• Today, I go to a retirement luncheon for the outgoing paramedic program director Linda Anderson, who has quietly yet relentlessly operated the program since 18 years ago in then-rural Northern California. Many, if not most, of the paramedics working in the area are graduates of her program.
• During the San Francisco EMS Awards ceremony, posthumous medals were awarded to the families of firefighter-paramedic Anthony Valerio and firefighter-EMT Vincent Perez, who died during a house fire in 2011.
• A local benefit today for a cardiac arrest survivor will reconnect the EMS providers with their patients in Sonoma County.
• Nationally, a moment of silence marked the one-year anniversary of the Joplin tornado.

This is but a brief list; these events remind me of why I love being part of the EMS family. We work hard to bring control to chaos, and we try to put the health and welfare of others above our own.

We do that despite low pay and no recognition. We answer the call day and night, 24/7/365, all the while worrying about paying the bills, raising families and having relationship problems — in other words, being human.

As a profession, we've grown a lot since the 1970s, and we still have a long way to go in defining our national identity. From Johnny and Roy to community paramedics, the future seems a bit brighter than usual this week.

Celebrate National EMS Week. It's our moment to be proud of what we do.

Basic airway management will not protect against aspiration of gastric contents should vomiting occur. Always have suction equipment on and ready during airway procedures. The gold standard for securing the airway is still endotracheal intubation.

Some EMS systems may authorize use of extraglottic devices by basic level providers; however, this article is intended to stress simple, basic techniques.

It is not uncommon for me to find a compromised patient with a poorly managed airway during the wait for medication-assisted intubation/rapid sequence intubation (RSI). I am easily guilty of the same poor technique during the setup for RSI unless I frequently review the process.

Good oxygenation is a must prior to starting RSI.

Basic airway management starts with assessment of the airway. Is the airway free of obstructions" Is the respiratory rate and volume adequate" It's a common belief that airway obstruction is usually caused by the tongue, yet studies have shown that the epiglottis and other soft structures in the hypopharynx are more likely responsible for these obstructions¹.

Suctioning and anatomical positioning such as the head tilt, chin lift or jaw thrust will in most circumstances relieve these obstructions regardless of the anatomy responsible for causing them.

We are taught these airway techniques in various classes (first responder, EMT, nursing, ACLS, PHTLS, ATLS, etc.), but in practice, it is easy and common to rush and fail to use good-quality basic airway management skills.

This is typically all the patient with spontaneous sonorous respirations requires for an open airway. Adjuncts to help in maintaining the open airway are also helpful.

Oral airway devices: Oropharyngeal airways will relieve soft tissue obstruction of the posterior airway by displacement of the tongue and soft tissue anteriorly. They should only be used in the unconscious patient as vomiting, aspiration and laryngospasm may otherwise occur.

There are two primary insertion techniques:

1. The airway device may be inserted sideways or upside-down and, once it is well into the mouth, rotated and advanced in to the full position
2. A tongue blade can hold the tongue in a down and forward position until the airway is in place

Choose the method that works best for you so long as the end result is correct².

The desirable results: The patient is not responding with a gag reflex or snoring, and air is going in and out. Be vigilant in observing for vomiting.

Nasal airway: The nasopharyngeal airway is another option. These are placed in either nasal passage and allow unobstructed routes for ventilation through the nose to the hypopharyngeal area. They tend to be less stimulating than the oral airway but can cause epistaxis.

The base of the nasal passage is relatively flat and parallel to the roof of the mouth. When inserting the airway, lift slightly on the tip of the nose with the free hand, and place the lubricated airway straight into the passage with the bevel against the nasal septum, not upward as is the natural tendency. This limits contact with the turbinates and hopefully avoids the resultant nosebleed.

The airway should be constructed of a soft, flexible material, and apply a water-based lubricant such as KY jelly prior to insertion².

Ventilation: Ventilating the patient after a clear airway has been established is the next technique to master. The American Heart Association's opinion on bag-mask ventilation is that when possible, it should be a two-person job. One provider should hold the mask with both hands and maintain proper position of the head while maintaining a good mask seal; the second provider should squeeze the bag.

Because assigning two people for this task is not always practical, we should use good technique and do the best possible job for the given situation³.

The bag-valve mask unit (BVM) should consist of a self-inflating bag, oxygen reservoir and non-rebreathing exhalation valve (NRV). The mask and NRV should be constructed of a clear see-through material to allow observation for emesis.

The bag should have the ability to deliver 800 ml while squeezing with one hand. It should not require oxygen flow or volume in the reservoir to inflate, and it must be constructed of a non-slip material for easy grasp and be able to deliver an FiO2 of 0.85 to 1.0⁴.

First, choose the proper size mask for an optimal fit. The best fit is the smallest mask that will provide a good seal around the mouth and nose. This will cause the least amount of dead space and be easier to hold. For patients with thick beards, the edentulous or anyone with facial deformity from trauma, it will be difficult to maintain a good seal.

Second, the mask should not be pressed down onto the face. This pressure will cause airway misalignment. The provider should for a "C" shape on the mask with the thumb and index finger and grasp the mandible with the remaining three fingers, pulling the face into the mask. This works best when using two hands but with practice can be accomplished with one. It will be easier for the provider to maintain correct positioning of the airway without the misaligning forces caused by pushing the mask down on the unsupported head and face.

Third, ventilations should be delivered with emphasis on a slow inspiratory phase (1.5 to 2.0 seconds) in the non-intubated patient. This should keep airway pressures low and minimize gastric inflation. The target is a high volume-low pressure ventilation⁵.

Advanced airway management will provide the best protection from aspiration. It is the most precise method for of control of the gases of respiration and supplies a medication route. However, the best advanced skills are of little value if the patient suffers a hypoxic insult during the basic airway management phase. Practice of high-quality basic skills is the foundation of good medical care.

References

1. Nandi PR, Charlesworth CH, Taylor SJ, et al: Effects of general anesthesia on the pharynx. Br J Anesth. 66:157, 1990.
2. Roberts JR, Hedges JR, Vrocher D, et al: Clinical procedures in emergency medicine. 4^th Ed., 2004, WB Saunders pg. 58.
3. Cummins R.O., Field J.M., et al. ECC/AHA, ACLS: Principals and Practice. Pg. 139-164.
4. Hess DR: Manual of gas powered resuscitators. Respiratory Care Equipment. Philadelphia: 1999, Lippincott Williams and Wilkins, pg. 187-202.
5. Miller R.D., Cucchiara R.F., et al. Miller: Anesthesia, 5th ed., 2000, Churchill Livingstone, Inc. Pg. 2533.

Introduction

Engine 49 and Rescue 7 respond to a report of child not breathing. They arrive to find a screaming mother holding a 6-month-old boy who is apneic and pulseless. The mother found the child unresponsive after placing the child down for a nap about 15 minutes ago. Paramedic Harris takes the child from the mother, begins cardiopulmonary resuscitation (CPR) and moves quickly to the ambulance.

Once inside, Harris discovers organized electrical activity at a rate of 20 complexes per minute, but the child remains pulseless. Paramedic Garcia attempts to establish intraosseous access while Harris tries to secure the airway with an endotracheal (ET) tube. Garcia gains intraosseous access quickly; however, multiple intubation attempts fail to secure the airway.

After a 45-minute resuscitation attempt in the local emergency department, the physician declares futility and terminates all further resuscitation efforts.

On the way back to the station, Harris wonders whether an alternative form of airway control would have resulted in a different outcome.

Review

Researchers in Pennsylvania designed a pilot study to examine two issues related to the use of a pediatric supraglottic airway (Ritter & Guyette 2011). First, the researchers wanted to know if previous training with an adult supraglottic airway (SGA) was sufficient for EMS crews to demonstrate proficiency with a pediatric version of the same airway in a simulated respiratory arrest case. Second, they wanted to learn the preferences and perceptions of participants toward the device compared to other forms of airway control, such as the ET tube.

During the yearly skills review, researchers asked 45 flight nurses and paramedics to attempt successful placement of a pediatric King LT-D in a human simulator. Before the study, this particular pediatric airway was not part of the normal equipment carried by the air rescue service. However, each crew member had previous experience with an adult version of the SGA in both simulated and real patient contacts.

Researchers recorded whether the attempt was successful, the number of attempts required for successful insertion and how long the patient went without a breath while each crew member attempted insertion. In order to ensure accuracy, the researchers videotaped each attempt and measured time intervals from the recording.

The research team used an 11-point grading checklist to score individual crew member performance. A score of eight or better indicated competency in the airway management procedure. At the end of the exercise, each medic answered a series of questions concerning the device using a five-point Likert scale anchored at 1 = strongly agree to 5 = strongly disagree.

Results

Twenty-three of the 45 crew members (51 percent) were nurses, and the remainder were paramedics. The median average duration of employment with the air medical system was four years (range two to 12 years). The overwhelming majority of the team (95.5 percent) successfully inserted the pediatric airway on the first attempt in an average of 34 seconds (95 percent CI 26.4-67.3). Four members required two attempts; two of those resulted in successful insertions, and two did not.

Using the checklist, researchers determined that 90 percent of the crew members were competent in pediatric King LT-D insertion despite never having used the device before.

The most commonly missed step in the checklist was lubrication of the airway before insertion (30 percent completed), followed by preparation and checking equipment (60 percent completed), preoxygenation (66 percent completed) and failure to secure the airway after confirming successful insertion (73 percent completed).

Most crew members agreed or strongly agreed that their previous training and experience with the adult version of the King LT-D adequately prepared them for using the pediatric version. Most agreed that it was easier to insert the device than an ET tube and strongly agreed that they would use it as an alternative device for securing the pediatric airway. However, the crew strongly disagreed that they would use the King LT-D as the primary method of securing the pediatric airway.

What it means for you

The most recent version of the American Heart Association Emergency Cardiovascular Care guidelines places a higher priority on chest compressions than on ventilation for adult victims of cardiac arrest (Field et al. 2010). In general, however, the etiology of pediatric cardiac arrest is different from that of an adult (Berg, M. D. et al. 2010).

More specifically, infants and children more frequently develop cardiac arrest because of a progressively worsening hypoxic event (Kleinman et al. 2010). Respiratory failure develops, leading to bradycardia and hypotension and culminating in cardiac arrest (Young & Seidel 1999). It is therefore reasonable to believe that early effective ventilation may be more important for these patients than for adult victims of cardiac arrest.

In many systems, training and logistics limit paramedics to two forms of airway management and ventilation for small children. Basic techniques include head positioning, simple adjuncts and bag-mask ventilation. Advanced procedures usually involve only endotracheal intubation (ETI).

More than a decade ago, researchers in Los Angeles demonstrated that ETI did not provide greater survival or neurological advantages for pediatric patients suffering an out-of-hospital cardiac arrest when compared to use of the bag-valve mask (BVM) (Gausche et al. 2000).

