April 4, 2019 | View as webpage


My friend Rob Theriault, a paramedic, educator, author and speaker survived a STEMI and is recovering well. Theriault discussed his STEMI and what paramedics need to know with Chris Cebollero and Kelly Grayson on a recent Inside EMS podcast. He has some great tips for patient care gathered from his ride in the ambulance.

Keep reading for how EMS leads employers in suicide prevention and why heads-up CPR is not ready for prehospital care.


Greg Friese, MS, NRP
Editor-in-Chief, EMS1

P.S. Please forward this leadership brief to at least three rising EMS leaders and let those leaders know to sign up here for the Paramedic Chief Leadership Briefing.

In this issue:

By Greg Friese, MS, NRP

Researchers found that only "22% of employers currently have or plan to implement programs to address opioid use and suicide prevention in 2019" in a nationwide survey. The findings of 2019 Emerging Trends in Health Care Survey: Mental Health from Willis Towers Watson are especially disappointing as death rates from alcohol, drugs and suicide are the highest reported since 1999.

“The nation’s workforces are not immune from the critical mental and behavioral health issues sadly affecting millions of Americans, yet many employers are slow to put programs into place,” said Dr. Jeff Levin-Scherz. “Employers have a significant opportunity to do more to address the stigma tied to mental illness and help employees get the care they need.”

I don’t know the percentage of EMS employers who have programs in place to address opioid use and suicide prevention, but I believe EMS is further ahead than most occupations. Here’s why.

1. Grassroots advocacy organizations advocate for EMS providers

The Code Green Campaign, as well as Reviving Responders and the Firefighter Behavioral Health Alliance have maintained a persistent and dedicated effort through social media campaigns, conference presentations and digital media content to raise awareness of traumatic stress, mental stress and suicide prevention.

2. Research on first responder suicide, mental health and traumatic stress is ongoing

EMS professionals, some in pursuit of an advanced degree and others to complete an ambulance service manager project, research suicide to better understand it’s prevalence. Reviving Responders (read the original paper) began as an ASM Project.

A University of Arizona study found a higher rate of death by suicide among EMTs vs. the general public over a seven-year period. A University of Phoenix survey looked at first responders’ beliefs about the importance of mental health and the perceived repercussions for seeking help.

The “Emerging Research on Depression, PTSD and Suicide” presentation at the 2019 Pinnacle EMS leadership conference is sure to be well-attended.

3. Employers are taking action to prevent suicide

Motivated by advocacy, research and compassion, many EMS employers are implementing or improving programs to prevent suicide. Employee assistance programs, especially when EAP staff are trained to understand EMS, and peer support teams are increasingly implemented and relied on. EMS employers are also taking serious demands to improve overall health and wellness, help providers manage fatigue and mitigate traumatic stress regularly rather than letting stress accumulate.

4. National organizations are developing resources for providers and employers

The CrewCare app provides mental health insights to users aimed at increasing resilience. NAEMT published a “Guide to Building an Effective EMS Wellness and Resilience Program” in early 2019. The First Responder Center for Excellence, an affiliate of the National Fallen Firefighters Foundation, supports research and education to reduce first responder occupational illnesses, injuries and deaths.

5. State law mandates workers’ comp coverage for mental health services and PTSD

Several states have put into law requirements to make mental health services available to first responders. In early January, Massachusetts Gov. Charlie Baker signed Senate Bill 2633, which requires departments to have crisis intervention services to prevent PTSD in first responders who are dealing with psychological trauma. On Jan. 2, a Minnesota law stated that any first responder diagnosed with PTSD is eligible for worker’s compensation. Similar legislation has passed in Florida and Idaho.

What are the components of your department’s suicide prevention program? Share your practices, resources and ideas with other EMS leaders or by emailing greg.friese@ems1.com.

Additional resources for suicide prevention:

In this issue of Paramedic Chief, learn from EMS pioneers who are piloting community paramedicine and mobile healthcare initiatives and leading the charge for EMS in the post-overdose survival phase of the addiction cycle. 

Download this issue of Paramedic Chief

By William F. Toon

While there are some EMS agencies that have implemented some form or variation of a heads-up CPR protocol, caution is absolutely warranted as the concept of heads-up CPR is based on animal studies alone [1]. There is no clear consensus for the best approach of this new practice in an out-of-hospital setting.

EMS has all too often fallen victim to new devices or fads touted to make things better for the patient, provider or agency. By now, EMS leaders should know the relevance of using a formalized process to thoroughly evaluate anything new for their service. When dealing with patient care, carefully searching and reading the scientific literature should be an essential part of the process. It’s important that no patient be harmed by the adoption of any unproven practice, like heads-up CPR.

What is heads-up CPR?

It is not just simply elevating the patient’s head. The greatest benefit shown to date, in animal studies only, is for heads-up CPR to follow a specific sequence of implementation:

  • First, chest compressions are initiated with the patient in the supine position while utilizing an impedance-threshold-device (ITD) plus active compression/decompression (ACD) CPR.
  • Second, two minutes of ACD-CPR + ITD in the supine position is essential to prime the cardiocerebral blood flow.
  • Finally, the head and thorax are slowly elevated 30 degrees in a stepwise fashion.

When utilizing this entire process, a two-fold or more increase in blood flow to the brain over the supine position has reportedly been demonstrated, again, in animal studies only [2].

