saying that you can’t help right now, but maybe in a few days is not a bad compromise.

Keep a To-Do List
If you are like me, sometimes it feels like you're always forgetting something. One of the tools to assist me in keeping things in the forefront is utilizing a to-do list. With the use of smart phones, there are so many great apps to assist us in keeping our tasks inline.

Here are a couple ideas on using to-do lists:

• Keep a list of all task to complete.
• If they are large tasks, break them down into stages.
• Develop a system of prioritizing.

Failing to Prioritize
This is one of the more essential skills a leader must develop to make the best use of time. When you prioritize your tasks, it truly expands your understanding of what needs to be completed. This really comes in handy when time is limited. As you develop in your time management skills, take a look at the different prioritization tools out there and choose the best one to fit your style. A few prioritization tools include:

• The Urgent/Important Matrix
• Pareto Analysis
• Grid Analysis
• The Boston Matrix

Procrastination
I’ve said for years that procrastination is the art of keeping up with yesterday. Basically procrastination is putting off tasks for later what we should be doing right now. If you ever find the secret potion to stop procrastination, please share it with the rest of us!

In the meantime, four ways to help manage procrastination are:

• Determine why you are avoiding
• Set goals
• Get rid of distractions
• Make time for breaks

We have identified a few ways to better manage precious time. This is a tough skill to develop and utilize. Once you recognize how time management affects your productivity, you will see yourself becoming more focused, productive, and less stressed.

As the paramedics splint the leg and immobilize in preparation for transport, the patient winces with every movement. A construction supervisor asks if Paramedic Davis could administer something to help ease the patient's pain. Davis informs the supervisor that pain medication might actually compromise further assessment and complicate the patient's recovery. With the supervisor in the cab of the ambulance, Medic 17 transports the patient without incident, although the patient continued to complain throughout the twenty-minute trip.

During the initial assessment in the emergency department, the attending physician instructs the staff to administer analgesic medication as soon as possible. Before Medic 17 leaves the hospital, the patient is resting comfortably.

Three weeks later, Paramedic Davis and his partner are called to a meeting with the EMS Chief and the Medical Director. The patient has filed a formal complaint alleging that the EMS field treatment protocols allow analgesic administration given the patient presentation, but the medics did not administer the drugs because of racial bias. The Medical Director wants to know whether the patient's race influenced the decision to withhold the medication.

Study Review
Researchers in California examined the effect of patient race on prehospital administration of pain medication (Young, Hern, Alter, Barger, & Vahidnia, 2013). For the study, researchers selected an urban/suburban county with a population of just over one million people.

A single private EMS agency responded to the majority of 911 responses in the county. Paramedics entered the patient care information into an electronic patient care record (EPCR). During a 10-month period in 2009, researchers programmed the EPCR software to force medics to select the patient's race from a drop-down menu before being able to close the record.

Within that EMS agency, morphine was the only analgesic available for field administration. Medical protocols encouraged the paramedics to assess and record the findings of a pain scale and to treat pain with morphine, unless contraindications existed.

Researchers selected all EPCRs where the paramedic chose blunt trauma as the primary impression. From that sample, the team excluded patients under the age of 18 years and patients with a systolic blood pressure less than 85 mm Hg.

This generated a sample of 6561 patients who met the inclusion criteria. From that, the researchers excluded 163 cases because of incomplete records leaving a final sample of 6398 cases.

Of those, 516 patients (8%) received morphine before arriving at the hospital. Statisticians used multivariate analysis to examine the individual impact that a variety of factors had on whether the patients in the sample group received morphine. Neither the sex nor age of the patient appeared to influence the administration of morphine.

As one might expect, the odds of receiving morphine increased as the pain score increased (indicating more severe pain) and with an increased period before arrival at the hospital. However, this study was really about the influence of patient race on analgesic administration.

Statisticians use a technique called regression analysis to create a mathematical formula that shows the effects that each predictor variable has on outcome. Using that formula, the statistician can mathematically adjust all predictor variables except for the variable of interest, in this case race.

This would be analogous to saying, "If all other variables are equal, what effect does race play in morphine administration.

After controlling for the effects of sex, age, time spent with the patient and heart rate, the odds of receiving morphine following blunt trauma decreased if the patient was African-American when compared to being Caucasian, regardless of whether the paramedic recorded a pain score (OR = 0.55, 95% CI [0.33, 0.91]) or not (OR = 0.15, 95% CI [0.05, 0.52]).

The odds of a Hispanic patient receiving morphine was not different from a Caucasian patient if the paramedic recorded a pain score (OR = 0.57, 95% CI [0.33, 1.00]). However, if the paramedic did not record a pain score, the odd of a Hispanic patient receiving morphine significantly declined compared to Caucasian patients (OR = 0.29, 95% CI [0.10, 0.80]).

Odds Ratios
I hope that all the numbers and symbols in the previous paragraph are not making your head spin. An odds ratio represents the probability that something happens divided by the probability that it does not happen.

An odds ratio of one (OR = 1.00) means that the patient is just as likely to receive morphine as not receive morphine, sort of like a 50-50 chance. When the odds ratio is less than one (OR = 0.55), the patient is less likely to receive morphine; in this case the odds of an African American receiving morphine are almost half (0.55) the odds of a Caucasian receiving morphine (1.00).

In addition, you must always look at the series of symbols and numbers that follow the odds ratio. Bear in mind that regardless of what instrument a person uses to measure something, there is always some amount of measurement error.

Statistics attempts the explain probabilities given certain measurement errors. In the previous example, the notation 95% CI [0.33, 0.91]) means that if you were to conduct this investigation again, you might not get exactly the same odds ratio (OR = 0.55). Instead, you can be 95% confident that your new result would be within the interval 0.33 to 0.91, which is still below the value of one needed for a 50-50 chance.

What This Means for You
Pain relief is a common reason for people to seek emergency medical care. Researchers using data from the National Hospital Ambulatory Medical Care Survey report that one in five patients transported to the hospital have a complaint of moderate or severe pain (McLean, Maio, & Domeier, 2002).

Researchers in New Zealand found that 54% of patients had a complaint of pain upon arrival at the emergency department (Chambers & Guly, 1993).

The Care Quality Commission (2008) found that many patients experiencing pain while en route to the hospital felt the ambulance crew did not do everything they could to ease their discomfort. This study seems to support the Commission's findings as only 8% of the patients received prehospital analgesia.

Racial bias in analgesia administration is not unique to the prehospital environment. Physicians may under estimate pain severity in three-fourths of African American patients and over half of Hispanic patients (Anderson et al., 2000).

Many studies indicate that patient race and ethnicity affect analgesic administration in the emergency department (Heins et al., 2006; Pletcher, Kertesz, Kohn, & Gonzales, 2008; Tamayo-Sarver, Hinze, Cydulka, & Baker, 2003, Todd, Deaton, D'Adamo, & Goe, 2000; Todd, Samaroo, & Hoffman, 1993) although some researchers have not been able to demonstrate that such bias exists (Fuentes, Kohn, & Neighbor, 2002).

A variety of factors may contribute to analgesic administration disparities among the races. Although two studies failed to demonstrate racial or ethnic differences in the ability to perceive pain (Todd, Lee, & Hoffman, 1994) (Zatzick & Dimsdale, 1990), racial, ethnic or cultural factors can influence the way that patients verbally express pain (Greenwald, 1991) and healthcare providers generally perceive that African Americans feel less pain than do Caucasians (Trawalter, Hoffman, & Waytz, 2012).

These factors may affect health care provider's perceptions of the discomfort level experienced by the patient (Wandner, Scipio, Hirsh, Torres, & Robinson, 2012).

It is also possible that language barriers prohibit effective communication of pain levels, thereby contributing to less frequent analgesic administration to individuals who may not speak fluent English.

Over 80% of paid EMTs and paramedics in the United States are classified as "White not Hispanic" (National Highway Transportation Safety Administration, 2008) and it is reasonable to assume that English is their primary language. At the time of the study, the majority of both the paramedics working in Contra Costa County (78%) and the patient sample (62%) were Caucasian.

Since being Caucasian increased the odds of receiving analgesia in this study, one must consider that paramedics are more likely to administer analgesic medication to patients with similar racial and ethnic characteristics.

Although it is tempting to conclude that simply assessing pain on a standardized scale and recording the results increases awareness and compliance with prehospital analgesia, it is difficult to know whether the paramedics recorded the scores because they performed a more comprehensive examination or whether they proactively decided to give the medication and wanted an objective measure of whether the medication worked.

However, from the patient's perspective, the reason probably matters little.