In fact, three subgroups of children actually experienced significantly worse outcomes when paramedics attempted to place an endotracheal tube. Researchers in Northern California found a 46 percent complication rate and no statistical differences in outcome when paramedics performed ETI in children under the age of 19 years compared to airway management with a BVM (Aijian, Tsai, Knopp, & Kallsen 1989).

Spanish researchers studying cardiac arrest in children under the age of 16 years found the risk of death was 2.5 times higher if paramedics performed ETI (Lopez-Herce et al., 2005). A retrospective evaluation of data from the National Pediatric Trauma Registry could find no survival advantage offered by paramedic ETI for pediatric patients with severe head injury compared to treatment with a BVM (Cooper et al. 2001).

A Dutch pre-hospital pediatric study found statistically significant increases in mortality if paramedics performed ETI compared to endotracheal intubation by physicians (95 percent vs. 37 percent, respectively; p < .001) (Gerritse, Th Draaisma, Schalkwijk, van Grunsven, & Scheffer 2008).

Perhaps one explanation for the poor outcomes associated with ETI for victims of cardiac arrest is that many providers must interrupt chest compressions to intubate successfully. Within a few seconds of the interruption, blood flow through coronary arteries ceases (Paradis et al. 1990; Valenzuela et al. 2005; Wik et al. 2005), a detrimental consequence called the no-flow time (NFT).

Adult simulation studies suggest that healthcare providers of many disciplines can reliably insert the King LT-D airway while minimizing interruptions in chest compressions, thereby reducing or even eliminating NFT (Wiese, Bartels, Bergmann et al. 2008; Wiese, Bartels, Schultens et al. 2008) (Wong, Lim, & Gan 2007). The 2010 American Heart Association Guidelines for CPR (Berg, R. A. et al. 2010) emphasize the importance of reducing no-flow time.

Limitations

One important limitation of this study is in participant selection. This sample involved air medical providers with roughly equal participation of critical nurses and paramedics. The training level and skill proficiency maintenance of this group may not accurately represent those characteristics in another sample of prehospital care providers.

Another limitation lies in fact that this is a manikin study. The conditions under which the participants inserted the pediatric airway may have simulated actual field conditions; however, they were not actual field conditions. The literature is ripe with manikin and animal evidence that does not translate well when applied to human beings.

Supraglottic airways are recent introductions to the EMS discipline. We still do not definitively know about the risk/benefit ratio of the devices and whether they truly improve outcomes in real people. Although we should remain cautious, we must be careful not to discount evidence that IS available.

One of the most interesting results of this study is that the participants judged the device to be easier to insert than a pediatric endotracheal tube, but they strongly disagreed with using it as a primary means of airway control in the pediatric patient. If one truly believes that airway control is paramount to achieving a successful outcome following cardiac arrest, the logical conclusion is that the preferred method of airway control be the method that accomplishes effective ventilation but is easiest to perform.

Despite the lack of efficacy evidence for ETI of pediatric patients who suffer cardiac arrest, there are significant barriers to replacing the procedure with an alternative form of airway control (Youngquist, Gausche-Hill, Squire, & Koenig 2010).

Thomas Kuhn (1996) argues that scientific revolution within a certain discipline (such as EMS) occurs when an evidence-based paradigm replaces a previous paradigm. Paramedics began intubating pediatric patients because it was the only airway control device available at the dawn of EMS, not because scientific evidence demonstrated it was the best thing to do in the prehospital environment.

The current evidence suggests that by performing ETI, we may be hurting more children than we are helping. Outcome data following supraglottic airway insertion in the pediatric patient is lacking. EMS must decide whether we accept the evidence and become a profession or continue to hold on to our talismans, leeches and potions.

References

Aijian, P., Tsai, A., Knopp, R., & Kallsen, G. W. (1989). Endotracheal intubation of pediatric patients by paramedics [abstract]. Annals of Emergency Medicine, 18(5), 489-494. doi:10.1016/S0196-0644(89)80830-3

Berg, M. D., Schexnayder, S. M., Chameides, L., Terry, M., Donoghue, A., Hickey, R. W., Berg, R. A., Sutton, R. M., & Hazinski, M. F. (2010). Part 13: Pediatric basic life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 122(suppl 3), S862-S875. doi:10.1161/CIRCULATIONAHA.110.971085

Cooper, A., DiScala, C., Foltin, G., Tunik, M., Markenson, D., & Welborn, C. (2001). Prehospital endotracheal intubation for severe head injury in children: A reappraisal. Seminars in Pediatric Surgery 10(1), 3-6.

Field, J. M., Hazinski, M. F., Sayre, M. R., Chameides, L., Schexnayder, S. M., Hemphill, R., Samson, R. A., Kattwinkel, J., Berg, R. A., Bhanji, F., Cave, D. M., Jauch, E. C., Kudenchuk, P. J., Neumar, R. W., Peberdy, M. A., Perlman, J. M., Sinz, E., Travers, A. H., Berg, M. D., Billi, J. E., Eigel, B., Hickey, R. W., Kleinman, M. E., Link, M. S., Morrison, L. J., O'Connor, R. E., Shuster, M., Callaway, C. W., Cucchiara, B., Ferguson, J. D., Rea, T. D., & Vanden Hoek, T. L. (2010). Part 1: Executive summary: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 122(suppl 3), S640 –S656. doi:10.1161/CIRCULATIONAHA.110.970889

Gausche, M., Lewis, R. J., Stratton, S. J., Haynes, B. E., Gunter, C. S., Goodrich, S. M., Poore, P. D., McCollough, M. D., Henderson, D. P., Pratt, F. D., & Seidel, J. S. (2000). Effect of out-of-hospital pediatric tracheal intubation on survival and neurological outcome: A controlled clinical trial. Journal of the American Medical Association, 283(6), 783-790. doi:10.1001/jama.283.6.783

Gerritse, B. M., Th Draaisma, J. M., Schalkwijk, A., van Grunsven, P. M., & Scheffer, G. J. (2008). Should EMS-paramedics perform paediatric tracheal intubation in the field" Resuscitation, 79(2), 225-229. doi:10.1016/j.resuscitation.2008.05.016

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 Medical School at Dallas, 6300 Harry Hines Blvd, MC 9134, Dallas, Texas 75390-9134. E-mail: kenneth.navarro@utsouthwestern.edu

Still, a great many others believe that the world will undergo a drastic change late this year, either through a great spiritual transformation or an apocalyptic cataclysm. And if you don't have a plan in place, you're either going to die when the comet hits or be one of the unlucky survivors left eating feral housecats and picking through the rubble.

People engage in all sorts of risky behavior when they believe the end is near. They go skydiving. They go Rocky Mountain climbing. They go 2.7 seconds on a bull named Fu Manchu.

They tell their supervisors what they really think of them.

So it got me to thinking: If we knew this were the last EMS Week ever, how would we promote EMS if political correctness and long-term consequences weren't a concern" Here are my top 10 suggestions. Chime in with your own in the comments, but adopt them at your own risk… just in case the Mayans were wrong.

Hold a mass oxygen therapy seminar for nursing home nurses. It works just like a mass CPR training event but is much simpler. Divide your nurses into teams of two, and issue each team a soft, fluffy pillow. Have team members take turns holding the pillow over their partners' faces while paramedics with megaphones roam the crowd, barking, "This is what it feels like to your hypoxic patients when you administer oxygen via face mask at two liters per minute!"

Sponsor an EMS cultural exchange program between your communications center and the local cable company. Think of the possibilities here: Not only could cable subscribers get an installer dispatched right now and have EMS to thank for it, but certain 911 callers could be told, "You have an infected toenail" And it's been bothering you for a month" We'll have the paramedics right out to you, ma'am… a week from Tuesday between the hours of 11:00 am and 6:00 pm."

Sponsor free health screenings for all your system abusers. Check their blood pressure, blood glucose and cholesterol. Set up referrals for substance abuse, psychiatric counseling and homeless shelters. And most important, issue cards that contain all that information... and are also fitted with RFID tags that broadcast their location at all times. "Dispatch to Rescue 7, we have a man down call at the corner of Park and 7th Avenue, with multiple callers reporting. Also, be advised that Benny's chip has been broadcasting from that location for the past 15 minutes, and we tracked him from the liquor store on Park and 9th."

Partner with Home Depot and your local homeowners associations in sponsoring a "Find Your House at Night" seminar. Put all attendees in a darkened room. Then, without warning, play a recording of an ambulance siren at ear-splitting volume, and disorient them with the blinding glare of a million-candlepower spotlight. Then, turn on the lights and thank them all for coming. Tell them you'll be taking your show on the road to each of their neighborhoods in the coming months… unless they'd like to use the discount coupons so generously provided by their sponsors to purchase reflective numbers for their houses and curbs.

Partner with a NASCAR team to promote your new "pit crew CPR" protocols. Get the pit crew to show you how to lift an obese patient onto a spine board with a floor jack and fit an EZ-IO adapter onto an air wrench. Solicit sponsorship from equipment and supply vendors, and charge laypeople for "pit passes" to watch you practice megacode scenarios at your next ACLS class. Fastest megacode with the least amount of hands-off time wins the 2012 Physio Control Resuscitation Cup.

Hold a bystander training seminar. We all know that bystanders can be either a blessing or a curse, depending on how helpful they are. Well, here's our chance to train them up the right way. Suggested topics:

• Status Dramaticus: We Can Tell Your Loved One Is Faking a Seizure, and Now You Can, Too!
• Time Compression and 911: No, You Didn't Call 20 Minutes Ago
• Extrication 101: If You're Going to Pull the Victim from the Car before We Arrive, at Least Bring Him to the Side of the Road so We Don't Get Our Boots Muddy
• Cold Water and Junkies: It Just Results in Hypothermic Junkies
• The Paramedic Mosey: Waving Frantically and Shouting "Hurry Up!" Just Makes Us Walk Slower

Hold a cookout for staff from the local emergency departments. Serve and seat your favorite triage nurses immediately. For your, umm… "less-favored" triage nurses, tell them you're too busy to seat them right away and to just find an empty spot along the wall until you can get to them. When they point out that there are plenty of empty tables in plain sight, pretend you didn't hear them, or haughtily inform them that those tables are reserved for trauma nurses. Or telemetry nurses. Or obstetrical nurses. Any excuse will do.

"Bring Your Medical Director to Work" Day. I know many of us have never met that vague and mysterious figure who writes those absurdly restrictive protocols. Here's your chance to get to know him or her and show off your capabilities. So bring your medical director down to the station. Give a tour of the communications center. Invite him or her for a meal with the crews. Then go for a ride in one of the rigs… with your medical director strapped to a spine board and driving Code 3 down the roughest streets in your district. And if he or she complains that it's too painful, say that you're only allowed to give him 2 mg of morphine every 15 minutes, and even then only after obtaining permission from medical control at the receiving hospital. After all, it's protocol.

