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.

The agreement calls for collaboration on a wide range of policy and programmatic activities in areas such as advocacy, public awareness, education, and clinical standards. "We are excited about the opportunities this new partnership will present. We know we can accomplish more for the EMS profession working collaboratively. Bringing together the providers and the administrators will improve communications for all and advance our common interests," says Troy Hagen, NEMSMA President.

“NAEMT and NEMSMA share core values and represent EMS professionals working in all types of delivery models,” stated Don Lundy, NAEMT President. “There is tremendous synergy between our two organizations, and this agreement capitalizes on this synergy and our strengths to better support all of our members, and the industry at large. We are very excited about the
opportunities that this new relationship offers.”

About NAEMT
Formed in 1975 and today nearly 32,000 members strong, the National Association of Emergency Medical Technicians (NAEMT) is the only national association dedicated to representing the professional interests of all emergency medical services (EMS) practitioners, including paramedics, advanced emergency medical technicians, emergency medical
technicians, emergency medical responders and other professionals working in prehospital emergency medicine. NAEMT members work in all sectors of EMS, including government service agencies, fire departments, hospital-based ambulance services, private companies, industrial and special operations settings, and in the military.

About NEMSMA
With 1,500 members, NEMSMAis a professional association of EMS leaders dedicated to the discovery, development, and promotion of excellence in leadership and management in EMS systems, regardless of EMS system model, organizational structure or agency affiliation. For more information about NEMSMA initiatives, position papers and educational courses, go to nemsma.org

PHOENIX — A Phoenix firefighter died after he was pinned between two vehicles while working to extinguish a fire.

Phoenix police Sgt. Tommy Thompson said 23-year-old firefighter Bradley "Brad" Harper was “gravely injured” when he became pinned between two fire vehicles that were getting into position to fight a mulch fire near 39th Avenue and Lower Buckeye Road on Saturday.

Harper, who had been with the department for two years, was taken to St. Joseph's Hospital where he died from his injuries, said Thompson.

Full story: PD: Phoenix firefighter has died after an accident at the scene of a Phoenix fire

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.

LAKE GARDA, Italy — Matthew Gough, 25, was travelling around the world taking part in extreme sports when he decided to go base jumping in Lake Garda, Italy.

His previous 180 leaps have gone perfectly - but this time his parachute opened backwards and became twisted. He briefly floated before smashing into rocks and hurtled down the cliff face at speeds of 40mph, all the while filming his descent on his headcam. After bouncing down the cliff he landed just inches from death when a metal spike on the ground knocked his helmet off.

He was found at the foot of the cliff stunned but mostly unharmed except for minor injuries to his knees and ankle and was taken to hospital but was released a few hours later.

Full story: Base jumper survives 1000ft fall with minor injuries

"It was massive destruction last night," Oklahoma Gov. Mary Fallin said in an AP interview Tuesday. "It was an incredible sight to see how big the debris field was and how much destruction there was. It would be remarkable for anyone to survive."

The Associated Press reported that new search-and-rescue teams moved in as dawn broke Tuesday, taking over from the 200 or so emergency responders who scoured the neighborhood all night with a helicopter shining a spotlight from above to aid their search.

The death toll had been reported in the 50s, but authorities say that some of the bodies may have been double counted and the number was revised to 24. However, the full extent of lost lives may not be known for some time; some are estimating the toll could reach 90.

STANDISH, Maine — Already a dangerously accessible drug, experts say methamphetamines are easier to make than ever before, and because it can now be manufactured quickly and almost anywhere, specialized training to neutralize the toxic, explosive — and portable — chemicals is needed in Maine.

“All the stuff you see on TV, with beaker bottles and big labs, that’s old school,” said William York, CEO of the Gorham-based BioSpecialists LLC. “You could make 1 to 4 grams of methamphetamines in a backpack. No fancy glasswork, no lab coat and ‘Dr. Crazy’ [outfit], just a backpack. They’re doing it in campers, hotel rooms, trailers — anywhere. Somebody could walk into a [restaurant] restroom and not come out for an hour, and then that place has a major problem.”