Limitations
Paramedics chose the race and ethnicity of the patient. There was no standardized definitions provided and the paramedics were free to choose any race they desired. One must consider that patient self-selection of those variables could have altered the racial composition of the sample, which would produce a different outcome.

Another limitation is in pain perception. There is clear evidence that racial and ethnic groups report pain differently and it is reasonable to assume that difference exists within the same racial and ethnic category even with similar injuries.

The researchers in this study attempted to control for that difference by using a standard pain scale, however there is no way to know that a score reported by one patient means the same thing when selected by a different patient.

The authors did not attempt to control for injury severity. They used the imprecise term "blunt trauma" to select the sample. Blunt trauma can range from relatively minor contusion to life threatening abdominal or thoracic trauma.

It is reasonable to suspect that paramedics would be more likely to administer pain medication to patients with more severe injuries. It is not reasonable to expect that one racial or ethnic subgroup would be more likely to experience blunt traumatic events at a different rate.

Paramedics in this study who spent more time with patients were more likely to administer analgesic medications. The authors do not explain whether the increased out-of-hospital intervals resulted from increased distances or from other factors such as entrapment and extrication delays or a longer and more thorough assessment.

Summary
Every patient has a fundamental right to receive effective pain relief from healthcare providers, including those who work in the prehospital environment. Unfortunately, racial disparities in analgesic administration exist, although the reasons for those disparities are not clear. EMS personnel must guard against allowing racial and ethnic factors to influence the decision to administer pain medication.

References
Anderson, K. O., Mendoza, T. R., Valero, V., Richman, S. P., Russell, C., Hurley, J., DeLeon, C., Washington, P., Palos, G., Payne, R., & Cleeland, C. S. (2000). Minority cancer patients and their providers. Cancer, 88(8), 1929-1938. doi:10.1002/(SICI)1097-0142(20000415)88:8<1929::AID-CNCR23>3.0.CO;2-2

Care Quality Commission. (2008). Briefing note: Issues highlighted by the 2008 category C ambulance service user survey. Retrieved from http://www.cqc.org.uk/_db/_documents/Briefing_note_final.pdf

Chambers, J. A., & Guly, H. R. (1993). The need for better pre-hospital analgesia. Archives of Emergency Medicine, 10(3), 187-192.

Cleeland, C. S., Gonin, R., Baez, L., Loehrer, P., & Pandya, K. J. (1997). Pain and treatment of pain in minority patients with cancer. The Eastern Cooperative Oncology Group Minority Outpatient Pain Study. Annals of Internal Medicine, 127(9), 813-816. doi:10.7326/0003-4819-127-9-199711010-00006

Fuentes, E. F., Kohn, M. A., & Neighbor, M. L. (2002). Lack of association between patient ethnicity or race and fracture analgesia. Academic Emergency Med, 9(9), 910–915. doi:10.1197/aemj.9.9.910

Greenwald, H. P. (1991). Interethnic differences in pain perception. Pain, 44(2), 157–163. doi:10.1016/0304-3959(91)90130-P

Heins, J. K., Heins, A., Grammas, M., Costello, M., Huang, K., & Mishra, S. (2006). Disparities in analgesia and opioid prescribing practices for patients with musculoskeletal pain in the emergency department. Journal of Emergency Nursing, 32(3), 219–224. doi:10.1016/j.jen.2006.01.010

McEachin, C. C., McDermott, J. T., & Swor, R. (2002). Few emergency medical services patients with lower-extremity fractures receive prehospital analgesia. Prehospital Emergency Care, 6(4), 406–410.

McLean, S. A., Maio, R. F. & Domeier, R. M. (2002). The epidemiology of pain in the prehospital setting. Prehospital Emergency Care, 6(4), 402–405.

National Highway Transportation Safety Administration. (2008). EMS workforce for the 21st century: A national assessment. Final report. Washington, DC: NHTSA.

Pletcher, M. J., Kertesz, S. G., Kohn, M. A., & Gonzales, R. (2008). Trends in opioid prescribing by race/ethnicity for patients seeking care in US emergency departments. Journal of the American Medical Association, 299(1), 70–78. doi: 10.1001/jama.2007.64.

Tamayo-Sarver, J. H., Hinze, S. W., Cydulka, R. K., & Baker, D. W. (2003). Racial and ethnic disparities in emergency department analgesic prescription. American Journal of Public Health, 93(12), 2067–2073.

Todd, K. H., Deaton, C., D'Adamo, A. P., & Goe, L. (2000). Ethnicity and analgesic practice. Annals of Emergency Medicine, 35(1), 11–16. doi:10.1016/S0196-0644%2800%2970099-0

Todd, K. H., Lee, T., & Hoffman, J. R. (1994). The effect of ethnicity on physician estimates of pain severity in patients with isolated extremity trauma. Journal of the American Medical Association, 271(12), 925–928. doi:10.1001/jama.1994.03510360051035

Todd, K. H., Samaroo, N., & Hoffman, J. R. (1993). Ethnicity as a risk factor for inadequate emergency department analgesia. Journal of the American Medical Association, 269(12), 1537–1539. doi:10.1001/jama.1993.03500120075029

Trawalter, S., Hoffman, K. M., & Waytz, A. (2012). Racial bias in perceptions of others' pain. PLoS One, 7(11), e48546. doi:10.1371/journal.pone.0048546

Young, M. F., Hern, H. G., Alter, H. J., Barger, J., & Vahidnia, F. (2013). Racial differences in receiving morphine among prehospital patients with blunt trauma. Journal of Emergency Medicine, Article in Press. doi:10.1016/j.jemermed.2012.07.088

Wandner, L. D., Scipio, C. D., Hirsh, A. T., Torres, C. A, & Robinson, M. E. (2012).The perception of pain in others: how gender, race, and age influence pain expectations. Journal of Pain, 13(3), 220-227. doi:10.1016/j.jpain.2011.10.014

White, L. J., Cooper, J. D., Chambers, R. M., & Gradisek, R. E. (2000). Prehospital use of analgesia for suspected extremity fractures. Prehospital Emergency Care, 4(3), 205–208.

Zatzick, D. F., & Dimsdale, J. E. (1990). Cultural variations in response to painful stimuli. Psychosomatic Medicine, 52(5), 544–557.

The author has no financial interest, arrangement, or direct affiliation with any corporation that has a direct interest in the subject matter of this presentation, including manufacturer(s) of any products or provider(s) of services mentioned.

Send correspondence concerning this article to Kenneth W. Navarro, The University of Texas Southwestern School of Health Professions, 5323 Harry Hines Blvd, MC 9134, Dallas, Texas 75390-9134. E-mail: kenneth.navarro@utsouthwestern.edu

In the first six recessions, the economy would spring back within a year. Municipal budgets would return to their post-recession levels of revenue two years after the recession ended. The rate of recovery after the Great Recession has not been as robust as earlier events.

The U.S. Bureau of Labor Statistics noted in a 2012 report that: "many of the statistics that describe the U.S. economy have yet to return to their pre-recession values."²

This delayed recovery has decimated EMS agency budgets, starting in Fiscal Year 2009 (July 2008 – June 2009). Agencies are completing five years of hiring freezes, reduced salaries/benefits, delayed vehicle/equipment replacement and deferred repairs. Some agencies have exhausted their reserves and are facing unprecedented reorganizations.

What happened to the revenue"
Three sources of local government funding, representing two-thirds of the revenue stream are:

• Property Taxes
• Personal Income Taxes
• General Sales/Gross receipts

When the Great Recession started, there were thousands of people that lost their jobs. No income means no income taxes. Out-of-work people buy far fewer things, resulting in decreased sales tax revenue.

Henry Farber makes this point in a 2011 National Bureau of Economic Research working paper on job losses: "It is clear that the dynamics of unemployment in the Great Recession are fundamentally different from unemployment dynamics in earlier recessions."

Farber notes fewer than half who lost their job in the 2007–2009 recession had a job in 2010. Those who obtained new full-time jobs were making 21.8% less money.³

The unemployed and under-employed defaulted on mortgages. Their much reduced spending resulted in the closing of retail and service businesses. An abandoned house and an empty storefront generate no local government revenue.

The other third of the local revenue stream comes from state and federal payments. 33 to 42% of state revenue comes from federal payments.9 The amount of federal revenue passing through the state to the local municipalities is a trickle of what it was five years ago.⁴

EMS providers have been furloughed and watched benefits evaporate. Some lost their jobs. Many middle manager positions were eliminated, with the tasks pushed up or down the chain of command. Vehicles are working well past their replacement point and equipment is shopworn.

The legacy revenue model is broke.

