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ACTIVE SHOOTER Planning p. 14 HEAD Trauma p. 22 EMOTIONAL Intelligence p. 40 PERSONNEL Crisis p. 56
JULY 2017
SERVICE
ANIMALS
The truth about EMS transport of service
dogs & other support animals, p. 32
www.emstoday.com FEBRUARY 2123, 2018, CHARLOTTE, NC
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32 CANINE CAREGIVERS
The truth about EMS transport of
service dogs & other support animals
By Criss Brainard, EMT-P
JULY 2017 VOL. 42 NO. 7
40 THE IT FACTOR
Leading with emotional intelligence
By Robert P. Girardeau, MSM-HCA, NRP, FP-C
Contents
48 CONNECTING THE DOTS
DEPARTMENTS & COLUMNS
James Dunford, MD, has dedicated his career to helping the vulnerable 6 FROM THE EDITOR Institutional Knowledge
By A.J. Heightman, MPA, EMT-P
By Lauren Crosby, NREMT
12 LETTERS IN Your Own Words
14 EMS INSIDER News and Winning Strategies for EMS Leaders
40 18 PRO BONO Service Animals

By Christie Mellot, Esq., EMT-B
20 MANAGEMENT FOCUS Siren Science
By Vincent D. Robbins, FACHE, FACPE
22 CASE OF THE MONTH Sodium Bicarbonate
By Jazmine Valencia, NNP-BC, RN, CCRN; Thomas Carrion,
RN, CCRN; Mike Mendez, NRP; Kori Martinez, RN, CCRN, CFRN;
Greg Johnson, EMT-P; Aaron T. Britnell, EMT-P, CCEMT-P; Larry
D. Levy, MD, FAAEP, EMTP, ATP; Ken Davis, BA, EMT-P, FP-C &
Ryan Hodnick, DO, NRP, FAWM
26 EVIDENCE-BASED EMS Appropriate Referrals
By Christoph Redelsteiner, Dr.PhDr, MSW, MS, EMT-P
28 STREET SCIENCE Guidelines & Rules
By Keith Wesley, MD, FACEP & Karen Wesley, NREMT-P
56 FIELD PHYSICIANS Technicians & Clinicians
48 By Mark E.A. Escott, MD, MPH, FACEP
58 HANDS ON Product Reviews from Street Crews
By Fran Hildwine, BS, NRP
63 AD INDEX
64 LAST WORD The Ups & Downs of EMS
About the Cover

Service animals not only provide assistance for physical con-
ditions, but they often also provide emotional support. Learn
more about the factors EMS providers should take into account
when considering the transport or non-transport of a patients
service animal, pp. 3238. photo matthew strauss
www.jems.com jULY 2017 | JEMS 1
1707jems_1 1 6/9/17 9:08 AM

Control-Cric EDITOR-IN-CHIEF A.J. Heightman, MPA, EMT-P aheightman@pennwell.com

MANAGING EDITOR Ryan Kelley, NREMT rkelley@pennwell.com
SENIOR EDITOR Sarah Ferguson, MA sarahf@pennwell.com
Taking Control of an Otherwise

MEDICAL EDITOR Edward T. Dickinson, MD, NRP, FACEP
TECHNICAL EDITOR Carolyn Gates, EMT-P, FP-C
Chaotic Procedure
MOBILE INTEGRATED HEALTH EDITOR Matt Zavadsky, MS-HSA, EMT
CONTRIBUTING ILLUSTRATORS Steve Berry, NRP; Paul Combs, NREMT
CONTRIBUTING PHOTOGRAPHERS Vu Banh, Glen Ellman, Craig Jackson, Kevin Link, Courtney
McCain, Tom Page, Rick Roach, Scott Oglesbee, Steve Silverman, Matthew Strauss, Chris Swabb
EDITORIAL GRAPHIC DESIGNER Kermit Mulkins

PRODUCTION COORDINATOR Kimberlee Smith ksmith@pennwell.com
REPRINTS, ePRINTS & LICENSING Rae Lynn Cooper 918-831-9143 raec@pennwell.com
DIGITAL MEDIA CAMPAIGN MANAGER Erin Northrop erinn@pennwell.com
SUBSCRIPTION DEPARTMENT
(800) 869-6882 FAX: (866) 658-6156 JEMS@kmpsgroup.com
SENIOR AUDIENCE DEVELOPMENT MANAGER Jim Cowart jimc@pennwell.com
MARKETING MANAGER Ashley Cope ashleyc@pennwell.com
SALES & MARKETING SOLUTIONS

WESTERN U.S. Mike Shear 858-638-2623 mshear@pennwell.com
MIDWESTERN U.S. Melissa Roberts 918-831-9727 melissar@pennwell.com
NORTHEASTERN U.S. Rod Washington 918-831-9481 rodw@pennwell.com
SOUTHEASTERN U.S. & INTERNATIONAL Jared Auld 918-831-9440 jareda@pennwell.com
www.EMSToday.com
SENIOR VICE PRESIDENT/GROUP PUBLISHER MaryBeth DeWitt
EDUCATION DIRECTOR A.J. Heightman, MPA, EMT-P
CONFERENCE MANAGER Debbie Wells (Boyne) dboyne@pennwell.com
CONFERENCE COORDINATOR Sara Jones sjones@pennwell.com
MARKETING MANAGER Cassie Chitty cassiec@pennwell.com
SENIOR EVENT OPERATIONS MANAGER Emily Gotwals-Moreau emilyg@pennwell.com
The Cric-Knife has a 10mm dual sided blade,
with a sliding tracheal hook to maintain FOUNDING PUBLISHER James O. Page (19362004)
airway placement. CHAIRMAN Robert F. Biolchini

VICE CHAIRMAN Frank T. Lauinger
The Cric-Key has a pre-shaped stylet that provides PRESIDENT AND CHIEF EXECUTIVE OFFICER Mark C. Wilmoth
airway connrmation, with tactile feedback EXECUTIVE VICE PRESIDENT, CORPORATE DEVELOPMENT AND STRATEGY Jayne A. Gilsinger
of the tracheal rings. SENIOR VICE PRESIDENT, FINANCE AND CHIEF FINANCIAL OFFICER Brian Conway
SENIOR VICE PRESIDENT/GROUP PUBLISHER MaryBeth DeWitt marybethd@pennwell.com
1707jems_2 2 6/9/17 9:08 AM

1707jems_3 3 6/9/17 9:08 AM

EDITORIAL BOARD
UNITED STATES Andrew McCoy, MD, MS Jonathan D. Washko, FINLAND JAPAN William J. Leggio, EdD, NRP
Associate Medical Director, Seattle MBA, NREMT-P, AEMD Paramedic Program Coordinator, EMS
William K. Atkinson II, PHD, Pertti H. Kiira, RN Hiromichi Naito, MD, PhD
Fire Dept. Assistant Vice President, North Shore-LIJ Assistant Professor, Dept. of Emergency Education, Creighton Univ.
MPH, MPA, EMT-P Consultant of EMS
Health Care Advisor, Raleigh, N.C. Mike McEvoy, PHD, NRP, RN, CCRN Center for EMS Medicine, Okayama Univ. Hospital
James J. Augustine, MD, EMS Coordinator, Saratoga County, N.Y. Keith Wesley, MD, FACEP FRANCE Hideharu Tanaka, MD, PhD SCOTLAND
FACEP John McManus, Col. (Ret.), MD, Medical Director, HealthEast Medical Professor & Chairman, EMS System, Paul Gowens, FCPara, MSc, AASI,
Director of Clinical Operations, EMP MBA, MCR, FACEP, FAAEM Transportation Jean-Clause Deslandes, MD Graduate School & Research Insitute of
PGCert, DipIMC, RCSEd, MCMI
Management Professor of Emergency Medicine & Past Publisher, Urgence Practique Disaster & EMS, Kokushikan Univ.
Katherine H. West, BSN, Consultant Paramedic, Scottish
Paul Banerjee, DO EMS Fellowship Director, Georgia MSEd, CIC Marilyn Franchin, MD Ambulance Service
Medical Director, Polk County (Fla.) Regents Univ. Infection Control Consultant, Infection Prehospital Emergency Physician, Fire LUXEMBURG
Fire Rescue Jason McMullan, MD Control/Emerging Concepts Inc. Brigade of Paris Steve Greisch, RNA SINGAPORE
Bryan E. Bledsoe, DO, FACEP, Associate Director, Division of EMS, Registered Nurse Anesthetist & Continuing
Keith Widmeier, BA, NRP, FP-C Medical Education Instructor, Centre Marcus Ong Eng Hock
FAAEM Dept. of Emergency Medicine, Univ. GERMANY
Adjunct Faculty, Emergency Services
Professor of Emergency Medicine, Director, of Cincinnati Hospitalier Emile Mayrisch Senior Consultant, Clinician Scientist
Program, Jefferson College of Health Jan-Thorsten Grsner,
EMS Fellowship, Univ. of Nevada Mark Meredith, MD & Director of Research, Dept. of
Sciences
Scotty Bolleter, BS, EMT-P Associate Professor of Pediatrics, Le MD, FERC MEXICO Emergency Medicine, Singapore
Chief, Clinical Direction, Bulverde Spring Bonheur Childrens Hospital (Memphis,
Stephen R. Wirth, Esq. Director, Institute for Emergency General Hospital
Attorney, Page, Wolfberg & Wirth LLC. Armando Alvarez, BSBME,
Branch (Texas) Fire and EMS Tenn.) Medicine, Univ.Medical Center
MBA, EMT-P, PA
Douglas M. Wolfberg, Esq. Schleswig-Holstein CEO, Sistemedic SLOVAKIA
Criss Brainard, EMT-P David A. Miramontes, MD,
Fire Chief, San Miguel Fire & Rescue Attorney, Page, Wolfberg & Wirth LLC Klaus Runggaldier, PhD, EMT-P
FACEP, NREMT Viliam Dobias, MD, PhD
(Spring Valley, Calif.) Medical Director, San Antonio Fire Dept. Wayne M. Zygowicz, MS, Dean and Professor, Medical School THE NETHERLANDS Chair of Emergency Medicine, Medical
Chad Brocato, JD, DHSc, CFO EFO, EMT-P Hamburg, Univ. of Applied Sciences Ingrid Hoekstra, MSc School of Slovak Medical Univ.
Brent Myers, MD, MPH, FACEP
Assistant Chief, Pompano Beach (Fla.) Chief Medical Officer & Excutive Vice EMS Division Chief, Littleton (Colo.) and Medical Univ. Ambulance Nurse, RAVU Utrecht Bratislava
Fire Rescue President, Evolution Health Fire Rescue Ambulance Service, Dept. of Research
Thomas Semmel, EMT-P
Carol A. Cunningham, MD, Joseph P. Ornato, MD, FACP, Educator, European Resuscitation Council SLOVENIA
FAAEM, FAEMS
FACC, FACEP
MULTI-NATIONAL NEW ZEALAND
State Medical Director, Ohio Dept. of Andrej Fink, MSHS , RN, EMT-P
Public Safety, Division of EMS
Operational Medical Director, Richmond Jerry Overton, MPA HUNGARY Craig Ellis, MD Head of Ambulance Service, Univ. Medical
Ambulance Authority Chair, International Academies of National Medical Advisor, St. Johns
Mark E.A. Escott, MD, MPH, Laszlo Gorove, MD Centre Ljubljana
Paul E. Pepe, MD, MPH, MACP, Emergency Dispatch Ambulance Service
FACEP Managing Director, Hungarian Air
Medical Director, Austin-Travis County EMS FACEP, FCCM Corina Bilger, NREMT-Ret Ambulance Nonprofit Ltd. Hugo Goodson, MBA, PgCertEd, SOUTH AFRICA
Professor of Emergency Medicine, Director of International Sales, H&H BHSc
Jay Fitch, PhD Internal Medicine, Pediatrics, Public Medical Corp. Lecturer, Paramedicine, Auckland Univ. Neil Noble, CCP
President & Founding Partner, Fitch & Health, Univ. of Texas Southwestern ICELAND of Technology Director, Paramedics Australasia
Associates Medical Center
AUSTRALIA Njall Palsson, EMT-P
Ray Fowler, MD, FACEP, FAEMS David E. Persse, MD, FACEP President, Professional Division for EMT- NIGERIA SOUTH KOREA
Professor and Chief, Division of EMS, Colin Allen, EMT-P
Physician Director, City of Houston EMS Paramedics Nnamdi Nwauwa, EMT,
Univ. of Texas Southwestern School Director, Brisbane Operations Center, Sang Do Shin
of Medicine P. Daniel Patterson, PhD, Queensland Ambulance Service CCEMTP, MBBS, MPH, MMSCEM Professor, Dept. of Emergency Medicine,
MPH, EMT-B INDIA Founder, Emergency Response Services
Adam D. Fox, DPM, DO, FACS Paul Middleton Seoul National University College of
Research Associate, Cecil G. Sheps Center; Group
Section Chief, Division of Trauma, Rutgers Chair/Principal Investigator, DREAM George P. Abraham, MD, FRCS, Medicine and Seoul National University
N.J. Medical School N.C. Rural Health Research and Policy
(Distributed Research in Emergency
Ola Orekunrin, MD Hospital
FACS, FWACS, MHA
Mark Piehl, MD Director, Flying Doctors Service
John M. Gallagher, MD and Acute Medicine) Collaboration Medical Director, Western Alliance
Medical Director, Wichita/Sedgwick Pediatric Intensivist & Pediatric Critical EMS System SWEDEN
Care Transport Advisor, WakeMed Peter OMeara NORWAY
County (Ks.) EMS System Professor, Rural & Regional Paramedicine, G.V. Ramana Rao, MD, DPH, Kenneth Kronohage, MSc,
Ryan Gerecht, MD, CMTE Edward M. Racht, MD La Trobe Univ. (Victoria) Carl R. Christiansen, EMT-P,
PGDGM CRNA, BSc, RN
EMS and Emergency Medicine Physician, Chief Medical Officer, American Medical MPhilEd
Robyn Smith Director of Emergency Medicine Learning Hospital Lecturer, Oslo & Akershus Univ. President, Swedish Ambulance Forum
Tacoma, Wash. Response
Editorial Staff Member, Response Center & Research, GVK Emergency College of Applied Sciences
Jeffrey M. Goodloe, MD, NRP, Jeffrey P. Salomone, MD, FACS Management Research Institute UNITED ARAB EMIRATES
FACEP, FAEMS Trauma Medical Director, Banner Desert Live Oftedahl, Cand.Philol.
Medical Center/Cardon Childrens AUSTRIA Editor-in-Chief, Ambulanseforum Ahmed Alhajeri
Medical Director, EMS System for
Metropolitan Oklahoma City & Tulsa Medical Center Christoph Redelsteiner, IRELAND Ronald Rolfsen Deputy CEO, National Ambulance
Jullette M. Saussy, MD, FACEP DrPhDr, MSW, MS, EMT-P Darren Figgis Special Adviser, Division for Prehospital
Keith Griffiths Medicine, Ambulance Dept., Oslo
President, RedFlash Group Emergency Medical Physician Professor, Dept. Social Work & Health, Advanced Paramedic, Health Service UNITED KINGDOM
Univ. of Applied Sciences St. Plten Executive National Ambulance Service Univ. Hospital
Andrew J. Harrell, MD Geoffrey L. Shapiro Steinar Olsen, RN, NREMT-P Jon Ellis, MBA
Assistant Professor, Dept. of Emergency Director, EMS & Operational Medicine Technical Expert, BSI & CEN Committees
CANADA ISRAEL Director, Dept. of EMS, Norwegian
Medicine, Univ. of New Mexico Training, School of Medicine and Ambulance Systems & Patient
Directorate for Health
Joe Holley, MD Health Sciences EHS Program, George Randy Mellow Dov Maisel, EMT-P Handling Equipment
Medical Director, Memphis Fire Dept. Washington Univ. President, Paramedic Chiefs of Canada Senior Vice President of International POLAND Mike Jackson, MSc (Dist), DipIMC,
Chris Kaiser, NREMT-P Corey M. Slovis, MD, FACP, Ronald D. Stewart, MD, FACEP Operations, United Hatzalah United MBA, FCPara
Paramedic, Central Wisconsin FACEP, FAAEM Professor, Emergency Medicine, Rescue
Jamie Chebra, EMT-P, CEM,
MS, DHAc Chief Consultant Paramedic & Assistant
Medical Director, Metro Nashville Dalhousie Univ.
Dave Keseg, MD, FACEP Fire Dept. Sody Naimer EMS Educator & Advisor, Poland EMS Clinical Director, North West
Medical Director, Columbus Fire Dept. Senior Lecturer, Division of Community Systems Ambulance Service NHS Trust
Chetan U. Kharod, MD, MPH, E. Reed Smith, MD, FACEP CZECH REPUBLIC Health, Ben-Gurion Univ. of the Negev
Co-Chairman, Committee for Tactical
Marek Dabrowski Ian Maconochie, FRCPCH, FECM,
Colonel, USAF, MC, SFS
Emergency Casualty Care
Jana eblov, MD, PhD Oren Wacht, EMT-P, MHA, PhD Lecturer, Poznan Univ. Medical Sciences, FRCPI, FERC, PhD
Program Director, Dept. of Defense EMS & Head Physician, EMS Education, Central Rescue & Disaster Medicine Dept. and Consultant, Paediatric Emergency
Professor, Ben Gurion University, Dept. of
Disaster Medicine Fellowship Walt A. Stoy, PhD, EMT-P, CCEMTP Bohemian Region Sim Center
Medicine, St. Marys Hospital, Imperial
Professor & Director, Emergency Emergency Medicine & Health Systems
Keith Lurie, MD Management Mateusz Zgoda, MPH, EMT-P Academic Health Sciences Centre
Medicine, Univ. of Pittsburgh
Codirector, Central Minnesota Heart DENMARK Paramedic, Krakow Rescue Public
Center Resuscitation Center Peter P. Taillac, MD Ambulance Service Fionna Moore, MBE, FRCS, FRCSEd,
Medical Director, Bureau of EMS and
Kjeld Brogaard, EMT-P INDONESIA FRCEM, FIMC RCSEd
W. Ann Maggiore, JD, NREMT-P EMS Senior Manager, Falck Denmark
Clinical Instructor, Univ. of New Mexico, Preparedness, Utah Dept. of Health Ahed Al Najjar, BSc, AREMTP, SAUDI ARABIA Chief Executive, Consultant in Prehospital,
School of Medicine Freddy Lippert, MD London Ambulance Service NHS Trust
Michael Touchstone, MPH, FAHA Kenneth J. DAlessandro,
CEO, EMS Copenhagen Director of Life Support, EMS Faculty & Andy Newton, PhD
Shaughn Maxwell, EMT-P BS, EMT-P BS, MS EMS, EMT-P
Captain & Medical Services Officer, Regional Director, Philadelphia Regional Heidi Vikke, MSc Researcher, Prince Sultan Bin Abdulaziz EMS Program Advi er, Saudi Red Crescent Chief Clinical Officer, South East Coast
Snohomish County Fire District 1 (Wash.) Office of EMS Head of Research, Falck Denmark College for EMS King Saud Univ. Authority Ambulance Service NHS Trust
For complete bios of our Editorial Board members, visit jems.com/Editorial-Board.
4 JEMS | JULY 2017 www.Jems.com
1707jems_4 4 6/9/17 9:08 AM