Meth has become a scourge in some states — Missouri, Indiana and Tennessee are among the statistically hardest hit — with addictions spreading like wildfire and users notoriously appearing in police mugshots with gaunt faces, pale skin and sunken eyes. It’s the closest thing America has to a real zombie plague, said Lee Surgener of Akron-based Ohio Clan Lab Neutralization Techs.

Surgener was in Maine over the weekend delivering a Saturday seminar for area law enforcement officials and first responders on how to spot signs of methamphetamine production in their communities, followed by a Sunday training for BioSpecialists technicians on how to apply chemical cleansers to a location where the drug has been “cooked.”

Once the drug has been produced, the process leaves behind an almost molecular-level residue on every surface, soaked in nearby fabrics and lingering in out-of-reach heating ducts, Surgener said.

According to the Maine Department of Health and Human Services, there were seven methamphetamine labs discovered by police in 2012. That’s the highest number on record and a significant increase compared with 2009′s figure of just one.

“It’s not a significant problem compared to other states,” Surgener said. “But it’s going to spread.”

Surgener said if Maine is anything like his home state of Ohio, the number of labs recorded is likely a tip-of-the-iceberg number. In Ohio, he said it took high-profile tragedies to get the public and state leaders to realize the scope of the problem. He said he hopes that won’t be the case in Maine.

“For every meth lab the [drug enforcement agency] is busting, you may have four to 10 that people don’t know about,” he said. “It took a toddler dying and a nursing home burning up in Ohio before people woke up.”

In February of last year, 17-month-old Patrick Lerch died of methamphetamine poisoning in an Akron case that saw four people, including the child’s mother, convicted of crimes related to the death. The next month, a fire at Park Haven Nursing Home in Ashtabula, Ohio, killed one person and was traced back to a portable meth lab set up by visitors in a second-floor room of the building.

“This is the most dangerous drug on the planet,” York said. “Everything they need to cook this drug is available in a person’s hometown. … If they’ve got access to a drugstore and a hardware store, they’re in business.”

York said methamphetamines are popular among some users because the drug can be made privately using easy-to-find medicines, chemicals and instruments, allowing users to avoid meeting with dealers and keeping them another step away from possible detection by law enforcement. Also, he said the drug triggers a euphoric high that lasts between six and 16 hours. In comparison, cocaine users get a 30- to 60-minute high from that drug, York said.

But the process to produce meth covers the surrounding area with a toxic byproduct even after the operation has been disassembled and removed, Surgener said. The federal government has determined that any greater concentration than 0.1 micrograms per 100 centimeters squared is dangerous to be exposed to, he said.

That means less than a pinprick on the corner of a CD case can cause serious health problems, Surgener said, and items such as rugs and teddy bears can absorb 15 to 30 times that amount.

“You just can’t see it,” he said.

During Sunday morning’s training, BioSpecialists technicians mixed a chemical neutralizing agent and then sprayed the shaving cream-like substance over interior surfaces in a tax-acquired two-story home on Route 35 in Standish. Treatments such as that are necessary to make a home habitable again after methamphetamines are produced there.

State and local governments pay $15,000 to break down a lab and clean the surrounding structure, according to information posted online by Maine DHHS, but York said with proper training, private organizations like his may provide the service for less money.

The Standish home where Sunday’s training took place is vacant but was not actually the site of a methamphetamine lab. The training was agreed to by the town, said Ruth-Ann Labrecque, assistant to Town Manager Gordon Billington.

Surgener said larger scale meth lab operators often leave excess garbage around their properties, including bottles of leftover chemicals, and often can be identified by members of the public if they know what to look for.

“The telltale signs of what you’re looking for in a meth lab you can see without setting foot in the homes,” he said. “If the public gets informed, that goes a long way toward controlling the problem.”

Surgener added: “[Meth is] here. It’s not that it’s coming. It’s here now, and it’s not going anywhere.”

Copyright 2013 Bangor Daily News
All Rights Reserved

WASHINGTON — New research is challenging medical guidelines that say people with a heart-zapping device in their chests should avoid intense sports like basketball and soccer in favor of golf or bowling.

