Visualizing responder roles
First, if I were a teacher, how would I have taken action to protect the students in my care" Would I have been able to calmly and quickly escort them to an exit or guide them into a hiding place that offered concealment and cover"

Second, as a parent, how quickly can I get to my children's school" Would I cover the mile between me and my children on foot or with a vehicle" Once at the school, what would I do"

Finally, as a paramedic — and probably like all of you — I feel an urge to do what I am trained to do. Did you visualize applying a tourniquet to stop severe bleeding or inserting an oral airway"

Do you imagine these scenarios" Do you discuss the active shooter scenario in training and with your partners in law enforcement"

Active shooter response
The response to active shooter incidents is evolving. Law enforcement is training the first arriving officers to move quickly towards the sound ofgunfire rather than establishing a perimeter or waiting for a SWAT team.

Another emerging change is that paramedics are escorted by a second wave of police officers into the warm zone to seek out patients. The paramedic treatment role is straightforward — triage, stop severe bleeding, BLS airway maneuvers, and pocket mask or bag valve mask ventilation.

But before you can do any of that you need to be able to reach the patient.

Paramedic physical readiness
I know of many organizations that are mentally preparing paramedics with training to respond into the warm zone with police officers, but I am not sure if we are physically ready for the task ahead. Have you practiced and are you ready to:

• Rapidly exit your vehicle with a kit that contains triage tags, tourniquets, wound dressing, oral airways, and pocket masks"
• Move under the command of police officers at a pace from a fast walk to a sprint for distances up to a quarter mile"
• Drop to the ground or dive behind cover when ordered by your police officer escort.
• Kneel at the side of a patient, after sprinting to reach them, on a hard surface for 30-60 seconds to assess circulation, airway, and breathing"
• Spring back to your feet with your gear and move forward with the officers to reach more patients"
• Defend yourself from a hand to hand physical attack"
• Help one or two others drag or team carry a 180 pound patient behind cover and or concealment"

Readiness is multifaceted. There is a mental component of education and visualization. There is a technical component of applying lifesaving skills. The above physical readiness is not just the domain of only tactical medics. Every member of every ambulance crew needs to be physically ready.

Normally, I am strong believer that paramedics are at their best when they saunter into a scene, slowly walking and looking for clues and risks. But an active shooter incident is going to require repetitive bursts of significant physical activity.

What are you doing to make sure you are ready"

Author’s note: I appreciate the review and feedback of a final draft of this article by Chief Skip Kirkwood and Bryan Fass.

The tiered rate plan incentivizes us to shift our electricity usage and has resulted in us saving lots of money. Through planning ahead, intentional usage decisions and timing devices, we have dramatically shifted our electricity load to the lowest rate periods. This is what we have done in our home.

1. Schedule major appliance usage for low rate periods. For the first time, we are using the timer on our dishwasher so it automatically starts after 10 p.m. We do most of our clothing laundry on the weekends.

2. Charge mobile devices during the low rate period. The electricity to our charging station is on a timer that turns on at 1 a.m. and off at 7 a.m. All phone and tablet computer charging is done during these hours.

3. Add an electrical timer to devices only used during set periods. The gaming console and accompanying TV only have power for an hour before school and a few hours after school.

Earth Day 2012 takes place this Sunday, with events planned held worldwide to increase awareness and appreciation of the Earth's natural environment. So, it's a good time to see what you can do at your agency to save both resources and money.

Before putting charging stations for medical devices, such as cardiac monitors, or portable radios on a timer, check with the device manufacturer about optimal charging procedures.

But many of these tips could be implemented in station or workplace. I use the Utilitech Digital 8-Outlet Power Strip Time to set the on/off schedule for our charging station, game console and TV.

Ask your local utility if a tiered rate plan, that encourages conservation and load shifting, is available in your area.

Finally, remember the easiest thing you can do to save some electricity and put a little extra money in your pocket is to turn out the lights as you leave the room.

What are your energy saving tips" How do you encourage co-workers to help you conserve electricity – and reduce costs in the process"

The video, that debuted earlier this month at EMS Today in Baltimore, was funded and produced by apparel vendor Blauer.

I think the video production and message is outstanding. Paramedic Muhammad and Blauer showcase how social media can be used for entertainment and education.

Consider using the Keep Yourself Safe video in your EMT Basic or Refresher Class to:

1. Introduce and discuss different types of PPE. Play the video from start to finish. Afterwards, ask students to identify the different PPE featured in the video. As each type is identified, discuss when it is indicated and how it is best used.

2. Match appropriate PPE to different patient types and interventions. The video features several types of patient encounters. Ask students to select the best PPE for each patient.

3. Discuss assessment and treatment of different types of medical calls. Continue each call past what is featured in the video. How would students continue treatment for the behavioral emergency" How would they assess and treat the patient with chest pain"

4. Create your own PPE video. Instead of delivering the same old PPE lecture, challenge students, especially experienced EMTs, to create their own music video with the Keep Yourself Safe lyrics or their own lyrics. Share the videos with the rest of the class. Post the best videos to your school or department YouTube channel and Facebook page.