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FROM THE EDITOR
PUTTING ISSUES INTO PERSPECTIVE
INSTITUTIONAL
KNOWLEDGE
The often-unrecognized value of seasoned personnel
By A.J. Heightman, MPA, EMT-P
H
uman resource experts have shown In one case, a new fire chief moved an inex- out to reporterswho he kept well informed
that employees who leave an organi- perienced fire officer into the position of EMS on a daily basisand give them accurate facts
zation take a substantial amount of battalion chief position and transferred the and reasons why eliminating the ambulance
invaluable business and operational knowledge, seasoned 25-year EMS veteran to head up service would be detrimental to city residents.
as well as organizational and political contacts another division. The new EMS chief knew His well-established media sources would
and connections, with them. This large bun- nothing about this experienced employees then editorialize why the city should main-
dle of knowledge that a person acquires over EMS history, advances or projects underway. tain its valuable and highly respected ambu-
time is known as institutional knowledge. Their program has since spiraled backward; lance service.
Its difficult to replace or duplicate by orga- it will take years to recover from this loss of He also wisely mirrored the professional
nizations, especially when internal systems to institutional knowledge in that position. appearance of the respected medical commu-
retain, replace or document it are nonexistent. In another instance, an industry colleague nity, requiring his personnel to wear a uniform
Very few metrics or measures exist to quan- who did the work of four people stated her hat and white, starched coveralls or a starched
tify the lossor valueof institutional knowl- case to a new owner and requested more assis- white shirt and navy blue pants. In addition to
edge, continuity and history. The loss typically tance. It fell on deaf ears and resulted in her looking professional, he made sure his crews
is manifested as turnover, recruitment, replace- resignation. They lost more than 20 years of understood that bright white ensured they
ment and training costs that many organiza- solid institutional knowledge which may take could be easily seen in traffic and large crowds.
tions face.1 them years to recover. When I was 18 years old and heading out
Ive recently witnessed several people in I dont have firm solutions to stop inept, the front door to return to college, a man
our industry either pushed out of key posi- political or budget-blind managers from approached and asked me to get my father. I
tons or who quit after their experience and making stupid moves that cost them to lose did and he made my father sign for a certified
value to their organization was overlooked employees with extensive institutional knowl- letter from the city of Scranton informing him
or dismissed. edge, but I want to present a few points to that, because of severe budget problems, a deci-
make you more aware of the problem and help sion had been made to terminate the employ-
you avoid creating a black hole that will dam- ment of six firefighters. The city made the
age or slow the progress of your organization. crazy decision to eliminate the top three high-
est in seniority and three newest firefighters.
A PERSONAL EXAMPLE My dad was then number two in depart-
My fathers knowledge, ability and drive for ment seniority. I was crushed, but the cruel
serving the citizens of Scranton, Pa., as the action offered valuable imprint to my young
captain-in-charge of the fire departments mind, and because of what I saw occur after
ambulance division was legendary. I was in my father was summarily terminated after his
awe of how much he knew and, more impor- 30 years of experience, I became committed to
tantly, the people and connections he had made never ignore a persons institutional knowledge.
throughout his long career. My father attempted to move on, but, even
I was also amazed at how many times he though hed mentored each of his lieutenants,
saved the fire department ambulance divi- his staff hadnt been able to absorb the depth
Theres significant nutritional value in a fruit or veg- sion because of his institutional knowledge, of his institutional knowledge.
etable thats ripened just as theres also significant respect and political aptitude. Torn between the emotional pain and anger
value in the individual who has been cultivated, Every time the city council or mayor threat- of his abrupt dismissal and his dedication to
trained, nurtured, mentored and blossomed in your ened to eliminate the ambulance service to the city ambulance service, my father contin-
organization. Photo A.J. Heightman reduce the city budget, my dad would reach ued to counsel his beloved crews behind the
1707jems_6 6 6/9/17 9:08 AM

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FROM THE EDITOR
scenes. I listened intently to him during many to run it. That transfer of service lasted only workforce we had a few decades ago.
of those calls, each one a learning experience a few years before the hospital tired of sub- By the year 2018, many employers may
for me. It was both educational and heart- sidizing a loss leader and turned it over to see as many as five generations working side-
breaking as I watched the unraveling of the the private sector. by-side, which not only affects the organiza-
service he worked for decades to build. tional makeup, but also how the organization
The fire union fought in court for two years RETAINING INSTITUTIONAL addresses engagement, values, sustainment,
to have the top seniority employees reinstated KNOWLEDGE tenure, and how it retains and transfers insti-
and finally prevailed with the states supreme Throughout my career, Ive watched more tutional knowledge.
court overruling the citys action, forcing them EMS organizations than I can count disre- As baby boomers prepare to retire, some
to honor their seniority practices and rehire my gard institutional leadership in favor of pol- Generation Xers and many millennials wont
dad and the two other senior officers. itics or budgets. remain employed with your organization long
My father returned to his position after the The fact is that the loss of institutional enough to learn from their older colleagues.
two-year hiatus, but he was never the same knowledge can take the wind out of an EMS Because of this generational shift, the institu-
because, during his departure, the culture and organization or divisions sails and result in a tional knowledge, history and business conti-
work ethic of the ambulance division dra- significant setback in the programs and prog- nuity that veteran employees possessed might
matically changed. The person put in charge ress. In some cases, it can lead to the orga- disappear and could result in a steady increase
during his absence didnt possess the same nizations demise, particularly those that are in employee turnover and further loss of insti-
institutional knowledge or passion for the small and lack leadership depth and finan- tutional knowledge, translating into higher
position and immediately made changes that cial reserves. costs and lower institutional efficiency.1
degraded much of what my father This will be a rude awakening for
had put into place. agencies that ignore this issue and
He did away with the invalu- fail to work to retain institutional
able daily ledger each lieutenant All organizations should knowledge and proven processes.
had to read, contribute to, and sign
off on, when they started and ended implement a plan of IDENTIFY FUTURE LEADERS
their shift. It was a treasure trove of Your organization must have plans
institutional information. He also knowledge transfer in order in place in order to ensure continuity.
changed the color of uniforms from To address the loss of institutional
white to navy blue. to survive the loss of older knowledge, the U.S. Office of Per-
Although these may seem like sonnel Management (OPM) recom-
small changes, they took away an generational employees. mends that governmental agencies
encyclopedia of valuable knowledge focus on identifying leadership com-
and not only changed professional petencies among existing employees
look of the ambulance crews, but cost a young Ive witnessed medical directors who ded- in an effort to create a pipeline of new leaders.1
EMT firefighter his lifethe young EMT icated their every waking hour to build their In fact, all organizations should implement a
who served as my fathers partner for years was agencys capabilities and image get cast away plan of knowledge transfer in order to sur-
killed when he was struck by a vehicle whose like a dead fish when a new administration vive the loss of older generational employees.
driver saw the ambulance warning lights but came in, or when they made decisions or insti- As Ray Barishansky pointed out in a 2013
couldnt see the young firefighter dressed in tuted changes or improvements that city offi- EMS Insider article on the importance of
his dark navy blue uniform as he treated a cials or union leadership didnt like. mentoring, EMS is a field thats ripe for good
patient on a highway. Ive also watched as high-quality leaders mentorspeople who have been around the
My dad retired a few years later, and the transferred out of EMS or moved to another proverbial block, who understand EMS and
political appointee promoted to head up the agency because top leadership or staff failed know how to share their knowledge with oth-
ambulance division lacked not just his insti- to accept or respect their knowledge or rec- ers in a communicative, non-confrontational
tutional knowledge, but also his devotion to ommendations for changes and improvements. manner that can inspire.2
duty. This appointee was ultimately demoted Its not something that I think will ever go Barishansky wisely cautioned that when
because he delayed response to an emergency away, but its something that you as readers and selecting mentors in EMS, you have to remem-
call for 10 minutes as he awaited his cross- leaders can pay attention to and be conscious ber that age and seniority arent always the
shifter/relief who was a few minutes late. of so that you can avoid a loss of institutional same thing. Individuals start their EMS careers
The call turned out to be a response to one knowledge in your own organization. at different points in their lives, so you have
of my fathers most respected and experienced You must pay close attention to not just the to select a mentor based on what they know
lieutenants who had collapsed into cardiac inner workings of your department, but also its and not just based on their age. He also rec-
arrest in his home. He died and the family separate divisions and the various generations ommends you consider choosing a mentor
threatened to sue the city. your employees come from when working to whos worked in a variety of systems or held
The city settled out of court by giving up maintain institutional knowledge. a number of differing positions.2
the ambulance service to a hospital that wanted Todays workforce is very different from the Continued on page 63
1707jems_8 8 6/9/17 9:08 AM

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1707jems_11 11 6/9/17 9:08 AM

LETTERS
IN YOUR OWN WORDS
PHOTO COURTESY DAVE RYNDERS

TRAUMATIC CARDIAC ARREST
This month we hear from readers who had feedback and questions about an article in
our April issue, Trauma Resuscitation: An evidence-based review of prehospital trau-
matic cardiac arrest, by Matthew Chinn, MD, and M. Riccardo Colella, DO, MPH.
QUESTIONING COMPRESSIONS interfere with procedural interventions that not include data of total trauma arrests, only
External compressions add little to no value are likely to be more beneficial to patient out- those transported. It could represent only a
in hemorrhagic shock. You arent really going comes. Treating reversible causes of death from small fraction of traumatic arrests and looking
to increase perfusion and just make the hem- trauma, as you suggest, should be part of initial at the total numbers I suspect thats the case.
orrhage worse. If the patient codes just before management of traumatic arrest. We did elect to Lee H.
arrival, decompress both sides of the chest and include external compressions in the algorithm Via Facebook
pericardiocentesis. Call it if return of sponta- as theyre included in the NAEMSP/ASCOT
neous circulation isnt achived. If cardiac arrest Position Statement. We hope this article pro- AUTHORS MATTHEW CHINN,
is witnessed and < 10 min from trauma center motes discussion of the use of more advanced MD, & M. RICCARDO COLELLA,
(because after loading and into the bay you are resuscitation procedures, field thoracotomy and DO, MPH, RESPOND:
really looking at 15 minutes), go fast and needle REBOA as you mention, among others in the We agree that traumatic arrest survival numbers
both sides of the chest on the way in and get US. Additionally, we feel it highlights the poten- from systems that utilize physicians on scene
some access! The reason Europe does a good tial increased physician role here in the U.S. in are likely not directly applicable to the current
job is that they have low transport times and prehospital medical care from medical direc- system of EMS in the U.S. However, they do
judicious use of field thoracotomy and resus- tion to direct patient care. highlight the potential for medically salvageable
citative endovascular balloon occlusion of the With the formalization of EMS as a sub- patients and should maybe spark discussion on
aorta (REBOA). These arent commonly done specialty by the American Board of Medical how we can push to improve our current sys-
in the United States. Specialties (ABMS) in 2010 and the first EMS tem. We did try to ensure that this limitation
Josh G. physician certification exam in 2013, theres was addressed in the article as a possible con-
Via Facebook been a push toward recognizing the increas- founding factor.
ing physician expertise needed and the value You do bring up an excellent point regard-
AUTHORS MATTHEW CHINN, they provide to lead EMS here into the future. ing the inclusion criteria of the studies. The
MD, & M. RICCARDO COLELLA, Huber-Wagner et al. study only included those
DO, MPH, RESPOND: ON-SCENE PHYSICIANS? patients who received external compression and
The role of external compression is certainly The numbers used in this article reflect studies were transported to a trauma center. Similarly,
debatable and we feel that they shouldnt where they use physicians on scene and does Pickens et al. had limited field termination
1707jems_12 12 6/9/17 9:08 AM

criteria in consultation with medical control associated with increased mortality. The patients of access to a close Level 1 or 2 trauma center.
and therefore also did not include those patients most likely to survive were transported by civil- There are several studies looking at police or
who were terminated in the field. The Lockey ians or police, who rarely had CPR started other non-medical personnel vs. EMS transport
et al. study did include those patients that were before arriving at the hospital. and also BLS vs. ALS level of care in trauma
confirmed dead on scene and not transported; Peter C. that seem to imply that the rapidity of trans-
Leis et al. also included all patients attended to Via Facebook port to an appropriate hospital may play a role.
in the prehospital setting. Each of these studies We do know that often the opportunity for
certainly has their limitations and its difficult to AUTHORS MATTHEW CHINN, surgical intervention is within a finite time win-
make apples-to-apples comparisons, but we do MD, & M. RICCARDO COLELLA, dow and that longer downtimes lead to worse
feel that providing all the literature for review DO, MPH, RESPOND: outcomes. This is why we agree with your argu-
gives the most complete picture on the current We certainly agree that it may be reasonable to ment and would recommend for those patients
state of traumatic arrest resuscitation. consider rapid transportation (i.e., load and go) that are transported by this load-and-go prac-
in a subset of patients whose etiology and char- tice that procedures are performed in route and
IMMEDIATE TRANSPORT acteristics include: witnessed arrest, penetrating dont delay expeditious transport.
This article glosses over one of the most import- trauma of thoracic location, and close proximity
ant considerations for urban penetrating trauma (1015 minute) to a trauma center. CORRECTION
managementimmediate transport to a Level We also include the load-and-go recommen- In this article, the NAEMSP was referred to
1 trauma center. One study of patients who dation as the second bullet point of our example incorrectly as an association of EMS medical
received ED thoracotomies showed that each pathway. This practice would generally be most directors. The correct name is the National
prehospital procedure performed (e.g., spinal applicable to those services in urban settings Association of EMS Physicians. We regret
immobilization, IV access, intubation, etc.) was as you suggest, given their higher likelihood the error.
1707jems_13 13 6/9/17 9:08 AM

PHOTO COURTESY JONATHAN HEDRICK/BLACKSBURG (VA.) VOLUNTEER RESCUE SQUAD

A UNIQUE APPROACH
Active shooter planning & response in a healthcare setting
By Scott Cormier, NRP, CHEP
DEFINING ACTIVE SHOOTER
P
lanning for response to an active setting didnt yet exist. Run, hide, fight was
shooter event, from both a victim and thought to be too harsh, especially with a vul- To design an active shooter response plan, you
public safety perspective, began in ear- nerable patient population, and worries of first need to define what an active shooter is.
nest after the tragedy of the Columbine High abandonment, ethics and possible criminal An active shooter event, as defined by the FBI,
School shooting in 1999. In 2008, the Depart- charges confused the matter. Some healthcare is one or more individuals engaged in killing
ment of Homeland Security issued the guid- facilities ignored it; others made policy requir- or attempting to kill people in a populated
ance of evacuate, hide out and take action, ing staff to stay with patients, while others area. Between 2000 and 2013, there were four
which eventually became run, hide, fight. allowed staff to decide if they wanted to stay or active shooter incidents in healthcare facili-
However, guidelines for an active shooter in leave. None of it, however, was evidencebased, ties, resulting in 10 killed and 10 wounded.1
a hospital, nursing home or other healthcare or included experts to help design a solution. Active shooter is a unique event, and isnt a
1707jems_14 14 6/9/17 9:08 AM

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1707jems_15 15 6/9/17 9:08 AM