Bankruptcy as a municipal management tactic
Governing magazine lists 33 local governments that filed for bankruptcy.California is prominent in this list, with Vallejo as the first to file in 2008. Stockton has been the largest city, and San Bernardino the most recent. Municipalities that successfully file for bankruptcy can dissolve existing labor agreements and walk away from retirement program obligations – eliminating the two largest budgetary obligations.

The feature article for the March 2013 Governing magazine reviewed the impact from the earliest bankruptcies and indicated that this may be a valuable management tool.⁶

Some states passed regulations to make drastic changes in municipal operations without declaring bankruptcy. Michigan imposes emergency managers on cities and counties.⁷

Reduced revenue streams and increased demand for services
While municipalities have frozen or reduced resources to EMS, the workload continues to increase as more people call 9-1-1 and use emergency departments as their primary health care providers.

David Walker, immediate past head of the Government Accountability Office made this observation:

"Ultimately the government will need to spend less than projected and tax more than it historically has. That means that, over time, it will do less than people are expecting and tax more than people are accustomed to. In my view, our fiscal challenge is primarily a spending problem and needs to be addressed accordingly."⁹

How to fix a "spending" problem – redeploy assets for new revenue sources
An unintended consequence of the EMS Scope of Practice is the expanded role paramedics can assume in mobile health care. The implementation of the Patient Protection and Affordable Care Act in January 2014 provides significant opportunities for mobile healthcare providers.

Affiliating with an Accountable Care Organization (ACO) provides incentive for reducing return visits to the hospital and opportunities for a street-oriented caregiver to generate new sources of revenue while being part of a team committed to high quality medical care.¹⁰

EMS crews will schedule follow-up field visits with recently discharged patients. When at the patient's home the crew will review the patient discharge instructions, make sure the prescriptions are filled and access the home for obvious injury hazards. The ACO is motivated to avoid circumstances when the patient has to return to the hospital, and will pay the ems organization to perform this service.

This is the start of a dramatic shift in opportunities and compensation for EMS providers.

REFERENCES

Business Cycle Dating Committee. (April 23, 2012) U.S. Business Cycle Expansions and Contractions. In National Bureau of Economic Research. Retrieved May 20, 2013, from www.nber.org/cycles/US_Business_Cycle_Expansions_and_Contractions_20120423.pdf .

Bureau of Labor Statistics. (February 2012). The Recession of 2007–2009. In U.S. Bureau of Labor Statistics. Retrieved May 20, 2013, from www.bls.gov/spotlight/2012/recession/pdf/recession_bls_spotlight.pdf .

Farber, Henry. (September 2011). Job loss in the great recession: Historical perspective from the displaced workers survey, 1984–2010. (NBER Working Paper No. 17040). National Bureau of Economic Research. Retrieved December 2, 2012 from http://www.nber.org/papers/w17040

Gormley, William T. and Steven J. Balla. (2012) Bureaucracy and Democracy: Accountability and Performance. 3rd edition. Washington DC: CQ Press.

Governing Magazine. "Bankrupt Cities, Municipalities List and Map" webpage accessed June 1, 2013 from http://www.governing.com/gov-data/municipal-cities-counties-bankruptcies-and-defaults.html

Farmer, Liz. (2013 March) The 'B' Word: Is Municipal Bankruptcy's Stigma Fading" There's a growing sense among some leaders that municipal bankruptcy -- unthinkable just a few years ago -- may be a valuable tool. Governing magazine. Accessed June 1, 2013 from here

Lewis, Chris (2013 May 9) Does Michigan's Emergency-Manager Law Disenfranchise Black Citizens": A state law provides for takeover of cities with troubled finances. It just happens that the worst-hit places are also the poorest and blackest. The Atlantic. Accessed June 01, 2013 from here

Public Financial Management. (2011 October) "State Programs for Municipal Financial Recovery. An Overview." Philadelphia, PA: Public Financial Management. Accessed June 01, 2013 from here

Patton, Zack (2012 July) "David Walker's Plan to Fix America: After stepping down as head of the Government Accountability Office, David Walker started drawing the nation's roadmap to fiscal sustainability that's also applicable to states and cities." Governing. Accessed June 01, 2013 from here

Zavadsky, Matt (2012 June 28) "Cultivating Stakeholder Relationships Part 1: Healthcare Partners" EMS World. Accessed June 01, 2013 from here

The problem is that we often use it for too many other things.

I've met many who use the backboard as a portable stretcher, to move people from inside the house and over rough ground. This is actually kind of dangerous. Most backboard straps alone are not designed for challenging lifting angles. The patient will be more secure when they are wrapped in a flexible stretcher. Here are some examples.

1. The Flexible Stretcher

The first of these is the Reeves Stretcher. It is best described as a heavy duty coated tarpaulin style fabric that encircles the patient. Inside the two fluid resistant fabric layers there are narrow slats or boards, which provide longitudinal stability.

Around its perimeter are many handholds, both on the sides and ends. This makes it easy to get extra hands onboard when you need it. The patients weight creates a conforming U-shape in the center and the integrated straps secure the patient inside.

In places like Philadelphia they use these things every day. They are fast, effective, and safe to use moving patients down narrow stairways in narrow houses.

The Deluxe version upgrades the plastic buckles for seat-belt grade automotive buckles. It also adds extra slats in the middle to beef up the payload.

Ferno offers a similar product called simply the Ferno Flexible Stretcher. It's a couple of inches longer. It offers another great solution for moving people on uneven terrain where a wheeled stretcher can't work.

Use of the Flexible Stretcher seems to be somewhat regional. They are huge in the Northeast but maybe less popular in some other regions. Maybe it's because as you go west buildings are generally newer, with bigger doors, stairways and elevators. But they are some of the fastest tools for getting someone out of a tight back room or down stairs safely that cannot sit up.

2. The Scoop Stretcher

The next great tool is the orthopedic or scoop stretcher. This is another old-school patient handler that is used more in some areas and less so in others.

I remember seeing scoops in Connecticut mounted to the ceiling of the ambulance, above the cot. You could just drop them on your wheeled stretcher and carry them in.

The original idea was a rigid break-apart device. You undo the head and foot ends to gently insert each half under the shoulders, hips, and legs. This design allowed a casualty to be gently moved without excessive movement.

The whole idea is to pick someone up and then put them down somewhere else without moving them very much. They do this very well. One of the best applications of the scoop stretcher is when it is used with a vacuum mattress.

It's only a little more work to do something beautiful. You lift the patient, place them on a vacuum mattress, and evacuate the air in the mattress to secure the patient. You then use put the scoop under the vacuum mattress to move them onto the cot, and onto the ER bed. It is an elegant spinal solution, one commonly used in Europe.

Those following best practices in spinal immobilization will find reference to this technique. If you want to move a severely injured patient in the most careful and considerate way, this is how it's done.

They spend most of their transport time on a conforming vacuum mattress. They are much more comfortable and warmer. The primary exam in the ER goes much smoother because their sources of pain are less caused by what you did to them then by what happened to them.

There are some great newer versions. One is the newer plastic covered scoops like the Ferno EXL.

This modern orthopedic stretcher has an aluminum core covering in smooth plastic. It not only makes it easier to slide under the patient, but it also doesn't feel as cold to touch.

It is beautifully finished with no rough spots or edges. The center mechanism is the proven push-button latch at head and feet. It can be quickly length adjusted to fit most EMS patients.

It eliminates the need for a log-roll maneuver, which significantly decreases movement to the spine. The EXL is made from X-ray translucent, lightweight, high-impact composite materials. The two hinged, interlocking pieces allow operators to bring the two halves together beneath the patient and gently scoop them up.

I also love the Hartwell CombiCarrier II. This modernized scoop is really a combination scoop and backboard. It is reinforced plastic with a flat back and easy to use latch. It is rugged, fast, and incredibly effective.

3. The Vacuum Mattress

The first vacuum Mattress I was exposed to was the Germa, from Sweden. In Europe, a vacuum mattress is a common alternative to the spine board. It conforms to the anatomy, is comfortable and retains heat. Lying on a rigid spine board for any amount of time is frankly, miserable.

I spent a couple hours on a rigid spine board after my parachuting accident. Yep, my L2 was blown up into a hundred tiny pieces. But an hour lying on the board made me feel much worse. It was miserable.

A vacuum mattress is much more comfortable, because it conforms to the contours of your spine. I wish we used them a lot more in the USA. They could make a huge difference. If we used the scoop and vacuum mattress together we could move patients more gently and transport them more comfortably.

One of the most popular here is from Hartwell Medical. It is effective, affordable, and comfortable.