Goodbye, lights and sirens; hello, water-cooled machine guns and snowplow bumpers! Sure, it's a little harsh, but think of the educational and deterrent potential! When you get that guy in the Prius in front of you, pressing a cell phone to his ear and staring at you in the rearview mirror like a duck in thunder, just put a short burst into his gas tank and push him off the road. After driving past a few smoking hulks in the ditch, other drivers will learn to slow down and pull to the right. It'll be smooth sailing for every ambulance on the road right up until December 21, baby! And the best part is the apocalypse will probably happen before any of the lawsuits ever get to court!

Hold a picnic for your supervisors… in the parking lot of the local 7-11. Feed them bitter gas station coffee and frozen burritos, and right before they start to eat, announce that the picnic has been moved to the parking lot of another 7-11 ten blocks away. Do this every time they start to take a bite, and be sure to have 7-11 lock all the bathrooms. When they complain, explain that you're only trying to run the most efficient picnic possible, and remind them that plenty of other people want their jobs.

Today we have three basic types of CPAP delivery systems:

1. Combination ventilator with CPAP
2. CPAP standalone device
3. Disposable CPAP systems

Disposable CPAP devices have become popular for several important reasons. They are compact and lightweight. In rural areas, where CPAP treatments may be infrequent, they are affordable because they eliminate the need for any capital equipment. They also make a great choice for first responders. Finally, they allow for faster ER turnaround time. You can simply transfer the patient with a disposable CPAP to a wall oxygen flowmeter and clear the ER quickly.

We have recently seen the introduction of quite a few new disposable CPAP systems, giving EMS providers many disposable CPAP devices to choose from. The first popular disposable in EMS was the Boussignac CPAP.

The Boussignac CPAP device is an oxygen-powered disposable PEEP valve and mask assembly. It provides expiratory pressure support generated by the flow of oxygen from a standard regulated oxygen source.

It can provide CPAP of 5-10 cm by using 15-25 lpm of oxygen. It creates a "virtual PEEP valve," so to increase the PEEP, you simply turn up the oxygen flow rate.

It also provides substantial oxygen enrichment. Since it is an open system, patients can always freely inhale. This feature acts like a built -in safety to prevent inspiratory restriction.

The new O-Two Medical Technologies' single-use Open CPAP Device offers similar benefits. Like the Boussignac device, the O-Two device uses oxygen flow as a PEEP generator. You can also easily attach a nebulizer inline.

Another option is the Smith Oxy-PEEP. This product features a variable FiO2 Venturi, the only non-rebreathing oxygen reservoir bag, and an adjustable PEEP valve. It can provide low PEEP and high FiO2 simultaneously.

The O2ResQ is a true disposable CPAP of the Down's Flow type. It's very simple and easy to use. It has an innovative plastic expansion chamber with a Venturi air entrainment port and offers different threshold resistor-style PEEP valves.

The company recently introduced a newer model called the O2-MAX CPAP, which permits delivery of 30 to 100 percent oxygen.

The O2-MAX is attached to the high-pressure DISS port on a regulator to provide high-flow inspiratory support. If you have ever used a Respironics Whisperflow or Vital Signs Down's Flow, it will be instantly familiar to you.

Mercury Medical offers the Flow-Safe and the newer Flow-Safe II. The Flow-Safe has a built-in pressure manometer and pressure relief valve. You can easily see the actual pressures you are delivering. It is available in three different mask styles with a robust head strap system. They come in three color-coded sizes, and it can also easily accept a nebulizer.

Another new disposable CPAP type device is the Rescuer CPAP from BLS Systems. The Rescuer has a tubular oxygen reservoir and an anti-asphyxiation valve. This enables it to deliver high FiO2 at relatively low flow rates. The Rescuer can produce 15 cm of CPAP pressure at only 10 lpm oxygen flow.

It has an inhalation and, more important, an exhalation filter. This reduces the risk of transmitting airborne pathogens in a confined-space EMS environment. It also has a medication port built in.

In only a few short years, CPAP has come a long way in EMS. The disposable devices have become much more varied and intensely competitive. They are bringing real value to EMS providers by offering them a wide variety of relatively inexpensive, portable and lightweight CPAP devices for use in the field.

CPAP has been proved to be a great field treatment, particularly for CHF and pulmonary edema. It has prevented many of these patients from dangerously deteriorating. CPAP has saved lives, shortened hospital stays and reduced the frequency of endotracheal intubation.

In some areas, only paramedics can deliver CPAP, but I think CPAP is a non-invasive therapy and is entirely suitable for use by EMTs and first responders. In fact, another common name for delivering CPAP is "non-invasive ventilation."

If we can ventilate a patient who is not breathing, we should be allowed to help keep a patient breathing. These new disposable devices make providing CPAP therapy today both easier and more affordable.

To take a closer look at a few of these devices, check out my ParamedicTV.com video on the subject.

When I experience this, I try to remember management techniques that have served me well as a student, field EMS provider, educator, and manager:

1. Maintain a routine. Whether on the road or at home, I try to keep a similar routine of waking up, eating, working, family time and lights out. If my stress is work-related, I focus on resolving it during work time and keep it out of my mind during family time.
2. Prioritize personal health and wellness. For me, exercise, a full night’s sleep and eating well are even more important during high-stress periods. Tending to my basic needs helps me have the energy and focus to work through stressful challenges. I also find solo exercise, like running or biking, great for puzzling through complex challenges.
3. Schedule downtime with friends and family. No matter how many hours I work in a day, week or month, I simply can’t get everything done. Accepting that the to-do list will never be finished allows me to walk away from it at the end of the day, for the weekend or for a scheduled vacation. When I return, the to-do list is still waiting for me, but I have had valuable time away.
4. Realize stress is personal. We all experience and respond to the same stressors differently. Don’t let someone else’s stress become yours. If you are not worried about the NREMT exam, don’t start fretting just based on the reactions of your colleagues or instructor.
5. Realize stress is relevant. I like to take stock of my situation and acknowledge all that is going well and that I have many reasons to be grateful. Despite your current stress, take stock of what is going well for you.
6. Ask, "Why not me"" I have found it helpful to turn exasperating life events on their head by saying not "Why me"" but instead “Why not me"” When you run out of time to study for an exam or are asked to pair up with a struggling student, try this exercise. You might find that you handle the situation better than you imagined.

What are your stress-management tips" I am especially interested in how you manage your stress as you prepare for a test. Please share your thoughts and tips in the comments.

This has been one of the warmest winters on record. Yet, hypothermia continues to be a threat to our patients, especially our trauma patients.

Even in the sunshine state of Florida, hypothermia is a threat to those exposed to the elements. Trauma patients are exceptionally vulnerable to hypothermia. Patients experiencing shock, burns, and head and spinal injuries are most susceptible.

We know that hypothermic patients are never considered dead until they are warm and dead. Due to the mammalian reflex, our body shunts the blood from our periphery to our core body organs, perfusing them in order to maintain life.

It also slows perfusion to conserve and preserve our vital organs. Therefore, when the body begins to warm, the patient’s body begins to restore perfusion to areas where blood was shunted away.

In a traumatic patient, perfusion is compromised in a patient presenting with shock. In burn patients, we need to be concerned with fluid loss among other problems, and in spinal and head injuries, the regulation system of our body has been compromised.

In cardiac arrest patients (non-traumatic) with return of spontaneous circulation (ROSC), induced hypothermia is considered the standard of care.

However, in contrast, in patients with traumatic brain injuries, there are no significant differences in outcome with induced hypothermic treatment.

This trial (Daniel Limmer, Michael O’Keefe, 2009, Emergency Care) is thought to draw a final conclusion to a now nearly decade-long investigation as to whether hypothermia improves TBI outcomes.

We remain in need of effective TBI therapies, but researchers will have to look elsewhere as temperature control is clearly not the answer. Therefore, we know hypothermia is not the friend of a patient with a traumatic injury.

The best method to any problem is preventing it from happening in the first place. Our treatment in this situation mirrors our prevention practice.

However, the sooner we recognize the potential for the trauma patient to suffer from hypothermia, the better we can prevent the trauma patient from becoming more hypothermic.

In order to prevent the loss of body temperature, we need to know how we lose heat. We know that our body regulates our temperature; however, it is susceptible to lose heat through conduction, convection, radiation, evaporation, and respiration.

Conduction
If our patient is lying on a cold surface (a fall victim laying on a cold floor) or immersed in a cold environment (a dive injury with patient in the water), they are going to continue to lose heat. The body’s contact with a cold surface is going to lose heat quickly. A patient in water will lose heat up to 25 times faster.

You can prevent the patient from becoming hypothermic by putting a warm item, such as a warm blanket, between the patient and the surface, or remove the patient from the cold surface altogether.

Convection
The loss of heat through convection is when air or water passes over the body and carries away the heat. Getting the patient out of the environment prevents further harm. If the patient is entrapped in a vehicle, creating a shield with blankets or personnel to shield the patient from the wind will help in reducing the loss of heat through convection.

Radiation
A person loses heat merely by being in the environment , mainly through the head and neck. In addition, if the person has a head and neck injury, the patient’s perfusion to this area is more susceptible. Making sure the patient is covered with warm blankets will not only assist in the treatment of the patient, but also prevent the patient from losing more heat.

Evaporation
Evaporation occurs when the body perspires. In the efforts of our treatment of keeping the patient warm, we can also be detrimental to the patient by creating an environment so warm that they begin to perspire and then lose heat through perspiring. The patient then becomes hypothermic.

Respiration
When we exhale, we exhale warm air. If the ambient air of the incident scene is cold, the warm air the patient is exhaling can cause hypothermia for the patient. In addition, the rate and depth of the patient’s respiration has an effect on them. In most cases, a traumatic patient needs oxygen.

Providing oxygen will not only provide the patient with the much-needed oxygenation, but also help prevent hypothermia from their respiration.

Summary
Induced hypothermia in a ROSC patient is the standard of care. Hypothermic patients are never dead until they are warm and dead. Hypothermic traumatic patients are in jeopardy.

Our treatment for hypothermia is also our prevention for our trauma patient. It does not matter where you are in the country; if the environment is cooler than our body temperature, hypothermia is possible.

There are five ways our body loses heat. As part of our treatment for these patients, we should immediately take into consideration the prevention of hypothermia for our trauma patients. Tunnel visioning can be detrimental to the prevention of hypothermia in a trauma patient. Treating hypothermia in a trauma patient is the prevention of further hypothermia.

References

S. Andrew Josephson, MD, Hypothermia Ineffective in Traumatic Brain Injury Posted: 01/27/2011; AccessMedicine from McGraw-Hill © 2011 The McGraw-Hill Companies retrieved from http://www.medscape.com/viewarticle/735959 on March 18, 2012

Daniel Limmer, Michael O’Keefe (2009) Emergency Care, 11th Edition Upper Saddle River, NJ

When out-of-hospital is used for acute care or critical care, it means care provided in the prehospital environment or during an interfacility transport. Prehospital care is provided to a patient prior to delivery to a medical facility and is generally provided by ambulance personnel and scene first responders.

Prehospital care is commonly referred to as EMS or Emergency Medical Services, although that term also applies to a broader system of emergency care. You would think that most physicians who practice emergency medicine would be EMS experts but that's not necessarily true.