EMS INSIDER
suspicious person, hostage situation, a brawl, a facility, such as MRI machines, medical gases shooter incident: The fewer people there are
murder, suicide or knife attack. The distinction and hazardous materials. in the hot zone, the fewer targets and poten-
is important, because the response to each is The team published their consensus recom- tial victims. Getting people out of the imme-
unique. For example, during an event with a mendation guide, Active Shooter Planning diate areas of the shooter is the first priority.
knife, barricading may be more feasible than and Response in a Healthcare Setting,2 in the Hiding may not be adequate. Run, hide and
during a firearm attack. For a hostage event, summer of 2013 and later that fall the federal fight is the recommendation for the immedi-
cordoning the area and evacuating nearby peo- government released Incorporating Active ate areas where the shooter is located. This may
ple may be a plan of action. During a murder or Shooter Incident Planning into Health Care mean leaving patients behind, some of whom
murder-suicide, there may be no further threat. Facility Emergency Operations.3 may not be able to evacuate themselves. Its
During an active shooter event, everyone is at In 2015, the team released an updated ver- a life and death decision, and thats why its
risk while the shooter or shooters are engaged. sion of the planning and response guide, which important to discuss these options with staff
is available on the FBI active shooter web- before an incident occurs. Its also important
A MULTIDISCIPLINARY TEAM site. The updated guide includes a section for to remember that while run, hide and fight
In early 2013, the Healthcare and Public law enforcement responders, including tactics, are three separate options, you may use more
Health Sector Coordinating Council, a part of crime scene operations and interoperability, as than one of them in the course of the event.
the Critical Infrastructure Partnership Advi- well as a section on behavioral health support. For the rest of the healthcare facility (out-
sory Council, formed a multidisciplinary team The team has committed to reviewing and side of the shooters location), locking down
to look at active shooter response in healthcare. updating the guidance annually and is cur- the unit is imperativeand not an easy thing
The team was comprised of federal, state rently meeting, with an anticipated update to do. Knowing how to barricade doors with-
and private sector partners including clinicians, being released this fall. The new guide will out locks takes practice and planning. Those
law enforcement, civil rights attorneys, emer- include staff and administrative tools, unified units should also monitor the situation and
gency planners, responders, fire and EMS and command issues and answers, recovery and prepare to run if the shooter enters their imme-
leaders from law enforcement active shooter behavioral health assessment teams. diate area.
training programs. What about ambulatory patients, visitors,
The team discovered that not only was there RESPONDING TO THE EVENT and contractors? The guidelines recommend
confusion about how to prevent, respond to How do you respond to an active shooter event using plain language (and, when appropriate,
and recover from an event in a healthcare set- inside a healthcare facility, and how do you multilingual messaging) to announce whats
ting, there was also a lack of knowledge by law address ethical issues such as abandonment? happening and what to do. Although some
enforcement about the hazards in a healthcare Theres one fundamental point in an active would argue that could cause panic, decades
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1707jems_16 16 6/9/17 9:08 AM

of research on emergency communication have
consistently shown that during an emergency, JEMS.COM EXCLUSIVE ARTICLE
people dont panic from messaging, but rather DEFINING THE CONSUMMATE EMS PROFESSIONAL
dont respond appropriately because of the By Stephen R. Wirth, Esq., EMT-P
lack of guidance. Making sure the message is How do we foster a culture of accountability in our organizations? How do
easy to understand and giving specific instruc- we enact change in a positive, collaborative way? In this article, Wirth exam-
tions can help save lives, such as, There is an ines the importance of accountability, ownership and positive change in the
armed intruder on 6 East. Everyone on 6 East business of patient care. He outlines three core attributes that help define
should evacuate to another floor, and follow the consummate EMS professional.
the instructions of staff. All others should stay To read this full-length, exclusive article, visit jems.com/attributes-of-accountability.
away from 6E and follow staff instructions.
The EMS response to a healthcare active
shooter event is unique, as clinicians, med- may respond. Those agencies must also be a Justice: Washington, D.C., 2014.
ical supplies and equipment may be avail- part of the planning and training process, 2. International Association of EMS Chiefs. (January 2017.) Active
able on scene. Understanding how to and they should have copies of plans, con- shooter planning and response in a healthcare setting. Retrieved
utilize these assets must be preplanned. tact information, maps, communication and May 25, 2017, from www.fbi.gov/file-repository/active_shooter_
This plan should also include discus- access information. planning_and_response_in_a_healthcare_setting.pdf.
sion about whether victims will be treated Finally, behavioral health response needs 3. U.S. Department of Health and Human Services. (November
at the facility or transported elsewhere. to be planned before the incident and needs 2014.) Incorporating active shooter incident planning in to
Although EMS providers are now being to start as soon as the shooting has stopped. health care facility emergency operations plans. Retrieved
introduced to warm zone operations, med- Mental health recovery can be a long-term May 25, 2017, from www.phe.gov/preparedness/planning/
ical staff are not. They could be a welcome process for EMS and healthcare providers, Documents/active-shooter-planning-eop2014.pdf.
asset during an active shooter event. Its also and having a coordinated response can assure
important to understand the layout of the our caregivers have the necessary resources Scott Cormier, NRP, CHEP, serves as
building or campus, hazards and command to continue to do the great work we do. JEMS vice-president of emergency management,
center locations. environment of care, and safety for Medxcel
EMS and healthcare providers must also REFERENCES Facilities Management, and is a member of
remember that during a large-scale attack, 1. Blair J, Schweit K. A Study of active shooter incidents, 2000 the board of directors of the International
prehospital agencies from outside the service 2013. Federal Bureau of Investigation, U.S. Department of Association of EMS Chiefs.
1707jems_17 17 6/9/17 9:08 AM

PRO BONO
EMS LEGAL TIPS & ADVICE
SERVICE ANIMALS
Draft a policy to avoid unlawful discrimination claims
By Christie Mellot, Esq., EMT-B
I
n nearly 18 years of practice representing should be even rarer for an EMS agency to been certified, trained or licensed as a service
EMS agencies nationwide, weve dealt not allow a patients service animal to accom- animal.4 Second, its not necessary that the
with a number of cases involving alleged pany him or her in the back of the ambulance. dog wear a vest, ID tag, or anything else that
discrimination against patients based on race, The ADA specifies, a person with a dis- would identify it as a service animal.1 Third,
color, national origin, religion, sex, age, disabil- ability cannot be asked to remove his service allergies and fear of dogs are not valid reasons
ity and other protected categories. animal from the premises unless: 1) the animal for denying access or refusing service to people
Many EMS agencies dont realize that fed- is out of control and the handler does not take using service animals.5 EMS agencies should
eral and state laws protect the right of the effective action to control it, or 2) the animal also check their state laws related to service
patient with a disability to rely on a service is not housebroken.2 animals to ensure complete legal compliance.
animal to assist them with the activities of daily All EMS agencies should adopt a policy on
livingincluding accompanying them while the transport of service animals that complies CONCLUSION
in a motor vehicle, such as on a public con- with federal, state and local laws. This way, an Having a service animal policy can help ensure
veyance like a city bus and even an ambulance. EMS agency can ensure its staff knows how to that your EMS agency and its staff know
If your EMS agency outright refuses to properly handle a situation in which a patient whats required to comply with the ADA.
permit service animals to accompany patients presents with a service animal. A well-crafted policy can also help ensure
in ambulances, odds are your agency may be that patients with service animals will only
subject to a claim for unlawful discrimina- DRAFTING A POLICY be separated from their service animals on the
tion. With some exceptions related to safety, In drafting a service animal policy, the first rare occasion that the animal interferes with
these legal protections for individuals with a helpful thing to keep in mind is the federal patient care or starts exhibiting aggressive or
disability extend to allowing a service animal definition of service animal. protective behaviors that the patient is unable
to accompany the patient on an ambulance. The ADA defines a service animal as: to control. JEMS
The Disability Rights Section of the United [A]ny dog that is individually trained to do
States Department of Justice (DOJ) Civil work or perform tasks for the benefit of an REFERENCES
Rights Division is in charge of enforcing the individual with a disability, including physi- 1. Frequently asked questions about service animals and the ADA.
Americans with Disabilities Act (ADA). On cal, sensory, psychiatric, intellectual, or other (July 20, 2015.) U.S. Department of Justice Civil Rights Division:
its website, the DOJ has posted frequently mental disability.3 Information and Technical Assistance on the Americans with
asked questions about service animals and In drafting a service animal policy, its also Disabilities Act. Retrieved May 19, 2017, from www.ada.gov/
the ADA on its website. Question 16 asks, important to understand what EMS crews are regs2010/service_animal_qa.html.
Must a service animal be allowed to ride in permitted to ask patients concerning possible 2. 28 CFR 36.302(c)(2)(i) and (ii).
an ambulance with its handler?1 service animals. 3. 28 CFR 35.104, 36.104.
The answer is, Generally, yes. However, The ADA significantly limits the questions 4. 28 CFR 36.302(c)(6).
if the space in the ambulance is crowded and that a covered entitys employees, including 5. ADA requirements: Service animals. (July 12, 2011.) U.S. Depart-
the dogs presence would interfere with the EMS crews, can ask to determine if a dog is ment of Justice Civil Rights Division: Information and Technical
emergency medical staff s ability to treat the a service animal. In situations where its not Assistance on the Americans with Disabilities Act. Retrieved May
patient, staff should make other arrangements obvious that the dog is a service animal, EMS 19, 2017, from www.ada.gov/service_animals_2010.htm.
to have the do transported to the hospital.1 crews may only ask: 1) Is the dog a service
animal required because of a disability? and Christie Mellott, Esq., EMT-B, is an EMS
TRANSPORTING ANIMALS 2) What work or task has the dog been trained attorney with Page, Wolfberg & Wirth,
Most of us would agree that the space in the to perform?1 which represents EMS agencies throughout
back of an ambulance is always crowded. How- The DOJs interpretation of certain issues the United States.
ever, except in very rare circumstances, a ser- that EMS agencies may run across with respect Pro Bono is written by the attorneys at Page, Wolfberg &
vice animal thats well-trained wont interfere to service animals is also helpful to know when Wirth, The National EMS Industry Law Firm. Visit the firms
with a crews ability to treat the patient. This drafting a policy. First, its not permissible for website at www.pwwemslaw.com
means that, although it may be rare for crews an EMS crew to ask for or require documen- or find them on Facebook, Twitter
to encounter patients with service animals, it tation, such as proof that a service animal has or LinkedIn.
1707jems_18 18 6/9/17 9:08 AM

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1707jems_19 19 6/9/17 9:08 AM

MANAGEMENT FOCUS
STAY ON TOP OF YOUR GAME
SIREN SCIENCE
No more emergency warning devices?
By Vincent D. Robbins, FACHE, FACPE
W
hen an ambulance or medic unit is significant savings in response time with 2014, underscore the perception by many that
dispatched, we routinely turn on the use of EWD, however it did not assess an ambulance should respond fast.
our lights and siren to warn the patient outcomes.3 Still today, many contracts for EMS
public on the roadways of our approach, to take According to the National Highway Traf- require specified fractile response times,
priority in traffic and to reduce our response fic Safety Administration (NHTSA), between which require that a certain high percent-
time in getting to the patient. Most systems 1992 and 2011, there were an estimated mean age of responses must be in less than eight
continue to use lights and siren when mov- of 4,500 motor vehicle crashes involving an or nine minutes.
ing the patient to the hospital, at least when ambulance every year. Of these crashes, 65% Even more progressive EMS systems still
our practitioners believe the patient respond with EWD on most of their
is seriously ill or injured. dispatches. First responders, such
For years now, a growing num- as fire and police departments also
ber of our colleagues have begun to At what point do we engage emergency lights and siren
doubt the efficacy of using emer- when answering EMS calls.
gency warning devices (EWD). decide to follow the
Some believe they should only be FINAL THOUGHTS
used to respond to the scene, and logic of the science At what point do we decide to fol-
turned off when transporting the low the logic of the science and the
patient to the hospital. Others think & the evidence being evidence being collected on this
using them during transport to the issue? When do we decide to alter
hospital is still warranted in certain collected on this issue? our response to almost all EMS dis-
time-sensitive cases. Still others feel patches and transports to medical
we should abandon them altogether. facilities to a no lights and siren
resulted solely in property damage, 34% protocol nationwide? Is there a role for NHT-
MOUNTING EVIDENCE resulted in an injury and less than 1% ended SAs Office of EMS on this issue beyond the
Theres increasing evidence suggesting that with a fatality. Still, that less than 1% repre- release of information to the paramedicine
using EWDs contributes to traffic conges- sented an annual mean of 33 people. community? JEMS
tion, slowing provider response, causing more Theres an aspect of public expectation that
motor vehicle crashes and playing no appre- overlays this issue, which must be considered. REFERENCES
ciable part in helping the outcome of patients. Most in the field would agree that theres a 1. Kupas D, Dula D, Pino B. Patient outcome using medical proto-
There have been several studies looking at belief held by the public that the use of EWDs col to limit lights and siren transport. Prehosp Disaster Med.
the consequences and effectiveness of using saves time and saves lives. Failing to respond 1994;9(4):226229.
lights and siren specific to risk of injury (to to a persons emergency, whatever they per- 2. Brown L, Whitney C, Hunt R et al. Do warning lights and
the provider, patient and the public) as well ceive that to be, could be perceived as a cava- sirens reduce ambulance response times? Prehosp Emerg Care.
as patient outcomes. lier, uncaring attitude by the EMS providers. 2000;4(1):7074.
In 1994, a study regarding the use of a med- This could result in poor public opinion of the 3. Ho J, Lindquist M. Time saved with the use of emergency warn-
ically based protocol to limit the use of lights EMS agency and the quality of its services ing lights and siren while responding to requests for emer-
and siren resulted in 92% of patients being not exactly the kind of relationship we want gency medical aid in a rural environment. Prehosp Emerg Care.
safely triaged to non-EWD transport with- to build with the public. 2001;5(2):159162.
out adverse effect on their medical conditions In fact, some civil lawsuits against EMS
or outcomes.1 agencies filed over the years include allega- Vincent D. Robbins, FACHE, FACPE, is the
At least one study revealed that using tions that slow response times by ambulances president and CEO of MONOC, New Jerseys
EWD did reduce response times by a statisti- caused or contributed to the death of patients. single largest ALS and mobile integrated
cally significant amount, but failed to improve Headlines like NY city settles wrongful healthcare service. Hes In partnership with
patient outcomes.2 death suit over late ambulance arrival from also president of the
Another study also found a statistically the Lockport Union-Sun & Journal in May National EMS Management Association.
1707jems_20 20 6/9/17 9:08 AM

1707jems_21 21 6/9/17 9:08 AM

CASE OF THE MONTH
DILEMMAS IN DAY-TO-DAY CARE
SODIUM BICARBONATE
A tool for management of traumatic head injury?
By Jazmine Valencia, NNP-BC, RN, CCRN; Thomas Carrion, RN, CCRN;Mike Mendez, NRP;
Kori Martinez, RN, CCRN, CFRN; Greg Johnson, EMT-P; Aaron T. Britnell, EMT-P, CCEMT-P;
Larry D. Levy, MD, FAAEP, EMTP, ATP; Ken Davis, BA, EMT-P, FP-C & Ryan Hodnick, DO, NRP, FAWM
Y
our aeromedical EMS crew is dis- much fluid could be detrimental. (decerebrate or decorticate) with increasingly
patched to Mexico for a head injury The decision is made to reduce ICP using nonreactive pupils and changes in vital signs
patient whos an American citizen a medication approach. Both hypertonic saline such as bradycardia, hypertension and irreg-
being repatriated back home. and mannitol are used clinically to reduce ICP; ular respirations.
The patient is a 47-year-old male who was however, the clinic and the flight crew dont have The Monro-Kellie doctrine states that the
found unresponsive on the side of the road in access to either of the medications. After con- volume of contents within the skull: Brain,
Mexico the previous day and was diagnosed sultation with medical direction, the decision blood and CSF are constant. To maintain
with a subarachnoid hemorrhage. Its unclear is made to use sodium bicarbonate mixed with balance, an increase in one should cause a
what happened, but the patient may have fallen normal saline to obtain 3% hypertonic saline decrease in the other.1 After a traumatic insult
or been hit by a car. There are no signs of exter- solution. The patient is given the hypertonic to the brain, swelling of brain tissues ensues.
nal trauma noted. He was brought to the local saline solution with no increase of ICP and is If the pressure is allowed to increase with-
clinic where surgery was performed for a sub- able to complete the flight. out change, the brain can herniate through
arachnoid hemorrhage. one of the dural folds or, even worse, through
On arrival, the crew finds an intubated male DISCUSSION the foramen magnum at the base of the skull.
with a Glasgow coma scale (GCS) of 3 with Increased ICP is a common problem faced by At the same time, its important to optimize
pupils of 4 mm and nonreactive bilaterally. On EMS providers when working with trauma the patients intravascular volume as well as
physical exam, the crew notes a Foley catheter patients with head injuries. An increase in mean arterial pressure to maintain adequate
coming from his skull with a glove containing ICP compresses the brain within the rigid cerebral blood flow.
serosanguinous fluid tied to the other end. The skull, thereby reducing blood flow and wors- Its also important to prevent hypoxia,
Foley catheter was placed within the patients ening damage. maintain eucapnia, and decompress the stom-
ventricle in an attempt to drain cerebral spinal As the pressure in the head increases, the ach as increases in intra-abdominal pressure
fluid (CSF) and decrease intracranial pressure. brain can no longer stay within the rigid skull can translate to other compartments.1 In the
The patient has no intracranial pressure and begins to herniate. On physical examina- prehospital setting, its difficult to optimize
monitoring (ICP) in place. His vital signs are tion, this most often presents as posturing cerebral perfusion without intracranial pres-
as follows: Heart rate of 58, blood sure monitoring or medication to
pressure of 135/67, respiratory rate reduce cerebral swelling.
of 16 on a ventilator, blood oxygen If the ICP remains high, cere-
saturation (SpO2) of 100% with a bral injuries can worsen leading
fraction of inspired oxygen (FiO2) to poor neurological outcomes.
of 90%. A midazolam infusion is Medications such as mannitol and
running for sedation. hypertonic saline may be useful in
Transportation from the clinic reducing ICP. These medications
to the airport was initially arranged work by increasing the osmolal-
by means of a flatbed pick-up truck ity of the blood thus pulling fluid
followed by a three-hour jet flight from within the brain tissue to the
back to the United States. intravascular space.
The crew has concerns about The theory is that the fluid
cerebral herniation and doesnt want involved in the brain swelling is
to drain more fluid off via the Foley exchanged for perfusion of oxy-
catheter without knowing the ICP, Patients with traumatic head injuries are associated with high morbidity and gen-carrying blood to the dam-
understanding that draining too mortality. Photo courtesy Ryan Hodnick aged parts of the brain.
1707jems_22 22 6/9/17 9:08 AM