Lots of patients ignore that take-it-easy advice and stay in the game, and Monday's findings suggest vigorous exercise may be safe for many of them after all.

A registry tracked 372 people who stuck with competitive sports after having a defibrillator surgically implanted to guard against dangerous irregular heartbeats — and found that the lifesaving device worked when needed despite the physical exertion.

"This is good guidance for many of the sports. It should be reassuring that in fact many people can participate," said Dr. Gordon Tomaselli, a former American Heart Association president who wasn't involved with the new study — and cautions that questions remain.

More than 100,000 defibrillators are implanted in U.S. patients every year, devices that can detect when an abnormal heartbeat is forming and automatically shock the heart to help it get back into rhythm. Most recipients are older people with heart failure, too sick to worry about sports.

But increasingly, teenagers and younger adults receive these implants, people who may be more active and fit but have some underlying heart abnormality that puts them at risk of an arrhythmia. Last year, Utah State forward Danny Berger collapsed on the basketball court, was revived and had a defibrillator implanted; he has said he hopes to play again. Harder still is how to advise people who get the implants as a precaution, before any symptoms of trouble.

The big questions: Do the implants fire properly under the physical duress of competitive sports" Do they emit painful shocks more often" Might they break with a hit to the chest"

To begin finding out, Yale University heart specialist Dr. Rachel Lampert opened a national registry that, over 2 1/2 years, tracked defibrillator patients who decided to stick with sports. They included some high school and college athletes, as well as people who participated in community-level basketball, soccer, tennis and other sports or were runners, skiers, even a few rock climbers.

The implants did have to fire more often during physical activity, whether the people were playing ball or running for the bus. But they did their job — no one died, had to be resuscitated or experienced a shock-related injury, Lampert reported Monday in the journal Circulation.

During the study, 77 people received shocks: 10 percent during sports, 8 percent during other physical activities and 6 percent while resting. About two-thirds who received a shock did return to their sport rather than deciding to give it up, Lampert said.

"Despite the fact that people got shocked, they didn't have anything dangerous happen to them: The device worked," she said.

"It doesn't mean every patient can be doing every sport," Lampert added, advising that implant recipients talk with their doctors first. But, "we probably don't need the blanket restrictions in place."

However, the study is small and Tomaselli, the former heart association president, warned among the top concerns is whether contact sports, such as football and hockey, might loosen the implant. Too few of those patients enrolled in the registry to draw conclusions.

In addition, some patients with a rare heart condition required multiple shocks when they had an irregular heartbeat.

Still, "one of the reasons for having a defibrillator is to restore as much of a normal life as you possibly can," Tomaselli noted. To many people, "taking away competitive athletics is taking away a part of them."

When people do continue sports with the implant, Tomaselli said coaches, family and others must be fully aware of the risks _ and there should be an external defibrillator available during competition and practice in case the implant fails and emergency resuscitation is needed.

The study was paid for by three defibrillator manufacturers.

___

Online:

Implanted defibrillators: http://www.nhlbi.nih.gov/health/health-topics/topics/icd/

SAND SPRINGS, Okla. — A Tulsa man arrested Saturday on a public intoxication complaint is also accused of kicking a medic in the face as she treated him at the scene.

Officers were dispatched to the 200 block of East Morrow Road around 8:30 p.m. after 15 callers reported a drunken man walking in the roadway.

John Paul Jones, 43, was “extremely agitated, with both hands clinched into fists … and screaming multiple profanities” while walking down the road, police wrote in his arrest report.

Full story: Tulsan accused of kicking officer, paramedic in Sand Springs arrest

TOWN OF ULSTER, N.Y. — As EMS workers across the mid-Hudson observe National EMS Week, their thoughts and prayers are for one of their own.

Mobile Life Support Services paramedic William Spadafora remains in critical condition at Albany Medical Center following a head-on crash Saturday in the Town of Ulster.

News of his injury has led to an outpouring of concern from first responders and the emergency medical community. "He is benefiting from the thoughts and prayers of thousands of emergency service workers, EMTs, firefighters, individuals and agencies that have reached out to his friends and family," said Mobile Life CEO Scott Woebse.