Many emergency physicians were trained at a time where EMS was not a part of their curriculum; or were trained in a different medical specialty before starting a career in emergency medicine; or just haven't been actively involved with EMS.

Today, most or all emergency medicine residencies include EMS in their educational program and some offer EMS fellowships. And that's great for those services that have a medical director who is board certified in emergency medicine and active in EMS or has practiced emergency medicine for a long time and has made EMS a part of their practice.

But the reality is that many, if not the majority of EMS medical directors across the United States are not residency trained emergency medicine physicians and/or do not have a background in EMS. They are mostly volunteers or minimally compensated physicians who agree to be the medical director for the local EMS service.

It is important for these physicians to recognize the medical director's responsibility for the quality of out-of-hospital medical care provided by their EMS organization — even if they were told when they signed on that their involvement would be minimal and not take much of their time.

It is also important that the medical director is aware of any statutes, rules or regulations under his or her state licensing authority that may delineate the physician's responsibility as the EMS medical director.

The volunteer or semi-volunteer EMS physician is an essential element in maintaining the quality of care provided by the EMS system regardless of size. This is accomplished primarily through developing and maintaining a process to monitor and sustain the accepted standard of care.

That doesn't mean the medical director does all the work but it does require that the medical director understand EMS and EMS systems, and the process of quality improvement as it applies to out-of-hospital medicine.

For those physicians without an EMS background but a desire to be an active EMS medical director, help is available. Your state may offer or even require EMS medical director training. There are online resources for medical director training such as the Guide for Preparing Medical Directors available at http://www.medicaldirectoronline.org/.

The National Association of EMS Physicians (http://www.naemsp.org/ ) offers face-to-face medical director courses every year. And by the way, every EMS physician should be a member of the NAEMSP, an organization that is dedicated to EMS and the EMS physician.

NAEMSP provides educational opportunities, position papers, resources and reports on EMS topics, plus opportunities to serve on EMS related committees and the publication of the only peer-reviewed journal for out-of-hospital medical care: Prehospital Emergency Care.

Another resource for the EMS medical director is the American College of Emergency Physicians (http://www.acep.org/ ), offering various EMS publications and policy statements, plus a prehospital section in their journal, The Annals of Emergency Medicine.

To maximize the educational opportunities noted above, there's nothing like hopping a ride in the back of an ambulance and observing or providing care at the scene along with those who look to you for medical direction.

And it's OK if you're unsure what to do once you get there — just ask. Initially you may be assigned a job like holding c-spine, which gets you out of the way of the field providers but to your advantage gives you the best view of what occurs on scene.

Prehospital providers will tell you "it's different out there" and you need to become familiar with that difference, which means you need to go out there if you have never done so.

Not only do those experiences familiarize you with how things actually operate in the field, you gain credibility as their medical director; you're a "field doc".

The downside of being an active, involved medical director is that you may find it so rewarding that it begins to consume time that was once devoted to other activities. On occasion, EMS medical direction may feel more like a hobby as it takes up your free time and costs you money.

But if you get over extended and find yourself spending too much time in the back of a rig or figuring out how you can expand or improve the services provided, you may be able to find a local chapter of EMS Anonymous for excessively active medical directors or perhaps start one of your own to help contain your increasing ambulance addiction. Good luck.

The presenting symptoms were similar to many other incidents in emergency care: confusion, disorientation, garbled speech and headaches. But this is actually a description of the EMS providers walking through the exhibit area of the big EMS meeting…

They were listening to multiple speakers in conference sessions, and looking through dozens of exhibits of new products that relate to airway management and ventilation for the EMS provider. How are EMS leaders and providers going to address the patient needs for a safe and effective airway in this time of expanding options"

The need for airway management remains the "A" goal in every trauma, cardiac, medical and pediatric algorithm designed for emergency care. There have never been the huge number and types of options now available for managing the airway, available to first responders, Basic Life Support (BLS), and Advanced Life Support (ALS) personnel.

EMS providers must be skilled in managing airways and ventilation using multiple devices, from airways using oral, nasal and tracheal devices; then attaching them to ventilating machinery that delivers oxygen, ambient air, and medications at various mixtures, rates and pressures.

With each type of patient encounter, the combination of devices must be chosen to improve the patient outcome or to minimize risks of a bad outcome. These two goals drive the choice of products that are purchased and placed in service, accompanied by the needed training to successfully use the devices in patient care.

Prior generations of EMS providers had basically three choices of managing an airway. They were using an oral or nasopharyngeal airway; endotracheal intubation through the nose or the mouth using a laryngoscope; or invasively placing a needle or tube through the neck and into the trachea.

Ventilation was performed through a bag valve mask (BVM). While each of these options is still available, there are many more options to ultimately manage the airway and ventilate. It has also been very clear that devices that work well in anesthesia testing are not necessarily devices that work effectively in emergency care.

The reason is very simple: anesthesia patients have an empty stomach, are not going to be moved through a building, and are often medicated to a point of being sound asleep and flaccid. In the EMS field, those conditions only occur when the patient is dead.

Our current EMS challenges are finding the combination of equipment and procedures that will work in struggling patients who still have muscle tone, usually have a full stomach and are going to need to be moved both horizontally and vertically as part of their emergency care. And our equipment and procedures need to be flexible enough to manage humans of every single size and every environmental condition.

The best airway management possible is the one that the patient does him or herself. Providing support to a patient so he or she can maintain an airway is always the best first option. Positioning is the best method of airway management in many injured and ill patients, especially for the first arriving crew.

In appropriate cases of injured patients, spinal immobilization should be performed simultaneously with an upright or lateral position for adult and pediatric patients. Ventilation and oxygenation can be supplemented with a cannula, a mask, or a BVM.

In adult patients, Continuous Positive Airway Pressure (CPAP) can be used to augment ventilation and oxygenation in a patient who is breathing on his own, and has an intact face to strap the mask to.

There is growing evidence to indicate that cardiac arrest patients can be managed with passive oxygenation and little or no assisted ventilation, until it is proven that high efficiency chest compressions and the first rounds of electrical stimulation of the heart (defibrillation or cardioversion) are not restoring cardiac function.

In all other critical EMS patient encounters, the combination of devices must then improve patient outcome or minimize risks of a bad outcome. Why have we chosen endotracheal intubation as the gold standard for essentially all emergency patient groups" Intubation allows the EMS provider to relieve or prevent obstruction, provide assisted ventilations in a patient that is not able to adequately inhale, to prevent aspiration of stomach contents, blood and other foreign material, and to help the patient manage secretions.

Intubation is a dangerous procedure if it will cause obstruction or result in a tube in the esophagus, put the patient at risk of aspiration, result in long periods of oxygen desaturation, or prevent adequate exhalation (which is the risk when intubating the severe asthmatic patient).

Airway maneuvers and devices are also dangerous if they cause damage to upper airway structures that lead to bleeding, infections and long term loss of voice and swallowing functions.

Our airway procedures and equipment are enhanced by a new range of monitors and ventilation devices that result in tremendously less risk of placing a device that causes short or long term hypoxemia or obstruction. Pulse oximetry and capnography devices allow the EMS provider to instantly acknowledge poor oxygenation or ventilation and a tube that is in the esophagus or obstructing the trachea.

Still at the top of important airway devices is a size range of oral and nasopharyngeal airways, with an accompanying BVM. For essentially all emergency patients, the correct placement of one of these devices allows seconds to minutes to choose and place more advanced tracheal tubes or rescue airway devices .

If there is obstruction to the larynx or trachea, a deeper device will have to be utilized, but that is only a small number of emergency patients. The simple oropharyngeal airway device has been enhanced with a set of modifications to the distal end that facilitate ventilation closer to the larynx, and/or facilitate the placement of an endotracheal tube.

That is essentially what a laryngeal mask airway (an LMA) is, and its newer cousins (AirQ and I-Gel). The simple BVM has also been enhanced to allow controlled pressure and flow (the Smart Bag).

A huge array of devices are now available to improve the success rate of endotracheal intubation through the nose or the mouth. Beyond the basic direct laryngoscope are now mechanical devices that increase the available light, improve the angle, and guide the tube toward the trachea. These devices may have visual enhancements and ports to channel away secretions, blood or emesis.

Among all these choices, the EMS providers and the system's medical director must have essential protocols for use, and make decisions about how to stock and train on the items that will allow the best outcomes.

There is also a cost to all of these devices. As a priority, for all of the devices, the providers must be adequately trained in to manage the care of adult and pediatric, trauma or medical, patients. Each patient may have different needs for oral, nasal and rescue airways.

A couple of training scenarios
A cardiac arrest patient has priority need for quality and high efficiency chest compressions, and use of defibrillation and/or cardioversion. The airway protocol may include protection from aspiration, use of an appropriately sized oral airway, and passive ventilation with supplemental oxygen mask or assisted ventilations with a rate of 8 to 10 breaths a minute. Only after return of spontaneous circulation will endotracheal intubation be considered.

A patient with an exacerbation of heart or lung disease may present in respiratory distress, and need airway and ventilator management. The airway protocol may include keeping the patient in his/her preferred position, using pulse oximetry to guide oxygen therapy, and applying CPAP to assist the patient who is showing signs of respiratory distress.

For the medical patient who is no longer able to maintain oxygenation or ventilation, or unable to clear secretions, or is vomiting, the protocol will include endotracheal intubation by qualified Advanced Life Support personnel.

The protocol may allow for drug assistance to help the patient accept the airway, and a period of pre-oxygenation to reduce the impact of the airway intervention. The protocol is likely to include the need to pick an appropriate size tube, leave the patient in a position that will minimize the risk of aspiration, monitoring the patient for hypoxemia and stopping the airway attempt if it occurs, and securing the tube once it is placed a certain distance below the vocal cords.

Tube placement must be confirmed with an appropriate device at the time of placement, and at regular intervals afterward as the patient is moved to the Emergency Department. A rescue airway option for a medical patient who cannot be intubated must include the sizes needed for very small and very large patients.

Patients with wheezing will be provided a medication nebulizer and supplemental oxygen, with consideration of giving other medications by intravenous and subcutaneous routes. As mentioned previously, endotracheal intubation of the asthmatic patient is usually avoided, because the tube often worsens the patient's condition. Instead, the airway is maintained with a simple oral or nasal device as further medical therapies are deployed.

A child who has suffered a respiratory or cardiac arrest has airway and ventilation needs that must be managed using pediatric devices. Many pediatric protocols are written to include first line use of oral airways and BVM ventilation, with perhaps one attempt at endotracheal intubation using an appropriately sized tube.

Rescuers should anticipate that a child will vomit and avoid maneuvers that insufflate the stomach. Few rescue airways are manufactured in sizes for children.

In a trauma case where the patient's airway or chest is already unstable, all airway interventions must take into account the need for ongoing spinal movement restriction.