These are my three favorite patient handling tools. Having a variety of solutions is much better than relying on just one. Yes, this means you take an extra step or two. But it ensures quality care and helps manage patients in severe pain without making it any worse. Isn't that why we do EMS"

The accident happened on Rugby Street, near an abandoned factory building that abuts a playground and a few run down rentals. Broken bottles littered the empty parking lot of the factory. The sun brought the shattered shards and pieces to life with its rays, covering urban blight with sparkling gems.

Greens mixed with a few blues, but mostly clear glass reflected the light and softened the image that the rusted chain link fence topped with barbed wire insisted on conveying.

A crowd formed, as one often does at these things, and more flashing lights joined the ones illuminated by the bright midday sun adding more color to an otherwise dreary landscape.

Within seconds, a gang of perhaps forty people had gathered, surrounding us. The occupants of one of the damaged vehicles had run off shortly after the accident. The guys from the remaining car were in their early 20s, covered with tattoos, two wearing skull caps, the other two baseball caps on backwards, and all four could have fit another person in their clothes.

Shots fired
"Rescue 1 to Fire Alarm, can you expedite the police""

"Roger Rescue 1, nature""

"MVA on Rugby, hit and run, large crowd forming."

"Roger that."

As soon as I returned my mic to its clip the cavalry arrived, one cruiser and a rookie cop.

"Who’s hurt"" I asked the victims, who stayed close to their vehicle.

My neck, my back, my arm, my shoulder, blah blah blah.

Rescue 4 appeared, they took two and I took two. Before we made it to the rear of the rescue police cruisers began materializing, seemingly out of thin air. They had the intersection blockaded; nobody could come or go, including us.

"What's going on"" I asked the two gangsters with me.

"Don't know," they replied.

We couldn't move, I got out and asked one of the officers what was going on.

"Shots fired, we think the gun is in the car. These guys are from the North End."

"Perhaps the gun is on the person of one of the victims that is the back of Rescue 1," I said.

They sent a cop over to frisk the victims, and found nothing.

"Can you stand by till we finish"" asked another officer.

So I did. I sat in the back of Rescue 1 for a while, shooting the breeze with a couple of thugs. They weren't all that bad, once you got to know them.

"Is there a gun in the car""

"No way, not us."

"Are you North End guys still at war with the South Side""

"What do you know about that""

"I've been working this city for twenty years. I've taken at least ten guys your age from that parking lot, some full of bullets, some stabbed. Some lived, some didn't. See that playground" Last year I had one guy shot in the head under the monkey bars and another over by the swings, bullet holes in his chest. I've been to the North End and seen what happens when these things get out of control. Kids get killed. I don't know why, I don't live here, but it can't be worth it, it just can't."

"That's kid stuff; we don't get into that shit no more. Too busy working," said one of the guys.

"I've got kids now, don't want nothing to do with any of that. The kids coming up, they have no respect, they're all trying to make a name for themselves."

"Huh. We said that about you guys ten years ago. So, what are you now, retired""

"I guess you could say that."

"I was in a gang," I told them. When the laughter subsided I explained.

"What's so funny" We were some bad assed suburban kids. Even had a name, they called us the Megalomaniacs."

"Who called you that""

"Well, we did, actually. It was a secret name."

"The Megalomaniacs" What is that""

"Megalomania is defined as an excessive desire for wealth and power. The three of us liked the name so we named the gang after the concept."

"What, a gang of three intellectuals"" They laughed some more at that, and did some symbolic hand gesture thing.

"You laugh, but we went on a three day crime spree that is about to this day at the Warwick Police Department."

"Yeah, what you do, shoot up the schoolyard""

"Worse. We were playing at the schoolyard, got up on the roof and found an open window, so we let ourselves in. Had the place to ourselves for a couple hours. Before we left we filled a pillow case with pens, pencils, chalk and some erasers. Figured we would never have to buy school supplies again."

"You stole school supplies""

"Yup. Even took a stapler."

I thought they would roll out of the rescue at that one.

"Hey, wait a minute, ever been stuck in the finger by a staple" It leaves quite a mark!"

Redemption and reputation
The cops never found the gun, the guys insisted they were out of the gang, one worked at the cable company and the other was with a roofing company. They just looked like hoodlums. Once the thug life is in your blood, it never leaves you. Believe me, I know, I've been down that road. Redemption is possible but it is difficult once your reputation precedes you.

Our crime spree ended a few days after our school invasion. As luck would have it, some real criminals broke in the same weekend and stole TV's, computers, petty cash and destroyed the place before they left. A neighbor had seen our "gang" playing in the schoolyard and told the cops when they canvassed the neighborhood looking for clues.

They took us out of junior high for questioning. We almost went to Juvi but never ratted, even though we were pretty sure who the real thieves were. Gang's got pride, you know. I was lucky, I got out before puberty hit, and turned my life around. Not everybody is so lucky.

So watch your staplers, and if yours is missing, don't come looking for me, that was a different life. But if you ever need an eraser or two, I know a guy….

They don't need the facts and they don't need extraneous information to detour them from their righteous opinions about how society is breaking down. The fact that it happened is all they need. If this was the 1600s, that captain and all like him would be burnt at the stake for such a despicable transgression in the face of a society that trusted him for their very lives.

The real tragedy is that such headlines and the subsequent reactions are not at all uncommon. More frightening, though, is the frequency with which addiction leaches into the ranks of EMS providers in every corner of the world. Is it a sign of a collapsing society" Are the Four Horsemen (of the Apocalypse) on the horizon"

Give me a break!
It may be true that those who would steal or in any other way allow addiction to compromise the delivery of EMS must be removed from service, at least temporarily, but to castigate them as untouchable or irretrievable is even more despicable than the underlying act.

Over the years, I have been fortunate enough to have established a base constituency of loyal EMS1.com readers; individuals who enjoy and even apply much of what I write. I cannot begin to describe the pleasure that gives me and you will never know just how grateful I am for it.

Today, though, I call on those readers and all others to give this column and these words some special consideration.

More than anything, EMS is a superhero's business made up of flawed, mortal human beings who face the same demons as the rest of society. Much like the rest of society, addiction is one of those most awful and cunning demons. However, it is our response to that demon that matters more.

We're all human
Awhile back, I received a call from a paramedic I had known for a long, long time. He was a true believer; a provider in it to do good more than to do well. By the tone of his voice, I could tell he was in some serious trouble. His voice did not lie. He was.

It seemed that some time earlier he had suffered an injury off the job. The injury resulted in several surgeries and months of painful recovery, physical rehabilitation and pain medicine. It started as a as-needed remedy for intense pain, but became a physical necessity.

When the actual pain no longer necessitated the monthly refills, the feigned pain took over. When that excuse had run its course, new injuries and favors from friends took over. The cycle had begun.

Back at work, he became adept at leading his double life; on the job he was clean, sober and clear-headed, but off-duty the pills took over. The decline was slow, but steady. It would not be long before he would lose all control.

One day, on a call with the entire crew, he found himself in the home of a patient whose medicine cupboard was a veritable treasure trove of pain killing goodies. Jackpot!

While logging all of the medicines, it was easy to drop a full bottle of a certain pain killer into his pocket, and he did…completely undetected. The patient was transported and the scene was cleared and his addiction would be fed for a little while longer.

However, as he exited the scene with his supervisor, he was struck with a blunt and harsh realization: This is not who I am and it's not who I want to be! While still at the curbside, in front of the patient's home, he pulled the bottle from his pocket, handed it to his supervisor, and said: "I have a problem. I need help."

His supervisor considered the heartfelt and painfully honest plea for help.

But he was fired. He was stripped of his license. He was reported to local authorities and was charged with multiple felonies by the District Attorney. That was the response from his supervisor and the rest of the morally superior lemmings up the chain of command.

He asked for help; now he was looking at serious prison time. This brings us to the frightened and helpless tone in his voice when he called me.

Thankfully, his story ends with the proper treatment: A new career and the entire criminal case being dismissed. Unfortunately, similar stories continue to play out in agencies, both public and private, all across America. They do not, or will not, end so well.

Tough love
?Addiction is not at all unique to EMS. Addiction does not care what you do or who you do it with. It doesn't care what color you are or what continent you were born on or what language you learned first. It does not care how much money you make or where your parents went to school. Addiction is real and it is self-perpetuating.

So how do we deal with it in EMS"

Once you know that you are dealing with a problem of addiction, no matter what it is, apply the principles of tough love and unconditional equity.

Father Merrin said it best in 1973's The Exorcist: "…Especially important is the warning to avoid conversations with the demon. We may ask what is relevant but anything beyond that is dangerous. He is a liar. The demon is a liar. He will lie to confuse us. But he will also mix lies with the truth to attack us. The attack is psychological, Damien, and powerful. So don't listen to him. Remember that - do not listen."