Full story: Emergency workers pray for injured Ulster paramedic

LOS ANGELES, Calif.— When the national healthcare law takes full effect next year, millions of Americans risk disrupted health coverage because of common life events: getting married or divorced, having children or taking on a second job.

As their family incomes change, so too will their eligibility for public insurance programs. And if nothing is done, policymakers warn, many low-income patients will lose access to their doctors and medications during this massive game of health coverage pingpong.

Policymakers and healthcare industry leaders across the nation are paying close attention to the issue and working to close the coverage gaps before Jan. 1, said Alan Weil, executive director of the National Academy for State Health Policy.

Full story: Some could have gaps in medical coverage under new law

SACRAMENTO, Calif. — Years before a Las Vegas psychiatric hospital bused a homeless, schizophrenic man to Sacramento without arranging contacts or a plan for care, a different hospital ditched Gabino Olvera on Skid Row in Los Angeles.

Olvera, homeless and paraplegic, still dressed in his hospital gown and connected to a catheter bag, was found dragging himself along a gutter in 2007.

The case and others like it motivated the city of Los Angeles to adopt one of the toughest "patient-dumping" laws in the nation.

Full story: L.A. poised to go after Las Vegas hospital in patient-dumping cases

MECCA, Saudi Arabia — A toddler pulled from the wreckage of a car crash that killed five family members was sent to a morgue in a body bag in the belief he was dead.

Mohammed Eisa Danial Hayat was the sole survivor of the devastating crash during a pilgrimage to Mecca, Saudi Arabia, on February 8.

The unconscious toddler underwent a second ordeal when he was zipped into a body bag and transported to a morgue, it has been revealed.

But as he was being put into storage his body began moving and stunned officials rushed him by ambulance to hospital.

The potentially catastrophic mistake was revealed for the first time today as grieving relatives spoke of the accident.

They have also launched a campaign lobbying for better regulation of taxis in Saudi Arabia after the tragic events of last February.

Eisa and his family were travelling in a taxi when it hit a bridge and flipped over, killing the driver and the whole of his family.

The driver, understood to have been going too fast at the time, was uninsured and is believed to have fallen asleep at the wheel.

Eisa suffered a dislocated shoulder, broken arm and ribs in the crash but survived thanks to his grandfather holding him tightly in his arms.

His mother Bilques, 30, who was pregnant at the time and due to give birth in eight weeks, died in the accident.

Also killed were his father Mohammed, 33, grandfather Shaukat, 56, grandmother Abida, 47, and his aunt Saira, 29.

The devastating crash happened as the family, from Newport, south Wales, were in the country for Umrah, the Muslim pilgrimage to Mecca.

Officials on the scene in Saudi Arabia were so certain nobody had survived Eisa was taken to the morgue with his family and the driver.

The toddler, who has since turned two, is now back in Wales and being looked after by members of his parents' extended family.

"They thought oh, the little baby was dead, no-one could've survived that.' So they took him, zipped him up in the bag and took him to the morgue," Shaukat's brother, Shazada Hayat, told Wales On Sunday.

"He ended up in the mortuary. As they were putting him in [to storage], he moved around.

"They grabbed him, put him in an ambulance and rushed him to the Medina Children's Care Hospital."

He went on to speak of his family's efforts to get the law changed in Saudi Arabia to ensure only licensed and insured taxi drivers can operate.

"By us lobbying or asking for these changes, we might not be able to save hundreds and hundreds of lives, but if we could save one life, then it's a step in the right direction," he said.

"Our concern is wellbeing. These roads must be made safe, not only for the Saudis living there but those pilgrims going there. People come there from all over the world. We can't just stay silent and do nothing about it."

He also described the slow process of returning to normal for Eisa who barely ate anything for six weeks after the tragedy.

"Time is the great healer as they say. It may heal some parts but obviously there will always be a vacuum for him. No matter how much anyone tries, you can't replace the parents," said Mr Hayat.

Two weeks ago, the toddler and other family members travelled back to Saudi Arabia to visit the graves of those who died in the accident.

All five Hayats were buried at Jannat-ul-Baqi, a cemetery in Medina where the prophet Muhammed is said to be buried.