Common elements of the trauma airway protocol include the need to prepare an oral airway, a nasal airway, several endotracheal tubes and the rescue device available for either failed endotracheal intubation, or to capture an invasive airway in the patient's trachea. The protocol will include devices for securing and maintaining the tube in the proper place while the patient is maintained in trauma packaging.

A number of prehospital studies (1,2, 3, 4, 5, 6) underscore the dangers of pre-hospital airway management and the need to have ongoing monitoring to assure that tubes are in the correct place. All EMS airways should be approached with extreme caution, and EMTs provided with the training to use back-up rescue plans.

Providers and medical directors face many options for purchasing and placing each of these devices in service. After choices are made for basic airways, rescue devices must be purchased that meet the needs of the patients and the providers. Rescue airways have an important place in EMS. The selection of rescue airways is an important one, not for the airway that is ultimately selected, but for the training in proper use and patient selection that must be made.

References:

Denver Metro Airway Study Group: A Prospective Multicenter Evaluation of Prehospital Airway Management. Prehosp Emerg Care. 13(3):304-10. 2009

Guyette FX, Wang H, Cole JS: King Airway Use By Air Medical Providers. Prehosp Emerg Care. 11(4):473-476, 2007

O'Connor RE, Slovis CM, Hunt RC, et al. Eliminating errors in emergency medical services: realities and recommendations. Prehosp Emerg Care.6:107-113. 2002

Katz SH, Falk JL. Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Ann Emerg Med. 37:32-37. 2003

Jemmett ME, Kendal KM, Fourre MW, et al. Unrecognized misplacement of endotracheal tubes in a mixed urban to rural emergency medical services setting. Acad Emerg Med. 10: 961-965. 2003

Jones JH, Murphy MP, Dickson RL, et al. Emergency physician verified out-of-hospital intubation: miss rates by paramedics. Acad Emerg Med. 11:707-709. 2004

Believe me when I tell you that the various penalties are stiff.

At the end of the day, managing social media and its plethora of issues comes down to this: common sense. If you wouldn't want to be the subject of your post because no good can come of it or, it is hurtful or vengeful or just plain mean, then take a deep breath, count to 10 and move on with your life.

If EMS is a profession and not just a job, the more we act like professionals the more professionally we will be treated.

The primary purpose of the 12-lead ECG is to screen patients for cardiac ischemia, especially for acute ST-elevation myocardial infarction (STEMI). This allows EMS personnel to triage suspected acute STEMI patients to the most appropriate hospital (not necessarily the closest hospital) and it should allow prehospital activation of the cardiac cath lab which is particularly important on nights, weekends and holidays when the cath team needs to be called in from home.

So how do we “catch” as many acute STEMIs as possible" To answer this question we need to know how STEMI patients present. According to most studies approximately 80 percent of STEMI patients will present with a chief complaint of chest pain. Of course, that means that 20 percent (one out of five) will not present with classical chest pain (the so-called “anginal equivalents”).

That’s why we need to cast as wide a net as possible (within reason) we screen patients with possible ACS!

My department has a protocol that specifically deals with who should receive a 12-lead ECG. The indications include:

• Chest pain
• Atypical chest pain
• Epigastric pain
• Back, neck, jaw, or arm pain without chest pain
• Palpitations
• Syncope or near syncope
• Pulmonary edema
• Exertional dyspnea
• Weakness
• Diaphoresis unexplained by ambient temperature
• Feel of anxiety or impending doom
• Suspected diabetic ketoacidosis

(Note: Many protocols also include altered mental status although these patients should receive a CT scan prior to being sent to the cardiac cath lab. Neurological insult can sometimes cause ST/T-wave changes that mimic acute STEMI.)

It’s well understood that the vast majority of these patients will not be experiencing an acute STEMI, but that’s okay! Tim Phalen sometimes compares performing a prehospital 12-lead ECG to “panning for gold.” The bottom line is that we can’t tell who is experiencing an acute STEMI by just looking at them. That’s not to say the physical exam isn’t important — it is. But it’s the 12-lead ECG that should trigger the reperfusion process in an effective STEMI system.

I’ve heard many times that experienced paramedics don’t need a 12-lead ECG to identify a heart attack patient, or that experienced paramedics can tell when chest pain is “non-cardiac” or symptoms can be attributed to some other process. I would argue that experience can teach us when acute STEMI is less likely but we should still perform a 12-lead ECG.

Take this case for example.

EMS responded to a patient who had been out kayaking on a hot and humid day. He started to feel dehydrated, became weak and nauseated, and vomited. He looked ill so bystanders called 9-1-1. By the time paramedics arrived at the patient’s side the bystanders had given him water and the patient was feeling better.

Paramedics placed him on the cardiac monitor as part of their evaluation. No 12-lead ECG was performed. After all, it was obvious why this patient was dehydrated. He had been out kayaking on a hot and humid day!

Fortunately, the patient consented to being transported to the hospital.

Here is the 12-lead ECG that was obtained on arrival in the emergency department.

As it turned the cardiologist was attending another patient in the emergency department when the Code STEMI was called and the patient had an excellent door-to-balloon time.

Before

After

This story had a happy ending, but the patient dodged a bullet, and that’s not good from a patient safety perspective.

I’m sure that many of you picked up on the ST/T-wave abnormality in the 3-lead ECG and believe that would have triggered you to perform a full 12-lead ECG. While that may be true, I think it’s particularly unwise to screen patients with a 3-lead ECG unless you’re only interested in their heart rhythm.

For one thing, when you’re in “monitor mode” the low frequency / high pass filter is typically set to 1 Hz and will not display ST-segments accurately. To fully appreciate this point let’s show the exact some rhythm strip in “diagnostic mode” with the low frequency/high pass filter set to 0.05 Hz.

In addition, there are certain types of LAD occlusions that show nothing but ST-elevation in the precordial leads! That means you won’t even see reciprocal changes in the limb leads. You simply cannot do an adequate job screening patients for cardiac ischemia with a 3-lead ECG in monitor mode.

Some EMS systems have had such a hard time with paramedics delaying the 12-lead ECG because the patient is “already on the monitor” that they’ve insisted that the monitor not be powered on until all 10 electrodes are attached! That may sound extreme but this particular EMS system has one of the best “arrival on scene to 12-lead ECG” times in the business. In other words, the rule achieved the desired result.

Next month we’ll be back to our two-part case studies!

As a consultant and trainer, I step into all types of departments and agencies. I get to look at each organization's leadership, communications, best practices, injury data, system design and equipment.

Over the years, the terms "safety" and "wellness" have become too vague for our needs. We need to reduce soft-tissue traumas and injury, as it is the single-most expensive financial outlay for a department and the most debilitating for a responder.

A defining moment
Ask a group of emergency responders what wellness is and you will get varied and often contradicting answers. What is safety" Is it safety scene safety, near miss tracking and safety gear"

In EMS, each department has at least one to two people whose full-time job is devoted to clinical excellence. Each department has a whole staff devoted to billing and separate divisions dedicated to everything from fleet to logistics.

These clearly delineated departments do their jobs very well. But how many personnel are devoted 100 percent to soft-tissue injury reduction and ergonomics, also known as patient-handling excellence"

I have worked with departments that have over 65 percent of their workers' compensation claims from soft-tissue injury. When we calculate the overtime, staffing shortages, morale and new hire expenses we often see that these departments are spending almost 45 percent of their budgets on something that should not be a problem.

As public-safety professionals, we must admit that there is a problem; happily, this problem has an easy answer. As technology continues to improve in leaps and bounds, our ability to safely transport and move patients will get more effective.

I know of three different companies that will bring to market this year some patient-handling products that will rock the fire and EMS world, and I can't wait to see their impact.

The ultimate tool
As our reliance on tools and technology increases, our physical ability decreases. Your body is the ultimate tool and my frequent rebuttal at conferences to snarky questions about patient handling is, "Are you using the tool or is it using you""

It doesn't matter how advanced tools become. Without a physical training that includes balance of strength, mobility and flexibility, your chance of getting hurt moving patients is still high.

Does your department have an officer whose job it is to observe ergonomics on the street" Does your organization retrain on proper lifting and equipment handling every year" Do you have training modules on soft-tissue injury-reduction techniques, which is not DVD-based but hands-on learning"

Sadly we already know the answer to these questions, and it is why injury rates are and will remain so high.

When an individual or individuals who are already in training and supervisory roles are trained to become pre-hospital ergonomic specialists, we will see organizational and behavioral change. And when their job specifically requires them to observe, coach, teach and reinforce safe and efficient patient handling, we will see organizational and behavioral change.

It's this kind of change that facilitates the reduction in soft-tissue injuries, which can be accurately measured.

Call them safety officers. We have seen organizations promote individuals from within that have always pushed their peers to be fit and healthy.

Provide them with the additional training and knowledge. Then, watch how a safety officer who has a specific focus on reducing one of the costliest problems in public safety can turn your department around, empower it, and field a healthy and fit group of responders.

Some things to consider during this process are:

• Medicare pays on a fee schedule. Its published allowable reimbursement rates are listed on the Centers for Medicare and Medicaid Services website. A service should have charges that are no lower than these rates. Most commercial insurance companies have reimbursement rates that are much higher than the Medicare Fee Schedule rates. If you are only billing at the Medicare Allowable, you could be leaving money on the table.
• Timely follow-up is a key factor in successful collection of accounts. Many payers now have online access to allow providers to review claim status. Other methods include automated voice response systems, allowing you to obtain claim status over the phone. Finally, a call to customer service can help push a claim through. If you're not following up on a static claim, chances are no one else is either.
• Co-insurances, deductibles, balance after insurance and uninsured patient balances can be the hardest to collect. For many services, this category typically makes up 10 percent to 15 percent of the payer mix. Pursuing balances associated with these categories takes up precious patient account representative time. Using automated statements and dunning letters can be an effective way to handle these balances while allowing staff to focus on pursuing claims with insurance companies.
• Some services don't like the idea of using an outside collection agency. While we highly recommend doing so, it's not necessary if you have the resources and are willing to pursue these balances in small claims court. While this may seem harsh, if a service is not pursuing patients who will not pay, it is providing a disservice to those who do, because the cost of service will have to increase to make up the difference.
• Helping patients enroll in government assistance programs such as Medicaid is another way to potentially increase your collectable revenue while also providing quality customer service to your clients. Applications for assistance are available on most states' Health and Human Services websites. Print and mail an application to a patient if requested. An offer can be made to help them fill the application out over the phone and then mail it to them for review, signature and mailing. This can make the difference between getting paid something or getting paid nothing at all.

If you're considering the above factors and following the steps described, in addition to such basic necessities as doing good documentation to begin with, your collection rate is very likely "reasonable" — or close to it.

Now anyone with a cell phone can take a video of a scene and have it posted on YouTube within minutes. This can air your dirty laundry in public as it becomes hard to control videos that are posted online.

Depending on the video, there may also be HIPAA and privacy concerns (or even legal implications). You may not be able to control video shot by spectators, but it is crucial to control what video is taken department members and how it is used.