Addiction is the same demon that hides behind promises, lies and misdirection. You will want to believe, but you cannot afford to. You may have to walk with or even carry him or her to a place where real help can be had, but you cannot put him or her or yourself in a position where he or she will have access to the object of the addiction or the resources to procure it.

If you are a supervisor or a partner or someone else on the perimeter of EMS, offer and provide whatever help you can until you simply can't. And always remember that any addict is only as strong as his or her willingness to get well.

Unconditional equity
?As it should be with our patients, individual providers are to be treated equally in all circumstances. If equal treatment means you have no choice but to enforce a zero tolerance policy, then so be it. If equal treatment means that one person is afforded the opportunity for rehab, then so shall they all.

Whatever the response to the specter of addiction, it must be open, transparent, equal and defensible in court. The biggest mistake many agencies make is to hide or attempt to cover up addiction issues among their ranks.

I am involved in a case in which an agency was finally forced to fire a ranking officer for abusing alcohol on the job. The problem is that they have been aware of the issue for years and even secretly sent him to rehab. All the while, other members of the same agency have been terminated for mere allegations of substance abuse off the job or otherwise disciplined by the now former officer for a variety of dubious alleged policy violations. I predict that the agency has some serious problems ahead.

In the end, I urge everyone to take a breath and recognize that EMS captains don't just wake up one day and decide to steal narcotics from ambulances. While I don't know the specifics of that particular case, I do know that addiction is real and it is treatable. It grows like a cancer until it is wiped out or the host is dead.

I believe we owe it to those who have risked their lives for others to help them through their own darkest times before we simply cast them upon the trash heap of used and now useless human beings.

Does that mean 90% of your employees are heartless community haters" Of course not! In fact, many of those employees in the 90% group likely volunteer in the community in other outside of work sponsored events. They may volunteer through their church, a local pet rescue organization or as a mentor or Big Brother or Sister to at-risk kids.

Wherever they donate their time, it's obviously personally important, often passionately, to them.

The better question is — how can your agency receive credit for the personal volunteer efforts of your co-workers while they receive the recognition of performing good deeds" Once you figure out this riddle, you'll accomplish several things.

• Your employees will be happier as you recognize and appreciate what the good they do outside of work hours.
• Potential employees will like seeing the commitment and encouragement to be community involved.
• Decision makers in the community will credit the company for supporting and encouraging the personal efforts of your employees.
• You'll have a lot of no-cost media opportunities to promote and brand your agency through the amazing people who work for the company.

The best part is that you don't need a lot of money to succeed (I'll share some ideas how to stretch your budget later in this column). First and foremost is a decision to spend the time and energy to learn what your co-workers are already doing in the community.

Start with a simple survey to all of your employees asking:

• To what organizations do co-workers volunteer their personal time"
• Do they serve on any non-profit boards and what volunteer titles they hold (Board Member, Chairman, etc.)"
• Do they volunteer anywhere (little league coach, religious school teacher, food kitchen, etc.)"
• Where have they volunteered in the last 12 months — even if just once"
• To which charities do they donate their own money (church, pet rescues, cancer society, etc.)"
• How many volunteer hours do they perform each month"

I promise you'll be amazed to learn all that your co-workers do in the community.

Now compile the collected information into the following lists.

• All the organizations mentioned
• All of the boards/community groups of which your employees serve
• A total of all the volunteer hours for the entire year (if individual surveys say they volunteered 10 hours a month, multiple by 12 to show a total year average)
• A total dollar amount of personally donated dollars by employees

Draw a line under each list and add company coordinated or sponsored organizations, donated cash plus in-kind dollars and any in-kind donated hours (free standby's, etc.).

Now you've got an impressive list to promote! All you need to do is qualify the stats. Instead of saying "COMPANY donates more than X dollars to the community," now you simply say "COMPANY and it's employees donate more than X dollars to the community."

Don't hide the origin of the full list — highlight it. Take credit for hiring amazing people who not only do a great job for the company, but for the community as well!

Place the list on your company website and marketing materials. Even include the list in proposal bids to retain or expand service. This strategy is especially effective for companies that are unable to donate a lot of time or money as an organization in the community.

Over the years, I've helped many companies create philanthropic donation programs to help build their community image. The key is to start with a budget number and create a donation strategy that fits your marketing goals.

Let's say you have $20,000 total to donate. Are you better off donating the entire amount to one organization or giving $500 to 40 different organizations" The answer may depend on the community image you wish to create.

Are you trying to make a significant impact on solving a single problem" For example, if making sure every kid has a bike helmet to prevent head injuries is your focus, you can buy a lot of helmets with $20,000.

You can then spend the rest of the year passing them out at events, schools, etc., while collecting media attention along the way. Your agency can OWN this issue.

Or does your agency gain more by having 40 community organizations send you "thank you" letters" You can distribute 40 press releases or hold 40 events where you hand over check you write so that local leaders view your agency as a true community partner and supporter.

Here's another strategy — I once put together a successful program (outside the fire/ambulance industry) where each employee could choose where to designate a $50 donation from 25 to 50 pre-approved charities. The program was extremely popular with employees, led to great media coverage and ultimately only cost the company about $5000 — less than they expected.

My point is that it's not about the amount spent, but about the impression created. Yes, it feels good to be involved in your community. It feels even better to get credit as a company for that involvement, all while creating a positive image and reputation for your agency or company.

Does your company use another strategy" Share it in comments so we all can learn from your example!

The position recognizes that the essential life-saving public function fulfilled by EMS necessitates support by all levels of government to ensure its viability. The statement was created primarily as a message for elected government leaders at the local, state, and especially, federal level. Read the full message here:

Every day, thousands of people call 911 with the expectation that an ambulance will respond and emergency medical practitioners will treat and transport them in the event of a dangerous or lifethreatening crisis. Despite this public expectation, and 25 million ambulance transports every year in the United States, the essential public function of emergency medical services is not fully recognized at any level of government.

In addition to local responsibilities, EMS agencies are an integral component of each state's emergency response system and are a critical element of our nation's disaster and mass casualty response infrastructure. The vital role played by EMS in the Boston Marathon bombings, the Texas fertilizer plant explosion, Hurricane Sandy, and the Aurora and Tucson shootings just in recent
history illustrates its significance in saving lives in the worst of circumstances.

Funding for EMS must be sufficient to ensure an effective response not only in daily operations, but also in disasters, mass casualty incidents and other public health crises. Failure to address EMS funding and integration inhibits the ability of EMS to effectively serve in these multiple capacities.

Jim Judge, Chair of NAEMT’s Advocacy Committee, notes, “This position statement was written to serve as a tool for our members in advocating for EMS funding within their local communities, in state legislatures, and with their members of Congress. It makes the strong case that EMS is a shared responsibility between government at all levels. I hope our members will use this new
statement in advocating for passage of the Field EMS Bill.”

There was a recent article from a medical director that really hit home. This story exploded throughout most of the EMS social media outlets. Personally, I have consulted with and trained this department and it's tragic that they lost one of their own in the line of duty.

Responders, we have a problem and this problem has been here for a long time, simmering just under the surface of all branches in public service. Working long hours, battling constant fatigue and stress, being exposed daily to carcinogens/oxidizers, combined with a management system that unknowingly turns its back on the problems creates a very unhealthy environment. It makes our heroes basically a disposable commodity.

So, let's come at the problem from a different angle. We need to change a few things for ourselves so you can continue to do what you love and for what you train so hard for.

Get better sleep
Everything revolves around sleep. Fatigue makes mistakes: medication errors, poor decision making, bad driving, mood swings and weakened immunity are but a few. Try these tricks to get better sleep:

• Melatonin: A natural hormone that helps to regulate the sleep/wake cycle. Check with your doctor but studies clearly show that melatonin taken after a shift will help restore natural circadian rhythms.
• ZMA: A supplement thought to help muscle recovery and sleep, taken at night along with Melatonin may be a natural way to get more restful and healing sleep.
• Avoiding caffeine and sugar 4-5 hours before bed time is always a good choice so you can get to sleep.

Embrace healing foods
Most of what we eat is bad for us. Unfortunately, we live in a society and work in a job where it's easy to eat poorly. Heck, it's almost a job requirement. Try these easy steps:

• Bring it with you: Prepare your food ahead of time before you get to work. You make better choices when you have time to think about your meals.
• Color code your food: Nature made it easy for us, the darker the food (natural NOT man made) is the better it is for you. This holds true for fruits and veggies and most root vegetables.
• Snack more: Raw veggies, fruits, nuts, homemade protein bars and homemade smoothies are all EMS friendly and will stop the bad choices from happening in the first place.