"Not everyone gets buried next to the prophet. For a Muslim you could not get a higher honour than that. That is the part of it that keeps all the family going," said Mr Hayat.

Copyright 2013 Johnston Press Plc
All Rights Reserved

MONTPELIER, Vt. — One of the safest days of the year to have a medical emergency at the State House in Montpelier is May 21, 2013, and you won’t even have to dial 9-1-1. Just yell for help out the front door.

Emergency Medical Service (EMS) Day will bring together first responders from among the more than 2,000 EMS providers along the State House lawn as a part of National EMS Week celebrations.

Health Commissioner Harry Chen, MD will read a proclamation at 1 p.m. honoring EMS providers and recognizing the critical role they play every day in saving lives and responding to emergencies.

Nearly 60 percent of the 2,600 EMS responders statewide are volunteers who serve as first responders and with ambulance services in nearly every corner of the state. The event on May 21 will include an open-house with access to the EMS equipment and ambulances and demonstrations on how the equipment is utilized in an emergency.

“The rural nature of our state and the relatively small size of most Vermont communities makes it one of the toughest places in the nation to offer fast, reliable and high-level EMS services,” said Health Commissioner Harry Chen, MD, who worked as an emergency room physician for more than 20 years in Rutland. “EMS is a key component of our public health efforts and everyone associated with emergency medicine respects and appreciates the work they do.”

EMS providers also educate people about hazards such as fall prevention for the elderly, proper car seat use for children and infants, and wearing a helmet when riding a bicycle.

“Vermonters count on EMS as their community healthcare safety net. When people are not able to access healthcare any other way, they know that dialing 9-1-1 will bring them a response – anytime and anywhere,” said Chris Bell, director of the Health Department’s Office of Public Health Preparedness.

PETALUMA, Calif. — The American arm of Danish ambulance giant Falck, one of the largest ambulance companies in the world, has acquired Petaluma-based Verihealth Inc., an ambulance and medical transport company founded in 2000.

Terms of the deal, completed about a week ago, were not disclosed except that Verihealth is now a wholly owned subsidiary of privately held Falck USA, based in Seattle, according to CEO Boo Heffner.

“We’d been in discussions with Verihealth for about the last year and we very specifically targeted them as a great company,” Mr. Heffner told the Business Journal. “We’re very selective in who it is we acquire.”

Full story: Ambulance leader Falck acquires Verihealth

PORTSMOUTH, R.I. — For 77 years, Portsmouth's Volunteer Fire Department has supplied the town with state-of-the-art medical rescue equipment, but with a final donation last week that burden will now be on the taxpayers.

On Friday, the Portsmouth Volunteer Fire Department unveiled its final donation - a 2012 International/Horton Model 623 Medium Duty Ambulance at the cost of $205,000.

"This is top-of-the-line, state-of-the-art equipment and this is something that we may not be able to provide going forward," said Portsmouth Fire Department Chief Michael M. Cranston during a ceremony on Friday.

Full story: Portsmouth Volunteer Fire Department Donates Final Ambulance

As you finish checking out in line at the grocery store, dispatch calls over the radio, "Engine 2542, Medic 2552, respond Priority 3 to 226 1^st Street on a 66 year old male who fell from his wheelchair."

You go en route to the call and half way to the address dispatch updates "2542 and 2552, upgrade Priority 1, caller states the patient is not responding."

You arrive at a small house in an older part of the city. Bystanders meet you at the curb and urge you to come inside. You walk through the front door and are directed upstairs to a bedroom down a small hallway. A woman identifies herself as the 911 caller and the patient's daughter. When asked what happened she replies:

"My father lives alone and I come over in the afternoons to visit and make him dinner. Today I found him sitting in his wheelchair instead of his recliner. When I tried to help him out of the chair he couldn't stand and he slid to the floor. I thought he was just weak from being in his chair all day but I called 911 back when he couldn't answer my questions. He was fine when I talked to him on the phone a few hours ago!"