1707jems_23 23 6/9/17 9:08 AM

CASE OF THE MONTH
There are two different approaches for patients was thought to reduce ICP when no retain fluid when in circulation. If the hypo-
using medications to reduce swelling in the other means were unavailable. Current advance thalamus and pituitary gland are injured, this
brain. Mannitol is a sugar thats not utilized trauma life support (ATLS) guidelines rec- mechanism is lost and the patient can lose large
or absorbed by the body and works by caus- ommend using this method in moderation volumes of fluid via urination. It can be difficult
ing osmotic diuresis. The mechanism is sim- for as limited a period as possible and only to clinically distinguish DI from the osmotic
ilar to the way a patient with hyperglycemia when the patient is showing lateralizing signs diuresis caused by mannitol, and mannitol can
has polyuria from the excess sugar within the of herniation.1 exacerbate this effect.
blood stream.2 Both mannitol and hypertonic saline arent Hypertonic saline has multiple clinical uses.
On the other hand, hypertonic saline pulls often available to EMS. Some critical care agen- It can be used to correct hyponatremia and can
fluid from swollen tissue without causing the cies carry these medications; however, theyre be given as fluid in the setting of intravascu-
diuresis that can lead to hypotension and a often not the first to respond. Mannitol, as dis- lar depletion. It requires a lower total volume
decrease in cerebral perfusion pressure. Water cussed, is a sugar that the body does not absorb; of fluid administration than normal saline. It
passively follows the movement of sodium, its clinical use is limited to lowering ICP. When can be used to treat tricyclic antidepressant
thereby reducing the volume of fluid and swell- the solution gets cool, it crystalizes and needs (TCA) overdoses.
ing within the tissue. to be rewarmed prior to administration, which Sodium bicarbonate is simply a different
Primary brain injury isnt possible for us to makes it difficult to use in the field. form of hypertonic saline and is carried by many
change, as this can only be altered through Osmotic diuresis can also cause another EMS agencies. Its used to treat hyperkalemia,
injury prevention. As EMS providers, we can problem: intravascular depletion and ulti- TCA overdoses and other conditions. Approx-
prevent secondary brain injury by keeping our mately hypotension, which can worsen sec- imately 3% hypertonic saline can be obtained
patients euoxic and eucapneic and optimizing ondary brain injury. by mixing 300 cc of normal saline from a 500
cerebral perfusion pressure by maintaining an Patients with head injuries can also develop cc bag with 200 mEq of sodium bicarbonate
adequate BP and reducing ICP. diabetes insipidus (DI), which can complicate which translates to 4 ampules.
matters. This condition is caused by a loss of Two very promising studies show that when
TEACHING POINTS hypothalamic input of vasopressin and antid- adults with head injury and increased ICP are
In the past, hyperventilation in deteriorating iuretic hormone, which causes the kidneys to given 85 mEq of 8.4% sodium bicarbonate over
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20 minutes, they have results superior to 3% Thomas Carrion, RN, CCRN, is a flight nurse at Med Flight Ryan Hodnick, DO, NREMT-P, FAWM, is the medical director
hypertonic saline for up to six hours. Another Air Ambulance and a critical care nurse in the medical ICU for agencies in New Mexico including: Santa Fe Fire, Santa Fe
benefit of this treatment is that hyperchloremic at University of New Mexico Hospital. He can be reached at County Fire EMS, Artesia Fire, Carlsbad Fire and the Department
acidosis isnt caused by the sodium bicarbonate tcarrion2002@yahoo.com. of Energys Waste Isolation Pilot Plant. He serves as the asso-
solution, which is common with 3% hypertonic Mike Mendez, NRP, works as a rapid response para- ciate medical director and crew member for MedFlight based
saline administration.3,4 medic for University of New Mexico Hospital as well as a out of Albuquerque. Hes also medical director and paramedic
flight medic for Albuquerque MedFlight and can be reached for TriState CareFlight and is an employee of EMSRx. He can be
CONCLUSION at Jemez1722@yahoo.com. reached at lasvegas.em@gmail.com.
Patients with traumatic head injuries are asso- Kori Martinez, RN, CCRN, CFRN, is the chief flight
ciated with high morbidity and mortality and nurse at Med Flight Air Ambulance and can be reached at REFERENCES
are encountered by all EMS providers on a rel- kori@medflightair.com. 1. American College of Surgeons (Eds.): Advanced trauma
atively regular basis. Some still practice permis- Greg Johnson, EMT-P, is the safety officer at Med Flight life support, student course manual. American College of
sive hypocapnia, which is often difficult to do Air Ambulance and can be reached atbardmedic@gmail.com. Surgeons: Chicago, Ill., 2012.
and comes at other costs. Arron T. Britnell, EMT-P, CCEMT-P, is the program 2. Rickard AC, Smith JE, Newell P, et al. Salt or sugar for your
Sodium bicarbonate is a medication with director at MedFlight Air Ambulance and can be reached at injured brain? A meta-analysis of randomized controlled
many uses. It offers an accessible treatment aaron@medflightair.com. trials of mannitol versus hypertonic sodium solutions to
choice to patients with signs of increasing ICP Larry D. Levy, MD, FAAEP, EMTP, ATP, has worked in emer- manage raised intracranial pressure in traumatic brain
and is carried almost universally by EMS pro- gency medicine, critical care medicine and flight medicine for injury. Emerg Med J. 2014;31(8):679683.
viders. Its cheap, easy to administer, a familiar over 30 years. Hes the medical director at Med Flight Air Ambu- 3. Bourdeaux CP, Brown JM. Randomized controlled trial
medication and offers a simple way for EMS lance, an instructor of flight, trauma, cardiac and critical care comparing the effect of 8.4% sodium bicarbonate and
providers to decrease ICP. JEMS medicine and a pilot and medical flight crew member. He can 5% sodium chloride on raised intracranial pressure after
be reached at larry@medflightair.com. traumatic brain injury. Neurocrit Care. 2011;15(1):4245.
Jazmine Valencia, NNP-BC, RN, CCRN, is a flightnurse at Ken Davis, BA, EMT-P, FP-C, is the CEO of EMSRx, a regional 4. Bourdeaux C, Brown J. Sodium bicarbonate lowers intra-
Med Flight Air Ambulance in Albuquerque, N.M. She can be director for the Difficult Airway Course EMS and an active cranial pressure after traumatic brain injury. Neurocrit Care.
reachedatjvalencia@salud.unm.edu. flight paramedic. He can be reached at ken.davis@emsrx.com. 2010;13(1):2428.
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1707jems_25 25 6/9/17 9:08 AM

EVIDENCE-BASED EMS
INTERNATIONAL RESEARCH PERSPECTIVES
APPROPRIATE REFERRALS
Transport & referral strategies of international EMS systems
By Christoph Redelsteiner, Dr.PhDr, MSW, MS, EMT-P
MEETING NEEDS age of the regions inhabitants is 45 vs. the aver- Conclusion: Overall, in the observed services,
Redelsteiner C: Current and future requirements age age of EMS patients at 72 years. Calls for theres a tendency to treat and release patients
for gatekeeping in the prehospital setting with spe- patients older than 60, representing 27% of the if ambulance providers also have a nursing or
cial consideration of sociodemographic require- general population, make up for 79% of all calls. community/advanced paramedic background,
ments; with a special focus on two rural border Nearly three-quarters (75%) of the rural fam- combined with standardized assessment pro-
regions in the Austrian province of Burgenland. ily doctors in the region will retire by 2025. This tocols or if there are general practitioners sys-
Stumpf + Kossendey: Edewecht, Germany, 2016. requires steering patients, either by phone or tematically involved in out-of-hospital care.
[Book in German.] on-scene assessment, to resources that arent On-scene patient assessment requires a sys-
hospital-based and guiding patients to appro- tematic, reliable and specific low-threshold
Many European countries face a reduction of priate community resources. To control this mobile resource. General practitioners, nurses,
active physicians and health professionals on process, a tight logistical connection between social workers and paramedics could be utilized
one side and an increase of older people on the general practitioners, home nursing, EMS and for this task, following specific interprofessional
other. Although the ratio of emergency calls to hospitals is needed. training and education. A concept for a new
population remains stable, the overall number The seven hypothetical patient scenarios interdisciplinary degree program, the commu-
of calls is rising. (simple wound; adult asthma attack, known nity care specialist, could be usedand may be
Background: Current data show that in asthmatic; lumbago; cough and chest pain; fall especially helpful in rural regionsthat would
urban areas, 75% of calls to patients under age in nursing home; patient with fever; 75-year-old bridge social and health professions. Training and
20 are minor disturbances that could be taken male urinary catheter change) were compared in education for this role would include assessing,
care of by self-help, general practitioners or out- the context of provider type and system design clearing and treating non-emergent conditions
patient care clinics. Furthermore, 94% of these for services from 17 European nations and one (e.g., psychosocial and simple medical patients).
patients are transported to hospitals for evalu- in the United States. The organizational con- The overall goal is to adapt strategies of
ation. In rural settings, 72% of calls for an ALS text of these services is quite different, as are caller handling in dispatch centers and while
doctor unit are also non-emergent or could be the responding professions, which include basic on scene and facilitate collaboration and net-
covered by alternative resources. Prehospital ambulance attendants, nurses, paramedics, gen- working between the main primary care medical
EMS agencies are hence faced with a high vol- eral practitioners and emergency physicians or institutions and related social work, psychosocial
ume of requests for simple social, nursing and a combination of multiple tiers. and nursing resources to ensure fair, ethical and
medical interventions that could be served bet- Three major strategies have been detected: non-discriminatory distribution of care regard-
ter by other health and social care providers. 1) systems that use transport to hospital as a less of age, social level and urban/suburban/rural
Methods: This was a mixed method research prime strategy, are financed by a fee for trans- settings. JEMS
study. Quantitative data was researched by ret- port reimbursement, and where a large edu-
rospective assessment of calls, demand patterns cation gap exists between basic-trained EMS Christoph Redelsteiner, Dr.PhDr, MSW,
and call severity. Three different statistical prog- providers and ALS response by physicians; MS, EMT-P, is a professor at St. Pltens Uni-
nostic techniques were used to calculate future 2) systems that refer patients to alternative versity of Applied Sciences and scientific
call demand, combining historic data and demo- resources early on, such as during the 9-1-1 director of the Master in Emergency Health
graphic scenarios. Qualitative data was collected call; and 3) systems that refer systematically Services Management Program at Danube
by field research, responding to calls with differ- to alternative resources or dispatch non-ALS University in Austria. He was the first recipient of the James
ent services and creation of case reports. Field response for evaluation and on-scene treatment O. Page/JEMS Leadership Award and is a member of the JEMS
providers and managers of different services (e.g., via community paramedics). International Editorial Board.
were given seven hypothetical patient scenar-
ios and outlined their local strategy options to
triage and steer patients to different resources.
Asian
Results: Depending on the patient scenario, Association
the two rural regions studied will have to handle for EMS
a call increase of up to 12% by 2020 (34% by

U.S. Metropolitan Municipalities EMS Medical Directors Consortium (The Eagles Coalition)
2030) compared to 2013. Currently, the average
1707jems_26 26 6/9/17 9:09 AM

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References:
1. Rhodes A, Phillips G, Beale R, et al. The Surviving Sepsis Campagin bundles and outcome: results from the international Multicentre Prevalence Study on Sepsis
(the IMPreSS study). Intensive Care Med 2015;41:1620-1628 DOI 10.1007/s00134-015-3906-y
2. Stimac J, Paxton J. The Golden Hour of Volume Resuscitation: Pilot Data From the Shock Access For Emergent Resuscitation (SAFER) Study.
Annals of Emergency Medicine 2015;66(4S): S110

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1707jems_27 27 6/9/17 9:09 AM

STREET SCIENCE
CONVERSATIONS ABOUT EMS RESEARCH
GUIDELINES & RULES

Are we trying too hard for some cardiac arrests?
By Keith Wesley, MD, FACEP, FAEMS & Karen Wesley, NREMT-P
THE RESEARCH DOC WESLEY COMMENTS: MEDIC WESLEYS COMMENTS:

Drennan I, Case E, Verbeek P, et al. A comparison Deciding who should be transported and who Looking at the ROC database, were provided
of the Universal TOR Guideline to the absence of should be terminated on scene is one of the most with a ton of information on many issues of
prehospital ROSC and duration of resuscitation difficult decisions for EMS providers. The TOR resuscitation. The study of over 36,000 patients
in predicting futility from out-of-hospital cardiac has been validated showing that when all three provides us with valuable tools for the prehos-
arrest. Resuscitation. 2017;111:96102. conditions are met, terminating resuscitation in pital setting of cardiac arrest patients.
the field is appropriate. As Doc stated, the TOR is a three-step
THE SCIENCE Lets examine one of the truly concerning method for determining the likelihood of sur-
The authors wanted to determine how well the results in this study that the authors dont address. vival. But is it a guideline or a rule?
Universal Termination of Resuscitation (TOR) Although the authors were focused on the dismal The medical research community puts very
Guideline could predict survival from cardiac survival rate of those transported despite being little in the cant or wont category when deter-
arrest. recommended for termination by the guidelines, mining who should or can be transported.
The TOR recommends Sometimes the least likely
that resuscitation be termi- candidate for resuscitation
nated in the field when all is the one who survives, and
three of the following are Transporting patients who the patient who meets all the
true: 1) EMS didnt witness criteria for what should be a
the arrest; 2) return of spon- ultimately die is an over-triage that save ends up dying.
taneous circulation (ROSC) Were provided with sci-
didnt occur despite resusci- most systems are willing to accept, entific guidelines to assist us
tation attempts; and 3) the in making extremely difficult
patient was never defibril- but failing to transport patients for decisions in prehospital car-
lated. Specifically, the diac arrest patients. Some-
authors wanted to discover whom the TOR guidelines predicts times something tells us we
the survival rate of patients should keep trying despite
who were transported solely improved survival is unacceptable. the science-based score that
based on failing to obtain were provided. Thats why
ROSC. its a guideline and not a
Data were extracted from the Resuscita- there were 4,040 patients for whom the TOR rule. It allows us to sleep a little better some
tion Outcomes Consoritum PRIMED data- recommended transport but were instead termi- nights when we question whether we should
base, which was created to study the effect of nated on scene by EMS84.6% of them were have done more.
an impedance threshold device (ITD) and/or defibrillated and 15.3% were witnessed arrests. Although science supports us with guide-
immediate vs. delayed defibrillation. I can imagine countless scenarios where EMS lines, the heart and soul of the provider is often
Between 2007 and 2011 there were 36,543 would transport a cardiac arrest victim with- the rule. JEMS
cases of cardiac arrest. Of these, 9,467 (26%) out ROSC: Family dynamics, scene safety, poor
were transported without ROSC. Patients with- confidence in deciding to terminate and lack of Keith Wesley, MD, FACEP, FAEMS is the med-
out ROSC for whom the TOR recommend on-line medical control availability are a few. ical director for HealthEast Medical Trans-
termination at the scene had a survival rate of I would like to know why over 4,000 patients portation in St. Paul, Minn., and United EMS
0.7% compared to 3.0% of patients for whom for whom the TOR guidelines recommended in Wisconsin Rapids, Wis. He can be reached
the TOR recommended transport. transport were instead terminated, when these at drwesley@charter.net.
The authors concluded that transporting car- patients are the most likely to survive. Transport- Karen Wesley, NREMT-P, is a paramedic and
diac arrest patients based solely on the absence ing patients who ultimately die is an over-triage educator for Mayo Clinic Medical Transport
of ROSC isnt appropriate and encourage EMS that most systems are willing to accept, but failing and is the medic team leader for the Eau Claire
agencies to utilize the TOR fully to identify the to transport patients for whom the TOR guide- County (Wis.) Regional SWAT team. She can
best candidates for survival. lines predict improved survival is unacceptable. be reached at admkaren22@hotmail.com.
1707jems_28 28 6/9/17 9:09 AM