5. Invite an EMT or paramedic to give an online lecture to your class. Paramedic Muhammad works in New York City and encounters some different hazards than I might in rural Wisconsin.

If you are in a rural area, invite a big city medic to appear in your classroom by Skype to discuss PPE in the urban environment. If you are in an urban area invite a medic from a rural environment to discuss some of their experiences and PPE needs when responding to farms, industrial sites, or wilderness environments.

How else can you use Keep Yourself Safe as an educational tool"

I have had CPR certifications at three different organizations and have had several occasions where I had to take CPR more than once in a year.

Along the way I taught dozens of healthcare provider courses to groups ranging from police officers to manufacturing employees, from Sierra Club leaders to delinquent youth to college honors students.

Since I have spent more hours in CPR class than I care to remember, I tend to be a critical student. Fortunately my most recent healthcare provider recertification was memorable for all of the things the instructors did well.

1. Room set-up. Before class, the tables were pushed to the side of the room. Manikins were laid on the floor facing the screen. It was clear walking into the room that we would be expected to kneel on the floor to practice compressions on the manikins.

2. Ample equipment. The instructors prepared enough equipment so we never had more than two people to a manikin, BVM, or AED. Each student had their own pocket mask for the mask ventilation practice. Hands-on practice time was smooth with minimal downtime.

3. Timely and concise feedback. While we were following the timed practice with the video, the instructors were walking the room and providing timely and concise tips to improve compression rate, compression depth, or hand placement.

4. Stayed true to the AHA materials. Our instructors followed the AHA videos as they were designed to be played. I've heard too many instructors say, "You all probably know this, so we are going to skip ahead." Although CPR is regularly re-trained and practiced, it is rarely used. Regular refresher of knowledge and skills is crucial to effective performance.

5. Minimal story telling or extraneous information. Our instructors shared minimal "war stories." In the context of CPR, especially with healthcare providers that have low likelihood of actually providing CPR, I am not sure if stories about broken ribs, vomit, or dentures increase or decrease the provider's likelihood to take quickly take action should they see sudden cardiac arrest. Too often field anecdotes only inflate the storyteller's ego while adding little value to the course.

What are your tips for effective CPR instruction" As an instructor do you insert your own experiences into the curriculum and how does that enhance or detract from the student’s learning experience"

Substantial cajoling and adult guidance from mom in a Santa hat was required to initiate an orderly process of taking turns, appreciating a gift after it was opened, and taking occasional pauses for a meal or to welcome additional relatives.

I also know some families that have just the opposite process; a gift-opening free-for-all.

Kids scrape through the pile for the presents with their name on the label and tear into them as rapidly as possible. In a matter of minutes, the area around the Christmas tree is covered with wrapping paper, box debris, and toy parts.

Is your patient assessment like a gift-giving free-for-all or officiated like mom in a Santa hat"

In tiered response systems, a patient can be quickly surrounded by three or four medical first responders from a fire company, a two- or three-person ambulance crew, and even a police officer.

Sometimes this leads to a patient assessment free-for-all. A bewildered patient, roughed up like a new toy in the hands of a 3-year-old, is peppered with questions and poked and prodded by responders coming at them from three different directions.

Work with your on-scene crew to determine a process where each patient assessment question or assessment is treated like a gift.

Follow an orderly process to open the gifts, pause to appreciate the importance of each gift, and make sure really significant gifts, like hypotension in a chest pain patient or low blood sugar, are announced to the whole group before the next gift opening begins.

Continue the conversation in the comments. How do you keep the patient assessment process smooth and orderly"

On a skill sheet, patient assessment is presented as a linear process. First size up the scene, then complete the primary assessment followed by the secondary assessment. The steps of the primary assessment might be initiated during the size-up and continue into the secondary assessment. Because the EMT was at the runner’s side so quickly, he blocked her from being trampled by other runners and put a hand on her head to stabilize her c-spine, all while looking to see if she was breathing.

During the primary assessment, because of the urgency of the problems, provide treatments as you find the problems. If the patient doesn’t have a patent airway, then begin airway management. But, after your begin treatment or resolve a primary assessment problem, remember to complete the other components of the primary assessment.

There are three major components of the secondary assessment: patient history, vital signs, and physical exam. Start with the assessment component that is most suitable to the patient’s chief complaint. If the patient’s problem is trauma, then a detailed or head to toe physical exam maybe the best place to start. If the patient has a vague abdominal compliant, starting with the SAMPLE history will help you better understand the patient’s pain and the possible causes. For a patient with a problem that can be treated with a pharmacological intervention (like asthma or chest pain) start with getting a baseline set of vital signs.

Regardless of where you start, make sure to complete all three major components of the secondary assessment. You don’t have to complete the patient assessment as a linear process, but you do need to complete all the components. As you learn and improve your patient assessment skills, you can use a small notepad with the appropriate data fields for history, exam, and vital sign findings to ensure you collect all the information that is needed in a process that is logical for the patient and their complaint.