You approach the patient and notice that he is tracking you visually as you walk up. You introduce yourself and see that the patient is moving his lips trying to respond but is unable. You notice that his face is crooked and obviously weaker on one side. You ask him to lift his arms with his palms up and he is unable to lift his right arm.

Your partner checks the patient's vital signs and finds:

• BP 152/90
• HR 88, irregular
• RR 16

The patient's daughter says that he has a history of high blood pressure, irregular heartbeat and COPD. He takes atenolol, Coumadin, digoxin and several inhalers. She reports that he is in charge of taking his own medications.

Discussion

The standard procedure for evaluating stroke symptoms is the Cincinnati Prehospital Stroke Scale. In order to perform the stroke scale, a provider will ask the patient to perform several simple tasks: lift both arms and hold them up, palms upright, smile showing their teeth and recite the phrase "The sky is blue in Cincinnati". If the patient is unable to perform one or more these tasks, he has positive findings for a stroke.

There are two types of stroke: occlusive and hemorrhagic. An occlusive stroke occurs when blood flow to an area of the brain is blocked by a clot. These clots may have several causes but frequently result from an underlying heart rhythm like atrial fibrillation.

A hemorrhagic stroke, on the other hand, is caused by a ruptured blood vessel in the brain. As the patient bleeds, pressure increases in the skull resulting in changes to the patient's neurological status.

There are a few findings that indicate whether a patient is having an occlusive or hemorrhagic stroke. In a study published in 2011, researchers found that three types of patient presentation were associated with an occlusive stroke:

• Atrial fibrillation
• Diastolic BP < 100 mmHg
• No change from baseline level of consciousness ¹

With a cardiac condition like atrial fibrillation, patients are at a much higher risk of developing blood clots in the heart due to decreased blood flow in the atria. Once these clots form, they can leave the heart and lodge in the brain.

Baseline hypertension (> 100 mmHg diastolic) can weaken the walls of blood vessels in the brain. As the walls weaken the vessels are more likely to form aneurysms. If an aneurysm bursts, the bleeding can increase pressure in the skull causing the patient to develop stroke symptoms.

This study found the opposite correlation as well: patients not suffering from extreme hypertension were more likely to have an occlusive stroke.

In a hemorrhagic stroke, pressure in the brain from bleeding into a closed space (the skull) causes the brain to be pushed downward, towards the largest opening in the skull. This puts pressure on the midbrain located above the brain stem.

The midbrain controls alertness and sleep cycles. Since a hemorrhagic stroke can causes changes in level of consciousness, the researchers were also able to show that no loss of consciousness indicates a higher likelihood of occlusive stroke.

By understanding the differences between occlusive and hemorrhagic stroke, providers of all training levels can collect valuable information to pass on to hospital staff. When a patient suffering from a stroke arrives at the emergency department, the report from EMS responders sets a series of events in motion based on two particular pieces of information: Whether the stroke appears to be caused by a clot; and how long has the stroke been occurring.

One of the most important pieces of information an EMS provider can collect is when a stroke patient was last seen normal, and by whom. If a patient can be given "clot busting" drugs within 4 and a half hours of the time of symptom onset, their chance of recovery increases greatly.

Treatment

Based on the patient's positive stroke scale findings, the fact that he has a history of atrial fibrillation and does not have a diastolic blood pressure greater than 100 mmHg, you conclude that he probably has an occlusive stroke. You ask further questions of his family and learn that the patient spoke with his daughter on the phone approximately two hours earlier and that everything was okay. You record the daughter's name and phone number to bring to the hospital.

You also learn that the patient has not been taking his Coumadin regularly because he "doesn't like all the bruises". The transporting unit arrives and you assist in packaging the patient for transport.

Resolution

The ambulance crew contacts your station several days later. The patient arrived at the hospital approximately three hours after he was last witnessed acting normally. He was taken directly to the CT scanner in the ER and it was confirmed that he did not have a hemorrhagic stroke.

The patient and his family consented to drug therapy and his symptoms began resolving by the next morning. He is expected to be discharged for rehabilitation in the next day or two. It is anticipated that he will regain 95% of function back.