1707jems_29 29 6/9/17 9:09 AM

1707jems_30 30 6/9/17 9:09 AM
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1707jems_31 31 6/9/17 9:09 AM

1707jems_32 32 6/9/17 9:09 AM
The truth about EMS transport of
service dogs & other support animals
By Criss Brainard, EMT-P
E
ngine 30 and Medic 6 respond to their local shopping mall and find, Nancy,
a 38-year old female complaining of tightness in her chest. Nancy is sitting
on a sidewalk bus bench with her dog.
Bystanders tell you she seemed to get upset when she missed her bus and within
minutes began complaining she wasnt feeling well.
Nancy is visibly upset, but able to answer your questions appropriately. Her heart
rate is 96, strong, regular and corresponds to sinus rhythm on your monitor, with a
blood pressure of 156/88 and a respiratory rate of 28, non-labored.
The rest of her vital signs and physical assessment are within normal limits. She
denies any medical problems except occasional panic attacks. Nancy requests and
agrees to be transported to the hospital, which is 20 minutes away, but insists her
canine companion join her.
She tells you hes a service dog who provides her with emotional support and
produces official-looking papers indicating her dog has been certified by Service
Dogs of America.
ANIMALS SUPPORTING PATIENTS

Many of our patients have significant debilitating emotional and physical condi-
tions with complex treatment plans. Fortunately for thousands of people, like Nancy,
their comfort can be enhanced with a variety support animals, and the crews in
our scenario are faced with a situation thats becoming more common every day.
EMS providers are only required to accommodate service dogs as defined by the Americans with
Disabilities Act, and crews can legally deny transporting all other types of animals.
Photos Matthew Strauss
1707jems_33 33 6/9/17 9:09 AM

CANINE CAREGIVERS
EMS crews cant request documentation to prove

that a patients dog has been trained, certified or
licensed before accepting it as legitimate service ani-
mal, and service animals arent required to wear a
vest or any other identifier.
We are all familiar with a guide dog with a in our own country, with varying degrees of legitimate disability the ability to stay with
leather-handled harness leading a blind person post-traumatic stress disorder (PTSD).2 Many his or her service dog, if possible.
down our streets and safely navigating them have received effective support and treatment Unfortunately, many people (and some-
through traffic and many other everyday obsta- by the loving support of a service dog. times our patients) are abusing this valuable
cles. This human and canine partnership is no These service dogs have been trained to human-animal partnership, in order to take
longer limited to just a blind person, nor those perform specific tasks. For example, the ser- their pet with them to the store or hotel.
confined to a wheelchair. Today, specialized vice dog places a paw on the lap of a veteran There are dozens of online options to pay a
assistance is now available for patients with suffering from PTSD after sensing a trigger fee and with no credible justification; you can
dozens of other conditions. is occurring. This type of canine-specific task receive an officiallooking certificate, identifi-
Several types of animals, but primarily dogs, training is recognized by ADA requirements cation card and tag for the animals collar. The
are being trained in many new protection and that apply to paramedics and EMTs in the ADA doesnt recognize any of these types of
detection arenas. For example, since canines prehospital setting. programs and makes it clear these certifica-
have incredible senses, they can be trained to Federal and state service animal regulations dont provide any meaningful service
alert their human partner of an impending sei- tions are often broadly worded, which opens animal documentation.4
zure.1 This partnership is extremely valuable the door for people to label their pet as a ser- The slippery slope is knowing the ADA
and to be effective, its necessary for the dog vice animal and pass themselves off as a per- requirements and tactfully assessing each
to be with their human partner at all times. son with a disability. This is unfortunate but situation to determine a legitimate partner-
Service animals not only provide assistance a reality we must deal with in a professional, ship and to identify when someone is gaming
for physical conditions, but they often also non-threatening manner. the system.
provide emotional support. Our service men The Americans with Disabilities Act
and women, and even police officers, firefight- (ADA) lays out a set of guidelines that clar- REGULATIONS & RESPONSIBILITIES
ers and paramedics far too often are returning ify what is and what isnt a service animal.3 The U.S. Department of Justice published revi-
home from war or the violent streets right here No one would want to deny a person with a sions to ADA regulations on Sept. 15, 2010,
1707jems_34 34 6/9/17 9:09 AM

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CANINE CAREGIVERS
and implemented the requirements for both animal) whose sole function is to provide com- 1. If the service dog will fundamentally alter
state and local governmental services and fort, therapy or emotional support do not qual- the crews ability to provide lifesaving care;
public accommodations/commercial facili- ify as service animals under the ADA. They 2. The dog is out of control and the handler
ties. There are three key provisions EMS agen- havent been trained to perform a specific job does not take effective action to control
cies need to be aware of: or task, and therefore do not qualify as service it; or
1. Beginning on March 15, 2011, only dogs animals under the ADA.3 3. The dog isnt housebroken.3
are recognized as service animals. Theres no federal legal obligation to allow The patient is required to maintain control
2. A service animal is a dog thats individu- emotional support dogs to accompany a patient of the service dog at all times. This means that
ally trained to do work or perform tasks in the ambulance. However, some state or local the service dog must be harnessed, leashed or
for a person with a disability. governments have laws allowing people to take tethered, unless these devices interfere with the
3. Generally, entities (including prehospital emotional support animals into public places and service animals work or the individuals disabil-
providers) must permit service animals those laws may also apply to ambulance transport. ity prevents using these devices. In that case, the
to accompany people with disabilities in Although you should always abide by the individual must maintain control of the animal
all areas where members of the public are policies and protocols in place in your agency, through voice, signal, or other effective controls.
allowed to go.3 best practice would be to try and accommodate When the patient is unconscious or in a con-
Service animals are defined as dogs that are an emotional support dog based on the overall dition requiring critical lifesaving treatment and
individually trained to do work or perform tasks situation and available options. the dogs presence would compromise the care
for people with disabilities. Service animals are The decision to allow the patient and dog to or safety during transport, its best to make other
working animals, not pets. The work or task a remain together ultimately rests with the crew, transport arrangements for the dog.
dog has been trained to provide must be directly and is based on the patients need and ability to Note that the ADA doesnt allow exclusion
related to the persons disability. control the animal, as well as the crews ability of a service dog for allergies, personal bias, fears
Examples of this type of work or tasks to transport the dog safely. or other reasons not covered above.3 The ADA
include: guiding people who are blind, alert- doesnt specifically define whos responsible for
ing people who are deaf, pulling a wheelchair, TRANSPORT CONSIDERATIONS the service dog should it not be transported, but
alerting and protecting a person who is having ADA requirements for stores, restaurants, public best practices would certainly encourage pre-
a seizure, reminding a person with mental ill- locations, hotels and even airlines differ from hospital crews to make every effort to reunite
ness to take prescribed medications, calming a ambulance requirements. Under the ADA, state the dog with the patient as soon as reasonably
person with PTSD during an anxiety attack, or and local governments, businesses and non- possible (e.g., private car transport with family,
performing other important duties.3 profit organizations that serve the public must friends, law enforcement, etc.).
Its important to note that dogs (or any other allow service animals to accompany people with
disabilities in all areas of the facility where the BALANCING CARE & LEGAL
public is normally allowed to go. REQUIREMENTS
Stores, restaurants, public locations, hotels, Every EMS system, public or private, needs
and even airlines are required to honor a much to develop guidelines and logistical options to
broader definition of service/emotional sup- assist their crews in rapidly assessing alleged
port animal. Ambulances are only required to service dogs and the many other emotional
accommodate service dogs, and ambulance support animals that crews may encounter.
crews can legally deny transporting all other The ADA defines what we must accept
types of animals. as a service dog, tells us clearly the limits we
When its not obvious what service a dog can take to make that determination and also
provides, only limited inquiries are allowed. when we can deny allowing the service dog to
Crews may ask two questions: 1) Is the dog a be transported with their owner.
service animal required because of a disability? These ADA requirements arent sugges-
and 2) What work or task has the dog been tions for you to decide to comply with or not,
trained to perform?4 theyre legally binding and must be included
Crews cant ask about the persons disability, in your overall treatment plan.
request medical documentation, or ask that the Any time a crew opts not to allow a service
dog demonstrate its ability to perform the work dog into their patient transportation plan, two
or task. Crews may not require documentation distinct issues could result: 1) The patients
as proof that the dog has been trained, certified emotional well-being may suffer and will likely
or licensed before accepting it as legitimate ser- result in additional anxiety; and 2) refusing a
vice animal. Service animals arent required to legitimate disability accommodation could
wear a vest or any other identifier indicating it have legal repercussions.
Service animals not only provide assistance for as a service animal. When considering the emotional support
physical conditions, but they often also provide Prehospital crews can refuse to transport a animals role during patient transportation
emotional support. service dog for any one of three primary reasons: (i.e., any animal that doesnt fit the ADAs
1707jems_36 36 6/9/17 9:09 AM

SEE FOR YOURSELF!
1707jems_37 37 6/12/17 11:07 AM

CANINE CAREGIVERS
definition of a service dog) its certainly legal CONCLUSION hospital that the patients emotional sup-
to just say no, but consider if this is the best As the Medic 6 crew prepares to transport port dog was part of the overall care plan and
overall option for the patient. Think about it Nancy to the hospital, theyre faced with the requests assistance during off-load. JEMS
like this: If this were your mother or father, decision about what to do with her dog. Its
brother or sister, would you make the accom- clear the dog doesnt meet the ADAs specific Criss Brainard, EMT-P, is fire chief for San Miguel Fire &
modation necessary to allow the patient the service animal criteria and the crew can legally Rescue in Spring Valley, Calif. Hes also a member of the JEMS
added measure of emotional support? Also, deny allowing the dog to accompany Nancy Editorial Board.
if the news media were filming your interac- to the hospital in the ambulance. But during Acknowledgment: The dog that appears in the pho-
tion, how would you want your decision to be their brief interaction with Nancy, theyve been tos for this article is Molly, a diabetic alert dog provided by
portrayed to the public you serve? Would the able to appreciate the special bond between her Arizona Power Paws, a nonprofit that provides highly skilled
Monday morning quarterback of public opin- and her dog, and decide its best to transport assistance dogs to children and adults with disabilities as well
ion say you were reasonable in your actions? them together. as education and continuing support for working assistance
If you take the approach that every patient Medic 6s company policy allows the crew dog teams. Visit them online at www.azpowerpaws.org.
is a member of your family, why not make rea- the discretion to decide when its in the best
sonable accommodations to include the ani- interest of patient care to transport a service REFERENCES
mal in the transport arrangementsassuming animal as long as it can be accomplished in a 1. Seizure dogs. (n.d.) Epilepsy Foundation. Retrieved May 19, 2017,
it can be done safely, of course. safe manner. from www.epilepsy.com/get-help/staying-safe/seizure-dogs.
If you sense youre being manipulated or The crew documents their decision and 2. Krause-Parello CA, Sarni S, Padden E. Military veterans and canine
tricked into allowing the animal to ride along, notes the emotional calmness the dog brings to assistance for post-traumatic stress disorder: A narrative review
or if you see no benefit to the patients emo- Nancy. They also note that its obvious that her of the literature. Nurse Educ Today. 2016;47:4350.
tional or mental well-being, just say no. pet is a well-trained, obedient dog that clearly 3. ADA requirements: Service animals. (July 12, 2011.) U.S. Depart-
Whatever you decide, be sure its in line responds to Nancys direction. ment of Justice Civil Rights Division: Information and Technical
with your agencys policies. Alert and obey During transport, the dog sits on the floor Assistance on the Americans with Disabilities Act. Retrieved May
your chain of command as well as the receiving beside Nancy, where she is able to have both 19, 2017, from www.ada.gov/service_animals_2010.htm.
hospital. Be sure to document the presence of visual and physical contact. The emotional 4. Frequently asked questions about service animals and the ADA.
the animal, your decision to transport (or not bond between Nancy and her dog helps make (July 20, 2015.) U.S. Department of Justice Civil Rights Division:
to transport) as well as the rationale behind for a stress-free transport and the crew eas- Information and Technical Assistance on the Americans with
your decision. This will go a long way should ily works around him during their follow-up Disabilities Act. Retrieved May 19, 2017, from www.ada.gov/
questions or accusations arise. assessments. Medic 6 advises the receiving regs2010/service_animal_qa.html.
1707jems_38 38 6/9/17 9:09 AM

SEE FOR YOURSELF!
1707jems_39 39 6/12/17 11:07 AM

Leadership is brought to fruition by the success of
Leading with emotional intelligence individuals working together. Photos Vu Banh
By Robert P. Girardeau, MSM-HCA, NRP, FP-C occurring. Just look at the emergence of the
buzzword EMS 3.0, which dominates the
O
rganized prehospital emergency with all things, unchecked growth is unsus- leadership tracks at all the major conferences.
medicine is but a teenager in terms tainable and doomed to collapse.1 Just think of EMS 3.0 is all about the development of pre-
of its lifespan. The profession mean- the most recent recessions: the dot com bomb hospital emergency medicine into a healthcare
dered for many decades as communities around and housing market bubble burst. These were delivery model that brings greater value to its
the world realized that the novel services pro- both due to growth that was unchecked and stakeholders. Simply responding to calls is no
vided by the industry were necessary and valu- unfounded on sustainability. longer good enough.
able. Now as the necessity is well-understood, Our industry is no different. Now that the
EMS has experienced an explosive growth. growth of our industry has dominated the THE CASE FOR EMOTIONAL
However, the focus of our industrys future marketplace for most of its history, a para- INTELLIGENCE
cant and must not be reliant on growth. As digm shift from growth to development is Theres little doubt the development of our
1707jems_40 40 6/9/17 9:20 AM

industry rests in the hands of its leaders. As Its this very notion that implores leaders to the fabric of the current workforce, we must
EMS transitions to a delivery model thats not only commit to this journey of change, but also change the dynamics of how we lead them.
driven by quality of care, safety of services, also inspire everyone else within their scope The days of paternalistic leadership have come
innovation and cost containment for consum- of influence to achieve it. to pass.
ers, our leaders will be responsible for not only Innovating and inspiring change isnt some- A leaders ability to exert control and
blazing the trail forward, but also inspiring the thing that can be demanded of ones staff. It authority over individuals does little to inspire,
workforce to faithfully follow. takes leaders with the desire and ability to compel, and lead our industry into the next
The ability to lead our industrys human meet the frontline staff where they are in life chapter of its success. True leaders dont oper-
resource through this paradigm shift is at the and their profession, fully engage and empa- ate from a place of management and directive
crux of our success. This task is daunting and thize with the staff s journey and ultimately force. Instead, leaders operate from the deploy-
complex. Leaders will need to break ties with temper ones own ambitions and feelings in ment of a high degree of EI.
business as usual, develop innovative ways lieu of the greater good. Not only is this the True leadership is realized by the success of
of delivering services and unabashedly lead very essence of effective leadership, its also individuals working together to achieve a mis-
by example. One of the greatest barriers to the core tenet of emotional intelligence (EI). sion. In other words, leadership is evident by
future success is the memory of past success. As new generations come of age and change the relationships that people build and utilize
1707jems_41 41 6/9/17 9:20 AM

THE IT FACTOR
to achieve their success, not their obedience If this is the case, what makes the leaders of anything to do with how unintelligent or how
to the authority figure driving the processes.2 today and the recent past successful? unlucky he or she is. Rather, the number one
First, lets think of success in terms of the suc- reason that leaders fail is because they funda-
THE SCIENCE BEHIND THE THEORY cess equation: Skill + Luck = Success.4 Although mentally lack the ability to relate with people.6
Its important to realize that EI is a trait and this equation is well accepted throughout busi- One review of more than 500 senior executives
ability that individuals have, not a leadership ness and industry, why is it that most leaders found that EI was a much better predictor of
theory or management style. EI is the measur- who are studied are no more brilliant or skill- success than intelligence alone.7
able ability of an individual to monitor ones ful than you or I?
own feelings and emotions, monitor those of Certainly luck cant be the limiting factor. So, THEORY INTO PRACTICE
the people around them, discrimi- There are two basic questions at
nate among the emotions observed the core of practical EI: 1) What
and ultimately use this analysis to do I observe?; and 2) How do I
direct the leaders own thinking The reason that a leader fails react to what I observe?
and actions.3 The first question examines
The existence of EI was born out to make an organization ones ability to perceive and under-
of the question, what makes peo- stand the nuance of the human
ple successful? By many accounts, successful usually doesnt experience: emotions and feelings.
up until the late 20th century, most EI affords an individual with the
leaders were believed to be suc- have anything to do with skills to understand their own
cessful because they were at least emotions and those of the people
moderately intelligent, if not highly how unintelligent or how around them. This isnt as sim-
intelligent. However, as research ple as recognizing that someone
into organizational dynamics unlucky he or she is. looks mad. Instead, this type of
began to gain great attention in observation requires that a person
the second half of the 1900s, so did not only realize what the emotions
the study of leaders in many different disciplines something else is missing. EI is the it factor are in someone else, but also whats inciting
like business, politics and industry. that drives the equation to success. Leaders are those emotions.
The study of success and leadership began only successful if they use EI as the catalyst to The second question of EI addresses how we
to show that leaders were no longer the smart- propel the success equation forward.5 respond to our observations. How do we change
est people in the room. In fact, many had very The reason that a leader fails to make an our behavior in response to our own emotions
average intelligence. organization successful usually doesnt have and the emotions of the people around us? This
involves a person being able to adjust their own
emotions and behavior in order to motivate,
Figure 1: Definition of emotional intelligence (EI)8
compel and inspire certain behaviors in those
around them.
What I observe How I act
If we then go a step further with these ques-
tions, we end up with the four core principles
Personal management
of EI : 1) Self-awareness; 2) Self-management;
3) Empathy; and 4) Relationship management.
(See Figure 1.)
Self-awareness Self-management Self-awareness is the component of EI that
focuses on the appreciation and understanding
that a person has for his or her own self. Persons
who possess self-awareness operate from a sense
of pragmatic confidence and keen emotional
Emotional discernment. Self-awareness enables a person
intelligence to know what their own strengths and weak-
nesses are, act in a way that makes the greatest
Social management
use of their strengths and ask for help to com-

pensate for their weaknesses.
Relationship Self-awareness demands that individuals
Empathy
management have a very strong grasp of how their emo-
tions are triggered, how theyre balanced and
how they affect their behaviors. Knowing that
youre upset isnt good enough. You must know
that youre mad, the chain of events that got
1707jems_42 42 6/9/17 9:20 AM