Chain of custody
The first step is to outline exactly who is allowed to record events along with what happens to the recording. The best bet is to always have only one designated camera operator on scene, even if that role rotates among members.

That person then becomes responsible for the chain of custody of the video and is responsible if the video gets out. A camera operator with this level of responsibility is needed even for unmanned or helmet cameras.

Your camera operator needs to understand what can and cannot be shot, and also how to immediately secure the videos. Videos that are released to the public — including on sites like ParamedicTV — should only be with approval of the chief or the board.

Off button for med runs
Any video that includes EMS or direct patient care must be handled with a completely different set of rules. In this case you need legal advice as HIPAA regulations are very restrictive.

Peer review of videos can be accomplished with appropriate structure, but the videos have to be handled very carefully. This includes special regulations for encryption, destruction, consent and patient notification.

For most departments, the bottom line is that the amount of work needed to video medical calls may result in more work then they are worth. In fact, many departments have policies that expressly forbid all video, pictures and audio recording of medical scenes for this reason.

Fire scenes, without patient impact, may be a bit easier to video and more fruitful. For these cases, some departments have mounted video equipment on their apparatus, helmets or other equipment to provide multiple views of a scene.

There are still privacy concerns, especially if video is taken inside someone's home. What is visible from the street is often considered public. However, check with your attorney on what is required.

Making it count
Once you have the video, the question is, what to do with it" The natural inclination in the fire service is to use it to Monday morning quarterback.

Our debriefings in the fire service tend to focus on finger pointing, and videos can make this worse. As adults we are naturally hard on ourselves, and watching a video can be extremely difficult.

The goal of a video review is to identify both what went well and what could go better. It is not about what John did; it is about the overall system, response and results.

How you review the first video will set the tone for all future reviews. This includes both the actual debriefing and what is done with the video afterwards.

The best bet for everyone involved is to review the video as a group and immediately delete it. Keeping a video library is a good idea, but the last thing you want is a blooper reel showing up online.

Everyone needs to feel comfortable to review their own practice and know that their failures are not going to be criticized in public. This is especially true in the volunteer service.

There is a place for a video reel of pride. If you are going to keep video, only keep selected clips that show the positive acts of members and things you would have no problem showing to the public.

A reel of pride can help recruit new members and allow existing members to show their families what they do. Any video release like this needs to be tightly controlled; you should have a signed video release consent form from everyone in the video.

Video is here to stay. It is our place to determine how and when it will be used. We plan everything we can, and this is just another aspect. A bit of planning on both the recording and review can save a department from embarrassment and provide a source of growth.

Insightful arguments were made by my erudite colleagues on the podcast. They discussed what the potential benefits could likely be for patients and EMS if paramedics had to earn a two- or four-year degree as opposed to the certificate standard, now in place.

Perhaps not surprisingly, I found myself questioning this position on the podcast. While I certainly have nothing against advancing academic standards, there are several serious limitations with the concept of a degree minimum for paramedics.

For starters, we know that many EMS agencies struggle to keep up with the demand of educating new paramedics. They are certainly not likely to be supportive of a pathway that adds at minimum another year, and up to three more years to produce a qualified paramedic.

But wouldn't a degree level paramedic improve patient care" Since there are relatively few degreed paramedics out there practicing, I believe there is no evidence that an Associate or Bachelor educated paramedic can better take care of patients than a certified paramedic. We simply don't have an answer to the question.

However, the most important negative to the idea is that one has to ask if there are reasonable career enhancements available to those providers who would choose to pursue a degree program to become a paramedic.

EMS has not developed consistent career pathways that might reward a person seeking higher education. As a result, that particular motivation to attain a degree is not, yet, there.

So, given that limitation, if a degree standard was in place, could we really expect many individuals to commit the time and money necessary towards earning a degree" I don't think so.

The idea of judging the investment in higher education in terms of ultimate career enhancement may seem crass to some. In other words, shouldn't we just desire and appreciate a college-level experience for the sake of just seeking education"

Yes and no.

I have no problem with someone who chooses higher education for the sake of doing it. These are people who want to learn for learning's sake. Most of us probably know or work with such individuals. So for those in that category I say, have at it!

But there are likely more of us who don't see things quite that way. The reality is that most of us have significant financial and time constraints to consider. These demands only increase as we get a little older and gain more responsibilities.

So for most people, the questions are what is the time and investment involved in acquiring a college degree worth" Can I get a good job – or even a job at all – after graduation"

At least I think these should be the questions we ask. Most major purchases we make include a careful analysis of the potential benefits. Why shouldn't we do this with higher education"

Collegiate costs rose on average 8.3 percent from 2010 to 2011, according to an article in CNN Money from October 2011. This is obviously significantly ahead of the inflation rate.

Indeed, a rule of thumb is that college tuition increases can be expected to rise at a rate at least double that of inflation. Many institutions far exceed that. Much of this is fueled, in my opinion, by the great quantity of scholarships and federally funded grants and loans.

Despite the ever rising cost of tuition, many Bachelor's Degree recipients are unable to find jobs.

Why shouldn't the college education community be held to a standard of post graduate job attainment" What about enhanced career opportunities for those with a graduate degree over those with a certificate" Isn't that what most graduates ultimately want"

As the father of four children who funded their college experiences culminating in their Bachelor's Degrees, I am both a consumer and customer of higher education in its vast forms. From personal experience, I can say that not all degrees are created equally when it comes to the issue of employment.

So the point is that when we opine that a degree requirement should be an ideal for future paramedics, we are not considering reality. What motivates most people to advance"
The prospect of greater career options, which is really code for greater economic opportunity.

The EMS profession should take a page from the nursing profession. Nursing has created many opportunities for career enhancement for those with Bachelor's degrees, but even more for those who have achieved a Masters in Nursing. Most of these opportunities are in management in hospital settings, but include both corporate and government, too.

However, there is a tremendous opportunity for EMS to up the ante for higher education and career advancement. I refer to the future of community paramedicine and its related training requirements and patient care responsibilities. Like many, I believe that there is a very significant role for EMS in this area in the years ahead.

EMS is now at the threshold of defining the standards for these and other non-transport health care provider opportunities. It seems likely this may provide that path of career advancement, as well as higher reimbursement, for EMS.

If so, now is the time to mandate at least an Associate's, if not a Bachelor's, degree for those paramedics aspiring to be involved in these key non-transport patient care roles.

If not now, when" If EMS fails to seize this moment, the ideal of a college degree minimum for paramedics is whistling dixie.

William Sugiyama of the Oakland (CA) Fire Department was installed as IAEMSC President, following a two-year term as President-Elect and succeeds Chief Lawrence Tan of New Castle County (DE) EMS.

The current IAEMSC leadership
includes:
• Vice-President: Chief Robert McCaughan
Pittsburgh (PA) EMS
• Secretary: Chief Brendan Kearney
Boston (MA) EMS
• Treasurer: Chief Christian Callsen
Austin-Travis County (TX) EMS (Ret.)
• Directors (At Large): Chief Peter Howes (2014)
San Francisco (CA) Fire Department (Ret.)
Chief Chris Colangelo (2014)
Wake County (NC) EMS
Chief Martin VanBuren (2013)
Hennepin County (MN) EMS
Chief Patricia Dukes (2014)
Metro Chiefs Section Chair
Honolulu (HI) EMS
Chief Dean Wilkinson (2013)
Essex-Windsor EMS (Canada)
Chief James Cole (2013)
San Juan Island (WA) EMS

Chief James Robinson of Denver (CO) EMS was selected as President-Elect, and will become IAEMSC President in 2014.

The International Association of EMS Chiefs (IAEMSC) is a non-profit professional association established to support, promote and advance the leadership of response entities and to advocate for the EMS profession.

The IAEMSC membership consists of leaders from both career and volunteer EMS organizations, representing a diverse group of public and private EMS agencies that respond to over 3.3 million emergencies and transport over 2.78 million patients each year. The IAEMSC hosts
an annual EMS Leadership Summit in Washington, DC.

Additional information regarding the IAEMSC and membership opportunities is available at their web site located at www.iaemsc.org.

He was reported to the airline by the hotel shuttle bus driver. As someone who flies a lot, I appreciate the commitment this driver made to protect us all, for speaking up.

We have all been on hotel airport shuttle busses. Ask yourself, what would you have done if you had been on this shuttle" Would you have reported the pilot" Would you assume someone else would spot it and report it"

I don't want to be flown by a pilot who is legally drunk, exhibiting a known at-risk behavior, possibly endangering my life. I have the right to expect to be flown by a sober, competent pilot.

Let's put this in EMS terms and look at several at-risk behaviors that may put you and other innocent people including patients at risk. These behaviors include:

• Lifting incorrectly, risking low back injury, injury to partner and possibly dropping the patient.
• Proceeding through a red light at a busy intersection without stopping and clearing each lane.
• DWE: driving while exhausted for whatever reason.
• Not taking proper precautions such as wearing gloves, goggles and other protection.
• Not confirming tube placement.
• A partner clearly under the influence as the pilot described above.

If you were the partner in any of these situations, and the odds are very real you have, what would you do" Would you say something" Who would you talk to"

Would you talk to your partner or a supervisor/manager" Would you perhaps call the medical director" Is there ever a time when it would be OK to refuse to run a call"

Years ago I had the opportunity to take a driver instructor class unlike any I had every taken before. The instructors were former FAA investigators. They approached driver training and safety from a completely different direction.

The focus of their program was all about such questions as posed above, your decisions to those questions and communication skills.

During class, they told of an investigation they conducted after a passenger plane taxied off the end of a runway into the water beyond. When asked, the copilot acknowledged that in fact he saw the water, that he did not say anything to the pilot.

When asked why he remained silent, the copilot stated he assumed the pilot had to see the ocean directly in front of him — how could he not" It's easy to assume someone else will address the issue that it need not fall on you.

Why else might someone not say something" Other reasons identified included being afraid of confrontation and a fear of retribution. What if the person who runs the red light gets suspended or in some other way disciplined" Are you ready to take the heat"

In its simplest explanation, it's just easier to look the other way — less paperwork, less anxiety. No confrontation.

But what about those times when there is a crash, a patient drop, a back injury or a case of TB. How will you feel if you knew and failed to say something" How will you feel if there is a fatal collision and you did not do the right thing" What if this hotel shuttle driver did not say anything — remember, the pilot made it all the way to the plane.

Diabetes is common. An estimated 8.2 percent of adults in the U.S. (range 4.4 to 17.9 percent) have diabetes¹. Some 14 percent of total U.S. health care expenditures pay for treatment of people with diabetes, half of which pay for complications associated with vascular changes that lead to MIs (myocardial infarctions), strokes, kidney disease, retinal (eye) damage and foot ulcers.

The progression of these complications can be slowed with aggressive management of blood sugar levels and blood pressure as well as good eye care². Alterations in blood glucose levels, both high and low, are often encountered by EMS providers. Depending on where you work, hypo- or hyperglycemia will account for 3 to 4 percent of your total EMS responses.