References:

1. Yamashita S, Kimura K, Iguchi Y, et al. Kurashiki Prehospital Stroke Subtyping Score (KP3S) as a means of distinguishing occlusive from hemorrhagic stroke in emergency medical services. Eur Nerol. 2011; DOI: 10.1159/000324025.
2. Jauch EC, Saver JL, Adams HP, et al. Guidelines for the early management of patients with acute occlusive stroke: A guideline for healthcare professionals from the American Heart Association/American Association/ Stroke. 2013; DOI:10.1161.

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."

MOORE, Okla. — Emergency crews searched the broken remnants of an Oklahoma City suburb Tuesday for survivors of a massive tornado that flattened homes and demolished an elementary school. At least 24 people were killed, including at least nine children, and those numbers were expected to climb.

As the sun rose over the shattered community of Moore, the state medical examiner's office cut the estimated death toll by more than half but warned that the number was likely to climb again.

Spokeswoman Amy Elliott said she believes some victims were counted twice in the early chaos of the storm that struck Monday afternoon. Downed communication lines and problems sharing information with officers exacerbated the problem, she said.

"It was a very eventful night," Elliott said. "I truly expect that they'll find more today."

Authorities initially said as many as 51 people were dead, including 20 children.

New search-and-rescue teams moved at dawn Tuesday, taking over from the 200 or so emergency responders who worked all night. A helicopter shined a spotlight from above to aid in the search.

Fire Chief Gary Bird said fresh teams would search the whole community at least two more times to ensure that no survivors — or any of the dead — were overlooked. Crews painted an `X' on each structure to note it had been checked.

"That is to confirm we have done our due diligence for this city, for our citizens," Bird said.

The community of 56,000 people, 10 miles south of Oklahoma City, braced for another long, harrowing day.

"As long as we are here ... we are going to hold out hope that we will find survivors," said Trooper Betsy Randolph, a spokeswoman for the Oklahoma Highway Patrol.

More than 200 people had been treated at area hospitals.

Other search-and-rescue teams focused their efforts at Plaza Towers Elementary, where the storm ripped off the roof, knocked down walls and turned the playground into a mass of twisted plastic and metal as students and teachers huddled in hallways and bathrooms.

Oklahoma Gov. Mary Fallin said she watched up close late Monday as rescuers tried to find people in the wreckage of the school.

"It was an incredible sight to see how big the debris field was and how much destruction there was," Fallin said. "It would be remarkable for anyone to survive."

Seven of the nine dead children were killed at the school, but several students were pulled alive from under a collapsed wall and other heaps of mangled debris. Rescue workers passed the survivors down a human chain of parents and neighborhood volunteers. Parents carried children in their arms to a triage center in the parking lot. Some students looked dazed, others terrified.

Officials were still trying to account for a handful of children not found at the school who may have gone home early with their parents, Bird said Tuesday.

Many parents of missing schoolchildren initially came to St. Andrews United Methodist Church, which had been set up as a meeting site. But only high school students were brought to the church, causing confusion and frustration among parents of students enrolled at Plaza Towers. They were redirected to a Baptist church several miles away.

"It was very emotional — some people just holding on to each other, crying because they couldn't find a child; some people being angry and expressing it verbally" by shouting at one another, said D.A. Bennett, senior pastor at St. Andrews.

After hearing that the tornado was headed toward another school called Briarwood Elementary, David Wheeler left work and drove 100 mph through blinding rain and gusting wind to find his 8-year-old son, Gabriel. When he got to the school site, "it was like the earth was wiped clean, like the grass was just sheared off," Wheeler said.

Eventually, he found Gabriel, sitting with the teacher who had protected him. His back was cut and bruised and gravel was embedded in his head _ but he was alive. As the tornado approached, students at Briarwood were initially sent to the halls, but a third-grade teacher — whom Wheeler identified as Julie Simon — thought it didn't look safe and so ushered the children into a closet, he said.

The teacher shielded Gabriel with her arms and held him down as the tornado collapsed the roof and starting lifting students upward with a pull so strong that it sucked the glasses off their faces, Wheeler said.

"She saved their lives by putting them in a closet and holding their heads down," Wheeler said.

The tornado also grazed a theater, and leveled countless homes. Authorities were still trying to determine the full scope of the damage.