Move around
EMS, Fire and Law Enforcement are physical jobs. Physical fitness, physical ability and job specific strength are a requirement, not an option. One of the main reasons that medics are disposable is the simple fact that they are not fit for duty, therefore injury is more apt to occur.

Just walk, do step-ups, play Frisbee or wall ball. Floor based exercise is very EMS friendly and so are portable resistance bands that you can hook on your truck.

We owe it to ourselves, our families, our community and, yes, your employer to take action for ourselves. We laugh at what reality is out there on the streets, but can you look in the mirror and say you are any different"

Take positive steps now for yourself, take your wellness as seriously as you take your job and then maybe the respect EMS deserves will come to us.

Everyone knows that the wise bartender never discusses politics, sports or religion with his customers. There's just too much potential for conflict there. Most EMS bloggers and writers follow the same rules, for the same reasons.

I am not one of those writers.

I'm going to throw a little religion at y'all, and talk about what we believe, and why. I'm going to talk about dogma in medicine, and use religion to make my point.

I'm not going to evangelize to you about evidence-based medicine. Other people preach that better than I, and when it comes right down to it, I'm still a believer in some things, even if they have never been proven in a randomized, double-blinded controlled trial. The British Medical Journal made that point several years ago in this study:

Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials.

I think even the most ardent supporter of evidence-based medicine would agree that it would suck to be in the control group of a study to see if parachutes actually worked. I'd also like to point out that it doesn't require a parachute to skydive. It only requires a parachute to skydive twice.

But the efficacy of many of the things we do in EMS is not so intuitively obvious, and some of the things that we thought were intuitively obvious have persisted long enough that, when finally subjected to scientific scrutiny, we reject any evidence to the contrary.

Those things have become dogma.

The dictionary defines dogma as "a point of view or tenet put forth as authoritative without adequate grounds."

It's something we're expected to take on faith, and altogether too many of us do just that. We don't question, we just accept it as fact.

And it's easy to do, because at the heart of dogma in medicine is our desire to help our patients. It sounds good. The theory was plausible. The motivation was admirable. The goal was reachable. The lie was easy to believe, because every good lie contains a kernel of truth.

Although, "lie" may be too harsh a word, one that smacks of deliberate falsehoods. Perhaps we'd do better by labeling them "misconceptions," but the damage can be just as real.

And you know, dogma may sometimes serve a greater good. The dictionary also defines dogma as "a doctrine or body of doctrines concerning faith or morals formally stated and authoritatively proclaimed by a church."

When it comes right down to it, some things you just believe, despite the lack of scientific proof. As the noted philosopher Hub McCann said in Secondhand Lions:

"Sometimes the things that may or may not be true are the things a man needs to believe in the most; that people are basically good, that honor, courage and virtue mean everything, that power and money… money and power… mean nothing, that good always triumphs over evil, and that true love never dies . Doesn't matter if it's true or not. A man should believe in those things… because those are the things worth believing in."

Wise man, that Hub McCann.

He captures the essence of faith perfectly. When it drives us to love and serve our fellow man, it can be a wonderful thing. When it separates us, turns us against each other, makes us treat women like chattel or gays like second-class citizens, or fly planes into buildings, we have perverted faith into something obscene. We've placed more value on the wording of our moral code than on its intent.

And when that happens, it's time to abandon the dogma – medical or religious.

Far too few of us question what we're told in class, or critically examine the theory behind our practice. Far too many of us have invested our treatment protocols or algorithms with the power of faith. Far too many dubiously beneficial treatments persist as supposed standard of care for far too long, merely because we're afraid of lawyers. Far too many fervently believe in a treatment because they've seen it work with their own eyes.

There's a reason eyewitness testimony is so easily discredited; because people are fallible. Ask a prosecutor which he'd rather have: eyewitness testimony, or forensic evidence. By the same token, ask a defense attorney what he'd rather have to defend a malpractice case, an expert opinion backed up by organizational inertia and conjecture, or an expert opinion based upon scientific studies.

I'll bet a mint-condition pair of MAST pants that they'll both pick the science.

When I was a starry-eyed EMT student, I took what my instructors said on faith. After all, they were paramedics, and I wasn't. They had worked in the field, and I hadn't. They were teaching from a textbook written by doctors, people at the pinnacle of medical knowledge. They had to know what they were doing, right"

Turns out that, just like Dr. Hornstein's medical school professors, half of what Richard Pace and Randal Howard taught me was wrong. It just took me years to figure out which half. That was years spent, at the very least, doing my patients no good, and quite possibly doing them harm.

It's not that my teachers were stupid. What they taught was considered solid twenty years ago, but as it was subjected to scientific scrutiny, much of it fell apart.

They taught me that MAST pants auto-transfused two units of blood from the legs to the trunk.

They taught me to replace every milliliter of blood lost with three milliliters of isotonic crystalloid.

They taught me direct pressure and elevation was far better options than tourniquets for arterial extremity bleeding.

They taught me that antiarrhythmics were important for converting VF. I even memorized the sequence in which to give those selective cardiotoxins, and the indications for suppression of PVCs.

They taught me that even a millimeter of neck movement of a patient with an unstable cervical spine fracture might induce paralysis.

They taught me that the Golden Hour was an absolute, and that my portion of it was the Platinum Ten Minutes.

They taught me A-B-C, with all the immutability of something written on stone tablets. To do chest compressions while ignoring breathing altogether" Unthinkable.

But the most useful thing they passed along to me in training was what they didn't do. They didn't discourage me from questioning them, and they didn't require one specific approach to a problem. They taught me that as our knowledge expands, the more we realize how little knowledge we actually have.

In short, they let me keep a flexible mind. That alone has served me better in my career than anything written in a textbook. It allowed me to become a medic with twenty years of experience instead of a medic with one year of experience, repeated twenty times.

Accept nothing we have been taught at face value, most especially those things that we feel to be true. If our profession is to advance, we need to identify the things we do well, the things we don't do well, and recognize the lies we have been telling ourselves.

It's not necessary to completely abandon our faith in EMS.

But it is our professional obligation to question it.

In some cases, these stakeholders might create a local solution for you because of their influence and access to local funds. Or, after reviewing your grant request, these stakeholders may give your agency a reality check for what they think will succeed or what seems too self-serving and unnecessary.

In any case, key communicators in your community will be able to advocate for you and/or dispel any myths about your agency and its needs.

Who is an EMS stakeholder"
In a broad sense, stakeholders can be defined as individuals with or without formal EMS training who have a strong personal interest in advancing the effort to improve access to high quality EMS personnel and equipment. They strive to offer better EMS clinical services in the field and to keep the costs to what many perceive to be peace of mind healthcare affordable.

This interest could stem from the stakeholder feeling a personal responsibility to ensure good EMS care for his/her friends and neighbors. The stakeholder may have had an intimate experience with EMS, such as a personal or family experience, or by being a caregiver at some level in healthcare.

As a result of participating in the review of an agency’s application, stakeholders may and will most likely become knowledgeable advocates for EMS’ role in their communities’ efforts to save lives.

Create an "elite" appointment for these stakeholders
The stakeholder review process should also carry some prestige in the community, be publicized and celebrated. To that end, a municipal government body (i.e. city council or county commission) might assist you in appointing influential stakeholders to review your agency’s grant application(s).

A stakeholder’s invitation might indicate that the invitee has been chosen because of his/her past willingness to embrace the need for grants to achieve optimum patient care services. These individuals might also be appointed based on their previous experience with peer review processes.

They may have demonstrated the ability to interact effectively within groups (i.e. a leadership or participatory experience in a managerial, professional, or educational capacity). And, in exchange for the prestige your agency will assign to the grant review process, your grant review stakeholders should be able to commit to a minimum period of two years of participation at the time of selection. They will also attend at least one grant review session per year with a willingness to review a list of equipment, personnel, research and training grant opportunities prior to reviewing your department’s applications.

Baldwin and Gerard were selected from a highly competitive pool of immensely qualified EMS chief officers. Being designated for this fellowship is one of the highest honors for leaders in the field of Emergency Medical Services. Both recipients have longstanding contributions to the discipline of EMS and unparalleled commitments to the advancement of the EMS profession.

William Sugiyama, IAEMSC President, said “Chief Baldwin and EMS Coordinator Gerard represent some of the best of EMS leadership in the United States today. Over the course of their distinguished careers, they have helped to advance the discipline here and abroad. Their active involvement in EMS organizations locally, regionally, nationally, and internationally has resulted in contributions that further refine and advanced the discipline. We are proud to recognize Dave and Daniel for their commitment and accomplishments.” James L. Robinson, IAEMSC President-Elect, noted: “We are truly gratified by the generous support of Intermedix that enables IAEMSC to provide this opportunity for its membership. Intermedix has graciously supported this professional development initiative on an annual basis since 2006.”