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1707jems_43 43 6/12/17 10:14 AM

THE IT FACTOR
Figure 2: Everyday EI skills you mad, how being mad is manipulating your
actions and judgement, and how to subdue
your anger so that it doesnt affect the way you
Self-confidence Resilience interact with others.
Emotional insight Emotional balance Self-management is the second of the per-
Self-motivation sonal management principles. However, with
self-management, we move from making obser-
vations about our emotions to acting within the
constraints of those observations.
Self- Self- During times of distress, strong EI allows
awareness management a person to keep their own emotions in con-
stant check and prevent their emotions from
overwhelming a situation.
Because of this inner balancing act, lead-
Empathy Relationship ers with strong EI are quite resilient. Self-
management management enables them to stay calm, col-
lected and focused when placed under extreme
pressure and crisis. Additionally, once a per-
son does become upset, they can quickly move
Compelling on and overcome this emotional state. Finally,
Dual empathy communication self-management enables leaders with EI to
Listening excellence Team play motivate themselves in the face of adversity.
Despite setbacks, leaders can persevere without
needing the encouragement of others.
While self-management and awareness focus
on ones own observations and actions about
themselves, we also need to examine how lead-
ers observe and respond to those around them.
Dual empathy is the observational compo-
UNIT 148
nent of how a leader with strong EI works with
others. There are two basic parts to empathy:
Emotional empathy and cognitive empathy.
Emotional empathy is the ability to read and
THE SENTINEL understand another persons emotions quickly
360 Pound Capacity and accurately. Cognitive empathy is the abil-
ity to understand why people feel the way they
. $690
r s . ......... do about a subject. Dual empathy not only
e
Reclin nd enables a leader to understand a persons feel-
a 1065
S o fa s
t s .. ...... $ ings, but allows them to appreciate the perspec-
ea
Loves tives behind those feelings.
Relationship management is the final and
culminating principle of EI. When a leader
can effectively manage their relationships, they
THE XTINGUISHER communicate in a way that compels and moti-
THE SENTRY vates people toward a goal. This communica-
AMERICA
AM
AMERICA STR
MERICA S
STRONG
RON
RO
RONG
ONG
tion not only serves the goals of the leader, it
also empowers others to take ownership of the
Call Toll Free: tasks at hand. EI allows leaders to manage an
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1707jems_45 45 6/9/17 9:20 AM

THE IT FACTOR
where you feel emotionally comfortable. You
must be able to take a hard look at what triggers
and controls your own emotions. Its difficult
to examine and manage your own emotions if
theyre always guarded by the fear of embar-
rassment. Try working with close friends and
family first. Hopefully, these are people that
youre able to let your guard down with and
talk genuinely about introspection.
The first step in improving your EI is also the
most basic: Think before you act. So much of
EI is managing your own emotions and actions.
The emotional centers of your brain process
stimuli faster than the rational centers. Lead-
ers must constantly restrict the emotional cen-
ters of the brain from controlling their actions.
When I see or hear someone coming to me in
a state thats highly emotional and volatile, I
immediately begin slowing my thoughts down
Try hard to understand what a person is feeling, why a person is feeling it and how those feelings are and repeating in my head, Think it through,
impacting their behaviors. think it through. Volatility is contagious if
youre not prepared for it. Going into a situa-
by the rule, Experience doesnt make up for back, it was thought that EI was organic and tion with an understanding that you are going
education, and education doesnt make up for intrinsic. As is the case with cognitive intelli- to think things through is a great strategy for
talent. The most important factor in that rule gence, there will always be others out there who preventing an emotional, knee-jerk reaction.
is talent, but its also the hardest to gauge. Its are naturally gifted with a high degree of EI. Next, empathize with those around you.
hard to qualify someones ability to lead an However, as neuroscientists began to study and Actively listen and take a genuine interest in
organization without actually hiring them into understand neuroplasticity, they also discovered what people are saying. Pay special attention
a leadership position. that EI is a talent and skill that can be honed. to word choice and nonverbal cues. Try hard
In many cases, the talent that were talking So then how does one ultimately increase to understand what a person is feeling, why a
about here is EI. Does a potential leader have their own EI? Practice. There are three steps person is feeling it and how those feelings are
the ability to control themselves in tough situa- that new and emerging leaders can use as they impacting their behaviors. This takes lots of
tions, relate to people in a meaningful way and work towards strengthening their EI. practice. One of the keys to reading a persons
motivate a workforce to accomplish its mission? Prior to attempting to strengthen your EI, emotions is being genuinely concerned with the
Upon its initial emergence several decades its important that you find an environment reasons why a person feels the way they do. Its
difficult to read a persons emotions if you
dont really care.
ePCR Designed by First Responders Lastly, reflect on your interactions with
for First Responders people daily. I cant tell you the number of
times that Ive looked back on a conver-
sation and said, Well, I messed that up.
Intuitivedesignforeasy
And thats ok! Being able to examine what
datacollection you said, why you said it and how others
Interfacecustomized reacted to it is a very crucial skill needed
toyouragencys
specifications for strengthening your EI. It allows you
Allowsyourcommunity the chance to reshape and focus your skills.
paramedicineteamto
exchangeinformation Reflection allows you to learn from your
withyourePCRusers
in real time mistakes and successes, and improve and
NFIRSreportingavailable strengthen your EI. Ultimately, youre try-
ing to relate your behaviors and thoughts
to the principles and skills of strong EI.
(See Figure 2, p. 44.)
PUTTING IT ALL TOGETHER

www.wateronscene.com
This article has spent a lot of time talking
about feelings and emotions. This isnt
1707jems_46 46 6/9/17 9:20 AM

Safe Transport of
Children by EMS
INTERIM GUIDANCE
RECOMMENDATIONS BY
THE NATIONAL ASSOCIATION OF

STATE EMS OFFICIALS (NASEMSO)
b. EMS agencies should have appropriately-sized child

restraint system(s) readily available on all ambulances that
may transport children.
Additionally, personnel should be initially and recurrently
evaluated and trained on the correct use of those restraint
systems;
i. The device(s) should cover, at minimum, a weight
Reflection allows you to learn from your mistakes and successes, and improve range of between five (5) and 99 pounds (2.3 - 45 kg),
and strengthen your emotional intelligence. ideally supporting the safest transport possible for all
persons of any age or size;
something were used to in this industry, but we should be. As lead-
ers in an emerging industry thats at the foundation of so many com-
munities, we must arm ourselves with the tools to lead our workforce
THE QUANTUM ACR-4 EXCEEDS
into the future. THE ABOVE CRITERIA
EI isnt only a tool to help you motivate an organization toward The Ambulance Child Restraint provides the safe and effective
success and greatness, but its also the it factor in leadership. Its transport of infants and children in an ambulance, covering
what sets people apart. weight ranges from 4lbs to 99lbs.
As science begins to understand what goes into EI, more and more
XS S M L
strategies are emerging to improve it.
4-11 lbs 11-26lbs 22-55lbs 44-99 lbs
Our stakeholders rely on us to always be looking and moving for-
ward. Dont rest on the militarized leadership strategies of yesterday.
The ways of the past will keep you and our industry from being pro-
pelled to greatness. Leaders with strong EI are able to foster a work-
force thats dedicated, efficient, caring and focused. JEMS In addition to the Small (11-26lbs), Medium (22-55lbs) and
Large (44-99lbs) sizes, this innovative, flexible and fully
adjustable harnessing system now comes in an
Robert P. Girardeau, MSM-HCA, NRP, FP-C, is the operations supervisor and critical care/
Extra Small (4-11lbs) and are all colour coded for easy selection.
flight paramedic with Jefferson Healths Critical Care Transport and Flight Program, Jeff-
STAT. Hes also an educator and field provider in the greater Philadelphia area. He can be
reached at rgirardeau@gmail.com.
REFERENCES
1. DesJardins J: Business, ethics, and the environment: Imagining a sustainable future. Pearson Prentice
Hall: Upper Saddle River, N.J., 2007.
2. Porter-OGrady T, Malloch K: Quantum leadership (Fourth ed.). Jones & Bartlett Learning: Burling-
ton, Mass., 2015.
3. Salovey P, Mayer J. Emotional intelligence. Imagination, cognition, and personality. 1990;9(3):185211.
4. Mauboussin M: The success equation: Untangling skill and luck in business, sports, and investing.
Harvard Business Review Press: Boston, 2012.
5. Vandewaa E, Turnipseed D, Cain G. Panacea or placebo? An evaluation of the value of emotional
intelligence in healthcare workers. J Health Hum Serv Adm. 2016;38(4):438477.
6. Jones D. (October 25, 2015.) Proof success has nothing to do with a high IQ. Fortune Magazine.
Retrieved May 24, 2017, from www.fortune.com/2015/10/25/halogen-success-tips-high-iq/.
3000 Marcus Avenue, Suite 3E6,
7. Cherniss C. (1999.) The business case for emotional intelligence. Consortium for Research on Emo- Lake Success, NY 11042-1012
tional Intelligence in Organizations. Retrieved May 24, 2017, from www.eiconsortium.org/reports/ W: www.quantum-ems.com
business_case_for_ei.html. E: sales@quantum-ems.com
8. Goleman D. (April 7, 2015) How to be emotionally intelligent. The New York Times. Retrieved T: 516.321.9494
May 25, 2017, from www.nytimes.com/2015/04/12/education/edlife/how-to-be-emotionally-

intelligent.html.
www.jems.com For more information, visit JEMS.com/rs and enter 28.
1707jems_47 47 6/12/17 10:14 AM

James Dunford, MD, has dedicated James Dunford, MD, became the medical director
of the San Diego Fire-Rescue Department in 1986
his career to helping the vulnerable and the city of San Diegos medical director in 1997.
Photo courtesy James Dunford
By Lauren Crosby, NREMT
The first to graduate from college in his
I
t would be easy to trip over the seemingly Its from this belief that hes been instru- family, he actually credits a friend for pushing
endless supply of plaques and awards pos- mental in implementing several key projects him toward medicine. At the time, Dunford
sessed by James Dunford, MD, if they for his city, including San Diego Project Heart imagined applying his altruistic nature and aca-
werent so meticulously tucked away out of Beat, the Resource Access Program (RAP), demic curiosity to helping the planet through
sight. The fact that the awards are hidden Project 25, and countless medical trials in coor- science. His friend challenged him to use his
behind his well-organized desk isnt because dination with such impressive medical institu- talents to save people and to leave the algae to
their owner trivializes them. Its merely a tes- tions as National Institutes of Health (NIH), others, and after receiving his first acceptance
tament to the disarming humility of this emer- Resuscitation Outcomes Consortium (ROC), letter to medical school, Dunford began to rec-
gency physician. and the American Heart Association (AHA). ognize his ability to build a career in medicine.
Dunford isnt in it for the praise. Hes on a When asked why he chose medicine as a He enrolled in Columbia Universitys
tireless quest to fix a broken system. But tal- profession, Dunford responds like so many medical school and distinctly remembers the
ent like his cant hide behind a desk, which is other gifted yet unassuming innovators who moment in anatomy lab, when, after working
why its no surprise that hes the 2017 James seem to stumble into their brilliance: He deliv- on a cadaver for six weeks, its face was finally
O. Page/JEMS Leadership Award recipient. ers a casual shrug and smile, saying it never revealeda sweet old woman with a pink
Dunford passionately believes in helping really crossed his mind. bow in her hair. This planted the seed for his
some of societys most vulnerable patients who strong connection with his patients.
often pose the biggest financial burden on the EARLY LIFE But it was one of the first weekends he put
healthcare system and subsequently drain tax- Having lived in six different cities by the age his white coat on that resonated most. He was
payer dollars. of 15, Dunford developed resilience early on observing in the ED when an elderly male
Succinctly put, Dunford observed that and quickly realized he wanted to surround trauma patient from a motor vehicle crash was
100% of what comes into the hospital is bro- himself with intelligent, like-minded individ- rolled in. Asked to hold a catheter, he watched
ken, and 90% of it didnt have to be. uals in his education. in horror as blood gushed from the patients
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CONNECTING THE DOTS
bladder, which had been ruptured by a severe was tapped to help San Diego Fire-Rescue access defibrillation; hes looking to break the
pelvic fracture. After 15 seconds, he thought Department (SDFD) add paramedics on fire paradigm of healthcare.
he might faint and excused himself. engines in difficult-to-serve communities. He
At that moment, he recalled a story his was a natural fit for this task because he was DOLLARS & SENSE
dad, a pilot in World War II, once told him. already advising SDFD on dispatch and use Dunford has championed many programs in
After witnessing a dozen fellow pilots die in of automated external defibrillators (AEDs). San Diego that redefine the healthcare system
a plane accident when their parachutes didnt Spearheading initiatives to advance medical and connect vulnerable patients to the resources
open in time, Dunfords dad and other pilots care is an observable trend in Dunfords career. they need. The easiest way to justify these pro-
were immediately ordered up in the air before Hes tackled many EMS challenges, includ- grams is to show the cost savings, which Dun-
they could let the fear of the situation cripple ing implementation of the tremendously suc- ford has been able to do time and again.
them. So Dunford decided to jump back in cessful regional public access to defibrillation, In 1996, Dunford observed the San Diego
the saddle with his trauma patient. STelevation myocardial infarction (STEMI) Police Departments (SDPD) program for
He thought to himself, Now Ive got to and stroke systems, identifying pitfalls to endo- homeless outreach. With the assistance of two
decide whether Im going to be a subjective tracheal intubation in traumatic brain injury police officers, he recognized a handful of indi-
college kid whos going to faint at the sight of through use of continuously recorded end viduals frequently using the citys services, both
blood or if Im going to become the guy who tidal CO2 (EtCO2) data and, more recently, police and medical. This led to a simple study
fixes problems like this. The sooner I can get promoting real-time EMS access to patient of 18 individuals which found that those 18
to that strategy, the better off Ill be. data through the regional health information frequent flyers cost two hospitals and the com-
Experiences like that, particularly during exchange program. munity a total of $1.5 million.
a year spent in the San Diego VA Healthcare Countless students sing his praises as pro- When the mayor and police chief saw these
System overseeing a staggering 100-person a fessor emeritus of emergency medicine at the costs, they were galvanized to recommit to
day intake center with widespread acute illness, UCSD School of Medicine. But Dunfords problem-oriented policing. This gave birth
led Dunford to choose emergency medicine. real talent is seeing the big picture, which is to the Serial Inebriate Program (SIP), hop-
In 1980, Dunford was asked to join the first exactly what youd want in a city medical direc- ing to address the vexing issue of chronically
civilian aeromedical program in the country, tor, a position hes held in San Diego since its intoxicated individuals who consume com-
Life Flight San Diego. Over the next 6 years inception in 1997. munity resources.
he treated hundreds of acute trauma and med- Hes playing the long game in affecting No one wants to put someone in jail for
ical field emergencies. change in his medical community with pro- being drunk, but the consequences of some
In 1988, he founded the University of Cal- grams that continue to inspire both nationally peoples recidivism on society can be so cata-
ifornia, San Diego (UCSD) emergency med- and internationally. Hes not looking to just strophic that we need a rehabilitation strategy
icine training program and in 1990, Dunford do something like lead the nation in public to convince some folks to accept a meaning-
ful treatment program or face consequences,
says Dunford.
SIP was designed as a pilot program with
Dunford, the cooperation of SDPD and a
handful of key stakeholders, including the
court, city attorney, public defender, jails, sober-
ing center and an alcohol treatment provider.
Together, this group decided they would pro-
pose an alternative to incarceration for indi-
viduals with recidivist alcohol abuse problems.
The SIP criteria were defined by sobering
center personnel as any individual transported
by police to the detox center six times in 30
days. Instead of spending the night sobering
on a mat in the center, theyd have to spend
the night in jail and explain their behavior
to a judge.
After showing positive results for approx-
imately 580 people, SIP gained national rec-
ognition, bringing much-needed science to
In 2007, Dunford received the A Home for Every homelessness research.
Dunford was one of the six original physicians on American national research award from the U.S. In 2007, SIP was awarded the Interagency
San Diego Life Flight (19801986), the first civilian Interagency Council on Homelessness at the National Council on Homelessness Pursuit of Solutions
physician-staffed aeromedical program in the U.S. Press Club for his study of the San Diego Serial Inebri- Research Awardin Washington, D.C.
Photo courtesy James Dunford ate Program. Photo courtesy James Dunford The California Supreme Court also
1707jems_50 50 6/9/17 9:20 AM

