Since the recognition was initiated by President Ford in 1974, this event has drawn increasing attention across the United States, especially since 9/11.

However, I believe the tragic events of the past few months really show what EMS does when disaster strikes. Today Oklahoma rescuers are helping the community of Moore and surrounding towns begin to recover from the massive tornado strike. We pray for their safety and hope for the best for the survivors of their communities.

This follows EMS providers stepping up to the plate in Boston, West, Newtown and other cities across the nation in recent times.

In each incident, we did what we had to do — overcome adversity, and adapt to changing conditions.

Having a front seat to human tragedy and being in a position to help is an honor as well as a burden that we carry.

For this week, let's celebrate who we are and what we do to protect our communities. And the remaining 51 weeks of the year let's stand vigilant and be prepared for when the next big one hits.

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

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

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

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

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

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

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

About Intermedix Corporation

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

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

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

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

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

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

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

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

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

EMS providers began giving oxygen not because it had medically or scientifically demonstrated benefits for patients, but because they could. Yet, inarguably, hypoxia is bad.

John Scott Haldane, who formulated much of our understanding of gas physiology, said in 1917, “Hypoxia not only stops the motor, it wrecks the engine.”

Patients begin to suffer impaired mental function at oxygen saturations below 64 percent. People typically lose consciousness at saturations less than 56 percent, giving airplane passengers no more than 60 seconds to breathe supplemental oxygen when an airplane flying at 30,000 feet suddenly depressurizes^1-3.

More recent studies suggest that hyperoxia, or too much oxygen, can be equally dangerous. Hence the drug EMS providers administer most often may not be as safe as originally thought.

Studies on benefits and dangers of oxygen therapy are not new; intensive care practitioners have long recognized the adverse effects of using high concentration oxygen⁴.

The Guidelines for Emergency Cardiac Care (ECC) in 2000 and 2005 recommended against supplemental oxygen for patients with saturations above 90 percent. The current 2010 ECC Guidelines call for supplemental oxygen only when saturations are less than 94 percent, perhaps in an effort to soften the impact of change⁵.

What is new are prehospital research studies comparing outcomes of patients treated without oxygen or with oxygen titrated to saturations versus patients routinely given high flow oxygen. These data are frightening; they invariably show impressive patient harm from even short periods of hyperoxia.

We’ve known since 1999 that oxygen worsened survival in patients with minor to moderate strokes and made no difference for patients with severe stroke⁶. In fact, the American Heart Association recommended in 1994 against supplemental oxygen for non-hypoxemic stroke patients.

The dangers from giving oxygen to neonates have also been long appreciated⁷. The most compelling outcome studies of neonates published in 2004 and repeated in 2007 showed a significant increase in mortality of depressed newborns resuscitated with oxygen (13 percent) versus room air (8 percent)⁹. This led to the current neonatal resuscitation recommendations for use of room air positive pressure ventilation.

In 2002, a study of 5,549 trauma patients in Texas showed prehospital supplemental oxygen administration nearly doubled mortality⁹. A Tasmanian study of prehospital difficulty breathing patients published in 2010 compared patients treated with oxygen titrated to saturations of 88 to 92 percent to patients treated with non-rebreather oxygen masks.

It showed a reduction in deaths during subsequent hospitalization of 78 percent in COPD patients and 58 percent in all patients¹⁰. New studies are showing a troubling pattern of worse outcomes associated with hyperoxia post cardiac arrest¹¹.

Why would oxygen worsen patient outcomes" One mechanism may be absorption atelectasis. Gas laws mandate that increases in the concentration of one gas will displace or lower the concentration of others. Room air normally contains 21 percent oxygen, 78 percent nitrogen, and less than 1 percent carbon dioxide and other gases.

Nitrogen, the most abundant room air gas, is responsible for secretion of surfactant, the chemical that prevents collapse of the alveoli at end expiration. Premature infants often are not developed sufficiently to produce surfactant and require endotracheal administration of animal surfactant.

“Washout” of nitrogen in adult lungs occurs when high concentration oxygen is administered. Lower concentrations of nitrogen can lead to decreased surfactant production with subsequent atelectasis and collapse of alveoli, significantly impeding oxygen exchange.

Oxygen is also a free radical, meaning that it is a highly reactive species owing to its two unpaired electrons. From a physics perspective, free radicals have potential to do harm in the body.

The sun, chemicals in the atmosphere, radiation, drugs, viruses and bacteria, dietary fats, and stress all produce free radicals. Cells in the body endure thousands of hits from free radicals daily.

Normally, the body fends off free radical attacks using antioxidants. With aging and in cases of trauma, stroke, heart attack or other tissue injury, the balance of free radicals to antioxidants shifts.