Intermedix CEO Doug Shamon added, “We sponsor this scholarship with the recognition that promoting the advancement of EMS management as a profession is a highly worthy endeavor. We extend our congratulations to Chief Baldwin and EMS Coordinator Gerard and expect they will find this program to be an exceptional opportunity.”

Baldwin and Gerard will participate in the Harvard University John F. Kennedy School of Government Senior Executives in State and Local Government program in Cambridge, Massachusetts. The program provides experiences for participants both inside and outside the classroom to ensure that public officials are equipped on a daily basis to manage and lead results-driven government agencies and non-profit organizations. In particular, this program provides an opportunity to:

• Develop new conceptual frameworks for addressing program and policy issues;
• Explore the relationship between citizens and their government; and
• Examine the ethical and professional responsibilities of leadership

This three-week program is designed specifically to challenge assumptions about how to exercise leadership in the public sector. During the course of this program, participants learn strategies for establishing meaningful, attainable organizational objectives. Program participants also investigate the process of developing and evaluating policy alternatives and consider options for organizing and deploying resources to achieve these objectives.

For additional information about the International Association of Emergency Medical Services Chiefs, see www.IAEMSC.org - 1-877-442-3672.

About Intermedix Corporation

Intermedix focuses on the highly fragmented US healthcare and emergency response industries by delivering information technology and business services to manage the revenue cycle, promote preparedness and interoperability, and support incident response management, documentation, and reporting. Intermedix provides practice management and revenue cycle management services for emergency physicians and hospital emergency departments, emergency medical services (ambulance) agencies, anesthesiologists, primary care physicians, urgent care centers, and fire departments throughout the US. The company also provides technology solutions for federal, state and local government agencies, emergency management professionals, healthcare providers, and corporations using the brand names WebEOC®, EMResource™, EMTrack™, CORES, TripTix®, and Fleeteyes™.

Easy, right" But it does require a few basic skills, a couple of devices and some knowledge, all of which you have or should obtain.

Creating airway patency

First thing needed is a clear pathway to the lungs. If an obstruction is present it is most often due to the tongue and that can be moved out of the way with a head tilt/chin lift or jaw thrust. It may require insertion of an oral or nasal airway or a combination of techniques.

In a worse-case-scenario, think two nasal airways, one oral and your partner is pulling the jaw forward so you can get in a few breaths while planning your next move.

On the rare occasion when the obstruction is not the tongue, more invasive procedures may be required, such as cricothyroidotomy. Always keep suction handy to clear any blood, vomit or mucous you encounter.

Once the airway is open, you can begin to move air, but how much air" We know that providing too little or too much oxygen or leaving behind too much or too little carbon dioxide can be bad for the patient.

Managing oxygen levels

Pulse oximetry indirectly measures oxygen content in the blood and capnometry measures expired carbon dioxide; this combination will give you the information you need to keep your patient in the right air zone.

Pulse oximeters are cheap; there are no excuses for not having one.

With pulse oximetry you can determine if you need to dial down the oxygen level for your COPD patient whose usual O2 saturation is 90% ¹ or help maintain the post cardiac arrest patient's O2 saturation normal but less than 100% as too much oxygen decreases survival of injured cardiac cells².

The pulse oximeter will also inform you if your patient's oxygen level is too low and you need to increase the percentage of delivered oxygen. If you haven't reached your target O2 saturation on 100% inspired oxygen, it's time to add or increase the PEEP.

Positive end expiratory pressure, PEEP³, exists normally in your alveoli due to the column of air in the bronchioles, bronchi and trachea stacked above these air sacs. Without PEEP the alveoli would collapse with each breath and that would decrease the exchange of oxygen and carbon dioxide in the alveoli.

Patients with COPD learn to increase their personal PEEP by exhaling through pursed lips. This is the same mechanism used by a PEEP valve, a device that keeps extra back pressure on the expired air to increase the pressure in the air sacs. These devices come preset with a single pressure setting or with a range of pressures. Models are available to fit any ventilating mask or tube.

If your patient has persistent hypoxia despite administration of 100% oxygen, you can increase their PEEP to help push oxygen into the circulation. Just use the lowest pressure that accomplishes your oxygenation goals. Too much PEEP can cause the blood pressure to decline.

Be cautious with asthmatics or anyone with bronchospasm requiring manual or mechanical ventilation. Bronchospasm is like a partial one-way valve, it lets more air into the air sac then it lets out. The result is hyperinflation, a steady increase in air pressure in the air sacs that can adversely affect air exchange and potentially decrease the patient's blood pressure. Decrease the rate and volume of ventilation to allow extra time for expiration. If you use PEEP, monitor your patient closely and decrease or discontinue if the patient is not improving or gets worse.

Controlling carbon dioxide

Capnometry devices are more pricey but well worth the expense to improve your patient care. You can move a step up by using capnography which provides carbon dioxide numbers plus a waveform graph or picture of expired CO2. This waveform supplies information about lung conditions and about blood flow in general.

For example it will show you when bronchospasm is present. The normal CO2 waveform is a slightly upward sloping square. Bronchospasm changes the normal waveform to a shark fin shape. This will show up even if you don't hear wheezing with your stethoscope. That would be useful to know especially if you have a little albuterol handy.

With capnometry you can manage changes in CO2 by changing the minute volume (respiratory rate x tidal volume) just like your brain stem does normally. Carbon dioxide is an acidic waste product from normal cell metabolism that is continuously transported by the blood stream to the lungs for disposal.

Most of the time your goal for manual or mechanical ventilation is to maintain a normal exhaled CO2 level (35-45mmHg). One important exception is the ventilated asthmatic as it is critical to decrease the rate and volume of ventilation to allow for adequate alveolar emptying while maintaining sufficient oxygenation and accepting a rise in carbon dioxide⁴. The patient will normalize the elevated blood CO2 over time, but may die if you over-ventilate.

Summary

Whether your fingers are on the bag or on the dials of a machine, you remain the primary ventilator. With the basic overview presented above you can begin to optimize your patient's respiratory status and keep yourself part of the solution, and not part of the problem.

References

1. O'Driscoll BR, Howard LS, Davison AG: BTS guideline for emergency oxygen use in adult patients. Thorax. 2008;63(Suppl VI):vi1–vi68.

2. Peberdy MA, Callaway CW, Neumar RW, Geocadin RG, Zimmerman JL, Donnino M, Gabrielli A, Silvers SM, Zaritsky AL, Merchant R, VandenHoek TL, Kronick SL: Part 9: Post-Cardiac Arrest Care : 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010; 122: S768-S78

3. Neligan P: Why do we use PEEP". Available at http://www.ccmtutorials.com/rs/PEEP/index.htm

4. Stather DR, Stewart TE: Clinical review: Mechanical ventilation in severe asthma. Critical Care. 2005; 9:581-587. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1414026/pdf/cc3733.pdf

The players all wear helmets and the defense argues that the players all knew the risks.

For years, many in EMS have been aware that a leading cause of death and injury among medics following a collision is from a head injury. This is not really surprising as medics, while in the patient compartment, admittedly are often unrestrained and in a completely vulnerable state. Note the following quote:

"NIOSH crash tests also revealed the possibility of head injury if a worker's head strikes the cabinets immediately above or behind them, and noted that vehicle structural failures can be a contributing factor in adverse outcomes of EMS crashes."

Its an unfortunate truth that's been around way too long. Years ago I had the opportunity to watch several safety presentations. Prior to the presentation the presenter would ask the question, who among you would consider wearing a helmet while caring for a patient in the back of a moving ambulance. Very few hands went up.

Following the presentation wherein gruesome EMS collision images were presented the same question was asked. Following the presentation, the response was almost perfectly reversed; a very high number stated they would wear a helmet. I often wondered was this just a short-term response to an emotional event or did this represent a real desire" I have seen other safety-related items like safety vests embraced immediately, only to be later cast aside.

Following the presentation, I would also sometimes hear the question, "Where can I buy a suitable helmet"" From what I know, helmets are specialized based upon their intended use or the activity of the wearer. The needs of a firefighter inside a burning building and a rock climber are different, so the helmet, shape and function needs to be different. At the time there was no EMS intended helmet.

I was recently sent a model EMT-1 Paramedic Helmet made by B2 Helmets to evaluate. It is intended for use in a moving ambulance, as the ears are free so a stethoscope may be used. The B2 also has a half face shield to help protect against blood or other potentially infectious materials from getting into the eyes. The design allows the face shield to be worn over prescription glasses. There is also an optional lightweight LED light to help light up the rescuers field of vision.