Roofs were torn off houses, exposing metal rods left twisted like pretzels. Cars sat in heaps, crumpled and sprayed with caked-on mud. Insulation and siding was smashed up against the sides of any walls that remained standing. Yards were littered with pieces of wood, nails and pieces of electric poles.

President Barack Obama declared a major disaster and ordered federal aid to supplement state and local recovery efforts.

The National Weather Service issued an initial finding that the tornado was an EF-4 on the enhanced Fujita scale, the second most powerful type of twister. It estimated that the twister was at least half a mile wide.

The Storm Prediction Center in Norman, Okla., forecast more stormy weather Tuesday, predicting golf ball-sized hail, powerful winds and isolated, strong tornadoes in parts of Texas, Arkansas, Louisiana and Oklahoma. The area at risk does not include Moore.

In video of the storm, the dark funnel cloud could be seen marching slowly across the green landscape. As it churned through the community, the twister scattered shards of wood, awnings and glass all over the streets.

Monday's tornado loosely followed the path of a killer twister that slammed the region with 300 mph winds in May 1999. It was the fourth tornado to hit Moore since 1998.

The 1999 storm damaged 600 homes and about 100 businesses. Two or three schools were also hit, but "the kids were out of school, so there were no concerns," recalled City Manager Steve Eddy.

At the time of Monday's storm, the City Council was meeting. Local leaders watched the twister approaching on television before taking shelter in the bathroom.

"We blew our sirens probably five or six times," Eddy said. "We knew it was going to be significant, and there were are a lot of curse words flying."

Betty Snider, 81, scrambled inside with her son and husband. She put her husband, who recently had a stroke, in a bathroom, but there wasn't room for both of them. So she and her son huddled in a hallway.

"That is the loudest roar I've ever heard in my life," she said.

She said she didn't have time to do anything. She couldn't duck, couldn't cover her ears, couldn't find another place to hide.

Snider lived through the 1999 tornado, but said this was the closest a twister had ever come to her house, which was still standing.

Monday's twister also came almost exactly two years after an enormous twister ripped through the city of Joplin, Mo., killing 158 people and injuring hundreds more.

That May 22, 2011, tornado was the deadliest in the United States since modern tornado record keeping began in 1950, according to the National Oceanic and Atmospheric Administration. Before Joplin, the deadliest modern tornado was June 1953 in Flint, Mich., when 116 people died.

___

Associated Press writers Sean Murphy and Ramit Plushnik Masti; and Associated Press photographer Sue Ogrocki contributed to this report.

By Julie Shoemaker

We were paged out shortly after arriving on shift for a chest pain. Instead of an address, we were given a parking area in the Fish and Wildlife Reserve in our county. Upon arrival, we were met by the DNR officer who told us it was "a hike" to the patient location. He informed us our patient was not doing well and could not hike out.

The local volunteer fire department arrived and helped us pack all our equipment. We were very grateful for the first responders! We followed the DNR officer through briars, woods, across a creek and finally to our patient who was standing thigh deep in a swamp!

He was a large man (320 lbs), very pale and diaphoretic. He was complaining of crushing chest pain. We were not surprised our 12-lead showed significant S-T elevation in multiple leads. We immediately radioed for a helicopter and initiated a STEMI activate. We gave our patient baby aspirin and nitro as per protocol.

We now had to get our patient out of the swamp. With much help from first responders and the DNR officer, we carried our patient on a long spine board, taking turns. During the brief stops to swap out people carrying, we did quick vitals and administered our second and third nitros. Crossing the creek was a challenge. We put people on either side and one in the middle to pass our patient across the creek.

Once back at the ambulance, we had to drive a half of a mile to the landing zone. In this time, we started an IV and gathered additional patient information. The helicopter was on the ground waiting when we reached the landing zone. We handed off patient care and returned to base.

We later learned our patient had 100 percent blockage of the LAD! With the combined effort of my partner and I, first responders, DNR, the helicopter crew and receiving hospital, our patient when from duck hunting in a swamp to cath lab in under 90 minutes. It was a true team effort that saved a life!