Hypoglycemia refers to low blood glucose levels, which often exhibits signs and symptoms. The most common cause of hypoglycemia results from diabetes medications although hypoglycemia can occur in people without diabetes from a variety of other causes.

Most commonly, hypoglycemia occurs in patients taking insulin. While textbooks often outline very specific hypoglycemia signs and symptoms, they are, in reality, very non-specific.

Many patients will have tremors, palpitations, sweating, and/or hunger. These actually have a behavioral effect of encouraging the patient to eat. Blood pressure and heart rate will usually increase, but not significantly.

There may be observable behavioral changes, loss of awareness and, at very low glucose levels, seizures or unconsciousness³. While signs and symptoms vary tremendously between patients, they remain consistent in any single patient from episode to episode.

Many times, patients are unaware of their symptoms even though they may be obvious to others around them. Because patients often have amnesia, they may have trouble describing an episode. For this reason, it is important to obtain information from family, friends or bystanders when possible.

The primary fuel for the brain is glucose, yet it can neither make nor store it. Our survival mandates that the body tightly regulate glucose levels and prevent (or rapidly correct) hypoglycemia.

Ordinarily, this happens effortlessly. When blood glucose levels fall into the 80 to 85 mg/dL range, the body slows or stops secretion of insulin. The lower limit of normal blood glucose levels in adults is 70 mg/dL (in neonates, 40 mg/dL).

When blood glucose levels fall into the 65 to 70 mg/dL range in people without diabetes, there is an increased release of counter regulating hormones (epinephrine and glucagon).

People with diabetes may not produce glucagon or not respond to circulating glucagon by releasing liver glycogen stores. The corrections happen well before the onset of signs and symptoms, which usually occur when glucose levels reach 50 to 55 mg/dL.

These thresholds shift to higher values in people with poorly controlled diabetes and to lower values in people with lower than usual baseline glucose levels from intensive diabetes therapy. For patients taking insulin, treatment is warranted when blood glucose values fall below 70 mg/dL.

While hypoglycemia can result from prolonged fasting and other medical conditions, drugs are the most common cause. Persons with diabetes treated with insulin routinely experience numerous episodes of hypoglycemia; in fact, their blood glucose levels may be less than 50 to 60 mg/dL up to 10 percent of the time³.

Mild hypoglycemic episodes occur in 30 to 50 percent of patients treated with insulin and 16 to 20 percent of patients treated with oral diabetic medications^4.

Many factors including exercise and fever can increase glucose use in people taking insulin for treatment of diabetes, leading to hypoglycemic states from excess of circulating insulin.

Infants and children differ from adults in their ability to maintain normal glucose levels when not eating. An adult will maintain near normal glucose levels for weeks without eating; obese adults for months.

Children, however, drop their blood sugar levels to hypoglycemic values after 24 to 36 hours without food. The reasons for this are complex but important to consider when caring for younger patients.

Hyperglycemic emergencies ordinarily fall into one of two clinical syndromes: diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS). The key differences relate to the presence of ketoacids in the blood and the severity of the glucose elevation.

The earliest signs and symptoms of hyperglycemia are polyuria (excessive urination), polydipsia (excessive thirst), and weight loss (from the high urine output)⁵. In children and adolescents, fatigue is also a key early finding.

DKA has a relatively quick onset, ordinarily evolving over 24 hours. Blood glucose levels range between 500 and 800 mg/dL and the blood is markedly acidic.

Patients often present with shortness of breath and abdominal pain and – especially in children – with nausea and vomiting. They rarely have altered mental status but are volume depleted, may have a fruity acetone-like (nail polish remover) odor on their breath, and have deep, rapid (Kussmaul) respirations to compensate for their acidotic blood state.

Patients with HHS often have much higher blood glucose levels, often more than 1000 mg/dL. Onset and progression of HHS is generally much slower than DKA.

The higher glucose levels significantly increase the osmolality of the blood often resulting in neurological symptoms ranging from confusion to unconsciousness. Some patients develop stroke-like symptoms or seizures. HHS patients rarely, if ever, present with abdominal pain.

In most instances of DKA or HHS, a precipitating factor can be readily identified. These commonly include infection (most often pneumonia or urinary tract), insufficient insulin dosing, or newly diagnosed diabetes.

DKA is more commonly seen in undiagnosed diabetes. In children and adolescents, DKA resulting from insufficient or improper insulin dosing is a major cause of mortality.

Before putting all this information together, consider an important fact about blood sugar: hypoglycemia kills brain cells.

An unconscious patient may be hyperglycemia, hypoglycemic, or have a normal blood sugar. You can tell the difference with a finger stick glucose meter.

If the ability to measure glucose is not available, glucose should be given. The risk of permanent brain damage from hypoglycemia far outweighs the danger of increasing an already elevated blood sugar.

Rapid assessment using all the clues described previously suggests that the most likely patients to experience hypoglycemia are those who take insulin.

The next most likely are patients taking oral diabetes medications. Contributing factors to hypoglycemic episodes are exercise, fever, and too much insulin (or oral medication).

In a person with diagnosed diabetes, ask family or friends what the patient's usual hypoglycemic signs and symptoms are. If they are exhibiting different signs and symptoms, be suspicious that low blood sugar might not be the culprit.

Note that hyperglycemia, especially DKA (the most common cause of elevated blood sugar) often presents with abdominal pain, nausea and vomiting; not an altered level of consciousness.

In children, DKA will often mimic belly pain from appendicitis or gastroenteritis⁶. Be wary! Ultimately, the capability to measure blood glucose is the only definitive field assessment that will point you in the right direction. If you have any doubt, administer glucose.

Lastly, you may have noticed that nowhere in this article did I use the word, "diabetic." That term should be eliminated from your vocabulary and replaced with the phrase, "person with diabetes."

This switch in terminology acknowledges that the patient is responsible for managing the diabetes as a disease. When we call patients by the name of their disease, it sends a message that diabetes is controlling the patient.

Nothing could be further from the truth. As EMS providers, we should keep up with changing medical terminology, especially when it empowers our patients to take a more active role in their wellness.

References:

1. Cory S, Ussery-Hall A, Griffin-Blake S, et al. Prevalence of selected risk behaviors and chronic diseases and conditions-steps communities, United States, 2006-2007. MMWR CDC Surveill Summ 2010; 59:S1.
2. Nathan DM, Buse JB, Davidson MB, et al. Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2009; 32:193.
3. Cryer, PE. Hypoglycemia in diabetes. Pathophysiology, prevalence, and prevention. American Diabetes Association, Alexandria VA, 2009.
4. Zammitt NN, Frier BM. Hypoglycemia in type 2 diabetes: pathophysiology, frequency, and effects of different treatment modalities. Diabetes Care 2005; 28:2948.
5. Rose, BD, Post, TW, Clinical Physiology of Acid-Base and Electrolyte Disorders, 5th ed, McGraw-Hill, New York, 2001, pp. 809-815.
6. Chaussain JL, Georges P, Calzada L, Job JC. Glycemic response to 24-hour fast in normal children: III. Influence of age. J Pediatr 1977; 91:711.

Treatment Uses – For emergency treatment of Type I (anaphylactic) allergic reactions. Also approved for emergency treatment of asthma, blood coagulation disorder, cardiac arrest, mucosal congestion (when applied in topical spray form), excessive uterine contractions, glaucoma (in eye drop form), hypersensitivity reactions, syncope (fainting) due to complete heart block or carotid sinus hypersensitivity, hyperkalemia (high serum potassium levels), and an adjunct to decrease bleeding and increase duration of action when mixed with local anesthetic agents.

Epinephrine is also directly injected during endoscopy to treat actively bleeding upper gastrointestinal ulcers. Topical (applied to the skin) epinephrine solutions have been used to treat herpes simplex lesions.

Very dilute solutions have been injected into the penis to treat prolonged priapism (erection). Inhaled mixtures of epinephrine are used to treat asthma, croup, stridorous (reactive) upper airway conditions, acute wheezing and, with mixed results, cluster headaches. In cases of severe asthma, subcutaneous administration is superior to inhaled epinephrine.

Epinephrine has a wide variety of uses and can be administered by multiple routes. For the purposes of this column, discussion will be limited to uses of epinephrine auto-injectors, most often used for treatment of allergic reactions and severe asthma.

Of particular note, delays in epinephrine administration are an important contributor to adverse outcomes in allergic reactions and severe asthma. Epinephrine administration should be considered even when allergic symptoms involve only one body system (i.e., the skin).

Anaphylaxis is a life-threatening condition. Millions of severe allergic reactions occur annually; several hundred people die from food, insect sting and drug induced anaphylaxis.

A significant risk factor for death from anaphylaxis is delay administering epinephrine after onset of symptoms. Most allergic reactions are immune mediated, meaning that an individual is exposed to an allergen, develops antibodies to the allergen, and experiences an allergic response the next time they are exposed to the allergen. Hence, an individual may be very allergic to a food, insect, or drug but totally unaware of the allergy until they are exposed a second or third time.

Signs and symptoms are varied and may involve the skin (itching, swelling, rash, redness, hives), respiratory tract (runny nose, wheezing, congestion, cough, difficulty breathing), gastrointestinal tract (cramps, nausea, vomiting, diarrhea), and/or cardiovascular system (increased heart rate, low blood pressure, fainting, chest pain).

While cutaneous (skin) symptoms and wheezing are very common in anaphylaxis, cutaneous signs are absent in 20 percent of severe allergic reactions and respiratory symptoms occur in only 50 percent of cases. Treatment should not be delayed to observe for worsening symptoms.

Asthma, like anaphylaxis, can also be a life threatening problem. EMS providers who respond to an asthmatic patient in severe distress may find the patient unable to inhale metered dose or nebulized bronchodilators.

An EpiPen is an ideal (and often life saving) emergency treatment for these patients, allowed under many EMS protocols. In severe asthma, epinephrine is the agent of choice for emergency treatment.

Dosing and Administration – The United States Joint Task Force on Practice Parameters for Allergy and Immunology guidelines for management of anaphylaxis in adults call for epinephrine 0.2 to 0.5 milligrams (0.2 to 0.5 mL of a 1:1000 solution) injected IM (intramuscularly) in the lateral thigh muscle every 5 to 10 minutes as needed. If clinically appropriate, injections can be given more frequently than every 5 minutes.

Auto-injectors contain fixed doses of epinephrine. Hence, for adults and children 30 kilograms (66 pounds) and heavier with anaphylaxis, give 0.3 milligrams of epinephrine IM which equals 0.3 milliliters of a 1:1000 solution as contained in an auto-injector.

If severe anaphylaxis persists, the same dose may be repeated after 5 to 10 minutes or sooner if needed. The same dose is used for adults with intractable asthma, blood coagulation disorder, excessive uterine contractions and syncope due to complete heart block or carotid sinus hypersensivity.