Cell damage occurs when free radicals outnumber antioxidants, a condition called oxidative stress. Many disease processes including arthritis, cancer, diabetes, Alzheimer’s and Parkinson’s result from oxidative stress.

The concept of free radical damage suggests the old EMS notion that, “high flow oxygen won’t hurt anyone in the initial period of resuscitation” may be dead wrong.

Tissue damage is directly proportionate to the quantity of free radicals present at the site of injury. Supplemental oxygen administration during the initial moments of a stroke, myocardial infarct (MI) or major trauma may well increase tissue injury by flooding the injury site with free radicals.

Finally, consider this: five minutes of supplemental oxygen by non-rebreather decreases coronary blood flow by 30 percent, increases coronary resistance by 40 percent due to coronary artery constriction, and blunts the effect of vasodilator medications like nitroglycerine¹². These effects were demonstrated dramatically in cath lab studies¹³ published in 2005.

Wonder why the 2010 ECC Guidelines recommended against supplemental oxygen for chest pain patients without hypoxia" Now you know: supplemental oxygen reduces coronary blood flow and renders the vasodilators ALS providers use to treat chest pain ineffective.

Where do we go from here" Knowing that both hypoxia and hyperoxia are bad, EMS providers must stop giving oxygen routinely. Oxygen saturations should be measured on every patient.

Protocols need to be aligned to reflect the 2010 ECC guidelines: administer oxygen to keep saturations between 94 and 96 percent. No patient needs oxygen saturations above 97 percent and in truth, there is little to no evidence suggesting any clinical benefit of oxygen saturations above 90 percent in any patient.

Modifications in prehospital equipment will be inherent in controlling oxygen doses administered to patients. In all likelihood, the venturi mask will make a comeback, allowing EMS providers to deliver varied concentrations of oxygen as needed to keep oxygen saturations between 94 and 96 percent.

Few patients will require non-rebreather masks which are prone to deliver too much oxygen (hyperoxia). CPAP (Continuous Positive Airway Pressure) devices will also need redesign as most conventional EMS CPAP delivers 100 percent oxygen. A study conducted by Bledsoe, et al in Las Vegas found that prehospital CPAP using low oxygen levels (28 to 30 percent) was highly effective and safe¹⁴.

Bottom line: the drug we use most often can cause harm if we give it without good reason. In the absence of low saturations, oxygen will not help patients with shortness of breath and it may actually hurt them. The same holds true for neonates and virtually any patient with ongoing tissue injury from stroke, MI or trauma. Indeed, oxygen can be bad.

References:

Akero A, Christensen CC, Edvardsen A, et al. Hypoxaemia in chronic obstructive pulmonary disease patients during a commercial flight. Eur Respir J 2005;25:725–30.

Cottrell JJ, Lebovitz BL, Fennell RG, et al. Inflight arterial saturation: continuous monitoring by pulse oximetry. Aviat Space Environ Med 1995;66:126–30.

Hoffman CE, Clark RT, Brown EB. Blood oxygen saturations and duration of consciousness in anoxia at high altitudes. Am J Physiol 1946;145:685–92.

Alteiemer WA, Sinclair SE. Hyperoxia in the intensive care unit: why more is not always better. Curr Opin Crit Care 2007;13:73-78.

O'Connor RE, Brady W, Brooks SC, Diercks D, Egan J, Ghaemmaghami C, Menon V, O'Neil BJ, Travers AH and Yannopoulos D. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science Part 10: Acute Coronary Syndromes. Circulation 2010; 122: S787-S817.

Ronning OM, Guldvog B. Should Stroke Victims Routinely Receive Supplemental Oxygen" A Quasi-Randomized Controlled Trial. Stroke 1999;30:2033-2037.

Rabi Y, Rabi D, Yee W: Room air resuscitation of the depressed newborn: a systematic review and meta-analysis. Resuscitation 2007;72:353-363.

Davis PG, Tan A, O’Donnell CP, et al: Resuscitation of newborn infants with 100% oxygen or air: a systematic review and meta-analysis. Lancet 2004;364:1329-1333.

Stockinger ZT, McSwain NE. Prehospital Supplemental Oxygen in Trauma Patients: Its Efficacy and Implications for Military Medical Care. Mil Med. 2004;169:609-612.

Austin MA, Wills KE, Blizzard L, Walters EH, Wood-Baker R. Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial. BMJ 2010;341:c5462.