1707jems_51 51 6/9/17 9:20 AM

CONNECTING THE DOTS
recognized the constitutionality of SIP in 2004
in People v. Thomas Kellogg. The court ruled
that the act of being drunk in public can have
such negative societal consequences that the
state has a right to hold them responsible.
While working on combatting recidivist
alcoholics in the community, Dunford was
inspired to develop the Resource Access Pro-
gram (RAP) in the late 1990s, to address the
many other faces of frequent EMS use. He
developed RAP because he saw a need to con-
nect a different set of vulnerable patients to
community resources. People may be healthy,
but they arent health literate, says Dunford.
He admits this programs humble begin-
nings were conducted out of his office because
he would get complaints from medics about
running on the same patient 10 times. When
Dunford finished his workday, hed call the
frequent flyers doctors to try and determine
what was happening. He quickly noticed phy-
sicians had very little knowledge of what their
patients were doing. They didnt know that
their diabetic patients were creating havoc
for the city because their patients didnt share
In 2009, Dunford established the San Diego Resource Access Program (RAP) to address other (non-alcoholic) that information.
frequent users. RAP is a community paramedic-driven program enabled by advanced health information Dunford vividly remembers a moment at a
technology. In 2014, the Agency for Health Research and Quality selected RAP as a best practice on their private function when he was discussing a dia-
Health Care Innovation Exchange website. Photo courtesy Lizeth Romo betic man whose low sugar episodes resulted in
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1707jems_52 52 6/9/17 9:20 AM

three separate encounters with SWAT teams.
The internist with whom he was sharing the
story had a sudden epiphany and said, Hes
my patient!
The doctor had no clue his poorly con-
trolled diabetic patient was brandishing swords
and threatening an entire neighborhood when-
ever his glucose got low, which confirmed
Dunfords belief that he had zero ability to
assume any patient leaving his ED would (or
could) follow any of the discharge instructions
they received.
Although hed seen these patterns as an ED
doctor, as a city medical director he saw how
it impacted the whole city. All the programs
hes started have been created with the idea
of connecting the broken dots. San Diego Project Heart Beat, the regions public access to defibrillation (PAD) program has been named
Shouldnt society be able to get some- the nations best large PAD program. To date theyve distributed more than 8,500 AEDs and saved 153 lives.
one to a doctors appointment? Whose job Photo courtesy James Dunford
is that? Dunford asks. He challenges that no
matter the root causewhether brain cancer FULL OF HEART So in 2000, Dunford felt San Diego was
or diabetespatients wont get good care if Dunford explained its no coincidence the the ideal place to create a PAD program. That
they dont know about and have access to the Emergency Cardiovascular Care Update year, he attended a preconference workshop at
existing community resources. (ECCU) conference, hosted by the Citizen ECCU in which long-time friend and medi-
Another resource any community hoping to CPR Foundation, selects San Diego every five cal colleague Paul Pepe, MD, MPH, MACP,
boost its cardiac survival rates is public access years as its venue to announce the AHA guide- FACEP, FCCM, spoke of his involvement with
defibrillation (PAD). This need led to another line releases. They announce the guidelines Chicagos OHare Airport PAD project. At the
trendsetting initiative: San Diego Project Heart in San Diego because we walk the talk here, time, only OHare and Windsor, Ontario, Can-
Beat (SDPHB). says Dunford. ada, had preliminary results to report. Inspired
THE CHOICE IS NOT HARD
VS
Patient comfort matters! Make the change that truly

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Visit HartwellMedical.com/comfortmatters
1707jems_53 53 6/12/17 10:19 AM

CONNECTING THE DOTS
by their early success stories and following the OConnor appreciates Dunfords ability to bring to aggregate patient data that shows real-time
national trend set by the Clinton administra- together a community and all the key players trends, such as number of calls a patient has
tion to introduce AEDs in airports, Dunford to affect change in the healthcare system. She had in a given time period and estimated costs
immediately thought, We have to do this. This remembers his ability to see the whole picture associated with that patients care. Community
is something in our wheelhouse. even when she first met him as an SDFD EMT. paramedicine and RAP are critical for fixing
SDFD was one of the first fire departments Dr. Dunford would take the turnover from the problem of an overburdened healthcare
in the nation to carry AEDs on their appara- the paramedic and then turn his attention to system. The RAP program is a microcosm of
tus, after a local hospital paid the city a debt by me to see what my views were. No other doc- what we think needs to happen in the entire
purchasing AEDs in the early 1980s. Dunford tor even cared to address me, says OCon- country, which is helping expensive, vulnerable
approached SDFD Assistant Chief August nor. She credits Dunford with innate respect people to just get connected, says Dunford.
Ghio at the time and pitched what would toward others, saying, he truly cares about all Connecting the broken pieces works. Prob-
become SDPHB. people without bias. ably the most disappointing part of my career
After Ghios initial excitement about the has been [the recognition] that you couldnt
idea, others soon followed, including the AHA, THE FIGHT CONTINUES get financially motivated people to see there
the local firefighters union, a city council There are many battles to be fought as an was value in actually helping people like this.
member and the widow of an SCA victim, innovative EMS medical director, and Dun- It wasnt until we did Project 25 [that we]
along with an AED vendor that contributed ford is actively engaged in local and national finally convinced people of that.
$100,000 to get the program off the ground. battle lines. Locally, San Diego is involved in Project 25 was a United Way-funded pro-
In 2001, SDPHBs primary goal was to a California Health Workforce Pilot Proj- gram that teamed law enforcement, EMS, and
make AEDs as available as fire extinguish- ect, administered by the California Office of mental health to identify the top 25 users of
ers, with an initial target of having 250 AEDs Statewide Heath Planning and Development San Diegos emergency services and provide
available publically in San Diego County by and sponsored by California EMS Author- them housing and intensive care. The pro-
the Super Bowl in 2003. SDPHB surpassed its ity, that expands the scope of practice for grams aim was to reduce costs and improve
initial goal with 550 AEDs but now has more paramedics to test the effectiveness of com- health outcomes. After two years, costs
than 8,000 countywide.1 munity paramedicine.2 dropped by more than $2 million.3
The program and its success continue to The study was designed to test multiple Another project thats top of mind for Dun-
grow, drawing the attention of other major met- community paramedicine concepts, including ford is identifying the biggest obstacles to
ropolitan cities that look to emulate SDPHB. addressing the problem of frequent EMS users. promoting innovation and advancing EMS.
Perhaps most impressively, SDPHB boasts Results indicate a net savings of $45,607 per Dunford partnered with Mount Sinai Health
153 saves, including three children. Because month ($1,754 per patient per month) in San Systems Associate Medical Director of Pre-
of that, the Sudden Cardiac Arrest Association Diego alone for patients enrolled in the study.2 hospital Care Kevin G. Munjal, MD, MPH,
and International Association of Fire Chiefs Data like this helps Dunford continue to to tackle these issues with a two-year grant
have given awards to SDPHB twice for their fight for alternative healthcare options for awarded by the National Highway Traffic
PAD program. vulnerable patients. San Diego uses Street Safety Administration (NHTSA).
SDPHB Program Manager Maureen Sense, a homegrown technological solution Dunford and Munjal have completed the
Promoting Innovations in EMS proj-
ect designed to be what Dunford calls
Get the most out of your Mobile Integrated Healthcare the prelude to the next EMS Agenda
program with the patented* workflow of for the Future.
STREET SENSE WHATS NEXT?
The role of the community paramedic,
Let our fully-customizable algorithms
do the work in identifying your most the EMS medical director and the
vulnerable population industry of EMS itself will continue to
evolve, and Dunford will contribute to
Improve the well-being of your
population with care plans, this movement.
referrals, appointment scheduling When asked what he enjoys doing in
and patient outreach his free time, he can only talk about a
beloved 22-foot Catalina sailboat named
Measure the effectiveness of your
MIH program with Street Senses Sail La Vie for a moment before he
analytical tools shifts gears to discussing delivering
Grand Rounds in Seoul, South Korea,
on the San Diego trauma system or con-
World Advancement * Patent No. 9,237,243
sulting with a colleague in Saudi Arabia.
of Technology for www.wateronscene.com
EMS and Rescue sales@wateronscene.com Dunford has become a defender
of the citizen, refusing to see precious
1707jems_54 54 6/9/17 9:20 AM

IN GOOD COMPANY
Each year JEMS presents the James O. This year, James Dunford, MD, was nom- name all the programs Dunford has cham-
Page/JEMSLeadership Award, named for inated by SDFD Paramedic Carolyn Gates. pioned would be like trying to understand
founding publisher James O. Page. Like the Gates selected Dunford for the many accom- War and Peace from the CliffsNotes.
accomplishments of its namesake, the award plishments shes observed under his medical One of the things Gates appreciates most
honors individuals or agencies in EMS who direction in San Diego. is that Dunford is one of the most genuine
have improved the industry or brought about His career is so vast and distinguished, yet men she has ever met. She calls him kind
change, often through tenacious efforts. he remains such a humble man, says Gates. and caring. It has been a joy for her to watch
The 2016 recipient of the award was the She admires his down-to-earth approach and Dunford interact with her students, and she
NEMSMA Practitioner Mental Health and recalls him lying on his back in a classroom believes it takes a special kind of medical
Wellbeing Committee for their efforts to to help demonstrate a new technique for the director to devote the care he does to edu-
fight stress, depression and suicidal thoughts Valsalva maneuver. Gates also promotes his cation, the kind of man deserving of the
in the EMS workforce. far-reaching impact, saying that trying to James O. Page/JEMS Leadership Award.
healthcare resources wasted when he believes says Dunford. REFERENCES

we can handle these patients more effectively. He has no shortage of passion or ideas to 1. City of San Diego. (n.d.) About SDPHB. Project Heart Beat. Retrieved
Hed like to see his system evolve to a point improve the industry he so nobly serves. His Feb. 9, 2017, from www.sandiego.gov/sdprojectheartbeat/about.
where we have alternatives to transporting all is a career EMS providers will continue to fol- 2. Coffman J. (Jan. 23, 2017.) Evaluation of Californias com-
patients to the hospital. low as the James O. Page/JEMS Leadership munity paramedicine pilot program. Healthforce Center at
Hed also like to see connectivity in the Award is neither the first nor likely the last UCSF. Retrieved Feb. 13, 2017, from https://healthforce.
community increase, with a heightened aware- honor he will receive. The EMS community ucsf.edu/sites/healthforce.ucsf.edu/files/publication-pdf/
ness of the resources available. Dunford also owes its gratitude to Dunfords college friend Evaluation%20of%20California%C2%B9s%20CP%20Pilot%20
hopes to see traditional, hospital-based care who inspired the path hes on. Were all just Program_final2%5B1%5D.pdf.
for seniors become more effective at home. glad he picked people instead of algae. JEMS 3. CSH. (June 15, 2015.) Project 25: Housing home-
The motivation of everything I do comes less reduces costs. Corporation for Supportive Housing.
from 35 years of seeing just how messed up Lauren Crosby, NREMT, is a freelance writer and a former Retrieved Feb. 15, 2017, from www.csh.org/2015/06/
the healthcare system is for vulnerable people, editor of JEMS. project-25-report-housing-homeless-reduces-costs/.
1707jems_55 55 6/9/17 9:20 AM

FIELD PHYSICIANS
EMS DOCS PERSPECTIVES ON STREET MEDICINE
TECHNICIANS & CLINICIANS

How do we make room for both?
By Mark E.A. Escott, MD, MPH, FACEP
T
he future of EMS hangs in the balance the importance of conformity while penalizing completion in a rigid administrative framework.
and few seem to appreciate that the cri- those who think independently. We work hard to EMTs are focused on maintenance and man-
sis is no longer loomingits arrived. quash those who buck the system and stray from agement of the physical plant (i.e., ambulances
Over the past several years, weve witnessed the the prescribed path. This stepwise approach of and stations) while the paramedic is focused on
convergence of workforce shortages, decreas- EMT to advanced EMT to paramedic has been maintenance and management of the patient
ing reimbursement, increasing bills associated the primary path of advancement so far, but its and the clinical practice. When at the station,
with EMS transportation and worsening bud- no longer effective at providing the workforce the EMT is focused on resupply, equipment
get constraints which threaten the longevity of that our industry currently needs. maintenance and clinical skills training while
this third emergency service. Without question, we need technicians within the paramedic is focused on chart review, patient
Weve seen ad after ad for top-tier EMS sys- the EMS system and many of our personnel are follow-up, review of medical literature and prac-
tems in a perpetual hiring phase. Increased pay, well-suited for this essential role. Stations have tice improvement.
sign-on bonuses and relocation support often to be managed, vehicles have to be stocked and This model is by no means exclusionary
help entice prospective paramedics to come to cleaned, ambulances have to be driven by skilled toward the advancement of technicians but like
a new home. professionals and clinical procedures have to be the military, perhaps we should consider that the
Why do we continue to struggle to recruit performed. We also have many medical emer- technicians we enlist enter through a vocational
and retain our workforce in this exciting field? gencies that are suited to a highly protocolized, route and clinician/paramedics enter through a
Some will say that pay appropriate to the technician-based approach where procedural collegiate route. Then, you have an alternate path
demands of the job remains lacking. Though aptitude is critically important for success. that allows equipping technicians with the skills
many advocate for advancement of formal edu- Technicians are critical to the operation of to become clinicians.
cation requirements in order to justify signifi- EMS agencies; however, we do expect them to The future of the industry will be bleak if we
cant salary increases for clinician paramedics, transition to the role of a free-thinking clini- continue to embrace only the technician model,
theres also pressure to maintain the technician cian capable of managing complex situations which focuses on protocols directing our work-
model of care. and teams. Although a v fib cardiac arrest has force to transport patients to the hospital while
a relatively straightforward algorithm, pulseless doing what you can along the way.
THE CHALLENGE electrical activity and asystole arrests require We need to embrace recruiting and educat-
Some arguments focus on ease of recruitment significantly more evaluation, investigation and ing clinicians who can be decision-makers with a
and affordability of a less skilled workforce. The medical decision-making. medical education that goes beyond the current
workforce itself is divided on the issue, with In that circumstance, we need clinical masters pattern recognition-based approach and diverges
some EMTs and paramedics focused on hold- who can paint on a canvas that has no lines. The from the assumption that most patients will be
ing onto the public safety identity rather than challenge is that the personality needed to be a transported. This realignment will allow us to
accepting that the role of EMS is transitioning master clinician is often not someone whos toler- recruit college-educated paramedics who can
to one of healthcare delivery. The public safety ant of arbitrary rules. They often dont respond safely disposition patients, while we increase
model entices the workforce through the hope well to task assignments that arent consistent pay, increase autonomy and hopefully increase
of advancements in administrative hierarchy, with their level of aptitude. job satisfaction so that we can stem the hemor-
while the healthcare delivery model focuses on The conflict between education, mindset and rhage of the EMS workforce. JEMS
advancement of the clinical practice leading to task assignment may be part of the stress that
increased responsibility and autonomy. leads folks out of the industry and into other Mark E.A. Escott, MD, MPH, FACEP, is the
One of the key elements that we may be miss- healthcare areas where independent thinking medical director for Austin-Travis County
ing is that weve created one system and one is welcome. EMS System, a medical director and founder
path for entry into and advancement: Every- of Rice University EMS in Houston, and an
one enters the paramilitary-like EMS system A NEW APPROACH assistant professor of emergency medicine
as an EMT. During the indoctrination process, Perhaps the answer is to approach staffing with at Baylor College of Medicine. Hes the chair-elect of the
we stress the importance of the uniform, good an aim to align roles and responsibilities with the American College of Emergency Physicians Section of EMS
driving, radio operations, stocking, cleaning and personalities and skill sets of the individuals we and Prehospital Medicine and is board certified in emer-
following the rules of the organization. We stress recruit. We need folks who are focused on task gency medicine and subspecialty board certified in EMS.
1707jems_56 56 6/9/17 9:20 AM

YOU FOCUS ON SAVING THE PATIENTS LIFE
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1707jems_57 57 6/9/17 9:20 AM

HANDS ON
PRODUCT REVIEWS FROM STREET CREWS
School-Age Anti-Choking Training

Teaching CPR and first aid to the public is an important role for all EMS
professionals, and the public views EMS as the authority since we respond
to these emergencies every day. CPR and first aid classes all benefit from
increased levels of hands-on training. One skill thats always difficult to teach
is the Heimlich maneuverafter all, you cant have students vomiting in the
classroom after receiving abdominal thrusts from an overly excited classmate.
The new School-Age Anti-Choking Trainer from Act Fast is an adjustable,
wearable vest which allows the practice of abdominal thrusts with the payoff
of a dislodged foam plug flying into the air. Different colors and sizes of
foam plugs allow for different levels of difficulty in object removal. Theres
also a removable pad that can be placed between the shoulder blades for
instructors who teach back blows as part of the response to a choking victim.
VITALS
Dimensions: 16.5" x 10.5"
Weight: 1 lb.
Price: $109.00
www.actfastmed.com
855-934-9340
Consistent Chest Compressions