The helmet is FMVSS 218 (Federal Motor Vehicle Safety Standards) certified. This safety standard covers wheeled large motor vehicle applications.

I wore the B2 for a couple of days while typing, walking and riding in a vehicle just to see how it felt. I definitely knew I was wearing it but it was not uncomfortable. I wore the helmet on a very mild weather day so was not exposed to extreme temperature or humidity.

From rock climbing, bike riding, car racing to motorcycle riding there is a growing body of evidence that helmets make a difference. To be fair, the literature also points out that improperly worn or fitted helmets reduce the ability to decrease the risk of head injury. Even when properly worn, helmets do not prevent all head injury and are not intended to reduce neck injury risk.

To get helmets into the mainstream a change in culture is needed. When I was a kid I would never have considered wearing a helmet while riding a bike. Times have changed. The culture has changed. The media has driven a lot of the change, by providing the statistics and by the desire to save those we love.

I began my EMS career in the early/mid 70s and would not have given any thought to wearing a helmet then either. Back then we barely had seatbelts, let alone complete shoulder restraints or helmets. We did not have gloves back then or know of AIDS. We did many things back then that by todays standards would be considered wrong. We didn't have the choices then that we have today.

Again, times and the culture have changed. Whether riding bikes, playing football or riding in the back of an ambulance, the media and the statistics suggest we need better head protection. The lives we need to save are our own, both for ourselves and for the ones who love us.

Until something else or better comes along, industry designed helmets may offer the best protection. Until something better comes along use your noggin to lead change within your organization not to just be another statistic on a chart- consider head protection, consider a helmet. Watch the video about Shoal Ambulance's decision to require helmets. A truly industry leading move.

For more information on the B2 helmet, visit www.arasan.us.

The most fundamental element of emergency medical services is the interaction between the EMS provider and the patient who is ill or injured. Simultaneously many of our patients present with a variety of infectious diseases or conditions that expose us to infection. The patient, your family, and your fellow employees are counting on you to not get them infected.

There are many potential areas of infectious exposure for the patient and the EMS provider. An important one, under the direct control of the EMS providers, is the patient compartment area of the ambulance. There are several important strategies to improve the cleanliness of that area, and reduce exposures to infectious agents. Broadly, they are broken down into the following areas:

• Equipment maintenance and disinfection
• Patient compartment maintenance and disinfection
• Minimizing contamination during patient care activities
• Personal hygiene habits

A variety of processes, methods, cleaners and disinfectants are available to accomplish the basic task of eliminating the spread of infectious agents. The most important of these are simple, reliable, inexpensive, and compliant with rules published by the federal agencies that oversee patient and employee safety^1,2,3. Keeping the ambulance and patient equipment clean requires a few cleaning products, and good personal practices.

Clean equipment begins with good equipment.

EMS patient care should be provided with equipment designed for that purpose. It should be kept in good repair. This includes the stretchers, packaging equipment, and both durable and disposable patient care items. The surface of these items that are older or have been cleaned too many times will have their protective surfaces compromised, and may harbor all forms of infectious agents.

Consider all of the surfaces that you end up touching through the course of a call. Have you cleaned stethoscopes, BP cuffs, or handles of jump kits" What about grab rails of ambulance doors, or the steering wheel" You might want to wipe down these common areas of contact as part of your cleaning regiment.

Disposable equipment that is in packaging that has been torn or soaked in liquid may particularly be at risk of containing dangerous agents and should be discarded.

Protect equipment that is taken into the patient environment (street, home, business) by keeping it clean.

Keep the patient compartment tidy.

All of your mother's favorite rules about keeping your home clean also apply to the ambulance environment: "If stuff isn't laying on the floor or on the counters, it won't get dirty." Therefore, the best cleaning principles for the ambulance include the day to day responsibility of keeping the fewest amounts of material in the vehicle that are needed for the service (the rest of the inventory remaining in a clean storage area).

Keep vehicle compartments closed and the work surfaces clear, and only taking out what is immediately needed for patient care.

Reduce the load of dirt and infectious agents by keeping dirty equipment out of the vehicle. Promptly discard that is designed to be disposed after patient use, such as suction catheters, end-tidal carbon dioxide detectors, lancets, and emesis basins. Most contaminated equipment can be safely disposed of in regular trash bins found at the EMS service or at the emergency department. However, if the contaminated materials are clearly wet, i.e. fluids are draining from them, these should be safely disposed of in red biohazard bags and deposited in the designated biohazard waste bins.

Do not use seat cushions to "hold" needles. Sticking needles and sharps objects into the ambulance or stretcher cushion injects those materials with infectious agents. Under no conditions should you throw needles away in anything other than approved disposal containers, even if they are "safed" or capped appropriately.

Reduce the load of airborne agents in the ambulance. Patients with a known respiratory-spread infection, including tuberculosis, meningitis, and influenza should have a mask in place before they enter the vehicle. Take advantage of the compartment's ventilation system and circulate the air continuously.

The CDC recommends processes for "respiratory hygiene/cough etiquette." This includes providing tissue for the patient and a place to dispose of them, as well as masks for those who are coughing.

These basic steps keep the load of potential dirt and infectious agents out of the ambulance and away from patients and EMS personnel.

Minimize infection opportunities when providing patient care.

For patient encounters where dirt and infectious agents are likely, it is ideal if the patient can be cleaned before he/she is placed in the ambulance, or has protective equipment put in place before placement on the stretcher and in the vehicle.

Other examples include:

• Masking patients who are febrile and have and a cough to reduce the spread of airborne agents
• Covering wound infections with an absorbent pad (i.e. Chux) that will prevent an agent such as MRSA from contaminating the stretcher
• Removing clothing that has been exposed to bodily fluids such as diarrhea, urine and emesis and leaving it at the home. Consider wiping the patient down before moving them to the stretcher. Place an absorbent pad under the patient's buttocks.
• Providing a closable emesis container to the patient during transport. Open basins can spill their contents during transport.
• Considering what type of PPE best suits your patient's presentation. We know that gloves and protective eyewear is essentially a minimum, but if the patient is presenting with signs of an infection, consider a HEPA mask (N95 or P100) if the patient is coughing, or a face shield and gown for a patient with a lot of bodily fluids present.

Listen to your mother: Personal hygiene matters

EMS personnel can reduce the load in the ambulance by using great personal hygiene. Use soap and water to clean hands when soiled with dirt or body fluids and after caring for patients. Soap and water and scrubbing are the best way to avoid obtaining or transmitting infections from Clostridium difficile (C.diff) or norovirus. Otherwise, the Center for Disease Control's recommended method for hand sanitation is alcohol-based hand rub.

General methods to clean and disinfect

Cleaning and disinfection of the ambulance and equipment, rely on surface disinfection with approved cleaners, especially bleach. Routine cleaning and disinfection of surfaces should focus on those surfaces in proximity to the patient and those most frequently touched. Use CDC-registered disinfectants or detergents/disinfectants that is labeled for use in healthcare. Closely follow label and manufacturer recommendations for use of those cleaners, including the amount, dilution, contact time, safe use, and disposal.

The CDC outlines disinfection protocols for dangerous agents like Methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile (C.diff), tuberculosis, hepatitis, or norovirus to include the cleaning of surfaces with sodium hypochlorite (bleach) based product. The recommendation is for a bleach solution prepared fresh daily in a 1:10 dilution with water.

It is critical that certain patients be protected from infections that may be in the vehicle or carried by EMS personnel. In EMS we deal with all types of patients, including those who have reasons to be "afraid of you." Those are patients who have compromised immune systems, including little children, those with cancer, and those burned or badly injured. It is particularly important that those patients be cared for in a clean ambulance, with clean patient care equipment, and by EMS personnel who are using masks and gloves to protect the patient.

There is an excellent reference⁴ on EMS infection control that featured an interview of Katherine West, BSN, MSEd, CIC, who is an infection control consultant for Infection Control/Emerging Concepts, Inc. The article reviews a variety of cleaning materials and processes related to ambulance safety.

There are new techniques that are being introduced every year. Most are more expensive, and not yet proven for disinfection. As of 2013, the effectiveness and reliability of fogging, ultraviolet irradiation, and ozone are not proven to reduce infections in EMS providers or patients from the wide variety of agents that are present in the patient population, and will be present in the ambulance.

References

1. OSHA Compliance Directive CPL2-2.69
2. www.cdc.gov/hicpac/pdf/isolation/isolation2007.pdf
3. www.cdc.gov/HAI/settings/outpatient/outpatient-care-guidelines.html
4. "How Clean is Your Ambulance" The truth behind cleaning chemicals". McCallion, Teresa. EMS Insider May 10, 2012