Kilgannon JH, Jones AE, Parillo JE, at al. Emergency Medicine Shock Research Network (EMShockNet) Investigators. Relationship between supranormal oxygen tension and outcome after resuscitation from cardiac arrest. Circulation 2011;14:2717-2722.

Harten JM, Anderson KJ, Kinsella J, et al. Normobaric hyperoxia reduces cardiac index in patients after coronary artery bypass surgery. J Cardiothorac Vasc Anesth 2005;19:173–5.

McNulty PH, et al. Effects of supplemental oxygen administration on coronary blood flow in patients undergoing cardiac catheterization. Am J Physiol Heart Circ Physiol 2005; 288: H1057-H1062.

Bledsoe BE, Anderson E, Hodnick R, Johnson S, Dievendorf E. Low-Fractional Oxygen Concentration Continuous Positive Airway Pressure Is Effective In The Prehospital Setting. Prehosp Emerg Care 2012;16:217-221.

Usually, what is said in the ambulance stays in the ambulance, but every now and then some things just need to be shared.

1. Overheard in the back of Rescue 1, during a clean-up.

"Pi#$ isn't too bad."

"Puke is the worst."

"Nah, s@#!'s worse than puke, any day."

"Blood is easy, it doesn't stink."

"That's why pi#$ isn't bad, easy clean-up."

"Old piss is pretty bad."

"New s@#! is worse than old s@#!."

"It's still runny."

"Speaking of runny, snot's pretty bad."

"Yeah but you hardly ever wear it. "

"Yeah, puke wins that one."

"But s@#!'s still the worst."

"Yup. pi#$ is my favorite. Definitely."

"I guess."

2. Overheard in the front of Rescue 1. Very late at night.

"I wonder why we never get sick."

"Because we already are sick. There's only so much sickness to go around."

"Yeah, but we're surrounded with sick people all the time. We touch them, breathe their air and all that, you would think we would get sick more often."

"You think too much."

"And why do we carry people with back pain down three flights of stairs when our backs are worse that theirs""

"Because we can."

"So can they."

"The difference is, they know WE can."

"But we know THEY can."

"You think too much."

"I guess."

3. Overheard in the cab of Rescue 1 enroute to "man down."

"We're Cavemen, you know."

(From officer's seat, fiddling with the radio) "How so""

"The station is like our cave. It's dark, dreary and ugly."

"A man-cave."

"Right. Instead of wall paintings we have a big screen TV. Every now and then an emergency happens, we pile on our skins and forage into the wilderness to protect the women."

"Some of us are women."

"Right, there have always been strong women."

"Right. Remember Raquel Welch from 1,000,000 years BC""

"Who""

(Looks incredulously over at his man-boy driver) "Never mind."

"Anyway, when we get hungry we leave the cave to hunt for meat."

"The supermarket isn't exactly hunting."

"It is when you're looking for a deal."

"I guess."

"Then, we gather around the fire and eat."

"You do look like a bunch of Neanderthals at the table."

"Exactly. Cavemen."

"Right. (Keys the mike as driver stops the rescue in front of the "emergency.") "Rescue 1 on scene."

The cavemen load up their weapons and forage into the wilderness, looking for their victim.

4. Overheard on the Street:

Police officer: "Hey, were you guys there that day when that girl flashed us""

Firefighter 1: "Which girl""

Firefighter2: "What day""

Firefighter 3: "There have been so many, we forget."

The police officer walks back to his cruiser, shaking his head.

Police Officer: "I think I took the wrong test."

5. Overheard in the Cab of Rescue 1 after clearing Hasbro Children's Hospital:

"She was hot."

"She's fifteen, you pervert."

"Not her you idiot, her mother."

"Her mother is old enough to be your daughter."

"That means I'm old enough to be her mothers father."

"Right."

"She's still hot."

"And you're still old."

"Right."

"Rescue 1 in service."

6. Overheard in Rescue 1 after a visit to the Coffee Exchange where the crew was completely ignored by the college girls behind the counter.

Lt: "I don't get it. They don't give us the time of day. It wouldn't kill them to be nice to us. Jeez, girls aren't like they used to be. Why can't they even crack a smile""

Ryan: "Because I'm fat and you're 50."

Lt: "Oh, that. Carry on then."

7. Overheard at the ER

The ER was a madhouse, drunken street people, drunken college kids, drunken housewives, and drunken fools. Minor injuries, a few legitimate traumas, some sick old folks and a bunch of people vomiting. The wait was hours. In the middle of it all was a twenty something year old inmate from the ACI and two correctional officers.

The prisoner had a minor injury to his throat from an altercation and had been waiting for a long time. As I walked past them I overheard the inmate ask his guards, "Can I go back to my cell" Anywhere is better than here."