How do you make sure you complete all of the major components of the patient assessment" How can you help a new EMT overcome skill sheet rigidity"

My reply is usually to cup my hand behind one ear and shout, "What""

Much to my chagrin, few of them take the hint, but honestly, I'd rather deal with those kids than the ones who take a pressure, drape the scope around their neck, and confidently announce, "120/80…"

… for every patient.

Old, young, fat, thin, pink or pale, everybody has a suspiciously normal blood pressure that always ends with a zero. Just as bad are those who hesitantly stammer, "Uhhhh… 135/79""

My ears may suck, but my eyes are still pretty good, and try as I might, I've yet to be able to find those odd-numbered markings on a sphygmomanometer gauge. Thus, I'm forced to conclude that my rookie either has preternaturally sharp hearing and eyesight, or he's pulling those numbers out of his rectum. Judging from the uncertainty in their tone, I usually go with the latter.

Being a guy with a measurable hearing deficit in both ears – too much shooting as a kid without adequate ear protection – I've learned a few tricks over the years to allow me to hear what I need to hear in the back of the rig. Sometimes, when the sounds I'm listening for are in the high frequency range where most of my hearing loss is, I have to resort to things like assessing tactile fremitus, or rely on the ears of a trusted partner.

Luckily, Korotkoff sounds are low-frequency enough that I can still pick them out over the rumble of the road beneath my feet, but it takes a lot of practice and sometimes a few tricks to be able to distinguish the real stuff from the road noise. Here's a few of the tricks I've learned:

• Isolate the patient's arm from everything else. When you wrap the cuff around his arm, cup your non-dominant hand under his elbow, and tuck his palm beneath your elbow. Lift his arm off the mattress, stretcher rail, or whatever it's in contact with. If you like to lay the patient's arm across your lap while you auscultate a BP, lift your feet onto tiptoes to minimize transmission of road noise through the soles of your feet.
• Use the bell of your stethoscope, not the diaphragm. I spent 18 years in EMS without learning that trick, and it took a Stethoscopy For Dummies class from Bob Page for me to see the light. The bell of your stethoscope works better on those low-frequency sounds. Try for yourself, and you'll see.
• Use a good stethoscope. While you're on that initial gear-buying spree right after graduation from EMT school, say no to the spring-loaded window punch, Swiss army knife trauma shears and the glove holster, and treat yourself to a nice stethoscope instead. A few hundred bucks spent in the beginning will pay a career's worth of dividends. And whatever ‘scope you buy, take off the stock diaphragm and replace it with a disposable antimicrobial diaphragm. They're cleaner, safer for your patient, and they're much more acoustically sensitive.
• Turn your cuff upside down. You know those hoses that bump annoyingly against the head of your stethoscope" You can get them out of the way by turning the cuff upside down. It won't affect the accuracy of your findings, as long as you make sure the artery markers are still lined up correctly.
• Learn to palpate. It's not optimal, but sometimes you just can't hear a pressure. In all my time in EMS, I've only met one person that can get an accurate systolic and diastolic pressure from palpation, but unless your name is Liz Hyde, you'll just have to do like the rest of us mere mortals and settle for a rough systolic pressure.
• Turn off all the crap in the back of the rig. Being spec'ed for use in Louisiana summers, our rigs are equipped with air conditioners that keep the module a comfy 72 degrees – or at least that's the rumor. But however well they cool or don't cool, hearing anything over them is like straining to hear the whispered words of a lover over an F5 tornado. Except in the case of blood pressures, you can't lip read, smile and nod.

If you're one of those EMTs whose ears threaten to betray you when you need them most, try some of these BP tricks. Hopefully, they'll take some of the pressure off of getting a pressure.

After creating a free account, users can quickly upload PowerPoint presentation slides. Once uploaded to Slideshare, slides can be embedded in a blog post, linked to through Facebook or Twitter, or even presented from Slideshare in full-screen mode.

As a conference presenter, one of the most frequent requests I receive is "can I have a copy of your slides." Instead of having to copy slides to a USB flash drive or email them as a large attachment, I simply email the Slideshare link or hyperlink the text in an article.

I can also use Slideshare to:

1) Promote the topics I present at conferences
2) Provide a visual aid to participants in an audio conference call
3) Receive comments and questions from workshop participants long after the event was over

Paramedic students can use Slideshare to learn more about course topics. On Slideshare.net, Search CPAP, Capnography, or 12-Lead ECG to find presentations that might help you better understand a topic that was taught in class or find visuals to compliment your textbook reading.

You can also use Slideshare to land your first EMT or Paramedic job. EMS educator Rommie Duckworth recently posted: Mastering the Interview Process.

Are you using Slideshare" Have you found a particularly good Slideshare that has helped you better understand a topic"

With newer devices it's really important to understand what you should do to promote optimal battery life.

For some batteries, allowing them to run down is important; for others, keeping them full as often as possible maintains good battery health.

The bottom line is, with new communications devices, you must follow the manufacturer's advice closely.

By placing their head at the "foot" of the gurney, this allows you to work out of the captain's chair and gives you more room.

The hardest part of doing this is getting your partner to place the patient in this position. Old habits are hard to break and it may feel odd, but once in the truck you will find it much easier to deliver that new baby.