A patient in cardiac arrest requires compressions to be started as soon as possible, with
minimal interruption, at a rate of 100120 per minute and at a depth of 22.5" in order
to maximize odds for a successful resuscitation. The new Lifeline ARM from Defibtech is
a compact, portable, battery-operated compression machine that takes the guesswork
out of CPR quality. After centering the patient on the backboard, the rigid frame clicks
into place and the compression module, containing the rechargeable battery, is inserted
into the frame. The user quickly adjusts the piston using up/down soft keys and then
selects either continuous compressions for use with an advanced airway or the 30:2 ratio
for use with bag-valve mask ventilations. With a nominal operating battery runtime of
one hour, the Lifeline ARM can also be run on continuous AC power and the batteries are
quickly swappable. A USB port provides you the ability to download event information
and data logging to a PC.
VITALS
Dimensions: 24" x 18" x 10" (in case)
Weight: 15.9 lbs.
Charge time: < 2 hours
Price: Call for price
www.defibtech.com
866-333-4248
Fran Hildwine, BS, NRP, is a simulation learning technician at the Pennsylvania College of Health Sciences in Lancaster, Pa., and is also an EMS instructor
at Good Fellowship Ambulance Club in West Chester, Pa. Contact him at fran100b@zoominternet.net.
1707jems_58 58 6/9/17 9:20 AM

AURiS TRAINING STETHOSCOPE
THE A F FO RDA BLE TR AIN IN G STE TH O S C O P E
Works with iOS Rechargeable battery
Realistic sounds Adjustable for all levels
of training
For more information about the AURiS Training Stethoscope,

visit isimulate.com/auris or call us at 1-877-947-2831
Smart solutions to keep life going

1707jems_59 59 6/9/17 9:20 AM

For more product reviews: www.jems.com/Hands-On
Suction a SALAD
Whenever you arrive as the second unit on a critical call and hear the hum of the suction unit, you
know the call isnt going well. Clearing the airway of vomitus, blood and other nastiness takes time,
and it may significantly delay intubation. Jim DuCanto, MD, an anesthesiologist from Milwaukee
has collaborated with SSCOR in developing the DuCanto Catheter, which features a larger bore to
remove more material faster than the traditional Yankauer
suction catheter. The DuCanto Catheter also features a length VITALS
and geometry to facilitate the suction-assisted laryngoscopy Shaft diameter: 0.26" x 0.55"
airway decontamination (SALAD) technique pioneered by Shaft length: 9.3"
DuCanto. By eliminating the thumb hole to activate the Weight: 1 oz.
suction, the DuCanto Catheter can be placed in the posterior Price: $2.23
pharynx during laryngoscopy and fluids removed from the www.sscor.com
trachea and esophagus throughout the intubation procedure. 855-934-9340
VITALS
Dimensions (in bag): 26" x 19" x 9"
Deployed Length: 75"
Weight: 36 lbs.
Capacity: 400 lbs.
Price: $2,495.00
www.rapidextraction.com
Minimal Manpower Patient Mover
When you need to move a patient any distance more than a few hundred feet on
626-467-3105
uneven terrain it becomes very manpower intensive. Due to patient size and injury
type you may need up to six or eight people, and using less than four to carry a patient
over rocks, sand or hills is unsafe. So how do you safely move a patient from point A
to point B? Simpleyou roll them. The new REX One rapid extrication stretcher from
REX EMS enables a single rescuer to safely move a patient weighing up to 400 lbs. over
100 yards. The REX One can be deployed from its backpack in about a minute by simply
unfolding the sections, attaching the wheels and extending the handle. An optional
braking system gives you a margin of safety when moving downhill. There are three
tire options including 18" tubeless, 20" all-terrain and wide-track sand tires. Bicycle
////////////
EMS teams can also add a transport capability with the bike attachment hitch.
Advanced Airway Manikin

There are certain manikins that become staples in EMS education. Learning to ventilate, insert
oropharyngeal and nasopharyngeal airways, intubate, and use the variety of rescue airway devices usually
happens on an airway task trainer. These manikins have a head and torso along with smooth skin,
perfect teeth, perfect vocal cords and flexible necks. Once youve mastered the basics, its
time to move on to the more challenging airways of the 7S3 Modular Airway Trainer from
7-SIGMA Simulation Systems. The modular construction of this manikin allows you to change
from normal anatomy to a number of difficult airways including thermal burns, poor dental
anatomy and other abnormal pathologies. Changing
the anatomy is facilitated by a series of well-placed VITALS
tabs which securely engage with the tissue modules. Dimensions: 21" x 20" x 11"
Changing face skins, teeth and even the entire airway Weight: 52 lbs.
can be accomplished in about a minute. Youll also Price: $1,500.00$5,485.00 (based on options)
be able to add some diversity to your training with www.7-sigma.com/7S3
manikins available in light and dark skin tones. 888-722-8396
IN THE NEXT ISSUE: >> IndeeLift Human Floor Lift >> First Tactical EMS Bags
>> Streamlight Portable Scene Light >> QFlow >> Nasco SALAD Airway Simulator
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1707jems_62 62 6/9/17 9:20 AM

FROM THE EDITOR
Continued from page 8
Its wise advice, and in studying the value of departing individual used to do their job, institutional knowledge and develop strategies
and ability to capture institutional knowledge, whether it was from a manual, company to ensure business continuity. It can be tragic
Ive found other ways to address the loss of insti- policy, etc.; for your organization if you dont have a plan
tutional knowledge and transfer it to others:16 >> Adopt technology to help personnel in place to retain or capture the institutional
>> Do a workforce assessment, documenting enhance and remember processes; and knowledge of your seasoned employees. JEMS
and identifying critical knowledge held by >> Dont assume that time means knowledge.
existing employees; Make sure the knowledge being passed REFERENCES
>> Have tenured employees write their work along is true, accurate and updated when it 1. Pea AM. (Aug. 10, 2013.) Institutional knowledge: When employ-
processes down in the form of standard is passed down. You could be doing some- ees leave, what do we lose? HigherEdJobs. Retrieved June 5, 2017,
operating procedures; thing wrong the whole time and never know from www.higheredjobs.com/articles/articleDisplay.cfm?ID=468.
>> Enlist the assistance of existing and depart- about it, the correct information could be 2. Barishansky RM, Idler M. The importance of mentoring leader-
ing retirees to serve as mentors; getting watered down or changed as it ship: Developing an effective mentoring relationship. EMS Insider.
>> Closely observe work units, functions and moves from employee to employee when 2013;40(10):4.
processes; it isnt written down or if written down 3. Ashworth MJ. Preserving knowledge legacies: Workforce aging,
>> Institute better employee communications; with no version control. This could lead to turnover and human resource issues in the US electric power
>> Review and document processes; the remaining staff doing thing differently industry. International Journal of Human Resource Management.
>> Continually conduct specialized training; leading to chaos and confusion among the 2006:17(9):16591688.
>> Institute job-sharing between veteran rest of the organization, and when the group 4. Carter C. When your Gurus walk out the door. KM Review.
employees and newer employees; remaining leaves, youre left with no insti- 2004;7(3):1619.
>> Find other ways to get a lost employees tutional knowledge at all. 5. Stiller I. (Oct. 21, 2015.) Institutional knowl-
work completed; edge: When it works and when it doesnt. LinkedIn.
>> Have a succession plan for your most ten- CONCLUSION Retrieved June 5, 2017, from www.linkedin.com/pulse/
ured, valued and talented employees; Its difficult to quantify and replace employees, institutional-knowledge-when-works-doesnt-ivy-stubbs.
>> Have a succession plan for the informa- particularly where technical skills are essen- 6. Ashkenas R. (March 5, 2013.) How to preserve institutional
tion your key personnel possess; tial. Do everything you can to retain val- knowledge. Harvard Business Review. Retrieved June 5, 2017,
! >> Have staff learn the base knowledge that a ued employees, synthesize and capture their from www.hbr.org/2013/03/how-to-preserve-institutional.
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EMS Today 61 37 Medtronic 23 13 Ziamatic Corp 29 18
*IFC=Inside Front Cover, IBC=Inside Back Cover, and OBC=Outside Back Cover
FREE
1707jems_63 63 6/9/17 9:20 AM

LAST WORD
THE UPS & DOWNS OF EMS
STROKE CERTIFICATION
Bon Secours DePaul Medical Cen-
ter in Norfolk, Va., recently earned a
Comprehensive Stroke Center Certification
from DNV GL Healthcare, becoming one of
just 43 hospitals and medical centers in the
country to hold the prestigious title. In addi-
tion, Bon Secours Virginia is the only health
system on the east coast with two compre-
hensive stroke centers. After rigorous reviews
and examinations, this certification is given
to medical centers that are committed to top-
of-the-line diagnosis, treatment and rehabil-
itation of strokes.
In addition to offering comprehensive
stroke care, the Bon Secours DePaul Med-
ical Center provides stroke education pro-
grams to local fire and EMS professionals. Richard Young (left), a firefighter advanced EMT, and Heather Joyner, a firefighter paramedic with Norfolk
Not only does this training help hone the Fire-Rescue, deliver a patient to Bon Secours DePaul Medical Center in Norfolk, Va.
skills of EMS workers, it also helps strengthen Photo courtesy Richard Muldez/Bon Secours Hampton Roads Health System
collaboration between prehospital providers
and the hospital. Center knowing the patient will receive the the education and treatment of strokes. Rais-
Depending on the severity of a patients best treatment in the region. ing awareness as well as the hospitals ability
stroke symptoms, EMS can confidently take We give a thumbs up to the Bon Secours to provide exceptional and rapid interventions
the patient to Bon Secours DePaul Medical DePaul Medical Center for their dedication to for strokes will surely save lives.
LEGISLATIVE PROGRESS In 2015, a law was passed that allowed med- This legislation comes after a recent increase
In a victory for mobile integrated ics to help treat patients, even when its not in crimes against first responders. In 2016, 21
healthcare (MIH), Washington state an emergency police officers were killed ambush style, which
legislators recently passed a law that provides We give a thumbs up to the Washington was the highest amount in more than 20 years.
sustainable funding for community paramed- state government for realizing the importance A total of 135 officers were killed while on the
icine programs. Governor Jay Inslee signed of supporting community paramedicine pro- job in 2016the most since 2011.
House Bill 1358 into law in May, which prom- grams and mobile integrated healthcare. This Senator and former EMT Phil Boyle said in
ises to reimburse fire departments and EMS shift puts patient health and comfort first, a press release, With the staggering increase
for treating Medicaid patients who dont need streamlines the states emergency healthcare of targeted attacks on our law enforcement
ambulance transport to an ED. system and further strengthens the bond EMS and emergency personnel, this crucial piece
Local first responders are celebrating the has in caring for their community. of legislation shows our steadfast support for
law as a win for patient-centered care. This our first responders and that well do every-
law allows EMS to be recognized and used PROTECTING RESPONDERS thing we can to protect them.
less as a transportation service and more as a The New York state senate has passed We give a thumbs up to New York state
healthcare partner that serves it community a bill that would designate crimes legislators for committing to defend the states
throughout the continuum of patient care. It committed against fire, police and EMS pro- first responders and for taking a stand against
will also help prevent costly and unnecessary fessionals as hate crimes, therefore carrying senseless attacks. Although one law may not
transportations if the patient is first treated heftier fines and sentences. The Community completely prevent people from harming
in their home. Heroes Protection Act would bump up the invaluable medics, firefighters and law offi-
This is just the latest development in Wash- level of such crimes, turning a class C felony cers, it does send a message that such crimes
ingtons support of community paramedicine. into a class B felony, etc. will not be tolerated in any capacity. JEMS
JEMS (Journal of Emergency Medical Services) (ISSN 0197-2510) USPS 530-710, JEMS is published 12 times a year, monthly by PennWell Corporation, 1421 S. Sheridan, Tulsa, OK 74112. Periodicals postage
paid at Tulsa, OK 74112, and at additional mailing offices. SUBSCRIPTION PRICES: Send $19.99 for one year (12 issues) or $29.99 for two years (24 issues) to JEMS, P.O. Box 3425, Northbrook, IL 60065-9912,
or call 847-559-7330. Canada: Send $49 for one year (12 issues) or $94 for two years (24 issues). All other foreign subscriptions: Send $59 for one year (12 issues) or $114 for two years (24 issues). Single copy:
$10.00. POSTMASTER: Send address corrections to JEMS (Journal of Emergency Medical Services) , P.O. Box 3425, Northbrook, IL 60065-9912. Claims of non-receipt or damaged issues must be filed within
three months of cover date. JEMS is a registered trademark. PennWell Corporation 2017. All rights reserved. Reproduction in whole or in part without permission is prohibited. Permission, however, is
granted for employees of corporations licensed under the Annual Authorization Service offered by the Copyright Clearance Center Inc. (CCC), 222 Rosewood Drive, Danvers, Mass. 01923, or by calling CCCs
Customer Relations Department at 847-559-7330 prior to copying. We make portions of our subscriber list available to carefully screened companies that offer products and services that may be important
for your work. If you do not want to receive those offers and/or information via direct mail, please let us know by contacting us at List Services JEMS (Journal of Emergency Medical Services), 1421 South
Sheridan Road, Tulsa, OK 74112. Printed in the USA. GST No. 126813153. Publications Mail Agreement no. 40612608.
1707jems_64 64 6/9/17 9:21 AM

ems.stryker.com/powered-system
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Rated for extreme temperatures between -30F to 130F.
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Cleanable polyurethane coating can help to expedite the time

to clean and dry restraints.
Strykers Rugged-X restraints are compatible with

Power-PRO XT & Performance-PRO XT ambulance cots.
Experience the power at ems.stryker.com/powered-system
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1. Meets SAE J3027 dynamic crash standard with Power-LOAD cot fastener system used with Power-PRO XT ambulance cot, Performance-LOAD cot
fastener system used with Power-PRO XT ambulance cot, or Performance-LOAD cot fastener system used with Performance-PRO XT ambulance cot.
Stryker Corporation or its divisions or other corporate affiliated entities own, use or have applied for the following trademarks or service marks: Power-
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Safe, Fast, Effective.
1 2 3
The Arrow EZ-IO Intraosseous < 1% serious complication rate1

Vascular Access System from 10 seconds to achieve vascular access2
Teleflex is a safe1, fast 2 and effective3
97% first-attempt access success rate3
solution when intravenous access is
difficult or impossible to obtain in 5 L/hour infusion rates under pressure
emergency situations. via the proximal humerus4*
teleflex.com/ems
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References:
1 Teleflex Internal Data on File 2014.
2 Davidoff J, Fowler R, Gordon D, Klein G, Kovar J, Lozano M, Potkya J, Racht E, Saussy J, Swanson E, Yamada R, Miller L. Clinical evaluation of a novel intraosseous device
for adults: prospective, 250-patient, multi-center trial. JEMS 2005;30(10):s20-3. Research sponsored by Teleflex Incorporated.
3 Cooper BR, Mahoney PF, Hodgetts TJ, Mellor A. Intraosseous access (EZ-IO) for resuscitation: UK military combat experience. JR Army Med Corps. 2008;153:314-6.
4 Philbeck TE, Miller L J, Montez D, Puga T. Hurts so good; easing IO pain and pressure. JEMS 2010;35(9):58-69. Research sponsored by Teleflex Incorporated or its affiliates
*Based on adult proximal humerus data For more information, visit JEMS.com/rs and enter 40.
Apple and the Apple logo are trademarks of Apple Inc., registered in the U.S. and other countries.
Google Play is a trademark of Google Inc.
Teleflex, the Teleflex logo, Arrow and EZ-IO are trademarks or registered trademarks
of Teleflex Incorporated or its affiliates, in the U.S. and/or other countries.
2016 Teleflex Incorporated. All rights reserved. MC-002927
1707jems_C4 4 6/9/17 9:21 AM

If You See
No Way Out
Just Reach Out
Make the call to Make things Better
Photo Courtesy of Lauralee Veitch
Fire/EMS Helpline: 1-888-731-FIRE (3473)

Free, ConFidential, 24/7
TM
Find resources to Share the Load at www.nvfc.org/help

Persistent Sadness Suicidal Thoughts Substance Abuse Work/Life Stresses
Being an emergency medical provider brings many challenges. Remember,

you are not alone. Talk to someone you love. Talk to a friend or colleague.
Or talk to counselors trained and experienced in the firefighter and EMS
culture by calling the national Fire/EMS Helpline.
The Fire/EMS Helpline is brought to you by firefighters, for firefighters and emergency responders, in partnership with American Addiction Centers.
1707jems_NVFCPoster_1 1 6/12/17 11:58 AM

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DIGITAL PRODUCTS

TRANSPORT ASSESS VITALS CALCULATE MONITOR REVIEW

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About the Cover

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Control-Cric EDITOR-IN-CHIEF A.J. Heightman, MPA, EMT-P aheightman@pennwell.com

Taking Control of an Otherwise

EDITORIAL GRAPHIC DESIGNER Kermit Mulkins

SALES & MARKETING SOLUTIONS

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For complete bios of our Editorial Board members, visit jems.com/Editorial-Board.

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