For pediatric patients weighing between 15 and 30 kilograms (33 to 66 pounds), give 0.15 milligrams epinephrine IM which equals 0.3 milliliters of a 1:2000 solution contained in the pediatric auto-injector.
Administer an epinephrine auto-injector into the anterolateral aspect (side) of the thigh. If the patient is wearing clothing, administer through the clothing. It is important to hold the auto-injector in place on the thigh once the audible activation click is heard to assure delivery of the drug into the leg.

Auto-injector epinephrine should not be given intravenously (IV) or into the buttock. Do not use epinephrine that is pinkish colored, has precipitate present or is otherwise discolored.

The EpiPen manufacturer operates an excellent website with videos and instructional materials on proper use of the auto-injector (www.epipen.com).
Earlier preloaded epinephrine emergency kits were designed for subcutaneous (SC) administration; patients were often taught to administer the drug in the upper arm (deltoid muscle). However, studies have demonstrated that IM injection achieves significantly faster maximum plasma epinephrine levels compared to SC administration.

Additionally, IM injection into the vastus lateralis (anterolateral thigh) muscle are more effective than IM or SC injection into the upper arm, produce faster effects and greater peak plasma epinephrine levels.

Many drugs intended for injection work equally well orally (taken by mouth). Not so with epinephrine. Given orally, epinephrine will rapidly degrade in the GI tract and is not absorbed at all.

Epinephrine contained in auto-injectors contains sodium metabisulfite as a preservative. This should not deter administration of the medication to patients with sulfa allergies who have a legitimate allergic reaction or emergency condition. In fact, there are NO absolute contraindications for administration of epinephrine in a life-threatening emergency.

Earlier recommendations suggested that the risk of cardiac side effects in elderly patients outweighed use of epinephrine. A study of three sequential doses of auto-injector epinephrine in asthmatics aged 40 to 96 years old spaced 20 minutes apart demonstrated that epinephrine appears safe for asthmatic patients of any age.

Multiple other studies have confirmed the safety of epinephrine for treatment of severe asthma in patients of all ages. While epinephrine is a powerful medication with potential for significant cardiovascular effects, this should not preclude its use in any life-threatening emergency.

Overdoses of epinephrine can markedly elevate blood pressure and cause a multitude of tachy- and brady-arrhythmias. Pulmonary edema may result from simultaneous bronchodilation, peripheral vasoconstriction and excessive cardiac stimulation.

Treatment should be supportive and may require administration of beta blockers. Be mindful that epinephrine is rapidly inactivated in the body – symptoms are unlikely to be prolonged.

Pharmacology/Pharmacokinetics/Stability – Following subcutaneous or intramuscular administration for anaphylaxis or asthma, initial response to epinephrine is rapid. Duration is short. Injected epinephrine is rapidly inactivated and degraded by liver enzymes. Most of the degraded epinephrine is excreted by the kidneys.

Repeated injections of epinephrine, spaced at approximately 20 minute intervals, have been shown to sustain initial improvements without cumulative effects.

There are no studies on effects of epinephrine during pregnancy. It should be used if the potential benefits to the mother outweigh risks to the developing fetus. No studies have been conducted on breast milk of nursing mothers given epinephrine for anaphylaxis.

The mechanism of action of epinephrine is as a sympathomimetic catecholamine acting on both alpha- and beta-andrenergic receptors. Of catecholamines, it is the most potent activator of alpha receptors resulting in intense vasoconstriction. Its beta receptor action promotes bronchial smooth muscle relaxation, resulting in significant bronchodilation.

EpiPen and EpiPen Jr. are supplied in a 2-Pak carton containing two EpiPen Auto-Injectors (clipped together with an S-clip) and one EpiPen Auto-Injector training device. Single EpiPen and EpiPen Jr. units are no longer sold in the U.S.

EpiPen auto-injectors should be stored at controlled room temperature (77 F) with excursions between 59 and 86 F allowed. Epinephrine is theoretically light sensitive; keeping it in the carrier tube provided protects it from light. EpiPens should not be refrigerated.

Stability studies have shown degradation to less than 90 percent of labeled dose when stored for more than 3 months in low humidity (15 percent) and 4 months storage at high humidity (95 percent).

Interestingly, light had no effect on stability. There was no degradation when stored at 5 C (41 F) or at 70 C (158 F) for 8 hours a day over 12 weeks. Interestingly, 1:10,000 concentration epi completely degraded at the high temperature when stored for similar periods (of note for ALS drug boxes).

From a chemical standpoint, higher pH (above 5.5) promotes oxidation of epinephrine (causing it to become very unstable). This is a slow process, and is not likely to be clinically significant over short time periods (less than 2 hours). Hence, for ALS providers, it is not necessary to separate epinephrine from bicarbonate when administered through the same line.

Cautions and Warnings – Epinephrine auto-injectors are designed for self-administration in emergency situations. Their safety profile and ease of use has led to widespread use by EMS personnel, school officials, camp counselors, and medical personnel.

An auto-injector should not substitute for immediate medical care; patients should be advised to seek medical treatment following any use of an auto-injector.

Inadvertent injection of epinephrine into hands, feet, fingers or toes may result in loss of blood flow and severe tissue damage. A recent redesign of the EpiPen and EpiPen Jr. highlighted the needle with a brightly colored orange self retracting cap and warning label.

Unfortunately, a popular insulin auto-injector pen already on the market is operated by pressing on a brightly orange colored activator button. This has caused health care providers and patients with diabetes to inadvertently stab their fingers attempting to use EpiPens.

Every EpiPen package includes a training auto-injector; EMS personnel should practice frequently with the trainer to prevent misuse of the actual EpiPen in an emergency. In the event of injection into fingers or toes, seek immediate medical attention.

Important Side Effects and Interactions – Pulse rate and blood pressure are increased due to the alpha stimulating effects of epinephrine. Metabolic effects of epinephrine include elevated blood glucose resulting from inhibition of insulin secretion and increased lactate and free fatty acid concentrations in the blood due to receptor activation and a 20 to 30 percent increase in oxygen consumption with usual doses.

Side effects of epinephrine include increased heart rate, palpitations, sweating, nausea, vomiting, nervousness, tremors, dizziness, headache, and difficulty breathing.

There are 54 drugs and drug classes specifically reported to interact with epinephrine. Some are worth noting. Patients taking tricyclic antidepressants (TCAs), monomine oxidase inhibitors (MAOIs), or levothyroxine may experience greater and longer lasting effects of epinephrine.

Beta blockers may lessen or interfere with the therapeutic effects of epinephrine. Patients with hyperthyroidism, cardiovascular disease, diabetes, hypertension, pregnancy, or those weighing less than the recommended weights (30 kilograms for EpiPen and 15 kilograms for EpiPen Jr.) are at greater risk of developing side effects or adverse reactions. Angina may occur in patients with significant coronary artery disease.

Rapid rises in blood pressure leading to stroke have been reported following epinephrine administration, particularly in elderly patients with cardiovascular disease. As mentioned previously, none of these potential side effects should inhibit use of epinephrine in life-threatening emergencies.

Average Costs – U.S.

• EpiPen 2-Pak and EpiPen Jr. 2-Pak (brand name)

Patient cost: $187.89 and 203.29 each*
Large Hospital cost: $176.00 each (both adult and Jr.)
*(Wal Mart and Target don’t include this med in their $4/month programs)

References:
1. MICROMEDEX Healthcare Series: Thomson Micromedex, Greenwood Village, Colorado (accessed January, 2012).
2. Albany Medical Center Pharmacy, Albany, New York.

When I went to nursing school, few EMS professionals were considering nursing as an additional opportunity. Male EMS professionals were even less likely to take the big step. Today, things are quite different. In fact, since I completed nursing school only a short six years ago, I have heard from countless EMS colleagues considering the option. I guess once they saw that this dope could pull it off, anyone could!

In this economy, EMS professionals seem to be considering some of the same factors. They generally want the following out of a nursing program:

• To continue to work while attending school. This could mean that the option of attending courses part-time or on weekends and evenings is important. A predictable and consistent schedule is vital because convenience and scheduling are a top concern.
• Affordable education
• Value on clinical experience
• Credit for previous education, no matter when courses were completed. Many colleges and universities require major science courses to have been completed within the past five years. This could be an issue for the EMS professional who completed A&P or microbiology several years ago and has just now decided to pursue further education.
• To get 'er done! They expect to work hard and dedicate themselves, but they don't want to take two years to do it.
• Avoiding "death by PowerPoint" with focus on applying new clinical skills and the nursing process. EMS professionals tend to gravitate to programs that include clinical simulation, computer simulation, group learning and frequent computerized testing.
• To pass the NCLEX the first time. Therefore, a program's reputation and use of computerized test preparation is valuable.
• A different clinical experience from that of entry-level nursing students. EMS professionals don't want to spend much time in the ED or OR, but they want to branch out from their comfort zones by spending time in the ICU, pediatrics and OB.
• Respect from the nursing staff. They want to avoid any gender or professional (anti-paramedic) bias. I recall before I went to nursing school being told by my male nursing mentors, "Don’t tell the nursing faculty you are a paramedic!"

One of the all-around best choices is a paramedic-to-ADN "bridge" or "transition" program. These are typically facilitated by community colleges or universities and are usually more cost-effective than private colleges. Unlike traditional programs, there are relatively few real bridge programs across the country. The benefit of a true bridge program is that it articulates previous paramedic education into completed credit hours. This saves the student time and money.

For example, our institution started the first paramedic-to-ADN bridge program in our state and articulates 29 college credit hours for paramedic graduates from a state- or nationally accredited program. In addition, bridge programs often offer hybrid courses — part in-class, part online.

Those looking to maximize convenience with an online or distance program have two great choices to consider. I may be revealing a little personal bias here as I am a graduate of Excelsior College, but I would still keep this college on the top of my list of choices. Although tuition will be more than your local community college, you can’t beat the convenience. Excelsior College has been awarded the National League of Nursing (NLN) Education Excellence Award twice. It shares this honor with only one other educational institution.

In addition, Excelsior College cares more about what you know than when you learned it. So you will likely receive credit for those old courses you took 10 years ago. The downside is that its ADN program is not a bridge program, so you still have to take the complete load of nursing credits to graduate.

The flexibility of the program is very attractive, though. You can generally progress as slowly or quickly as you want. I took three months off in the middle of my coursework to deal with a family crisis and then started again when I could. Try that with a traditional program! It still only took me 16 months to complete my ADN program with Excelsior College.

Another top pick would be The College Network. It is well-known for its excellent academic support, resources, friendliness and convenience. Partnering with a variety of top national educational institutions, it offers online and distance learning and guaranteed financing. Many students value the "at your place, at your pace" philosophy.

Designed with working adults in mind, the Network has developed comprehensive learning modules to help nursing students succeed. Content from each course has been condensed and organized, making learning efficient. I wish I could have benefited from this resource when I went to school. The College Network also gives a 10 percent tuition discount for NAEMT members.

Hopefully, I have shed some light on some nursing programs that offer opportunities for EMS professionals. We wish you success in your future endeavors.