There are variations to the process, such as just ACD-CPR + ITD or mechanical CPR (piston or load-distributing band chest compression device) + ITD with some type of head- chest-up or complete reverse Trendelenburg. All these variations are also reported to show increase in blood flow to the brain over the supine position [2, 6, 7, 9, 10].

What to do before adding a new cardiac arrest procedure

EMS leaders should, at minimum, consider the following steps before implementing any new cardiac arrest procedure/practice:

  • Have a system in place to collect cardiac arrest data following the Utstein Resuscitation Registry Templates for Out-of-Hospital Cardiac Arrest [14].
  • A better option is to actively participate in Cardiac Arrest Registry to Enhance Survival or CARES. It is essential to know what you are doing now and how well you are doing it. Only then, when a new procedure or practice is put into place, can you know if there is improvement, and no change or harm being caused.
  • Focus on the chain of survival, particularly the components EMS can most greatly impact [15, 16]:
    • Recognition and activation. Dispatcher chest compression-only CPR
    • Early CPR. Bystanders performing chest compression-only CPR
    • Rapid defibrillation. Placement of AEDs in your community
    • Basic and advanced EMS. All EMS providers functioning as a well-oiled team to deliver high-quality CPR. High-quality CPR focuses on proper rate, proper depth, full chest recoil and minimizing any interruptions < 10 seconds.
  • Continuous training is essential to learn, maintain and improve CPR performance. New research shows that short duration training on manikins with real-time feedback completed monthly is the most effective approach [17].

What does the research say about heads-up CPR?

Developing an opinion based on the science or lack thereof of any emerging procedure, skill or tool is vital. Carefully research and read all the references found at the end of this article.

The majority of the studies on heads-up CPR have been done using a pig model [2, 6-9]. One uses a human cadaver model [2]. Some other related studies look at using the impedance-threshold-device with active-compression/decompression CPR or the impedance-threshold-device with mechanical (piston type) CPR with and without head elevation [6, 9, 10, 12, 13]. In a literature review, no studies were found utilizing a load-distributing band chest compression device (AutoPulse) for heads-up CPR.

None of the studies appear to be a well-designed, out-of-hospital study comparing conventional high-performance CPR versus any of the current models of heads-up CPR. In the case of heads-up CPR, it seems clear that EMS should wait for more definitive studies. Some of the information written there includes the following:

  • “There are also well-meaning zealots in the field of resuscitation who believe in early implementation of novel ideas. This zeal is born from frustration knowing that in many cities the survival to discharge rates remain very poor. Head up CPR, both in animals and in this human model, was beneficial only when coupled with ACD and the ITD. Thus, it is not just HUP CPR, it is device-assisted HUP CPR that appears to be beneficial. Maybe a name change of the technique would prevent misconception or misapplication of the technique" [3].
  • “There are no silver bullets in resuscitation; simply elevating the head during CPR will not improve neurological outcomes" [5]
  • “In this experimental animal model of BLS CPR, the head-up as compared to the standard supine position, despite increasing CPP, did not improve parameters of cerebral oxygenation or cerebral metabolism, as measured by multimodal neuromonitoring techniques" [9].

It’s time that EMS providers, leaders and agencies stop falling victim to models and devices touting the ability to save cardiac arrest patients. We will get much further by acting with caution, even skepticism, and asking for real proof from well-designed research studies.

About the author

William F. Toon, EdD., NRP, has been an EMS provider and educator since 1975. Bill has had experience with many different EMS delivery models, including volunteer, non-profit, for-profit, hospital, governmental (third service and fire department), fly car, ground ambulance and air ambulance.

Visit EMS1.com to review the references for this article.

Learn more about cardiac response quality improvement:

3 and out …

3. Celebrate 5 years of the Inside EMS podcast, one of the longest-running EMS podcasts. Subscribe now on Apple Podcasts, Google Play or SoundCloud and listen to top episodes like What STEMI patients need paramedics to know, the NAEMT president on a degree for paramedics and listen to the 5th-anniversary episode when it drops Friday.

2. Was Paul Tarashuck a patient? Is the EMS crew liable for his death? David Givot, an EMS1 advisory board member, reviews the body cam video and confronts the issues of patient abandonment, negligence and responsibility.

1. ET3 Top 10. Ryan S. Stark, attorney at law, breaks down the 10 things we learned from the CMS ET3 webinar.

Submit a Chief Report

Paramedic Chiefs want to hear about your successes and learn how you are solving the pressing challenges of EMS leadership. Send your Chief Report to greg.friese@praetoriandigital.com for consideration in an upcoming edition of the Paramedic Chief Leadership Briefing.

Manage Credentials & Offline Training in EMS1 Academy
EMS1 Academy's online training solution helps agencies maintain license and credential compliance by offering a powerful library of more than 225 accredited courses and includes automated reporting, progress tracking and more
Join Paramedic Chief LinkedIn Group
Learn EMS Leadership Solutions
Excel as a Paramedic Chief
Find, apply for EMS Grants
EMS1 does not send unsolicited messages. You are receiving this email because you have signed up for EMS1 and subscribed to this newsletter. Click here to unsubscribe. Visit our Customer Support page to report any email problems or subscribe to our other newsletters.